Cancer of the larynx

Overview

Laryngeal cancer is a type of cancer that affects the larynx (voice box).

The larynx is part of the throat found at the entrance of the windpipe (trachea). It plays an important role in helping you breathe and speak.

In the UK, there are about 2,000 new cases of laryngeal cancer each year.

The condition is more common in people over the age of 60. It's more common in men than women.

Symptoms of laryngeal cancer

The main symptoms of laryngeal cancer is having a hoarse voice for more than 3 weeks:

a change in your voice, such as sounding hoarse
pain when swallowing or difficulty swallowing
a lump or swelling in your neck
a long-lasting cough or breathlessness
a persistent sore throat or earache
in severe cases, difficulty breathing

Some people may also experience bad breath, unexplained weight loss, or fatigue (extreme tiredness).

When to see your GP

You should visit your GP if you have had a hoarse voice for more than three weeks.

These symptoms are often caused by less serious conditions, such as laryngitis, but it's a good idea to get them checked out.

If necessary, your GP can refer you to a hospital specialist for further tests to confirm or rule out cancer.

What causes laryngeal cancer?

It's not clear exactly what causes laryngeal cancer, but your risk of getting the condition is increased by:

smoking tobacco
regularly drinking large amounts of alcohol
having family members ( such as a parent, brother, sister or child ) who have had laryngeal cancer
having an unhealthy diet low in fruit and vegetables
exposure to certain chemicals and substances, such as asbestos and coal dust

By adopting a healthy lifestyle, including avoiding alcohol and tobacco, you can significantly reduce your chances of developing laryngeal cancer.

How laryngeal cancer is treated

The main treatments for laryngeal cancer are radiotherapy, surgery and chemotherapy and targeted cancer medicines.

Radiotherapy or surgery to remove the cancerous cells from the larynx can often cure laryngeal cancer if it's diagnosed early.

If the cancer is advanced, a combination of surgery to remove part or all of the larynx, radiotherapy and chemotherapy can be used.

If you have surgery to remove your larynx, you'll no longer be able to speak or breathe in the usual way. Instead, you will breathe through a permanent hole in your neck (stoma) and you will need additional treatment and speech and language therapy to help you communicate..

This may include a valve being placed in your throat, or an electrical device you hold against your throat to produce sound.

Outlook

The outlook for laryngeal cancer depends on the extent of the cancer when it's diagnosed and treated.

Fortunately, most laryngeal cancers are diagnosed at an early stage, which means the outlook is generally better than some other types of cancer.

Overall, about 65 out of every 100 people will live for at least 5 years or more after diagnosis and about 55 out of every 100 people will live for 10 years or more.

If you smoke, quitting smoking after being diagnosed with laryngeal cancer may improve your outlook.

Who can get it

Laryngeal cancer is caused by changes in the cells of the larynx, although it's not clear exactly why this happens.

All cancers begin with a change in a cell's DNA. DNA provides our cells with a basic set of instructions, such as when to grow and reproduce.

A change in DNA can alter the instructions that control cell growth, which means cells continue to grow instead of stopping when they should. This causes the cells to reproduce in an uncontrollable manner, producing a growth of tissue called a tumour.

It's not known why the DNA inside the cells of the larynx is affected in cases of laryngeal cancer. But it appears that exposure to things that can damage the cells and tissue of the larynx increases the risk of cancer developing.

What can increase your risk?

A number of things can increase your chances of developing laryngeal cancer.

Alcohol and tobacco

Alcohol and tobacco are the two main things that can increase your risk of developing laryngeal cancer. They're thought to contain chemicals that can damage the cells of the larynx.

The more you drink or smoke, the higher your risk of developing laryngeal cancer.

If you drink alcohol regularly and also smoke, your risk of laryngeal cancer increases even further.

By stopping both drinking and smoking , you can significantly reduce your risk of developing the condition.

Family history

People who have a parent, brother, sister or child who has been diagnosed with laryngeal cancer are more likely to develop laryngeal cancer than someone without a family history.

Diet

There's evidence to suggest that a diet high in red meat, processed food and fried food might increase your risk of developing laryngeal cancer.

Having a "Mediterranean diet" or a diet containing plenty of fruit and vegetables may reduce your risk.

Human papilloma virus (HPV)

Human papilloma virus (HPV) is the name given to a group of viruses that affect the skin and moist membranes that line the body, such as those in the cervix (neck of the womb), anus, mouth and throat. it's often spread during sex, including oral sex.

