Guidance

Chapter 6: Oral cancer

Updated 9 November 2021

This guidance is issued jointly by the Department of Health and Social Care, the Welsh Government, the Department of Health Northern Ireland, Public Health England, NHS England and NHS Improvement, and with the support of the British Association for the Study of Community Dentistry.

Delivering Better Oral Health has been developed with the support of the 4 UK Chief Dental Officers.

Whilst this guidance seeks to ensure a consistent UK wide approach to prevention of oral diseases, some differences in operational delivery and organisational responsibilities may apply in Wales, Northern Ireland and England. In Scotland the guidance will be used to inform oral health improvement policy.

---

Definitions

In this guideline, oral cancer is defined as cancerous lesions of 3 distinct sites: oral cavity (mouth), oropharynx (throat) and lip (outer)^{[footnote 1]}, although these cancers can, and do, cross anatomical boundaries.

The International Classification of Diseases and Related Health Problems 10th Revision (World Health Organization (WHO), 2016), defines these lesions as follows:

• mouth (oral cavity) cancer: inner lip (C00.3–C00.9), other and unspecified parts of the tongue (C02) (excluding lingual tonsil C2.4), gum (C03), floor of the mouth (C04), palate (C05), and other and unspecified parts of the mouth (C06)
• oropharyngeal cancer: base of the tongue (C01), lingual tonsil (C2.4), tonsil (C09), oropharynx (C10), and other (C14: pharynx unspecified, Waldeyer’s ring, overlapping sites of oral cavity and pharynx)
• lip cancer: outer lip (C00.0; C00.1; C00.2)

Epidemiology

In 2016, 3,744 people in the UK were diagnosed with mouth cancer (Table 6.1)^{[footnote 2]}. The risk of oral cancer increases with age. Age-standardised incidence rates of mouth cancer are higher in Scotland than the rest of the UK, and are rising in England and Wales^{[footnote 2]}. Mouth cancer is much more common among males than females with a ratio of approximately 2:1; more common among older age groups, with the peak age for diagnosis being 66 to 70 years^{[footnote 3][footnote 4]}.

Data from Scotland reveal wide socioeconomic inequalities in the incidence of oral cancer with those from lowest socioeconomic groups having a near 3-fold greater incidence risk ratio than those from the highest socioeconomic groups^{[footnote 4]}; while data from London suggests some South East Asian ethnic groups have higher incidence rate ratios of mouth cancer than their white counterparts^{[footnote 5]}.

Oropharyngeal cancer

Oropharyngeal cancer incidence rates are rising rapidly in all 4 UK countries, with 2,977 people in England diagnosed with oropharyngeal cancer in 2016^{[footnote 2]}. In Wales, oropharyngeal cancer now exceeds oral cavity cancer rates (Table 6.1)^{[footnote 2]}, and has been reported as the fastest rising incidence of any cancer in Scotland^{[footnote 6]}. The risk of oropharyngeal cancer is more than 3 times higher among men than women, and over 3-fold higher among those from more deprived socioeconomic areas than less deprived areas^{[footnote 4]}. There is some evidence that people with human papilloma virus (HPV)-related^{[footnote 7]} cancers (such as oropharyngeal cancer) are diagnosed at a younger age^{[footnote 8]}, although this is not substantially younger than oral cavity cancer, with the peak age for oropharyngeal cancer diagnosis being 61 to 65 years^{[footnote 4]}.

Lip cancer

Lip cancer (outer) is far less common (Table 6.2) than cancers of the oral cavity (which includes the inner lip) and oropharyngeal cancer. The rates among men are slightly higher than among women.

