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Cancer Medicine :: Oral and Oropharyngeal Cancer

Oral and Oropharyngeal Cancer

General treatment information

After the cancer is found and staged, your doctor will discuss treatment choices with you. Based on the stage and location of the tumor, you may have different types of doctors on your treatment team. These doctors may include:

                  

An otolaryngologist (also know as an ear, nose, and throat, or ENT doctor): a surgeon who treats certain diseases of the head and neck.

An oral and maxillofacial surgeon: a dental surgeon who treats diseases of the mouth, teeth, and jaws.

A radiation oncologist: a doctor who treats cancer with radiation therapy.

A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy or targeted therapy.

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, nutrition specialists, social workers, and other health professionals.

It is important to discuss all of your treatment options, including goals and possible side effects, with your doctors to help make the decision that best fits your needs. It’s also very important to ask questions if there is anything you’re not sure about.  If time permits, it is often a good idea to get a second opinion. A second opinion can provide you with more information and help you feel confident about your chosen treatment plan.

The main treatment options for people with oral and oropharyngeal cancers are:Surgery,Radiation therapy,Chemotherapy,Targeted therapy,Palliative treatment.

These may be used either alone or in combination, depending on the stage and location of the tumor. In general, surgery is the first treatment for cancers of the oral cavity, and may be followed by radiation or combined chemotherapy and radiation. Oropharyngeal cancers are usually treated with a combination of chemotherapy and radiation.

It is important to take time and think about all of your choices. When you choose a treatment plan, consider your overall health, the type and stage of the cancer, the chances of curing the disease, and the possible impact of the treatment on important functions like speech, chewing, and swallowing.

Surgery for oral cavity and oropharyngeal cancer

Several types of operations can be used to treat oral cavity and oropharyngeal cancers. Depending on where the cancer is and its stage, different operations may be used to remove the cancer.

After surgery to remove the cancer, reconstructive surgery may be used to help restore the appearance and function of the areas affected by the cancer or its treatment.

Tumor resection:In this operation, the surgeon removes (resects) the entire tumor and an area of normal-appearing tissue around it. Removing the normal tissue lessens the chance of leaving any cancer behind.

The primary tumor can be removed using a variety of approaches depending on its size and location. For example, if a tumor is in the front of the mouth, it can be removed relatively easily. Sometimes with a larger tumor, especially when it involves the oropharynx, the cancer is removed through an incision in the neck or by cutting the jaw bone with a special saw to provide access to the tumor (mandibulotomy).

Based on the location and size of the tumor, one of the operations listed here may be needed to remove it.

Mohs micrographic surgery (for some cancers of the lip)

Some cancers of the lip may be removed by Mohs surgery, also known as micrographic surgery. In this method, the tumor is removed in very thin slices. Each slice is looked at right away under the microscope to see if there are cancer cells. The surgeon continues to remove more slices until no cancer cells are seen.

This method can reduce the amount of normal tissue removed with the tumor, which limits the change in appearance the surgery causes. It requires a surgeon trained in the technique and may take more time than a standard tumor resection.

Glossectomy (removal of the tongue):Glossectomy may be needed to treat cancer of the tongue. For smaller cancers, only part of the tongue may need to be removed (partial glossectomy). For larger cancers, the entire tongue may need to be removed (total glossectomy).

Mandibulectomy (removal of the jaw bone)

A mandibulectomy (or mandibular resection) removes all or part of the jaw bone (mandible). This operation may be needed if the tumor has grown into the jaw bone. If a tumor near the jaw is hard to move when the doctor examines the area, it often means that the cancer has grown into the jaw bone.

If the jaw bone looks normal on x-ray, and there is no evidence the cancer has spread into the jaw bone, a partial-thickness mandibular resection may be all that is needed. In this operation, also known as a marginal mandibulectomy, a piece of jaw bone is removed, but the bone is not cut all the way through.

If the x-ray shows the tumor has grown into the jaw bone, a whole portion of the mandible will need to be removed in an operation called a segmental mandibulectomy. The removed piece of the jaw can then be replaced with a piece of bone from another part of the body, such as the fibula (the smaller of the lower leg bones), hip bone, or the shoulder blade. Depending on the situation, sometimes a metal plate or a piece of bone from a deceased donor may be used instead.

Maxillectomy :If cancer has grown into the hard palate (front part of the roof of the mouth), all or part of the involved bone (maxilla) will need to be removed. This operation is called a maxillectomy or partial maxillectomy.

The hole in the roof of the mouth this operation creates can be filled with a special denture called a prosthesis. This is created by a prosthodontist, a dentist with special training.

Robotic surgery: Increasingly, trans-oral robotic surgery (TORS) is being used to resect cancers of the throat (including the oropharynx). Since the more standard, open surgeries for throat cancer can cause a number of problems, these cancers have often been treated with chemotherapy combined with radiation (called chemoradiation) over the past decade. However, newer robotic surgeries allow surgeons to remove pharynx cancers with fewer side effects. Complete resection with surgery may allow patients to avoid further treatment with radiation and/or chemotherapy. Since these procedures are newer, it is important for them to be done by surgeons (and at treatment centers) with experience in this approach.

