What is oropharyngeal cancer?

The oropharynx is the part of the throat right behind the mouth. Water and food pass through it on their way to the trachea (wind pipe) and oesophagus (food pipe). It is composed of the soft palate (soft portion of the roof of the mouth), tonsils, back of tongue and side and back wall of the throat.

Cancer of the oropharynx is a disease of the throat where abnormal cells grow out of control and spread quickly. They may spread to the glands of the neck and in some instances to other parts of the body like the chest.

What are the causes of oropharyngeal cancer?

The two greatest factors that increase the risk of oropharyngeal cancer are tobacco and alcohol.

• Tobacco: This is the leading cause of head and neck cancer. It includes all tobacco products, including cigarettes, cigars, pipes, smokeless tobacco, chewing tobacco, snuff and betel quid
• Alcohol: Frequent or heavy consumption of any type of alcohol, such as beer, wine, or liquor, also raises the risk

Another important factor that increases the risk of oropharyngeal cancer is HPV.

• Human Papilloma Virus-the number of cases with HPV-associated oropharyngeal cancers are rising. This is similar to HPV-associated cervical and ano-genital cancer. It is a sexually-transmitted virus associated with number of lifetime oral sex partners.

What is HPV?

Human Papilloma Virus aka HPV is a virus that is passed from person to person through genital contact or oral sex. Majority of people do not show signs or symptoms of HPV infection and thus infected individuals remain oblivious. The immune system will clear HPV in 90% if cases within 9 months-24 months. There is no known treatment for HPV. In some people, the immune system doesn’t clear the virus from their bodies, the reason is unknown. Some of these people are at increased risk of developing cancer, but after 20-30 years have elapsed. Prevention is by abstinence, safe sexual practices or vaccination. Vaccination is recommended to prior to sexual activity. The vaccine is ineffective if already infected with HPV.

Can I get cancer from my spouse who has HPV-associated oropharyngeal cancer?

Most adults have already been infected by HPV by their 50’s. The immune system in the majority clears up the virus effectively in 24 months. Those with HPV-associated oropharyngeal cancer probably got infected 20-30 years prior as a young adult. If you have been in a monogamous relationship, there is little concern as you most likely were exposed to the virus and developed natural immunity against it. The evidence so far doesn’t call for any lifestyle modification. If you are young, it is advised to be more selective and conservative with your sexual practices.

What are the symptoms of oropharyngeal cancer?

The most common symptoms of hypopharyngeal cancer are:

• Difficulty or painful swallowing
• Sore or ulcer in the mouth that doesn’t go away
• Lump in the neck
• Difficulty opening the mouth (trismus)
• Sore throat that doesn’t go away
• Change or hoarseness  of voice for a prolonged time
• Trouble breathing or noisy breathing
• Persistent ear pain
• Cough or coughing up blood

The above complaints are frequently caused by other conditions other than cancer of the oropharynx. However, persistence of symptoms despite appropriate treatment should increase suspicion of cancer

How is oropharyngeal cancer tested?

Getting to a diagnosis starts with a history and a physical examination.

If the history and physical examination make the ENT doctor less suspicious that your lesion is cancer, he or she might try some medications and rehabilitation before jumping to a diagnosis of cancer.

If the ENT doctor raises the possibility of oropharyngeal cancer, a cancer work up is initiated.

Looking into your mouth and down your throat with a mirror or endoscopy (a tube with a camera passed) or an examination under anaesthesia (in an operating room is performed.  Imaging procedures (Xrays, ultrasound, CT scans or MRIs) to create a picture of inside of the body, and laboratory tests is done. This helps with staging the disease and knowing its extent. Knowing the stage of the disease helps the ENT doctor plan treatment.

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. A fine needle aspirate is done is commonly done if you have a lump in the neck. The doctor puts a thin needle in the lump and removes a small sample of tissue. Then a pathologist looks at the tissue under a microscope. These are the only ways to be certain if you have cancer.

If you came to the ENT doctor after having a lesion removed and found it was cancer only after having the lesion removed, the doctor might skip some of the tests and jump to follow-up or additional treatment.

Be sure to bring all the reports and images with you from any prior treatment or if it is for a second opinion.

What are the stages of oropharyngeal cancer?

