Tonsil cancer: symptoms, HPV link, diagnosis and treatment

Cancer Research UK lists the possible symptoms of mouth and oropharyngeal cancer as ulcers that do not heal, a lump in the neck, pain in the mouth, red or white patches in the mouth or throat, a persistent sore throat, pain or difficulty swallowing, speech problems, weight loss and bad breath. A persistent sore throat, particularly on one side, is described as a common symptom of oropharyngeal cancer.

It also lists other symptoms that include a feeling of a lump on one side of the mouth or throat, an unusually large tonsil on one side, unusual bleeding or numbness in the mouth, loose teeth for no clear reason, difficulty moving the jaw and pain in the ear that does not get better in a few days. The voice may be quieter, husky or sound as if you have a cold all the time.

The charity stresses that most people with these symptoms do not have cancer. A sore throat can be caused by viral or bacterial infections, acid reflux, smoking and hay fever. A hot, red, painful neck lump usually means an infection, whereas cancer usually forms a lump that slowly gets bigger.

• A sore throat that does not go away, especially on one side

• A lump in the neck that slowly gets bigger

• One tonsil that is unusually large

• Pain or difficulty swallowing, or food sticking

• Earache on one side that does not settle within a few days

• A mouth or throat ulcer that does not heal

• A change in voice, or unexplained weight loss

Cancer Research UK says that if you have any of these symptoms you must get them checked by your GP or dentist, remembering they can all be caused by other conditions. The NHS says for mouth cancer symptoms to see a GP if you have a mouth ulcer that has lasted more than 3 weeks, a lump in your mouth, on your lip, on your neck or in your throat, a red or white patch, pain that is not going away, difficulty swallowing or speaking, or a hoarse voice that does not go away.

The NHS says you may get an urgent referral for tests or to see a specialist in hospital if the GP thinks you have symptoms that could be cancer, and that this does not definitely mean you have cancer. Finding cancer early may make it easier to treat.

The tonsils are two small masses of tissue at the back of the throat. Cancer Research UK includes tonsil cancer in oropharyngeal cancer, which develops when abnormal cells in the oropharynx divide and grow uncontrollably. Most start in squamous cells and are called squamous cell carcinoma.

The charity points out that the term throat cancer is confusing, because people use it to mean several different cancers, including cancers of the voice box, food pipe and thyroid, and advises knowing the exact type because cancers are treated according to where they start. Around 8,900 new cases of mouth and oropharyngeal cancer are diagnosed in the UK each year.

Cancer Research UK says smoking tobacco and drinking alcohol increase the risk, and that smoking and drinking together increase it further. HPV is another main risk factor. It says that HPV causes around 50 out of every 100 oropharyngeal cancers in the UK, and the main type found is HPV 16. The link to HPV is much stronger for oropharyngeal cancers than for mouth cancers, and HPV-positive cases have been increasing in recent years.

HPV spreads through close skin-to-skin contact, usually during sexual activity, and around 80 out of 100 people will be infected at some time. For most it causes no harm and gets better on its own. Compared with HPV-negative oropharyngeal cancer, people with HPV-positive cancer are generally younger, do not usually smoke and drink little or no alcohol.

Other risk factors include age (most head and neck cancers are in people aged 65 to 69), a weakened immune system (for example HIV or medicines after an organ transplant), red or white patches in the mouth, a brother or sister who had head and neck cancer, and previous squamous cell cancer of the cervix, food pipe or lung.

Cancer Research UK says most people start with a GP or dentist, who examines the mouth and neck and may arrange blood tests to check general health, though no blood test can diagnose mouth or oropharyngeal cancer. A head and neck or ENT specialist then does more tests, usually starting with a nasoendoscopy in the outpatient clinic, where a thin flexible tube with a camera is passed through the nose into the throat. It can be uncomfortable but does not usually hurt and lasts a few minutes.

A biopsy is needed to confirm cancer. An incisional biopsy under local anaesthetic is used for easy-to-reach areas, and a panendoscopy under general anaesthetic for hard-to-reach areas such as the back of the throat. Oropharyngeal cancer tissue or a lymph node is tested for HPV. Scans may include CT, MRI, ultrasound of the neck lymph nodes and PET-CT.

Cancer Research UK says treatments include surgery, radiotherapy, chemoradiotherapy, and targeted and immunotherapy drugs. What you have depends on your cancer type, size, whether it has spread (the stage) and your general health. A team of doctors and other professionals discusses the best treatment and care for you.

Surgery and chemoradiotherapy (chemotherapy and radiotherapy together) are described as main treatments. Cancer Research UK adds that smoking during radiotherapy affects the ability of treatment to cure the cancer, so it is important to stop smoking before treatment. After treatment you have regular check-ups at the hospital. The charity also describes preparing for treatment (prehabilitation) to help you feel more in control.

Cancer Research UK says your outlook depends on the stage of the cancer, which part of the mouth or oropharynx is involved, whether the cancer contains HPV, and your general health and fitness. Oropharyngeal cancers containing HPV tend to have a better outlook, including at stage 3 and 4.

The charity gives five-year survival figures for oropharyngeal cancers diagnosed in England between 2014 and 2016, not age-standardised. They do not predict what will happen to any individual; your specialist can give a more personal picture.

On the NHS, a GP or dentist can make an urgent suspected cancer referral to an ENT or head and neck team. Cancer Research UK says a specialist team, usually including a surgeon, oncologist and specialist nurses, plans treatment. Private ENT consultations and nasoendoscopy are available if you wish to be seen sooner, but treatment for confirmed cancer is delivered by a head and neck multidisciplinary team, so ask who will be on your team and where treatment would take place.