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Cancer

Head and neck cancers - recognition and referral

Last revised in April 2025

Laryngeal cancerOver 2,000 new laryngeal cancers are diagnosed each year in the UK.Five year survival is 70%.

Head and neck cancers - recognition and referral: Summary

  • Laryngeal cancer
    • Over 2000 new laryngeal cancers are diagnosed each year in the UK.
    • The 5 year survival is 70%.
    • The most common symptom is hoarseness, sometimes accompanied by throat pain.
    • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 years and over with:
      • Persistent unexplained hoarseness, or
      • An unexplained lump in the neck (new NICE recommendation for 2015).
  • Oral cancer
    • Over 6500 new oral cancers are diagnosed each year in the UK.
    • It is seen in both sexes. Two-thirds of new diagnoses are in males.
    • Symptoms include persistent ulceration, a mass, or abnormal bleeding. It can present as advanced disease with regional lymphadenopathy.
    • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
      • Unexplained ulceration in the oral cavity lasting for more than 3 weeks, or
      • A persistent and unexplained lump in the neck (new NICE recommendation for 2015).
    • Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
      • A lump on the lip or in the oral cavity, or
      • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia (new NICE recommendation for 2015).
    • Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
      • A lump on the lip or in the oral cavity consistent with oral cancer, or
      • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia (new NICE recommendation for 2015).
  • Thyroid cancer
    • Over 2500 new thyroid cancers are diagnosed each year in the UK.
    • It is seen in both sexes. Approximately 70% of new diagnoses are in females.
    • The 5 year survival is over 90%.
    • Thyroid cancer usually presents as a nodule within the thyroid gland, or as diffuse thyroid swelling. The cancer may also present with regional lymphadenopathy.
    • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump (new NICE recommendation for 2015).

Have I got the right topic?

From birth onwards.

This CKS topic is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015]. This topic covers the recognition and referral of suspected cancer.

This CKS topic does not cover the management of patients with head or neck cancers.

There is a separate CKS topic on Aphthous ulcer.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

Previous changes

February 2021 — minor update. Minor change to align with house style. 

August 2020 — reviewed. This topic is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral.

November 2016 — minor update. The National Institute for Health and Care Excellence (NICE) quality standards for suspected cancer have been added to this topic.

September to October 2015 — reviewed. This topic is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral (2015). This CKS topic replaces the former topic on Head/neck cancer - suspected.

June 2009 — converted from CKS guidance to CKS topic structure. No changes to recommendations have been made. Issued in July 2009.

September 2008 — minor correction to the Changes section. Issued September 2008.

October 2005 — minor technical update. Issued in November 2005.

July 2005 — revised to reflect the update to the Referral guidelines for suspected cancer published by the National Institute for Health and Care Excellence in June 2005. Issued in July 2005.

April 2000 — issued in December 2000.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 August 2020.

HTAs (Health Technology Assessments)

No new HTAs since 1 August 2020.

Economic appraisals

No new economic appraisals relevant to England since 1 August 2020.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 August 2020.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 August 2020.

New policies

No new national policies or guidelines since 1 August 2020.

New safety alerts

No new safety alerts since 1 August 2020.

Changes in product availability

No changes in product availability since 1 August 2020.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Recognize symptoms suggestive of head and neck cancers.
  • Refer people with suspected head and neck cancers within the appropriate timescales as defined by the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].
  • Offer appropriate patient information and support for people with suspected cancer.

Outcome measures

No outcome measures were identified for this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

  • GPs have direct access to diagnostic endoscopy, ultrasound, MRI, X-ray and CT for people with suspected cancer.
  • People presenting in primary care with symptoms that suggest oesophageal or stomach cancer have an urgent direct access upper gastrointestinal endoscopy.
  • Adults presenting in primary care with symptoms that suggest colorectal cancer, who do not meet the referral pathway criteria, have a test for blood in their faeces.
  • People with suspected cancer who are referred to a cancer service are given written information encouraging them to attend.

[NICE, 2016]

Background information

How might it present?

