After determining a diagnosis and completing a full pre-treatment evaluation, doctors will recommend a course of treatment for their patients. It is important to know that the pre-treatment evaluation for oropharyngeal cancer will also involve testing for the presence of HPV in the tumor cells.
In general, there are three different options for the treatment of oropharyngeal cancers that can be used alone or in combination:
For oropharyngeal cancers there is no one, standard treatment plan. Instead, patients and their care teams should have extensive discussions to determine the best treatment course.
The presence of HPV infection will affect the treatment plan for oropharyngeal cancer, as HPV-mediated oropharyngeal cancers are typically more amenable to minimally invasive surgical resections and also more responsive to radiation than non HPV-mediated cancers.Below are the general treatment options for oropharyngeal cancers, depending on T, N, and M stages:
T1-2, N0-1
- For small primary tumors, with at most one lymph node located on the same side as the tumor (T1-2, N0-1), the options for treatment are as follows:
- Surgery to remove the primary tumor with a neck dissection to remove lymph nodes from one or both sides of the neck.
- Minimally invasive Transoral Robotic Surgery (TORS) or Transoral Laser Microsurgery (TLM) are typically used for early T-stage cancers and have been shown to have superior functional outcomes and fewer complications than traditional open surgical options.
- Radiation therapy with or without chemotherapy.
- Chemotherapy is only used for T2,N1 cancers.
- Enrollment in a clinical trial.
- Surgery to remove the primary tumor with a neck dissection to remove lymph nodes from one or both sides of the neck.
- If a non-surgical approach is chosen as the initial treatment, and more cancer is found to remain after treatment either immediately following therapy or at any time thereafter, then surgery should be performed to resect the remaining disease and reconstruct the region.
- If surgical removal is chosen as the initial treatment, then the cancer will be analyzed under a microscope to determine if any additional treatment is needed. This decision will be made based on the presence of any adverse features such as:
- Positive margins (the presence of cancer cells at the edge of the tissue that was removed).
- Spread of the cancer beyond the lymph nodes in the neck (extranodal extension).
- A more extensive cancer than was expected (T3 or T4 tumors and/or N2 or N3 disease in the neck lymph nodes).
- Cancerous lymph nodes in unusual parts of the neck.
- Tumor invasion into or around nerves (perineural invasion).
- Tumor invasion into blood vessels (lymphovascular invasion).
- If there are no adverse features, then no further treatment will be needed.
- If there are multiple positive lymph nodes without any adverse features, adjuvant radiation therapy will be given after surgery.
- If lymph nodes show extranodal extension (ENE), then adjuvant radiation and chemotherapy will likely be recommended.
T3-4a, N0-1
- For locally advanced cancers, which have large primary tumors, the treatment options are as follows:
- Surgery to remove the primary tumor along with neck dissection to remove lymph nodes from the neck, with or without radiation and/or chemotherapy.
- Select HPV-mediated T3 tumors may be candidates for Minimally invasive Transoral Robotic Surgery (TORS) or Transoral Laser Microsurgery (TLM).
- More traditional open surgical approaches are required for T4a tumors and some T3 tumors.
- Chemotherapy and radiation.
- Enrollment in a clinical trial.
- Induction chemotherapy may be an option for some patients.
- Surgery to remove the primary tumor along with neck dissection to remove lymph nodes from the neck, with or without radiation and/or chemotherapy.
- If a non-surgical approach is chosen as the initial treatment, and more cancer is found to remain after treatment, then surgery should be performed to remove any cancer that is left.
- If surgical removal is chosen as the initial treatment, then the cancer will be analyzed under a microscope to determine if any additional treatment is needed. This decision will be made based on the presence of any adverse features such as:
- Positive margins (the presence of cancer cells at the edge of the tissue that was resected).
- Spread of the cancer beyond the lymph nodes in the neck, also referred to as extranodal extension (ENE).
- A more extensive cancer than was expected (T3 or T4 tumors and/or N2 or N3 disease in the neck lymph nodes).
- Cancerous lymph nodes in unusual parts of the neck.
- Tumor invasion into or around nerves (perineural invasion).
- Tumor invasion into blood vessels (lymphovascular invasion).
- Postoperative (adjuvant) radiation treatment is given for any T4a tumor and select T3 tumors with adverse pathologic features.
- Chemotherapy will also be recommended when ENE or positive surgical margins are found on final pathology.
Any T, N2-3
- For cancers involving multiple lymph nodes in the neck, large lymph nodes, lymph nodes on the opposite side of the neck to the primary tumor, and/or lymph nodes on both sides of the neck, the treatment options are as follows:
- Chemotherapy and radiation.
- Surgery to remove the primary tumor along with neck dissection to remove lymph nodes from the neck, followed by radiation with or without chemotherapy.
- Minimally invasive Transoral Robotic Surgery (TORS) or Transoral Laser Microsurgery (TLM) are typically used for T1-T2 and select T3 cancers and have been shown to have superior functional outcomes and fewer complications than traditional open surgical options.
- More traditional open surgical approaches are required for T4a tumors and some T3 tumors.
- Induction chemotherapy may be an option for some patients.
- Enrollment in a clinical trial.
- If a non-surgical approach is chosen as the initial treatment, and more cancer is found to remain after treatment, then surgery should be performed to remove any cancer that is left.
- If a non-surgical approach is chosen as the initial treatment, and the cancer is gone from the primary site, the lymph nodes in the neck should be examined regularly by physical exam and by imaging, for any evidence of cancer.
- If cancer is found in the lymph nodes, a neck dissection will be necessary
- If surgical removal is chosen as the initial treatment, then the cancer will be analyzed under a microscope to determine if any additional treatment is needed. This decision will be made based on the presence of any adverse features such as:
- Positive margins (the presence of cancer cells at the edge of the tissue that was resected) .
- Spread of the cancer beyond the lymph nodes in the neck (extranodal extension).
- A more extensive cancer than was expected (T3 or T4 tumors and/or N2 or N3 disease in the neck lymph nodes).
- Cancerous lymph nodes in unusual parts of the neck.
- Tumor invasion into or around nerves (perineural invasion).
- Tumor invasion into blood vessels (lymphovascular invasion).
- Postoperative (adjuvant) radiation treatment is given for any T4a tumor and select T3 tumors with adverse pathologic features, as well as, N2 or greater nodal disease.
- Chemotherapy will also be recommended when ENE or positive surgical margins are found on final pathology.
T4b, any N; unresectable neck disease; or patients unfit for surgery
- In cases that are very advanced, or in patients who are extremely sick, patients should have an extensive discussion with their doctor in order to consider the possibility of palliative therapy or hospice care.
