Head & Neck

Throat Cancer

The throat, also referred to as the pharynx (FAYR-inx), is a muscular, hollow tube about 5 inches long. As part of both the respiratory and the digestive systems, it functions as a passageway for air, food and liquid. It begins at the back of the nasal cavity and curves down to meet the esophagus and trachea (windpipe). It is divided into three parts: the nasopharynx, the oropharynx and the hypopharynx.

Cancer of the throat (pharyngeal cancer) may be more specifically referred to by the affected region: nasopharyngeal cancer, oropharyngeal cancer or hypopharyngeal cancer. Although the oropharynx is at the back of the mouth, oropharyngeal cancer is diagnosed as a throat cancer because the oropharynx is a part of the throat. Today, the human papillomavirus (HPV) is linked to most oropharyngeal cancers. Nasopharyngeal cancer may be caused by the Epstein-Barr virus (EBV), particularly in people of Asian descent. Also known as human herpesvirus 4, EBV is among the most common human viruses.

Throat cancer typically begins in the thin, flat squamous (SKWAY-mus) cells lining the mucous membranes. The following symptoms often lead to detecting throat cancer: persistent sore throat; difficulty swallowing, moving the tongue or opening the mouth wide; trouble breathing or speaking; ear pain or decreased hearing; voice changes; or lump in the back of the mouth, throat or neck. HPV-related cancers are often accompanied by a painless neck mass.

Common Treatments

The region of the throat where the cancer occurs, whether the cancer is primary or recurrent, and the presence of certain biomarkers related to the human papillomavirus (HPV) will guide your doctor’s recommendation for treatment. Ask your doctor if your diagnosis is HPV+ or HPV-.

Your doctor will focus on preserving as much normal function as possible throughout treatment and may use one or more of the following options. (See Treatment Options for general descriptions of each treatment type.)

Surgery

Surgery is commonly used to treat oropharyngeal and hypopharyngeal cancers. It is rarely used for nasopharyngeal cancers because the area can be difficult to reach. However, it may be used for nasopharyngeal cancers to remove lymph nodes.

One or more of the following surgeries may be used.

Glossectomy for the partial or complete removal of the tongue.

Mandibulectomy for the partial or complete removal of the jawbone, which is needed when cancer has spread.

Maxillectomy for the partial or complete removal of the bony part of the roof of the mouth.

Laryngopharyngectomy to remove tumors in the hypopharynx. This is the partial or complete removal of the larynx (voice box), the vocal folds and pharynx. With this approach, a surgeon reconstructs the pharynx.

Laryngectomy (partial or total) removes the larynx, and the surgeon creates a stoma for breathing (see Living With a Stoma).

Minimally invasive surgical options for oropharyngeal cancers may be available, including transoral robotic surgery (TORS) and transoral laser microsurgery (TLM). For both, a surgeon uses robot-like instruments to remove a tumor from the throat. A lymph node dissection (lymphadenectomy) to remove lymph nodes may also be performed.

Reconstructive surgery that occurs during or after surgery to remove the cancer may be recommended to replace missing tissue, skin or jawbone to restore appearance and function (See Reconstructive Surgery).

Radiation Therapy

Radiation therapy may be given alone or with chemotherapy as a first-line treatment for some throat cancers in which surgery would damage the ability to swallow. The most common type of radiation therapy used for head and neck cancers is external-beam radiation therapy (EBRT) and includes intensity-modulated radiation therapy (IMRT), stereotactic radiation therapy and proton therapy.

Hyperfractionated radiation therapy, in which the radiation is given in smaller doses but more frequently, may be used for certain cases of advanced throat cancer to improve the way the tumor responds to treatment.

Chemotherapy

Chemotherapy may be given before (neoadjuvant therapy) or after surgery (adjuvant therapy). It may also be used with radiation therapy (chemoradiation) after surgery to remove larger throat cancers if the risk for recurrence is high. In some cases, chemo-radiation may be an option for the first treatment used. Chemotherapy given alone may be used to treat recurrent cancer (cancer that has returned) or in cancers that are not surgically resectable. In this case, the goal of treatment is not to cure the cancer but to prevent growth and spread.

Immunotherapy

A form of immunotherapy called immune checkpoint inhibitors may be an option for treating recurrent or metastatic throat cancer that has stopped responding to chemotherapy. Other immunotherapy options may be available in clinical trials.