Staging is a process that tells the doctor if the cancer has spread and if it has, how far. It depends on the severity of the original tumour, and whether the cancer has spread to lymph nodes or distant parts of the body. Staging is an important step in evaluating treatment options. Staging is slightly different for each specific type of head and neck cancer, but can be generalized as follows:

• Stage 0: Also called “carcinoma in situ,” meaning it has not yet invaded nearby tissue.
• Stage 1: Cancer has invaded nearby tissue, but has not yet spread to lymph nodes or other parts of the body
• Stage 2: Cancer has grown even deeper into nearby tissue, but still has not spread to lymph nodes or other parts of the body.
• Stage 3: Cancer has either grown much deeper into surrounding tissue or started to spread to one lymph node.
• Stage 4a: Cancer has grown completely through surrounding tissue into adjacent structures (such as tissue, cartilage, bone, or nerves) and may have spread to a few lymph nodes OR cancer has spread to more than one lymph node.
• Stage 4b: Cancer has spread (metastasized) to other parts of the body.

It is staged by physical examination, endoscopy and various imaging and lab tests. Staging helps understand the spread and extent of the disease.

The staging of the cancer is important in treatment options and prognosis.

What are the treatment options?

In deciding which treatment strategy would be suitable for an individual patient, important considerations include location of the cancer, stage of disease, ability to tolerate treatment, expected functional outcomes and associated illnesses.

Treatment options depend on one or more of the following:

• Surgery: If surgery is selected as the best treatment option, the treatment goals will be to remove as much of the cancer as possible in addition to preserving form and function of surrounding anatomic structures. If surrounding anatomic structures are damaged during the removal of the tumour, reconstructive surgery will be performed to rebuild or restore the structure, function and cosmetic appearance of the structures that were removed. Surgery to aid in breathing and eating may be performed as well.
• Radiotherapy: Radiotherapy uses high energy rays produced by a machine to kill cancer cells. One advantage of radiation over surgery is that it can be administered on an outpatient basis, which means you will not have to be admitted to the hospital. Also, it avoids the risks of general anaesthesia during surgery, which is particularly important in patients with many medical problems or even just one severe medical problem. Also, radiation therapy as a treatment allows for the possibility of organ preservation; for example, patients can be treated for cancer of the larynx (voice box) without the need to remove the larynx. One disadvantage of radiation is that patients need to come into a treatment facility five days per week for six to eight weeks (though this schedule can vary). Also, there are a number of side effects, both immediate and long-term, that need to be considered
• Chemotherapy: Chemotherapy is the use of drugs to target rapidly growing cells in an effort to destroy cancer cells. In many cases, chemotherapy can be delivered on an outpatient basis. This means you go to a special chemotherapy infusion centre for the day. The frequency you will need to receive chemotherapy and how long will be determined by your doctor and may change from the original plan depending on what type of side-effects you have and how the tumour responds. In some cases, the chemotherapy might be administered once per week for three weeks. In other cases, it might be delivered three days in a row and then every week for a few weeks.

What are the side effects of the treatment options?

• Surgery: Side effects are both general and specific to the location of the tumour. They include:
  • Difficulty swallowing
  • Anaesthesia risks
  • Infections-wound contamination
  • Blood loss-blood loss is inevitable though it can be minimised by surgical techniques or treated with a blood transfusion
  • Air embolus-this is air entering into the blood stream, it is very rare but serious.
  • Chyle leak-damage to the thoracic duct leads to a chyle leak.
  • Nerve damage-nerves may be inadvertently damaged because of extensive tumour involvement and removal. Repair may be done immediately or later or rehabilitation instituted.
• Radiotherapy: There are number of side effects of radiation therapy. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation.
  • Xerostomia (dry mouth)-The most common long-term side effect of radiation therapy for the treatment of head and neck cancer is xerostomia (dry mouth). It occurs when salivary glands are radiated or in the line of radiation. Aside from being bothersome to patients, including making it difficult to eat and speak, there is great risk of dental cavities and dental disease because saliva helps prevent dental disease.
  • Osteoradionecrosis (bone death)-This is necrosis (or death) of bone that has been exposed to radiation. The bone often becomes exposed through the skin or mucosa and can progress to an actual fracture of the bone. Osteoradionecrosis (ORN) can cause severe pain as well as chronic and persistent infections. Treatment is essentially by visiting a dentist before radiotherapy to make sure the teeth are in the best possible health.
  • Odynophagia (and mucositis)-This is pain with swallowing. It can be caused as the mouth and throat lining starts sloughing off and becomes inflamed (mucositis).
  • Skin changes-Patients will usually lose hair in the region that received radiation.
  • Hypothyroidism-The thyroid gland is located immediately in front of many parts of the throat. Therefore, damage to the thyroid gland can occur following radiation for head and neck cancers. This will result in hypothyroidism, or an underactive thyroid, which can actually be quite delayed in its presentation. Feeling tired and weight gain are the common complaints.
  • Pharyngoesophageal stenosis-This can be another delayed problem caused by radiation. Pharyngoesophageal (PE) stenosis is an area of narrowing in the throat or oesophagus (feeding tube). This narrowing can make it difficult to eat, particularly solid food.
  • Secondary cancers-Paradoxically, even though radiation is used to treat cancer, years later it can actually result in new cancers appearing. The risk increases with high dosage and greater time since treatment. The secondary cancer can be quite different from the original. Secondary cancers are rare.
• Chemotherapy: You will almost certainly experience side effects from chemotherapy. While chemotherapy targets cancer cells, these medications can also cause damage to normal cells. Finding the right balance can be difficult, and your medical oncologist will speak to you about those issues. Also, while some side effects are common to most chemotherapies, other side effects are specific to certain drugs.

