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Living with cancer·Standard of care

Oral tongue and floor of mouth cancer: the decisions you may face

Cancer page →Second-opinion finder →

5 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

One path named

Biopsy, MRI or CT of the tongue and neck to measure depth of invasion and nodes, chest imaging or PET-CT for advanced stage, and dental assessment before radiotherapy.

Guideline
NCCN Guidelines: Head and Neck Cancers
The path, in plain words
PET/CTStandard of care

PET and CT in one machine, so hot spots on the PET are pinned to exact locations on the CT.

  • Anatomy plus biology
  • Standard for lymphoma, lung, melanoma, head and neck staging
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
PET/CT
  • CT radiation added to PET dose
Questions to ask about this decision
  1. Is PET/CT the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Head and Neck Cancers), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (diagnosis and staging), which of the standard options do you recommend and why?
    Why: Guideline options include: Biopsy, MRI or CT of the tongue and neck to measure depth of invasion and nodes, chest imaging or PET-CT for advanced stage, and dental assessment before radiotherapy.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Primary treatment (T1 to T2, clinically node-negative)

One path named

Partial glossectomy or floor-of-mouth resection with at least 5 mm margins and elective neck dissection (Tata Memorial trial); sentinel node biopsy as an alternative in small tumours.

Guideline
NCCN · Category 1 (elective neck dissection)
The path, in plain words
Sentinel lymph node biopsyStandard of care

Removing just the first lymph node a tumour drains to, instead of all of them, to check for spread.

  • Avoids lymphoedema from full dissection
The evidence behind it
The main trade-offs on record
Sentinel lymph node biopsy
  • False negatives in ~5-10%
Questions to ask about this decision
  1. Is Sentinel lymph node biopsy the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial), and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Head and Neck Cancers), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (primary treatment (t1 to t2, clinically node-negative)), which of the standard options do you recommend and why?
    Why: Guideline options include: Partial glossectomy or floor-of-mouth resection with at least 5 mm margins and elective neck dissection (Tata Memorial trial); sentinel node biopsy as an alternative in small tumours.
  7. How do the results of Elective vs therapeutic neck dissection in node-negative oral cancer (Tata Memorial) apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Locally advanced

Locally advanced (T3 to T4 or node-positive)

2 options

Resection with neck dissection and free-flap reconstruction, then postoperative radiotherapy, or cisplatin chemoradiation for extranodal extension or positive margins.

Guideline
NCCN · Category 1 (chemoradiation for extranodal e…
The options, in plain words
IMRT / IGRT (modern external beam)Standard of care

IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.

  • Conformal dose, fewer side effects
  • Hypofractionation saves visits
CisplatinApprovedCytotoxic chemotherapy (platinum)

Cisplatin is the original platinum chemotherapy, discovered by accident in 1965; it cures testicular cancer and makes radiation work better in cervical and head and neck cancer.

Also referenced:Chemoradiation (chemoradiotherapy, CRT)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
IMRT / IGRT (modern external beam)
  • Low-dose bath to normal tissue
  • Motion management
Cisplatinall recorded rates →
  • Dose reduce or avoid for CrCl below 60 (carboplatin is the alternative).
Questions to ask about this decision
  1. Between IMRT / IGRT (modern external beam) and Cisplatin, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Head and Neck Cancers), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (locally advanced (t3 to t4 or node-positive)), which of the standard options do you recommend and why?
    Why: Guideline options include: Resection with neck dissection and free-flap reconstruction, then postoperative radiotherapy, or cisplatin chemoradiation for extranodal extension or positive margins.
  6. Am I a candidate for Cisplatin, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Advanced, first line

Recurrent or metastatic

2 optionsCompare side by side →

Pembrolizumab alone or with platinum-fluorouracil (KEYNOTE-048); oral metronomic methotrexate-celecoxib where resources are limited.

Guideline
NCCN · Category 1
The options, in plain words
PembrolizumabApprovedMonoclonal antibody (anti-PD-1)

Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.

MethotrexateApprovedAntifolate (DHFR inhibitor)

The 1948 antifolate that produced the first chemotherapy remissions in childhood leukaemia and the first cure of a solid tumour; still essential in ALL, lymphoma, osteosarcoma and CNS lymphoma.

