Oropharyngeal Cancer Timeline: Immunotherapy, Surgery and Radiation
For some advanced cancers that can be removed and carry the PD-L1 marker, the immunotherapy drug pembrolizumab is given before surgery and continued during and after radiation. This newer track is less common for oropharyngeal cancer and is used mostly for HPV-negative cancers.
This page is one of six treatment-track timelines for oropharyngeal cancer. The steps before treatment, how a track is chosen and the long-term follow-up schedule are covered on the oropharyngeal cancer treatment timelines page.
Teal words in the timeline are links. On a phone, swipe sideways to see the whole graphic.
Who follows this track
This track is for some locally advanced head and neck cancers that can be removed with surgery and whose cancer cells carry a marker called PD-L1, measured on the biopsy tissue. In a large study of people with such cancers, adding pembrolizumab before and after standard surgery and radiation lowered the chance of the cancer returning or growing. Only about 1 in 10 people in that study had oropharyngeal cancer, which is one reason this track is less common for oropharyngeal cancer than chemoradiation or surgery followed by added treatment.
Before treatment (weeks 0 to 4)
The biopsy, scans, p16 (HPV) result, meetings with the care team, dental check, baseline swallow test, dietitian visit and the tumor board's recommendation are described on the overview page. On this track, the biopsy is also tested for PD-L1.
Treatment
Pembrolizumab before surgery (about weeks 4 to 10): two doses by IV, 3 weeks apart (immunotherapy for head and neck cancers).
Surgery (about week 11): removal of the tumor and a neck dissection (see throat cancer treatments).
Radiation (about weeks 16 to 22): radiation 5 days a week for about 6 weeks, with cisplatin chemotherapy added when the removed tissue shows higher-risk features.
Pembrolizumab with and after radiation (about weeks 16 to 61): a dose every 3 weeks, 3 doses during radiation and then 12 more, for about a year in all after radiation begins.
Side effects and healing
Radiation side effects follow the same pattern as on other radiation tracks: a sore mouth and throat that peaks near the end of radiation and heals over the next few weeks, swallowing and taste changes that improve over 6 to 12 months, and dry mouth that often partly recovers over 1 to 2 years.
Immunotherapy side effects: pembrolizumab can cause the immune system to inflame healthy organs, most often the thyroid, and less often the skin, bowel, lungs or liver. In the large study, about 1 in 5 people who received it developed an underactive thyroid (hypothyroidism). Regular blood tests check for these effects throughout treatment.
Cisplatin, when given, adds the effects described on the chemoradiation timeline.
Check-ups and scans
A PET-CT scan about 12 weeks after radiation checks whether treatment worked. On this track it happens while pembrolizumab is still being given.
In this timeline, the follow-up clock starts when pembrolizumab ends, about a year after radiation begins. Check-ups then follow the usual schedule: every 1 to 3 months in the first year, every 2 to 6 months in the second, every 4 to 8 months in years 3 to 5, then yearly.
Quality of life on this track
The large study reported only how scores changed from the start, not average scores at each time point, so the timeline describes them in words:
During the 2 doses before surgery, scores changed by 3 points or less, which is not a noticeable change.
About 6 months and 1 year after radiation began, overall quality of life, swallowing and speech scores were within about 3 points of people treated without pembrolizumab.
The questionnaires used to measure quality of life are described on the quality-of-life questionnaires page.
Long-term care
Dental visits and possible fluoride treatments continue for life, because of the jaw-healing risk after radiation (osteoradionecrosis).
A thyroid blood test (TSH) every 6 to 12 months for 3 years checks for hypothyroidism, which both radiation and pembrolizumab can cause.
Swallowing exercises and periodic checks continue, and staying tobacco-free lowers the risk of the cancer returning or a new cancer.
This page