The type of treatment your doctor will recommend depends on the tumor site and how far the cancer has spread. This section lists the options usually considered for each stage of oral cavity or oropharyngeal cancer. These are general comments about treatment, because the approach to each site may be different. Your doctor may have reasons for suggesting a treatment option not mentioned here.
Stage 0 (carcinoma in situ)
Although cancer in this stage has not become invasive (started to grow into deeper layers of tissue), it can do so if not treated. The usual treatment is to remove the top layers of tissue along with a small margin of normal tissue. This is known as surgical stripping or thin resection. Close follow-up to see if any cancer has come back (recurrence) is important. Carcinoma in situ that keeps coming back after resection may require radiation therapy.
Nearly all patients at this stage survive a long time without the need for more intensive treatment. But it is important to note that continuing to smoke increases the risk that a new cancer will develop.
Stages I and II
Most patients with stage I or II oral cavity and oropharyngeal cancer can be successfully treated with either surgery or radiation therapy. Both approaches work equally well in treating these cancers. The choice of treatment is influenced by the expected side effects.
Lip: Lip cancer is generally treated with surgery, including Mohs surgery. Radiation therapy or more extensive surgery may be used if the tumor turns out to be larger than expected. If needed, special reconstructive surgery can help correct the defect in the lip.
Radiation alone may also be used as the first treatment. This is usually external beam radiation, sometimes along with brachytherapy. Surgery may be used if radiation doesn't completely get rid of the tumor.
If the tumor is thick, the surgeon may remove and examine lymph nodes in the neck.
Floor of the mouth: Surgery is preferred if it can be done because radiation may cause bone damage. If the cancer does not appear to have been completely removed by surgery, radiation may be added. This cancer readily spreads to neck lymph nodes. Surgery (neck dissection) may be recommended to remove these. Usually, the surgeon will remove lymph nodes from the side of the neck nearest the tumor. But if the tumor is in the middle, then lymph nodes on both sides of the neck will need to be removed.
Front of the tongue: Surgery is preferred for small tumors and radiation for larger ones, especially if cutting the tumor out would impair speech or swallowing. If surgery could not remove all the cancer, radiation may be added. For larger tumors, removal of neck lymph nodes will likely be recommended.
Buccal mucosa (cheek): These cancers are usually treated with surgery. Radiation may be another option. If surgery is used, radiation may be added. If the tumor is large, the neck lymph nodes will be removed as well.
Lower gums: Cancer in the lower gums is usually treated with surgery, which may include removing part of the mandible (jaw bone). Radiation may be added if all of the cancer could not be removed. Radiation may be used as the main treatment, but it carries a risk of damage to the jaw bone. Surgery to remove the neck nodes is often recommended.
Upper gums and hard palate: Cancers in the upper gum or hard palate (the front of the roof of the mouth) are also usually managed with surgery. Radiation may be added as well if needed. Lymph nodes in the neck may be removed.
Back of the tongue: Radiation is generally preferred because surgery would cause more problems with speech and swallowing, although surgery is used in some cases. The lymph nodes in the neck generally need to be treated as well.
Soft palate (back of the roof of the mouth): Because surgery would probably interfere with speech and swallowing, radiation is often the preferred treatment. Radiation may also be given to the neck. If surgery is used as the first treatment, then the neck nodes also might be removed.
Tonsils: Surgery and radiation (perhaps combined with chemotherapy) work about equally well in treating cancer of the tonsils. If the cancer will need to be treated with radiation after surgery, many doctors prefer giving the radiation treatments first. Then, surgery is still an option if radiation doesn't get rid of all the cancer. The neck lymph nodes can be treated the same way — surgery or radiation.
Stages III and IV
More advanced oral cavity and oropharyngeal cancers generally require a combination of either surgery and radiation, radiation and chemotherapy (or cetuximab), or a combination of all three. The effect of combining radiation with both chemotherapy and cetuximab is also being studied. The choice of treatment is influenced by where the cancer is, how much it has spread, the expected side effects, and the patient's current health status.
Surgery usually includes a neck dissection because of the high risk of cancer spread to the lymph nodes. Radiation therapy often is required after surgery, particularly if the tumor has spread to the lymph nodes. Sometimes chemotherapy is given as well, especially if the cancer has worrisome features. The amount of tissue removed during surgery depends on the extent of cancer, and the method of reconstruction depends on the surgical defect created.
Primary tumors that are too large to be completely removed by surgery are often treated with radiation, either alone or with chemotherapy (or cetuximab). Doctors are also studying giving chemo as the first treatment, although not all doctors agree with this approach. Sometimes, these treatments may shrink the tumor enough so that surgery can be done.
Cancers that have already spread to other parts of the body are usually treated with chemotherapy, often along with cetuximab. Other treatments such as radiation may also be used to help relieve symptoms from the cancer or to help prevent problems from occurring.
Clinical trials are looking at different ways of combining radiation and chemotherapy with or without cetuximab or other new agents to improve survival and quality of life, and reduce the need for radical resection of advanced oral cavity and oropharyngeal cancers.
Recurrent oral cavity or oropharyngeal cancer
When cancer come backs after treatment, it is called recurrent cancer. Recurrence can be local (in or near the same place it started) or distant (spread to bone or organs such as the lungs). Treatment options for recurrent cancers depend on the location and size of the cancer, what treatments have already been used, and on the person's general health.
If the cancer comes back in the same area and radiation therapy was used as the first treatment, surgery is often the next treatment if possible. Usually, external beam radiation therapy cannot be repeated in the same site except in selected cases. However, brachytherapy can often be used to control the cancer if it has come back in the place it started. If surgery was used first, more surgery, radiation therapy, chemotherapy, or a combination of these may be considered.
If the cancer comes back in a distant area, chemotherapy (and/or cetuximab) is the preferred form of treatment. This may shrink or slow the growth of some cancers for a while and help relieve symptoms, but these cancers are very difficult to cure. If further treatment is recommended, it's important to talk to your doctor so that you understand what the goal of treatment is — whether it is to try to cure the cancer or to keep it under control for as long as possible and relieve symptoms. This can help you weigh the pros and cons of each treatment. Because these cancers are hard to treat, clinical trials of newer treatments may be a good option for some people.
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