Oropharyngeal Cancer Treatment (Adult) (PDQ®): Treatment - Patient Information [NCI]
General Information About Oropharyngeal Cancer
Oropharyngeal cancer is a disease in which malignant (cancer) cells form in the tissues of the oropharynx.
The oropharynx is the middle part of the pharynx (throat), behind the mouth. The pharynx is a hollow tube about 5 inches long that starts behind the nose and ends where the trachea (windpipe) and esophagus (tube from the throat to the stomach) begin. Air and food pass through the pharynx on the way to the trachea or the esophagus.
Anatomy of the pharynx (throat). The pharynx is a hollow tube that starts behind the nose, goes down the neck, and ends at the top of the trachea and esophagus. The three parts of the pharynx are the nasopharynx, oropharynx, and hypopharynx.
The oropharynx includes the following:
- Soft palate.
- Side and back walls of the throat.
- Tonsils.
- Back one-third of the tongue.
Parts of the oropharynx. The oropharynx includes the soft palate, the side and back walls of the throat, the tonsils, and the back one-third of the tongue.
Oropharyngeal cancer is a type of head and neck cancer. Sometimes more than one cancer can occur in the oropharynx and in other parts of the oral cavity, nose, pharynx, larynx (voice box), trachea, or esophagus at the same time.
Most oropharyngeal cancers are squamous cell carcinomas. Squamous cells are the thin, flat cells lining the inside of the oropharynx.
Smoking or being infected with human papillomavirus (HPV) can increase the risk of oropharyngeal cancer.
Anything that increases a person's chance of getting a disease is called a risk factor. Not every person with one or more of these risk factors will develop oropharyngeal cancer, and it will develop in people who don't have any known risk factors. Talk with your doctor if you think you may be at risk.
The most common risk factors for oropharyngeal cancer include the following:
- A history of smoking cigarettes for more than 10 pack years and other tobacco use.
- Heavy alcohol use.
- Being infected with human papillomavirus (HPV), especially HPV type 16. The number of cases of oropharyngeal cancers linked to HPV infection is increasing.
- Personal history of head and neck cancer.
- Chewing betel quid, a stimulant commonly used in parts of Asia.
Signs and symptoms of oropharyngeal cancer include a lump in the neck and a sore throat.
These and other signs and symptoms may be caused by oropharyngeal cancer or by other conditions. Check with your doctor if you have any of the following:
- A sore throat that does not go away.
- Trouble swallowing.
- Trouble opening the mouth fully.
- Trouble moving the tongue.
- Weight loss for no known reason.
- Ear pain.
- A lump in the back of the mouth, throat, or neck.
- A white patch on the tongue or lining of the mouth that does not go away.
- Coughing up blood.
Sometimes oropharyngeal cancer does not cause early signs or symptoms.
Tests that examine the mouth and throat are used to diagnose and stage oropharyngeal cancer.
In addition to asking about your personal and family health history and doing a physical exam, your doctor may perform the following tests and procedures:
- Physical exam of the mouth and neck: An exam in which the doctor or dentist looks at the mouth and neck, under the tongue, and down the throat with a small, long-handled mirror to check for abnormal areas.
- Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks a person's mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam.
- PET-CT scan: A procedure that combines the pictures from a positron emission tomography (PET) scan and a computed tomography (CT) scan. The PET and CT scans are done at the same time with the same machine. The combined scans give more detailed pictures of areas inside the body than either scan gives by itself. A PET-CT scan may be used to help diagnose disease, such as cancer, plan treatment, or find out how well treatment is working.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the head, neck, chest, and lymph nodes, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye is injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
Computed tomography (CT) scan of the head and neck. The patient lies on a table that slides through the CT scanner, which takes x-ray pictures of the inside of the head and neck. - PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
PET (positron emission tomography) scan. The patient lies on a table that slides through the PET machine. The head rest and white strap help the patient lie still. A small amount of radioactive glucose (sugar) is injected into the patient's vein, and a scanner makes a picture of where the glucose is being used in the body. Cancer cells show up brighter in the picture because they take up more glucose than normal cells do.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the head, neck, chest, and lymph nodes, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye is injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
- Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A fine-needle biopsy is usually done to remove a sample of tissue using a thin needle.
