Tonsil Cancer

HPV-positive vs HPV-negative tonsil cancer

Tonsil cancer is a form of oropharyngeal cancer, part of the wider group of head and neck cancers.

HPV-related oropharyngeal cancer has risen sharply in recent decades in the US and is now more common than HPV-related cervical cancer.

Risk factors

• HPV infection, mainly through oral sex and number of oral sex partners
• smoking and other tobacco use
• heavy alcohol use, especially combined with smoking
• weakened immunity, including HIV
• male sex

Symptoms

• a painless lump in the neck (enlarged lymph node), often the first sign
• one tonsil larger than the other (unlike tonsillitis, which usually affects both and settles within days)
• persistent sore throat
• pain in one ear (referred pain)
• difficulty or pain when swallowing
• a sore or white or red patch on the tonsil
• bleeding from the mouth
• changes in voice
• weight loss

Diagnosis

• examination of the mouth, throat and neck
• flexible nasendoscopy: a thin camera through the nose
• biopsy of the tonsil, or a fine-needle aspiration of a neck lump
• HPV testing: p16 staining and sometimes HPV DNA or RNA tests, which affect staging and outlook
• imaging: CT or MRI of the neck, PET-CT to check spread
• dental assessment before radiotherapy

HPV-positive and HPV-negative cancers are staged separately because their outcomes differ.

Treatment

Treatment is planned by a head and neck cancer team.

Early-stage disease

• transoral robotic surgery (TORS) or transoral laser surgery to remove the tonsil and tumor, often with removal of neck lymph nodes
• or radiotherapy alone

More advanced disease

• chemoradiotherapy: radiotherapy combined with cisplatin chemotherapy
• surgery followed by radiotherapy with or without chemotherapy, depending on findings

Recurrent or metastatic disease

• immunotherapy (pembrolizumab or nivolumab), chemotherapy, cetuximab
• clinical trials, including treatment de-escalation for HPV-positive cancers

Side effects

• dry mouth and taste changes
• difficulty swallowing
• sore mouth (mucositis)
• neck stiffness and lymphedema
• dental problems and jaw bone damage
• hearing loss and kidney effects from cisplatin

Speech and swallowing therapy, dietitians and dental care help recovery.

Outlook

HPV-positive tonsil cancer has an excellent outlook, with high cure rates even when lymph nodes are involved. HPV-negative cancers, often linked with smoking, have lower survival. Stopping smoking improves treatment outcomes.

Prevention

• HPV vaccination, recommended at age 11 to 12 with catch-up through 26, protects against the HPV types that cause most oropharyngeal cancers
• not smoking and limiting alcohol
• regular dental checks, which can pick up mouth and throat changes
• seeing a doctor for persistent throat symptoms or neck lumps

Frequently asked questions

What are the first signs of tonsil cancer?

The first sign is often a painless lump in the neck. Others include one tonsil larger than the other, a sore throat or one-sided ear pain lasting more than 3 weeks, and difficulty swallowing.

Is tonsil cancer caused by HPV?

Most tonsil cancers in the US are caused by HPV, especially HPV type 16. Smoking and heavy drinking cause most of the rest. HPV-related cancers tend to respond better to treatment.

What is the survival rate for tonsil cancer?

HPV-positive tonsil cancer has a high survival rate, often over 80% to 90% at 5 years for many stages. HPV-negative cancers have lower survival. Your care team can give a personalized estimate.

How is tonsil cancer treated?

Treatment may include surgery through the mouth, radiotherapy, chemotherapy or a combination. Advanced or recurrent cancer may be treated with immunotherapy. A head and neck cancer team plans treatment.

Can the HPV vaccine prevent tonsil cancer?

The HPV vaccine protects against HPV types that cause most oropharyngeal cancers, including tonsil cancer. Vaccination at age 11 to 12, before exposure, is most effective.