Pharyngeal Cancer Treatment Protocols 

Updated: Feb 29, 2016
  • Author: Marvaretta M Stevenson, MD; Chief Editor: Guy J Petruzzelli, MD, PhD, MBA, FACS  more...
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Treatment Protocols

Treatment protocols for pharyngeal cancers are provided below, including the following:

  • Generalized first-line therapy based on stage
  • Chemoradiation therapy and induction chemotherapy for locally advanced disease
  • First-, second-, and third-line chemotherapy for metastatic or recurrent disease

Generalized treatment recommendations for pharyngeal cancers

See the list below:

  • Treatment plans for all disease stages should be discussed at a multidisciplinary tumor conference involving ear, nose, throat (ENT) surgeons; radiation oncologists; and medical oncologists
  • Selected patients with advanced or metastatic disease may receive surgical resection of their primary tumors, depending on their response to first-line therapy

Surgery or radiation therapy for early or localized pharyngeal cancers

Stages I-II [1, 2] :

  • Primary treatment for oropharyngeal cancers is surgical resection or definitive radiation therapy
  • Surgery is the preferred approach, except for some patients who may have early lip, retromolar trigone, and soft palate cancers
  • Radiation therapy is preferred for patients who may not be able to tolerate surgery
  • The radiation dose depends on tumor size; however, for early stage disease, doses of 66-74 Gy (2.0 Gy/fraction; daily Monday-Friday in 7wk) may be used with adequate results

Chemotherapy with radiation therapy for locally advanced pharyngeal cancers

Stages III-IVB [1, 2] :

  • Surgery should be considered for locally advanced disease; however, definitive radiation therapy, concurrent chemoradiation, and induction therapy are alternative options for patients who are not candidates for surgery
  • Concurrent chemoradiation therapy is the current standard of care for patients with locally advanced squamous cell carcinoma of the head and neck
  • Chemotherapy is given for the duration of radiation therapy unless otherwise stated; definitive radiation doses used are 66-74 Gy (2.0 Gy/fraction; daily Monday-Friday in 7wk)
  • Conventional fractionation for concurrent chemoradiation up to 70 Gy (2.0 Gy/fraction)
  • Postoperative radiation dose is 60-66 Gy (2.0 Gy/fraction); preferred interval between resection and postoperative radiation therapy is 6 wk
  • The decision to treat the patient with concurrent chemoradiation therapy rather than surgery, radiation, or chemotherapy individually should be made by a multidisciplinary tumor board (including a medical oncologist, a radiation therapist, and an ENT surgeon)

Acceptable chemotherapy regimens for primary systemic therapy with concurrent radiation:

  • Cisplatin 100 mg/m 2 IV on days 1, 22, and 43 [1, 2, 3, 4] or  40-50 mg/m 2 IV weekly for 6-7wk [5] or
  • Cetuximab 400 mg/m 2 IV loading dose 1 wk before the start of radiation therapy, then  250 mg/m 2 weekly (premedicate with dexamethasone, diphenhydramine, and ranitidine) [6, 7] ; or
  • Cisplatin 20 mg/m 2 IV on day 2 weekly for up to 7 wk plus  paclitaxel 30 mg/m 2 IV on day 1 weekly for up to 7 wk [8] or
  • Cisplatin 20 mg/m 2/day IV on days 1-4 and 22-25 plus  fluorouracil (5-FU) 1000 mg/m 2/day by continuous IV infusion on days 1-4 and 22-25 [9, 10, 11] or
  • 5-FU 800 mg/m 2 by continuous IV infusion on days 1-5 given on the days of radiation plus  hydroxyurea 1 g PO q12 h (11 doses per cycle); chemotherapy and radiation given every other week for a total of 13 wk [8] or
  • Carboplatin 70 mg/m 2/day IV on days 1-4, 22-25, and 43-46 plus  5-FU 600 mg/m 2/day by continuous IV infusion on days 1-4, 22-25, and 43-46 [12] or
  • Carboplatin area under the curve (AUC) 1.5 IV on day 1 weekly plus  paclitaxel 45 mg/m 2 IV on day 1 weekly [13] (see also the Carboplatin AUC Dose Calculation [Calvert formula] calculator)

Acceptable chemotherapy regimens for patients receiving postoperative concurrent chemoradiation:

  • Cisplatin 100 mg/m 2 IV on days 1, 22, and 43 [3, 4] or  40-50 mg/m 2 IV weekly for 6-7wk [5]

Induction chemotherapy for locally advanced pharyngeal cancers

Stages III-IVB:

  • Induction chemotherapy is typically given to patients with stage III-IVB disease in order to shrink a primary tumor to reduce its bulkiness in preparation for future surgery or radiation therapy
  • The decision to treat the patient with induction chemotherapy rather than concurrent chemoradiation or surgery, radiation, or chemotherapy alone should be made by a multidisciplinary tumor board (including a medical oncologist, a radiation therapist, and an ENT surgeon) [1, 2]

Acceptable chemotherapy regimens for induction chemotherapy:

