Your doctor will look inside your nose and throat using a very thin flexible tube with a tiny light and camera on it (called an endoscope). This can be done in an office or clinic.
Oropharyngeal Cancer (Tonsil Cancer)
Includes Tonsil Cancer
Introduction
What is Oropharyngeal Cancer?
It is a type of Throat Cancer that your doctor might call by the part it has grown in, like Tonsil Cancer or Tongue Base Cancer. If it's not the cancer type you're looking for, please explore the information about other types of Throat Cancers or other types of Head and Neck Cancers.
Cancer that starts anywhere in the oropharynx is called Oropharyngeal Cancer. Your doctor may also call it by the part it has grown in, like tonsil or tongue base cancer. Most Oropharyngeal Cancers start in the cells that line the surface of the throat (called squamous cell carcinomas).
Cancer occurs when cells become abnormal, grow uncontrollably and have the potential to spread to other parts of the body. These cells build up to form a mass (or lump).
Watch a 3D video explainer about Oropharyngeal Cancer:
What is the oropharynx?
The oropharynx is the middle part of the throat, that is directly behind the mouth.
The oropharynx is made up of four parts (see diagram below):
- sides of the throat, including the tonsils
- base of the tongue (back third of the tongue), sitting above the voice box
- soft roof of the mouth (or the soft palate) and the fleshy part of skin hanging from the roof (or the uvula)
- back wall of the throat (or the posterior pharyngeal wall)
What does the oropharynx do?
The oropharynx has two main jobs:
- it allows air to pass from the nose and mouth, through the voice box and windpipe, into the lungs
- it pushes food and drinks from the mouth, down the food passage to the stomach. The base of the tongue base helps stop food and drinks from entering the voicebox and the lungs.
Diagram of the oropharynx and the surrounding areas:
What causes Oropharyngeal Cancer?
Doctors often can’t explain why a person gets cancer. But we do know what makes some cancers more likely.
The main causes of Oropharyngeal Cancer are:
- Human Papillomavirus (HPV) infection (especially HPV types 16 and 18) — We now know HPV causes many oropharyngeal cancers.
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Smoking (cigarettes, cigars or pipes) or using smokeless tobacco (snuff and chewing tobacco) — If a person smokes or has smoked in the past, they have a higher risk of getting oropharyngal cancer than someone who does not smoke. Get information about quitting smoking.
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Drinking alcohol — If a person drinks a lot of alcohol over many years, they have a higher risk of getting oropharyngeal cancer, especially combined with smoking. Get information about reducing how much alcohol you drink.
Symptoms, Signs and Tests for Oropharyngeal Cancer
The signs and symptoms of Oropharyngeal Cancer depend on where the cancer is, its size and how far it has spread in the body. Oropharyngeal Cancer can show up in different ways. Common signs and symptoms may include:
- a sore throat that doesn’t go away
- a sore (like an ulcer) in the throat
- a lump in the throat
- a lump in the neck (this is common and may be the only sign in many people)
- trouble swallowing food, or moving the tongue
- trouble opening the mouth
- trouble breathing
- noisy breathing
- ear pain
- coughing up blood
- voice change
- unexplained weight loss
Most often these symptoms are not from Oropharyngeal Cancer. However, if you have any of these symptoms for more than a few weeks, talk to your doctor as early as possible. They may be able to help diagnose and treat you.
What are the tests for Oropharyngeal Cancer
It is important that your doctor establishes the diagnosis of Oropharyngeal Cancer, assesses the size of the cancer and whether it has spread to the lymph nodes in the neck or elsewhere in the body. To answer these questions your doctor will need to do the following things:
- talk with you about your medical history. This includes signs you may have noticed, any other health conditions, medications that you are taking, and whether you smoke or drink alcohol
- perform a physical examination by feeling and looking inside your throat and neck
- order diagnostic tests, which may include scans.
Not everyone will need to have every test for Oropharyngeal Cancer. Your doctor will recommend tests that are right for you.
