Mouth cancers are the most common cancers of the head and neck area. They can begin in any part of the mouth.
Around 1,900 people are diagnosed with cancer of the tongue each year in the UK and 1,800 are diagnosed with cancers affecting other parts of the mouth. Cancer of the lip is uncommon, with around 340 people diagnosed with it each year.
Mouth cancer is more common in people over 45 and it affects more men than women. Most mouth cancers develop from cells that line the mouth or cover the tongue and are called squamous cell cancers.
The area of the mouth (oral cavity) includes the:
front two-thirds of the tongue
upper and lower gums
inside lining of the cheeks and lips
floor of the mouth, under the tongue
roof of the mouth (the hard palate)
area behind the wisdom teeth.
Causes of mouth cancer
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The main causes of mouth cancers are smoking and drinking heavily, and the risk is greater if you do both. Other causes include chewing tobacco or chewing betel or paan, which is a cultural tradition in some Asian communities.
There are other things that may increase the risk of getting mouth cancer, such as eating a poor diet and not cleaning your teeth or seeing a dentist regularly enough. Having a weakened immune system or a virus called human papilloma virus (HPV) are also possible risk factors. Being exposed to sunlight over a long period of time is a risk factor for cancer of the lip.
Mouth cancer, like other cancers, isn’t infectious and can’t be passed on to other people.
Signs and symptoms of mouth cancer
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The two most common symptoms of mouth cancer are:
an ulcer in the mouth that doesn’t heal
discomfort or pain in the mouth that doesn’t go away.
Not everyone has pain or an ulcer. Other symptoms include:
a white (leukoplakia) or red (erythroplakia) patch in the mouth or throat that doesn’t go away
a lump or thickening on the lip, or in the mouth or throat
difficulty or pain with chewing, swallowing or speaking
bleeding or numbness in the mouth
loose teeth for no obvious reason
a lump in the neck
a lot of weight loss over a short time
bad breath (halitosis).
These symptoms are common in conditions other than cancer. However, if you have any of these symptoms, it's important to let your doctor or dentist know straight away. Mouth cancer can be treated more successfully when it’s diagnosed early.
How mouth cancer is diagnosed
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Your GP or dentist will examine your mouth closely, especially the area under the tongue. They will refer you to a hospital for any further tests and for specialist advice and treatment.
The specialist will examine your mouth using a small mirror and light. A very thin, flexible tube with a light at the end (endoscope) can be used to get a better view of the back of the mouth and throat.
To make a diagnosis, your specialist will remove a small piece of tissue (biopsy) to be examined under a microscope. This is usually done under a general anaesthetic, so you may need to spend the night in hospital.
You’ll have blood tests, and possibly a chest x-ray, to check your general health. There are several other tests that may be used to help diagnose mouth cancer and to check whether or not the cancer has spread. The results of these tests will help your specialist decide the best type of treatment for you.
The doctor may want to take x-rays of your face or neck to see whether any bones have been affected. A special x-ray known as an orthopantomogram (OPG) may be taken to look at your jaw and teeth.
MRI (magnetic resonance imaging) scan
This test uses magnetism to build up a detailed picture of areas of your body.
Before the scan, you may be asked to complete and sign a checklist. This is to make sure that it’s safe for you to have an MRI scan.
Before the scan, you’ll be asked to remove any metal belongings, including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test you'll be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones.
CT (computerised tomography) scan
A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10-30 minutes. CT scans use a small amount of radiation, which is very unlikely to harm you and won't harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.
You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you’re allergic to iodine or have asthma, you could have a more serious reaction to the injection, so it's important to let the hospital doctor know beforehand.
Staging and grading of mouth cancer
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The stage of a cancer is a term used to describe its size and whether or not it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment for you.
The most commonly used staging system is called the TNM system:
T refers to the size or position of the primary tumour (where the cancer first starts in the body).
N refers to which lymph nodes are affected, if any.
M refers to metastatic disease (when the cancer has spread to other parts of the body).
The T, N and M will often have numbers attached to describe the detail. For example, a T1 tumour may be very small and just in one layer of tissue, whereas a T4 tumour may be larger and spread through several layers of tissue.
The exact details of the T, N and M will depend on the type of cancer.
Number staging system
In addition to TNM staging, you’ll probably hear the doctors use a number staging system. There are usually three or four number stages for each cancer type.
Stage 1 describes a cancer at an early stage when it is usually small in size and hasn’t spread. Whereas stage 4 describes cancer at a more advanced stage when it has usually spread to other parts of the body. Stages 2 and 3 are in between these stages.
The number stages are made up of different combinations of the TNM stages. So, a stage 1 cancer may be described as either T1, N0, M0 or T2, N0, M0.
Number stages may also be subdivided to give more detailed information about tumour size and spread. For example, a stage 3 cancer may be subdivided into stage 3a, stage 3b and stage 3c. A stage 3b cancer may differ from a stage 3a cancer in either the tumour size or if the cancer has spread to lymph nodes.
Talking about staging
In the last few years, staging systems have become increasingly complex and they now describe the size and spread of different types of cancer in much greater detail. This can be very helpful in planning the details of treatment or predicting outcomes.
