What is Oropharynx Cancer?

Cancer of the oropharynx includes that behind the last molar ("wisdom tooth"). It is thus distinct from " oral cavity" areas in front of the last molar, that is in the mouth. The specific areas, or "subsites" of the oropharynx are the tonsils, tonsilar arches, soft palate, walls of the pharynx, and the base and first 1/3 of the tongue. The front 2/3 of the tongue is in the oral cavity, and thus considered a different area for medical purposes. Thus, cancers of areas behind the last molar, but above the windpipe (larynx) and foodpipe (esophagus), are oropharynx cancer. Cancers of our 3 major salivary glands (parotid, submaxillary, sublingual) are considered separately, as well as those of the jaw bones, muscles and thyroid. In practice, it is important to identify the area the cancerarose from, even if it subsequently spread to other areas. Some-times, a cancer will start in the mouth or larynx but extend into the oropharynx. It is the area it originally arose from which determines what type of cancer it is. In practice, the most common types of cancer to arise in the oropharynx are from the tonsils and tongue base , and most research has been done on therapy for these areas.

Cells in the throat are subjected to lots of injury from heat and abrasion, and thus must divide frequently to replace those lost due to injury and old age. Normally, cells divide quickly as we develop in the womb and through infancy, and then the rate slows
down considerably, just to replace cells that die. The division of cells in the throat and elsewhere is under very tight control, regulated by the genes within the cells. Cancer starts in a single, abnormal cell unable to control it's division processes. When this control is lost, the cell may start to divide in a haphazard, uncontrolled manner, creating many similar altered cells, and grow to form a swelling of abnormal cells, called a "tumor". A"benign" tumor only grows within its local area, it does not spread to distant organs, and it is not cancer. In contrast, a "malignant"tumorcan spread to any area of the body,it is cancer. It is this ability to spread, or"metastasize", to vital organs which makes a cancer so dangerous. Cancers of the throat tend to grow to large sizes locally before they spread, but any cancer can spread at any time.

How Common is Oropharynx Cancer?

Each year in the United States there are about 8,000 new cases of oropharynx cancer leading to3,000 deaths annually from this disease. Men are affected twice as often as women. Overall, oropharynx cancer represents about 1% of all new cancers each year. There are about 150,000 new cancers of the entire head and neck area each year, which causes 20,000 deaths annually. This is important since a person who gets one cancer of the head and neck area is at markedly increased risk to develop another one in a different area (that is another "primary"). It is also more common in those who have (or had) lung , pancreas, esophagus or colon cancers. Oropharynx cancer is more common in blacks than whites, and in those of "lower socioeconomic status" (poor people). The average patient is 60 years old.

What Causes, or Increases Risk for Oropharynx Cancer?

Like any cancer, the exact reason why one person gets oropharynx cancer and another does not remains unknown. However, several"risk factors" have been shown to be be much more likely to be present in mouth cancer patients:

Tobacco Usage is the single strongest risk factor for developing cancers of the head and neck, and especially mouth, esophagus, and oropharynx . Any form of tobacco taken through the mouth, whether smoked or chewed, increases the risk over time. It often takes several decades of use to get cancer but children who use chewing tobacco (often to emulate famous baseball players) have gotten mouth cancer. The more tobacco that is used, for a longer period of time, the higher the chance to get mouth cancer. Likewise, when use is stopped, the risk declines almost to normal over a 5 to 10 year period.

Alcohol Usage is the next strongest risk factor after tobacco. Occasional wine or beer may raise risk very slightly, if at all, but frequent use of strong drinks like whiskey will increase cancer risk to the mouth, throat, esophagus (food pipe), stomach and pancreas. Furthermore,combiningalcohol with tobacco will have a super additive" effect to greatly increase cancer risk for all of these areas. This means that the risk is much more than twice as high as for using either tobacco or alcohol alone. Like tobacco, people who stop frequent drinking will gradually lower their cancer risk to nearly that of non-drinkers.

Poor Oral Hygiene The more unclean the mouth and throat are, the more it is subject to constant irritation from grime. Each teaspoon of saliva contains about one billion bacteria, which are making waste products which cling to teeth and tonsils ("plaque"). This allows gum disease (pyorrhea) to lead to subsequent tooth loss. Although plaque itself is not showto cause cancer, it helps other chemicals (like in smoke) to stick in the mouth and throat, irritate it, and stimulate the cells to divide. The more cells divide, the more chance one of them will become cancerous. That is why the common thread of many risk factors is irritation, leading to lots of cell division.