The most common tests for Oropharyngeal Cancer are:
This involves taking a piece of tissue (sample) either from the throat or from a lymph node in the neck, if it appears to be involved by the cancer. A pathologist then looks at the sample under a microscope to check for cancer cells. This is often the only sure way to tell if you have cancer. If the suspicious area can be safely accessed through the mouth, your doctor may take a sample for biopsy in the office. However, this is often not possible because the cancer may be too far back and some patients need to be asleep under a general anaesthetic for the biopsy. This is usually done as a day procedure.
Your doctor may order one of two types of biopsies of the lymph nodes in your neck. Both are usually done using an ultrasound scan to make sure the needle is in the right spot.
- Needle biopsy (Fine Needle Aspiration or FNA) is used when there is a lump (enlarged lymph node) in the neck that could have cancer cells in it. During the procedure, your doctor will take some cells from the lump using a needle. It may feel a bit uncomfortable during the biopsy.
- Core biopsy uses a bigger needle to get more cells for the biopsy. This is more uncomfortable than needle biopsy so doctors only use this if it is really needed.
This uses X-rays to take pictures of the inside of the body. If a person has cancer, a CT scan can help the doctor to see where it is, measure how big it is, and if it has spread into nearby organs or other parts of your body.
MRI (Magnetic Resonance Imaging) Scan
This uses magnetic fields, to take pictures of the inside of the body. This helps your doctor see how far a cancer has grown into the tissue around it. Not all people with oropharyngeal cancer need a MRI scan.
PET (Positron Emission Tomography) Scan
This is a whole body scan that uses a radioactive form of sugar which can show if the oropharyngeal cancer has spread to the lymph nodes or elsewhere in the body.
Treatment Options for Oropharyngeal Cancer (Includes Tonsil Cancer)
Following a diagnosis of Oropharyngeal Cancer, your cancer care team will discuss the treatment options including the possibility of participating in a clinical trial that is suitable for you. This is also a good time to consider if you would like a second opinion.
The most suitable treatment for Oropharyngeal Cancer depends on many things including:
- size and location of the cancer
- whether the cancer has spread
- whether the cancer is caused by smoking or HPV
- personal factors (e.g. age, general health and treatment history)
- treatments available (and whether any clinical trials are available)
- your preferences for treatment
There are three types of treatment available for Oropharyngeal Cancer. These include:
- Surgery
- Radiation therapy
- Chemotherapy
For many people there may be more than one treatment option that gives approximately the same chance of curing the cancer. Each treatment option has its advantages and disadvantages.
Generally, people with curable Oropharyngeal Cancer may be offered one of two treatment options: surgery and definitive radiation therapy.
- Surgery — which depending on the pathology results, may need to be followed by a course of radiation therapy (adjuvant radiation therapy); either on its own or at the same time (concurrent) as chemotherapy.
- Definitive Radiation Therapy — either on its own or at the same time as chemotherapy (concurrent chemoradiation)
Surgery for Oropharyngeal Cancer
There are a number of different operations that can help treat Oropharyngeal Cancer. If surgery is recommended, the type of operation will depend on the person and their cancer.
While some people can be treated with surgery alone, others may need extra treatment after surgery to reduce the risk of the cancer returning. Your cancer care team will help decide whether it is necessary for you, based on a detailed report on the cancer from the pathologist 1–2 weeks after surgery.
Adding another type of treatment after surgery is called adjuvant therapy.
This can be either radiation therapy alone or in combination with chemotherapy (chemoradiation), which is typically started about 4 weeks after surgery to allow recovery and for planning purposes. The treatment itself usually lasts about 6 weeks.
How Can I Prepare for the Surgery?
Your doctor will explain details of the surgery, general risks and side effects of surgery. Ask your doctor if you have questions. They may recommend:
- stopping blood thinners (e.g. aspirin) before surgery to reduce the risk of bleeding
- special stockings to reduce the risk of blood clots
- early mobilisation (i.e. not to stay in bed) to reduce the risk of blood clots and chest infection
- antibiotics to lower the risk of wound infection
If you smoke, it is important that you consider stopping smoking before starting treatment to help reduce the risk of infection and help you recover after your treatment.
The different surgical options for Oropharyngeal Cancer include:
Trans-Oral Robotic Surgery (TORS)
Sometimes, Oropharyngeal Cancers can be removed through the mouth without any external cuts using a robotic system or by using laser surgery.
