Treatment options for mouth and oropharyngeal cancer

There are different treatment options for mouth and oropharyngeal cancer. These include:

• surgery
• radiotherapy
• chemotherapy
• chemotherapy with radiotherapy (chemoradiotherapy )
• targeted cancer drugs and immunotherapy

Deciding what treatment you need

A team of doctors and other professionals discuss the best treatment and care for you. They are the multidisciplinary team (MDT). Your MDT might include:

Specialist head and neck surgeons

Head and neck surgeons may include: 

• oral and maxillofacial surgeons

• ear, nose and throat (ENT) surgeons

• plastic surgeons

Oral and maxillofacial surgeons 

They are doctors trained both as doctors and dentists. These surgeons remove the cancer and also rebuild the tissue lost due to the cancer or surgery.

ENT surgeon 

These are qualified specialist surgeons trained in treating conditions of the ear, nose, throat and neck. They can also be called otolaryngologists. 

Plastic surgeons

Sometimes a plastic surgeon may rebuild the area where the surgeon has removed cancer. This is called reconstruction. Plastic surgery is common after surgery to remove a cancer of the head and neck.

A cancer specialist in radiotherapy (clinical oncologist) and drug treatment (medical oncologist)

They are specialist doctors and plan your treatment using:

• radiotherapy
• chemotherapy
• targeted cancer drugs
• immunotherapy 

Restorative dental specialist

A restorative dentist is a specialist in replacing lost tissues and teeth.

They assess your teeth before you have treatment. And may recommend that you have some teeth removed if they are decaying or loose. This is so they don't cause problems later on. 

The restorative dentist also gives you advice on how to look after your mouth and teeth during and after treatment. You may also see a dental hygienist to help keep your mouth and teeth clean. And reduce the risk of infection.

The restorative dentist will also help your recovery. They may suggest using false teeth or a replacement part (prosthesis). They can help to make your facial appearance as normal as possible after treatment.   

Head and neck clinical nurse specialist 

A clinical nurse specialist is a qualified nurse who has knowledge of head and neck cancers. They help to organise the care between doctors and other health professionals. They support you before, during and after treatment and make sure you have the information you need to understand the treatment. 

A clinical nurse specialist (CNS) is often your key worker. 

Dietitian 

Dietitians play an essential role in helping you with problems you may have with your diet and eating. You usually met them before your treatment and regularly throughout.

Speech and language therapist

Speech and language therapists play an important role before, during and after your treatment. They help you with speech and swallowing difficulties and to recover after treatment. The aim is to help you eat and drink safely. They can give information to your family or carer on how to support you with swallowing difficulties. They will continue to help you throughout your treatment and rehabilitation. 

Pathologist

An expert who examines any cancer or tissue removed by a surgeon.

Other health professionals

You may also need help and support from other health specialists, for example, physiotherapists and social workers .

Your treatment depends on:

• where your cancer is in your mouth or oropharynx

• how far it has grown or spread (the stage)

• the type of cancer

• how abnormal the cells look under a microscope (the grade)

• your general health and level of fitness

• the side effects of the treatment and how these will affect you

• your preferences

Your MDT will discuss your treatment, its benefits, whether there are other options, and the possible side effects with you.

Treatment overview

You might have one type of treatment or a combination of treatments. Your doctor and nurse will talk to you about the treatment that is best for you. The main treatments are:

• surgery

• radiotherapy

• chemotherapy

• chemotherapy with radiotherapy (chemoradiotherapy)

• targeted cancer drugs and immunotherapy

Surgery 

Surgery is a common treatment for mouth and early stage oropharyngeal cancer. It is sometimes the only treatment you need. You may have radiotherapy after your surgery.

How much surgery you have depends on the size and location of your cancer. Your surgeon removes the cancer and a border (margin) of normal tissue around it. You might also have surgery to remove all or some of the lymph nodes in your neck.

You might need a bigger operation if your surgeon needs to remove part of your jawbone or tongue. When the surgeon removes a large area of tissue, they rebuild (reconstruct) the area.

Sometimes, it is possible to have further surgery for mouth and oropharyngeal cancer if your cancer comes back (a recurrence).

Radiotherapy 

Radiotherapy uses high energy x-rays to destroy cancer cells. External beam radiotherapy directs radiotherapy treatment at the cancer from a machine. 

You might have external radiotherapy as your main (primary) treatment instead of surgery for oropharyngeal cancer.  You may have it with or without chemotherapy.

Radiotherapy is not usually the main treatment for mouth cancer, but you may have it if you:

• are not fit enough to have surgery
• don’t want surgery
• have and early stage lip cancer

You might have radiotherapy after surgery. This is to kill any cancer cells that might still be around the site of surgery. You might also have radiotherapy to the neck area to kill cancer cells in the lymph nodes. This is to lower the risk of the cancer coming back.

If you need radiotherapy for mouth and oropharyngeal cancer, you usually have external radiotherapy.  Very rarely, your doctor might suggest internal radiotherapy. This is called brachytherapy. It is only available in a few specialist centres. Your doctor will tell you more about this treatment if it is available and suitable for you. 

You may also have radiotherapy if your cancer comes back. This will depend on:

• whether you had radiotherapy or surgery before
• the time since your previous treatment

You can have radiotherapy on its own or together with chemotherapy (chemoradiotherapy).