Laryngectomy (removal of the voice box): Very rarely, surgery to remove large tumors of the tongue or oropharynx may also require removing tissue that a person needs to swallow normally. As a result, food may enter the windpipe (trachea) and reach the lungs, where it can cause pneumonia. When this is a significant risk, sometimes the voice box (larynx) is removed together with the primary tumor. This operation is called a laryngectomy.

When the voice box is removed, the windpipe is attached to a hole (stoma) made in the skin in the front of the neck for the patient to breathe through (instead of breathing through the mouth or nose). This is known as a tracheostomy (see picture).

Losing your voice box will mean that normal speech is no longer possible, but people can learn other forms of speaking. 

Neck dissection:Cancers of the oral cavity and oropharynx often spread to the lymph nodes in the neck. Depending on the stage and location of the cancer, it may be necessary to remove these lymph nodes (and other nearby tissues). This operation, called a neck dissection or lymph node dissection, is done at the same time as the surgery to remove the main tumor. The goal is to remove lymph nodes proven or likely to contain cancer.

There are several types of neck dissection procedures, and they differ in how much tissue is removed from the neck. The amount of tissue removed depends on the primary cancer’s size and how much it has spread to lymph nodes.

In a partial or selective neck dissection only a few lymph nodes are removed.

For a modified radical neck dissection, most lymph nodes on one side of the neck between the jaw bone and collarbone, as well as some muscle and nerve tissue are removed.

In a radical neck dissection, nearly all nodes on one side, as well as even more muscles, nerves, and veins are removed.

The most common side effects of any neck dissection are numbness of the ear, weakness when raising the arm above the head, and weakness of the lower lip. These side effects are caused by injury during the operation to certain nerves that supply these areas. After a selective neck dissection, the nerve might only be injured. If so, the weakness of the shoulder and lower lip usually goes away after a few months. But if a nerve is removed as part of a radical neck dissection or because of involvement with tumor, the weakness will be permanent.

After any neck dissection procedure, physical therapists can teach the patient exercises to improve neck and shoulder movement.

Reconstructive surgery: Operations may be needed to help restore the structure or function of areas affected by more extensive surgeries to remove the cancer.

For small tumors, the narrow zone of normal tissue removed along with the tumor is usually small enough that reconstructive surgery is not needed. But removing larger tumors may cause defects in the mouth, throat, or neck that will need to be repaired. Sometimes a thin slice of skin, taken from the thigh or other area, can be used to repair a small defect. This is called a skin graft.

To repair a larger defect, more tissue may be needed. A piece of muscle with or without skin may be rotated from an area close by, such as the chest (pectoralis major pedicle flap) or upper part of the back (trapezius pedicle flap).

Thanks to advances in microvascular surgery (sewing together small blood vessels under a microscope), surgeons have many more options for reconstructing the oral cavity and oropharynx. Tissue from other areas of the body, such as the intestine, arm muscle, abdominal muscle, or lower leg bone, may be used to replace parts of the mouth, throat, or jaw bone.

Before you have extensive head and neck surgery, it is a good idea to ask the surgeon about your options for reconstructive surgery.

Tracheotomy/tracheostomy:A tracheotomy is an incision (hole) made through the skin in the front of the neck and into the trachea (windpipe). It is done to help a person breathe. It may be used in different circumstances.

If a lot of swelling is expected in the airway after the cancer is removed, the doctor may want to do a temporary tracheotomy (using a small plastic tube) to allow the person to breathe more easily until the swelling goes down. It stays in place for a short time, and is then removed later when it is no longer needed.

If the cancer is blocking the throat and is too large to remove completely, an opening may be made to connect a lower part of the windpipe to a stoma (hole) in the front of the neck to bypass the tumor and allow the person to breathe more comfortably. This is known as a tracheostomy. A permanent tracheostomy is also needed after a total laryngectomy.

Gastrostomy tube:Cancers in the oral cavity and oropharynx may prevent you from swallowing enough food to maintain good nutrition. This can make you weak and make it harder to complete treatment. Sometimes the treatment itself can make it hard to eat enough.

A gastrostomy tube (G tube) is a feeding tube that is placed through the skin and muscle of your abdomen directly into your stomach. Sometimes this tube is placed during an operation, but often it is placed endoscopically. While the patient is sedated, the doctor passes a long thin tube with a camera on the end down the throat to see directly into the stomach. When the feeding tube is placed through endoscopy, it is called a percutaneous endoscopic gastrostomy, or PEG tube. Once in place, it can be used to deliver nutrition directly into the stomach.

Patients are fed special liquid nutrients that are dripped through the tube. As long as they can still swallow normally, patients with these tubes can also eat normal food as well.

PEGs can be used to feed a patient for as long as needed. Sometimes these tubes are used for a short time to help keep a patient healthy and fed during treatment. They can be easily removed when the patient can eat normally.