Targeted Therapy

These drugs may be an option to treat types of throat cancer that contain specific genetic abnormalities, proteins or growth factors. Targeted therapy drugs may be given alone or in combination with chemotherapy or radiation therapy.

Clinical Trials

Other throat cancer treatments continue to be evaluated in clinical trials. Ask your doctor if a clinical trial is an option for you (see Clinical Trials).

 

HPV and Cancer

Human papillomavirus (HPV), a virus that can lead to cancer, is the most common sexually transmitted disease in the United States. Most people acquire it during their lifetime, and the majority are able to heal from the infection, often without symptoms. If the infection does not resolve, however, it may turn into cancer.

More than 150 types of HPV exist and about 40 types can be spread through sexual contact from the skin and mucous membranes (lining of the mouth, throat or genital tract) of infected people to the skin and mucous membranes of their partners. HPV-related throat cancers are increasing fastest among men in the United States. Nine strains of HPV are known to cause cancer, with HPV being linked to approximately 70 percent of oropharyngeal cancers. Oropharyngeal cancers affect the middle part of the throat, including the base of the tongue and tonsils. HPV is also linked to anal, cervical, penile, vaginal and vulvar cancers.

If your doctor suspected throat cancer, you were likely tested for the HPV biomarker. Its presence helped your doctor appropriately stage the cancer and determine which treatment may be most effective for you. HPV biomarker testing may also be conducted to predict an HPV-associated throat cancer recurrence.

Your health care team and the throat cancer resources in this guide can help you learn more about HPV and how your diagnosis may affect your loved ones. Ask your doctor about the recommended screenings and vaccinations for your partner and your children as well as the potential benefit of being vaccinated after your head and neck cancer diagnosis. Although the HPV vaccination does not treat existing infections or diseases (this is why the HPV vaccine works best when given before any exposure to HPV), it can prevent new infections with the types of HPV that most often cause oropharyngeal and other cancers.

Three vaccines are approved by the U.S. Food and Drug Administration (FDA) for male and female children and young adults, 9 to 26 years old, to provide protection against new HPV infections. They do not treat existing HPV infections. The vaccines are Gardasil (Human Papillomavirus Quadrivalent [Types 6, 11, 16, and 18] Vaccine, Recombinant), Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) and Cervarix (Human Papillomavirus Bivalent [Types 16 and 18] Vaccine, Recombinant). Gardasil 9’s approval was recently expanded to include adult males and females ages 27 through 45 years.

Certain lifestyle habits may help decrease the chance of getting the virus, such as limiting your use of alcohol and avoiding all tobacco products, including smokeless products, as they may increase your risk of developing oropharyngeal cancers. Additionally, using condoms and dental dams properly may lower the chance that HPV is passed from one person to another.

Staging

Diagnosing your type of throat cancer is an important step in creating the best treatment plan for you. Your doctor will perform a thorough exam, imaging studies, blood tests and a biopsy and use these test results to stage the cancer. Staging determines the extent of your cancer, where it is located and whether it has metastasized (spread) to nearby organs, tissues or lymph nodes, or to other parts of your body.

The TNM staging system, developed by the American Joint Committee on Cancer (AJCC), is typically used to classify and stage throat cancer. This system classifies the cancer by tumor (T), node (N) and metastasis (M). The T category describes the size and location of the primary tumor. The N category indicates whether the lymph nodes show evidence of cancer cells. The number and location of these lymph nodes are important because they show how far the disease has spread. The M category describes metastasis (spread of cancer to another part of the body), if any.

Staging Criteria

Once the cancer is classified, an overall stage is assigned. Throat cancer may be Stage 0 through Stage IV. Also known as “in situ,” Stage 0 is a precursor of an invasive cancer. Stages I and II are generally confined to the local area where the cancer is found, and Stage III has spread to the regional lymph nodes in the neck. Stage IV is further divided into Stages IVA, IVB and IVC. Stages IVA and IVB are locally or regionally advanced disease, and Stage IVC has spread to distant sites, such as the liver, lungs or bone.

These basic stages are designed to group patients who have a similar prognosis (outlook). This grouping allows doctors to more accurately predict outcomes for patients depending on the type of treatment they receive. In certain cancers, the stage is also determined by other factors. For throat cancer, the presence of human papillomavirus (HPV) and the location of the cancer cells are considered..

