Tongue Cancer: First Signs, Stages and Treatment

A sore on the tongue that has not healed in two or three weeks, a white or red patch along its edge, or a small lump that feels hard to the touch is usually put down to a rubbing tooth or a mouth ulcer. Most of these really are harmless. But this is exactly how tongue cancer begins, quietly. When it is caught early, it can be treated while preserving the tongue's function. This article explains the first signs of tongue cancer, how to tell it apart from a mouth ulcer, which doctor to see and the treatment options.

What is tongue cancer?

Tongue cancer is a malignant tumour that develops from the cells lining the surface of the tongue. More than 90% of cases are squamous cell carcinoma. The disease is divided into two groups depending on where in the tongue it starts, and this distinction also affects treatment:

Oral tongue cancer: Develops in the front two-thirds of the tongue, the part you can see in the mouth. It most often appears on the sides of the tongue. Because it is visible, it tends to be noticed earlier. It belongs to the group of mouth cancers.
Base of tongue cancer: Develops in the back third of the tongue, which extends down into the throat. Because it cannot be seen, it is often noticed later. In recent years it has become clear that a large share of tumours in this area are linked to HPV infection.

First signs of tongue cancer

In its early stages, tongue cancer is usually painless, so the first signs are easy to miss. If any of the following changes last longer than two to three weeks, you should be examined:

A sore on the tongue that does not heal, especially on the side of the tongue
A white patch that cannot be wiped away (leukoplakia) or a red, velvety patch (erythroplakia)
Hardness, thickening or a raised area you can feel with your finger
An area that bleeds for no obvious reason
Numbness, burning or persistent pain in the tongue
Pain that spreads to the ear on the same side
Difficulty speaking or swallowing, or trouble moving the tongue
A lump in the neck that you can feel and that does not go away

Most oral tongue tumours appear as a long-standing sore with slightly raised edges and a firm base. Red patches carry a higher risk of cancer than white patches.

Symptoms of base of tongue cancer

Tumours at the base of the tongue usually grow out of sight. Typical complaints are a sore throat that will not go away, a feeling of something stuck in the throat, difficulty swallowing, earache and a muffled "hot potato" voice. In some patients, the first and only sign is a painless lump in the neck. That is why any neck lump lasting more than three weeks should always be checked.

Cancer of the floor of the mouth and the uvula

Tumours of the floor of the mouth, beneath the tongue, look much like tongue cancer: a sore that does not heal, a white or red patch, or a swelling. They are treated by the same team. The uvula, by contrast, is not part of the tongue; it is the small flap of tissue that hangs from the back of the soft palate. Cancer here is rare and is classed with throat cancers. A sore or swelling on the uvula that does not go away, or a sore throat on one side only, calls for an ear, nose and throat examination.

A sore on the tongue: mouth ulcer or cancer?

The vast majority of sores on the tongue are mouth ulcers (canker sores) or sores caused by rubbing from a tooth or denture. The table below helps explain the differences, but a definite diagnosis can only be made by examination and biopsy.

	Mouth ulcer	Traumatic ulcer	Tongue cancer
Appearance	Round, with a yellowish-white base and a red border	Irregular sore where a sharp tooth or denture touches	Sore with raised edges and a firm base, or a white and red patch
Pain	Noticeable, worse when eating	Present, lasts as long as the rubbing continues	Usually absent at first
Duration	Heals in 7–14 days	Heals in 1–2 weeks once the cause is removed	Does not heal on its own, grows slowly
Feel	Soft	Soft	Hard, with thickened surrounding tissue

In short, any sore on the tongue that has not healed within two or three weeks, even after a sharp tooth has been smoothed or a denture adjusted, should be examined. For more detail on mouth ulcers, see our page on mouth ulcers.

What causes tongue cancer?

Cigarettes and other tobacco products: The most important risk factor. Shisha (waterpipe), pipes and chewing tobacco also raise the risk.
Alcohol: The risk multiplies, especially when combined with smoking.
HPV infection: Closely linked to cancers of the throat region, particularly of the base of the tongue.
Long-standing leukoplakia and erythroplakia: These are precancerous lesions that can turn into cancer and need regular follow-up.
Oral health: Poor oral hygiene and broken teeth or ill-fitting dentures that constantly rub against the tongue are considered possible contributing factors.
Weakened immunity: The risk is higher in people taking immunosuppressive drugs after an organ transplant.

Tongue cancer is most common over the age of 50. In recent years, however, it has become more frequent in younger patients who neither smoke nor drink. For help quitting smoking, contact our Smoking Cessation Clinic; for protection against HPV, see our page on the HPV vaccine.

Which doctor treats tongue cancer?

If you notice a suspicious change on your tongue, see an ear, nose and throat (ENT) specialist, ideally one who focuses on head and neck surgery. Dentists are also often the first to notice changes on the tongue during routine check-ups and refer patients when needed. Once a diagnosis is made, treatment is planned by a team including a head and neck surgeon, radiation oncologist, medical oncologist, plastic surgeon, speech and language therapist and dietitian.

How is tongue cancer diagnosed?

