Laryngeal cancer is cancer of the larynx or voice box.
The larynx is located where the throat divides into the esophagus and the trachea. The esophagus is the tube that takes food to the stomach. The trachea, or windpipe, takes air to the lungs. The area where the larynx is located is sometimes called the Adam's apple.
The larynx has two main functions. It contains the vocal cords, cartilage, and small muscles that make up the voice box. When a person speaks, small muscles tighten the vocal cords, narrowing the distance between them. As air is exhaled past the tightened vocal cords, it creates sounds that are formed into speech by the mouth, lips, and tongue.
The second function of the larynx is to allow air to enter the trachea and to keep food, saliva, and foreign material from entering the lungs. A flap of tissue called the epiglottis covers the trachea each time a person swallows. This blocks foreign material from entering the lungs. When not swallowing, the epiglottis retracts, and air flows into the trachea. During treatment for cancer of the larynx, both of these functions may be lost.
Cancers of the larynx develop slowly. About 95% of these cancers develop from thin, flat cells similar to skin cells called squamous epithelial cells. These cells line the larynx. Gradually, the squamous epithelial cells begin to change and are replaced with abnormal cells. These abnormal cells are not cancerous but are pre-malignant cells that have the potential to develop into cancer. This condition is called dysplasia. Most people with dysplasia never develop cancer. The condition simply goes away without any treatment, especially if the person with dysplasia stops smoking or drinking alcohol.
The larynx is made up of three parts, the glottis, the supraglottis, and the subglottis. Cancer can start in any of these regions. Treatment and survival rates depend on which parts of the larynx are affected and whether the cancer has spread to neighboring areas of the neck or distant parts of the body.
The glottis is the middle part of the larynx. It contains the vocal cords. Cancers that develop on the vocal cords are often diagnosed very early because even small vocal cord tumors cause hoarseness. In addition, the vocal cords have no connection to the lymphatic system. This means that cancers on the vocal cord do not spread easily. When confined to the vocal cords without any involvement of other parts of the larynx, the cure rate for this cancer is 75% to 95%.
The supraglottis is the area above the vocal cords. It contains the epiglottis, which protects the trachea from foreign materials. Cancers that develop in this region are usually not found as early as cancers of the glottis
The subglottis is the region below the vocal cords. Cancer starting in the subglottis region is rare. When it does, it is usually detected only after it has spread to the vocal cords, where it causes obvious symptoms such as hoarseness. Because the cancer has already begun to spread by the time it is detected, survival rates are generally lower than for cancers in other parts of the larynx.
About 12, 000 new cases of cancer of the larynx develop in the United States each year. Each year, about 3, 900 die of the disease. Laryngeal cancer is between four and five times more common in men than in women. Almost all men who develop laryngeal cancer are over age 55. Laryngeal cancer is about 50% more common among African-American men than among other Americans.
It is thought that older men are more likely to develop laryngeal cancer than women because the two main risk factors for acquiring the disease are lifetime habits of smoking and alcohol abuse. More men smoke and drink more than women, and more African-American men are heavy smokers than other men in the United States. However, as smoking becomes more prevalent among women, it seems likely that more cases of laryngeal cancer in females will be seen.
Causes and symptoms
Laryngeal cancer develops when the normal cells lining the larynx are replaced with abnormal cells (dysplasia) that become malignant and reproduce to form tumors. The development of dysplasia is strongly linked to life-long habits of smoking and heavy use of alcohol. The more a person smokes, the greater the risk of developing laryngeal cancer. It is unusual for someone who does not smoke or drink to develop cancer of the larynx. Occasionally, however, people who inhale asbestos particles, wood dust, paint or industrial chemical fumes over a long period of time develop the disease.
The symptoms of laryngeal cancer depend on the location of the tumor. Tumors on the vocal cords are rarely painful, but cause hoarseness. Anyone who is continually hoarse for more than two weeks or who has a cough that does not go away should be checked by a doctor.