Download PDF - Neck Dissection
Download PDF - Return to Activity Following Neck Dissection
This involves removal of lymph nodes from the neck. This is important even when there is no sign of cancer in the lymph nodes on your scan, because there is a risk of microscopic cancer in the lymph glands of the neck.
Surgery for oropharyngeal cancer may need to be more extensive in some patients. This can be because the cancer is too far back to remove through the mouth or because it is very large. A mandibulotomy involves cutting the jaw bone to allow better access to the cancer in the throat. The jaw is put back together at the end of the operation with titanium plates.
Free Flap Reconstructive Surgery
Download PDF - Free Flap Reconstructive Surgery
In people, who have had a large area of tissue taken out, they may need reconstructive surgery. This involves taking skin and its blood supply from another part of the body and using that skin to cover the throat. This operation is carried out by a surgeon who specialises in reconstructive surgery, your head and neck surgeon or another surgeon.
A tracheostomy is used to create an opening in the trachea (windpipe) in the lower neck, where a tube is inserted to allow air to flow in and out, when you breathe. This is used as swelling after major head and neck surgery may affect your ability to breathe. The tracheostomy tube is usually removed within a week of surgery once normal breathing is possible.
- A gastrostomy tube (called a PEG tube) goes through the skin and the muscles of your abdominal wall into the stomach. Gastrostomy is recommended if feeding is needed for a medium to longer time (months or years).
- A nasogastric tube goes through the nose down into the stomach. Nasogastric feeding is used for short time (days or weeks).
Side Effects of Surgery
Treatment for Oropharyngeal Cancer (including Tonsil Cancer) may lead to a number of side effects . You may not experience all of the side effects. Speak with your doctor if you have any questions or concerns about treatment side effects.
Radiation Therapy for Oropharyngeal Cancer
The most common radiation therapy approach for Oropharyngeal Cancer is called external beam radiation. This type of radiation therapy applies radiation from outside the body.
Radiation therapy can be used in the following ways:
Definitive
Radiation therapy is the main treatment for oropharyngeal cancer. It is used without surgery to cure oropharyngeal cancer. Typically radiation therapy is delivered daily (but not on weekends) for 7 weeks. Sometimes chemotherapy is added to the radiation therapy (chemoradiation) to make it more effective.
Adjuvant
This is when radiation therapy is given after surgery to kill cancer cells that may not have been taken out during surgery. It usually starts about 4 weeks after surgery to allow recovery from surgery. Radiation therapy treatment usually lasts for about 6 weeks. Sometimes chemotherapy is added to the adjuvant radiation therapy (chemoradiation) to make it more effective.
Palliative
In cases where a cure is not possible, radiation therapy is used to relieve symptoms of advanced Oropharyngeal Cancer. Symptoms that may require palliative radiation therapy include pain, bleeding, breathing and trouble swallowing.
How do I Prepare for Radiation Therapy?
You will meet with many members of the cancer care team, who will help you learn how to look after yourself through radiation therapy, recovery and long term follow-up. They will also talk to you about side effects and how to manage them. It may be helpful to write down questions as they come up, so you can ask anyone in your cancer care team when you see them.
Radiation Therapy Mask-Making and Simulation
Radiation therapy is a precise treatment. In order to make sure, that the cancer is covered by the treatment, you will need to be very still during the treatment, usually for about five minutes. A radiation therapy mask that is made to fit perfectly to your shape, will be put on you during each treatment to help the machine target where the cancer is.
You will have a planning CT scan (and sometimes other scans) with the mask on. Your radiation oncologist and radiation therapists will use these scans with all your other clinical information to develop a radiation therapy plan just for you (a personalised plan). Your plan will be checked by the radiation therapy and radiation oncology physics team before it is ready to be used for your treatment. This whole process can take approximately 2-3 weeks.
Teeth and Mouth Care
You might need to have some of your teeth taken out, this will depend on the area being treated and the dose of radiation therapy. It is important to take out any broken or infected teeth before radiation therapy. Taking out unhealthy teeth after radiation therapy can cause problems with the jaw bone.
