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Cancer of the tonsils and back of the tongue, a head and neck cancer, now comes mostly from HPV infection rather than smoking, and behaves like a different disease: it responds well to chemoradiation, most patients are cured, and the research question is how much treatment can safely be removed.
Oropharyngeal squamous cell carcinoma arises in the tonsils, base of tongue, soft palate and pharyngeal wall. In North America and Europe most cases are now caused by HPV type 16 and are staged separately because they carry a far better outlook than tobacco-related, HPV-negative tumours, which are more often p53-mutant and resistant. Standard treatment is cisplatin chemoradiation, or transoral robotic surgery with neck dissection and adjuvant treatment for smaller tumours; cetuximab proved inferior to cisplatin in HPV-positive disease in RTOG 1016 and De-ESCALaTE. Trials are testing lower radiotherapy doses, fewer drugs and circulating HPV DNA to guide de-escalation in HPV-positive patients, while HPV vaccination is expected to prevent most future cases. Recurrent or metastatic disease is treated with pembrolizumab, alone or with chemotherapy, on KEYNOTE-048.
The fastest-rising head and neck cancer in high-income countries, now driven mainly by human papillomavirus in men in their fifties and sixties; HPV-positive disease is cured in most cases, HPV-negative disease in far fewer.
Site decides cause and behaviour: HPV drives oropharyngeal cancer, EBV drives nasopharyngeal cancer, tobacco drives oral and laryngeal cancer; all drain into the neck node levels that surgeons and radiotherapists map.
Same organ: Acinic cell carcinoma of the salivary glands, Carcinoma ex pleomorphic adenoma, Multiple endocrine neoplasia type 1 (MEN1), Multiple endocrine neoplasia type 2 (MEN2A and MEN2B), Hyperparathyroidism-jaw tumour syndrome (CDC73-related parathyroid carcinoma), Laryngeal and hypopharyngeal cancer, Oral cavity cancer (mouth and tongue), Head and neck squamous cell carcinoma, Nasopharyngeal carcinoma, Salivary gland cancers, Papillary thyroid cancer, Follicular thyroid cancer, Medullary thyroid cancer, Anaplastic thyroid cancer, Thyroid cancer, Nasal cavity and paranasal sinus cancers (including esthesioneuroblastoma), NUT carcinoma (midline carcinoma with NUTM1 rearrangement), Parathyroid carcinoma, Multiple endocrine neoplasia syndromes (MEN1, MEN2, MEN4), HPV-positive oropharyngeal cancer, HPV-negative head and neck squamous cell carcinoma (including HPV-negative oropharyngeal cancer), Recurrent or metastatic head and neck squamous cell carcinoma, Hypopharyngeal cancer, Adenoid cystic carcinoma, Salivary duct carcinoma, Mucoepidermoid carcinoma, Oral tongue and floor of mouth cancer, Buccal mucosa and gingivobuccal cancer (oral cancer in India), Lip cancer, Locoregionally advanced nasopharyngeal carcinoma (stage III to IVA), Recurrent and metastatic nasopharyngeal carcinoma, Esthesioneuroblastoma (olfactory neuroblastoma), Sinonasal undifferentiated carcinoma (SNUC) and SWI/SNF-deficient sinonasal carcinoma
Nothing recorded yet.
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Examination and biopsy with p16 and HPV testing, PET-CT, and separate staging for HPV-positive disease.
Transoral robotic or laser surgery with neck dissection, or radiotherapy alone, chosen by expected function.
Cisplatin chemoradiation (70 Gy); cetuximab only for patients who cannot have cisplatin, since RTOG 1016 and De-ESCALaTE showed it inferior in HPV-positive disease.
Pembrolizumab alone for PD-L1-positive disease or with platinum-fluorouracil (KEYNOTE-048); nivolumab after platinum (CheckMate 141).
HPV vaccination of girls and boys; smoking cessation.
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4 trials on record are attached to one of the types below rather than to Oropharyngeal cancer (tonsil and base of tongue) itself. They are grouped by the type that holds them, so someone still working out which type they have can see the whole field from here.
Cetuximab is not an acceptable substitute for cisplatin in HPV-positive disease; de-escalation must be tested through other routes such as dose reduction after response or surgery-based pathways.
Cisplatin chemoradiation is the standard for HPV-positive oropharyngeal cancer; cetuximab is reserved for patients who cannot receive cisplatin.
Patients with head and neck squamous cell cancer that has recurred or spread should be treated first with pembrolizumab: alone if their tumour is strongly PD-L1 positive and they can wait for a slower response, or with chemotherapy if the tumour is bulky or PD-L1 low. Cetuximab-based chemotherapy is no longer the default. Long-term follow-up shows a small but real group of patients alive at four to five years, which was almost unheard of before.
PD-1 blockade after platinum became standard, and the trial opened the way for first-line pembrolizumab in KEYNOTE-048.
HPV-positive oropharyngeal cancer is now staged and studied separately, and this risk model underlies de-escalation trials and the eighth-edition staging system.
Query for this cancer: (TITLE:"Oropharyngeal cancer" OR ABSTRACT:"Oropharyngeal cancer" OR TITLE:"tonsil and base of tongue" OR ABSTRACT:"tonsil and base of tongue" OR TITLE:"Oropharynx cancer" OR ABSTRACT:"Oropharynx cancer" OR TITLE:"Tonsil cancer" OR ABSTRACT:"Tonsil cancer" OR TITLE:"Base of tongue cancer" OR ABSTRACT:"Base of tongue cancer" OR TITLE:"HPV-positive head and neck cancer" OR ABSTRACT:"HPV-positive head and neck cancer") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Oropharyngeal cancer (tonsil and base of tongue), not a curated reading list.
Gillison and colleagues show HPV16 in a distinct subset of tumours.
RTOG 0129 analysis: three-year survival 82 versus 57 percent.
The targets of this cancer's medicines and the ones linked to it directly.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Dose reduce or avoid for CrCl below 60 (carboplatin is the alternative).
Immunotherapy can attack hormone-producing glands: most often the thyroid (usually ending in an under-active thyroid needing lifelong tablets), and less often the pituitary (hypophysitis) or adrenal glands, which can be life-threatening if missed.
Reactions around the moment a drug is given: chills, fever or breathlessness from antibodies (infusion reactions), true allergy (hypersensitivity, rarely anaphylaxis), and leakage of a damaging drug into tissue around the vein (extravasation).
See all on the product pages:CetuximabCisplatinNivolumabPembrolizumab·Printable cards in the navigator
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Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record.
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