The United States is currently witnessing an increase in the incidence of oropharyngeal carcinoma at a time when the incidence of all other subsites of head and neck cancer are decreasing. These discordant findings are related to the increased incidence of Human Papilloma Virus induced oropharyngeal cancers over the last decade, primarily in non-smokers, and the decrease overall in smoking related head and neck cancers as the overall incidence of tobacco use has decreased over the same time interval. As a consequence of this “epidemic”, oropharyngeal carcinoma (squamous cell carcinoma involving the tonsil, base of tongue and oropharyngeal walls) is one of the more common head and neck cancer presentations to the Saint Louis University Cancer Center’s Multidisciplinary Head and Neck Cancer team. All patients that present to this group undergo a comprehensive staging process, a multidisciplinary evaluation that includes discussion in the setting of a multidisciplinary tumor board and when appropriate, group evaluation in the Multidisciplinary Head and Neck Tumor Clinic. Members of the multidisciplinary team include head and neck surgical oncology, medical oncology, radiation oncology, oncology dietetics, oncology social work, oncology nursing, dental hygiene-oral health specialists and speech and language pathologists. Complex treatment plans are developed in “real time” between the members of the group and the patient often in one visit. The depth of this team is capable of addressing many of the significant psychosocial aspects that accompany not only the diagnosis but the logistics of treatment regimens with this degree of complexity.  

The management of head and neck cancer in the last two decades has been evolving towards a goal of achieving the very best survival outcomes with the smallest degree of morbidity related to treatment. In head and neck cancer this “morbidity” ultimately is related to dysfunction seen in swallowing, speech, chronic pain and the psychosocial stigmata that accompany extensive surgery of a very visible area of the body. We are a very social species; eating meals and language are central to how we relate and communicate to one another. Both may be dramatically affected in patients in an attempt to cure their oropharyngeal cancer. As a consequence, state of the art management of head and neck cancer takes aim at striking a balance between the toxicity of multimodality treatment, survival and long term function as related to speech and swallowing.   Current treatment strategies for oropharyngeal carcinoma are as follows. Patients that present with oropharyngeal carcinoma of early stage frequently may be treated with unimodality (either surgery or radiation alone) therapy or bimodality therapy (limited surgery followed by radiation therapy of a lesser dose). Patients with intermediate stage disease may be treated with more extensive surgery followed by postoperative radiation or concurrent chemoradiotherapy, depending upon final analysis of the resection specimen and the presence of high risk prognostic factors. These intermediate stage patients may alternatively be treated with definitive radiation or chemoradiation depending on the details of their disease at presentation. Patients that present with potentially curable late stage disease in nearly all cases will undergo combined concurrent chemoradiotherapy with curative intent with surgical resection taking a salvage role.    

The Saint Louis Cancer Center Experience  

The vast majority of patients that present to the Saint Louis University Cancer Center with oropharyngeal cancer do so with intermediate to advanced disease (figure 1). This is consistent with that seen at most academic medical centers (figure 2) and is related to the fact that the primary tumors may develop with very little symptoms and only the finding of a neck mass (metastatic lymph node) will call attention to the patient that there may be a problem. By this point the patient will have developed stage III disease (moderately advanced).  

The chosen modalities of treatment at our institution are a reflection of the cross section of disease stage at presentation and is represented in figure 3a. A national comparison group over the same interval is presented in figure 3b.    

Nearly 70 percent of our patients had radiation as a component to their treatment, highlighting the importance of this modality in the treatment patients with oropharyngeal cancer. Nearly 40 percent of patients underwent definitive treatment that utilized chemoradiotherapy without surgery of any kind, while about 45 percent of patients required surgery in attempt to control their disease.  

Outcomes of the group treated at the Saint Louis University Cancer Center since 2004 as measured in percent of overall survival and survival based on primary modality of treatment at two or four years is presented in table 1 and compared to national data. The results are comparable between our treatment group and the national cohort.    

The management of oropharyngeal cancer continues to evolve. Chemoradiotherapy is taking a more prominent role in the treatment of this disease while surgery is increasingly employed as primary treatment of early staged disease or as salvage therapy of more advanced disease after primary non-surgical management. It is clear that patients benefit from the meticulous evaluation, treatment planning, depth and support provided by a coordinated multidisciplinary team approach dedicated to maximizing survival and function while attempting to minimize toxicity related to treatment. Figure 4.