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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 the primary site or FNA of the neck to confirm a diagnosis of cancer
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
Testing for HPV
EUA with endoscopy as needed
A dental evaluation with or without jaw x-rays
Nutrition, speech and swallowing evaluation and maybe even a hearing evaluation
Pretreatment medical clearance and evaluation 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:

Surgical removal (with or without reconstruction)
Radiation (a few different types)
Medications (chemotherapy and biologic medications)

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 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 For select patients, induction chemotherapy, followed by radiation For select patients, induction 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, your doctor will determine 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 the lymph nodes in the neck will have to be evaluated. 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 Tumor inside veins Then, If there are no adverse features (see above), 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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² Blot WJ, McLaughlin JK, Winn DM, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer research. Jun 1 1988;48(11):3282-3287.

³ D'Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. The New England journal of medicine. May 10 2007;356(19):1944-1956.

⁴ Moreno-Lopez LA, Esparza-Gomez GC, Gonzalez-Navarro A, Cerero-Lapiedra R, Gonzalez-Hernandez MJ, Dominguez-Rojas V. Risk of oral cancer associated with tobacco smoking, alcohol consumption and oral hygiene: a case-control study in Madrid, Spain. Oral oncology. Mar 2000;36(2):170-174.

⁵ Koivunen P, Rantala N, Hyrynkangas K, Jokinen K, Alho OP. The impact of patient and professional diagnostic delays on survival in pharyngeal cancer. Cancer. Dec 1 2001;92(11):2885-2891.

⁶ Roistacher SL, Tanenbaum D. Myofascial pain associated with oropharyngeal cancer. Oral surgery, oral medicine, and oral pathology. May 1986;61(5):459-462.

⁷ Rogers SN, Vedpathak SV, Lowe D. Reasons for delayed presentation in oral and oropharyngeal cancer: the patients perspective. The British journal of oral & maxillofacial surgery. Jul 2011;49(5):349-353.

⁸ Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

⁹ Krause CJ, Carey TE, Ott RW, Hurbis C, McClatchey KD, Regezi JA. Human squamous cell carcinoma. Establishment and characterization of new permanent cell lines. Arch Otolaryngol. Nov 1981;107(11):703-710.

¹⁰ Licitra L, Perrone F, Bossi P, et al. High-risk human papillomavirus affects prognosis in patients with surgically treated oropharyngeal squamous cell carcinoma. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. Dec 20 2006;24(36):5630-5636.

¹¹ Eveson JW, Cawson RA. Tumours of the minor (oropharyngeal) salivary glands: a demographic study of 336 cases. Journal of oral pathology. Jul 1985;14(6):500-509.

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.

¹³ Jan JC, Hsu WH, Liu SA, Wong YK, Poon CK, Jiang RS, Jan JS, Chen IF. Prognostic factors in patients with buccal squamous cell carcinoma: 10-year experience. J Oral Maxillofac Surg. 2011 Feb;69(2):396-404.

¹⁴ Sinha P, Lewis JS Jr, Piccirillo JF, Kallogjeri D, Haughey BH. Extracapsular spread and adjuvant therapy in human papillomavirus-related, p16-positive oropharyngeal carcinoma. Cancer. 2012 Jul 15;118(14):3519-30.

¹⁵ Pradhan SA, Rajpal RM. Marginal mandibulectomy in the mangement of squamous cancer of the oral cavity. Indian J Cancer. 1987;24; 167-171.

¹⁶ Maddox WA, Urist MM. Histopathological prognostic factors of certain primary oral cavity cancers. 1990 Dec;4(12):39-42; discussion 42, 45-6.

¹⁷ Piccirillo JF, Costas I, Reichman ME. Chapter 2: Cancers of the Head and Neck. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

¹⁸ Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010.

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