The guideline first addresses the addition of chemotherapy to curative RT for oropharyngeal cancer, recommending concurrent chemoradiation for patients with stage IV disease or stage III disease with large-volume tumors, but not for patients with stage I-II disease. Recommendations by disease stage are as follows:

Stage IV: Patients with stage IVA-B tumors receiving definitive RT should receive concurrent high-dose intermittent cisplatin. Advanced-stage patients who are medically unfit for high-dose cisplatin should receive concurrent cetuximab or carboplatin-fluorouracil; weekly cisplatin may be considered for these patients with the caveat that there is limited prospective evidence to support its use. Concurrent cetuximab should not be co-delivered to patients receiving definitive chemoradiation (CRT), nor should intra-arterial chemotherapy be used in this population.


Stage III: Patients with stage III OPSCC receiving definitive RT should receive concurrent systemic therapy for T3 N0-1 tumors. CRT may be considered for larger volume T1-T2 N1 tumors that are at substantial risk for locoregional recurrence. Systemic therapy for other stage III patients may convey unnecessary toxicity.

Stage I-II: Concurrent systemic therapy is not recommended for patients with stage I-II OPSCC receiving definitive RT, due to a lack of evidence supporting its use for early-stage disease.

The guideline also provides guidance for the use of radiation and chemoradiation following primary surgery for OPSCC. Post-operative, or adjuvant, RT is recommended for patients who show pathologic risk factors for disease recurrence, such as positive surgical margins or positive lymph nodes following surgery, although concurrent chemoradiation is strongly recommended only for high-risk patients. Recommendations by treatment type and risk level are as follows:

Concurrent systemic therapy for high-risk patients: Systemic therapy, specifically high-dose intermittent cisplatin, should be delivered with post-surgical RT for patients with positive surgical margins and/or extracapsular extension. Weekly cisplatin may be delivered to post-operative patients who are unable to tolerate high-dose cisplatin. Post-operative patients who are unable to tolerate cisplatin-based chemoradiotherapy should not routinely receive concurrent chemotherapy. Existing prospective data do not support the use of cetuximab, concurrent weekly carboplatin or routine concurrent weekly docetaxel with post-operative RT, although clinical trials are underway to examine these alternative agents.

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