Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure that the following steps are completed.

Pre-treatment Evaluation
 A full history and physical examination, including a complete head and neck exam (mirror and fibreoptic exam, if needed)
 An evaluation by the members of a head and neck cancer team
 A biopsy of the primary site or FNA of the neck to confirm a diagnosis of cancer
 Imaging of the lungs to check for spread, if needed
 Imaging of the primary tumour and the neck with CT and/or MRI
 Maybe a PET-CT for advanced cancers
 Testing for HPV
 EUA with endoscopy as needed
 A dental evaluation with or without jaw x-rays
 Nutrition, speech and swallowing evaluation and maybe even a hearing evaluation
 Pre-treatment medical clearance and evaluation of medical conditions

Then your doctor will recommend a course of treatment for you, depending on several factors. As with all cancers in the head and neck, there are three general options to consider:
 Surgical removal (with or without reconstruction)
 Radiation (a few different types)
 Medications (chemotherapy and biologic medications)

For oropharyngeal cancer, there is not one clear treatment method. You should have an extensive discussion with your cancer team to decide upon the best treatment course for you personally.

T1-2, N0-1 For small primary tumours, with at most one lymph node on the same side as the primary tumour (T1-2, N0-1), the options for treatment are as follows:
• Radiation therapy
• Surgery to remove the primary tumour (see Pharyngectomy) with or without removal of lymph nodes from the neck one or both sides of the neck (see Neck Dissection)
• Radiation along with chemotherapy (for T2, N1 only)
• A clinical trial
If treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features, which include:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
For example:
• If there are no adverse features, then no further treatment is needed
• If there is one positive node without any adverse features, then your doctors might consider radiation therapy for you
• If there are adverse features, radiation, chemotherapy with radiation, or additional surgery will probably be recommended. Talk to your doctor for details
T3-4a, N0-1 These are locally advanced cancers, which means that the primary tumour is quite large. In this case, there are a few treatment options that your doctors will consider:
• Chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• For select patients, induction chemotherapy, followed by radiation
• For select patients, induction chemotherapy, followed by more chemotherapy along with radiation
• A clinical trial
Again, if treatment without surgery is chosen and there appears to be cancer left after treatment, then surgery should be performed to remove everything (see Pharyngectomy and Neck Dissection).
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
Then,
• If there are no adverse features (see above), then radiation will be added
• If the adverse features include spread of cancer outside of the capsule of the lymph node and/or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended
Any T, N2-3 This is a cancer involving either many lymph nodes in the neck, large lymph nodes in the neck, and/or lymph nodes on both sides of the neck and/or lymph nodes on the side of the neck opposite to the main tumour mass. There are a few options for the initial treatment:
• Chemotherapy along with radiation
• For select patients, induction chemotherapy, followed by radiation
• For select patients, induction chemotherapy, followed by more chemotherapy along with radiation
• Surgery to remove the main tumour and lymph nodes from the neck, followed by either radiation or chemotherapy with radiation, depending on pathology
• A clinical trial
If a non-surgical treatment is chosen as the first line, your doctor will determine whether the cancer is gone:
• If there is any cancer left at the primary site, then your doctor might recommend surgery along with a neck dissection
• If the cancer is gone from the primary site, then the lymph nodes in the neck will have to be evaluated. If at any point there is evidence of cancer in the neck, your doctor will likely recommend a neck dissection
If the first treatment that you and your doctor decide upon is surgical removal of the cancer, then the cancer must be analysed under the microscope to determine if additional treatment is needed. Your doctors will be on the lookout for any adverse features such as:
• Spread of cancer outside of a lymph node
• Cancer at the margins of the surgical removal
• A more extensive cancer than anticipated before the operation (pT3 or pT4, or N2 or N3)
• Positive nodes in level IV or V
• Perineural invasion
• Tumour inside veins
Then, If there are no adverse features (see above), then no additional treatment is necessary
• If the adverse features include spread of cancer outside the capsule of the lymph node, or if there is cancer at the margins of the surgical removal, then chemotherapy and radiation will be recommended
• If the adverse features are any of the others, then either radiation alone or radiation along with chemotherapy will be recommended
T4b, any N
Unresectable neck disease
Unfit for surgery In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.