Should I see a mouth cancer specialist?

It can be very difficult for GPs to decide who to refer to a specialist. With many symptoms, it is perfectly right that your GP should ask you to wait to see if your symptoms go away on their own, or respond to treatment such as antibiotics. If GPs referred everyone with any symptom to a specialist immediately, the system would get jammed. People needing urgent appointments wouldn't then be able to get them.

The National Institute for Health and Clinical Excellence (NICE) has produced guidelines for GPs in the UK to help them decide which patients need to be seen urgently by a specialist. These guidelines on referrals for head and neck cancers were revised in June 2005.

While reading these guidelines, it is important to remember that

• Mouth and oropharyngeal cancers are rare – there are about 3,600 cases diagnosed each year in the UK
• A number of risk factors affect your chances of developing a mouth or oropharyngeal cancer
• There are very few cases diagnosed in people under 50
• General symptoms such as bad breath are much more likely to be something less serious

According to the NICE guidelines, you should ideally get an appointment within 2 weeks if you have symptoms that could be due to cancer. The guidelines say that you may need an urgent referral to a specialist for possible mouth and oropharyngeal cancer if you have

• Mouth ulcers that do not go away after 3 weeks
• Swelling in the mouth that does not go away after 3 weeks
• Red and white patches in the mouth (that are not thrush) and are painful, swollen or bleeding
• An unexplained sore or painful throat that has lasted longer than it should
• An unexplained lump in your neck that has changed in the previous 3 to 6 weeks
• Unexplained swelling in the glands under your ear, or around your lower jaw, that does not go away
• Unexplained pain on one side of your head or neck for more than 4 weeks, with ear ache for no apparent reason
• Any other signs or symptoms affecting your mouth that can't be explained and have lasted for more than 6 weeks

Your doctor may also want to refer you to a dentist urgently if you have a loose tooth for more than 3 weeks, for no apparent reason.

It is important to bear in mind that some of the symptoms above can be caused by other less serious medical conditions. They do not necessarily mean that you have cancer of the mouth or oropharynx. But you could be more at risk of mouth or oropharyngeal cancer if you are a long term smoker (especially if you drink as well) or if you chew tobacco (betel quid, paan, gutkha).

The NICE guidelines also say that the GP should send you for an urgent chest X-ray if you have had a hoarse, husky, or quieter than normal, voice for more than 3 weeks, particularly if you are

• A smoker aged 50 or over
• A regular heavy drinker

The reason for the X-ray is to try and rule out a lung cancer or head and neck cancer.

Your doctor may send you to a specialist as a non urgent referral if you have red or white patches in your mouth that are not painful, swollen or bleeding. There are conditions called erythroplakia and leukoplakia which are not cancerous, but can lead to cancer over time if they are not treated.

Your GP may also refer you to a specialist if they suspect that you have a mouth condition called lichen planus, which causes chronic inflammation of the skin lining your mouth. This condition is not related to cancer.

If you are concerned that your GP is not taking your symptoms as seriously as you think they should, you could print this page and take it along to an appointment. Ask your GP to talk it through with you and then you may be able to decide together whether you need to see a specialist, and if so, how soon.