HPV is known to cause changes in the cells of the cervix, which can lead to cervical cancer. It's thought the virus may have a similar effect on the cells of the throat, but more research is needed.

Exposure to harmful substances

Having a job where you're exposed to high levels of certain substances may also increase your risk of developing laryngeal cancer. These include:

asbestos
coal or wood dust
paint or diesel fumes
nickel
sulphuric acid fumes
formaldehyde (a chemical used in a wide range of industrial processes, such as paint manufacturing and cosmetics)
isopropyl alcohol (often used as a cleaning solvent)

Diagnosis

If you have symptoms of laryngeal cancer, such as a hoarse voice and pain when swallowing, your GP will ask about your symptoms and recent medical history.

They may also examine the inside and outside of your throat for abnormalities, such as lumps and swellings.

If laryngeal cancer is suspected, you'll probably be referred to the ear, nose and throat (ENT) department of your local hospital for further testing.

The National Institute for Health and Care Excellence (NICE) recommends that anyone aged 45 or over with persistent unexplained hoarseness or an unexplained lump in their neck should have an appointment with a specialist within two weeks.

The main tests that may be carried out in hospital are described below.

Nasendoscope

A nasendoscopy is a procedure used to get a clear view of your larynx.

During the procedure, a small, flexible tube with a light and video camera at one end (endoscope) is inserted into one of your nostrils and passed down the back of your throat. The images from the endoscope are displayed on a monitor.

You'll usually be awake while this is carried out and it may feel uncomfortable. A local anaesthetic spray is sometimes used to numb your nose and throat beforehand, so you don't feel any pain.

Laryngoscopy

If it wasn't possible to get a good view of your larynx during a nasendoscopy, or a possible problem is spotted, you may have a further test called a laryngoscopy.

Like a nasendoscopy, this procedure involves using an endoscope to examine your larynx. However, the endoscope used during a laryngoscopy is longer and inserted through the mouth. This allows the larynx to be seen in greater detail.

A laryngoscopy can be very uncomfortable, so it's usually carried out under general anaesthetic (where you're asleep). You should be able to leave hospital as soon as you've recovered from the effects of anaesthetic, which is usually the same day or the day after.

Biopsy

During a nasendoscopy or laryngoscopy, your doctor may use small instruments to remove a sample of cells from your larynx so it can be examined for signs of cancer. This is known as a biopsy.

Alternatively, if you have a lump in your neck, a needle and syringe can be used to remove a tissue sample. This is known as fine needle aspiration.

Further testing

If the results of the biopsy show you have cancer and there's a risk it may have spread, you'll probably be referred for further testing to assess how widespread the cancer is. The tests may include:

a computerised tomography (CT) scan – a series of X-rays are taken to build up a more detailed three-dimensional picture of your larynx and the surrounding tissue
a magnetic resonance imaging (MRI) scan – a strong magnetic field and radio waves are used to produce a more detailed image of your larynx and the surrounding tissue
a PET-CT scan - a CT scan is used to take pictures of the inside of your body after you have been injected with a mildly radioactive substance that helps show cancerous areas more clearly
an ultrasound scan - high frequency sound waves are used to check for signs of cancer in the lymph nodes (glands found throughout the body) near the larynx

Staging and grading

After these tests have been completed, your doctor should be able to tell you the extent of the cancer. This is known as the stage and grade of the cancer.

Healthcare professionals use a system called the TNM system to stage laryngeal cancer. T describes the size of the tumour, N describes whether cancer has spread to the lymph nodes and M gives an indication of whether the cancer has spread to other parts of the body.

The T stage is given as a number from 1-4 –Small tumours confined to one part of the larynx are described as T1 tumours and large tumours that have grown into tissues outside the larynx are described as T4.
The N stage is given as a number from 0-3 –N0 means the lymph nodes are not affected, whereas stages N2 to N3 mean that one or more lymph nodes are affected.
The M stage is given as either M0 or M1 –M0 means the cancer has not spread to other parts of the body and M1 means that it has.

There are also three different grades (1-3) used to describe laryngeal cancer. Lower-grade cancers, such as grade 1, tend to grow more slowly and are less likely to spread. Higher-grade cancers, such as grade 3, grow quickly and are more likely to spread.

