Treatment Options for 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 (HPV) status of the tumor , the stages may be higher or lower than previous staging systems. Treatment strategies are slowly changing with this new staging system so you should discuss your stage and treatment options with your physician. 

Treatment for oropharyngeal cancer is based largely on the stage (extent) of the cancer and if it is caused by an HPV infection (p16-positive), but other factors can also be important.

Most experts agree that treatment in a clinical trial should be considered for any cancer in the head and neck areas. This way, people might have a chance to get new treatments that may be better than standard ones.

Stage 0 (carcinoma in situ) oropharyngeal cancer

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 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.

Nearly all people with this stage live a long time without the need for more treatment. Still, it's important to note that continuing to smoke increases the risk that a new cancer will develop. If you're thinking about quitting smoking and need help, talk to your doctor, or call the American Cancer Society at 1-800-227-2345 for information and support.

Early-stage oropharyngeal cancer

Early-stage oropharyngeal cancers (back of the tongue, soft palate, and tonsils) typically include most stage I and II (p16/HPV-positive and p16/HPV-negative) cancers. The main treatment options include radiation therapy aimed at the cancer and the 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, then chemoradiation might be the first treatment.

Locally advanced oropharyngeal cancer

Locally advanced oropharyngeal cancers 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 would include 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 (p16/HPV-positive or p16/HPV-negative) are treated with chemoradiation. Surgery might also be an option if the surgeon thinks that the cancer can be removed safely. The choice of treatment is often guided by where the cancer is, how much it has spread, the expected side effects, patient preferences, and the patient’s current health status.

Any cancer that is still present after chemoradiation is often 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. Sometimes, chemo might be given as the first treatment, followed by radiation alone or chemoradiation, and then surgery if needed.

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, 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 to 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 the cancer first started (local), in nearby lymph nodes (regional), or it can spread to other organs such as the lungs or bone (distant). 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. Because these cancers can be hard to treat, clinical trials of newer treatments may be a good option for some people.

Treatment options for recurrent oropharyngeal cancer are the same as for recurrent oral cavity cancer.