What follow-up care and preventive measures are recommended for a patient with a history of tongue cancer?

Follow-Up Care for Tongue Cancer Survivors

Patients with a history of tongue cancer require structured surveillance with clinical examinations every 1-3 months in year 1, every 2-6 months in year 2, every 4-8 months in years 3-5, and annually thereafter, with mandatory ongoing otolaryngology specialist involvement throughout the surveillance period. 1

Surveillance Schedule and Clinical Examination

The surveillance intensity must be highest in the first year when recurrence risk peaks, with 89% of recurrences occurring within the first 60 months. 2

Examination Frequency

• Year 1: Every 1-3 months 1
• Year 2: Every 2-6 months 1
• Years 3-5: Every 4-8 months 1
• After 5 years: Annually 1

Required Examination Components

Each visit must include direct nasopharyngolaryngoscopy by an otolaryngologist or head and neck specialist to visualize the entire upper aerodigestive tract (oral cavity, oropharynx, hypopharynx, larynx) plus systematic neck palpation. 1

The examination must specifically assess for:

• Local recurrence at the primary tongue site (occurs as commonly as neck recurrence) 2
• Regional neck lymphadenopathy through systematic palpation 1
• Second primary cancers in high-risk sites (oral cavity, pharynx, larynx, lung, esophagus) 1
• Mucosal changes including ulceration, white/red patches, or masses 3

Imaging Surveillance

Baseline imaging of the primary site and neck should be obtained within 6 months of completing treatment. 1

Routine reimaging is NOT recommended in asymptomatic patients without clinical findings suggestive of recurrence. 1 This is a critical pitfall to avoid—imaging should be symptom-driven or findings-driven, not calendar-driven after the baseline study.

For patients who had advanced disease (T3/T4 or N2/N3), baseline imaging is particularly important per NCCN recommendations. 1

Thyroid Function Monitoring

Measure TSH every 6-12 months in patients who received neck radiation therapy or had surgical compromise of the thyroid gland. 1 The frequency should be guided by the extent of radiation field and surgical intervention to the thyroid region.

Dental and Oral Care

Patients must maintain close follow-up with a dental professional specializing in oncology care, as proper preventive care reduces caries and gingival disease risk. 1

Specific Dental Recommendations

• Use prescription 1.1% sodium fluoride toothpaste daily 1
• Seek immediate professional attention for any intraoral changes 1
• Avoid tobacco, alcohol (including alcohol-containing mouthwash), spicy/abrasive foods, extreme temperature liquids, sugar-containing products, and acidic/citric liquids 1
• Remove dentures at night to avoid irritation 1

Patient Education on Warning Signs

Educate patients to immediately report:

• New or persistent oral pain, ulceration, or masses 4, 5
• Neck lumps or swelling (25% of tongue cancer patients have neck metastases at diagnosis) 4
• Dysphagia or odynophagia 5, 6
• Unexplained ear pain 5
• Unexplained weight loss 5
• Voice changes or speech difficulty 1

Risk Factor Modification

Tobacco and alcohol cessation are mandatory, as these are the most important modifiable risk factors for recurrence and second primary cancers. 4, 5

Second primary cancers develop in 21% of tongue cancer survivors, with 54% of these patients dying from their second primary rather than the original cancer. 2 This underscores why lifelong surveillance and risk factor modification are essential.

Evaluation of Concerning Findings

Any persistent cervical lymphadenopathy for ≥2 weeks without fluctuation requires immediate referral back to the otolaryngologist, as this is concerning for recurrence. 7

Physical examination findings requiring urgent specialist evaluation include:

• Lymph nodes >1.5 cm, firm, or fixed to adjacent tissues 7
• Ulceration of overlying skin 7
• New oral cavity masses with infiltrative or ulcerative characteristics 3

If recurrence is suspected, obtain contrast-enhanced CT or MRI of the head and neck immediately to assess extent. 3

Speech and Swallowing Assessment

Screen for speech disturbance at each visit, and refer to an experienced speech-language pathologist if communication disorder exists. 1

Assess swallowing function, as severe dysphagia is a common late effect and may indicate recurrence. 8

Critical Pitfalls to Avoid

• Do not assume benign imaging findings rule out malignancy—continued evaluation is necessary until definitive diagnosis is obtained 7
• Do not prescribe antibiotics for persistent lymphadenopathy without clear bacterial infection, as this delays diagnosis of recurrence 7
• Do not rely solely on patient-reported symptoms—many recurrences are detected on routine specialist examination before symptoms develop 1
• Do not discontinue specialist follow-up after 5 years—annual otolaryngology examination should continue lifelong due to second primary cancer risk 1, 2

Prognosis Context

Clear surgical margins significantly improve survival, while recurrence significantly decreases survival. 2 The overall 5-year disease-specific survival for oral tongue cancer is approximately 57-73% depending on stage and treatment, but drops to 27% for base of tongue lesions. 5, 2, 6 Early detection of recurrence through structured surveillance offers the best chance for successful salvage therapy, particularly for local-only recurrence. 1