If the swallowing problem is likely to be only short-term, another option is to place a nasogastric feeding tube (an NG tube). This tube goes in through the nose, down the esophagus, and into the stomach. Again, special liquid nutrients are dripped through the tube. Some patients dislike having a tube coming out of their nose, and prefer a PEG.

In either case, the patient and family are taught how to use the tube. After the patient goes home, home health nurses usually visit to make sure the patient is comfortable with tube feedings.

Dental extraction and implants:When radiation treatment is planned, a dental evaluation must be done. Depending on the radiation plan and condition of the patient’s teeth, some or even all of the teeth may need to be removed before radiation can be given. The teeth may be removed either by the head and neck surgeon or an oral surgeon. If left in, teeth that are broken or infected (abscessed) are very likely to cause problems (such as infections and areas of necrosis (bone death) in the jaw) if exposed to radiation.

If part of the jaw bone (mandible) is removed and reconstructed with bone from another part of the body, the surgeon might place dental implants (hardware to which prosthetic teeth can be attached) in the bone. This can be done either at the same time the mandible is reconstructed or at a later date.

Surgery risks and side effects

All surgery carries risk, including blood clots, infections, complications from anesthesia, and pneumonia. These risks are generally low but are higher with more complicated operations.

If the surgery is not too complex, the main side effect may be some pain afterward, which can be treated with medicines if needed.

Surgery for cancers that are large or hard to reach may be very complicated, in which case side effects may include infection, wound breakdown, problems with eating and speaking, or on very rare occasions death during or shortly after the procedure. Surgery also can be disfiguring, especially if bones in the face or jaw need to be removed. The surgeon’s skill is very important in minimizing these side effects, while removing all of the cancer.

Impact of glossectomy: Most people can still speak if only part of the tongue is removed, but they often notice that their speech isn’t as clear as it once was. The tongue is important in swallowing, so this may also be affected. Speech therapy can often help with these problems.

When the entire tongue is removed, patients lose the ability to speak and swallow. With reconstructive surgery and a good rehabilitation program including speech therapy, some patients may regain the ability to swallow and speak well enough to be understood.

Impact of laryngectomy: Laryngectomy, the surgery that removes the voice box, leaves a person without the normal means of speech. There are several ways to restore one’s voice. 

After a laryngectomy, the person breathes through a stoma (tracheostomy) placed in the front of the lower neck. Having a stoma means that the air you breathe in and out will no longer pass through your nose or mouth, which would normally help moisten, warm, and filter the air (removing dust and other particles). The air reaching the lungs will be dryer and cooler. This may irritate the lining of the breathing tubes and cause thick or crusty mucus to build up.

It is important to learn how to take care of your stoma. You will need to use a humidifier over the stoma as much as possible, especially soon after the operation, until the airway lining has a chance to adjust to the drier air now reaching it. You will also need to learn how to suction out and clean your stoma to help keep your airway open. Your doctors, nurses, and other health care professionals can teach you how to care for and protect your stoma, which includes precautions to keep water from entering the windpipe while showering or bathing, as well as keeping small particles out of the windpipe.

Impact of facial bone removal: Some cancers of the head and neck are treated by operations that remove part of the facial bone structure. Because the changes that result are so visible, they can have a major effect on how people view themselves. These surgeries can also affect speech and swallowing.

It’s important to talk with your doctor before the surgery about what these changes might be to help prepare you for them. He or she can also give you an idea about what options might be available afterward. Recent advances in facial prostheses (man-made replacements) and in reconstructive surgery now give many people a more normal look and clearer speech. Ears and noses can be made out of plastic, tinted to match the skin, and attached to the face. All of these things can be a great help to a person’s self-esteem.

Radiation therapy for oral cavity and oropharyngeal cancer

Radiation therapy uses high-energy x-rays or particles to destroy cancer cells or slow their rate of growth. Radiation therapy can be used in several situations for oral and oropharyngeal cancers:

It can be used as the main treatment for small cancers.

Patients with larger cancers may need both surgery and radiation therapy or a combination of radiation therapy and chemotherapy or a “targeted” agent .

After surgery, radiation therapy can be used, either alone or with chemotherapy, as an additional (adjuvant) treatment to try to kill any small deposits of cancer that may not have been removed during surgery. This is known as adjuvant radiation therapy.

Radiation may be used (along with chemotherapy) to try to shrink some larger cancers before surgery. This is called neoadjuvant therapy. In some cases this makes it possible to use less radical surgery and remove less tissue.

Radiation therapy can also be used to relieve symptoms of more advanced cancer, such as pain, bleeding, trouble swallowing, and problems caused by bone metastases.

External beam radiation therapy:The most common way to give radiation for these cancers is to carefully focus a beam of radiation from a machine outside the body. This is known as external beam radiation therapy. To reduce the risk of side effects, doctors carefully figure out the exact dose needed and aim the beam as accurately as they can to hit the carefully outlined target.

Before your treatments start, the radiation team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. Radiation therapy is much like getting an x-ray, but the radiation is stronger. The procedure itself is painless. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — takes longer. Treatments are usually given 5 days a week for 6 to 7 weeks. Other schedules for radiation doses have been studied in clinical trials.

