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Cancer Medicine :: Laryngeal and Hypopharyngeal Cancer

Laryngeal and Hypopharyngeal Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for these specific types of cancers. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

Laryngeal and hypopharyngeal cancer can often be successfully eliminated, especially if they are found early. Although eliminating the cancer is the primary goal of treatment, preserving the function of the affected organs is also very important. When doctors plan treatment, they consider how treatment might affect a person’s quality of life, including how a person feels, looks, talks, eats, and breathes. Cancers of the larynx and hypopharynx and their treatments can have a significant impact on these functions, so decisions should be made carefully.

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. An evaluation should be done by each specialist before any treatment begins. The team may include medical and radiation oncologists, surgeons, otolaryngologists (ear, nose, and throat doctors), maxillofacial prosthodontists (specialists who perform restorative surgery to the head and neck areas), dentists, physical therapists, speech pathologists, audiologists, psychiatrists, dietitians, nurses, physician assistants, and social workers. Diagnostic radiologists and pathologists also are an integral part of the treatment team because they assist with diagnosis and staging.

There are three main treatment options for laryngeal and hypopharyngeal cancer: surgery, radiation therapy, and chemotherapy. One or a combination of these therapies may be used to treat the cancer. Surgery and radiation therapy are the most common forms of treatment for laryngeal and hypopharyngeal cancer. Chemotherapy may be used in combination with radiation therapy to increase the chance of destroying cancer cells.

Descriptions of these common treatment options are listed below. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. 

Surgery

During surgery, a surgical oncologist (a doctor who specializes in treating cancer using surgery) performs an operation to remove the cancerous tumor and some of the healthy tissue around it (called a margin). The goal of surgery is to remove the entire tumor and leave negative margins (no trace of cancer in the healthy tissue). Sometimes it is not possible to completely remove the cancer. In these cases, other treatments will be recommended.

The most common surgical procedures used to treat laryngeal or hypopharyngeal cancer include:

Partial laryngectomy. This is the removal of part of the larynx, preserving the voice. The following are some of the different types of partial laryngectomies:

Supraglottic laryngectomy: The removal of the area above the vocal folds. If part of the hypopharynx is to be removed with the cancer, this is called a partial pharyngectomy.

Cordectomy: The removal of a vocal fold

Vertical hemilaryngectomy: The removal of one side of the larynx

Supracricoid partial laryngectomy: The removal of the vocal folds and the area surrounding them

Total laryngectomy. This is the removal of the entire larynx. During this operation, a hole called a stoma is made in the front of the neck through the windpipe to allow the person to breathe. This is called a tracheostomy (see below). Because the vocal folds have been removed, people can no longer speak using their vocal folds after a total laryngectomy. However, a speech pathologist can teach people to speak in a different way after the surgery.

Laryngopharyngectomy. A laryngopharyngectomy is the removal of the entire larynx, including the vocal folds, and part or all of the pharynx. After this surgery, doctors must reconstruct the pharynx using flaps of skin from the forearm, other parts of the body, or a segment of the intestine. Like a total laryngectomy, people can no longer speak using the vocal folds after laryngopharyngectomy, and they may also have difficulty swallowing. However, speech pathologists can help people learn to speak and swallow afterwards.

Tracheostomy. In both partial and total laryngectomies, the surgeon makes a hole called a stoma in the front of the neck into the windpipe or trachea. A tube is often inserted to keep the hole open. Air enters and leaves the windpipe (trachea) and lungs through the stoma, allowing the person to breathe.

In a partial laryngectomy, the stoma is usually temporary. After recovery from the partial laryngectomy, the tube is removed, the hole heals shut, and the person can then breathe and talk in the same way as before the surgery. In some cases, the voice may be hoarse or weak.

In a total laryngectomy, the stoma is permanent, and the person breathes through the stoma and must learn to speak in a new way.

Neck dissection. If the cancer has spread to the lymph nodes in the neck some of these lymph nodes may need to be surgically removed. This is called a neck dissection. There are several types of neck dissections, depending on the stage and location of the cancer. Some or all the lymph nodes in the neck may have to be removed (partial neck dissection, modified neck dissection, selective neck dissection). A patient may have varying degrees of stiffness in the shoulder and the neck and loss of sensation in the neck after this surgery.

Laser surgery. Laser surgery uses a beam of light to remove the tumor. Such a tool can remove a small tumor of the larynx and perform a partial laryngectomy. This tool is a relatively new treatment approach not yet widely used, and it should be performed by an experienced doctor.

Reconstruction (plastic surgery). This type of operation is aimed at restoring a person’s appearance and function of the affected area. For example, if the surgery requires major tissue removal, reconstructive or plastic surgery may be done to replace the missing tissue.