Diet, Nutrition and the Role of Your Dietitian
Your cancer and its treatment can make it hard to eat and drink. Your doctor will recommend you see a dietitian to maximise your nutrition during treatment as well as while you are recovering. Sometime feeding tubes may be recommended depending on the area being treated and the dose of radiation therapy.
There are two common types of feeding tubes:
- Gastrostomy tube (sometimes called a PEG tube): this type of tube is inserted through your abdominal wall into your stomach, with part of the tube staying outside the stomach. A syringe can be attached to the tube to give you food this way if needed. The tube is inserted using a camera through the mouth into the stomach (gastroscopy) or using a CT scanner to guide insertion directly through the skin. If a PEG tube is needed, your doctor will organise this before starting your radiation therapy
- Nasogastric tube: this type of tube goes through the nose down into the stomach and is usually used for short periods (days or weeks). A nasogastric tube can be inserted at any time (before, during or after treatment).
Speech, Voice and Swallowing
Your cancer and its treatment can make swallowing and speech difficult. Your doctor will recommend you see a speech pathologist, who can help you with ways to manage swallowing and communication difficulties, during and after treatment.
There are many other aspects of supportive care that are available, ask your doctor if you have any specific needs.
Side Effects
The side-effects of radiation therapy start around two weeks into treatment and progress through treatment to peak in the last week or just after treatment ends. The side effects start to improve 2-3 weeks after the end of treatment.
Side effects associated with radiation therapy depend on:
- the dose of radiation therapy
- the area being treated
- whether or not chemotherapy is added to the radiation.
Each person responds to radiation therapy differently. Some people may experience a few side effects while others may not experience any at all.
The following are some common side effects of radiation therapy.
- tiredness
- skin irritation in the treated area e.g. redness, dryness and itching, weeping skin, scaling or sometimes skin breakdown (sores)
- dry mouth and throat due to loss of saliva (called xerostomia)
- altered taste, which is usually a loss of taste or sometimes an unpleasant taste in the mouth
- pain on swallowing or difficulty with swallowing
- loss of weight
Most side effects are short lived and may go away within 4–6 weeks of finishing radiation therapy. Some side effects may last for months after you finish radiation therapy and some may be permanent.
Once your radiation therapy ends, you will have regular follow-up appointments so your cancer care team can check your recovery and monitor any side effects that you may have. About 12 weeks after your last radiation therapy session, your doctor will usually arrange for a PET scan to make sure the cancer has completely gone. If the cancer has not gone away after radiation therapy, or comes back in the future, you may still be able to have surgery to try to remove the cancer.
Your doctor may recommend some specific supportive care options to help you during your treatment and recovery.
Chemotherapy for Oropharyngeal Cancer
Chemotherapy works by destroying or damaging cancer cells. For Oropharyngeal Cancer, it is usually given into a vein through a needle with a cannula (tube) attached.
There are a number of ways that chemotherapy may be used to treat Oropharyngeal Cancers:
Definitive
Sometimes chemotherapy is added to definitive radiation therapy (chemoradiation). It is usually used for advanced stage Oropharyngeal Cancers. This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. Although chemotherapy makes the radiation more effective at destroying cancer cells, it may also lead to increased side effects for most patients.
Adjuvant
This is when chemotherapy is given after surgery, usually in combination with radiation therapy (called concurrent chemoradiation). This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. Although chemotherapy makes the radiation more effective at destroying cancer cells, it may also lead to increased side effects for most patients.
Neo-adjuvant
This is when chemotherapy is given before surgery or radiation therapy to help shrink large cancers making them easier to remove during surgery, or target with radiation therapy.
Palliative
This is used when the cancer is incurable. The cancer may be too large or has spread too much to be removed by surgery. Palliative chemotherapy helps to slow the growth of cancer and reduce symptoms. It is important to remember that palliative chemotherapy is not as intense as other types and is much less likely to have significant side effects.
Before you start treatment, your medical oncologist will choose one or more chemotherapy medications that will be best to treat the type of cancer you have.
The chemotherapy medications your doctor chooses may depend on:
- whether the treatment is curative or palliative
- when it is used
- your medical history
Side Effects
The side effects of chemotherapy depend on the medication used and the the dose. The most common medications are cisplatin, carboplatin and 5-Fluoruracil (5-FU).
