Squamous cell cancer of the oropharynx is the most common type of oropharyngeal cancer. This information should be read with our information about head and neck cancers, which has more about the tests and treatments. Other rare types of cancer can develop in the oropharynx, such as salivary gland cancer, melanoma, lymphoma, small cell cancer and sarcoma. These are treated in different ways.

The oropharynx is the part of the throat directly behind the mouth. This area helps you speak and swallow. 'Oro' means mouth and 'pharynx' is the throat. The oropharynx includes the:

• soft part of the roof of the mouth (soft palate)
• base of the tongue (the part you can’t see)
• side walls of the throat (where the tonsils are)
• back wall of the throat (posterior pharyngeal wall).

  

Drinking alcohol and smoking or chewing tobacco increases your risk of oropharyngeal cancer. The risk is even higher if you do both.

Many cases of oropharyngeal cancer are linked to an infection called human papilloma virus (HPV). HPV is a common virus spread through skin contact, often during sex. Most people who are sexually active will have HPV at some time during their life. 

The body’s immune system is normally able to get rid of an HPV infection, and usually infections come and go without causing any problems. Most people with HPV in the mouth will not develop oropharyngeal cancer. But it's thought that, in some people, the virus can lie dormant for many months or even years before causing cell changes. These cell changes may develop into cancer. 

Eating a poor diet with low levels of fruit and vegetables may also increase the risk of oropharyngeal cancer.

Often the first symptom is a painless swelling or lump in the neck. Other common symptoms include:

• a sore throat or tongue
• earache
• difficulty swallowing or moving your mouth and jaw
• changes in your voice
• bad breath
• unexplained weight loss.

These symptoms can be caused by other conditions, but it’s important to have them checked by your doctor. Oropharyngeal cancer can be treated more successfully when it’s diagnosed early.

You usually start by seeing your GP. If they are unsure what the problem is, or think that your symptoms could be caused by cancer, they will refer you to a hospital specialist. If your only symptom is a lump in your neck, you may be referred to a hospital neck lump clinic.

At the hospital

The specialist doctor will ask you about your symptoms and general health. They will examine your throat using a small mirror and light. They may use a thin, flexible tube with a light and a camera at the end (nasendoscope) to get a better view of the back of your throat. The doctor passes the nasendoscope into your nostril. This can be uncomfortable, so the doctor may numb your nose and throat with a local anaesthetic spray first. If you have this spray, you should not eat or drink for about an hour afterwards, or until the numb feeling has gone.

To make a diagnosis, the doctor removes a small piece of tissue or cells (biopsy). A doctor who specialises in analysing cells (pathologist) examines the biopsy under a microscope to look for signs of cancer. The doctor may give you an injection to numb the area, then collect biopsies while they are examining you. Or they will arrange for you to have a general anaesthetic.

At the neck lump clinic

This is a one-stop clinic where you can have all the tests needed to check for cancer in a neck lump. You’ll usually have an ultrasound scan and a sample of tissue taken from the lump using fine needle aspiration. Sometimes your throat is also examined using a nasendoscope. The clinic can often give you the results of your tests on the same day, but sometimes you may need to wait longer.

Ultrasound scan

This test uses sound waves to produce a picture of your neck and lymph nodes on a computer screen. Lymph nodes are part of your body’s system to protect you from infection and disease. Sometimes oropharyngeal cancer can spread to the neck lymph nodes.

The scan is painless and only takes a few minutes. Some gel is spread onto your neck and a small device, which produces sound waves, is moved over the skin. The doctor will look for any changes in the size or appearance of the lymph nodes in your neck.

Fine needle aspiration (FNA) of the lymph nodes

You may have this test if the lymph nodes in your neck don’t feel or look normal on the scan. It is done to see if there are any cancer cells in the lymph nodes.

The doctor passes a fine needle into the lymph node and removes (aspirates) some cells into a syringe. This might feel a little uncomfortable but it’s very quick. You don’t usually need a local anaesthetic to numb the area. You might have an ultrasound scan at the same time to help guide the needle. After the test, a doctor will examine the sample under a microscope to check for cancer cells.

Other tests may be used to help diagnose oropharyngeal cancer and to check whether it has spread.

CT (computerised tomography) scan

A CT scan takes a series of x-rays, which build up a three-dimensional picture of the inside of the body. The scan takes 10–30 minutes and is painless. It uses a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It’s important to let your doctor know if you are allergic to iodine or have asthma, because you could have a more serious reaction to the injection.