Ill-Fitting Dentures irritate the gum lining ("gingiva") and trap debris. This can lead to tongue cancers over time.

Betel-Nut Chewing in Indian populations is strongly associated with tooth loss, mouth and throat cancer, again the common factor is prolonged irritation.

Infections such as syphilis and some viruses can lead to cancer over time, these cause throat sores which heal poorly. The constant attempt to heal leads to chronic cell division and thus more chance for cancer. Viruses can also get into the mouth cells themselves and change the genes in them to form a cancer cell. This elaborate process is called "oncogene activation".

Lowered Immunity such as from AIDS or transplant anti-rejection drugs will increase the risk for many cancers, including those of the "aero-digestive tract" (i.e. the area from the nose and mouth to the lungs and stomach). This will be especially important in combination with the other risk factors noted above.

Precancerous "Plaques" can develop in the mouth and throat, from chronic irritation. These may be white in color ("leukoplakia") or red (erythroplasia") and may or may not become cancerous. They must be monitored closely.

History of Cancer of the aero-digestive tract can mean as much as 5% chance of a separate simultaneous cancer, and a 25% chance of developing another cancer in this area over time (especially if risks like smoking are continued).

What are the Symptoms of Oropharynx Cancer?

A cancer must grow to 1 billion cells to be just 1 cm. (about 1/2) across, so a very early cancer will have no symptoms and likely go undetected. As it grows, it produces symptoms in it's local area, and eventually in distant areas as it spreads. A throat cancer may be first noticed by the patient or their dentist, with these possible findings:

1) A Sore that Doesn't Heal is one of the American Cancer Societies "7 signs of cancer" and the most frequent symptom of mouth cancer. It can be flat, raised or a pit (ulcer), and is usually hard and not very tender. It tends to grow slowly.

2) Local Pain is possible as the tumor enlarges, especially if it invades nerves. The throat shares nerves with the ears , so some deep cancers cause pain in
these areas ('referred pain"). Interestingly, the further back in the mouth or throat a cancer arises, the deeper in the ear the pain appears.

3) Difficulty Chewing, Swallowing or Speaking is caused by mechanical factors the tumor enlarges. Dentures may not fit anymore; one side of the face or neck may become swollen. If a duct from a salivary gland is blocked, it may also swell. The patient may lose weight from difficulty with eating.

4) Swelling in the Neck is possible as the lymph nodes in the neck are invaded. The chance for this increases with enlarging cancer and those near the mid-line of the throat; at diagnosis as many as 80% of patients may have spread to neck ("cervical") lymph nodes. This swelling is usually firm and painless. Neck lymph nodes can also swell up from non-cancerous conditions such as infection, so swelling alone does not prove cancer. However, larger, harder and more persistent swellings are more likely to be cancerous.

5) Nerve Syndromes result from lymph nodes getting invaded by cancer, then enlarging and pressing upon crucial nerves for the face. The nerves then fail. Two particular syndromes include the Jacod's (leading to trouble with facial expression, eye and jaw movement) and Villaret's (trouble swallowing and tongue and neck movement problems). These will worsen if untreated.

6) Distant Spread Symptoms are uncommon with mouth cancer until the tumor has grown very large locally and spread to lymph nodes in the neck. Cancer can spread to any area in the body, but most likely goes to lung, liver, bone brain. New symptoms in these areas are very suspicious for spread in the patient with a large throat cancer. The chance of distant spread from a small cancer (< 3 cm.) is less than 2%, so an extensive procedure to look for symptomless spread to distant body areas is not warranted.

How Does Oropharynx Cancer Spread?

The behavior of a disease in the average patient is called it's "natural history". Recall that cancer starts in a single cell, which divides in an uncontrolled manner to make millions and billions of copies of itself. It generally starts on the surface of the mouth (the "mucosa") and gradually penetrates deeper. As it goes deeper, it can invade lymphatic channels and spread to local lymph nodes in the neck. It may invade nerves and cause pain, and into the underlying bone to destroy it. Commonly, an untreated throat cancer will grow larger and larger in it's local area ultimately become a huge, infected and bleeding mass. It may then protrude through the skin to form a gaping and seeping wound, and spread via the bloodstream to distant organs.