In general, surgery often causes swelling of the mouth and throat, making it difficult to breathe. After the operation, the lungs and windpipe produce a great deal of mucus. The mucus is removed with a small suction tube until the person learns to cough through the stoma. Similarly, saliva may need to be suctioned from the mouth because swelling in the throat can prevent swallowing. Talk with your doctor about what you can expect after surgery is over.

Surgery may cause permanent loss of voice or impaired speech, difficulty swallowing or talking, facial disfigurement, numbness in parts of the neck and throat, and less mobility in the shoulder and neck area. Surgery can also decrease thyroid gland function, especially after a total laryngectomy. Rehabilitation of lost or altered physical functions and emotional support services are important parts of care following surgery. This may take time and require the expertise of different members of the treatment team. Patients are encouraged to talk with their health care team about what to expect before any surgery.

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A newer method of external radiation therapy, known as intensity modulated radiation therapy (IMRT), allows for more effective doses of radiation therapy to be delivered while reducing the damage to healthy cells, thus causing fewer side effects. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

Radiation therapy can be the main treatment for head and neck cancer or used postoperatively (after surgery) to destroy small pockets of cancer that cannot be removed surgically.

Before beginning radiation therapy for any head and neck cancer, people should receive a thorough examination from an oncologic dentist (a dentist with experience in treating people with head and neck cancer). Since radiation therapy can cause tooth decay, damaged teeth may need to be removed. Often, tooth decay can be prevented with proper treatment from a dentist before beginning radiation therapy. 

It is also important that people receive counseling and evaluation from a speech pathologist who has experience treating people with head and neck cancer. Since radiation therapy can cause swelling and scarring, the voice and swallowing are often affected. Speech pathologists can provide people with exercises and techniques to prevent long-term speech and swallowing problems.

In addition, radiation therapy to the head and neck may cause redness or skin irritation to the treated area, swelling, dry mouth or thickened saliva from damage to salivary glands (which can be temporary or permanent), bone pain, nausea, fatigue, mouth sores and/or sore throat, and dental problems (usually preventable, see above). Other side effects may include pain or difficulty swallowing; hoarseness or changes in the voice; loss of appetite, due to a change in sense of taste; hearing loss due to a buildup of fluid in the middle ear or nerve damage; buildup of earwax, which dries out because of the radiation therapy’s effect on the ear canal; and scarring (fibrosis). Talk with your doctor or nurse about how side effects will be managed.

Radiation therapy may also cause a condition called hypothyroidism, in which the thyroid gland (located in the neck) slows down and causes the person to feel tired and sluggish. Every person who receives radiation therapy to the neck area should have his or her thyroid checked regularly.

Most long-term side effects of radiation therapy can be prevented or reduced. It is important that all members of the multidisciplinary treatment team see the patient before radiation therapy begins in order to prevent or reduce long-term problems. 

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

For laryngeal and hypopharyngeal cancer, chemotherapy may be used as a neoadjuvant therapy (treatment before surgery, radiation therapy, or both) or an adjuvant therapy (treatment after surgery, radiation therapy, or both).

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, nausea and vomiting, hair loss, loss of appetite, diarrhea, dry mouth, hearing loss, and open sores in the mouth that can lead to infections.

 The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Concomitant chemoradiotherapy

Depending on the stage of the cancer, concomitant chemoradiotherapy (a combination of chemotherapy and radiation therapy) may be used to avoid a laryngectomy, preserving the larynx and its ability to function. For many people, this is the preferred standard treatment option; however, concurrent chemotherapy and radiation therapy can cause more side effects than treatment with radiation therapy alone.

Induction chemotherapy (initial treatment before surgery or radiation therapy) has also been shown to allow for larynx preservation. Cetuximab (Erbitux; see below) with radiation therapy is being investigated.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. 

Cetuximab is a targeted treatment approved for use in combination with radiation therapy (see above) for head and neck cancer that has not spread. It is also approved for use with chemotherapy to treat patients with metastatic cancer. Targeted therapy is an area of active research for head and neck cancers. 

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. 

Recurrent cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). Most recurrences at the original cancer site and in the neck happen in the first 18 to 24 months after the original treatment. People who stop using tobacco, preferably before treatment begins, have a better chance of surviving longer.

When there is a recurrence, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. In particular, treatment planning when there is tumor spread and growth at distant organs  requires very careful evaluation and treatment. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, radiation therapy, chemotherapy, and targeted therapy), but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic cancer

If cancer has spread to another organ in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer because there can be different opinions about the best treatment plan. 

Typically, the treatment recommendation includes systemic chemotherapy, either using standard drugs or investigational drugs as part of a clinical trial. Your health care team may recommend a treatment plan that includes surgery or radiation therapy, as well. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Clinical Trials

Doctors and scientists are always looking for better ways to treat patients with laryngeal or hypopharyngeal cancer. To make scientific advances, doctors create research studies involving volunteers, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating laryngeal and hypopharyngeal cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with laryngeal or hypopharyngeal cancer.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. 

