Guidance on Referral of Suspected Oral / Oropharyngeal Cancer

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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 (, National Institute for Health & Care Excellence ( and British Association of Head & Neck Oncologists (

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

  • Difficulty in swallowing or unintended weight loss

  • Speech problems

  • A lump in the neck

  • Unusual bleeding or numbness in the mouth /face

  • Loose teeth for no apparent reason

  • Non-healing dental extraction socket(s)

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

  • Mouth and oropharyngeal cancers are relatively uncommon to see in primary care – there are about 6,800 cases in total diagnosed each year in the UK

  • A number of factors affect the risk of developing oral or oropharyngeal cancer

  • General symptoms such as halitosis or oral pain are much more likely to be related to a benign cause

The following are the categories of patients/conditions that should be referred urgently according to current NICE guidance

  1. unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are:

  • painful, or

  • swollen, or

  • bleeding

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

  1. unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks

  2. adult patients with unexplained tooth mobility persisting for more than 3 weeks, an urgent referral to a dentist should be made

  3. 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.

  4. 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

  5. unexplained persistent swelling in the parotid or submandibular gland

  6. unexplained persistent sore or painful throat

  7. 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

and addressed (by email only) to the Oxford University Hospitals 2WW appointments bureau at

2 Week Rule Referral for Suspected Head and Neck Cancer (Including Thyroid): GP Proforma (INPS) Oxfordshire


July 2014

Please email to - please request a Read Receipt when sending

Patient’s details

Patient’s background and culture







1st language




Interpreter required? Y N



GP details



Referring GP


Pt Address







GP address


GP Tel no




GP Fax no


Hospital No


GP Email


Home tel


Date of ref


Work tel


Date ref received


Mobile tel


Dentist details



Telephone Number




Fax Number


If cancer is suspected, is the patient aware?


Is the patient available for an appointment within the next 14 days?

Y N (Needs to be available)

For the 9 weeks from referral, patients will be required to be available for further hospital appointments and investigations. Please ensure that you have explained this to your patient.

Patient is available for the 9 weeks from referral

To ensure your patient is seen within 14 days appointments may be offered at either Oxford or Banbury. Please tick to confirm you have explained this to your patient.

Has the patient been given the Fast Track Pathway information leaflet?

It can be printed from this link:


Please indicate patient’s preferred contact number:

Home Work Mobile

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.

Cancer Area Suspected

Oral Cavity


Salivary Gland

Sinus Nasal




Post Nasal Space

Symptoms – unexplained

Persistent hoarseness 6 weeks, or longer

Clinical Examination

Oral ulceration/tumour > 4 weeks

Pain on swallowing over 3 weeks

Lump in neck > 4 weeks

Dysphagia > 3 weeks

Unilateral Otalgia with a normal otoscopy

Weight loss with Hoarse > 3 weeks and normal CXR

Cranial neuropathy – e.g

Weakness in presence of parotid lump

Unilateral sore throat

Unexplained red/white patches oral mucosa or lichen planus which are painful, swollen or bleeding

Thyroid swelling associated with

Longstanding nodule sudden recent change in size

A history of neck irradiation

A family history of an endocrine tumour

Orbital mass

Unexplained hoarseness or voice changes

Tonsillar enlargement / ulceration

Cervical lymphadenopathy

Non – healing tooth extraction sockets / unexplained loosening of teeth

Children and teenagers

Patient aged 65 years

and older

Other –

please state


Risk Factors

Amount smoked per day


Alcohol consumed – units per week


Is the patient on an anti-coagulant


Please state if you are attaching a letter or computer printout with this information


Current Medication


Relevant PMH

Allergies / adverse reactions (may be none)

Additional Information


Please email to - please request a Read Receipt when


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