Table 6.1: UK Cancer registry data: latest numbers (n) and (European) age-standardised incidence rates per 100,000 person-years, by sex

	Oral cavity cancer	(OCC)	Oropharyngeal cancer	(OPC)	Year
Country	Incidence rate	N	Incidence rate	N	Date
England					2016
Females	4.8 per 100,000	1309	2.7 per 100,000	712
Males	7.3 per 100,000	1779	9.1 per 100,000	2265
Northern Ireland					2016
Females	3.9 per 100,000	34	2.1 per 100,000	18
Males	5.9 per 100,000	46	6.8 per 100,000	55
Scotland					2016
Females	5.6 per 100,000	160	2.7 per 100,000	77
Males	10.0 per 100,000	240	9.7 per 100,000	247
Wales					2015
Females	3.7 per 100,000	64	2.9 per 100,000	48
Males	7.4 per 100,000	112	10.5 per 100,000	159

Source: UK Cancer Registry^{[footnote 2]}

Table 6.2: England Cancer Registry data: latest numbers (n) and (European) age-standardised incidence rates (EASR) per 100,000 person-years, by sex

Site	Cases (n)	EASR
Oral cavity
Females	1,332	4.8 per 100,000
Males	1,776	7.2 per 100,000
Total	3,108	6.0 per 100,000
Oropharyngeal
Females	731	2.7 per 100,000
Males	2,324	9.2 per 100,000
Total	3,055	5.9 per 100,000
Outer lip
Females	48	0.2 per 100,000
Males	68	0.3 per 100,000
Total	116	0.2 per 100,000

Source: National Cancer Registration and Analysis Service (NCRAS), Oral cancer incidence data request 2019 (NCRAS, 2019)^{[footnote 9]}.

Mortality

Survival rates are improving but remain poor overall. Just over half of all people (56%) diagnosed with mouth cancer between 2009 and 2013 in England survived for 5 years or more^{[footnote 10]}. The prognosis for oropharyngeal cancer is a little better, with 66% of people diagnosed with oropharyngeal cancer during 2009 to 2013 surviving for 5 years or more. Earlier detection can improve prognosis.

Risk factors

The major risk factors for oral cancers are tobacco use (Chapter 11) and alcohol consumption (particularly in excess) (Chapter 12), and in combination with one another. Infection with the human papilloma virus is an important risk for oropharyngeal cancer^{[footnote 7]}, possibly in combination with tobacco and alcohol^{[footnote 7]}. Excessive exposure to ultra violet (UV) light is a risk factor for outer lip cancer. There is limited evidence in relation to dietary risk factors associated with oral cancer (Chapter 10). An overview of risk factor management is presented in the toolkit in Chapter 2, table 3.

Compared with zero tobacco use and alcohol consumption, the risks of mouth and oropharyngeal cancer increase with any level of tobacco use or alcohol consumption – there are no safe lower limits^{[footnote 11]}.

While most of the available evidence focuses on smoking tobacco, a growing body of evidence shows that use of smokeless (chewing) tobacco, often used as a component of betel quid, and betel quid without tobacco (for example betel quid and areca nut), is associated with increased risk of oral cavity cancer^{[footnote 12]}.

Smoking duration is more important than frequency as a risk for oral cancer (as with lung cancer); thus, fewer cigarettes per day over a longer number of years has a higher level of risk for oral cancer than more cigarettes per day over fewer years. In contrast, frequency of alcohol consumption is more important than duration; thus, higher consumption (more than three drinks per day) over a few years has a higher risk for oral cancer than a lower intake over many years^{[footnote 13]}.

Using both tobacco and alcohol increases the risk of oral cancer exponentially for individuals. It is estimated that people who both drink and smoke heavily have an over 10-fold increased risk of developing oral cancer than those people who abstain from both products^{[footnote 14]}. Prevention approaches for smoking and tobacco use are addressed more fully in Chapters 11 and 12 respectively.

Oral HPV infection is a major risk factor for oropharyngeal cancer in particular^{[footnote 15][footnote 16]}. The effects on the primary prevention of oropharyngeal cancer of extending the school-based HPV vaccination programme to include boys as well as girls will take several decades to become apparent. HPV may be spread through sexual contact, particularly oral sex^{[footnote 17]}. In theory the risk of HPV-related oropharyngeal cancer may be reduced by changes in sexual behaviour and adoption of safer sexual practices. However, as the natural history, prevalence, persistence and determinants of oral HPV infection and oropharyngeal cancer are poorly understood, the strongest preventive approach is, therefore, to recommend vaccination for young people, both boys and girls.

