Mouth cancer

Mouth cancer, which doctors also call oral cancer, is one of the most common types of head and neck cancer. It can start in any part of the mouth.

Your mouth is also called the oral cavity. It includes the:

• lips
• front part of the tongue, called the oral tongue
• floor of the mouth, under the tongue
• inside of the cheek
• roof of the mouth, called the hard palate
• area behind the wisdom teeth
• upper and lower gums

Mouth cancer most often starts on the side of the tongue or on the floor of the mouth.

Macmillan Cancer Support, a UK charity, has more information on what cancer is.

The two main causes of mouth cancer are:

• smoking or chewing tobacco
• drinking large amounts of alcohol

If you do both, your risk of developing mouth cancer is higher still.

A few other things may also raise your risk of mouth cancer:

• chewing betel quid (paan), gutkha or pan masala (even if it doesn't have tobacco in it)
• having medical problems that cause a weak immune system
• eating an unhealthy diet without enough fresh fruit and vegetables
• long-term ultraviolet light exposure (from sunlight, sunbeds or sunlamps), which increases the risk of lip cancer

Having one or more of these risk factors doesn't mean you'll get mouth cancer. And having none of them doesn't mean you'll never develop it.

You usually start by seeing your doctor or dentist. They'll examine your mouth closely, and 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 will ask about your symptoms and your general health. They'll then check your mouth using a small mirror and a bright light. If a lump in your neck is your only symptom, 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.

A nasendoscope is a thin, flexible tube with a light and a camera at the end. Your doctor uses it to look inside your nose, the back of your nose and your throat.

To diagnose mouth cancer, your doctor needs to take a small piece of tissue or some cells (this is called a biopsy) from the area that looks abnormal. The doctor may do this while they're examining you with the nasendoscope. Sometimes they will arrange for you to have a general anaesthetic so the biopsy can be taken.

The sample then goes to a doctor called a pathologist, who looks at it under a microscope to check for cancer cells.

If you have a lump or a swelling in your neck, you'll usually have an ultrasound scan of the area. The scan uses soundwaves to make a picture of your neck and the lymph nodes close by.

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

The doctor passes a fine needle into the lump. They then withdraw (aspirate) some cells into the syringe. Sometimes an ultrasound scan is used as support, to help guide the needle into the right area.

Your doctor may use these tests to help diagnose mouth cancer, and to check whether the cancer has spread.

A CT scan takes a series of X-rays and puts them together to build a three-dimensional (3D) picture of the inside of your head and neck.

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

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

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

The grade of the cancer describes how the cancer cells look under the microscope. It 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 staging systems most commonly used for mouth cancer are the TNM and number staging systems.

TNM stands for tumour, node and metastases.

The T in the staging system describes the size of the tumour and whether it has grown into the areas around it. It is numbered from 0 to 4, depending on how big the tumour is and how far it has spread.

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 the tumour 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 the tumour 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.

The N in mouth cancer staging tells you whether the cancer has spread to the lymph nodes.

To find out the grade of mouth cancer, a doctor looks at a sample of the cancer cells under a microscope.

Grade 1, also called low grade, means the cancer cells look like normal cells and usually grow slowly. With grade 2 and grade 3, the cells look different from normal cells and grow slightly faster.

Mouth cancer is treated with surgery, radiotherapy and chemotherapy. In some cases, doctors may also use targeted therapies and immunotherapies.

Surgery is the main treatment for early-stage mouth cancer. For many people it's the only treatment needed to remove the cancer. Sometimes the surgeon also removes some lymph nodes in the neck.

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

Doctors often give radiotherapy after surgery, to reduce the risk of the cancer coming back. If surgery isn't possible, you usually have radiotherapy instead of surgery.

You can have it on its own, but it's often given with chemotherapy. Chemotherapy and radiotherapy together is called chemoradiation.

Chemotherapy uses anti-cancer drugs, also called cytotoxic drugs, to destroy cancer cells. For mouth cancer, the drugs doctors use most often are cisplatin and fluorouracil (5FU).

Chemoradiation, also called chemoradiotherapy, is when you have chemotherapy and radiotherapy together. Chemotherapy can make mouth cancer cells more sensitive to radiotherapy, so the two treatments work better side by side.

After mouth cancer treatment, you'll have regular follow-up appointments. You may also see your multidisciplinary team (MDT) regularly. 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, tell your doctor or nurse as soon as possible.

Some side effects of treatment take a long time to get better after treatment ends, and some never go away completely. These are called long-term effects.

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

Macmillan Cancer Support has more information about the long-term and late effects of treatment for head and neck cancer, which includes mouth cancer.

Head and neck cancer, and the treatment for it, can sometimes affect your sex life. If you're worried about this, talk to your doctor or nurse for support.

Some treatments for mouth cancer 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 has more information about:

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

Even if you already live a healthy life, you may want to make a few positive changes during and after your mouth cancer treatment. If you smoke or drink alcohol, for example, it's best to avoid smoking and to cut down on alcohol.

Eating well and staying active can improve your health and wellbeing, and they can help your body recover too. If you have trouble eating after treatment, a dietitian can help you with it.

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. Your body image may be affected too, but there are ways to help you manage these changes.

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

There are also national support groups that you may find helpful. These include:

• The Mouth Cancer Foundation, which gives information and support to people affected by head and neck cancers
• Changing Faces, which gives advice and information to anyone affected by a change in their appearance
• The Swallows, which offers a 24-hour support line to anyone affected by head and neck cancer
• Salivary Gland Cancer UK, which 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, where you can talk to others affected by head and neck cancer, ask questions and share your experience

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