Hyperfractionation refers to giving the total radiation dose in a larger number of doses, for example giving 2 smaller doses per day instead of 1 larger dose.

Accelerated fractionation means giving 2 or more doses each day so that the radiation treatment is completed faster (3 weeks instead of 6 weeks, for instance).

Hyperfractionation and accelerated fractionation schedules may reduce the risk of cancer coming back in or near the place it started (called local recurrence) and may help some patients live longer. The drawback is that treatments given on these schedules also tend to have more severe side effects.

Some newer techniques help doctors focus the radiation more precisely:Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses the results of imaging tests such as MRI and special computer programs to precisely map the cancer’s location. Radiation beams are then shaped and aimed at the tumor from several directions, which makes it less likely to damage normal tissues. By aiming the radiation more accurately, doctors can reduce radiation damage to important normal tissues in the area (such as nerves, blood vessels, and other organs) and lower side effects. In theory, this type of radiation therapy may be able to cure more cancers by increasing the radiation dose to the tumor itself. Long-term study results are still needed to confirm this.

Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D therapy. It uses a computer-driven machine that actually moves around the patient as it delivers radiation. In addition to shaping the beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This lowers severe side effects while allowing doctors to deliver an even higher dose to the cancer areas. Many major hospitals and cancer centers now use IMRT as the standard way to deliver external beam radiation.

Brachytherapy:Another way to deliver radiation is by placing radioactive materials directly into or near the cancer. This method is called internal radiation, interstitial radiation, or brachytherapy. The radiation travels only a very short distance, which limits its effects on nearby normal tissues.

Brachytherapy is not used often to treat oral cavity or oropharyngeal cancers because newer external radiation approaches, such as IMRT, are now very precise. When brachytherapy is used, it is most often combined with external radiation to treat early lip or mouth cancers.

Different types of brachytherapy may be used. In one form, hollow catheters (thin tubes) are placed into or around the tumor during surgery and are left in place for several days while the patient stays in the hospital. Radioactive materials are then inserted into the tubes for a short time each day.

In another form, small radioactive pellets (about the size and shape of a grain of rice) are placed directly into the tumor. The pellets give off low levels of radioactivity for several weeks and eventually lose their strength. The pellets themselves are left in place permanently and rarely cause any problems.

Possible side effects of radiation therapy:Radiation of the mouth and throat area can cause several short-term side effects, including: Skin changes like a sunburn or suntan on the head and neck that slowly fades away,Hoarseness,Loss of sense of taste,Redness and soreness of the mouth and throat.

Sometimes open sores develop in the mouth and throat, making it hard to eat and drink during treatment. Liquid feeding through a tube placed into the stomach may be needed. This is known as a gastrostomy or G tube.

Radiotherapy may also cause long-term or permanent side effects:Damage to the salivary glands: Permanent damage to the salivary (spit) glands can cause a dry mouth. This can lead to problems eating and swallowing.

The lack of saliva can also lead to tooth decay (cavities). People treated with radiation to the mouth or neck need to practice careful oral hygiene to help prevent this problem. Fluoride treatments may also help.

Newer radiotherapy techniques such as IMRT may help reduce this side effect. A drug called amifostine (Ethyol®) can also help reduce this side effect by limiting radiation damage to normal tissues. It is injected under the skin or into a vein a few minutes before each radiation treatment. Amifostine has side effects, such as low blood pressure, nausea, and vomiting, that can make it hard to tolerate.

Damage to the jaw bone: This problem, known as osteoradionecrosis of the jaw, can be a serious side effect of radiation treatment. This is more common after tooth infection, extraction, or trauma, and it can be hard to treat. The main symptom is pain in the jaw. In some cases, the bone actually breaks. Sometimes the fractured bone heals by itself, but often the damaged bone will have to be treated surgically.

To help prevent this problem, people getting radiation to the mouth or throat area typically need to see a dentist for treatment to address any problems with their teeth before radiation is started. In some cases, teeth may need to be removed.

Damage to the pituitary or thyroid gland: If the pituitary or thyroid gland is exposed to radiation, their production of hormones may decrease over time. This can lead to problems with metabolism that may need to be corrected with medicine.

Radiation side effects are likely to be more severe in people who are getting chemotherapy at the same time. These people also have to contend with the side effects of the chemotherapy itself, which can make this treatment hard to tolerate. For this reason, it’s important that people getting both chemotherapy and radiation are in relatively good health before starting treatment, that they understand the potential for serious side effects, and that they are treated at a medical center with a lot of experience with this approach.

Chemotherapy for oral cavity and oropharyngeal cancer:Chemotherapy (chemo) is the use of anti-cancer drugs that are given into a vein or taken by mouth. These drugs enter the bloodstream and can reach cancer that has spread to organs beyond the head and neck. It may be used in several different situations:

Chemo (typically combined with radiation therapy) may be used instead of surgery as the main treatment for some cancers.