During the examination, the tongue, the floor of the mouth and the lymph nodes in the neck are inspected and felt. To see the base of the tongue, the doctor uses endoscopy, passing a thin, flexible camera through the nose. A definite diagnosis requires a biopsy: a small piece of tissue is taken from the suspicious area under local anaesthetic.

If cancer is confirmed, an MRI scan shows how deeply the tumour has grown into the tongue, and an ultrasound or CT scan is used to assess the lymph nodes in the neck. If advanced disease is suspected, PET-CT is used to see how far it has spread. In tongue cancer, the depth of the tumour (depth of invasion) is one of the most important findings, as it determines both the stage and the treatment needed for the lymph nodes in the neck.

Tongue cancer stages

Stage	Tumour status
Stage 1	Tumour 2 cm or smaller, no more than 5 mm deep, not spread to the lymph nodes
Stage 2	Tumour smaller than 2 cm but deeper, or between 2 and 4 cm; not spread to the lymph nodes
Stage 3	Tumour larger than 4 cm or deeper than 10 mm, or spread to a single small lymph node on the same side
Stage 4	Tumour has grown into nearby structures such as the jawbone or skin, or spread to more than one or to a large lymph node, or to distant organs

Is tongue cancer deadly?

Tongue cancer is a serious disease, but the outcome depends largely on when it is caught. In patients treated while the disease is still confined to the tongue, the five-year survival rate is above roughly 80%. The rate falls when the cancer has spread to the lymph nodes in the neck and drops considerably when it has spread to distant organs. HPV-related base of tongue cancers are known to respond better to treatment. The biggest risk, then, is waiting on a sore that will not heal because "it doesn't hurt anyway".

Tongue cancer treatment

Surgery: will my tongue be removed?

Surgery is the main treatment for oral tongue cancer. The tumour is removed together with a margin of healthy tissue around it. At an early stage this means taking out only a small part of the tongue (partial glossectomy), and most patients regain much of their ability to speak and swallow within a short time. With larger tumours, half of the tongue or more may be removed. In that case, the tongue is reconstructed during the same operation using tissue taken from the forearm or thigh. These reconstructions are carried out together with the plastic and reconstructive surgery team. Removing the whole tongue is considered only for very advanced tumours.

Once the tumour exceeds a certain depth, the lymph nodes in the neck are also removed in the same operation (neck dissection), even if there is no visible spread to them. This is because tongue cancer can spread to the neck even at an early stage.

Radiotherapy and chemotherapy

If the risk of the tumour coming back after surgery is high, radiotherapy is given. In high-risk cases, chemotherapy is added to radiotherapy. Base of tongue cancers, on the other hand, are often treated without surgery, using radiotherapy and chemotherapy together. For suitable patients, transoral robotic surgery to the base of the tongue is another option.

Immunotherapy and targeted therapies

For cancer that has come back or spread to distant organs, immunotherapy and targeted drugs are used. In some patients these treatments can keep the disease under control for a long time.

Life after treatment

Because treatment for tongue cancer can affect speaking, swallowing and eating, supportive care is important during recovery:

Speech and swallowing therapy: Starts as soon as possible after surgery and strengthens the function of the remaining part of the tongue. This support is provided at our Speech, Voice and Swallowing Therapy Clinic.
Nutrition: Soft foods and liquids may be needed at first. Oncology nutrition support is recommended to prevent weight loss.
Mouth and dental care: Dental treatment should be completed before radiotherapy, and regular mouth care is needed during and after treatment to manage dry mouth.
Regular check-ups: Because recurrences mostly occur in the first two years, check-ups are frequent during this period. Staying away from smoking and alcohol lowers the risk both of recurrence and of a new cancer developing.

Tongue cancer is assessed together with other cancers of the mouth and throat. For more information, see our pages on head and neck cancers and lip cancer.

Frequently asked questions about tongue cancer

What is the first sign of tongue cancer?

The most common first sign is a sore that does not heal within two to three weeks, especially on the side of the tongue, or a white or red patch that cannot be wiped away. A hard area you can feel when touching the tongue is another early sign. There is usually no pain at first.

Is tongue cancer painful?

In the early stages it is usually painless. As the tumour grows, pain or burning in the tongue, pain spreading to the ear on the same side and difficulty swallowing may develop. The absence of pain does not mean a sore is harmless.

Which doctor should I see for tongue cancer?

See an ear, nose and throat (ENT) specialist, ideally one who focuses on head and neck surgery. Dentists can also spot suspicious changes during routine check-ups and refer you.

Is tongue cancer deadly?

In patients treated at an early stage, while the disease is still confined to the tongue, the five-year survival rate is above roughly 80%. The rate falls when the cancer spreads to the lymph nodes in the neck or to distant organs, which is why early diagnosis matters so much.

Will my tongue be removed?

At an early stage, only the small part of the tongue containing the tumour is removed, and most patients keep much of their ability to speak and swallow. With larger tumours, the removed part is reconstructed in the same operation using tissue from the forearm or thigh. Removing the whole tongue is rare.

Can tongue cancer be cured?

Yes. At an early stage, surgery alone is often enough. In more advanced stages, radiotherapy and chemotherapy are added to surgery. Base of tongue cancers can be treated with radiotherapy and chemotherapy together. For cancer that has spread, immunotherapy options are available.