Head and neck cancer: symptoms, causes, tests and treatment

Macmillan Cancer Support says symptoms depend on where in the head and neck the cancer started and whether it has spread to nearby lymph nodes. Many of these symptoms can be caused by conditions other than cancer, but Macmillan stresses that it is important to have them checked by your GP or dentist, especially if they do not go away or are getting worse.

The symptoms that Macmillan says should lead to an urgent referral to a specialist within 2 weeks are listed first below, followed by other signs it describes.

• A mouth ulcer, including on the tongue, that lasts more than 3 weeks.

• A red patch (erythroplakia), a red and white patch (erythroleukoplakia) or a white patch (leukoplakia) inside the mouth.

• A lump in the neck that does not go away after 2 to 3 weeks.

• A lump on the lip or anywhere inside the mouth that does not go away.

• A sore tongue that is not getting better.

• Throat pain, persistent hoarseness and difficulty swallowing that is not improving.

• Pain or bleeding: discomfort in the mouth, bleeding in the mouth or nosebleeds, a sore throat or earache that does not get better, pain in the cheek or face, or pain behind the nose or in the upper teeth.

• Swelling in the upper neck, in front of or behind the ear, under the jawbone, in the cheek or around the eyes.

• A blocked nose on one side that does not clear, or breathing more loudly than usual.

• Bad breath that does not improve with better oral hygiene.

• Difficulty or pain with chewing, swallowing or speaking, loose teeth for no obvious reason or dentures that no longer fit, changes in speech, numbness of the cheek, upper lip, upper teeth or side of the nose, drooping on one side of the face or difficulty opening the mouth, and changes in hearing.

• Losing weight for no obvious reason.

Macmillan explains that when a cancer in the mouth or throat spreads, the first place it usually goes is the lymph nodes in the neck, which can cause a painless lump. It also says swollen lymph nodes are more likely to be caused by an infection than by cancer. If a lump in the neck does not go away after 2 to 3 weeks, your GP should refer you to a specialist, or to a one-stop neck lump clinic.

NICE guidance for GPs (NG12, suspected cancer) says to consider a suspected cancer pathway referral for oral cancer in people with unexplained ulceration in the mouth lasting more than 3 weeks or a persistent unexplained neck lump, and for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness or an unexplained neck lump. It also says dentists should consider urgent referral for a lump on the lip or in the mouth, or a red or red and white patch.

Do not wait for symptoms to become severe. NHS inform advises contacting your GP practice or dentist as soon as possible if you have these symptoms for 3 or more weeks.

NHS inform says the main risk factors are tobacco and alcohol, especially when combined. Risks are associated with all types of tobacco use, including chewing tobacco, not just smoking. It also says head and neck cancer is much more common in men than in women.

Some risk factors depend on the type. NHS inform says many cancers are linked to infections: human papillomavirus (HPV) for some oropharyngeal cancers, and Epstein-Barr virus (EBV) for nasopharyngeal cancer. When oropharyngeal cancer is found, the cancer cells are tested for HPV, and NHS inform says HPV-related head and neck cancers usually have a good outlook. Cells from nasopharyngeal cancer are tested for EBV.

Head and neck cancers are named after where they start and the type of cell. NHS inform lists the following areas. It also says other cancers can start in the head and neck but are not head and neck cancers, such as thyroid cancer, oesophageal cancer, brain tumours and tracheal cancer.

NHS inform says that if your GP or dentist thinks your symptoms could be linked to cancer, they will refer you to a specialist, usually an oral and maxillofacial surgeon or an ear, nose and throat (ENT) surgeon. If your only symptom is a neck lump, you may be seen in a one-stop neck lump clinic where you can have all the tests needed in one visit, which may include an ultrasound scan, a biopsy and nasendoscopy (a look at the back of the mouth, nose and throat). You may get results on the same day or 7 to 10 days later.

At hospital, the specialist will ask about your symptoms and examine your mouth, throat and neck. You may have an endoscope test, sometimes under general anaesthetic (panendoscopy), and a biopsy. If cancer is found, staging tests such as X-rays, CT, MRI or PET-CT show its size and position and whether it has spread. Oropharyngeal cancer cells are tested for HPV and nasopharyngeal cancer cells for EBV.

NHS inform explains that the stage describes the size of the cancer and whether it has spread, and the grade describes how the cells look under the microscope. Both help you and your doctors decide on treatment.

NHS inform says that because head and neck cancer is not common, you are usually treated in a specialist head and neck unit, where a multidisciplinary team (MDT) discusses the best treatment for you. Before treatment you may be advised on preparation, which can include stopping smoking or drinking, dental checks, dietary advice and certain exercises to lower the risk of side effects. Treatment aims to remove or destroy the cancer and reduce the risk of it coming back while keeping appearance, speech and swallowing as intact as possible.

For early-stage cancer, NHS inform says small cancers that have not spread can usually be treated with surgery, and if the operation causes small changes to speech, chewing or swallowing you can usually adapt quickly. Radiotherapy may be suggested instead if the cancer is in a difficult-to-reach area or surgery would cause major changes.

For locally advanced cancer, where the cancer is bigger or has spread to neck lymph nodes, you usually need more than one type of treatment. Chemoradiation is often the main treatment. If you have surgery, you may also have lymph nodes in the neck removed, and some people have chemoradiation or radiotherapy afterwards to treat any remaining cancer cells.

If the cancer cannot be cured, NHS inform says you may be given treatment to control it for as long as possible and to manage symptoms, usually chemotherapy, targeted therapy or immunotherapy, alongside supportive or palliative care.

NHS inform says that after treatment you will have regular follow-up appointments for several years. Your specialist will regularly examine your head and neck, which is the most important part of follow-up, and you may sometimes have scans. It can take several months for side effects to improve.

Tell your specialist about ongoing side effects, symptoms that are not improving and any new symptoms that do not get better within 2 weeks. Contact your doctor or nurse as soon as possible if you notice a new ulcer or neck lump, pain, or difficulty swallowing or speaking; you do not need to wait for the next appointment.

Treatment can affect how you eat and drink, or your speech, and some of these changes return to normal or near normal as the area recovers. Late effects are side effects that do not improve or appear years after treatment. A speech and language therapist and a dietitian help you cope with changes, and NHS inform says talking to your nurse can help if treatment has changed your appearance or voice.

On the NHS you start with your GP or dentist, who can refer you on a suspected cancer pathway to an ENT or oral and maxillofacial surgeon, often through a one-stop neck lump clinic. Treatment is planned by a specialist multidisciplinary team in a head and neck unit, and is free at the point of use.

Some people have a private consultation, scan or biopsy to avoid waiting. If cancer is suspected, tell your GP, and make sure results are shared with the NHS team that will plan treatment, since NHS inform describes treatment as being decided by a specialist team.

NHS inform lists national support groups for people affected by head and neck cancer, including the Mouth Cancer Foundation, Changing Faces (for changes in appearance), The Swallows (a support line for head and neck cancer) and Salivary Gland Cancer UK. Macmillan Cancer Support also provides information and an online forum.