Chemo (combined with radiation therapy) may be given after surgery to try to kill any small deposits of cancer cells that may have been left behind. This is known as adjuvant chemotherapy.

Chemo (sometimes with radiation) may be used to try to shrink some larger cancers before surgery. This is called neoadjuvant or induction chemotherapy. In some cases this makes it possible to use less radical surgery and remove less tissue. This can lead to fewer serious side effects from surgery.

Chemo (with or without radiation) can be used to treat cancers that are too large or have spread too far to be removed by surgery. The goal is to slow the growth of the cancer for as long as possible and to help relieve any symptoms the cancer is causing.

The chemo drugs used most often for cancers of the oral cavity and oropharynx are: Cisplatin,5-fluorouracil (5-FU),Carboplatin,Paclitaxel (Taxol®),Docetaxel, (Taxotere®), Methotrexate,Ifosfamide (Ifex®),Bleomycin

A chemo drug may be used alone or combined with other drugs. Combining drugs can often shrink tumors more effectively, but will likely cause more side effects. A commonly used combination is cisplatin and 5-FU. This combination is more effective than either drug alone in shrinking cancers of the oral cavity and oropharynx. Doctors have also seen good results when adding the drug docetaxel to these 2 drugs.

Doctors give chemotherapy in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Each chemotherapy cycle typically lasts for a few weeks.

Chemo is often given at the same time as radiation (known as chemoradiation). Cisplatin alone is usually the preferred chemo drug when given along with radiation. Some doctors prefer to give the radiation and chemo before surgery. However, the side effects can be severe and may be too much for some patients.

In patients whose cancers are too advanced for surgery but not widespread, chemo and radiation given together might produce a better outcome than radiation alone. But this combined approach can be hard to tolerate, especially for people in poor health.

Possible side effects of chemotherapy

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles are also affected. This can lead to some side effects.

The side effects of chemo depend on the type and dose of drugs given and how long they are taken. These side effects can include:Hair loss,Mouth sores,Loss of appetite,Nausea and vomiting,Diarrhea,Low blood counts

Chemo can affect the blood-producing cells of the bone marrow, leading to low blood counts. This can lead to:Increased chance of infections (due to low white blood cell counts),Easy bruising or bleeding (due to low blood platelet counts),Fatigue (due to low red blood cell counts)

Along with the risks above, some side effects are seen more often with certain chemo drugs. For example, 5-FU often causes diarrhea. This is often treated with drugs like loperamide. Cisplatin can cause nerve damage (called neuropathy). This can lead to hearing loss as well as numbness and tingling in the hands and feet. This often improves once treatment is stopped, but it can persist a long time in some cases.

Although most side effects improve once treatment is stopped, some can last a long time or even be permanent. If your doctor plans treatment with chemo be sure to discuss the drugs that will be used and the possible side effects. Once chemo is started, let your health care team know if you have side effects, so they can be treated. There are ways to prevent or treat many of the side effects of chemo. For example, many good drugs are available to help prevent or treat nausea and vomiting.

Targeted therapy for oral cavity and oropharyngeal cancer:As researchers have learned more about the changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. Targeted drugs work differently from standard chemotherapy drugs. They often have different (and less severe) side effects.

Cetuximab (Erbitux®) is a monoclonal antibody (a man-made version of an immune system protein) that targets epidermal growth factor receptor (EGFR), a protein on the surface of certain cells that helps them grow and divide. Oral cavity and oropharyngeal cancer cells often have more than normal amounts of EGFR. By blocking EGFR, cetuximab can slow or stop cell growth.

Cetuximab may be combined with radiation therapy for some earlier stage cancers. For more advanced cancers, it may be combined with standard chemo drugs such as cisplatin, or it may be used by itself.

Cetuximab is given by infusion into a vein (IV), usually once a week. A rare but serious side effect of cetuximab is an allergic reaction during the first infusion, which could cause problems with breathing and low blood pressure. You may be given medicine before treatment to help prevent this. Many people develop skin problems such as an acne-like rash on the face and chest during treatment, which in some cases can lead to infections. Other side effects may include headache, tiredness, fever, and diarrhea.

Palliative treatment for oral cavity and oropharyngeal cancer:Most of this document discusses ways to remove or to destroy cancer cells or to slow their growth. But maintaining a patient’s quality of life is another important goal of treatment. This is true for people being treated to try to cure the cancer and for people whose cancer is too advanced to be cured. If the goal of treatment is a cure, palliative treatments can help ease symptoms from the cancer treatment itself. If the cancer is advanced, palliative treatment may play an even larger role, helping to keep the person comfortable and maintain quality of life for as long as possible.

Pain is a significant concern for many patients with cancer. It can almost always be treated effectively with milder drugs like ibuprofen or acetaminophen or, if needed, with stronger medicines like morphine or similar drugs (known as opioids). Taking these drugs does not mean a person will become addicted. Many studies have shown that people with cancer who take opioids for pain as their doctor directed typically do not become addicted. For more information on pain, what can be done about it, and how to keep track of it. 