You’ll probably be able to go home as soon as the scan is over.

MRI scan

This test uses magnetism to build up a detailed picture of areas of your body. The scanner is a powerful magnet so you may be asked to complete and sign a checklist to make sure it's safe for you. The checklist asks about any metal implants you may have, such as a pacemaker, surgical clips, bone pins, etc. You should also tell your doctor if you've ever worked with metal or in the metal industry as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body it's likely that you won't be able to have an MRI scan. In this situation another type of scan can be used.

Before the scan, you'll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm, which doesn't usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test you'll lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic. It's also noisy, but you'll be given earplugs or headphones. You can hear, and speak to, the person operating the scanner.

Staging

The stage of a cancer describes its size and whether it has spread. Knowing the stage helps doctors decide on the best treatment for you. The two most commonly used staging systems are the TNM and the number system.

TNM staging system

T describes the size of the tumour and whether it has grown into areas around the oropharynx. For example, a T1 tumour is small and only in the oropharynx, while a T4 tumour has spread into nearby areas, such as muscles or bones.

N describes whether the cancer has spread to the neck lymph nodes. N0 means that no lymph nodes are affected. N1, N2 or N3 means there are cancer cells in the neck lymph nodes.

M describes whether the cancer has spread to another part of the body. This is called metastatic cancer. M0 means the cancer hasn’t spread, and M1 means the cancer has spread to distant organs such as the liver or lungs.

Number staging system

Oropharyngeal cancer can also be given a number stage from 1 to 4.

Stage 1 - the tumour is 2cm or less and only in the oropharynx. This is called T1 N0 M0 in the TNM system.

Stage 2 - the tumour is between 2cm and 4cm and only in the oropharynx.

Stage 3 - the tumour is larger than 4 cm and only in the oropharynx or there is cancer in the oropharynx and in one nearby lymph node.

Stage 4 - the tumour has spread to other areas around the oropharynx and/or has spread into the neck lymph nodes and/or has spread to distant organs.

Talking about staging

Your doctor or nurse will be able to give you more information about staging. To keep things simple, they may use the following words:

• ‘Early’ and ‘local’ to describe a small cancer that is only in the oropharynx.
• ‘Locally advanced’ and ‘advanced’ to describe oropharyngeal cancer that is large, or has spread to other areas of the neck or neck lymph nodes.
• ‘Metastatic’ and ‘secondary’ to describe cancer that has spread to distant organs, such as the liver of lungs.

Grading and testing for HPV

Doctors will look at a sample of the cancer cells under a microscope to find the grade of the cancer. They may also test if the cancer was caused by the human papilloma virus (HPV). The grade and HPV result gives the doctor an idea of how a cancer may develop and how different treatments are likely to work.

Grade 1 – the cancer cells tend to grow slowly and look quite similar to normal cells

Grade 2 and 3 – the cancer cells look more abnormal

Grade 4 – the cancer cells tend to grow more quickly and look very abnormal.

Your treatment will depend on the stage and grade of the cancer as well as your general health. Your specialist doctor plans your treatment carefully. The aim is to treat the cancer while doing as little damage to your throat and appearance as possible. They will talk to you about the best treatment options for you and any likely side effects.

Treatments used for oropharyngeal cancer include surgery, radiotherapy, chemotherapy and targeted therapy. If you have a small, early stage cancer, you may be treated with either surgery or radiotherapy. If the cancer is larger or has spread to the lymph nodes, you will usually have a combination of treatments. Often chemotherapy and radiotherapy are given together. This is called chemoradiation. Some people have surgery followed by radiotherapy or chemoradiation.

Surgery

Surgery can be used to remove early stage oropharyngeal cancer. Sometimes surgery is used to treat more advanced stages of oropharyngeal cancer.

How the surgeon removes the cancer depends on its size and where it is. They will explain the operation to you beforehand, and you will be able to ask any questions you have about it.

For small cancers, it may be possible to do the operation through the open mouth. This is called transoral surgery. The surgeon uses a thin flexible tube with a light and camera at the end (endoscope) to see the throat clearly. They then carefully remove the cancer, often using a small laser. Transoral surgery doesn’t leave any scars on your neck or face. You may also recover faster, and have fewer problems with your speech or ability to swallow.