You can read more about the stages and grades of laryngeal cancer on the Cancer Research UK website.

Treatment

The treatment for laryngeal cancer largely depends on the size of the cancer. The main treatments are radiotherapy, surgery, chemotherapy and targeted cancer medicines.

Most hospitals use multidisciplinary teams (MDTs) of specialists that work together to decide the best way to proceed with your treatment.

Members of your MDT will probably include a surgeon, a clinical oncologist (a specialist in non-surgical treatment of cancer), and a specialist cancer nurse who will be responsible for co-ordinating your care.

Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions you'd like to ask your care team. For example, you may want to find out the advantages and disadvantages of particular treatments.

Your treatment plan

Your recommended treatment plan will depend on the stage of the cancer (see Laryngeal cancer - diagnosis for more information about staging).

If you have early-stage laryngeal cancer, it may be possible to remove the cancer using surgery (endoscopic resection) or radiotherapy alone. This may also be the case with slightly larger cancers, although a combination of surgery and radiotherapy is sometimes required.

In later-stage laryngeal cancer, more extensive surgery may be needed. Radiotherapy and chemotherapy will probably be used in combination. In some cases, the entire larynx may have to be removed.

A medication called cetuximab may be used in cases where chemotherapy is not suitable.

Radiotherapy

Radiotherapy uses controlled doses of high-energy radiation to destroy cancerous cells. It can be used as a treatment on its own for early-stage laryngeal cancer, or it can be used after surgery to stop cancerous cells returning. It's sometimes combined with chemotherapy.

The energy beams used during radiotherapy have to be precisely targeted to your larynx. To ensure the beams are directed at the exact area, a special plastic mask will be made to hold your head in the right position. A mould of your face will be taken, so that the mask can be made before treatment starts.

Radiotherapy is usually given in short daily sessions from Monday to Friday, with a break from treatment at the weekend. The course of treatment usually lasts for three to seven weeks.

As well as killing cancerous cells, radiotherapy can affect healthy tissue and has a number of side effects, including:

sore, red skin (similar to sunburn)
mouth ulcers
dry mouth
loss of taste
loss of appetite
tiredness
feeling sick

Your MDT will monitor any side effects and treat them when possible. For example, protective gels can be used to treat mouth ulcers, and medicines are available for a dry mouth.

Radiotherapy can sometimes cause your throat tissue to become inflamed. Severe inflammation can cause breathing difficulties. Call 111 or Contact your local accident and emergency (A&E) department as soon as possible if you have difficulty breathing.

Most side effects should pass within a few weeks of treatment finishing.

See the topic about Radiotherapy for more information.

Surgery

There are three types of surgery that can be used to treat laryngeal cancer. They are:

endoscopic resection
partial laryngectomy
total laryngectomy

These are described below.

Endoscopic resection

Endoscopic resection can be used in early-stage laryngeal cancer.

During the procedure, a surgeon uses a special microscope to get a magnified view of the larynx. This allows them to remove the cancer either with a laser or small surgical instruments.

An endoscopic resection is carried out under general anaesthetic, so you will be unconscious during the procedure and won't feel any pain.

Your mouth and throat may feel sore for a few weeks after the operation and there's a risk of your voice changing as a result of the procedure, which can be permanent.

Partial laryngectomy

A partial laryngectomy can be used to treat some laryngeal cancers. The operation involves surgically removing the affected part of your larynx. Some of your vocal cords will be left in place, so you will still be able to talk, but your voice may be quite hoarse or weak.

While your larynx is healing, you may find breathing difficult. Your surgeon may need to create a temporary hole in your neck, which will be attached to a tube you can breathe through. This is known as a temporary tracheostomy.

Once your larynx has healed, the tube can be removed and the hole will heal, leaving a small scar.

This operation is uncommon nowadays, as endoscopic resection is preferred whenever possible.

Total laryngectomy

A total laryngectomy is usually used to treat advanced laryngeal cancer. The operation involves removing your entire larynx. Nearby lymph nodes (small glands that form part of the immune system) may also need to be removed if the cancer has spread to them.

As your vocal cords will be removed, you won't be able to speak in the usual way after the operation. However, there are several ways to help to learn you to talk again.

If you have a total laryngectomy, your surgeon will also need to create a permanent hole in your neck (called a stoma) to help you breath after the operation.

You will be given training on how to keep your stoma clean. Having a stoma can seem daunting and frightening at first, but most people get used to it after a few months.