Nutrition is another important concern for people with head and neck cancers such as oral cavity or oropharyngeal cancers. Both the cancer and its treatment may make it hard to swallow. If this affects how a person eats or drinks, they may need to have a feeding tube placed. This tube will most likely be needed for a short time during treatment, but in some cases it may need to be left in longer. For more information on what to eat during cancer treatment.

There are many other ways your doctor can help maintain your quality of life and control your symptoms. But this means that you have to tell your doctor how you are feeling and what symptoms you are having. Some people don’t like to disappoint their doctors by telling them they are not feeling well. This does no one any good. Your doctor wants to know how you really feel. Talking about the symptoms you are having lets your doctor give treatments that can relieve the symptoms. Getting effective treatment can help you feel better and let you concentrate on the things that are important in your life.

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 combined 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: Lip cancer is generally treated with surgery, including Mohs surgery. Radiation therapy or more extensive surgery may be used if the tumor turns out to be larger than expected. If needed, special reconstructive surgery can help correct the defect in the lip.

Radiation alone may also be used as the first treatment. This is usually external beam radiation, sometimes along with brachytherapy. Surgery may be used if radiation doesn’t completely get rid of the tumor.

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 to be checked for cancer spread.

Floor of the mouth: Surgery is preferred if it can be done because radiation may cause bone damage. If the cancer does not appear to have been completely removed by surgery, radiation (often combined with chemo) may be added. This cancer readily spreads to neck lymph nodes. Surgery (neck dissection) may be recommended to remove these. Usually, the surgeon will remove lymph nodes from the side of the neck nearest the tumor. But if the tumor is in the middle, then lymph nodes on both sides of the neck will need to be removed.

Front of the tongue: Surgery is preferred for small tumors and radiation for larger ones, especially if cutting the tumor out would impair speech or swallowing. If surgery could not remove all the cancer, radiation (often combined with chemo) may be added. Larger tumors are more likely to have spread to lymph nodes in the neck, so these lymph nodes are often removed and checked for cancer.

Buccal mucosa (cheek): These cancers are usually treated with surgery. Radiation may be another option. If surgery is used, radiation may be added. Larger tumors are more likely to have spread to lymph nodes in the neck, so these lymph nodes are often removed and checked for cancer..

Lower gums: Cancer in the lower gums is usually treated with surgery, which may include removing part of the mandible (jaw bone). Radiation (often combined with chemo) may be added if all of the cancer could not be removed. Radiation may be used as the main treatment, but it carries a risk of damage to the jaw bone. Surgery to remove the lymph nodes in the neck is often recommended.

Upper gums and hard palate: Cancers in the upper gum or hard palate (the front of the roof of the mouth) are also usually managed with surgery. Radiation (often with chemo) may be added as well if needed because some of the cancer was left behind. Lymph nodes in the neck may be removed.

Back of the tongue: Radiation is generally preferred because surgery would cause more problems with speech and swallowing, although surgery is used in some cases. The lymph nodes in the neck generally need to be treated (or removed) as well. If any cancer remains after surgery, radiation (often with chemo) is often used.

Soft palate (back of the roof of the mouth): Because surgery would probably interfere with speech and swallowing, radiation is often the preferred treatment. Radiation may also be given to the neck. If surgery is used as the first treatment, then the lymph nodes in the neck also might be removed. If any cancer remains after surgery, radiation (often with chemo) is often used.

Tonsils: Surgery and radiation (perhaps combined with chemotherapy) work about equally well in treating cancer of the tonsils. If the cancer will need to be treated with radiation after surgery, many doctors prefer giving the radiation treatments first. Then, surgery is still an option if radiation doesn’t get rid of all the cancer. The neck lymph nodes can be treated the same way with surgery or radiation.

Stages III and IV:More advanced oral cavity and oropharyngeal cancers generally require a combination of either surgery and radiation, radiation and chemo (or cetuximab), or a combination of all three. The effect of combining radiation with both chemo and cetuximab is also being studied. 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.

Stages III and IV include cancers that have spread to lymph nodes in the neck. When lymph node spread is known to have occurred (for example, based on a fine needle biopsy), a neck dissection (removal of the lymph nodes in the neck) needs to be done. But even when the neck lymph nodes aren’t known to contain cancer, the tumors in this stage are large and advanced, and have a high risk of spreading to the lymph nodes. Because of this, neck dissection is often a part of treatment for stage III and IV cancers.

Radiation therapy often is required after surgery, particularly if the tumor has spread to the lymph nodes. Sometimes chemo is given as well, especially if the cancer has worrisome features. The amount of tissue removed during surgery depends on the extent of cancer, and the method of reconstruction depends on the surgical defect created.

Primary tumors that are too large to be completely removed by surgery are often treated with radiation, either alone or with chemo (or cetuximab). Some doctors give chemo as the first treatment, followed by chemoradiation (chemo and radiation given together), although not all doctors agree with this approach. Sometimes, these treatments may shrink the tumor enough so that surgery can be done.

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 possible. 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. 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.

What happens after treatment for oral cavity and oropharyngeal cancers?