UV light is a known risk factor for all skin cancers, including cancer of the outer lip^{[footnote 18]}. It is advisable to avoid the use of sunbeds and tanning salons^{[footnote 19]}. Sun exposure is necessary for production of vitamin D, but dental teams may want to familiarise themselves with NICE guideline 34 Sunlight exposure: risks and benefits, which recommends avoiding getting sunburnt, for example, by seeking shade when outside for a prolonged period, especially in the middle of the day (11am to 3pm) and wearing sun-protective clothing (such as hats, sunglasses and limb-covering close-weave clothing)^{[footnote 20]}.

Diets low in fruit and non-starchy vegetables are deleterious for general health. Fruit and non-starchy vegetables are rich in fibre, vitamins, minerals, antioxidants and phytochemicals, which help to protect against cancer in general (Chapter 10). There is limited new evidence in relation to dietary risk factors associated with oral cancers^{[footnote 21]}. Obesity is increasingly being associated with many cancers^{[footnote 22]}, but oral cancers seem to be an exception with oral cancer risk associated with those with low body mass index (BMI)^{[footnote 23]}. Overall the evidence supports promoting increased consumption of non-starchy vegetables and fruit as part of a healthy diet^{[footnote 24][footnote 25][footnote 26]}.

Associations between the risk of oral cancers and poor oral health are emerging. After adjusting for smoking and alcohol consumption, having few missing teeth, regular dental attendance, and daily toothbrushing are associated with a reduced risk of mouth and oropharyngeal cancers, but wearing a denture was not associated with increased risks^{[footnote 27][footnote 28]}. There seems to be little evidence to show increased risks for oral cancer with mouthwash use^{[footnote 29]}. Management of the risk factors for oral cancer, is outlined in Chapter 1.

Early detection and management pathway

Dentists, and other members of the clinical dental team, are the only dedicated professionals regularly examining a patients’ mouth. Early identification, diagnosis and management of oral cancers can achieve better outcomes for patients. Dental teams have a pivotal role in the early detection of oral cancer and oral potentially malignant disorders or pre-cancers^{[footnote 30]}, including cancers and conditions that can precede the onset of invasive cancer. These may present as solitary lesions or be multifocal or widespread conditions within the oral cavity such as leukoplakia^{[footnote 31]}. A pathway of care for the early detection and prevention of oral cancer is outlined below.

All patients

1. Ask

Explore risk factors, especially tobacco use.

Use Audit-C questionnaire or scratch card for alcohol consumption.

Record advice given and patient’s response in the clinical notes.

2. Examine

Extraoral: lips, neck, nodes (visual and tactile).

Intraoral: soft tissues (visual and tactile).

High-risk patients

1. Advise

Share the best approaches to changing modifiable risk factors in line with tobacco (Chapter 11) and alcohol pathways (Chapter 12).

2. Act

If a patient is interested in quitting smoking and/or reducing drinking, act to assist them to address these risk factors by:

• providing information leaflets
• referring tobacco users to local stop smoking support, GP or pharmacist
• considering referral of patients with higher risk alcohol consumption, particularly in combination with tobacco use to their GP or community specialist alcohol treatment service (Chapter 12)
• encouraging them on their journey and building their confidence

If the patient is not interested in quitting smoking and/or reducing alcohol consumption:

• make a simple statement, for example: ‘That’s fine, but help is available. Let me know if you change your mind’
• record advice given and patient’s response in the clinical notes
• keep asking and advising – it can make a difference

Support patients with a diagnosis of oral cancer or potentially premalignant oral epithelial lesions. Ongoing dental care is particularly important for this group of patients, particularly those who have had radiotherapy. They are at a higher risk of a range of conditions including dental caries, oral mucositis and osteonecrosis (32).

It is good practice for clinical dental teams to take an up-to-date medical, social and dental history and perform an intraoral and extraoral conventional visual and tactile examination in all adults at each patient visit^{[footnote 33]}. This may identify possible risk factors for oral cancer, and potentially malignant disorders and oral cancers. This is in line with the UK’s national regulatory body’s recommendations^{[footnote 34]}.