Tumors in the supraglottal region above the vocal cords often cause more, but less distinct symptoms. These include:
- persistent sore throat
- pain when swallowing
- difficulty swallowing or frequent choking on food
- bad breath
- lumps in the neck
- persistent ear pain (called referred pain; the source of the pain is not the ear)
- change in voice quality
Tumors that begin below the vocal cords are rare, but may cause noisy or difficult breathing. All the symptoms above can also be caused other cancers as well as by less serious illnesses. However, if these symptoms persist, it is important to see a doctor and find their cause, because the earlier cancer treatment begins, the more successful it is.
On the first visit to a doctor for symptoms that suggest laryngeal cancer, the doctor first takes a complete medical history, including family history of cancer and lifestyle information about smoking and alcohol use. The doctor also does a physical examination, paying special attention to the neck region for lumps, tenderness, or swelling.
The next step is examination by an otolaryngologist, or ear, nose, and throat (ENT) specialist. This doctor also performs a physical examination, but in addition will
A more extensive examination involves a laryngoscopy. In a laryngoscopy, a lighted fiberoptic tube called a laryngoscope that contains a tiny camera is inserted through the patient's nose and mouth and snaked down the throat so that the doctor can see the larynx and surrounding area. This procedure can be done with a sedative and local anesthetic in a doctor's office. More often, the procedure is done in an outpatient surgery clinic or hospital under general anesthesia. This allows the doctor to use tiny clips on the end of the laryngoscope to take biopsies (tissue samples) of any abnormal-looking areas.
Laryngoscopies are normally painless and take about one hour. Some people find their throat feels scratchy after the procedure. Since laryngoscopies are done under sedation, patients should not drive immediately after the procedure, and should have someone available to take them home. Laryngoscopy is a standard procedure that is covered by insurance.
The locations of the samples taken during the laryngoscopy are recorded, and the samples are then sent to the laboratory where they are examined under the microscope by a pathologist who specializes in diagnosing diseases through cell samples and laboratory tests. It may take several days to get the results. Based on the findings of the pathologist, cancer can be diagnosed and staged.
Once cancer is diagnosed, other tests will probably be done to help determine the exact size and location of the tumors. This information is helpful in determining which treatments are most appropriate. These tests may include:
- Endoscopy. Similar to a laryngoscopy, this test is done when it appears that cancer may have spread to other areas, such as the esophagus or trachea.
- Computed tomography (CT or CAT) scan. Using xray images taken from several angles and computer modeling, CT scans allow parts of the body to be seen as a cross section. This helps locate and size the tumors, and provides information on whether they can be surgically removed.
- Magnetic resonance imaging (MRI). MRI uses magnets and radio waves to create more detailed cross-sectional scans than computed tomography. This detailed information is needed if surgery on the larynx area is planned.
- Barium swallow. Barium is a substance that, unlike soft tissue, shows up on x rays. Swallowed barium coats the throat and allows x-ray pictures to be made of the tissues lining the throat.
- Chest x ray. Done to determine if cancer has spread to the lungs. Since most people with laryngeal cancer are smokers, the risk of also having lung cancer or emphysema is high.
- Fine needle aspiration (FNA) biopsy. If any lumps on the neck are found, a thin needle is inserted into the lump, and some cells are removed for analysis by the pathologist.
- Additional blood and urine tests. These tests do not diagnose cancer, but help to determine the patient's general health and provide information to determine which cancer treatments are most appropriate.
An otolaryngologist and an oncologist (cancer specialist) generally lead the treatment team. They are supported by radiologists to interpret CT and MRI scans, a head and neck surgeon, and nurses with special training in assisting cancer patients.
A speech pathologist is often involved in treatment, both before surgery to discuss various options for communication if the larynx is removed, and after surgery to teach alternate forms of voice communication. A social worker, psychologist, or family counselor may help both the patient and the family meet the changes and challenges that living with laryngeal cancer brings.
At any point in the process, the patient may want to get a second opinion from another doctor in the same specialty. This is a common practice and does not indicate a lack of faith in the original doctor, but simply a desire for more information. Some insurance companies require a second opinion before surgery is done.