Chemotherapy

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in your bloodstream.

You might have chemotherapy if your cancer has:

• come back
• spread to other parts of the body (advanced cancer).

You may have chemotherapy with radiotherapy (chemoradiotherapy). It helps the radiotherapy to work better.

For mouth cancer that is advanced or has come back, you may have chemotherapy with the targeted drug cetuximab.

Chemoradiotherapy 

You might have chemotherapy together with radiotherapy. This is called chemoradiotherapy.

You might have chemoradiotherapy:

• as your main treatment for oropharyngeal cancer if surgery is not a suitable option
• after surgery for mouth cancer that has spread into surrounding tissues or into nearby lymph nodes
• after surgery for mouth or oropharyngeal cancer that has spread into surrounding tissues or outside lymph nodes
• for advanced oropharyngeal cancer

Targeted cancer drugs and immunotherapy

Targeted cancer drugs work by targeting the differences in cancer cells that help them to grow and survive. Other drugs help the immune system to attack cancer. They are called immunotherapies.

You might have the targeted drug cetuximab:

• with radiotherapy for locally advanced squamous cell cancer 
• with platinum chemotherapy for squamous cell mouth cancer that has come back or has spread to other parts of the body (metastatic)

You might have the immunotherapy drugs pembrolizumab or nivolumab.

You have pembrolizumab if you have squamous cell cancer that has been tested for a type of protein called programmed cell death ligand 1 (PD-L1) and: 

• you haven’t had any treatment for an advanced cancer
• your cancer has come back and you can’t have surgery to remove the cancer

In Scotland, the Scottish Medicines Consortium (SMC) says that you can have pembrolizumab by itself or at the same time as platinum based chemotherapy if your tumour has higher levels of PD-L1 protein.

You have nivolumab if you have squamous cell cancer and:

• your cancer has come back or has spread to other parts of the body
• you had platinum based chemotherapy (such as cisplatin or carboplatin), and your cancer has started to grow within 6 months of having chemotherapy

In Scotland, the Scottish Medicines Consortium (SMC) says that you can have nivolumab if your cancer continues to grow while on or after having platinum based chemotherapy. You can have these immunotherapy treatments for up to 2 years.

Treatment by stage

Your treatment depends on the stage of your cancer.

Stage 0 (carcinoma in situ) 

The cancer cells are all contained within the lining of the mouth or oropharynx. If left untreated, there is a high chance of the cells developing into an invasive cancer. 

Your doctor may completely remove the cancer cells during a biopsy if the affected area is very small. Or you may need to have minor surgery. Your doctor removes the cancer cells by taking a thin layer of tissue from the affected area. A specialist doctor called a pathologist looks at the tissue under a microscope to check for cancer cells.

Your doctor will monitor you closely after treatment.

If you smoke and continue to do so, it is much more likely that you will develop cancerous cells again in the future. This might mean having further surgery or even radiotherapy. Your surgeon, oncologist, or clinical nurse specialist will be able to offer you support with giving up smoking and refer you to your local stop smoking service.

Stage 1 and 2

Your treatment depends on where in the mouth or oropharynx your cancer is. When deciding on your treatment plan, your doctor considers the possible side effects of treatment, and your general health. 

The 2 main treatment options are:

• surgery – you might need to have radiotherapy or chemoradiotherapy after surgery

• external radiotherapy with or without chemotherapy as your main treatment if you have oropharyngeal cancer

You might have surgery to remove the cancer. The surgeon might also remove some of the lymph nodes in your neck. This operation is called a neck dissection. You might need to have radiotherapy after surgery. You may have radiotherapy on its own or combined with chemotherapy. This is to kill off any remaining cancer cells. It reduces the chance of cancer coming back in future. 

Or you might have external radiotherapy as your main treatment instead of surgery for oropharyngeal cancer. The radiotherapy treatment area is likely to include the lymph nodes in your neck. Your oncologist will let you know if you're having one or both sides of your neck treated.

Stage 3 and 4

The main treatment options are:

• surgery – you might need to have radiotherapy or chemoradiotherapy after surgery

• chemoradiotherapy as your main treatment

• chemotherapy, immunotherapy, or targeted drugs

• supportive care to treat symptoms

You might have surgery to remove the cancer. This usually includes removing lymph nodes in the neck during an operation called a neck dissection. You may also have radiotherapy after surgery. You might have radiotherapy on its own or together with chemotherapy (chemoradiotherapy). This is to kill off any remaining cancer cells. It reduces the chance of cancer coming back in the future.

Or your doctor might suggest chemoradiotherapy as your main treatment. The radiotherapy treatment area is likely to include the lymph nodes in your neck. Your oncologist will let you know if you're having one or both sides of your neck treated.

You might have a targeted cancer drug called cetuximab alongside radiotherapy if you can’t have chemotherapy. You might have radiotherapy on its own if you aren’t able to have combined treatment.

You might have chemotherapy or immunotherapy on its own if:

• the cancer has spread outside of the mouth, throat, and neck area, for example, to the lungs (advanced cancer)

• it's not possible to have surgery and radiotherapy

To relieve symptoms, you might need treatment and supportive care. For example, painkillers or surgery can help with breathing or eating. 

Clinical trials

Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.