Oropharyngeal cancer, which affects the back of the throat, is strongly connected to the human papillomavirus (HPV). This subtype of throat cancer has a different biological profile than cancers caused by tobacco and alcohol use. This distinction is significant because HPV-positive tumors respond more favorably to treatment and have higher survival rates.
Diagnosis and Staging Process
A thorough diagnostic and staging process confirms the cancer’s presence and extent. It begins with a physical examination of the throat and neck for abnormalities. An endoscope, a thin tube with a camera, is used to get a clear view of the oropharynx, including the base of the tongue and tonsils.
If a suspicious area is found, a biopsy is performed to collect a tissue sample for a pathologist to examine. The tissue is also tested for HPV using an immunohistochemistry (IHC) stain for a protein called p16. A positive p16 test is the standard for classifying the cancer as HPV-positive, serving as a marker for an active HPV infection in the tumor cells.
Once cancer is confirmed, imaging tests like CT, MRI, and PET scans determine the tumor’s size and if it has spread. This information is used to stage the cancer using the TNM system, which considers tumor size (T), lymph node involvement (N), and metastasis (M). HPV-positive throat cancers use a specific staging system that reflects their better prognosis. Because of this, the stage can be more favorable than an HPV-negative cancer with similar characteristics.
Standard Treatment Approaches
The goal of treatment is to achieve a cure while preserving throat functions like speaking, swallowing, and breathing. The main options are radiation therapy, chemotherapy, and surgery, often used in combination. The choice of treatment depends on the cancer’s stage and location.
Radiation therapy uses high-energy rays to destroy cancer cells. A technique called Intensity-Modulated Radiation Therapy (IMRT) is used to shape radiation beams precisely to the tumor, sparing healthy tissues like salivary glands. Treatment is administered daily, five days a week, for six to seven weeks. Side effects can include skin redness, sore throat, changes in taste, and fatigue.
Chemotherapy is given with radiation in a strategy called concurrent chemoradiation. The drugs make cancer cells more sensitive to radiation, increasing effectiveness. The most common agent is cisplatin, administered intravenously every three weeks during radiation. This combination adds systemic side effects like nausea, fatigue, and increased infection risk.
Surgical approaches are now more advanced and less invasive. For early-stage tumors, surgeons can use methods like Transoral Robotic Surgery (TORS) or Transoral Laser Microsurgery (TLM). These techniques allow tumor removal through the mouth, avoiding large external incisions. Surgery may be the primary treatment for smaller tumors or be followed by radiation, and a neck dissection to remove lymph nodes is also a procedure to check for spread.
Targeted Therapy and Immunotherapy
Newer drug classes offer more specific ways to fight cancer than standard chemotherapy. Targeted therapy and immunotherapy are alternative approaches for certain patients. They work by interfering with molecules involved in cancer growth or by using the patient’s immune system to fight the disease.
Targeted therapy drugs interact with specific proteins that help cancer cells grow. For this cancer, a target is the epidermal growth factor receptor (EGFR). The EGFR inhibitor cetuximab can be an alternative to cisplatin for patients unable to tolerate its side effects, and it is given with radiation. However, clinical trials show that cisplatin with radiation leads to better survival outcomes for patients who can tolerate it.
Immunotherapy stimulates the body’s immune system to attack cancer cells. Checkpoint inhibitors are a category of these drugs effective for cancers that have recurred or spread. Drugs like pembrolizumab and nivolumab block the PD-1 protein on immune cells, which “unmasks” cancer cells so the immune system can destroy them. For recurrent or metastatic head and neck cancer, pembrolizumab is a first-line treatment, used alone or with chemotherapy.
Clinical Trials and Treatment De-escalation
Due to high cure rates with standard treatments, a focus of current research is treatment de-escalation. The goal is to reduce long-term side effects from aggressive therapy, improving quality of life for survivors. Since many patients are younger and may live for decades after treatment, mitigating chronic side effects is a priority.
Researchers are investigating de-escalation strategies in clinical trials. One approach is using lower radiation doses, reducing the standard 70 Gy to 60 Gy or less in select patients based on tumor response. Another strategy is replacing standard cisplatin with a less toxic agent, though this is still being optimized for effectiveness.
Other trials focus on using surgery as the sole initial treatment for some early-stage cancers, reserving radiation for recurrence. Induction chemotherapy, given before radiation, is also studied to shrink tumors and allow for less intense treatment. These de-escalation approaches are still under investigation, so interested patients should discuss clinical trial enrollment with their care team.
Recovery and Long-Term Survivorship
The period after active treatment focuses on recovery, monitoring for recurrence, and managing persistent side effects. Life after treatment involves a routine of follow-up care and rehabilitation to help survivors regain function and maintain quality of life.
A regular schedule of follow-up appointments monitors the patient’s health. These visits include physical exams of the head and neck and may involve periodic CT or PET scans to check for recurrence. Surveillance is most frequent in the first few years after treatment and becomes less frequent over time.
Many survivors experience long-term side effects from radiation’s effects on head and neck tissues. A common issue is xerostomia (permanent dry mouth) from damaged salivary glands. Another challenge is dysphagia (difficulty swallowing), which can result from tissue stiffening and may worsen years after treatment. Other potential long-term effects include neck stiffness, dental problems, and changes in taste.
Rehabilitation is a large part of recovery. Speech and swallowing therapists help patients manage dysphagia with exercises to maintain muscle strength and flexibility, and they may recommend dietary changes. Maintaining a healthy lifestyle, including stopping smoking and limiting alcohol, is emphasized to support overall health.