Extra-oral examinations during routine check-ups provide a good opportunity for members of the dental team to identify potential lip cancers. Most symptomless mouth cancers can be detected by means of a visual examination by clinicians^{[footnote 35]}.

Signs and symptoms of oral potentially malignant disorders

Signs and symptoms of an oral malignancy or potentially malignant disorders are as follows:

• unexplained ulceration or swelling and/or induration in the oral cavity lasting for more than 3 weeks
• a persistent and unexplained lump in the head or neck
• a lump on the lip or in the oral cavity
• a red patch in the oral cavity consistent with erythroplakia
• a red and white patch in the oral cavity consistent with erythroleukoplakia (‘speckled leukoplakia’)
• persistent (not intermittent) hoarseness lasting for more than 3 weeks (if other symptoms are present to suggest suspicion of lung cancer, refer via lung cancer guideline)
• persistent pain in the throat or pain on swallowing lasting for more than 3 weeks

Sources: National Collaborating Centre for Cancer (2015) Suspected cancer: recognition and referral, NICE^{[footnote 36]}. Scottish referral guidelines for suspected cancer^{[footnote 37]}.

Less common but important signs and symptoms may include:

• unexplained tooth mobility not associated with periodontal disease
• delayed healing of an extraction site
• fixation of lesion
• regional lymph node enlargement
• dysphagia
• weight loss
• cranial neuropathies

Urgent referrals

For adult patients with a clinically evident suspicious mucosal lesion, or symptom(s) suggestive of oral malignancy, clinicians should provide immediate referral to a specialist ^{[footnote 33]}. Dental team members must therefore use an ‘urgent suspected cancer pathway referral’ (for an appointment within 2 weeks) for those with any of the above symptoms^{[footnote 38]}. General medical practitioners (GPs) have an established system for making such rapid referrals and dental team members should also ensure that they are familiar with, and can refer in accordance with, local head and neck cancer policies and procedures to ensure that a patient is seen by the correct specialist team^{[footnote 38]}. It is vitally important that the dental team is aware of this guidance and facilitate the necessary appointment so that this does not lead to patient delays in receiving care^{[footnote 39]}, should they require it.

The gold standard for diagnosis is a scalpel biopsy and histological assessment^{[footnote 40]}, which is best carried out by the specialist head and neck cancer team in line with national guidance. There is no evidence currently to support the use of diagnostic adjuncts such as vital staining or light-based detection methods for the evaluation of potentially premalignant oral epithelial lesions among adult patients with clinically evident, seemingly innocuous, or suspicious lesions^{[footnote 40]}.

Further guidance on patient support, and the diagnostic process is available in NICE guidance on recognition and referral^{[footnote 41]}.

Prevention post-treatment for oral cancer

In advance of their cancer treatment and therapies, patients should have received appropriate care to manage and stabilise their other oral diseases such as dental caries and periodontal diseases. Afterwards, it is important that patients who have received surgery, radiotherapy and/or chemotherapy in the head and neck area make regular visits for dental care. They should be made aware that they are now at increased risk of a range of oral conditions including dental caries, periodonitis/peri-implantitis, mucositis and osteoradionecrosis^{[footnote 42]}. It is particularly important that dental teams provide appropriate additional preventive care and support for these patients who may have long-term or lifelong limited opening and reduced salivary flow^{[footnote 42]}.

Resources

Suspected cancer: recognition and referral. NICE guideline [NG12].

CRUK and BDA Oral Cancer Recognition Toolkit.

Mouth Cancer Foundation.

RCS Clinical Guidelines: The Oral Management of Oncology Patients Requiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation.

