Mouth cancer

Mouth cancer usually develops because of a small number of well-known causes. Smoking or chewing tobacco is the biggest one, and drinking large amounts of alcohol is another. If someone both smokes or chews tobacco and drinks heavily, their risk climbs even higher than either habit alone would cause.

A few other things can raise your risk as well. Chewing betel quid (paan), gutkha or pan masala can contribute, even in versions that do not contain tobacco. A weak immune system caused by an underlying medical problem is another factor, and so is a diet that lacks enough fresh fruit and vegetables. Spending long periods in strong sunlight, or using sunbeds or sunlamps over the years, can also increase the risk of cancer on the lips specifically.

It helps to keep these risk factors in perspective. Having one or more of them does not mean mouth cancer is certain to develop, and having none of them does not guarantee that it will not happen either.

Diagnosing mouth cancer

You usually start by seeing your GP or dentist. They’ll examine your mouth closely. If they think your symptoms could be linked to cancer, they’ll refer you to a specialist doctor.

You may see an:

• oral and maxillofacial specialist (OMFS), or
• ear, nose and throat (ENT) specialist

You usually see a specialist within 2 weeks.

The specialist doctor will ask about your symptoms and general health. They’ll check your mouth using a small mirror and bright light. If your only symptom is a lump in your neck, you may be referred to a hospital that has a neck lump clinic.

You may have some of the following tests to diagnose mouth cancer.

Nasendoscopy

A nasendoscope is a thin, flexible tube with a light and camera on the end. It allows your doctor to look inside your nose, the back of your nose and your throat.

Biopsy

To make a diagnosis, your doctor needs to remove a small piece of tissue or some cells (biopsy) from the area that looks abnormal. Your doctor may take a biopsy while they’re examining you with the nasendoscope. Sometimes they might arrange for you to have a general anaesthetic to take the biopsy.

A doctor called a pathologist looks at the sample under a microscope to check for cancer cells.

Ultrasound scan of the neck

If you have a lump or a swelling in your neck, you’ll usually have an ultrasound scan of the area. This uses soundwaves to produce a picture of your neck and nearby lymph nodes

Fine needle aspiration (FNA) of the lymph nodes

You may have a fine needle aspiration test to see whether there are any cancer cells in the lymph nodes in the neck. It can also be used to take samples from the mouth.

The doctor will pass a fine needle into the lump. They’ll then withdraw (aspirate) some cells into the syringe. Sometimes they’ll use an ultrasound scan to help guide the needle into the area.

Macmillan Cancer Support have more information about tests for head and neck cancer.

Further tests for mouth cancer

These tests may be used to help diagnose mouth cancer and to check whether it has spread.

CT scan

A CT scan takes a series of X-rays. This builds up a three-dimensional (3D) picture of the inside of the head and neck.

MRI scan

An MRI scan uses magnetism to build up a detailed picture of areas of the head and neck.

Waiting for test results can be a difficult time. Macmillan Cancer Support have more information that can help.

Staging and grading of mouth cancer

The results of your tests helps your doctors find out more about the size, depth and position of the cancer and whether it has spread. This is called staging.

The grade of the cancer describes how the cancer cells look under the microscope. This gives an idea of how quickly the cancer might develop.

Knowing the grade and stage helps your doctors plan the best treatment for you.

The most commonly used staging systems for mouth cancer are the TNM and number staging systems.

TNM staging system

TNM stands for tumour, node and metastases.

Tumour (T)

T describes the size of the tumour and whether it has grown into the surrounding areas. It’s numbered 0 and 4 depending on the size and extent of the tumour.

T0 means there are no signs of a tumour in the mouth, but there may be abnormal cells that are pre-cancerous.

T1 means the tumour is smaller than 2cm and less than 5mm deep.

T2 means the tumour may be smaller than 2cm and deeper than 5mm but not deeper than 10mm. Or, tumours may be larger than 2cm but less than 4cm and not deeper than 10mm.

T3 means the tumour may be larger than 2cm but less than 4cm and deeper than 10mm. Or, tumours may be larger than 4cm but not deeper than 10mm.

T4 means the tumour may be larger than 4cm and deeper than 10mm. Or, the tumour may have spread into nearby areas, like muscles or bones.

Nodes (N)

Nodes describes whether the cancer has spread to the lymph nodes.

