Brad Morris M.D., Otolarnygologist
Overall, head and neck squamous cell carcinoma rates have been slowly declining, but human papilloma virus (HPV) related oropharyngeal cancer has been on the rise. The American Cancer Society estimates that over 45,000 people will be diagnosed with oropharyngeal cancer in 2015. Currently, it is the 8th most common cancer in men.
What is the Oropharynx?
The oropharynx consists of the tonsils, the soft palate, the posterior pharyngeal wall, and base of tongue. Most of this area is visible, but often parts of the tonsils and a large portion of the base of tongue cannot be seen by directly looking into the mouth. A more detailed head and neck exam with a mirror or flexible scope is required to exam these areas. When the linings of the mouth and throat become damaged at the DNA level, squamous cell carcinoma can develop leading to uncontrolled growth and spread.
Symptoms of Oropharyngeal Cancer
The most common signs or symptoms include: persistent sore throat, bad breath, red or white patches in the back of the throat, a feeling of something stuck in the throat, neck mass, numbness or weakness of tongue, coughing up blood, hoarseness, changes in speech, fatigue, unexplained weight loss, difficulty opening the mouth, and unexplained one-sided ear pain.
Several risks factors have been linked to developing oropharyngeal cancer. Tobacco use, particularly smoking, is the strongest risk factor. Eighty-five percent of all head and neck cancers can be linked to tobacco use, which includes oropharyngeal cancer. Heavy and frequent alcohol abuse has also been linked.
For years, the majority of head and neck cancers were linked to smoking and alcohol. However, in the last few decades, a rise in non-smoker oropharyngeal cancer revealed human papillomavirus (HPV) related cancers. Currently, 70% of all oropharyngeal cancers are HPV related, which is increased five-fold over the last two decades. HPV is a sexually transmitted virus that has many different subtypes. Certain types cause genital warts, while other types cause cervical cancer in females. These strains are the same, which cause oropharyngeal cancer. Statistics show that close to 90% of adults have been exposed to HPV and 70% show evidence of a previous infection. Increased risk of exposure to the virus comes from increase number of sexual partners and oral sex.
Other risk factors include: poor oral hygiene, poor nutrition, a weakened immune system, and marijuana use.
Evaluation for Oropharyngeal Cancer
Patients with signs or symptoms of oropharyngeal cancer need to be examined by an otolaryngologist (ENT specialist). A thorough head and neck examine will determine further workup. Imaging is often obtained with CT scans, MRIs, and CT PET scans. Fine needle biopsies are performed if lymph nodes in the neck are involved with cancer. Surgery is often required to diagnose the exact location of the tumor with biopsies or even a tonsillectomy. All biopsies are tested for HPV.
The primary goal of treatment is cure by maintaining voice and swallowing function. Radiation therapy with chemotherapy has become the mainstay treatment for years. Surgery can play a role in early stage disease and in cases of treatment failure.
The prognosis, as with all cancers, depends on the overall staging. Early stage oropharyngeal cancer has 5-year survival data of 83%. Survival decreases with more advance staging. HPV status has also been shown to indicate improved survival. HPV-positive tumors are thought to be more radiation sensitive. Some experts also suggest the HPV-positive cancers are often found in younger, healthier individuals which makes for a better chance of survival.
The primary prevention method is healthy lifestyle choices to prevent oropharyngeal cancer. Smoking cessation, alcohol in moderation, and limiting sexual partners to reduce risk of HPV exposure are the most important. Other measures include: good oral hygiene, healthy diet, and exercise. Screening methods other than a standard physical examination are currently not available. Efforts to control HPV-related cancer may be improved with increased vaccinations of adolescents and young adults with the HPV vaccines. The vaccine has not been available long enough to provide a decline in cancer, but maybe in the next 50 years it will show promise. Also, it is important to understand the vaccine will not help in treatment of already diagnosed individuals.
A multidisciplinary approach is taken with all patients diagnosed with oropharyngeal cancer. The team of providers includes: Otolaryngologists, Radiation Oncologists, Oncologists, Radiologists, Oral surgeons, Dentists, Nutritionists, Speech therapists, etc.
American Cancer Society
NIH National Cancer Institute