References

1. World Health Organization (WHO), The International Classification of Diseases and Related Health Problems 10th Revision Geneva, 2016. ↩

2. Conway DI, Purkayastha M, Chestnutt IG. The changing epidemiology of oral cancer: definitions, trends, and risk factors. British Dental Journal. 2018;225:867. ↩ ↩² ↩³ ↩⁴ ↩⁵

3. Conway DI, Brenner DR, McMahon AD, Macpherson LM, Agudo A, Ahrens W, and others. Estimating and explaining the effect of education and income on head and neck cancer risk: INHANCE consortium pooled analysis of 31 case-control studies from 27 countries. International Journal of Cancer. 2015;136(5):1125-39. ↩

4. Purkayastha M, McMahon AD, Gibson J, Conway DI. Trends of oral cavity, oropharyngeal and laryngeal cancer incidence in Scotland (1975-2012) - A socioeconomic perspective. Oral Oncology. 2016;61:70-5. ↩ ↩² ↩³ ↩⁴

5. Tataru D, Mak V, Simo R, Davies EA, Gallagher JE. Trends in the epidemiology of head and neck cancer in London. Clinical Otolaryngology. 2017;42(1):104-14. ↩

6. Junor EJ, Kerr GR, Brewster DH. Fastest increasing cancer in Scotland, especially in men. British Medical Journal. 2010;340:c2512. ↩

7. Centre for Disease Control. Cancers Associated with Human Papillomavirus (HPV) 2021 (updated 23 September 2020) ↩ ↩² ↩³

8. Gillison ML, Broutian T, Pickard RK, Tong ZY, Xiao W, Kahle L, and others. Prevalence of oral HPV infection in the United States, 2009-2010. Journal of the American Medical Association. 2012;307(7):693-703. ↩

9. Oral cancer incidence: data request, National Cancer Registration and Analysis Service (NCRAS), 2019. ↩

10. Muller P, Belot A, Morris M, Rachet B. Net survival and the probability of cancer death from rare cancers, London: London School of Hygiene and Tropical Medicine; 2016 ↩

11. Lubin JH, Muscat J, Gaudet MM, Olshan AF, Curado MP, Dal Maso L, and others. An examination of male and female odds ratios by BMI, cigarette smoking, and alcohol consumption for cancers of the oral cavity, pharynx, and larynx in pooled data from 15 case-control studies. Cancer Causes and Control. 2011;22(9):1217-31. ↩

12. Gupta B, Johnson NW. Systematic review and meta-analysis of association of smokeless tobacco and of betel quid without tobacco with incidence of oral cancer in South Asia and the Pacific. PloS one. 2014;9(11):e113385. ↩

13. Lubin JH, Purdue M, Kelsey K, Zhang ZF, Winn D, Wei Q, and others. Total exposure and exposure rate effects for alcohol and smoking and risk of head and neck cancer: a pooled analysis of case-control studies. American Journal of Epidemiology. 2009;170(8):937-47. ↩

14. Hashibe M, Brennan P, Chuang SC, Boccia S, Castellsague X, Chen C, and others. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer epidemiology, biomarkers and prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2009;18(2):541-50. ↩

15. Anantharaman D, Abedi-Ardekani B, Beachler DC, Gheit T, Olshan AF, Wisniewski K, and others. Geographic heterogeneity in the prevalence of human papillomavirus in head and neck cancer. International Journal of Cancer. 2017;140(9):1968-75. ↩

16. Lingen MW, Xiao W, Schmitt A, Jiang B, Pickard R, Kreinbrink P, and others. Low etiologic fraction for high-risk human papillomavirus in oral cavity squamous cell carcinomas. Oral Oncology. 2013;49(1):1-8. ↩

17. NHS, Sexual activities and risk, NHS 2018 (updated 17 November 2018). ↩

18. Lucas R MT, Smith W, Armstrong B. Solar ultraviolet radiation: global burden of disease from solar ultraviolet radiation, No. 13. 2006 [cited 11.12.2019]. In: Environmental Burden of Disease Series. Geneva: World Health Organization, [cited 11.12.2019]. ↩

19. McWhirter E, Souter LH, Rumble RB, Rosen CF, Tenkate T, McLaughlin J, and others. The use of indoor tanning devices and the risk of developing cutaneous malignant melanoma: a systematic review and clinical practice guideline. Toronto (ON): Cancer Care Ontario; 2014 23 July 2014. Contract No.: 8. ↩

20. NICE. Sunlight exposure: risks and benefits [NG34]. London: National Institute for Clinical Excellence; 2016 09 February 2016. Contract No.: NG 34. ↩