Metastases (M)

M describes whether the cancer has spread to another part of the body (called metastatic cancer).

The number staging system combines all the information from TNM staging and gives it a number from 1 to 4.

Macmillan Cancer Support have more information about the staging and grading of head and neck cancer.

Grading of mouth cancer

A doctor looks at a sample of the cancer cells under a microscope to find out the grade of the cancer.

Grade 1 or low grade means the cancer cells look like normal cells and usually grow slowly.

Grade 2 and 3 means the cancer cells look different to normal cells and are slightly faster growing.

Treatment for mouth cancer

Treatment for mouth cancers include surgery, radiotherapy and chemotherapy. Sometimes targeted therapies and immunotherapies may be used.

Surgery

Surgery is the main treatment for early-stage mouth cancer. It’s often the only treatment needed to remove an early-stage mouth cancer. Sometimes some lymph nodes in the neck may also be removed.

Radiotherapy

Radiotherapy uses high-energy rays to destroy the cancer cells, while doing as little harm as possible to normal cells.

Radiotherapy is often used after surgery to reduce the risk of the cancer coming back. If surgery isn’t possible, you usually have radiotherapy instead of surgery.

It can be used on its own but is often given with chemotherapy. Chemotherapy and radiotherapy together is called chemoradiation.

Chemotherapy

Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells. The chemotherapy drugs most often used to treat mouth cancer are cisplatin and fluorouracil (5FU).

Chemoradiation

Chemoradiation or chemoradiotherapy is when you have chemotherapy and radiotherapy together. Chemotherapy can make the cancer cells more sensitive to radiotherapy treatment.

Targeted therapies

Targeted therapy work by targeting something in or around the cancer cell that’s helping it grow and survive. Cetuximab is the most commonly used targeted therapy to treat mouth cancer.

Macmillan Cancer Support have more information about treatment for mouth cancer.

You may have some treatments as part of a clinical trial.

After mouth cancer treatment

You’ll have regular follow-up appointments after treatment.

You may also have regular follow-up appointments with your multidisciplinary team (MDT). This can include a:

• speech and language therapist (SLT)
• dietitian
• restorative dentist
• dental hygienist
• physiotherapist

If you have any problems or notice new symptoms between appointments, let your doctor or nurse know as soon as possible.

Long-term or late effects

Some treatment side effects may take a long time to improve after treatment finishes, or they may become permanent. These are called long-term effects.

Other side effects can develop months or even years after treatment has finished. These are known as late effects.

Macmillan Cancer Support have more information about long-term and late effects of head and neck cancer treatment.

Sex life

Head and neck cancer and its treatment can sometimes have an effect on your sex life.

If you’re worried about this, talk to your doctor or nurse.

Macmillan Cancer Support have more information on cancer and sex.

Fertility

Some cancer treatments can also affect whether you can get pregnant or make someone pregnant. If you’re worried about this, it’s important to talk with your doctor before you start treatment.

Macmillan Cancer Support have more information about:

• fertility in women after treatment
• fertility in men after treatment
• LGBTQ+ people and cancer treatment

Wellbeing and recovery

Even if you already have a healthy lifestyle, you may choose to make some positive lifestyle changes during and after treatment. For example, if you smoke or drink alcohol, it’s best to avoid smoking or reduce the amount of alcohol.

Eating well and keeping active can improve your health and wellbeing. It can also help your body recover. A dietitian can help with any difficulties you might have with eating after treatment.

Getting support

It may take several months to recover from treatment. It can be hard if treatment has changed your appearance, how you eat or drink, or your voice. This may also affect your body image but there are ways to help you to manage any changes.

You may still be coping with difficult feelings. Talking to your family and friends or health professionals about how you feel can help them know how to support your wellbeing.

There are also national support groups that you may find helpful. This includes:

• The Mouth Cancer Foundation – information and support to people affected by head and neck cancers
• Changing Faces – advice and information for anyone who is affected by a change in their appearance
• The Swallows – offers a 24-hour support line to anyone affected by head and neck cancer
• Salivary Gland Cancer UK – supports people with rare salivary gland cancers

Macmillan Cancer Support also has further information to support you. You can:

• phone the Macmillan Support Line on 0808 808 00 00
• chat to Macmillan specialists online
• use the Macmillan head and neck cancer forum – you can talk to others affected by head and neck cancer, ask questions and share your experience

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