However, doctors will often use a much simpler approach when talking about staging. They might use words like ‘early’ or ‘local’ if the cancer hasn't spread, ‘locally advanced’ if it has begun to spread into surrounding tissues or nearby lymph nodes, or ‘advanced’ or ‘widespread’ if it has spread to other parts of the body. Your doctors can give you more information about the stage of your particular cancer.
Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how the cancer may behave.
Low-grade means that the cancer cells look like normal cells. High-grade means the cells look abnormal. A low-grade tumour will usually grow more slowly and be less likely to spread than a high-grade tumour.
Treatment for mouth cancer
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Your treatment will depend on the stage and grade of your cancer, as well as your general health. Your specialist will explain more about the most appropriate treatment for you. You may also be seen by a specialist nurse who will give you information and emotional support.
The usual treatments for mouth cancer include:
Your doctor will recommend the treatment that is likely to be the most successful in treating your cancer. They will also consider the side effects you’re likely to have and how treatment will affect your ability to speak and swallow.
In early mouth cancer, both surgery and radiotherapy are equally effective. You’ll probably have radiotherapy if surgery is likely to seriously affect your speech and swallowing. Larger cancers will usually be treated with a combination of different treatments.
The following treatments can either be given separately or combined in a number of ways.
The cancer is removed along with a margin of clear tissue. How much tissue is removed depends on the size of the cancer and where it is in your mouth.
Many mouth cancers spread to the lymph nodes in the neck, so these nodes are also usually removed (called a neck dissection) even if there is no evidence that they are affected. This is to reduce the chance of the cancer coming back.
The length of time you spend in hospital will depend on the extent of the surgery you need. Your surgeon will explain more about this to you.
People having more complicated surgery may be looked after in a high dependency unit or intensive care for a while after their operation.
Some people may need to have a larger operation that involves removing part of their jawbone or tongue. This will be done by a specialist head and neck surgeon.
The surgery will involve rebuilding the area using tissue, skin or bone taken from somewhere else in the body. People having this type of surgery may need to stay in hospital for up to a few weeks.
Mohs micrographic surgery (MMS)
This is a specialised type of surgery where the tumour is removed piece by piece and examined under a microscope straight away. Skin tissue is gradually removed until there are no signs of cancer cells. This type of surgery is often used in places where it's important to remove as little healthy tissue as possible, such as the lips.
Side effects of surgery
These depend on the type and extent of surgery that you have. Side effects may affect your speech, swallowing or your sense of taste and smell. Some types of surgery may result in a change in your appearance.
You will usually see a dietitian and speech therapist after your operation. They will help you to cope with some of these changes.
You can read more detailed information about surgery and its effects in our section on head and neck cancers.
Radiotherapy treats cancer by using high-energy rays to destroy cancer cells, while doing as little harm as possible to normal tissue.
Radiotherapy can be given alone to treat early mouth cancers (radical radiotherapy). It can also be given after surgery to reduce the risk of the cancer coming back (adjuvant radiotherapy), or if the cancer comes back after previous surgery. Radiotherapy may also be given to any lymph nodes in the neck that have been affected by the cancer. This type of radiotherapy is called external radiotherapy. It is given from a radiotherapy machine, much like an x-ray machine. It does not make you radioactive.
Some people are given radiotherapy together with chemotherapy. This is called chemoradiation.
Internal radiotherapy, known as brachytherapy, is sometimes used to treat small cancers in areas such as the lip or tongue. With brachytherapy, a solid radioactive material is placed close to the tumour.
Side effects of radiotherapy
During radiotherapy the skin over your face and neck will usually redden or darken and become sore (like sunburn). This can start after about two weeks of treatment and may last for 2–4 weeks after treatment has finished. Sometimes your skin will peel or break. The radiotherapy team will tell you how to look after your skin.
Your mouth and throat will usually become sore and inflamed after a couple of weeks of treatment and you may develop some mouth ulcers. Your voice may also become hoarse. There may be changes to your sense of taste and smell. Eating food can become difficult and swallowing can be painful. Your doctor can prescribe some medicines to help improve this.
Occasionally, some people may need to have artificial feeding through a tube if they’re unable to eat and are losing a lot of weight. A tube may be passed through the nose and into the stomach (nasogastric tube), or passed directly into the stomach. This is only done for a short time until treatment is finished and your swallowing is back to normal.
Radiotherapy to this area can cause the salivary glands to produce less saliva. The lining of the mouth and throat may become dry and this can make eating and speech difficult. There are artificial saliva sprays that can help make your mouth feel more comfortable. You can read more about this in our information on coping with a dry mouth. Most of these side effects are usually temporary and will gradually improve once your treatment is over. However, many people continue to have problems with a dry mouth after their treatment is over. A specialised way of giving radiotherapy called Intensity-modulated radiation therapy (IMRT) is available in some hospitals. IMRT reduces the risk of damage to the healthy tissue surrounding the tumour, and so it can reduce the risk of long-term dry mouth.
You can read more information about the side effects and how to cope with them in our section on head and neck cancers, and our information on radiotherapy.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.
