Overview

Mouth cancer, also known as oral cancer, is where a tumourdevelops in the lining of the mouth. It may be on the surface of the tongue, the insides of the cheeks, the roof of the mouth (palate), or the lips or gums.

Tumours can also develop in the glands that produce saliva, the tonsils at the back of the mouth, and the part of the throat connecting your mouth to your windpipe (pharynx). However, these are less common.

Title
Mouth cancer

Types

Mouth cancer is categorised by the type of cell the cancer (carcinoma) starts in.

Squamous cell carcinoma is the most common type of mouth cancer, accounting for 9 out of 10 cases.

Squamous cells are found in many places around the body, including the inside of the mouth and the skin.

Less common types of mouth cancer include:

  • adenocarcinomas – cancers that develop inside the salivary glands
  • sarcomas – these grow from abnormalities in the bone, cartilage, muscle or other body tissue
  • oral malignant melanomas – where the cancer starts in melanocytes, the cells that produce skin pigment; they appear as very dark, mottled swellings that often bleed
  • lymphomas – these grow from cells normally found in lymph glands, but can also develop in the mouth
Symptoms

Symptoms of mouth cancer include:

  • sore mouth ulcers that don't heal within several weeks
  • unexplained, persistent lumps in the mouth that don't go away
  • unexplained, persistent lumps in the neck that don't go away
  • unexplained looseness of teeth, or sockets that don't heal after extractions
  • unexplained, persistent numbness or an odd feeling on the lip or tongue
  • sometimes, white or red patches on the lining of the mouth or tongue – these can be early signs of cancer, so they should also be investigated
  • changes in speech, such as a lisp

See your GP or dentist if these symptoms don't heal within three weeks, particularly if you drink or smoke heavily.

Causes

Things that increase your risk of developing mouth cancer include:

  • smoking or using other forms of tobacco
  • drinking alcohol – people who drink and smoke heavily have a much higher risk compared with the population at large
  • infection with the human papilloma virus (HPV) – HPV is the virus that causes genital warts
Diagnosis

If you have symptoms of mouth cancer, your GP or dentist will carry out a physical examination and ask about your symptoms.

If mouth cancer is suspected, you'll be referred to hospital for further tests or to speak to a specialist oral and maxillofacial surgeon.

In 2015, the National Institute for Health and Care Excellence (NICE) published guidelines to help GPs recognise the signs and symptoms of mouth cancer and refer people for the right tests faster.

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Biopsy

A small sample of affected tissue will need to be removed to check for the presence of cancerous cells. This procedure is known as a biopsy.

The main methods used to carry out a biopsy in cases of suspected mouth cancer are:

  • an incision or punch biopsy
  • a fine needle aspiration with cytology
  • a nasendoscopy
  • a panendoscopy

The samples taken during a biopsy are sent to a specialist doctor called a pathologist, who examines them under a microscope.

They'll report back to the surgeon to tell them whether it's cancer and, if it is, what type and what grade it is.

Incision and punch biopsy

An incision biopsy is usually carried out under local anaesthesia if the affected area of tissue is easily accessible, such as on your tongue or the inside of your mouth.

After the area has been numbed with a local anaesthetic, the surgeon will cut away a small section of affected tissue and remove it with tweezers.

The wound is sometimes closed with dissolvable stitches. The procedure isn't painful, but the affected area can be a little sore afterwards.

A punch biopsy is where an even smaller piece of tissue is removed and no stitching is used.

Fine needle aspiration cytology

A fine needle aspiration cytology (FNAC) may be used if you have a swelling in your neck that's thought to be a secondary from the mouth cancer.

It's usually done at the same time as an ultrasound scan of the neck is carried out.

FNA is a bit like having a blood test. A very small needle is used to draw out a small sample of cells and fluid from the lump so it can be checked for cancer.

The procedure is very quick and the discomfort felt is the same as with a blood test.

Nasendoscopy

A nasendoscope is a long, thin, flexible tube with a camera and a light at one end. It's guided through the nose and into the throat.

It's usually used if the suspected tissue is inside your nose, throat (pharynx) or voice box (larynx).