For some people with oral cavity or oropharyngeal cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer growing or coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives. 

For other people, the cancer may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to help keep the cancer in check for as long as possible. Learning to live with cancer as a more of a chronic disease can be difficult and very stressful. It has its own type of uncertainty. 

Follow-up care

If you have completed treatment, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or imaging tests (such as MRI or CT scans) to look for signs of cancer return. Your health care team will discuss which tests should be done and how often based on the type and initial stage of your cancer, the type of treatment you received, and the response to that treatment.

Patients with cancer of the oral cavity or oropharynx may develop recurrences or new cancers in the head and neck area or lungs. Therefore, they must be followed closely after treatment. Recurrences happen most often in the first 2 years after treatment, so patients are usually examined about every few months during the first 2 years and then less often after that.

For someone who was treated with radiation to the neck, blood tests to look at thyroid function may be needed as well.

With improvements in surgery and radiation therapy, the ability to control a patient’s main cancer mass has greatly improved. However, development of second cancers in the head and neck or lungs remains an important risk.

Many studies have found that the patient’s quality of life tends to get worse in the first few months after treatment. After that, however, if the patient has given up smoking and drinking alcohol, things tend to get better. Within a year, many patients are feeling reasonably well and happy.

Almost any cancer treatment can have side effects. Some may last for a few weeks to several months, but others can last the rest of your life. Don’t hesitate to tell your cancer care team about any symptoms or side effects that bother you so they can help you manage them.

It is very important to report any new symptoms to the doctor right away, because they may prompt your doctor to do tests that could help find recurrent cancer as early as possible, when the likelihood of successful treatment is greatest.

It’s important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

If cancer does recur, treatment will depend on the location of the cancer and what treatments you’ve had before. 

Problems with eating and nutrition:Cancers of the mouth and throat and their treatments can sometimes cause problems such as trouble swallowing, loss or change in taste, dry mouth, or even loss of teeth. This can make it hard to eat, which can lead to weight loss and weakness due to poor nutrition.

Some people may need to adjust what they eat during and after treatment. Some may even need a feeding tube placed into the stomach for a short time during and after treatment. You may want to consult with a nutritionist to help find ways to meet your individual nutritional needs. If dry mouth is making it hard to eat, your doctor may recommend a saliva substitute. This can help you maintain your weight and nutritional intake.

Speech and swallowing therapy:Oral cavity or oropharyngeal cancers and their treatments may affect a person’s speech and ability to swallow. A speech therapist may help with these. These experts are knowledgeable about speech and swallowing problems.

What’s new in oral cavity and oropharyngeal cancer research and treatment?

Important research into oral and oropharyngeal cancers is taking place in many university hospitals, medical centers, and other institutions around the country. Each year, scientists find out more about what causes the disease, how to prevent it, and how to improve treatment.

DNA changes:A great deal of research is being done to learn what DNA changes cause the cells of the oral cavity and oropharynx to become cancerous.

One of the changes often found in DNA of oral cancer cells is a mutation of the p53 gene. The protein produced by this gene normally works to prevent cells from growing too much and helps to destroy cells with too much damage for the cells to repair. Changes in the p53 gene can lead to increased growth of abnormal cells and formation of cancers. Some studies suggest that tests to detect these p53 gene changes may allow oral and oropharyngeal tumors to be found early. These tests may also be used to better define surgical margins (area of normal cells after the tumor is removed) and to determine which tumors are most likely to respond to surgery or radiation therapy.

Another DNA change found in some oropharyngeal cancer cells (and less often in oral cancer cells) is the presence of DNA from a human papilloma virus (HPV). Some parts of the HPV DNA instruct the cells to make proteins that inactivate the p53 protein, which may allow the cancer cells to grow and divide. Studies are looking at whether tests to detect HPV DNA may help in diagnosing these cancers.

In addition, most studies suggest that oropharyngeal cancers that are linked with HPV tend to have a better outcome than those without HPV. Studies are being done to see if HPV-linked cancers can be treated less aggressively without reducing survival. Researchers are also working on treatments aimed at HPV infections or that target HPV-infected cancer cells.

Prevention

Chemoprevention: As mentioned in the section “Can oral cavity and oropharyngeal cancers be prevented?“ doctors are looking for medicines to help prevent these cancers, particularly in people at increased risk, such as those with leukoplakia or erythroplakia.

So far, studies using isotretinoin (13-cis-retinoic acid) and other drugs related to vitamin A (retinoids) have not found any long-term benefit in helping patients avoid cancer or live longer.

Several other types of drugs are now being tested to help prevent these cancers. Non-steroidal anti-inflammatory drugs (NSAIDs), such as sulindac and celecoxib are being tested as chemopreventive drugs. Some early research has found that certain extracts of black raspberries may help prevent these cancers. Another compound showing some promise is known as Bowman-Birk inhibitor (BBI), a protein derived from soybeans.

All of these drugs and compounds would need further study before they could be recommended.

Treatment

Surgery:Doctors continue to refine surgery techniques to try to limit the amount of normal tissue that is removed along with the tumor. This may help limit the side effects after treatment.