  • Docetaxel 75 mg/m 2 IV on day 1 plus  cisplatin 100 mg/m 2 IV on day 1 plus  5-FU 100 mg/m 2/day by continuous IV infusion on days 1-4 every 3 wk for 3 cycles; then  3-8 wk later, carboplatin AUC 1.5 IV weekly for up to 7wk during radiation therapy; then  6-12 wk later, pursue surgery, if applicable [14, 15] ; or
  • Docetaxel 75 mg/m 2 IV on day 1 plus  cisplatin 75 mg/m 2 IV on day 1 plus  5-FU 750 mg/m 2/day by continuous IV infusion on days 1-4 every 3wk for 4 cycles; then  4-7wk later, radiation; surgical resection can be pursued before or after chemotherapy [16]
  • Paclitaxel 175 mg/m 2 IV on day 1 plus  cisplatin 100 mg/m 2 IV on day 2 plus  5-FU 500 mg/m 2/day by continuous IV infusion on days 2-6 every 3 wk for 3 cycles; then  radiation with cisplatin 100 mg/m 2 IV on days 1, 22, and 43 [17]

First-line chemotherapy for metastatic or recurrent pharyngeal cancers

Stage IVC:

  • Treatment recommendations include the use of single-agent or combination chemotherapy
  • Platinum-based chemotherapy regimens are preferred if the patient can tolerate these agents; if not, single agents have been used in this setting [1, 2]
  • Below are first-line chemotherapy options for metastatic disease or recurrent squamous head and neck cancers (after surgery and/or radiation)

Acceptable chemotherapy regimens in patients with metastatic (incurable) head and neck cancers (unless otherwise stated, goal is to complete at least six cycles):

  • Cisplatin 100 mg/m 2 IV on day 1 every 3 wk for six cycles plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3 wk for six cycles plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [18] ; or
  • Carboplatin AUC 5 IV on day 1 every 3 wk for six cycles plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3 wk for six cycles plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [18] ; or
  • Cisplatin 75 mg/m 2 IV on day 1 plus  docetaxel 75 mg/m 2 IV on day 1 every 3 wk [19, 20] or
  • Cisplatin 75 mg/m 2 IV on day 1 plus  paclitaxel 175 mg/m 2 IV on day 1 every 3 wk [21, 22] or
  • Carboplatin AUC 6 IV on day 1 plus  docetaxel 65 mg/m 2 IV on day 1 every 3 wk [23] or
  • Carboplatin AUC 6 IV on day 1 plus  paclitaxel 200 mg/m 2 IV on day 1 every 3 wk [24] or
  • Cisplatin 75-100 mg/m 2 IV on day 1 every 3-4 wk plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly (premedicate with dexamethasone, diphenhydramine, and ranitidine) [25, 26, 27] ; or
  • Cisplatin 100 mg/m 2 IV on day 1 plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3 wk [11, 22, 28, 29, 30] or
  • Methotrexate 40 mg/m 2 IV weekly (3 wk equals one cycle) [11, 28] or
  • Paclitaxel 200 mg/m 2 IV every 3 wk [31, 32] or
  • Docetaxel 75 mg/m 2 IV every 3 wk [33, 34, 35] or
  • Cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [36]

Second- and third-line chemotherapy for metastatic or recurrent pharyngeal cancers

Stage IVC:

  • Second-line chemotherapy is given after disease progression or recurrence following completion of first-line therapy
  • Third-line therapies are given after disease progression or recurrence following completion of first-line and second-line therapies
  • Second- and third-line regimens are similar to regimens used as first-line therapy but usually offer lower response rates and survival benefits
  • Patients should be treated with platinum-based chemotherapy regimens if they have not previously received a platinum-based drug

Acceptable chemotherapy regimens in patients with recurrent head and neck cancers (unless otherwise stated, goal is to complete at least six cycles):

  • Cisplatin 100 mg/m 2 IV on day 1 every 3 wk for six cycles plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3 wk for six cycles plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [18] ; or
  • Carboplatin AUC 5 IV on day 1 every 3 wk for six cycles plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3wk for six cycles plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [19] ; or
  • Cisplatin 75 mg/m 2 IV on day 1 plus  docetaxel 75 mg/m 2 IV on day 1 every 3 wk [19] or
  • Cisplatin 75 mg/m 2 IV on day 1 plus  paclitaxel 175 mg/m 2 IV on day 1 every 3 wk [21, 22] or
  • Carboplatin AUC 6 IV on day 1 plus  docetaxel 65 mg/m 2 IV on day 1 every 3 wk [23] or
  • Carboplatin AUC 6 IV on day 1 plus  paclitaxel 200 mg/m 2 IV on day 1 every 3 wk [24] or
  • Cisplatin 75-100 mg/m 2 IV on day 1 every 3-4 wk plus  cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly (premedicate with dexamethasone, diphenhydramine, and ranitidine) [25, 26, 27] ; or
  • Cisplatin 100 mg/m 2 IV on day 1 plus  5-FU 1000 mg/m 2/day by continuous IV infusion on days 1-4 every 3wk [11, 22, 28, 29, 30] or
  • Methotrexate 40 mg/m 2 IV weekly (3 wk equals one cycle) [11, 28] or
  • Paclitaxel 200 mg/m 2 IV every 3 wk [2, 32] or
  • Docetaxel 75 mg/m 2 IV every 3 wk [33, 34, 35] or
  • Cetuximab 400 mg/m 2 IV loading dose on day 1, then  250 mg/m 2 IV weekly until disease progression (premedicate with dexamethasone, diphenhydramine, and ranitidine) [36]