  • Laryngeal cancer
    • The most common symptom of laryngeal cancer is believed to be hoarseness, sometimes accompanied by other symptoms such as throat pain.
    • The main method of diagnosis is by laryngoscopy and biopsy, which is performed in secondary care.
  • Oral cancer
    • Oral cancer can present with persistent ulceration, a mass, or abnormal bleeding. It can present as advanced disease with regional lymphadenopathy.
    • Some oral cancers can be recognized visually, but definitive diagnosis requires biopsy, performed in secondary care.
  • Thyroid cancer
    • Is believed to usually present with a nodule within the thyroid gland, or as diffuse thyroid swelling.
    • The cancer may also present with regional lymphadenopathy.
    • Definitive diagnosis requires biopsy, performed in secondary care.

[National Collaborating Centre for Cancer, 2015]

How common is it?

  • Laryngeal cancer
    • Just over 2000 new laryngeal cancers are diagnosed each year in the UK.
    • A full time GP is likely to diagnose approximately one person with laryngeal cancer during their career.
  • Oral cancer
    • Over 6500 new oral cancers are diagnosed each year in the UK.
    • Many are diagnosed and referred by dental surgeons.
    • It is seen in both sexes, though two-thirds of new diagnoses are in males.
  • Thyroid cancer
    • Over 2500 new thyroid cancers are diagnosed each year in the UK.
    • A full time GP is likely to diagnose approximately 1–2 people with thyroid cancer during their career.
    • It is seen in both sexes, although around 70% of new diagnoses are in females.

[National Collaborating Centre for Cancer, 2015]

What is the prognosis?

  • Laryngeal cancer — 5 year survival is 70%.
  • Oral cancers — survival rates vary considerably.
  • Thyroid cancer — 5 year survival rate is over 90%.

[National Collaborating Centre for Cancer, 2015]

Diagnosis of head and neck cancers

Symptoms suggestive of head and neck cancers

Table 2. Symptoms suggestive of head and neck cancers.

Symptom

Possible cancer

Referral recommendation

Lip or oral cavity lumpOral

Consider an urgent referral (for an appointment within 2 weeks) for assessment by a dentist

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) in people when assessed by a dentist as having a lump on the lip or in the oral cavity consistent with oral cancer

Neck lump (persistent and unexplained)OralConsider a suspected cancer pathway referral (for an appointment within 2 weeks)
Neck lump (unexplained), 45 years and overLaryngealConsider a suspected cancer pathway referral (for an appointment within 2 weeks)
Hoarseness (persistent and unexplained), 45 years and overLaryngealConsider a suspected cancer pathway referral (for an appointment within 2 weeks)
Oral cavity red or red and white patch consistent with erythroplakia or erythroleukoplakiaOral

Consider urgent referral (for an appointment within 2 weeks) for assessment by a dentist

Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for people when assessed by a dentist as having a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Ulceration in the oral cavity (unexplained and lasting for more than 3 weeks)OralConsider a suspected cancer pathway referral (for an appointment within 2 weeks)
Thyroid lump (unexplained)ThyroidConsider a suspected cancer pathway referral (for an appointment within 2 weeks)
Data from: [NICE, 2015]

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Management

Scenario: Referral for head and neck cancer

From birth onwards.

Referral timelines

  • The terms used in the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral are as follows:
    • Immediate: an acute admission or referral occurring within a few hours, or even more quickly if necessary.
    • Urgent: to happen/be performed within 2 weeks.
    • Very urgent: to happen within 48 hours.
    • Non-urgent: the timescale generally used for a referral or investigation that is not considered very urgent or urgent.
    • Suspected cancer pathway referral: the patient is seen within the national target for cancer referrals.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Referral for suspected laryngeal cancer

  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 years and over with:
    • Persistent unexplained hoarseness, or
    • An unexplained lump in the neck.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Referral for suspected oral cancer

  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
    • Unexplained ulceration in the oral cavity lasting for more than 3 weeks, or
    • A persistent and unexplained lump in the neck .
  • Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
    • A lump on the lip or in the oral cavity, or
    • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
  • Consider a suspected cancer pathway referral by the dentist (for an appointment within 2 weeks) for oral cancer in people when assessed by a dentist as having either:
    • A lump on the lip or in the oral cavity consistent with oral cancer, or
    • A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Referral for suspected thyroid cancer

  • Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Diagnostic and referral process

  • Discussion with a specialist (for example, by telephone or email) should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical.
  • Put in place local arrangements to ensure that letters about non-urgent referrals are assessed by the specialist, so that the person can be seen more urgently if necessary.
  • Put in place local arrangements to ensure that there is a maximum waiting period for non-urgent referrals, in accordance with national targets and local arrangements.
  • Ensure local arrangements are in place to identify people who miss their appointments so that they can be followed up.
  • Include all appropriate information in referral correspondence, including whether the referral is urgent or non-urgent.
  • Use local referral proformas if these are in use.
  • Once the decision to refer has been made, make sure that the referral is made within 1 working day.
  • Take part in continuing education, peer review, and other activities to improve and maintain clinical consulting, reasoning, and diagnostic skills, in order to identify at an early stage people who may have cancer, and to communicate the possibility of cancer to the person.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Patient information and support

  • Discuss with people with suspected cancer (and their carers as appropriate, taking account of the need for confidentiality) their preferences for being involved in decision-making about referral options and further investigations including their potential risks and benefits.
  • Explain to people who are being referred with suspected cancer that they are being referred to a cancer service. Reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them.
  • Give the person information on the possible diagnosis (both benign and malignant) in accordance with their wishes for information.
  • The information given to people with suspected cancer and their families and/or carers should cover, among other issues:
    • Where the person is being referred to.
    • How long they will have to wait for the appointment.
    • How to obtain further information about the type of cancer suspected or help before the specialist appointment.
    • What to expect from the service the person will be attending.
    • What type of tests may be carried out, and what will happen during diagnostic procedures.
    • How long it will take to get a diagnosis or test results.
    • Whether they can take someone with them to the appointment.
    • Who to contact if they do not receive confirmation of an appointment.
    • Other sources of support.
  • Provide information that is appropriate for the person in terms of language, ability, and culture, recognizing the potential for different cultural meanings associated with the possibility of cancer.
  • Have information available in a variety of formats on both local and national sources of information and support for people who are being referred with suspected cancer.
  • When referring a person with suspected cancer to a specialist service, assess their need for continuing support while waiting for their referral appointment. This should include inviting the person to contact their healthcare professional again if they have more concerns or questions before they see a specialist.
  • If the person has additional support needs because of their personal circumstances, inform the specialist (with the person's agreement).
  • When cancer is suspected in a child, discuss the referral decision and information to be given to the child with the parents or carers (and the child if appropriate).

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Safety netting

  • Safety netting involves active monitoring of low risk people presenting with symptoms in primary care.
  • Explain to people who are being offered safety netting which symptoms to look out for and when they should return for re-evaluation. It may be appropriate to provide written information.
  • Reassure people in the safety netting group who are concerned that they may have cancer that with their current symptoms their risk of having cancer is low.
  • Ensure that the results of investigations are reviewed and acted upon appropriately, with the healthcare professional who ordered the investigation taking or explicitly passing on responsibility for this. Be aware of the possibility of false-negative results for chest X-rays and tests for occult blood in faeces.
  • Consider a review for people with any symptom that is associated with an increased risk of cancer, but who do not meet the criteria for referral or other investigative action. The review may be planned within a time frame agreed with the person or patient-initiated if new symptoms develop, the person continues to be concerned, or their symptoms recur, persist, or worsen.

Basis for recommendation

This is a direct implementation of the National Institute for Health and Care Excellence guideline Suspected cancer: recognition and referral [NICE, 2015].

Supporting evidence

A summary of the evidence on which the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015] is based is provided in the full guideline Suspected cancer: recognition and referral. Full guideline June 2015 [National Collaborating Centre for Cancer, 2015].

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].

Search dates

September 2015 - August 2020

Key search terms

A full literature search was not conducted as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Suspected cancer: recognition and referral [NICE, 2015].

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

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