The Tonsillectomy-Cancer Debate: Weighing Risk and Benefit in Pediatric Care
Does adenotonsillectomy increase the risk of cancer?
Kara D. Meister, MD, on behalf of the Pediatric Otolaryngology Education Committee
The Case FOR Increased Cancer Risk
The evidence supporting a potential link between tonsillectomy and cancer risk is increasingly substantial. The Swedish cohort study examined nearly five million individuals over 36 years of follow-up care, finding a modestly increased overall risk of cancer following surgical removal of tonsils, adenoids, or both tonsils and adenoids.1 Specifically, the study identified increased risk for breast cancer, prostate cancer, thyroid cancer, and lymphoma, with hazard ratios of 1.10 for any cancer in both population and sibling comparisons.1
The study's methodology is likely as robust as possible outside of a randomized controlled trial. By utilizing Sweden's comprehensive Patient Register, which has tracked hospital-based care since 1964, researchers addressed several previous criticisms of the literature, including controlling for surgical indication, comorbidities, and surveillance bias.1 The sibling-controlled design is powerful because it suggests these associations are unlikely due to shared genetic, lifestyle, or environmental factors within families.1
Supporting this association, a Taiwanese study reported marginally increased breast cancer risk in tonsillectomy patients with more than three years of follow-up care (adjusted IRR = 2.62; CI = 0.97-7.03), and a comprehensive meta-analysis confirmed these findings (OR, 1.24; 95% CI: 1.11-1.39). 2,3 Notably, the Swedish study found that the increased risk remained consistent regardless of surgery type (tonsillectomy, adenoidectomy, or adenotonsillectomy), age at surgery, or indication for the procedure.1
Biological plausibility supports these findings. Tonsils and adenoids serve as secondary lymphoid organs integral to immune surveillance and education. Their removal may compromise the body's immunologic defenses against cancer cell proliferation, particularly for cancers associated with infectious exposures or autoimmune processes. Byproducts of chronic inflammation, such as COX-2, have been correlated with estrogen synthesis and breast cell proliferation in vitro, suggesting a mechanistic pathway, though this is not fully elucidated.4
What about oropharyngeal squamous cell carcinoma? While tonsillectomy decreases tonsil cancer risk by 60-83%, it appears to increase base of tongue cancer risk 1.8- to 2.5-fold, suggesting the procedure may shift the anatomic site rather than prevent oropharyngeal cancer development.5
The Case AGAINST a Causal Relationship
However, several important counterarguments deserve consideration. First, the absolute numbers are modest. While statistically significant, a hazard ratio of 1.10 represents a 10% relative increase in risk. When counseling individual patients, this translates to an absolute risk increase that may not be clinically meaningful for most children.
The causality question remains unresolved. It's unclear whether the surgical procedure itself increases cancer risk, or whether individuals requiring surgery possess underlying immune dysfunction or infectious exposures predisposing them to both chronic tonsillar disease (i.e., tonsillitis, tonsillar hypertrophy, etc.) and future malignancy. The study's finding that risk remained unchanged across different surgical indications paradoxically both strengthens and weakens the argument—it could suggest that the surgery itself is causal, or, alternatively, that an unmeasured confounding factor drives both the need for surgery and subsequent cancer risk.
Previous research has failed to demonstrate significant permanent damage to the immune system following tonsillectomy. Some studies show only transient immune decline, while others, including a meta-analysis by Bitar et al., found no negative immunological sequelae.6,7 This challenges the immune dysfunction hypothesis.
Additionally, the theory that tonsillectomy serves as a proxy for viral infections (such as EBV or HPV) occurring at critical developmental periods, rather than representing a causal factor itself, deserves consideration. Under this framework, the surgery is merely a marker for underlying processes that are already increasing cancer risk.