Also referenced:Recurrent or metastatic head and neck squamous cell carcinoma
The evidence behind it
  • KEYNOTE-048Phase 3NCT023580312019882 peopleevidence 95
    Tests Pembrolizumab
    Untreated recurrent or metastatic HNSCC: pembrolizumab alone, pembrolizumab + platinum/5-FU, or cetuximab + platinum/5-FU (EXTREME)

    OS 14.9 vs 10.7 months (CPS ≥20, monotherapy); 13.0 vs 10.7 (all, with chemotherapy).

    Overall survival, CPS ≥20, pembrolizumab monotherapy (months): Pembrolizumab 14.9 vs Cetuximab + chemotherapy 10.7 · HR 0.61 · source
  • Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial)Phase 32020422 peopleevidence 83
    Tests Methotrexate
    Recurrent, metastatic or inoperable head and neck carcinoma, palliative intent: oral methotrexate 15 mg/m2 weekly plus celecoxib 200 mg twice daily vs intravenous cisplatin
    Show survival figures (1)

    Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.

    • Median OS 7.5 vs 6.1 months, HR 0.773; grade 3+ adverse events 19% vs 30%.
    Median overall survival (months): Oral metronomic (methotrexate + celecoxib) 7.5 (n=213) vs IV cisplatin 6.1 (n=209) · HR 0.773 · source
The main trade-offs on record
Pembrolizumaball recorded rates →
Side effectAny gradeGrade 3+
Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients8%-
Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients3.4%-
Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients1.7%-
Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients0.7%-
  • No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Methotrexateall recorded rates →
  • High-dose methotrexate requires normal renal function, hydration, urine alkalinisation and leucovorin rescue with level monitoring.
Questions to ask about this decision
  1. Between Pembrolizumab and Methotrexate, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in KEYNOTE-048 and Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial), and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. Which side effects of Pembrolizumab are most likely for me, which are reversible, and which would make us stop?
    Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
  5. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  6. Does your recommendation follow the current guideline (NCCN Guidelines: Head and Neck Cancers), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  7. For my situation (recurrent or metastatic), which of the standard options do you recommend and why?
    Why: Guideline options include: Pembrolizumab alone or with platinum-fluorouracil (KEYNOTE-048); oral metronomic methotrexate-celecoxib where resources are limited.
  8. Am I a candidate for Pembrolizumab, Methotrexate, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  9. How do the results of KEYNOTE-048 and Oral metronomic chemotherapy vs intravenous cisplatin (Tata Memorial) apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

3 options

Tobacco, alcohol and betel quid cessation; treatment of leukoplakia and erythroplakia; oral examination in high-risk people.

The options, in plain words
Smoking cessation in cancer patientsEstablished

Stopping smoking after a cancer diagnosis improves survival, reduces treatment complications and second cancers, and is the single most effective supportive intervention that oncology services still routinely fail to deliver.

  • Large survival effect in lung and head and neck cancer
  • Cheap, effective drugs available
  • Opt-out models are proven to raise uptake
Alcohol reduction, pricing and cancer warning labelsEstablished

Alcohol causes at least seven cancers and there is no safe threshold. Price, availability and cancer warning labels are the tools that work; most people still do not know alcohol causes cancer.

  • Causal evidence is settled
  • Pricing and taxation have robust quasi-experimental evidence
  • Labelling is cheap and reaches everyone
Oral cancer visual screeningEstablished

A trained health worker looking inside the mouth with a light can find mouth cancer early; in India this cut deaths by a third among people who use tobacco or alcohol.

  • No equipment, deliverable by community health workers
  • Randomised evidence of mortality reduction in high-risk users
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Smoking cessation in cancer patients
  • Under-delivered: most patients never offered treatment
  • Stigma and fatalism among patients and clinicians
  • Reimbursement gaps for cessation pharmacotherapy
Alcohol reduction, pricing and cancer warning labels
  • Industry lobbying and trade-law challenges
  • Low public awareness
  • Little trial evidence for reduction after diagnosis
Oral cancer visual screening
  • Benefit confined to tobacco and alcohol users
  • Compliance with referral for biopsy is the weak link
  • Does not address HPV-related oropharyngeal cancer
Questions to ask about this decision
  1. Between Smoking cessation in cancer patients, Alcohol reduction, pricing and cancer warning labels and Oral cancer visual screening, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. For my situation (prevention), which of the standard options do you recommend and why?
    Why: Guideline options include: Tobacco, alcohol and betel quid cessation; treatment of leukoplakia and erythroplakia; oral examination in high-risk people.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.