How is Oropharynx Cancer Diagnosed and Evaluated?

The only way to absolutely diagnose any cancer is to get a piece of it ("biopsy") and analyze it under the microscope. A pathologist examines the biopsy specimen, this is a physician who specializes in making diagnoses from tissue samples. The usual steps in the evaluation of a suspected mouth cancer include:

Physical Examination is done carefully and includes a meticulous description of the tumor, including it's location, size, color, texture, and whether it is "fixed" to underlying tissue or can be moved about. The doctor looks for white patches ("leukoplakia") and reddish patches ("erythroplasia") which may be pre-cancerous areas. The condition of the teeth are noted. A thorough exam of the neck is always done, noting any enlarged enlarged glands which may represent the cancer spreading to lymph nodes. The back of the throat is examined, and a mirror is used to visualize the vocal cords ("indirect laryngoscopy"). The nerves which arise from the brain (12 of them called "cranial nerves) supplying the face, eyes ears nose and throat are tested to look for signs of nerve invasion or compression by cancerous lymph nodes. Naturally, it is also appropriate to do a complete exam of the rest of the body to assess general health and look for signs of distant cancer spread.

Endoscopic Examination means placing a visualization tube under light local anesthesia into the nose and down the throat. The preferred procedure is a "triple endoscopy", which looks at the nose, esophagus and larynx (voicebox). This procedure is usually performed by an Ear, Nose and Throat doctor ("ENT" or "otolaryngologist"). Clear endoscopic visualization of the larynx is called "direct laryngoscopy" and is performed after spraying some mild numbing medicine (lidocaine) into the throat to help prevent irritation and gagging. A biopsy is taken of any suspicious areas, and sometimes "blind biopsies" are taken of areas most likely to develop cancer (such as the tonsil). This is done since, as mentioned, 5% of patients will have a "second primary" when they come to medical attention-- that means another simultaneous cancer. Endoscopy is a very safe procedure, and is the clearest way to actually look at tissues of the aero-digestive tract.

Blood and Urine Tests are standard pre-operative ones to assess general health; there are no special blood tests ("tumor markers") yet to detect spread of squamous cell cancer as there are for some other cancers. Routine tests include Complete Blood Count("CBC") to look for anemia and infection. A Blood Chemistry Panel ("SMA") measures sodium, potassium, blood sugar, cholesterol and liver and kidney function. If a major surgery is contemplated, blood tests for clotting ability (PT, PTT and bleeding time ) are standard. A Urinalysis(UA) to check for protein, blood or infection completes the lab tests.

Imaging Tests are done in the radiology department and standardly include a Chest X-ray to look for signs of infection or lung tumors. Special imaging of the head and neck is often obtained; a"panorex" is a series of jaw X-rays which is excellent for detecting spread of cancer to local bone. A CT scan in "thin slices" of the tumor area helps define the extent of the tumor, and is excellent for looking for spread to lymph nodes behind the pharynx which cannot be detected on standard physical exam. Another excellent test to study the soft tissues in the neck is the more expensive Magnetic Resonance Imaging (MRI) scan. MRI, which uses magnetism instead of radiation, allows the area to be viewed in three dimensions. It is great for looking at the tumor as well as checking local muscle, cartilage and nervesfor signs of invasion by cancer. Contrast material can be injected into the bloodstream prior to either CT scan or MRI, the contrast runs through and highlights blood vessels. If getting a CT with contrast, ask for "omnipaque" contrast; other types are less expensive but more likely to cause an allergic reaction. For MRI scans, a different type of contrast, called "gadolinium" is used.

Other more exotic tests are only obtained in the presence of suspicious symptoms. For instance, a bone scan is gotten if there is new bone pain, a CT of the Chest and Abdomen is ordered if the plain Chest X-ray appears to show tumor in the lung, and a CT of the Brain is gotten if new neurological symptoms occur. There are special tests which can be ordered to look at just about any area of the body-- but only if necessary.

Biopsy of the tumor is crucial, since only by examining an actual piece of the tumor under the microscope can a diagnosis of cancer be made, and then the particular type known with certainty. For a very small tumor, the whole of it may be removed, along with a "safety margin" of surrounding normal tissue, and sent for evaluation ("Excisional Biopsy"). For a larger tumor, a cut is made into it so some tissue can be removed for examination ("Incisional Biopsy"). It usually takes several days (of anxious waiting) for the pathology report to come back.

