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Soft Palate Cancer

Deciding on a Treatment Plan

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®)Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers to decide on the appropriate treatment course.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org. If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam if needed)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy of primary site or FNA of the neck to confirm a diagnosis of cancer
  • Testing for HPV
  • Imaging of the lungs to check for spread, if needed
  • Imaging of the primary tumor and the neck with CT and/or MRI
  • Maybe a PET-CT for advanced cancers
  • A dental evaluation with or without jaw x-rays as needed
  • Nutrition, speech, and swallowing evaluation and maybe even a hearing evaluation
  • Examination under anesthesia with endoscopy as needed
  • Pretreatment medical clearance and optimization of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on a number of factors. As with all cancers in the head and neck, there are three general options to consider:

For oropharyngeal cancer, there is not one clear treatment method. You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally. The options that your doctor will recommend will likely be as follows based on the NCCN Guidelines® for Head and Neck Cancers, depending on the stage of cancer you have.12Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

T1-2, N0-1 For small primary tumors, with at most one lymph node on the same side as the primary tumor (T1-2, N0-1), the options for treatment are as follows:

  • Radiation therapy
  • Surgery to remove the primary tumor (see Pharyngectomy) with or without removal of lymph nodes from the neck one or both sides of the neck (see Neck Dissection)
  • Radiation along with chemotherapy (for T2,N1 only)
  • A clinical trial

If treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).

If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer has to be analyzed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features, which include:

  • Spread of cancer outside of a lymph node
  • Cancer at the margins of the surgical removal
  • A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
  • Positive nodes in level IV or V
  • Perineural invasion—tumor invasion of surrounding nerves
  • Tumor inside veins

For example:

  • If there are no adverse features, then no further treatment is needed.
  • If there is one positive node without any adverse features, then your doctors might consider radiation therapy for you.
  • If there are adverse features, radiation, chemotherapy with radiation, or additional surgery will probably be recommended. Talk to your doctor for details.

 

T3-4a, N0-1 These are locally advanced cancers, which means that the primary tumor is quite large. In this case, there are a few treatment options that your doctors will consider:

  • Chemotherapy along with radiation
  • Surgery to remove the main tumor and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
  • For select patients induction chemotherapy, followed by radiation
  • For select patients induction chemotherapy, followed by more chemotherapy along with radiation
  • A clinical trial

Again, if treatment without surgery is chosen and there appears to be cancer left after treatment, then  surgery should be performed to remove everything (see Pharyngectomy, and Neck Dissection).

If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer has to be analyzed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features:

  • Spread of cancer outside of a lymph node
  • Cancer at the margins of the surgical removal
  • A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
  • Positive nodes in level IV or V
  • Perineural invasion
  • Tumor inside veins

Then,

  • If there are no adverse features (see above), then radiation will be added.
  • If the adverse features include spread of cancer outside of the capsule of the lymph node and/or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended.
  • If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended.
Any T, N2-3  This is a cancer involving either many lymph nodes in the neck, large lymph nodes in the neck, and/or lymph nodes on both sides of the neck and/or lymph nodes on the side of the neck opposite to the main tumor mass.There are a few options for the initial treatment:

  • Chemotherapy along with radiation
  • Chemotherapy, followed by radiation
  • Chemotherapy, followed by more chemotherapy along with radiation
  • Surgery to remove the main tumor and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
  • A clinical trial

If a non-surgical treatment is chosen as the first line, you need to look at whether the cancer is gone:

  • If there is any cancer left at the primary site, then your doctor might recommend surgery along with a neck dissection.
  • If the cancer is gone from the primary site, then you need to look at the neck. If at any point there is evidence of cancer in the neck, your doctor will likely recommend a neck dissection.

If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer has to be analyzed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features such as:

  • Spread of cancer outside of a lymph node
  • Cancer at the margins of the surgical removal
  • A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
  • Positive nodes in level IV or V
  • Perineural invasion (invasion of the tumor into surrounding nerves)
  • Tumor inside veins

Then,

  • If there are no adverse features (see above) after the first-line treatment is completed, then no additional treatment is necessary.
  • If the adverse features include spread of cancer outside the capsule of the lymph node, or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended.
  • If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended.
T4b, any N

Unresectable neck disease

Unfit for surgery 

In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.
References

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12 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 7, 2016. To view the most recent and complete version of the guideline, go online to www.nccn.org.

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