If the cancer is larger or in a difficult position, the surgeon may do the operation through a cut on the neck. Sometimes they need to remove part of the jawbone or tongue to remove the cancer. The surgeon may use tissue, skin or bone taken from somewhere else in the body to rebuild these areas.

The surgeon may also remove some lymph nodes from your neck. Again this is done through a cut on the neck. They may do this to remove cancer that has spread to the lymph nodes, or to reduce the risk of the cancer coming back.

How long you stay in hospital depends on the operation you need. If your surgery is more complicated, you might stay in hospital for up to three weeks. You may be looked after in a high dependency unit or intensive care for a while after the operation.

Effects of surgery

Depending on the type of operation you have, your speech, swallow or your sense of taste and smell might be affected. Some operations may leave scars or a change in your appearance. Your surgeon will explain what to expect. A speech therapist will help you to cope with any changes to your speech or swallow. You can read more in our general information about head and neck cancers. You may also find some of these organisations helpful:

• Changing Faces supports people who have conditions or injuries which affect their appearance. It offers a skin camouflage service for people living with scarring or a skin condition that affects their confidence.
  Tel 0300 012 0275 (Mon-Fri, 10am- 4pm)
  Email info@changingfaces.org.uk
• Let’s Face It is a support network for people with facial disfigurements.
  Tel 01843 833724
  Email chrisletsfaceit@aol.com
• Saving Faces has an expert patient helpline that puts people in touch with someone who’s had the same condition or similar surgery.
  Tel 07792357972 (Mon-Fri, 9am-5pm)
  Email helpline@savingfaces.co.uk

Radiotherapy and chemoradiation

Radiotherapy uses high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal tissue.

Radiotherapy can be given on its own with the aim of curing an early cancer. It may also be used in combination with surgery, chemotherapy or targeted therapy to treat larger cancers and cancer that has spread to lymph nodes.

Radiotherapy can be used after surgery to reduce the risk of the cancer coming back. The lymph nodes in your neck are often treated even if there are no signs of cancer there. Again, this reduces the risk of cancer coming back.

Chemoradiation is often used as the main treatment for locally advanced oropharyngeal cancer. It may also be given after surgery. Having chemotherapy and radiotherapy together is more effective than either treatment alone. However, the side effects are also worse during treatment. It’s important that you're well enough to cope with having both treatments together.

You have radiotherapy as a series of short, daily sessions (called fractions) over 4–7 weeks from a machine similar to a large x-ray machine. Radiotherapy only treats the area of the body that the rays are aimed at. It doesn’t make you radioactive. If you are having radiotherapy to control symptoms of advanced cancer, such as pain, you might only need a few days of treatment or even just a single dose.

A newer way of giving radiotherapy called intensity-modulated radiotherapy (IMRT) is available in some hospitals. With IMRT, the radiotherapy beams are shaped very precisely to the area of cancer. This makes sure that a higher dose of radiation is given to the tumour, while healthy areas nearby get a lower dose of radiation. IMRT may have fewer side effects (such as dry mouth) than other types of radiotherapy.

Side effects of radiotherapy

You may develop side effects during radiotherapy. These usually disappear gradually over a few weeks or months after treatment finishes. Your radiotherapy team will let you know what to expect. Tell them about any side effects you have. There are often things they can do to help.

Your radiotherapy team will give you advice about skin care during treatment. It’s common to have a skin reaction in the area of your face and neck being treated. The skin can become sore, red and may peel or become blistered. This usually starts about 2–¬3 weeks after treatment starts and may last for three or four weeks after treatment ends. Let your radiotherapy team know if your skin becomes sore. They can give you painkillers, and advice about caring for your skin until it heals.

It’s also important to look after your mouth during radiotherapy. Following a mouth care routine to keep your mouth clean will help to prevent problems. Your mouth and throat may become sore after a couple of weeks of treatment. You may get some mouth ulcers and your voice may become hoarse. You might find your sense of taste and smell change. Eating food can become difficult and swallowing can be painful. Your doctor can prescribe medicines to help.

If you find it hard to eat and drink because of any side effects, let your doctor or nurse know. They can give you advice and medications to help. They may refer you to a dietitian for more advice. You may need food supplements to add extra energy and/or protein to your diet. Some can be used to replace meals, while others are used in addition to your normal diet. Although a few of these products are available directly from your chemist or the supermarket, your doctor, nurse or dietitian can also prescribe them for you.