They can be given:
before radiotherapy or (rarely) before surgery
at the same time as radiotherapy (chemoradiation)
after radiotherapy or surgery (adjuvant chemotherapy)
if the cancer has spread to other parts of the body, or has come back after earlier treatment.
After surgery, chemotherapy can reduce the chance of the cancer coming back. If the cancer does come back, chemotherapy can be used to control symptoms. Chemotherapy isn’t usually used to treat lip cancer.
Cisplatin and fluorouracil (5FU) are the two most commonly used chemotherapy drugs for mouth cancer. Different drugs are used if the cancer comes back. These can include docetaxel (Taxotere®), paclitaxel (Taxol®) or gemcitabine (Gemzar®).
The drugs are usually given by injection into a vein (intravenously). They can temporarily reduce the number of normal blood cells in your blood. When your blood count is low you're more likely to get an infection. During chemotherapy your blood will be tested regularly. If necessary, you can have antibiotics to treat any infection. Blood transfusions may be given if you become anaemic (low number of red blood cells) due to chemotherapy.
Chemotherapy can also cause side effects such as feeling tired, a sore mouth, feeling sick (nausea) or being sick (vomiting), diarrhoea and hair loss. Let your doctor or nurse know about any side effects as they can often prescribe drugs to reduce these.
Chemoradiation (chemotherapy and radiotherapy together) may be used instead of surgery to treat some small mouth cancers. It has less of an effect on speech and swallowing than surgery. It’s important that you're fit enough to cope with having the two treatments together.
The immediate side effects are worse when both chemotherapy and radiotherapy are given together. You may still need surgery afterwards if chemoradiation doesn’t completely get rid of your cancer.
Chemoradiation can also be given after surgery to reduce the chances of the cancer coming back.
In order to grow and divide, cancer cells ‘communicate’ with each other using chemical signals. Biological therapies are drugs that interfere with this process and so affect the cancer’s ability to grow.
Cetuximab is the most commonly used biological therapy to treat mouth cancer. It’s given as a drip (infusion) into a vein.
It may be used:
in combination with radiotherapy for people who aren’t fit enough to cope with the side effects of chemoradiation
as part of a clinical trial in combination with chemoradiation
with palliative chemotherapy.
How cetuximab works
Most squamous cell cancers of the mouth have proteins called epidermal growth factor receptors (EGFRs) on their surface. When chemical messengers in the body called growth factors attach to these receptors, it stimulates the cancer to grow.
Cetuximab stops the growth factors from attaching to receptors on the cancer and so may stop it growing. It may also make the cancer more sensitive to the effects of radiotherapy.
Your specialist will be able to tell you more about this and whether it’s a suitable treatment for you.
Dr Andrew Sykes explains the possible treatment for cancer of the head and neck.
After your treatment is completed, you will have regular check-ups and possibly scans or x-rays. These will probably continue for several years. If you have any problems, or notice any new symptoms between these times, let your doctor know as soon as possible.
You are likely to experience a number of different feelings, from shock and disbelief to feeling frightened and angry. These feelings can be overwhelming and difficult to control, particularly if you have experienced changes in your appearance. These feelings are natural and it’s important for you to be able to express them.
Everyone has their own way of coping with difficult situations. Some people find it helpful to talk to family or friends, while others prefer to get help from people outside their situation. Some people prefer to keep their feelings to themselves. There’s no right or wrong way to cope.
You can talk to your doctor or specialist nurse about how you’re feeling. They may be able to refer you to a trained counsellor who can listen and help you deal with difficult emotions. Our cancer support specialists can also help you find a counsellor in your area.
Many people find it helpful to talk to other people going through a similar experience. We can give you more information about support groups in your area.
This section has been compiled using information from a number of reliable sources, including:
National Institute for Health and Clinical Excellence (NICE). Cetuximab for the treatment of locally advanced squamous cell cancer of the head and neck. 2008. National Institute for Health and Clinical Excellence (NICE).
National Institute for Health and Clinical Excellence (NICE). Improving Outcomes in Head and Neck Cancers. November 2004. National Institute for Health and Clinical Excellence (NICE).
Matta A, Ralhan R. Overview of current andfuture biologically based targeted therapies in head and neck squamous cell carcinoma. Head and Neck Oncology. 2009. 1:6.
Myers, et al. Cancer of the Head and Neck. 4th edition. 2003. Elsevier Science.
UpToDate. Treatment of early stage (stage 1 and 2) head and neck cancer: The oral cavity. www.uptodate.com (accessed September 2012).
Souhami, Hochauser. Cancer and its management. 6th edition. 2010. Wiley Blackwell.
Werning J. Oral Cancer: Diagnosis, Management, and Rehabilitation. 2007. Thieme Publishing.
UpToDate. Systemic therapy for metastatic and recurrent head and neck cancer. www.uptodate.com (accessed September 2012).
Thanks to Dr Amen Sibtain, Consultant Clinical Oncologist, and the people affected by cancer who reviewed this edition. Reviewing information is just one way you can help when you join our Cancer Voices Network.