A nasendoscopy takes about 30 seconds. Local anaesthetic may be sprayed into your nose and throat to reduce any discomfort.

Occasionally, tissue may be taken using a telescopic punch biopsy. Sometimes the surgeon will let you see the images on the computer screen.

Panendoscopy

A panendoscopy is carried out under general anaesthetic. It's used to investigate the same areas as a nasendoscopy, but uses larger telescopes that would be uncomfortable if you were conscious.

The scopes give better access, so the procedure can also be used to remove small tumours.

Further tests

If the biopsy confirms that you have mouth cancer, you'll need further tests to check what stage it's reached before any treatment is planned.

These tests usually involve having scans to check whether the cancer has spread into tissues next to the primary cancer, such as the jaw or skin, as well as scans to check for spread into the lymph glands in your neck.

It's rare for mouth cancer to spread further than these glands, but you'll also have scans to check the rest of your body.

Tests you may have include:

The X-rays and scans will be looked at by a specialist doctor called a radiologist. They'll write a report and put it on the hospital computer system. The report forms a major part of decisions about staging.

After these tests have been completed, it should be possible to determine the stage and grade of your cancer.

Staging and grading

Staging is a measure of how far the cancer has spread. The TNM system of staging is used for staging mouth cancer:

  • T – relates to the size of the tumour (also called the primary cancer) in the mouth; T1 is the smallest and T4 is the largest or most deeply invasive
  • N – is used to show whether there are secondaries (metastases) in the neck lymph glands; N0 means none have been found during examination or on scans, and N1, N2 and N3 indicate the extent of neck secondaries
  • M – refers to whether there are secondaries elsewhere in the body

The grade describes how aggressive the cancer is and how fast it's likely to spread in future.

The three grades of mouth cancer are:

  • low grade – the slowest
  • moderate grade
  • high grade – the most aggressive

Staging and grading will help determine whether you have:

  • early mouth cancer – usually curable with a small operation
  • intermediate mouth cancer – still has a high chance of a cure, but will almost certainly need a long operation and radiotherapy
  • advanced mouth cancer – has a lower chance of a cure and will definitely need all three treatments (surgery, radiotherapy and chemotherapy)

Staging and grading your cancer will help your surgeon and multidisciplinary team (MDT) decide how you should be treated

Treatment

If mouth cancer is caught early, relatively minor surgery can be used, which has a very high chance of curing the cancer so it never comes back.

That's why you should report any changes in your mouth to your dentist and doctor immediately.

Even in cases of advanced mouth cancer, improvements in surgery, radiotherapy and medication mean that the chances of a cure are better than 50:50.

However, you'll need treatment with surgery, radiotherapyand medication over a period of at least four months.

Your treatment team

Mouth cancer may affect structures in the body that are important for breathing, eating and speaking. It may also affect appearance.

This means that as well as being treated by surgeons and clinical oncologists, you'll also see a dietitian, speech and language therapist, and dentist.

You'll also usually have the support of a nurse who specialises in head and neck cancer (a clinical nurse specialist).

Being diagnosed with cancer can cause stress and anxiety for both you and your family. In some hospitals, a psychologist will be available to provide help and support if you need them.

If swallowing difficulties temporarily make it difficult for you to get the nutrition you need by mouth, you may need to have a tube inserted through your nose and fed down into your stomach (nasogastric tube).

If the problem is likely to be long-term, a specialist gastroenterologist or radiologist will insert a tube directly into your stomach (gastrostomy).

Your treatment plan

Your treatment for mouth cancer will depend on a number of different things, including:

  • the type and size of the cancer
  • the grade and how far it's spread
  • your general health

If the cancer hasn't spread beyond the mouth or oropharynx – the bit of your throat at the back of your mouth – a complete cure may be possible using surgery alone.

If the cancer is large or has spread to your neck, surgery, radiotherapy and even chemotherapy may be necessary to control it.

Your surgeons and doctors will make recommendations about your treatment with the help and advice of all of your care team, but the final decision will be yours.

Before going to hospital to discuss your treatment options, you may find it useful to write a list of questions to ask the specialist.