Clinical staging, treatments, and prognosis
Once cancer of the larynx is found, more tests will be done to find out if cancer cells have spread to other parts of the body. This is called staging. A doctor needs to know the stage of the disease to plan treatment. In cancer of the larynx, the definitions of the early stages depend on where the cancer started.
The cancer is only in the area where it started and has not spread to lymph nodes in the area or to other parts of the body. The exact definition of stage I depends on where the cancer started, as follows:
- Supraglottis: The cancer is only in one area of the supraglottis and the vocal cords can move normally.
- Glottis: The cancer is only in the vocal cords and the vocal cords can move normally.
- Subglottis: The cancer has not spread outside of the subglottis.
The cancer is only in the larynx and has not spread to lymph nodes in the area or to other parts of the body. The exact definition of stage II depends on where the cancer started, as follows:
- Supraglottis: The cancer is in more than one area of the supraglottis, but the vocal cords can move normally.
- Glottis: The cancer has spread to the supraglottis or the subglottis or both. The vocal cords may or may not be able to move normally.
- Subglottis: The cancer has spread to the vocal cords, which may or may not be able to move normally.
Either of the following may be true:
- The cancer has not spread outside of the larynx, but the vocal cords cannot move normally, or the cancer has spread to tissues next to the larynx.
- The cancer has spread to one lymph node on the same side of the neck as the cancer, and the lymph node measures no more than 3 centimeters (just over 1 inch).
Any of the following may be true:
- The cancer has spread to tissues around the larynx, such as the pharynx or the tissues in the neck. The lymph nodes in the area may or may not contain cancer.
- The cancer has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node that measures more than 6 centimeters (over 2 inches).
- The cancer has spread to other parts of the body.
Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the larynx or in another part of the body.
Treatment is based on the stage of the cancer as well as its location and the health of the individual. Generally, there are three types of treatments for cancer of the larynx. These are surgery, radiation, and chemotherapy. They can be used alone or in combination based in the stage of the caner. Getting a second opinion after the cancer has been staged can be very helpful in sorting out treatment options and should always be considered.
The goal of surgery is to cut out the tissue that contains malignant cells. There are several common surgeries to treat laryngeal cancer.
Stage III and stage IV cancers are usually treated with total laryngectomy. This is an operation to remove the entire larynx. Sometimes other tissues around the larynx are also removed. Total laryngectomy removes the vocal cords. Alternate methods of voice communication must be learned with the help of a speech pathologist.
Smaller tumors are sometimes treated by partial laryngectomy. The goal is to remove the cancer but save as much of the larynx (and corresponding speech capability) as possible. Very small tumors or cancer in situ are sometimes successfully treated with laser excision surgery. In this type of surgery, a narrowly targeted beam of light from a laser is used to remove the cancer.
Advanced cancer (Stages III and IV) that has spread to the lymph nodes often requires an operation called a neck dissection. The goal of a neck dissection is to remove the lymph nodes and prevent the cancer from spreading. There are several forms of neck dissection. A radical neck dissection is the operation that removes the most tissue.
Several other operations are sometimes performed because of laryngeal cancer. A tracheotomy is a surgical procedure in which an artificial opening is made in the trachea (windpipe) to allow air into the lungs. This operation
Radiation therapy uses high-energy rays, such as x rays or gamma rays, to kill cancer cells. The advantage of radiation therapy is that it preserves the larynx and the ability to speak. The disadvantage is that it may not kill all the cancer cells. Radiation therapy can be used alone in early stage cancers or in combination with surgery. Sometimes it is tried first with the plan that if it fails to cure the cancer, surgery still remains an option. Often, radiation therapy is used after surgery for advanced cancers to kill any cells the surgeon might not have removed.
There are two types of radiation therapy. External beam radiation therapy focuses rays from outside the body on the cancerous tissue. This is the most common type of radiation therapy used to treat laryngeal cancer. With internal radiation therapy, also called brachytherapy, radioactive materials are placed directly on the cancerous tissue. This type of radiation therapy is a much less common treatment for laryngeal cancer.
