HPV-positive oropharyngeal cancer: lines of therapy

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7 standard-of-care settings across 5 lines and 1 biomarker subgroup. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

Line	All comers
Screening, prevention and diagnosis	3
Early / localised	1
Locally advanced	1
Advanced, first line	1
Other settings	1

Screening, prevention and diagnosis

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Diagnosis and staging	Fine-needle biopsy of the neck node with p16 staining, HPV confirmation where p16 is equivocal, examination and imaging of the tonsils and tongue base, and PET-CT; staged with the HPV-positive system.	HPV-positive (p16) head and neck cancerPET/CT	NCCN Guidelines: Head and Neck Cancers	92
All comers	Surveillance	Examination and PET-CT at about three months; circulating tumour HPV DNA is emerging as a blood test for recurrence.	PET/CTCirculating tumour HPV DNA (ctHPV-DNA)		92
All comers	Prevention	HPV vaccination of girls and boys before exposure; catch-up vaccination of men is being argued for.	HPV & HBV vaccinationNonavalent HPV vaccineCatch-up HPV vaccination for men to prevent throat cancer		86

Early / localised

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Early disease (small primary, limited nodes)	Transoral robotic surgery with neck dissection and pathology-guided adjuvant radiotherapy (E3311), or radiotherapy alone; choice by expected swallowing and voice.	Transoral robotic surgery (TORS)IMRT / IGRT (modern external beam)ECOG-ACRIN E3311	NCCN · Category 2A	93

Locally advanced

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Locally advanced disease	Cisplatin chemoradiation to 70 Gy; cetuximab only for patients who cannot have cisplatin, since RTOG 1016 and De-ESCALaTE showed it inferior.	CisplatinChemoradiation (chemoradiotherapy, CRT)IMRT / IGRT (modern external beam)CetuximabRTOG 1016De-ESCALaTE HPV	NCCN · Category 1	93

Advanced, first line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Recurrent or metastatic	Pembrolizumab alone or with platinum-fluorouracil (KEYNOTE-048); HPV-positive tumours respond at least as well as HPV-negative ones.	PembrolizumabKEYNOTE-048Recurrent or metastatic head and neck squamous cell carcinoma	NCCN · Category 1	98

Other settings

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	De-escalation	Reduced-dose or chemotherapy-free treatment only within a trial; NRG-HN005 showed that lowering the dose in definitive chemoradiation on HPV status alone loses control.	NRG-HN002 & NRG-HN005 (HPV+ de-escalation)PATHOSCirculating tumour HPV DNA (ctHPV-DNA)Caution: de-escalating radiation on HPV status alone		52

Sequence and caution pairings

Caution

Caution: de-escalating radiation on HPV status alone

Being HPV-positive is not enough to justify less radiation; trials that tried it saw more relapses.

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.