What are the Types of Oropharynx Cancer?

Over 95% of cancers in the throat arise from the surface lining ("mucosa") which is made up of a type of cell called "epithelial"."squamous cell carcinoma". Thus, almost all cancers in the throat are this squamous cell carcinoma type. Much less common (<2%) the small saliva gland in the palate or inside of the cheek become cancerous, this type is then called"adenocarcinoma". More rare still are cancers arising from the immune system cells in the mouth("lymphoma") or the muscle, bone or cartilage("sarcoma") , the therapy for these cancers follows that of when they occur elsewhere in the body (where they are more common). Since thesquamous carcinoma type is by far the most common, the treatments to be discussed here are for it.

How is the Extent of Oropharynx Cancer Guaged?

Like all cancers, the extent of throat cancer is given by the"stage". These stages were developed by the American Joint Committee on Cancer (AJCC) to help make appropriate treatment decisions, and tally the results of therapy for various levels of disease. The stage grouping for mouth cancer is:

In general, cancers of the tonsil and soft palate do better than the base of the tongue or wall of the pharynx; that is that the deeper into the throat an oropharynx cancer is located, the more poorly it tends to do. Similarly, cancer near the front of the mouth tends to do better than that at the rear of the mouth. One obvious reason for these trends is that is easier to discover and treat cancers closer to the lips than deep within the throat. Cancers deeper in the throat tend to be larger, and more likely to have spread to lymph glands, when first discovered. The average 5-year survivals given above include anything the patient may pass away from, including heart attack, strokes and other cancers. Many patients do much better than the above numbers with the latest effective treatment. Fortunately, there has been an overall improvement in survival over the past 20 years.

What is the Conventional Treatment for Oropharynx Cancer?

Conventional treatment for oropharynx cancer involves surgery and radiation therapy, and often both together for more advanced cancers. Chemotherapy is in itself not curative for squamous cell carcinoma, but may be used as an "adjunct" (extra therapy) along with radiation and surgery to improve cure rates. It may also prevent new cancers from arising in the area. The specifics of each therapy is now described:

Conventional Treatment:

Surgery is a possible way to deal with small (i.e. stage I and II) cancers which have not spread. It also has it's place in more advanced cancers, when combined with other treatment. If all the cancer removed at surgery, the patient will be cured. The surgery is performed by an "otolaryngologist", that is a head and neck surgeon (an ENT who specializes in cancer surgery). The chance of being able to remove all of the cancer decreases as the tumor gets larger and lymph nodes are involved. Two other important considerations in surgery are not comprising function (i.e. drastic surgery which leaves the patient unable to speak or swallow) and cosmesis (how the patient looks after surgery). Heroic operations to remove large cancers are rarely successful, since the cancer has usually spread by this time to structures that the surgeon cannot safely remove. Patients themselves usually do not want an operation that cuts out the tongue, or leaves their appearance socially unacceptable. Fortunately, advances in surgical techniques, such as plastics and using tissue from other body areas to fill in gaps, have been developed. The following are some considerations for surgery:

For small cancers, either surgery or radiation are generally equally effective, but only one of these "modalities" should be used. The other treatment is then saved for "salvage" if the initial treatment fails. There is no sense in giving the side-effects of both therapies if not necessary. If the patient is in decent medical condition, then surgery will be recommended first. The cancer is removed with with a wide "safety margin" of surrounding normal tissue, and sent to pathology for confirmation of "clear margins" (meaning no cancer specimen's edge). If there is suspicion of neck lymph node involvement, a"neck dissection" can be done to look for disease there; this leaves skin scarring. Overall, surgery for small cancers is quick, with healing time of several weeks and high cure rate.

If the cancer has not been totally removed at surgery, either at its original site or in the neck, then subsequent radiation therapy will be necessary for cure. The chances for successful surgery are best for cancers in the tonsil region . When cancer involves the base of tongue, total tongue amputation ("radical glossectomy") is the only good cancer operation, but leaves the patient unable to speak and taste. For pharyngeal wall and soft palate cancers, it is difficult to get a good "margin" (cancer-free area) around the cancer, and the chance of spread to lymph nodes is high (as much as 80%). Thus, radiation (as will be described) is the common therapy recommended for cancer in these areas, even when it is stage I. However, bear in mind that success for any surgery will depend upon the skill and experience of the surgeon, and there are often vast variations in experience (and daring) between different surgeons. Many otolaryngologists are much more comfortable treating allergies and infections than cancer, so when getting a surgical opinion make sure the surgeon is a cancer specialist.