Sometimes your doctor may reassess your stage after treatment or if cancer recurs. This is known as restaging. It is rarely done but typically involves the same diagnostic tests used for the original staging. If a new stage is assigned, it’s often preceded by an “r” to denote that it’s been restaged and different from the original stage given at diagnosis.

Look carefully at the table headlines and sections to ensure you view the information that applies to your diagnosis as each has unique staging characteristics.

TNM Classification for Oropharyngeal (HPV-) and Hypopharyngeal Cancers

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
Tis Carcinoma in situ.
Oropharyngeal (HPV-)
T1 Tumor 2 cm or smaller in greatest dimension.
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension.
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottis.
T4 Moderately advanced or very advanced local disease.
  T4a Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible (jawbone).
  T4b Very advanced local disease. Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery.
Hypopharyngeal
T1 Tumor limited to one subsite of hypopharynx and/or 2 cm or smaller in greatest dimension.
T2 Tumor invades more than one subsite of hypopharynx or an adjacent site, or measures larger than 2 cm but not larger than 4 cm in greatest dimension without fixation of hemilarynx.
T3 Tumor larger than 4 cm in greatest dimension or with fixation of hemilarynx or extension to esophageal mucosa.
T4 Moderately advanced and very advanced local disease.
  T4a Moderately advanced local disease. Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle or central compartment soft tissue.
  T4b Very advanced local disease. Tumor invades prevertebral fascia, encases carotid artery or involves mediastinal structures.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(-).
N2 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-);
or in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE(-).
  N2a Metastasis in single ipsilateral (on the same side) node 3 cm or smaller in greatest dimension and ENE*(+);
or a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-).
  N2b Metastasis in multiple ipsilateral (on the same side) nodes none larger than 6 cm in greatest dimension and ENE*(-).
  N2c Metastasis in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE*(-).
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-);
or metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
  N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-).
  N3b Metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.
*Extranodal extension (ENE) refers to cancer cells that have spread beyond the lymph node into surrounding tissues.

Staging Oropharyngeal (HPV-) and Hypopharyngeal Cancers

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3
T1, T2, T3
N0
N1
M0
M0
IVA T4a
T1, T2, T3, T4a
N0, N1
N2
M0
M0
IVB Any T
T4b
N3
Any N
M0
M0
IVC Any T Any N M1

Classifying Oropharyngeal (HPV+) Cancer

Classification Definition
Tumor (T)
T0 No primary identified.
T1 Tumor 2 cm or smaller in greatest dimension.
T2 Tumor larger than 2 cm but not larger than 4 cm in greatest dimension.
T3 Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottis.
T4 Moderately advanced local disease. Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate or mandible (jawbone) or beyond.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in four or fewer lymph nodes.
N2 Metastasis in more than four lymph nodes.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

Staging Oropharyngeal (HPV+) Cancer

Stage T N M
I T0, T1, T2 N0, N1 M0
II T0, T1, T2
T3, T4
N2
N0, N1
M0
M0
III T3, T4 N2 M0
IV Any T Any N M1

Classifying Nasopharyngeal Cancer

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
T0 No tumor identified, but EBV-positive cervical node(s) involvement.
Tis Carcinoma in situ.
T1 Tumor confined to nasopharynx (behind nasal cavity/upper part of throat), or extension to oropharynx and/or nasal cavity without parapharyngeal involvement.
T2 Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles).
T3 Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses.
T4 Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle.
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Unilateral (on one side) metastasis in cervical lymph node(s) and/or unilateral or bilateral metastasis (on both sides) in retropharyngeal lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage.
N2 Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage.
N3 Unilateral (on one side) or bilateral (on both sides) metastasis in cervical lymph node(s), larger than 6 cm in greatest dimension, and/or extension below the caudal border of cricoid cartilage.
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

Staging Nasopharyngeal Cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T0, T1, T2
T2
N1
N0
M0
M0
III T0, T1, T2, T3
T3
T3
N2
N0
N1
M0
M0
M0
IVA T4
T4
T4
Any T
N0
N1
N2
N3
M0
M0
M0
M0
IVB Any T Any N M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media.

 

Key Takeaways

  • Your personalized treatment plan will be based on your diagnosis and other unique factors.
  • Ask your doctor about potential side effects with each type of recommended treatment.
  • Communicate frequently with your health care team about symptoms and side effects.
  • Learn more about HPV and how it may affect you and your loved ones.

Additional Resources

 

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