The most common side effects are:

• • Mucositis- This is inflammation and ulceration of the lining of your mouth and throat. Mucositis can cause severe pain and difficulty with eating and drinking
  • Hearing loss- Associated symptoms might include ringing in the ears (tinnitus).
  • Kidney problems-This is a problem with all chemotherapy drugs.
  • Nausea and vomiting-This is common and you might require additional medication to reduce the nausea.
  • Rash- The rash looks similar to acne. Fortunately, the rash goes away after stopping treatment, and there is no significant pain or problems related to rashes
  • Neuropathy- This is a nerve problem that usually starts as a feeling of numbness or tingling in the fingers or toes. It can also feel like an electric bolt that shoots down an arm or a leg. It may not be bothersome and easy to deal with; or it may be severe enough to stop the drugs.

Other side effects include:

• • Diarrhea / constipation
  • Low blood counts
  • Tiredness
  • Loss of appetite
  • Bleeding problems
  • Sexual and fertility changes
  • Infection
  • Urination changes
  • Swelling
  • Memory changes

Is there follow up after treatment?

After treatment, your doctor will check you every so often to see if the cancer comes back. Follow-up tests can include exams, blood tests, and imaging tests. People who are treated for laryngeal cancer also need to see their dentist for regular follow-ups.

You should also watch for the symptoms listed above. Having those symptoms could mean your laryngeal cancer has come back. Tell your doctor if you have any symptoms.

 

What is recurrent oropharyngeal cancer?

Recurrent cancer is cancer that has come back after it has been successfully treated. The cancer is likely to come back in the first 2 or 3 years. It may come back in the oropharynx or other parts of the body.

What are the treatment options for recurrent oropharyngeal cancer?

The treatment options for cancer of the oropharynx that has come back are:

• Surgery with or without radiotherapy
• Radiotherapy
• Chemotherapy

Questions to ask your doctor.

One of your biggest allies in battling cancer is your ENT doctor and cancer doctor (oncologist). Questions are your primary resource to gain a better understanding of your disease and enhance your quality of care. Well-thought-out questions can help you get the most out of your appointments and can make all the difference. Here are some questions you may want to ask:

• What diagnostic tests do I need? What do they involve?
• Can you explain my pathology report and test results to me?
• What is the stage of the disease? What is the prognosis?
• What is the goal of treatment? What are my treatment options?
• What are the benefits of each treatment?
• What are the risks and side effects of each treatment?
• How will my condition be monitored during treatment?
• Do you have any advice on managing side effects? What can I do to take care of myself during treatment?
• What is treatment recovery like?
• What should I tell other people (kids, parents, siblings, friends, etc.) about my cancer when they ask?
• What will my follow-up appointment schedule be like?

Disclaimer

The content on the Nairobi ENT website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions.

References

1. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers.
2. Shah, Jatin P., and William Lydiatt. “Treatment of cancer of the head and neck.” CA: a cancer journal for clinicians 45.6 (1995): 352-368.