The following procedures may be used to remove samples of cells or tissue:
- Endoscopy: A procedure to look at organs and tissues inside the body to check for abnormal areas. An endoscope is inserted through an incision (cut) in the skin or opening in the body, such as the mouth or nose. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove abnormal tissue or lymph node samples, which are checked under a microscope for signs of disease. The nose, throat, back of the tongue, esophagus, stomach, larynx, windpipe, and large airways will be checked. The type of endoscopy is named for the part of the body that is being examined. For example, pharyngoscopy is an exam to check the pharynx.
- Laryngoscopy: A procedure in which the doctor checks the larynx (voice box) with a mirror or a laryngoscope to check for abnormal areas. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing the inside of the throat and voice box. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
If cancer is found, the following test may be done to study the cancer cells:
- HPV test (human papillomavirus test): A laboratory test used to check the sample of tissue for certain types of HPV infection, such as HPV type 16. This test is done because oropharyngeal cancer can be caused by HPV infection. This is important because HPV-positive oropharyngeal cancer has a better prognosis and is treated differently than HPV-negative oropharyngeal cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis depends on the following:
- Whether the patient has HPV infection of the oropharynx.
- Whether the patient has a history of smoking cigarettes for ten or more pack years.
- The stage of the cancer.
- The number and size of lymph nodes with cancer.
Oropharyngeal tumors related to HPV infection have a better prognosis and are less likely to recur than tumors not linked to HPV infection.
Treatment options depend on the following:
- The stage of the cancer.
- Keeping the patient's ability to speak and swallow as normal as possible.
- The patient's general health.
Patients with oropharyngeal cancer have an increased risk of another cancer in the head or neck. This risk is increased in patients who continue to smoke or drink alcohol after treatment.
For more information, see Cigarette Smoking: Health Risks and How to Quit.
Stages of Oropharyngeal Cancer
After oropharyngeal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the oropharynx or to other parts of the body.
The process used to find out if cancer has spread within the oropharynx or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The results of some of the tests used to diagnose oropharyngeal cancer are often used to stage the disease.
There are three ways that cancer spreads in the body.
Cancer can spread through tissue, the lymph system, and the blood:
- Tissue. The cancer spreads from where it began by growing into nearby areas.
- Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
- Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
Cancer may spread from where it began to other parts of the body.
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
- Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
- Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if oropharyngeal cancer spreads to the lung, the cancer cells in the lung are actually oropharyngeal cancer cells. The disease is metastatic oropharyngeal cancer, not lung cancer.
The following stages are used for HPV-positive oropharyngeal cancer:
Stage I
In stage I, one of the following is true:
- one or more lymph nodes with cancer that is HPV p16-positive are found but the place where the cancer began is not known. The lymph nodes with cancer are 6 centimeters or smaller, on one side of the neck; or
- cancer is found in the oropharynx (throat) and the tumor is 4 centimeters or smaller. Cancer may have spread to one or more lymph nodes that are 6 centimeters or smaller, on the same side of the neck as the primary tumor.
Tumor sizes are often measured in centimeters (cm) or inches. Common food items that can be used to show tumor size in cm include: a pea (1 cm), a peanut (2 cm), a grape (3 cm), a walnut (4 cm), a lime (5 cm or 2 inches), an egg (6 cm), a peach (7 cm), and a grapefruit (10 cm or 4 inches).
Stage II
In stage II, one of the following is true:
- one or more lymph nodes with cancer that is HPV p16-positive are found but the place where the cancer began is not known. The lymph nodes with cancer are 6 centimeters or smaller, on one or both sides of the neck; or
- the tumor is 4 centimeters or smaller. Cancer has spread to lymph nodes that are 6 centimeters or smaller, on the opposite side of the neck as the primary tumor or on both sides of the neck; or
- the tumor is larger than 4 centimeters or cancer has spread to the top of the epiglottis (the flap that covers the trachea during swallowing). Cancer may have spread to one or more lymph nodes that are 6 centimeters or smaller, anywhere in the neck.