External radiation therapy is given in doses called fractions. A common treatment involves giving fractions five days a week for seven weeks. Clinical trials are underway to determine the benefits of accelerating the delivery of fractions (accelerated fractionation) or dividing fractions into smaller doses given more than once a day (hyperfractionation). Side effects of radiation therapy include dry mouth, sore throat, hoarseness, skin problems, trouble swallowing, and diminished ability to taste.
Chemotherapy is the use of drugs to kill cancer cells. Unlike radiation therapy, which is targeted to a specific tissue, chemotherapy drugs are either taken by mouth or intravenously (through a vein) and circulate throughout the whole body. They are used mainly to treat advanced laryngeal cancer that is inoperable or that has metastasized to a distant site. Chemotherapy is often used after surgery or in combination with radiation therapy. Clinical trials are underway to determine the best combination of treatments for advanced cancer.
The two most common chemotherapy drugs used to treat laryngeal cancer are cisplatin and fluorouracil (5-FU). There are many side effects associated with chemotherapy drugs, including nausea and vomiting, loss of appetite (anorexia), hair loss (alopecia), diarrhea, and mouth sores. Chemotherapy can also damage the blood-producing cells of the bone marrow, which can result in low blood cell counts, increased chance of infection, and abnormal bleeding or bruising.
Cure rates and survival rates can predict group outcomes, but can never precisely predict the outcome for a single individual. However, the earlier laryngeal cancer is discovered and treated, the more likely it will be cured.
Cancers found in stage 0 and stage 1 have a 75% to 95% cure rate depending on the site. Late stage cancers that have metastasized have a very poor survival rate, with intermediate stages falling somewhere in between. People who have had laryngeal cancer are at greatest risk for recurrence (having cancer come back), especially in the head and neck, during the first two to three years after treatment. Check-ups during the first year are needed every other month, and four times a year during the second year. It is rare for laryngeal cancer to recur after five years of being cancer-free.
Alternative and complementary therapies
Alternative and complementary therapies range from herbal remedies, vitamin supplements, and special diets to spiritual practices, acupuncture, massage, and similar treatments. When these therapies are used in
Complementary or alternative therapies are widely used by people with cancer. One large study published in the Journal of Clinical Oncology in July, 2000 found that 83% of all cancer patients studied used some form of complementary or alternative medicine as part of their cancer treatment. No specific alternative therapies have been directed toward laryngeal cancer. However, good nutrition and activities that reduce stress and promote a positive view of life have no unwanted side effects and appear to be beneficial in boosting the immune system in fighting cancer.
Unlike traditional pharmaceuticals, complementary and alternative therapies are not evaluated by the United States Food and Drug Administration (FDA) for either safety or effectiveness. These therapies may have interactions with traditional pharmaceuticals. Patients should be wary of "miracle cures" and notify their doctors if they are using herbal remedies, vitamin supplements or other unprescribed treatments. Alternative and experimental treatments normally are not covered by insurance.
Coping with cancer treatment
Cancer treatment, even when successful, has many unwanted side effects. In laryngeal cancer, the biggest side effects are the loss of speech due to total laryngectomy and the need to breathe through a hole in the neck called a stoma. Several alternative methods of sound production, both mechanical and learned, are available, and should be discussed with a speech pathologist. Support groups also exist for people who have had their larynx removed. Coping with speech loss and care of the stoma is discussed more extensively in the laryngectomy entry.
Chemotherapy brings with it a host of unwanted side effects, many of which disappear after the chemotherapy stops. For example, hair will re-grow, and until it does, a wig can be used. Medications are available to treat nausea and vomiting. Side effects such as dry skin are treated symptomatically.
Clinical trials are government-regulated studies of new treatments and techniques that may prove beneficial in diagnosing or treating a disease. Participation is always voluntary and at no cost to the participant. Clinical trials are conducted in three phases. Phase 1 tests the safety of the treatment and looks for harmful side effects. Phase 2 tests the effectiveness of the treatment. Phase 3 compares the treatment to other treatments available for the same condition.