Each person responds to chemotherapy differently. Some people may experience a few side effects while others may not experience any at all. The following are common side effects of chemotherapy:
- a feeling of wanting to vomit (nausea) or vomiting
- more side effects of radiation, if you have chemotherapy at the same time as radiation
- loss of feeling in the fingers and toes
- kidney damage (caused by some medications)
- hearing loss/thinning
- ringing in the ears
- rash
- higher risk of infection (if the chemotherapy reduces the number of white cells in the blood)
Most of these side effects are short lived and may go away once you finish chemotherapy. Some side effects can take months or years to improve or may be permanent.
Once your treatments end, you will have regular follow-up appointments so that your doctor can check your recovery, make sure the cancer has not returned and monitor and treat any side effects that you may have.
Your doctor may recommend that you receive some specific supportive care to help during your recovery.
Questions to Ask
- Exactly what type of Oropharyngeal Cancer do I have? Where is it located?
- Why did I get this cancer? Is it related to the HPV virus?
- What stage is the cancer?
- What are my treatment options? Which treatment do you recommend for me and why?
- Have you discussed my case at a Multidisciplinary Team meeting and what were the recommendations?
- Who will be part of the cancer care team, and what does each person do? Should I see another specialist before treatment, such as a radiation oncologist, medical oncologist, plastic surgeon, dentist, dietitian or speech pathologist?
- What are the possible side effects of treatment in the short- and long-term? How can they be prevented or managed?
- Will the treatment affect my ability to eat, swallow, or speak? Will I need a feeding tube?
- What will happen if I don't have any treatment?
- How much will the treatment and/or operation cost? Will Medicare or my health insurance cover it?
- What follow-up tests will I need? How often will they be?
- Am I suitable for any clinical trials?
- What lifestyle changes (diet, exercise) do you recommend I make?
- Who can I call if I have any problems or questions?
- Where can I find emotional support for me and my family? Is there a support group or psychologist you can recommend?
- If I wanted to get a second opinion, can you provide all my medical details? Do you mind if I get a second opinion?
Follow Up Care
You will need regular check-up of your mouth, throat and neck after treatment for Oropharyngeal Cancer. This will include a physical exam and checking your nose and throat with a thin, flexible tube with and camera (nasoendoscopy).
Some people may also need imaging studies such as CT, MRI or PET scans during follow-up. Ask your doctor if you need any of these scans. It is important to keep up with follow-up meetings, to make sure that if the cancer comes back, it is caught and treated as early as possible. If you have any concerns between visits, you should contact your doctor.
People with smoking related oropharyngeal cancer have a higher risk of getting another cancer in their head and neck such as the throat or voice box. This is another reason to keep your follow-up visits to your doctor. People who smoke can reduce the risk of their cancer coming back or getting a new cancer, if they quit smoking. Ask your health care team for advice if this applies to you.
Mental Health for People with Cancer
Sometimes this is referred to as psychosocial aspects or survivorship.
Being diagnosed with cancer and having treatment can lead to extra worries or concerns for you and the people caring for you. Depending on the treatment, you may experience any of the following:
- low mood or depression
- anxiety
- disfigurement
- difficulties with eating
- difficulties with speaking
- changes in sexual activity
You may have got through the diagnosis and treatment for laryngeal cancer, but you may be finding it difficult to deal with some of the side effects of treatment. Speak with you doctor about any difficulties you may be experiencing. Your doctor may give you a referral to a psychologist or another healthcare professional who can help you. Speak with your family and friends too about any concerns you may have.
You may find it helps to join a patient support group and speak with others who are having treatment for head and neck cancer. You can also find help and advice in online self-help resources such as beyondblue.
Further information about coping with cancer is available here
Prognosis
Prognosis means the chance of recovery and cure. In oropharyngeal cancer, the prognosis depends on:
- the HPV status of the cancer
- the stage of the cancer
- whether you smoke
Staging systems for Oropharyngeal Cancer can help give a guide to prognosis, but are often not very accurate at predicting the chance of cure for a given person. It is best to discuss your prognosis with your doctor. Usually, if the cancer has not come back after 5 years, you would be considered to be cured.
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