For larger cancers (stage II, III and locally advanced stage IV) both surgery and radiation are needed for the best chance of cure. The goal of surgery is to help restore function immediately (as when swallowing has been blocked by a large tumor) and to try to remove all "gross disease" (that which can be seen and felt).

Radiation treatment is then used after the operation to mop up residual disease. The extremes to which surgery are taken depend upon the likelihood for cure, and the effectiveness of radiation for destroying remaining microscopic disease. Surgery is indicated for large primary tumors and lymph nodes larger than 3 cm. in the neck, since a high enough radiation dose to eradicate these will cause unacceptable side effects (see section on radiation therapy). In general, when we really don't know if that is cancer or not. While a CT scan of the chest will help define the shape of the abnormality, only an actual biopsy of it (commonly done in the radiology department under CT guidance) will prove if it's cancer or not. These "staging procedures" are crucial to determine the proper therapy. If spread cannot be proven (but is possible), or is very small and removed, the patient in good general condition may want to be aggressive, and get major surgery. It is possible that control of the local disease in the mouth will lengthen lifespan, and it will certainly improve daily life. Some surgeons are willing to be much more aggressive than others, and the key is to pick a highly experienced cancer surgeon and be comfortable with them. Commonly, however, a patient with evidence of distant spread will be referred for radiation treatment, with the addition of chemotherapy if cure is the goal.

Radiation Therapy has been used for eight decades for many cancers, including those of the mouth. In fact, radiation is quite successful in treatment of throat cancer; for small tumors it isequally effective as surgery, and for larger tumors in poorly accessible areas it is more effective than surgery. Radiation may be given alone, or be added to surgery ("adjuvant therapy") . It may be combined with chemotherapy, or all three methods of surgery, radiation and chemotherapy can be offered together ("multimodality therapy") . Radiation is prescribed by a "radiation oncologist", who is a cancer doctor specializing in it's administration. It can be given in several forms, most commonly a series of "external beam" treatments with photons or electrons. Less commonly for the head and neck region, actual radioactive sources can be implanted for a period of time ranging from hours to days to kill cancer cells ("brachytherapy"). Occasionally patients have both methods utilized.

After being seen in consultation by the radiation oncologist, the patient getting external beam treatment is scheduled for"simulation".

X-rays are taken to confirm positioning. A CT scan may be gotten in conjunction with the simulation. Information from the simulation, along with other scans, is fed into a "treatment planning computer" and a "plan" is generated. This plan tells how much radiation is going to the cancer, and how much to local normal tissues. Special lead "blocks", which fit into the head of the treatment machine, determine the shape of the radiation field administered. The patient then returns to the department for their "treatment start", which takes about 45 minutes. They lay upon a hard table in a shielded room, and are aligned with laser lights shone upon the marks on the mask. The actual machine which delivers photons or electrons is called a "linear accelerator" or "Linac" for short; occasionally Cobalt-60 machines are still used. The head of the machine pivots around the patient, so they stay perfectly still during the treatment, even as the radiation is delivered from various angles. The actual treatment only takes several minutes per day, and is usually given from Monday through Friday for 6 or 7 weeks. The usual dose is 60 to 75 Gray (units of radiation) to the actual tumor, with less to surrounding tissues. This is given in"fractions" of about 2 Gray per treatment, accounting for the 7 or so weeks of total therapy. For head and neck cancers, a combination of photons and electrons is often utilized. High energy photons (about 4 to 10 Million volts) will penetrate very deep, and tend to spare the skin, while high energy electrons give shallower dose to "boost" up the dose the the more superficial tissues. The "plan" from the simulation helps determine the optimal mixture of photon and electron dose. If a treatment day is missed, it is simply tacked onto the end so that the same total prescribed dose is given. The actual treatment is given by "radiation therapy technologists", or R.T.T.'s, who are supervised by the physician. A radiation physicist checks over the treatment plan as a safety measure.