21. Edefonti V, Hashibe M, Ambrogi F, Parpinel M, Bravi F, Talamini R, and others. Nutrient-based dietary patterns and the risk of head and neck cancer: a pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Annals of Oncology: official journal of the European Society for Medical Oncology. 2012;23(7):1869-80. ↩

22. Arnold M, Leitzmann M, Freisling H, Bray F, Romieu I, Renehan A, and others. Obesity and cancer: An update of the global impact. Cancer Epidemiology. 2016;41:8-15. ↩

23. Gaudet MM, Olshan AF, Chuang SC, Berthiller J, Zhang ZF, Lissowska J, and others. Body mass index and risk of head and neck cancer in a pooled analysis of case-control studies in the International Head and Neck Cancer Epidemiology (INHANCE) Consortium. International Journal of Epidemiology. 2010;39(4):1091-102. ↩

24. Chuang S-C, Jenab M, Heck JE, Bosetti C, Talamini R, Matsuo K, and others. Diet and the risk of head and neck cancer: a pooled analysis in the INHANCE consortium. Cancer Causes and Control. 2012;23(1):69-88. ↩

25. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC: AICR; 2007. ↩

26. World Cancer Research Fund, American Institute for Cancer Research. Wholegrains, vegetables and fruit and the risk of cancer. 2018. Contract No.: Third. ↩

27. Ahrens W, Pohlabeln H, Foraita R, Nelis M, Lagiou P, Lagiou A, and others. Oral health, dental care and mouthwash associated with upper aerodigestive tract cancer risk in Europe: the ARCAGE study. Oral Oncology. 2014;50(6):616-25. ↩

28. Hashim D, Sartori S, Brennan P, Curado MP, Wunsch-Filho V, Divaris K, and others. The role of oral hygiene in head and neck cancer: results from International Head and Neck Cancer Epidemiology (INHANCE) consortium. Annals of oncology: official journal of the European Society for Medical Oncology. 2016;27(8):1619-25. ↩

29. Gandini S, Negri E, Boffetta P, La Vecchia C, Boyle P. Mouthwash and oral cancer risk quantitative meta-analysis of epidemiologic studies. Annals of Agricultural and Environmental Medicine. 2012;19(2):173-80. ↩

30. Awadallah M, Idle M, Patel K, Kademani D. Management update of potentially premalignant oral epithelial lesions. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2018;125(6):628-36. ↩

31. Warnakulasuriya S. Clinical features and presentation of oral potentially malignant disorders. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2018;125(6):582-90. ↩

32. Lingen MW, Abt E, Agrawal N, Chaturvedi AK, Cohen E, D’Souza G, and others. Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: A report of the American Dental Association. The Journal of the American Dental Association. 2017;148(10):712-27.e10. ↩ ↩²

33. General Dental Council. Oral Cancer - Improving Early Detection. London: GDC; 2012. ↩

34. Walsh T, Liu JLY, Brocklehurst P, Glenny AM, Lingen M, Kerr AR, and others. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database of Systematic Reviews. 2013(11). ↩

35. NICE. Scenario: Referral for head and neck cancer, 2016. ↩

36. Scottish Government. Scottish referral guidelines for suspected cancer. 2019. ↩

37. National Institute of Clinical Excellence (NICE). Head and neck cancer. 2017 March. ↩ ↩²

38. Grimes D, Patel J, Avery C. New NICE referral guidance for oral cancer: does it risk delay in diagnosis? British Journal of Oral and Maxillofacial Surgery. 2017;55(4):404-6. ↩

39. Macey R, Walsh T, Brocklehurst P, Kerr AR, Liu JLY, Lingen MW, and others. Diagnostic tests for oral cancer and potentially malignant disorders in patients presenting with clinically evident lesions. Cochrane Database of Systematic Reviews. 2015(5). ↩ ↩²

40. NICE. Head and neck cancers - recognition and referral NG12 (updated) 2015. ↩

41. RCSEng, BSDH. The Oral Management of Oncology PatientsRequiring Radiotherapy, Chemotherapy and/or Bone Marrow Transplantation Clinical Guidelines. London: RCSEng and BSDH; 2018. ↩ ↩²