For example, you may want to find out about the advantages and disadvantages of particular treatments.

Before treatment begins

Radiotherapy makes the teeth more sensitive and vulnerable to infection, so you'll be given a full dental examination and any necessary work will be carried out before you begin your treatment.

If you smoke or drink, stopping will increase the chances of your treatment being successful.

Your GP and specialist nurse can give you help and support if you're finding it difficult to quit smoking and give up drinking.

Surgery

For mouth cancer, the aim of surgery is to remove any affected tissue while minimising damage to the rest of the mouth.

If your cancer is advanced, it may be necessary to remove part of your mouth lining and, in some cases, facial skin. This can be replaced using skin taken from elsewhere in the body, such as your forearm or chest.

If your tongue is affected, part of it will have to be removed, known as a partial glossectomy.

The tongue may be left to heal on its own – this usually takes three to four weeks – or it may need to be reconstructed using grafted tissue.

If the cancer has invaded deep into your jawbone, the affected part of the jaw will need to be removed.

Surgeons now use a complex technology called 3D printing to plan the reconstruction so that the replacement bone matches the removed bone almost exactly.

The grafted bone is kept alive by carefully joining tiny arteries and veins under a microscope (microvascular surgery). This increases the length of the operation.

The bone and muscle used for this replacement is usually taken from the lower leg, hip or shoulder blade. Dental implants can often be put into the new bone so that dental bridges can be made to replace lost teeth.

Occasionally, other bones, such as cheekbones, may have to be removed to get rid of the cancer completely.

These can be replaced with bone from other parts of the body, or a specialist dentist can make an extensive denture called an obturator, which holds the cheek out from the inside to give a relatively normal appearance.

During surgery, your surgeon may also remove lymph nodes near the site of the initial tumour. This is often carried out as a preventative measure in case they contain small numbers of cancerous cells that can't be detected on any scans.

The thought of having reconstructive facial surgery can be worrying. Your surgeon will explain the operation to you in detail and answer any questions or concerns you have.

You may also find it useful and reassuring to talk to other people who've had the same operation.

Your surgeon may be able to put you in touch with one of their former patients. Or a support group, such as Saving Faces, will be able to put you in phone contact with former patients.

Radiotherapy

Radiotherapy uses doses of radiation to kill cancerous cells. In mouth cancer, it's usually used after surgery to prevent the cancer returning. In throat cancer, it's often the first treatment to be given, in combination with medication (chemoradiotherapy).

The treatment is usually given every day over the course of six weeks, depending on the size of the cancer and how far it's spread.

As well as killing cancerous cells, radiotherapy can also affect healthy tissue.

It has a number of side effects, including:

Any side effects will be monitored by your care team and treated where possible.

The side effects of radiotherapy can be distressing, but many of them will improve once the radiotherapy is complete.

Internal radiotherapy

Internal radiotherapy, also known as brachytherapy, can be used to treat early-stage cancers of the tongue. It involves placing radioactive implants directly into the tumour while you're under a general anaesthetic.

The implants will be left in for one to eight days, during which time the cancer cells will receive a much higher dose of radiation than the rest of your mouth.

Visits by friends and family will need to be restricted because of the radiation. Pregnant women and children won't be able to visit you.

The radioactive implants will cause your mouth to become swollen, and you'll experience some pain 5 to 10 days after the implants are removed.

Chemotherapy

Chemotherapy is sometimes used in combination with radiotherapy when the cancer is widespread, or if it's thought there's a significant risk of the cancer returning.

Chemotherapy uses powerful cancer-killing medicines, which damage the DNA of the cancerous cells, interrupting their ability to reproduce.

The medicines used in chemotherapy can sometimes damage healthy tissue, as well as the cancerous tissue.

Adverse side effects are common and include:

  • tiredness (fatigue)
  • sore mouth
  • mouth ulcers
  • feeling sick
  • being sick
  • hair loss
  • hearing and balance problems
  • kidney problems
  • numbness and tenderness of the hands and feet

These side effects usually stop once treatment has finished.

