Guidance on Referral of Suspected Oral / Oropharyngeal Cancer The following guidance has been produced to assist in the early detection, referral and diagnosis of suspected oral / oropharyngeal cancer.
The following information is by no means comprehensive or indeed prescriptive, but is aimed at assisting decision-making in primary care when suspecting a diagnosis of potential cancer. Further more detailed information can be obtained from Cancer Research UK (http://www.cancerresearchuk.org/), National Institute for Health & Care Excellence (http://www.nice.org.uk/guidance) and British Association of Head & Neck Oncologists (www.bahno.org.uk)
The following symptoms and signs can be the presenting features in oral & oropharyngeal cancer. It is important to stress that a thorough history and clinical examination, as well as assessment of risk factors, will aid clinical decision making regarding the suspicion of cancer :
Ulcers that do not heal
Persistent lump in the mouth / throat
Persistent discomfort or pain in the mouth
Persistent White or red patches in the mouth or throat
These symptoms can be very similar to those of other less serious conditions. It can be difficult for GPs and GDPs to decide who may have a cancer and who may have something much more minor that will go away on its own. Similarly It can be difficult for Primary care practitioners to decide who to refer to a specialist.
With many of the listed symptoms, it can be perfectly appropriate that you could monitor the patient to see if their symptoms go away spontaneously, or respond to treatment such as antibiotics or anti-fungal therapy. Referring everyone with these symptom for a specialist opinion immediately, would overwhelm secondary care services and result in patients needing urgent appointments not getting them.
The National Institute for Health and Care Excellence (NICE) has produced guidelines for GPs in the UK to help them decide which patients need to be seen urgently by a specialist. While reading these guidelines, it is important to remember that
unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are:
A non-urgent referral should be made in the absence of these features. If oral lichen planus is confirmed, the patient should be monitored for oral cancer as part of routine dental examination
unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks
hoarseness persisting for more than 3 weeks, particularly smokers aged 50 years and older and heavy drinkers, an urgent referral for a chest X-ray should be made. Patients with positive findings should be referred urgently to a team specialising in the management of lung cancer. Patients with a negative finding should be urgently referred to a team specialising in head and neck cancer.
an unexplained lump in the neck which has recently appeared or a lump which has not been diagnosed before that has changed over a period of 3 to 6 weeks
unexplained persistent swelling in the parotid or submandibular gland
unexplained persistent sore or painful throat
unilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but with normal otoscopy
**** In Oxford, all suspected Head & Neck cancer referrals should be sent on*** the designated 2 week wait referral form - see below – also available online at
Your patient will be seen under the 2 week rule if one or more of the following criteria are present.
Please tick the appropriate box(es) and add relevant details below Once cancer has been excluded your patient will be referred back to you, their GP, other than in exceptional circumstances where immediate onward referral is deemed clinically necessary by the secondary care clinician.