Treatment options for oral cavity and oropharyngeal cancer by stage
The type of treatment your doctor will recommend depends on the tumor site and how far the cancer has spread. This section lists the options usually considered for each stage of oral cavity or oropharyngeal cancer. These are general comments about treatment, because the approach to each site may be different. Your doctor may have reasons for suggesting a treatment option not mentioned here.
Stage 0 (carcinoma in situ)
Although cancer in this stage has not become invasive (started to grow into deeper layers of tissue), it can do so if not treated. The usual treatment is to remove the top layers of tissue along with a small margin of normal tissue. This is known as surgical stripping or thin resection. Close follow-up to see if any cancer has come back (recurrence) is important. Carcinoma in situ that keeps coming back after resection may require radiation therapy.
Nearly all patients at this stage survive a long time without the need for more intensive treatment. But it is 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 can be successfully treated with either surgery or radiation therapy. Chemotherapy (chemo) may be given with radiation, especially to treat any cancer left after surgery. Both surgery and radiation work well in treating these cancers. The choice of treatment is influenced by the expected side effects, including how the treatment might affect your appearance and ability to speak and swallow.
Lip: Small cancers are often removed with surgery, with Mohs surgery as an option. Radiation alone may also be used as the first treatment. Surgery may be needed later if radiation doesn’t completely get rid of the tumor.
Large or deep cancers often require surgery. If needed, special reconstructive surgery can help correct the defect in the lip.
If the tumor is thick, this increases the risk that the cancer may have spread to lymph nodes in the neck, so the surgeon may remove them (lymph node dissection) to 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 (lymph node dissection) to check for cancer spread. If the cancer does not appear to have been completely removed by surgery or if has a high risk of coming back based on how the cancer cells look under the microscope, radiation (often combined with chemo) may be added.
Radiation can be used instead of surgery as the main treatment in some patients. This is most often used in patients who can’t have surgery because of 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) in some cases. This would mean removing lymph nodes in the neck as well (lymph node dissection). If any cancer remains after surgery, radiation (often with chemo) is often used.
Stages III and IVA
Oral cavity cancers (cancers of floor of the mouth, front of the tongue, inside of the cheek, gums, and hard palate): Stages III and IVA include larger cancers, those that have grown into nearby tissues, and those that have spread to nearby lymph nodes in the neck. These cancers are often treated with a combination of surgery and radiation. Surgery is often done first and includes removal of neck lymph nodes (lymph node dissection).
Oropharyngeal cancers (cancers of the back of the tongue, soft palate, and tonsils): Stages III and IVA include larger cancers, those that have grown into nearby tissues, and those that have spread to nearby lymph nodes in the neck. These cancers are often treated with a combination of radiation and chemo (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, and the patient’s current health status.
Some doctors give chemo as the first treatment, followed by chemoradiation (chemo and radiation given together), and then surgery if needed. Not all doctors agree with this approach, though.
Cancers that have already spread to other parts of the body 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 problems from occurring.
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 resection of advanced oral cavity and oropharyngeal cancers.
Recurrent oral cavity or oropharyngeal cancer
When cancer come backs after treatment, it is called recurrent cancer. Recurrence can be local (in or near the same place it started), regional (in nearby lymph nodes), or distant (spread to bone or organs such as the lungs). Treatment options for recurrent cancers depend on the location and size of the cancer, what treatments have already been used, and on 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 selected cases. However, 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 considered.
If the cancer comes back in the lymph nodes in the neck, these 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 form of treatment. This may shrink or slow the growth of some cancers for a while and help relieve symptoms, but these cancers are very difficult to cure. 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 is 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.