Radiation is usually very well tolerated, treatments themselves are painless . The side-effects of localized radiation are generally only within the area treated. That is, patients will lose scalp hair only if the actual scalp is treated, or become sterile only if the testicles or ovaries are treated. The side effects of radiation are thus specific for the area treated, and are divided into"acute" and "late"acute reactions, which start after about a week of treatment, include skin reddening and irritation; this may progress to frank peeling. Special salves or steroid creams may be prescribed to alleviate this. A foreign, "metallic" taste may be noted in the mouth, and the saliva thickens. The salivary glands may initially swell, and mouth dryness occurs as the dose to these glands builds up. Soreness in the mouth and throat may be quite painful, and require special numbing agents (viscous lidocaine) to make eating less uncomfortable. Mild narcotic may be needed for relief.

Weight loss is common with treatment for head and neck cancers, so nutrition must be carefully monitored. Some patients even require a temporary feeding tube ("PEG") placed through the abdominal wall and into the stomach during treatment. This tube is removed when the acute radiation reaction subsides. Mouth and throat pain may be increased by fungal infections, like thrush, which are more likely during radiation. Hair on the face is lost during treatment, but a man's beard will usually grow back, albeit thinner. There is often a sense of fatigue during the therapy period. Overall, treatment is not pleasant, but is made more tolerable by prescribing relieving medications as appropriate. People differ in their tolerance to radiation, and to really effectively kill the tumor cells, it is necessary to get an acute reaction showing that both cancer and normal cells in the mouth are dying. The normal ones can be repaired and replaced, but not the cancerous ones. This is why radiation works.

The matter of more ultimate concern is "late" reactions, for these may stay with the patient indefinitely. The frequency and severity of late reactions are less when therapy is given as many small fractions, and this is why we take many weeks to give it all. The most common late reaction from treatment of throat cancer is dry mouth, called "xerostomia" in medical parlance. This is due to damage to salivary glands, which then produce a thickened, whitish saliva. Artificial saliva ("salivart"), pills which will stimulate saliva ("pilocarpine"), humidifiers and plain spray bottles may be tried to moisten the mouth. Taste is usually decreased also, leading to a craving for sweet foods. The combination of dry mouth and sweet diet leads to more chances for dental problems, so the teeth must be carefully checked prior to starting radiation therapy, and regularly in the years afterward. If major dental procedures are needed after radiation therapy, the jaw bone may die in places ("osteoradionecrosis") and need to be surgically removed. The skin in the area of treatment is often slightly discolored, and may be of tougher texture. A more grave concern is of damage to the spinal cord, which in this area tolerated about 50 Gray of radiation. Beyond this, the chance for damage increases dramatically. Mild damage is shown by an shock-like sensation going through the body with neck flexion ("Lhermitte's sign"), but this is actually temporary and scary but not dangerous. Serious damage results in paralysis, but fortunately this is extremely rare with modern radiation techniques (less than 1 in 500 patients). Another rare but possible complication is the development of a second cancer in the area due to radiation, these are usually of the bone, cartilage or muscle ("sarcomas"). The worst complication is failure of treatment to control the existing cancer, so it is crucial that radiation be given meticulously yet aggressively by a highly experienced radiation oncologist. A fringe benefit of radiation is that the cancer often continues to shrink after therapy is completed. This is because cancer cells treated by radiation die when they try to divide; this may occur months or years after therapy. Moreover, if an area of tumor is still present after treatment, it may not represent cancer, but merely scar tissue and swelling. It is truly remarkable and gratifying to see the locally advanced cancers cured by proper radiation treatment!

Several other methods of radiation administration are worthy of note. A smaller machine ("orthovoltage") can be equipped with a "cone" to aim a beam of photons directly on a tumor on the soft palate or tonsil("intra-oral cone therapy"). Different sizes of cones, inserted into the mouth, can be used for various tumors, with consistent positioning. The orthovoltage radiation delivered through the cone gives a strong dose on the surface of the tumor; this dose quickly decreases with distance (not very penetrating). Thus, only relatively thin tumors near the surface of the mouth or tongue are effectively treated with the cone, but it is very useful to give localized"boost" therapy to a large tumor after external beam treatment. Not all radiation therapy departments have an orthovoltage machine, but many university hospital departments do. Like other external beam therapy, intra-oral cone is done as a series of treatments, 3 or 5 days per week for several weeks, and takes about 15 minutes per day total. However, acute reactions of redness and soreness can be severe.

