This article is on Oropharyngeal Cancer (OPC). It is intended to help inform patients, relatives of patients and health professionals. The information in the grey boxes is more technical and intended more for Health professionals that are reading this article.

 

What is Oropharyngeal Cancer (OPC)?

The oropharynx is the area of the throat situated behind the mouth, it has a number of important structures within it. The GREEN highlighted section in the (Figure) represents the oropharynx. This area is comprised of the Tonsils, Soft palate (back part of the roof of the mouth), the base of the tongue (back 1/3 of the tongue), the posterior pharyngeal wall (which is the back wall of the throat visible when the mouth is open).

Oropharyngeal Cancers

Any cancers that arise from any of the structures around this area are termed Oropharyngeal Cancers (OPCs)

 

Who gets Oropharyngeal Cancers?

Numerous studies show that OPCs usually occur in Adults in 5th decade of life and older (average age 62) , twice more likely in men than women (1.1), higher rates in Maori than European NZ population (1.2).

Human papillomavirus (HPV)-related OPCs occur in a younger age group than non-HPV related cancers and are typically seen between 30 and 60 years of age. These cancers rarely occur in children.

 

What are the causes?

  • Tobacco use: including cigarettes, cigars, pipes, chewing tobacco, and snuff, is the single largest risk factor.
  • Alcohol:Frequent and heavy consumption of alcohol increases the risk of OPC, and using alcohol and tobacco together increases this risk even more.
  • Human papillomavirus (HPV).Studies show that infection with the HPV virus increases the risk for OPCs. In recent years, HPV-related oropharyngeal cancer has become more common. Sexual activity, including oral sex, with someone who has HPV is the most common way someone gets HPV. There are different types of HPV, called strains. Some HPV strains are more strongly associated with certain types of cancers.

There are vaccines available to protect you from HPV.

  • Poor oral hygiene.People with poor oral hygiene or dental care may have an increased risk of oral cavity cancer. Poor dental health or ongoing irritation from poorly fitting dentures, especially when combined with alcohol and tobacco products, may contribute to an increased risk of OPCs.
  • Marijuana use.Recent studies have suggested that using of marijuana may pose a higher-than-average risk for OPCs

Eighty-five percent (85%) of head and neck cancer is linked to tobacco use. Pipe smoking in particular has been linked to cancer in the part of the lips that touch the pipe stem. Chewing tobacco or snuff is associated with a 50% increase in the risk of developing cancer in the cheeks, gums, and inner surface of the lips, where the tobacco has the most contact.

 

What are the symptoms?

  • A sore in the mouth that does not heal; this is the most common symptom.
  • Red or white patch on the tonsil, or lining of the mouth,
  • Lump on the back of the mouth, neck, or throat .
  • Persistent sore throat or feeling that something is caught in the throat
  • Hoarseness or change in voice
  • Numbness of the mouth or tongue
  • Pain or bleeding in the mouth
  • Difficulty chewing, swallowing, or moving the jaws or tongue
  • Pain in the ear and/or jaw
  • Changes in speech
  • Unexplained weight loss

 

How is it diagnosed?

The diagnosis can sometimes involve several steps, requiring input from several services within the health care system and this can sometimes be difficult and require a number of appointments for a patient. The aim of the tests is to learn what type of cancer it is, how extensive it is, and if it has spread to other parts of the body. A patient’s general health can also affect the decision of what tests can be performed. The doctor will usually use a combination of the following:

Physical examination: usually performed in the clinical setting. A medical history and your risk factors will be asked. The doctor will look in the mouth and feel for any lumps on the neck. People with OPCs have a higher risk of other cancers elsewhere in the head and neck area, therefore a thorough examination is performed.

Endoscopy. This allows the doctor to see the back of the mouth and throat. In the clinic room, a thin, flexible tube with an attached light and view lens, called a flexible fibreoptic endoscope is inserted through the nose to examine the back of the nose and throat. An anaesthetic spray to numb the nose and throat can be used to make the patient more comfortable, but often the examination is tolerated without it. If an area looks suspicious, the doctor may take a biopsy (small piece of tissue for diagnosis) in the clinic, sometimes this requires a general anaesthetic (the patient is put to sleep) for harder to reach parts of the oropharynx.

