Oral Cavity and Oropharyngeal Cancer Stages

After someone is diagnosed with oral cavity or oropharyngeal cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a cancer describes how much cancer is in the body. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer's stage when talking about survival statistics.

The earliest stage oral cavity or oropharyngeal cancers are called stage 0 (carcinoma in situ), and then range from stages I (1) through IV (4). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more. And within a stage, an earlier letter means a lower stage. Although each person’s cancer experience is unique, cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

How is the stage determined?

The staging system most often used for oral cavity or oropharyngeal cancers is the American Joint Committee on Cancer (AJCC) TNM system, which is based on 3 key pieces of information:

  • The extent of the tumor (T): How large is the main (primary) tumor and which, if any, tissues of the oral cavity or oropharynx it has spread to?
  • The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes?
  • The spread (metastasis) to distant sites (M): Has the cancer spread to distant organs such as the lungs?

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once a person’s T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage. For more information see Cancer Staging.

The staging system in the table below is based on the most recent AJCC system, effective January 2018. It uses the pathologic stage (also called the surgical stage). It's determined by examining the tissue removed during an operation. Sometimes, if surgery isn't possible right away or at all, the cancer will be given a clinical stage instead (which is not shown below). This is based on the results of a physical exam, endoscopy exam, biopsy, and imaging tests. The clinical stage will be used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates, and it may not predict the patient’s outlook as accurately as a pathologic stage.

Oropharyngeal cancers that contain HPV DNA (called p16 positive) tend to have a better outlook than those without HPV (p16 negative). Because p16 positive cancers have a better prognosis than p16 negative oropharyngeal cancers, separate staging systems are used. Both systems are described below.

Cancer staging can be complex, so ask your doctor to explain it to you in a way you understand. 

Lip, oral cavity, and p16 negative oropharynx stages

AJCC stage

Stage grouping

Lip, oral cavity and p16 negative oropharynx stage description*

0

Tis

N0

M0

The cancer is still within the epithelium (the top layer of cells lining the oral cavity and oropharynx) and has not yet grown into deeper layers.

It has not spread to nearby lymph nodes (N0) or distant sites (M0). This stage is also known as carcinoma in situ (Tis).

I

T1

N0

M0

The cancer is 2 cm (about ¾ inch) or smaller. It’s not growing into nearby tissues (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

 

II

T2

N0

M0

The cancer is larger than 2 cm but no larger than 4 cm (about 1½ inch). It’s not growing into nearby tissues (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

III

 

T3

N0

M0

The cancer is larger than 4 cm (T3). For cancers of the oropharynx, T3 also includes tumors that are growing into the epiglottis (the base of the tongue). It has not spread to nearby lymph nodes (N0) or to distant sites (M0).

OR

T1, T2, T3

N1

M0

The cancer is any size and may have grown into nearby structures if oropharynx cancer(T1-T3) AND has spread to 1 lymph node on the same side as the primary tumor. The cancer has not grown outside of the lymph node and the lymph node is no larger than 3 cm (about 1¼ inch) (N1). It has not spread to distant sites (M0).

IVA

T4a

N0 or N1

M0

The cancer is any size and is growing into nearby structures such as:

  • For lip cancers: nearby bone, the inferior alveolar nerve (the nerve to the jawbone), the floor of the mouth, or the skin of the chin or nose (T4a)
  • For oral cavity cancers: the bones of the jaw or face, deep muscle of the tongue, skin of the face, or the maxillary sinus (T4a)
  • For oropharyngeal cancers: the larynx (voice box), the tongue muscle, or bones such as the medial pterygoid, the hard palate, or the jaw (T4a).

This is known as moderately advanced local disease (T4a).  

AND either of the following:

  • It has not spread to nearby lymph nodes (N0)
  • It has spread to 1 lymph node on the same side as the primary tumor, but has not grown outside of the lymph node and the lymph node is no larger than 3 cm (about 1¼ inch) (N1).

It has not spread to distant sites (M0).

OR

T1, T2, T3 or T4a

N2

M0

The cancer is any size and may have grown into nearby structures (T0-T4a). It has not spread to distant organs (M0). It has spread to one of the following:

  • 1 lymph node on the same side as the primary tumor, but it has not grown outside of the lymph node and the lymph node is larger than 3 cm but not larger than 6 cm (about 2½ inches) (N2a) OR
  • It has spread to more than 1 lymph node on the same side as the primary tumor, but it has not grown outside of any of the lymph nodes and none are larger than 6 cm (N2b) OR
  • It has spread to 1 or more lymph nodes either on the opposite side of the primary tumor or on both sides of the neck, but has not grown outside any of the lymph nodes and none are larger than 6 cm (N2c).