Some people will need further treatment in hospital for a short time to help with side effects. For example, if you need more help to control pain or need to be fed through a tube because you can’t eat and are losing weight. Tube feeding, known as enteral nutrition is usually only done for a short time until treatment is finished and your swallowing is back to normal.

Radiotherapy also affects your salivary glands. Your saliva may become thicker, stringy and sticky. Your mouth and throat may also feel dry, which can make eating and talking difficult. Your doctor can prescribe mouthwashes, lozenges, artificial saliva sprays or gels to help. Changes in your saliva usually get better within about eight weeks of radiotherapy ending.

Most side effects get better after treatment ends. But, many people continue to have a dry mouth after treatment is over. Radiotherapy to the head and neck can cause other long term effects. These aren’t as common, but can happen months or even years after your treatment.

Our general information about head and neck cancer has more about radiotherapy, coping with side effects and the long term effects.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. For oropharyngeal cancer, it’s usually given with radiotherapy. Chemotherapy may be given alone if cancer has spread to other parts of the body.

Side effects of chemotherapy

The side effects depend on the drug or combination of drugs you are given. Your doctor or nurse will explain any treatment you are offered and what to expect.

The chemotherapy drugs most often used to treat oropharyngeal cancer are cisplatin, fluorouracil (5FU), carboplatin, docetaxel (Taxotere®) and paclitaxel (Taxol®). These are usually given into a vein (intravenously).

Chemotherapy drugs can reduce the number of white blood cells in your blood during treatment. This will make you more likely to get an infection. Your doctor or nurse will give you advice about what to do if this happens.

Chemotherapy can also cause side effects such as feeling tired, a sore mouth, feeling sick (nausea) or being sick (vomiting), diarrhoea and hair loss. Let your doctor or nurse know about any side effects during treatment. They can often give you advice and help to reduce these.

We have more information about coping with the side effects of chemotherapy and about different chemotherapy drugs.

Targeted therapies

Targeted therapies are drugs that target the differences between cancer cells and normal cells. Cetuximab is the most commonly used targeted therapy to treat oropharyngeal cancer. This drug may stop the cancer cells growing and dividing. It may also make the cancer more sensitive to the effects of radiotherapy. It’s given as a drip (infusion) into a vein once a week. You might have this with radiotherapy if you can’t have chemoradiation, or with chemotherapy to treat cancer that has spread or come back.

Side effects of cetuximab

The most common side effect of cetuximab is a skin rash on the face, neck or body. This may begin during the first three weeks of treatment. Your specialist nurse or doctor will give you advice on what can help. It usually goes away completely when treatment stops.

Cetuximab may cause an allergic reaction while the drip is being given. This is more common with the first treatment, so you have the first dose slowly over a few hours. The nurse will give you drugs to help prevent or reduce this. If you have a reaction, they will treat it quickly.

Signs of a reaction can include:

• a headache
• high temperature or chills
• a rash
• feeling itchy, sick, breathless or unwell
• having pain in your back, tummy or chest.

Tell your nurse straight away if you have any of these symptoms. Rarely, a reaction can happen a few hours after treatment. If you develop any of these symptoms or feel unwell after you get home, contact the hospital straight away for advice.

After your treatment is completed, you will have regular check-ups and possibly scans or x-rays. These may continue for several years. If you have any problems or notice new symptoms between these times, let your doctor know as soon as possible.

You may have many different emotions, from shock and disbelief to fear and anger. At times, these feelings can be overwhelming and hard to control. But they are natural and it’s important to be able to express them.

For some people, it takes several months to recover from treatment for oropharyngeal cancer. It can be hard to cope with the thought of having treatment that may change your appearance, voice or how you eat and drink. Talking to other people in a similar position may help you feel less alone. Our online community is also a good place to meet people who may be in a similar situation.

Everyone has their own way of coping. Some people find it helps to talk to family or friends, while others get help from people outside their situation. You may want to talk to our cancer support specialists free on 0808 808 00 00, Monday–Friday, 9am–8pm. Help is available if you need it.

Some of these organisations may be able to help you cope with your feelings:

• The Mouth Cancer Foundation gives information and support through their website and telephone helpline to people affected by head and neck cancers.
  Tel 01924 950 950 (Mon–Fri, 9am–5pm)
  Email info@mouthcancerfoundation.org
• The Rarer Cancers Foundation provides guidance, information and support for people affected by rare types of cancer.
  Tel 0800 334 5551
  Email patientsupport@rarercancers.org.uk