The selection of clinical trials underway changes frequently. Clinical trials for laryngeal cancer currently focus treating advanced cancers by combining radiation and surgical therapy, radiation and chemotherapy, and different combinations of chemotherapy drugs. Other studies are examining the most effective timing and duration of radiation therapy.
Current information on what clinical trials are available and where they are being held is available by entering the search term "laryngeal cancer" at the following web sites:
- National Cancer Institute. <http://cancertrials.nci.nih.gov> or (800) 4-CANCER.
- National Institutes of Health Clinical Trials. <http://clinicaltrials.gov>
- Center Watch: A Clinical Trials Listing. <http://www.centerwatch.com>
By far, the most effective way to prevent laryngeal cancer is not to smoke. Smokers who quit smoking also significantly decrease their risk of developing the disease. Other ways to prevent laryngeal cancer include limiting the use of alcohol, eating a well-balanced diet, seeking treatment for prolonged heartburn, and avoiding inhaling asbestos and chemical fumes.
Being diagnosed with cancer is a traumatic event. Not only is one's health affected, one's whole life suddenly revolves around trips to the doctor for cancer treatment and adjusting to the side effects of these treatments. This is stressful for both the cancer patient and his or her family members. It is not unusual for family members to feel resentful of the changes that occur in the family, and then feel guilty about feeling resentful.
The loss of voice because of laryngeal surgery may be the most traumatic effect of laryngeal cancer. Losing the ability to communicate easily with others can be isolating. Support groups and psychological counseling is helpful for both the cancer patient and family members. Many national organizations that support cancer education can provide information on in-person or on-line support and education groups.
Ahmad, I., B.N. Kumar, K. Radford, J. O'Connell, and A.J.Batch. "Surgical Voice Restoration Following Ablative
American Cancer Society. National Headquarters, 1599 Clifton Rd. NE, Atlanta, GA 30329. 800 (ACS)-2345. <http://www.cancer.org>
National Cancer Institute. Cancer Information Service. Bldg.31, Room 10A19, 9000 Rockville Pike, Bethesda, MD20892. (800) 4-CANCER. <http://www.nci.nih.gov/cancerinfo/index.html>
National Cancer Institute Office of Cancer Complementary and Alternative Medicine. <http://occam.nci.nih.gov>
National Center for Complementary and Alternative Medicine. P. O. Box 8218, Silver Spring, MD 20907-8281. (888)644-6226. <http://nccam.nih.gov>
"What you Need to Know About Cancer of the Larynx." Can cerNet November 2000. 19 July 2001 <http://www.cancernet.nci.nih.gov>
"Laryngeal Cancer." CancerNet 19 July 2001 <http://www.graylab.ac.uk/cancernet/201519.html#3_STAGEEXPLANATION>
Tish Davidson, A.M.
QUESTIONS TO ASK THE DOCTOR
- What stage is my cancer, and what exactly does that mean?
- What are possible treatments for my cancer?
- How long will my treatment last?
- What are some of the changes in my activities that will occur because of my treatment?
- What is daily life like after a laryngectomy?
- How will I speak?
- I've heard about clinical trials using radiation and drugs to treat cancer of the larynx. Where can I find out more about these trials?
- What changes in my lifestyle can I make to help improve my chances of beating this cancer?
- How often will I have to have check-ups?
- What is the likelihood that I will survive this cancer?
- Can you suggest any support groups that would be helpful to me or my family?
—The abnormal change in size, shape or organization of adult cells.
—Clear, slightly yellow fluid carried by a network of thin tubes to every part of the body. Cells that fight infection are carried in the lymph.
—Primary defense against infection in the body. The lymphatic system consists of tissues, organs, and channels (similar to veins) that produce, store, and transport lymph and white blood cells to fight infection.
—Small, bean-shaped collections of tissue found in a lymph vessel. They produce cells and proteins that fight infection, and also filter lymph. Nodes are sometimes called lymph glands.
—Spread of cells from the original site of the cancer to other parts of the body where secondary tumors are formed.
—Cancerous. Cells tend to reproduce without normal controls on growth and form tumors or invade other tissues.