Another different strategy for administering radiation is "brachytherapy", which means "slow therapy". For throat cancers, this is accomplished by actually sewing ("implanting") a radiation source, such as Iridium-192 wire, into the tumor. Another name for this procedure is"interstitial brachytherapy", interstitial meaning that the radioactive sources actually penetrate the flesh. The further into the throat the cancer is, the more difficult it is to do a proper implantation procedure. In fact, many doctors feel that it is not practical to implant the base of tongue or pharyngeal walls at all, owing to the technical difficulties involved. However, some physicians are more aggressive about this, and will certainly at least consider implant for the tonsil areas.

The noted radiation oncologist Dr. Wang, at Memorial Sloan Kettering in New York, has written extensively on head and neck cancer, and has performed implants of the deep structures of the throat with variable success. Implants area routine at some cancer centers for the oral tongue, cheek and lip areas. The advantage of an "implant", like the cone treatment, is that high doses of radiation are given to the local tumor area but very little to the surrounding normal tissues. Therefore, the side-effects to these normal tissues are much less. The actual dose to the tumor and other local tissue are seen by a "plan" generated by the radiation physics department, much like the that previously described. This plan says how long the radiation source will be in place. Of course, implantation is a surgical procedure which requires anesthesia. It may be used in combination with external beam therapy, as a "boost", or for relapsed cancer for which no further external beam treatment can be given. The radioactive wire stays in for several days (during which time the patient is hospitalized) and then is clipped and removed. Although uncommon, this procedure may be repeated. Only specialized radiation oncology facilities do head and neck cancer implantation, so not all radiation doctors are familiar with the techniques.The side effects are usually less than with "external beam", since the dose is being given very slowly, which is like breaking the therapy into very many fractions. A University Academic Center where Resident Doctors are being trained is most likely to offer brachytherapy. Nonetheless, in experienced hands it is a valuable tool to fight cancer.

Chemotherapy is not curative alone for throat cancer, but may be used effectively in combination with other therapies. It is only recommended for large cancers, those that have recurred, or those that have spread to distant organs. Chemotherapy may be given before, after, or at the same time as radiation treatments, and may precede or follow surgery. Many agents have been tried for squamous cell cancer of the head and neck, either alone or in combination. Much progress has been made in using the chemotherapy along with radiation and surgery, given in "clinical trials" where results and side-effects for treatments can be monitored and compared.

The most effective single chemotherapy agents are Cisplatinum and 5-Fluoroura- cil (5-FU),Methotrexate and Bleomycin."complete response" . If the response is complete (no evidence of disease left) it lasts an average of one year. Unfortunately, cancers become resistant to chemotherapy much as bacteria develop resistance to antibiotic. Thus, even an excellent response to chemotherapy does not mean definite cure, or even improved survival. Overall in the literature, their is a small trend to increased survival when chemotherapy is added to standard surgery and radiation, and this is an area of intense research. In some studies, the main gain of chemotherapy appears to be a slightly decreased level of distant spread, rather than any affect on the original tumor location. This would be expected, since if the chemotherapy works at all on a large tumor mass, it should certainly work on the microscopic cells sloughed off the tumor which spread to other body areas. Other studies show better tumor shrinkage when radiation and chemotherapy are given together, as some agents (e.g. Cisplatin) appear to "radiosensitize" the tumor mass.

What is the Latest Effective Therapy for Oropharynx Cancer?

The latest effective therapy is refinements in conventional therapy for mouth cancer.Improved surgical techniques include use of operative lasers and plastic reconstruction of areas destroyed by tumor, to maintain proper speech, chewing and swallowing. Bone grafts and muscle "flaps" can be taken from other body areas to reconstruct the jaw, if necessary, and preserve acceptable cosmetic appearance. The surgeon can rely upon radiation therapy afterward to eliminate microscopic cancer remaining, and therefore less mutilating surgeries can be done initially. Improved dental techniques can implant prosthetic teeth to replace those that must be pulled prior to radiation therapy. Hyperbaric (high pressure) oxygen treatments have been found to help healing in the jaw when surgeries are done after radiation.

