Treatment Options for Oropharyngeal Cancer by Stage

Stage 0 (carcinoma in situ) oropharyngeal cancer

Cancer in this stage is on the surface layer and hasn’t started to grow into deeper layers of tissue, but it can do so if it isn’t treated.

The usual treatment is surgery to remove the top layers of tissue along with a small margin (edge) of normal tissue. This is generally Mohs surgery, surgical stripping, or thin resection.

Close follow-up is important to watch for any signs that the cancer has come back. Carcinoma in situ that keeps coming back after surgery may need to be treated with radiation therapy.

Early-stage oropharyngeal cancer

Early-stage oropharyngeal cancers (back of the tongue, soft palate, and tonsils) typically include most stage I and II cancers, p16/HPV-positive or p16/HPV-negative.

The main treatment options include:

• Radiation therapy aimed at the cancer and lymph nodes in the neck, or
• Surgery of the main tumor along with removal of the lymph nodes in the neck (lymph node dissection)

After surgery, if any cancer remains or if there is a high chance of the cancer coming back, chemoradiation is often used.

Sometimes, if imaging or a biopsy shows the lymph nodes in the neck have cancer, chemoradiation might be the first treatment.

Locally advanced oropharyngeal cancer

These are larger cancers in the back of the tongue, soft palate, and tonsils that have grown into nearby tissues, and/or have spread to nearby lymph nodes in the neck.

In general, this includes most stage III, IVA, and IVB p16/HPV-negative cancers and most stage I, II, and III p16/HPV-positive cancers in the TNM system.

• Most locally advanced oropharyngeal cancers are treated with chemoradiation.
• Any cancer that is still present after chemoradiation is often removed with surgery.
• Sometimes, chemo might be given as the first treatment, followed by radiation alone or chemoradiation, and then surgery if needed.

Surgery might also be an option as the first treatment if the surgeon thinks the cancer can be removed safely. If surgery is planned, immunotherapy with a drug called a checkpoint inhibitor might be given both before and after surgery. Radiation or chemoradiation might be given after surgery as well.

The choice of treatment is often guided by the location of the cancer, how much it has spread, the expected side effects, and a person's current health and preferences.

If the cancer has spread to neck lymph nodes, these might also need to be removed with a lymph node dissection.

Metastatic oropharyngeal cancer

Metastatic oropharyngeal cancers (back of the tongue, soft palate, and tonsils) include stage IVC p16/HPV-negative cancers and stage IV p16/HPV-positive cancers that have spread to other parts of the body, such as the lungs.

• These cancers are usually treated with chemo, the targeted drug cetuximab, or both.
• Immunotherapy, alone or with chemo, might be another option.

Treatments such as radiation may also be used to help relieve symptoms from the cancer or help prevent new problems.

Recurrent oropharyngeal cancer

When cancer comes back after treatment, it's called recurrent cancer. It can:

• Come back in or near the same place it first started (local)
• Come back in nearby lymph nodes (regional)
• Spread to other organs such as the lungs or bone (distant)

Treatment options for recurrent oropharyngeal cancers depend on the location and size of the cancer, what treatments have already been used, and a person’s general health. Because these cancers can be hard to treat, clinical trials of newer treatments may be a good option for some people.

Local recurrence

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 person is healthy enough for surgery.

Usually, external beam radiation therapy can’t be repeated in the same site except in certain cases. But internal radiation (brachytherapy) can often be used to control the cancer if it comes back in the place it started.

If surgery was used first, more surgery, radiation therapy, chemo, the targeted drug cetuximab, immunotherapy, or a combination of these may be an option.

Regional recurrence

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 or chemoradiation.

Distant recurrence

If the cancer comes back in a distant area, chemo (and/or cetuximab) is often used. Immunotherapy with or without chemo might be an option as well. Treatment might shrink or slow the growth of some cancers for a while and help relieve symptoms, but these cancers are very hard to cure.

If further treatment is recommended, it’s important to talk to your cancer care team so you understand the goal of treatment. Ask whether the goal is to try to cure the cancer or to relieve symptoms and keep the cancer under control for as long as possible. This can help you weigh the risks and benefits of each option.