See Laryngeal cancer - recovery for more information about adjusting to life after a laryngectomy.

Chemotherapy

Chemotherapy uses powerful cancer-killing medicines to damage the DNA of the cancerous cells and stop them reproducing. It may be used to shrink a tumour before surgery or radiotherapy, or in combination with radiotherapy to make the radiotherapy more effective.

It can also be used to treat laryngeal cancer that's advanced or has come back after treatment. In this situation, it can relieve symptoms and may slow the cancer's growth.

Chemotherapy medication is usually given as an injection into a vein (intravenously) You may need to stay in hospital for a few days during each treatment or you may just come in for a short visit each time.

Chemotherapy can sometimes damage healthy tissue as well as the cancerous tissue. This, unfortunately, means side effects are common, such as:

feeling and being sick
hair loss
loss of appetite
diarrhoea
sore mouth and mouth ulcers
tiredness

Chemotherapy can also weaken your immune system, making you more vulnerable to infection and illness.

It's therefore important to report any symptoms of a potential infection to your MDT, such as a high temperature, chills or a persistent cough. You should also avoid close contact with people known to have an infection.

The side effects of chemotherapy should improve after your treatment has finished.

Cetuximab

Cetuximab is a targeted cancer medicine. These medications target and disrupt the processes that cancerous cells use to grow and reproduce.

Cetuximab can be used in combination with radiotherapy to treat more advanced laryngeal cancer, when it's not possible to use chemotherapy. For example, people with kidney or heart disease, or people with an ongoing infection, may not be able to have chemotherapy, because it could make them very ill.

Cetuximab is given slowly through a drip into your vein (intravenously)

Side effects of cetuximab include:

rashes
feeling sick
diarrhoea
shortness of breath

Cetuximab can also trigger allergic reactions in some people, which can cause problems such as a swollen tongue or throat. In a few cases, the reaction can be severe and potentially life-threatening.

Most serious reactions occur within a day of treatment starting, so you'll be closely monitored once your treatment begins. If you have symptoms of a severe reaction, such as a rapid heartbeat or breathing problems, medication can be used to relieve them such as steroids.

Immunotherapy

A type of immunotherapy medicine called a checkpoint inhibitor is used to treat laryngeal cancer that has spread or cannot be removed through surgery.

Immunotherapy stimulates your immune system to target and kill cancer cells. Checkpoint inhibitors help the immune system to do this by blocking the signals that stop white blood cells attacking cancer cells.

It's possible to have a skin reaction when taking immunotherapy. The most common reaction is a rash, while some people get itchy skin, or patches of white or paler skin.

Speak to your care team about other side effects of immunotherapy.

Recovery

If you've had some or all of your larynx removed (laryngectomy), it's likely that you'll need to spend one or two days in an intensive care unit until you've recovered.

You won't be able to eat until your throat has healed, which for most people takes at least a week or two. While your throat heals, you'll need to be fed through a tube that's passed through your nose and into your stomach.

If you've had all of your larynx removed (total laryngectomy), you won't be able to speak normally, because you will no longer have vocal cords. There are a number of different ways you can learn to communicate again, although they can take weeks or months to learn.

This means it's likely that you will need.to use different ways to communicate, such as using pen and paper, during the first few weeks or months after surgery.

This can be a very frustrating experience. The loss of something you have previously taken for granted can be difficult to cope with.

Your emotions

The emotional impact of living with a laryngectomy can be significant. Many people report experiencing a rollercoaster effect.

For example, you may feel down when laryngeal cancer is diagnosed, then feel up after the cancer has been removed, then feel down again as you try to come to terms with the practicalities of living with a laryngectomy.

These emotional changes can sometimes trigger feelings of depression.You may be depressed if you have felt very down during the past month and you no longer take pleasure in doing things you usually enjoy.

Contact your GP or care team for advice if you think you may be depressed. There are a range of effective treatments available.

The National Association of Laryngectomee Clubs (NALC) is also a useful resource for people trying to come to terms with living with a laryngectomy. NALC is a patient support group that provides advice on all aspects of living with a laryngectomy.

Looking after your stoma

If you've had all of your larynx removed, the surgeon will need to create a permanent hole in your throat through which you will breathe (a stoma). During the first few months after surgery, it's likely that your stoma will produce a lot of mucus, particularly if you've had radiotherapy.