Stage III
In stage III, one of the following is true:
- cancer has spread to the larynx (voice box), front part of the roof of the mouth, lower jaw, muscles that move the tongue, or to other parts of the head or neck. Cancer may have spread to lymph nodes in the neck; or
- the tumor is any size and cancer may have spread to the larynx, front part of the roof of the mouth, lower jaw, muscles that move the tongue, or to other parts of the head or neck. Cancer has spread to one or more lymph nodes that are larger than 6 centimeters, anywhere in the neck.
Stage IV
In stage IV, cancer has spread to other parts of the body, such as the lung or bone.
The following stages are used for HPV-negative oropharyngeal cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the lining of the oropharynx (throat). These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
In stage I, cancer has formed. The tumor is 2 centimeters or smaller.
Tumor sizes are often measured in centimeters (cm) or inches. Common food items that can be used to show tumor size in cm include: a pea (1 cm), a peanut (2 cm), a grape (3 cm), a walnut (4 cm), a lime (5 cm or 2 inches), an egg (6 cm), a peach (7 cm), and a grapefruit (10 cm or 4 inches).
Stage II
In stage II, the tumor is larger than 2 centimeters but not larger than 4 centimeters.
Stage III
In stage III, the cancer:
- is either larger than 4 centimeters or has spread to the top of the epiglottis (the flap that covers the trachea during swallowing); or
- is any size. Cancer has spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the primary tumor.
Stage IV
Stage IV is divided into stages IVA, IVB, and IVC.
- In stage IVA, cancer:
- has spread to the larynx (voice box), front part of the roof of the mouth, lower jaw, or muscles that move the tongue. Cancer may have spread to one lymph node that is 3 centimeters or smaller, on the same side of the neck as the primary tumor; or
- is any size and may have spread to the top of the epiglottis, larynx, front part of the roof of the mouth, lower jaw, or muscles that move the tongue. Cancer has spread to one of the following:
- one lymph node that is larger than 3 centimeters but not larger than 6 centimeters, on the same side of the neck as the primary tumor; or
- more than one lymph node that is 6 centimeters or smaller, anywhere in the neck.
- In stage IVB, cancer:
- has spread to the muscle that moves the lower jaw, the bone attached to the muscle that moves the lower jaw, the base of the skull, or to the area behind the nose or around the carotid artery. Cancer may have spread to lymph nodes in the neck; or
- may be any size and may have spread to other parts of the head or neck. Cancer has spread to a lymph node that is larger than 6 centimeters or has spread through the outside covering of a lymph node into nearby connective tissue.
- In stage IVC, cancer has spread to other parts of the body, such as the lung, liver, or bone.
Oropharyngeal cancer can recur (come back) after it has been treated.
The cancer may come back in the oropharynx or in other parts of the body.
Treatment Option Overview
There are different types of treatment for patients with oropharyngeal cancer.
Different types of treatment are available for patients with oropharyngeal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Patients with oropharyngeal cancer should have their treatment planned by a team of doctors with expertise in treating head and neck cancer.
The patient's treatment will be overseen by a medical oncologist, a doctor who specializes in treating people with cancer. Because the oropharynx helps in breathing, eating, and talking, patients may need special help adjusting to the side effects of the cancer and its treatment. The medical oncologist may refer the patient to other health professionals with special training in the treatment of patients with head and neck cancer. These may include the following specialists:
- Head and neck surgeon.
- Radiation oncologist.
- Plastic surgeon.
- Dentist.
- Dietitian.
- Psychologist.
- Rehabilitation specialist.
- Speech therapist.