Biopsy. This is the removal of a small amount of tissue for examination under a microscope and this can make a definite diagnosis in most cases. More biopsies may be required if the first does not reveal the diagnosis. If neck lumps are also present a needle biopsy of these may be done either ‘free hand’ by the doctor in the clinic or using ultrasound imaging-guidance.

Imaging: There are different forms of imaging that may be used, in many cases a combination of images may be required for diagnosing and treatment planning . Some of these are listed below;

  • Ultrasound (+/- fine needle biopsy)
  • Computed tomography(CT, previous called CAT) scan
  • Magnetic resonance imaging (MRI)
  • Positron emission tomography – computed tomographyor PET-CT scan
  • Further specialist scans such as angiography to look at blood vessels or an orthopantomogram (OPG) to look at the teeth and jaw

Each of the aforementioned scans provide different types of information for the doctor to make a diagnosis and treatment plan, the choice can sometimes be influenced by the patient’s general health.

 

What are the potential complications?

Most of the complications associated with OPCs are linked with the location in which they occur. Some common complications are sudden/ gradual onset difficulty breathing (stridor), swallowing (dysphagia), speaking (hoarseness).

Local or distant spread of the OPC (metastasis) may cause complications (e.g. bone pain) and other general complications that are linked with cancers such as clotting problems (D.I.C).

 

What are the Treatment/ Management options?

Generally, the treatment options are:

  1. No treatment
  2. Chemotherapy and radiation therapy
  3. Surgery
  4. Palliative or non-curative treatment, this may include a number of the above treatments and in some cases a new medical treatment called immunotherapy. The intent is to delay progression of the disease but treatment will not cure the disease.

Management decisions are made with the patient and based on recommendations from an expert panel of doctors and allied health professionals (multidisciplinary team meeting or tumour board). Decision making can be complex and based on patient factors, disease factors and institution/available healthcare factors.

The staging of a cancer is important and is a way of describing where a cancer is located, if or where it has spread, and whether it is affecting other parts of the body. One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and images to answer these questions.

In all cases, a team of doctors will work together with the patient to tailor the best treatment plan. Specialists often form a multidisciplinary team to care for each patient. This team may include:

  • Medical oncologist:A doctor who treats cancer using chemotherapy or other medications, such as targeted therapy.
  • Radiation oncologist:A doctor who specializes in treating cancer using radiation therapy.
  • Otolaryngologist- Head and Neck Surgeon:A doctor who specializes in diseases of the ear, nose, throat and neck. The surgeon is most often sub-specialised in head and neck cancer surgery.
  • Reconstructive/plastic surgeon: A doctor who specializes in reconstructive surgery, which is done to help repair damage caused by cancer surgery treatment.
  • Head and Neck cancer nurse specialist: specialist nurse trained in the management of head and neck cancer patients.
  • Maxillofacial prosthodontist:A specialist who performs restorative surgery in the head and neck areas.
  • Oncologic dentist or oral oncologist:Dentists experienced in caring for people with head and neck cancer.
  • Prosthodontist:A dental specialist with expertise in the restoration and replacement of broken teeth with crowns, bridges, or dentures.
  • Physical therapist: A health care professional who helps patients improve their physical strength and ability to move.
  • Speech-language therapist/pathologist: A health care professional who specializes in communication and swallowing disorders. A speech-language pathologist helps patients regain their speaking, swallowing, and oral motor skills after cancer treatment that affects the head, mouth, and neck.
  • Audiologist:A health care professional who treats and manages hearing problems that may be caused by the tumor itself or the cancer treatment.
  • Psychologist/psychiatrist: These mental health professionals address the emotional, psychological, and behavioral needs of the person with cancer and those of his or her family.

There are two staging systems in place for oropharyngeal cancer based on the AJCC, one for HPV-negative disease and one for HPV positive disease. Below is the staging for HPV-negative disease.

Tumor (T):How large is the primary tumor? Where is it located?
Node (N):Has the tumor spread to the lymph nodes? If so, where and how many?
Metastasis (M):Has the cancer spread to other parts of the body? If so, where and how much?