Clinical Implications and Shared Decision-Making
When balancing this evidence in clinical practice, it’s all about perspective. While the data suggest a potential association between tonsillectomy and cancer risk, the absolute increases are modest and must be weighed against the well-established benefits of indicated surgery. For children with severe obstructive sleep apnea, recurrent infections significantly impacting quality of life, or other clear indications, the immediate and substantial benefits may outweigh correlated long-term risks. In addition, whether childhood exposure to OSA-related intermittent hypoxia carries forward cancer risk into adulthood is unknown; there are no studies evaluating whether pediatric OSA increases adult cancer risk.
This represents an opportunity for shared decision-making and the art of medicine. Each family deserves individualized counseling that acknowledges the data while contextualizing its limitations and relevance to a specific situation. I am particularly interested in whether partial or intracapsular tonsillectomy might balance short-term benefits—such as improving sleep-disordered breathing—with potential long-term risks, preserving some immunologic function while addressing more immediate concerns.
Ultimately, these findings underscore the need for continued research, long-term follow-up of surgical patients, and thoughtful clinical decision-making that honors both evidence and individual patient factors.
Disclaimer: A large language model was used for grammar and writing style; the content and interpretation of the data are original to the human author.
References
- Liang J, Huang Y, Yin L, Sadeghi F, Yang Y, Xiao X, Adami HO, Ye W, Zhang Z, Fang F. Cancer risk following surgical removal of tonsils and adenoids - a population-based, sibling-controlled cohort study in Sweden. BMC Med. 2023 May 24;21(1):194. doi: 10.1186/s12916-023-02902-x. PMID: 37226237; PMCID: PMC10210283.
- Sun LM, Chen HJ, Li TC, Sung FC, Kao CH. A nationwide population-based cohort study on tonsillectomy and subsequent cancer incidence. Laryngoscope. 2015 Jan;125(1):134-9. doi: 10.1002/lary.24864. Epub 2014 Aug 5. PMID: 25130597.
- Kacimi SEO, Elgenidy A, Cheema HA, Ould Setti M, Khosla AA, Benmelouka AY, Aloulou M, Djebabria K, Shamseldin LS, Riffi O, Mesli NS, Sekkal HZ, Afifi AM, Shah J, Ghozy S. Prior Tonsillectomy and the Risk of Breast Cancer in Females: A Systematic Review and Meta-analysis. Front Oncol. 2022 Jul 20;12:925596. doi: 10.3389/fonc.2022.925596. PMID: 35936707; PMCID: PMC9350012.
- Richards JA, Petrel TA, Brueggemeier RW. Signaling pathways regulating aromatase and cyclooxygenases in normal and malignant breast cells. J Steroid Biochem Mol Biol. 2002 Feb;80(2):203-12. doi: 10.1016/s0960-0760(01)00187-x. PMID: 11897504.
- Zevallos JP, Mazul AL, Rodriguez N, Weissler MC, Brennan P, Anantharaman D, Abedi-Ardekani B, Neil Hayes D, Olshan AF. Previous tonsillectomy modifies odds of tonsil and base of tongue cancer. Br J Cancer. 2016 Mar 29;114(7):832-8. doi: 10.1038/bjc.2016.63. Epub 2016 Mar 15. PMID: 26977858; PMCID: PMC4984870.
- Yan Y, Song Y, Liu Y, Su J, Cui L, Wang J, Geng J, Liu X, Shi Y, Quan S, Hang A, Zuo L. Short- and long-term impacts of adenoidectomy with/without tonsillectomy on immune function of young children <3 years of age: A cohort study. Medicine (Baltimore). 2019 May;98(19):e15530. doi: 10.1097/MD.0000000000015530. PMID: 31083200; PMCID: PMC6531274.
- Bitar MA, Dowli A, Mourad M. The effect of tonsillectomy on the immune system: A systematic review and meta-analysis. Int J Pediatr Otorhinolaryngol. 2015 Aug;79(8):1184-91. doi: 10.1016/j.ijporl.2015.05.016. Epub 2015 May 27. PMID: 26055199.