Radiation improvements include the use of sophisticated three - dimensional treatment plans which tell the dose to each area in the head and neck, and allow a prediction of the most suitable energies of radiation to be used. If an implant is possible, superior results are obtained when combining external beam therapy (50 Gray) and an implant (30 Gray) compared to external beam alone. A newer way of giving brachytherapy is"High-Dose Rate" ("HDR") . This means that "catheters" (tubes) are inserted through the tumor area, and a series of treatments is given by loading them with a high-dose radiation source. It takes about 10 minutes per treatment, and this may be repeated 5 to 7 times about 1 week apart. This repetition helps reduce the "late-effects". In this way, an extremely high dose can be safely given to the local tumor area. A more readily available way of increasing effectiveness of radiation treatments in head and neck cancers is"hyperfractionation" . This will mean getting more treatments (usually 2 per day) at a lower dose per treatment. Although inconvenient, it has improved response to radiation by about 20% in major studies! It is recommended for large tumors which will need a higher dose of radiation (over 70 Gray) to control them. Fortunately, since smaller "fractions" are given with each treatment, it leads to less "late" side-effects than conventional radiation treatments, even while giving a higher total dose! A new and exciting way of increasing the effectiveness of radiation is "hyperthermia". This means heating the area of the tumor, usually just prior to radiation treatment.

Cancer cell kill is much greater when the area is heated. The main difficulty in giving hyperthermia treatment is the uniform heating of the tumor area, but new microwave heating helps do this. Hyperthermia is only available at major medical University Radiation Oncology departments, but has now been shown convincingly to improve radiation results. The side-effects are only a small increase in normal radiation reaction.

Chemotherapy improvements have been slow, and are based on clinical trials. If it is given at the same time as radiation therapy, it's called"chemoradiation" . This is very effective at shrinking the tumor, but has severe local reaction of skin sloughing and mouth ulceration, and so must be carefully monitored. Chemo-radiation may be given before, after, or instead of surgery. Patients with large tumors now have them shrunk with chemo-radiation prior to getting surgery, as a less mutilating procedure may then be effective (as compared to if radical surgery was performed first). Patients getting chemo-radiation may be unable to eat due to the soreness, and so often get a temporary feeding tube. About 6 weeks is given after chemo-radiation to allow the tumor to shrink and then surgery may be performed. The latest agents for chemoradiation are Taxol andCisplatinum . This are given intravenously, up to 24 hours prior to the radiation. Blood counts and nutrition are tracked, and a temporary break in treatment may be required if the local reaction gets too intense. The radiation may be hyperfractionated to improve effectiveness and decrease late side-effects. This aggressive treatment will then maximize all established therapies.

Another aspect to chemotherapy is "chemoprevention" of new cancers. Vitamin A derivative (Cis-Retinoin) has been shown to help treat small cancers, and prevent new ones from forming. The dose for this is now being established (high dose has unacceptable side effects). Nonetheless, taking vitamins A and E are thought to help prevent a whole spectrum of aero-digestive cancers.

Overall, slow but steady progress is being made for mouth cancers, and survival has improved perhaps 20% over the past 3 decades . Even patients with advanced cancer have more hope than ever before, at least for comfort. Since radiation is a mainstay of therapy, it is crucial to get an appointment with an up-to-date radiation oncologist who communicates well with you. Younger radiation oncologists often have had better training than the older generation, since only in the last 2 decades did this specialty gain much prestige (and difficulty getting into). New research is always continuing in cooperative clinical trials, by the RTOG and EORTC. Patients who have large cancers and wish to be aggressive should find an oncologist they are comfortable talking too, preferably at a University Academic Center, and seriously consider joining a recent clinical trial. Current major trials (there are new ones opening and closing every month) can be found on the National Cancer Institutes website (call them at 1-800-4-Cancer). Patients should embark upon a program to maintain nutrition, exercise, increase spirituality, and select a reasonable alternative medicine regimen in addition to doing conventional medical treatment. This combined approach is superior to just counting on a pill or ray to cure cancer. If the patient still smokes, they should quit, since results are better in even recent non-smokers. Above all, realize that while more patients are being cured than ever before, many people are also living longer and productive lives with their cancer, and keep a positive attitude to have the best chance for success.

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This is the full transcript, offered freely in the spirit of internet sharing, of CancerAnswers' report on Tongue Base and Tonsil Cancer. Much more, including latest additional treatments for Tongue Base and Tonsil Cancer can be found on our order page. Thank you for using CancerAnswers as your information resource.