The following types of treatment are used:
Surgery
Surgery (removing the cancer in an operation) is a common treatment of all stages of oropharyngeal cancer. A surgeon may remove the cancer and some of the healthy tissue around the cancer. After the surgeon removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.
New types of surgery, including transoral robotic surgery, are being studied for the treatment of oropharyngeal cancer. Transoral robotic surgery may be used to remove cancer from hard-to-reach areas of the mouth and throat. Cameras attached to a robot give a 3-dimensional (3D) image that a surgeon can see. Using a computer, the surgeon guides very small tools at the ends of the robot arms to remove the cancer. This procedure may also be done using an endoscope.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.
External-beam radiation therapy of the head and neck. A machine is used to aim high-energy radiation at the cancer. The machine can rotate around the patient, delivering radiation from many different angles to provide highly conformal treatment. A mesh mask helps keep the patient's head and neck from moving during treatment. Small ink marks are put on the mask. The ink marks are used to line up the radiation machine in the same position before each treatment.
Certain ways of giving radiation therapy can help keep radiation from damaging nearby healthy tissue. These types of radiation therapy include the following:
- Intensity-modulated radiation therapy (IMRT): IMRT is a type of 3-dimensional (3-D) radiation therapy that uses a computer to make pictures of the size and shape of the tumor. Thin beams of radiation of different intensities (strengths) are aimed at the tumor from many angles.
- Stereotactic body radiation therapy: Stereotactic body radiation therapy is a type of external radiation therapy. Special equipment is used to place the patient in the same position for each radiation treatment. Once a day for several days, a radiation machine aims a larger than usual dose of radiation directly at the tumor. By having the patient in the same position for each treatment, there is less damage to nearby healthy tissue. This procedure is also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy.
In advanced oropharyngeal cancer, dividing the daily dose of radiation into smaller-dose treatments improves the way the tumor responds to treatment. This is called hyperfractionated radiation therapy.
Radiation therapy may work better in patients who have stopped smoking before beginning treatment.
If the thyroid or pituitary gland are part of the radiation treatment area, the patient has an increased risk of hypothyroidism (too little thyroid hormone). A blood test to check the thyroid hormone level in the body should be done before and after treatment.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
See Drugs Approved for Head and Neck Cancer for more information. (Oropharyngeal cancer is a type of head and neck cancer.)
Targeted therapy
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Monoclonal antibodies are a type of targeted therapy being used in the treatment of oropharyngeal cancer.
Monoclonal antibodies are immune system proteins made in the laboratory to treat many diseases, including cancer. As a cancer treatment, these antibodies can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies are able to then kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells.
Cetuximab is a type of monoclonal antibody that works by binding to a protein on the surface of the cancer cells and stops the cells from growing and dividing. It is used in the treatment of recurrent and metastatic oropharyngeal cancer.
See Drugs Approved for Head and Neck Cancer for more information. Oropharyngeal cancer is a type of head and neck cancer.
New types of treatment are being tested in clinical trials.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI website.
Immunotherapy
Immunotherapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer.
PD-1 is a protein on the surface of T cells that helps keep the body's immune responses in check. PD-L1 is a protein found on some types of cancer cells. When PD-1 attaches to PD-L1, it stops the T cell from killing the cancer cell. PD-1 and PD-L1 inhibitors keep PD-1 and PD-L1 proteins from attaching to each other. This allows the T cells to kill cancer cells.
Pembrolizumab and nivolumab are types of PD-1 inhibitors being studied in the treatment of oropharyngeal cancer.
Immune checkpoint inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help keep immune responses in check. The binding of PD-L1 to PD-1 keeps T cells from killing tumor cells in the body (left panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor cells (right panel).
Treatment for oropharyngeal cancer may cause side effects.
For information about side effects caused by treatment for cancer, see our Side Effects page.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI's clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Following treatment, it is important to have careful head and neck exams to look for signs that the cancer has come back. Check-ups will be done every 6 to 12 weeks in the first year, every 3 months in the second year, every 3 to 4 months in the third year, and every 6 months thereafter.