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Coping with Side Effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for laryngeal and hypopharyngeal cancer are described in detail within the Treatment section. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with laryngeal or hypopharyngeal cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. 

After Treatment

After treatment for laryngeal or hypopharyngeal cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

People recovering from laryngeal or hypopharyngeal cancer should receive regular follow-up medical and dental examinations to check for signs of recurring cancer or a second primary cancer (a new type of cancer somewhere else in the body), as well as to manage any late or long-term side effects from cancer treatment.

A common follow-up schedule for people after treatment for either of these types of cancer is every two months for the first year, every four months for the second year, every six months for the third year, and once a year after that. Diagnostic tests and examinations may be repeated to look for a recurrence or monitor the progress of current treatment. If radiation therapy was given, a person should have his or her thyroid function checked regularly. If a person uses tobacco, it is important to be monitored for possible second cancers in the lung, esophagus, and head and neck, even without recurrence of the initial cancer. Enrollment in clinical trials researching new ways to prevent these diseases may also be an option.

Rehabilitation is a major part of follow-up care after head and neck cancer treatment. However, people should meet with all rehabilitation specialists before their head and neck cancer treatment begins. Following treatment, people may receive physical therapy to maintain range of movement and speech therapy to regain skills, such as speech and swallowing. When the cancer treatment impairs swallowing, exercise plans can often be designed to strengthen and maintain the ability to eat and swallow. It is important that people receive early evaluation by a speech pathologist and other members of the health care team to start specific treatment programs and avoid later problems. Supportive care to manage symptoms and maintain nutrition during treatment may also be recommended. Some people may need to learn new ways to eat or prepare food.

Sometimes rehabilitation requires developing a new voice. After a total laryngectomy, some people can learn to use the esophagus to produce sound; this is called esophageal speech. Some people use an electronic battery-powered device called an electrolarynx that produces vibration that is transmitted through the tissues of the neck or delivered into the mouth via a plastic tube for speech production. A third method of voice rehabilitation, called tracheoesophageal (TE) voice restoration, is performed in many people who have had a laryngectomy. TE speech is similar to normal laryngeal speech because it uses air from the lungs to power speech production just as it did prior to laryngectomy. A small, removable prosthesis (artificial device) that sits inside the stoma allows air from the lungs to pass into the esophagus for sound production. The sound then travels into the mouth for speech.

People may look different, feel tired, and be unable to talk or eat the way they used to before treatment. People who have a tracheostomy need to learn how to take care of the stoma and keep it clean. Some people may experience depression. The health care team can help people adjust and connect them with both physical and emotional support services.

People recovering from laryngeal or hypopharyngeal cancer are also encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for you needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about laryngeal and hypopharyngeal cancer, ways to prevent them, how to best treat them, and how to provide the best care to people diagnosed with these diseases. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Radiation therapy approaches. Researchers are evaluating more effective ways of using radiation treatment. One promising approach, radiosensitization, involves giving drugs that make the cancer cells more sensitive to radiation therapy so they can be destroyed more easily. Another approach is called hyperfractionated radiation therapy, in which radiation therapy is given in several small doses per day.

Targeted and tumor-specific therapy. Increasing knowledge of the biology of cancer is leading to the development of biologic and targeted therapies. Multiple new drugs are currently under various stages of development. They offer real hope for targeted tumor-specific approaches for these types of cancer (and head and neck cancer, in general).

As discussed in the Treatment section, cetuximab (a monoclonal antibody directed at the epidermal growth factor receptor, or EGFR) is already approved for use with current radiation therapy approaches. A monoclonal antibody is a type of targeted therapy. It is directed against a specific protein in the cancer cells, in this case EGFR, and it does not affect cells that don’t have that protein. Other EGFR inhibitors under study are erlotinib (Tarceva), gefitinib (Iressa), lapatinib (Tykerb), and panitumumab (Vectibix), often in combination with other treatments.

In addition, another avenue researchers are studying includes antiangiogenesis. This explores how tumors develop their blood supply and how drugs can disrupt that. Drugs under investigation in this area include bevacizumab (Avastin) and sunitinib (Sutent). The hope is that these and other more targeted therapies will offer new treatment options with equal or greater effectiveness and fewer side effects. 

Chemoprevention. Researchers are evaluating the benefits of using chemotherapy as a way to prevent second cancers following treatment.

Photodynamic therapy. In photodynamic therapy, a substance that is photosensitive (sensitive to light) is injected into the blood. Cancer cells hold onto the substance longer than normal cells. Then, laser lights are directed at the area of the tumor, and the substance in the cells is activated to destroy the cancer cells.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current laryngeal and hypopharyngeal cancer treatments in order to improve patients’ comfort and quality of life.

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