Excessive mucus can cause breathing difficulties, so a tube may be attached to your stoma to help you breathe more easily. Once the production of mucus has settled down, the tube can be removed.

It's important to clean your stoma at least once a day, otherwise it can become crusty and may become vulnerable to infection. A specialist nurse can teach you how to keep your stoma clean.

You'll be given special filters to place over your stoma that can help keep your stoma moist and free of germs.

It's important to remember that you'll need to cover your stoma with a tissue when you cough or sneeze, rather than covering your mouth or nose. This is because mucus or saliva will come out of your stoma.

You can read more about adjusting to a stoma in the Handbook for laryngectomy patients (PDF, 508kb) produced by NALC.

Speaking after surgery

If your larynx has been completely removed as part of your treatment for laryngeal cancer, you'll need additional treatment to help restore your voice. or learn new ways of speaking.

Before your laryngectomy, you may meet a speech and language therapist (SLT) to discuss possible treatment options for restoring your voice. An SLT is a healthcare professional who specialises in helping people who have difficulties speaking and using language.

There are several different treatment options, which are briefly outlined below.

Voice prosthesis

A voice prosthesis is an artificial valve implanted into your neck. When you want to speak, you cover the stoma and breathe out through the valve.

The valve produces a noise, which you can use to make words by moving your lips and mouth in the usual way. The voice that's produced by the valve sounds natural, although it may be lower-pitched than your previous voice.

If you choose to have a voice prosthesis, it can be fitted during the surgery to remove your larynx.

Oesophageal speech

Oesophageal speech is a technique for speaking that your SLT can teach you. It involves learning to push air through your oesophagus (gullet). As the air moves through your oesophagus, it vibrates and makes a noise. You can produce words by moving your lips and mouth.

Some people find it quite easy to learn oesophageal speech, whereas others find it difficult. Regular practice by yourself and with your SLT can help you improve.

Electrolarynx

An electrolarynx is a small, battery-operated electrical device that vibrates and produces sound. You hold the device under your chin, and as you move your mouth and lips the vibrations translate into spoken words. Your SLT can train you to use it correctly.

Swallowing after treatment

Treatment for laryngeal cancer can make your throat very sore and will cause difficulty swallowing.

You may have to have food given through a tube in your nose or stomach after radiotherapy or surgery.

You may also have to avoid certain foods and make changes to your diet when you're able to eat normally again.

Prevention

It's thought that most laryngeal cancers can be prevented by adopting a healthy lifestyle.

Avoiding tobacco products, cutting down on how much alcohol you drink and having a healthy diet are particularly important in reducing your chances of developing the condition.

Avoiding tobacco products

Using tobacco products increases your chances of developing several different types of cancer, including laryngeal cancer.

Tobacco comes in many forms, including:

cigarettes
pipe tobacco
cigars
cigarillos
snuff (powdered tobacco snorted through the nose)
chewing tobacco

If you smoke or use other tobacco products, stopping will have both short- and long-term health benefits, including significantly reducing your risk of developing laryngeal cancer.

If you decide to stop smoking you can contact Help Me Quit on 0808 250 116.

If you want to stop smoking, but don't want to be referred to a stop smoking service, your GP should be able to prescribe medical treatment to help with any withdrawal symptoms you may have.

Cutting down on alcohol

Staying within the recommended guidelines for alcohol consumption will also reduce your risk of developing laryngeal and liver cancers.

men and women are advised not to regularly drink more than 14 units a week
spread your drinking over 3 days or more if you drink as much as 14 units a week

A unit of alcohol is equal to about half a pint of normal-strength lager or a pub measure (25ml) or spirits. Read more about alcohol units.

Contact your GP if you're finding it difficult to reduce the amount of alcohol you drink. You may need additional treatment, which could include counselling, group work or medication.

Healthy diet

Research shows a diet that contains plenty of fresh fruits and vegetables, particularly tomatoes, citrus fruit (such as oranges, grapefruits and lemons), olive oil and fish oil, may reduce your risk of getting laryngeal cancer. This type of diet is sometimes known as a "Mediterranean diet".

Eating plenty of fruit and vegetables each day may help to reduce your chances of developing many types of cancer, including laryngeal cancer.

Read about food and diet and healthy eating for more information and advice.

The information on this page has been adapted by NHS Wales from original content supplied by

NHS website nhs.uk