Transoral robotic surgery: For this surgery, the surgeon operates from a control panel that allows him or her to precisely move robotic arms. The arms hold long surgical tools that are passed down the throat. This technique requires smaller incisions, so if it proves successful it might lessen the side effects from surgery. This approach is most commonly being used to treat tumors in the throat.

Sentinel lymph node mapping and biopsy: In many oral cancers, the nearby lymph nodes are routinely removed during surgery (known as a lymph node dissection). A sentinel lymph node biopsy can help the doctor determine whether the cancer has spread to these nodes beforehand, which may allow the patient to avoid this surgery if the cancer has not spread. Sentinel node mapping and biopsy helps the doctor identify and examine the sentinel node(s) — the one(s) that the cancer would have spread to first before it went to other nodes. If this node doesn’t contain cancer, it’s very unlikely that any other nodes would contain cancer either.

In this procedure, the surgeon injects a radioactive material around the tumor, usually the day before surgery. The material will travel the same route that any cancer cells would likely have taken if they went to the lymph nodes. On the day of surgery a blue dye is injected into the tumor site, which will also travel to the nearby lymph nodes.

During surgery, the surgeon can use a radiation detector to find the lymph node region that the radioactivity (and presumably the cancer) may have spread to. The surgeon then cuts into the area to look for radioactive or blue stained lymph nodes. These are removed and examined by a pathologist. If there is no cancer, then no further surgery is needed. If there is cancer, then all the lymph nodes in the area will be removed.

Most doctors still consider this procedure to be experimental for cancers of the mouth and throat, and more work is needed to tell if this can replace routine lymph node removals.

New chemotherapy approaches: A great deal of research is focusing on improving results from chemotherapy in people with these cancers. This includes finding the best time to give these drugs, figuring out which combinations of drugs work best, and determining how best to use these drugs with other forms of treatment.

Researchers also continue to develop new chemotherapy drugs that might be more effective against advanced oral and oropharyngeal cancers.

In one newer approach to treating head and neck cancers, the doctor injects the drug directly into the tumor (intralesional chemotherapy). Success with this approach has been limited in the past because the drug tended to spread out of the tumors and to nearby tissues and the rest of the body quite quickly. Recent advances in preparing the drug solution so that it remains in the tumor (such as suspending it in a gel) have renewed interest in this treatment.

New radiotherapy methods: Doctors are always looking at newer ways of focusing radiation on tumors more precisely to help them get more radiation to the tumor while limiting side effects to nearby areas. This is especially important for head and neck tumors like oral cavity and oropharyngeal cancers, where there are often many important structures very close to the tumor. With more powerful computers and newer radiation techniques, doctors are now able to plan and deliver radiation therapy more precisely than ever before.

Stereotactic radiosurgery/stereotactic radiotherapy: This type of treatment delivers a large, precise radiation dose to the tumor area in a single session (called radiosurgery, though there is no actual surgery involved) or in a few sessions (radiotherapy).

In one technique, radiation beams from a machine are focused at the tumor from hundreds of different angles for a short period of time. Another approach uses a movable linear accelerator (a machine that creates radiation) that is controlled by a computer. Instead of delivering many beams at once, this machine moves around to deliver radiation to the tumor from different angles.

This treatment is used mostly for some brain and spinal cord tumors, but some doctors are now using it to treat recurrent oropharyngeal cancer.

Proton beam therapy: This approach uses a beam of protons rather than x-rays to kill cancer cells. Unlike x-rays, which release energy both before and after they hit their target, protons cause little damage to tissues they pass through and then release their energy after traveling a certain distance. In theory, this allows more radiation to go to the tumor with less damage to nearby normal tissues. Proton beam therapy requires highly specialized equipment and is not widely available. At this time, it is not clear that this type of radiation is any better than more standard approaches to radiation therapy (such as intensity modulated radiation therapy) in treating mouth and throat cancers.

Targeted therapy: Clinical trials are studying several targeted therapies that block the action of substances (such as growth factors and growth factor receptors) that cause head and neck cancers to grow and spread.

Doctors are studying several  types of targeted drugs.

Vaccines:Most people think of vaccines as a way to prevent infectious diseases such as polio or measles. As mentioned earlier, vaccines against human papilloma virus (HPV) infection are already being used to help prevent cervical cancer. They may have the added benefit of preventing some oral cancers as well, although they won’t help treat the disease.

However, some vaccines are being studied as a way to treat people with cancer by helping their immune system recognize and attack the cancer cells. Many of these vaccines involve dendritic cells (cells of the immune system), which are removed from the patient’s blood and exposed in the lab to something that causes them to attack tumor cells. The dendritic cells are then injected back into the body, where they should induce other immune system cells to attack the patient’s cancer.

Gene therapy
New discoveries about how changes in the DNA of cells in the mouth and throat cause these cells to become cancerous are being applied to experimental treatments intended to reverse these changes. Gene therapies that interfere with the growth-stimulating effect of certain HPVs are also being developed.

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