Treatment Options for Oral Cavity and Oropharyngeal Cancer by Stage

This information is based on AJCC Staging systems prior to 2018 which were primarily based on tumor size and lymph node status. Since the updated staging system for oropharyngeal cancer now also includes the p16 status of the tumor, the stages may be higher or lower than previous staging systems. Whether or not treatment strategies will change with this new staging system are yet to be determined. You should discuss your stage and treatment options with your physician. 

The type of treatment your doctor will recommend depends on where the tumor is and how far the cancer has spread. Here are common ways to treat different stages of oral cavity and oropharyngeal cancer. But each situation is different. Your doctor may have reasons for suggesting a treatment option not mentioned here.

Most experts agree that treatment in a clinical trial should be considered for any type or stage of cancer in the head and neck areas. This way people can get the best treatment available now and may also get the new treatments that are thought to be even better.

Stage 0 (carcinoma in situ)

Although cancer in this stage is on the surface layer and has not started to grow into deeper layers of tissue, it can do so if not treated. The usual treatment is surgery (usually Mohs surgery, surgical stripping, or thin resection) to remove the top layers of tissue along with a small margin (edge) of normal tissue. Close follow-up is important to watch for signs that the cancer has come back. Carcinoma in situ that keeps coming back after surgery may need to be treated with radiation therapy.

Nearly all people with this stage survive a long time without the need for more intense treatment. Still, it's 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 do well when treated with surgery and/or radiation therapy. Chemotherapy (chemo) given along with radiation (called chemoradiation) is another option. It can be used alone, but it's most often used after surgery to treat any cancer cells that may be left behind. Both surgery and radiation work well in treating these cancers. The choice depends on your preferences and the expected side effects, including how the treatment might affect how you look and how you swallow and speak.

Lip

Surgery is preferred for small cancers that can be removed. Radiation alone may also be used as the first treatment. In this case, surgery might be needed later if radiation doesn’t completely get rid of the tumor.

Large or deep cancers often require surgery. If needed, reconstructive surgery can help correct the defect in the lip.

If the tumor is thick, it increases the risk that the cancer might have spread to lymph nodes in the neck, so the surgeon may remove them (called lymph node dissection) so they can be checked for cancer spread.

Oral cavity

For cancers of the floor of the mouth, front of the tongue, inside of the cheek, gums, and hard palate, surgery is the main treatment. Lymph nodes in the neck may be removed (called lymph node dissection) to check them for cancer spread. If it looks like the cancer hasn't been completely removed or if it has a high risk of coming back based on how the cancer cells look under the microscope (grade), radiation (often combined with chemo) may be added.

Radiation can be used instead of surgery as the main treatment for some people. This is most often done for people who can’t have surgery because of other medical problems.

Oropharynx

For cancers of the back of the tongue, soft palate, and tonsils, the main treatment is radiation therapy aimed at the cancer and the lymph nodes in the neck. Surgery can be used as the main treatment (instead of radiation). This would include removing lymph nodes in the neck (lymph node dissection). If any cancer remains after surgery, chemoradiation is often used.

Stages III, IV, and IVA

Oral cavity cancers

These stage III and IVA cancers in the floor of the mouth, front of the tongue, inside of the cheek, gums, and hard palate include bigger cancers, those that have grown into nearby tissues, and/or those that have spread to nearby lymph nodes in the neck. They're often treated with a combination of surgery and radiation. Surgery is often done first and includes taking out some of the neck lymph nodes (lymph node dissection).

Oropharyngeal cancers

These are cancers in the back of the tongue, soft palate, and tonsils that are larger cancers, have grown into nearby tissues, and/or have spread to nearby lymph nodes in the neck. These cancers are often treated with chemoradiation, although radiation and cetuximab may be used in some cases. The effect of combining radiation with both chemo and cetuximab is also being studied. Any cancer that remains after chemoradiation is removed with surgery. If the cancer has spread to neck lymph nodes, they may also need to be removed (a lymph node dissection) after chemoradiation is done.

Another option is to treat first with surgery to remove the cancer and neck lymph nodes. This is often followed by radiation or chemoradiation to lower the chance of the cancer coming back.

The choice of treatment is influenced by where the cancer is, how much it has spread, the expected side effects, patient preferences, and the patient’s current health status.

Some doctors give chemo as the first treatment, followed by chemoradiation, and then surgery if needed. Not all doctors agree with this approach, though.

Stages IVB and IVC

These are HPV-negative cancers that have already spread into nearby tissues, structures, and maybe lymph nodes. Stage IVC cancers have spread to other parts of the body, such as the lungs. These cancers are usually treated with chemo, cetuximab, or both. Other treatments such as radiation may also be used to help relieve symptoms from the cancer or to help prevent new problems.

Clinical trials are looking at different ways of combining radiation and chemo with or without cetuximab or other new agents to improve survival and quality of life, and reduce the need for radical or deforming surgery to treat these advanced cancers in the mouth and throat.

Recurrent oral cavity or oropharyngeal cancer

When cancer come backs after treatment, it's called recurrent cancer. Recurrence can be local (in or near the same place the cancer first started), regional (in nearby lymph nodes), or distant (spread to other organs such as the lungs or bone). Treatment options for recurrent cancers depend on the location and size of the cancer, what treatments have already been used, and 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 the cancer can be removed completely and the patient is healthy enough for surgery. Usually, external beam radiation therapy cannot be repeated in the same site except in certain cases. But internal radiation (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, chemo, cetuximab, or a combination of these may be options.

If the cancer comes back in the lymph nodes in the neck, the nodes are often removed with surgery (lymph node dissection). This may be followed by radiation.

If the cancer comes back in a distant area, chemo (and/or cetuximab) is the preferred treatment. This may shrink or slow the growth of some cancers for a while and help relieve symptoms, but these cancers are very hard to cure.

If chemo is no longer working, a newer option might be treatment with an immunotherapy drug such as pembrolizumab (Keytruda) or nivolumab (Opdivo). These drugs can help the body’s own immune system attack the cancer. 

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's 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.

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.

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

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