 

IVB

Any T

N3

M0

The cancer is any size and may have grown into nearby soft tissues or structures (Any T) AND any of the following:

  • It has spread to 1 lymph node that's larger than 6 cm but has not grown outside of the lymph node (N3a) OR
  • It has spread to 1 lymph node that's larger than 3 cm and has clearly grown outside the lymph node (N3b) OR
  • It has spread to more than 1 lymph node on the same side, the opposite side, or both sides of the primary cancer with growth outside of the lymph node(s) (N3b) OR
  • It has spread to 1 lymph node on the opposite side of the primary cancer that's 3 cm or smaller and has grown outside of the lymph node (N3b). 

It has not spread to distant organs (M0).

OR

T4b

Any N

M0

The cancer is any size and is growing into nearby structures such as the base of the skull or other bones nearby, or it surrounds the carotid artery. This is known as very advanced local disease (T4b). It might or might not have spread to nearby lymph nodes (Any N). It has not spread to distant organs (M0).

IVC

Any T

Any N

M1

The cancer is any size and may have grown into nearby soft tissues or structures (Any T) AND it might or might not have spread to nearby lymph nodes (Any N). It has spread to distant sites such as the lungs (M1).

* The following additional categories are not described in the table above:

  • TX: Main tumor cannot be assessed due to lack of information.
  • T0: No evidence of a primary tumor.
  • NX: Regional lymph nodes cannot be assessed due to lack of information. 

p16 positive oropharynx stages

AJCC stage

Stage grouping

p16 positive oropharynx stage description*

I

T0, T1 or T2

N0 or N1

M0

The cancer is no larger than 4 cm (about 1 1/2 inches) (T0 to T2) AND any of the following:

  • It has not spread to nearby lymph nodes (N0) OR
  • It has spread to 1 or more lymph nodes on the same side as the primary cancer, and none are larger than 6 cm (N1).

It has not spread to distant sites (M0).

 

II

T0, T1 or T2

N2

M0

The cancer is no larger than 4 cm (about 1 1/2 inches) (T0 to T2) AND it has spread to 1 or more lymph nodes on the opposite side of the primary cancer or both sides of the neck, and none are larger than 6 cm (N2). It has not spread to distant sites (M0).

OR

T3 or T4

N0 or N1

M0

The cancer is larger than 4 cm (about 1 1/2 inches) (T3) OR is growing into the epiglottis (the base of the tongue) (T3) OR is growing into the larynx (voice box), the tongue muscle, or bones such as the medial pterygoid plate, the hard palate, or the jaw (T4) AND any of the following:

  • It has not spread to nearby lymph nodes (N0) OR
  • It has spread to 1 or more lymph nodes on the same side as the primary cancer, and none are larger than 6 cm (N1).

It has not spread to distant sites (M0).

III

 

T3 or T4

N2

M0

The cancer is larger than 4 cm (about 1 1/2 inches) (T3) OR is growing into the epiglottis (the base of the tongue) (T3) OR is growing into the larynx (voice box), the tongue muscle, or bones such as the medial pterygoid plate, the hard palate, or the jaw (T4) AND it has spread to 1 or more lymph nodes on the opposite side of the primary cancer or both sides of the neck, and none are larger than 6 cm (N2). It has not spread to distant sites (M0).

IV

Any T

Any N

M1

The cancer is any size and may have grown into nearby structures (Any T) AND it might or might not have spread to nearby lymph nodes (Any N). It has spread to distant sites such as the lungs  or bones (M1).

* The following additional categories are not described in the table above:

  • TX: Main tumor cannot be assessed due to lack of information.
  • T0: No evidence of a primary tumor.
  • NX: Regional lymph nodes cannot be assessed due to lack of information.

Recurrent (relapsed) cancer

This is not an actual stage in the TNM system. Recurrent (relapsed) cancer means that the cancer has come back (recurred) after treatment. Recurrent oral cavity or oropharyngeal cancer may return in the mouth or throat (local recurrence), in nearby lymph nodes (regional recurrence), or in another part of the body, such as the lungs (distant recurrence).

Talk with your doctor if you have any questions about the stage of your cancer or how it affects your treatment.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master's-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

American Joint Committee on Cancer. Lip and Oral Cavity. In: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017:79.

American Joint Committee on Cancer. HPV-Mediated (p16+) Oropharyngeal Cancer. In: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017:113.

American Joint Committee on Cancer. Oropharynx (p16-) and Hypopharynx. In: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017:123.

Last Medical Review: March 9, 2018 Last Revised: March 9, 2018

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