TX: The primary tumor cannot be evaluated.
Tis: Describes a stage called carcinoma (cancer) in situ. This is a very early cancer where cancer cells are found only in 1 layer of tissue.
T1: The tumor is 2 cm or smaller at its greatest dimension.
T2: The tumor is larger than 2 cm but not larger than 4 cm.
T3: The tumor is larger than 4 cm or has spread to the epiglottis, which is the flap of cartilage that diverts food into the esophagus.
T4a: The tumor has invaded the larynx, muscle of the tongue, muscles in the jaw, roof of the mouth, or jawbone.
T4b: The tumor has invaded muscles and bones in the region of the mouth; the nasopharynx, which is the air passageway at the upper part of the throat behind the nose; or the base of the skull, or the tumor encases the carotid artery.

NX: The regional lymph nodes cannot be evaluated.
N0 (N plus zero): There is no evidence of cancer in the regional lymph nodes.
N1: The cancer has spread to a single lymph node on the same side as the primary tumor, and the cancer found in the node is 3 cm or smaller. There is no ENE.
N2a: Cancer has spread to a single lymph node on the same side as the primary tumor and is larger than 3 cm but not larger than 6 cm. There is no ENE.
N2b: Cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measures larger than 6 cm. There is no ENE.
N2c: Cancer has spread to more than 1 lymph node on either side of the body, and none measures larger than 6 cm. There is no ENE.
N3a: The cancer is found in a lymph node and is larger than 6 cm. There is no ENE.
N3b: There is ENE in any lymph node.

M0 (M plus zero): Cancer has not spread to other parts of the body.
M1Cancer has spread to other parts of the body.

 

Can you prevent OPCs?

You cannot absolutely prevent any form of cancer from occurring, but one can reduce the probability of developing this disease by avoiding the risk factors. These are known from information acquired from numerous studies that show a dramatic increase in the risk of developing OPCs.

 

What are the treatment options?

Control of symptoms and improvement of quality of life are the aims of CRS treatment. Using a bottle designed for washing salt water through the nose and nasal sprays containing anti-inflammatory steroid medicines are safe and effective initial options.

Antibiotic and steroid tablets are options for some patients and a review by an ENT Surgeon may also be required if symptoms are not well controlled. Endoscopic Sinus Surgery is commonly offered to patients with CRS who do not respond to routine medical treatment.

An acute sinus infection can still occur, please see Acute Rhinosinusitis for management options.

 

What is the prognosis?

There are several factors that affect the prognosis, Prognosis is the term used to describe having no signs of cancer after finishing treatment or living with, through, and beyond cancer. It can be referred to as survival rate in some parts of the world. For OPCs there is a numerous amount of data out there, but what is unifiable is that an early diagnosis or lower Stage of disease boasts a better prognosis.

  • Overall, 60% of people with oral cancer survive for 5 years (1.3)

(THIS BIT ON PROGNOSIS NEEDS TO BE RE-WRITTEN  definition of prognosis is iffy, ‘survival rate’ is used universally in studies (overall survival and disease-specific survival. It’s confusing and doesn’t give much information. See AJCC manual for survival rates for the different stages of disease but note there is a difference between HPV + and HPV -). J.

 

What are the day to day impacts?

This varies quite diagonally (??) between patients, depending on the site, stage, treatment and the general health of the patient. Patients with OPCs attend regular clinic appointments with head and neck surgeons or oncologists to ensure appropriate management of the treatment consequences and early detection of any recurrence of cancer.

 

Further reading:

1. The patient Resource.com

 

References:
1.1.Oral and Oropharyngeal Cancer: Statistics
Statistics adapted from the American Cancer Society’s (ACS) publication, Cancer Facts & Figures 2020, and the ACS website (January 2020).
1.2 Sociodemographic differences in the incidence of oropharyngeal and oral cavity squamous cell cancers in New Zealand
Australian and New Zealand journal of Public Health
First published:31 March 2015
1.3 National institute of Dental and craniofacial Research
Source: Surveillance, Epidemiology, and End Results (SEER) Program, National Cancer Institute
Surveillance Research Program, based on previous submissions of SEER data(1977-2003)

 

Author + Affiliation:
Dr Tonye Onyemelukwe, Department of Otolaryngology, Waikato Hospital.
Reviewed by Dr James Sanders, Otolaryngology, Waikato Hospital.

Date of Publication +/- Review:
Date of Publication:
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