Chemotherapy also weakens your immune system and makes you more vulnerable to infection.

Cetuximab

Cetuximab is a new type of medication, known as a biologic or antibody, which is sometimes used instead of standard chemotherapy to treat mouth cancer.

It doesn't cause all of the side effects of standard chemotherapy and is normally used in combination with radiotherapy.

Cetuximab targets proteins on the surface of cancer cells, known as epidermal growth factor receptors. These receptors help the cancer grow – by targeting them, cetuximab prevents the cancer spreading.

The National Institute for Health and Care Excellence (NICE) ruled that cetuximab didn't represent a cost effective treatment in most cases and has recommended it only be used in people who are:

  • in a good state of health and likely to make a good recovery if treated
  • unable to have chemotherapy for medical reasons – for example, because they have kidney disease or are pregnant

Skin reactions often occur during the first three weeks of treatment with cetuximab. About 8 out of 10 (80%) people who have cetuximab are affected. An acne-like rash is the most common type of skin reaction.

Photodynamic therapy (PDT)

Photodynamic therapy (PDT) may be recommended if there are mouth lesions that are close to turning into cancer, or the cancer is just on the surface of the mouth lining at a very early stage. However, its cure rate hasn't yet been compared with conventional treatment.

PDT can also be used to temporarily control cancer where it's been decided that further conventional treatment won't provide a cure or benefit.

PDT involves taking a medicine that makes all your skin and other tissues sensitive to the effects of light. The cancerous tissue becomes even more sensitive.

After receiving the medicine, light is shone on to the cancer using lasers. This destroys the surface of the cancer and some mouth lining next to it.

You have to stay in a dark room for seven days with no light whatsoever, including no TV and no bed light. If you're exposed to any light at all over this period, you'll develop serious sunburn.

Prevention

The three most effective ways of preventing mouth cancer developing, or preventing it coming back after successful treatment, are:

  • not smoking
  • ensuring you don't drink more than the recommended weekly limits for alcohol
  • eating a healthy, Mediterranean-style diet that includes plenty of fresh vegetables – particularly tomatoes – and citrus fruits, olive oil and fish

The NHS recommends you drink no more than 14 units of alcohol a week.

If you drink as much as 14 units a week, it's best to spread it evenly over three or more days.

It's also important that you have regular dental check-ups – dentists can often spot the early stages of mouth cancer.

Complications

Mouth cancer and its treatment can cause a number of complications, including changes to the appearance of your mouth, difficulty swallowing (dysphagia), and speech problems.

These effects can sometimes cause emotional problems and withdrawal from normal life.

Dysphagia

A speech and language therapist will assess your swallowing reflex using a test called a videofluoroscopy.

This test involves swallowing food and liquid that a special dye has been added to while a moving X-ray is taken.

The dye shows up on X-ray, and allows the speech therapist to see your swallowing reflex and assess whether there is a risk of food or liquid entering your lungs when you eat or drink.

If there's a risk, you may need to have a feeding tube for a short period, which will be directly connected to your stomach (gastrostomy). You'll be given exercises to help you learn how to swallow properly again.

Speech

Like swallowing, your ability to speak clearly involves a complex interaction of muscles, bones and tissue, including your tongue, teeth, lips and soft palate.

Radiotherapy and surgery can affect this process, making it difficult to pronounce certain sounds. If your speech is severely affected, you may have problems making yourself understood.

A speech and language therapist will help you improve your speech by teaching you a number of exercises that develop your range of vocal movements. They'll also teach you new ways of producing sounds.

Emotional impact

The emotional impact of living with mouth cancer can be significant. Many people experience a "roller coaster" effect.

For example, you may feel down when you're first diagnosed, but feel up when the cancer responds to treatment. You may then feel down again as you try to come to terms with the side effects of treatment.

These emotional changes can sometimes trigger depression. Signs that you may be depressed include feeling down or hopeless during the past month and no longer taking pleasure in the things you usually enjoy.

You should see your GP if you think you're depressed. A number of effective treatments are available for depression, including antidepressants and talking therapies, such as cognitive behavioural therapy (CBT)