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Treatment
What are the treatment options for advanced cancer?
Treatment for advanced laryngeal cancer (stages II-IV) focuses on
the role of the three main types of head and neck cancer therapies:
- Surgery (surgical)
- Radiation therapy (non-surgical)
- Chemotherapy (non-surgical)
Note: Radiochemotherapy is a combination of radiation therapy and chemotherapy.
Multi-Modality Therapy – Combination of Treatment Options for T3 and T4 Tumors
- In tumors that are advanced (T3 and T4),
multi-modality therapy is likely to be recommended. With multi-modality
therapy, more than one treatment will be combined to improve the cure
rates and survival as well as preserve the larynx.
- Currently a broad spectrum of non-surgical and surgical procedures is available to treat advanced laryngeal cancer.
Towards Increased Emphasis on Laryngeal Preservation
- New studies evaluating quality of life in the treatment of advanced laryngeal cancer raise the issue of the
lifestyle costs the patient and physician must consider when choosing a
particular therapy.
- Both patients and physicians are
currently placing a renewed emphasis on treatment approaches that
preserve key functions of the larynx – breathing, protecting the airway
during swallowing, and producing voice. This emphasis is influencing
both surgical and non-surgical treatment approaches.
 Red Flag
Ultimate Survival and Tumor Control Are First Priority
While
the patient and physician must consider all options, control of the
tumor, and ultimately survival, are the main considerations in deciding
on a treatment for advanced laryngeal cancer.
Key Functions of Larynx Can Be Addressed in Both Surgical and Non-Surgical Approaches
Along with tumor control, the preservation of laryngeal functions –
breathing, protecting the airway during swallowing, and producing voice
– needs to be addressed. Loss of laryngeal function occurs in both
surgical and non-surgical treatment strategies.
Laryngeal Preservation Can and Should Be Addressed With Surgical Treatment Plans
- Loss of laryngeal function occurs obviously in surgical procedures that remove part of the larynx (partial laryngectomies).
- Although
these procedures may seem wholly destructive to the larynx,
preservation of laryngeal function can be addressed, resulting in
restoration and/or rehabilitation of voice.
Loss of Laryngeal Function Can Occur in Non-Surgical Therapy
- Laryngeal function can also be lost as a result
of non-surgical therapy (radiation and/or chemotherapy), even though
these treatments keep the larynx intact anatomically.
- The
acute and chronic side effects of radiation and/or chemotherapy
affecting both the larynx and surrounding tissues can result in
dysfunction of normal tissue and permanent scarring – to the point that
the larynx, although structurally present, cannot function.
- Patients
may experience difficulties with speaking, breathing and swallowing.
Some of these effects may improve over time, while others are more
permanent.
Issues in the Treatment of T2 Laryngeal Tumors
Radiation therapy, widely used for T2 tumors, can result in significant loss of larynx function.
Radiation Therapy Cannot Distinguish Cancer from Normal Tissue
T2 laryngeal tumors, particularly those that begin on the vocal
folds, are likely to be treated primarily with radiation therapy alone.
These tumors are often only on one side of the larynx. However,
radiation, which cannot distinguish between normal and cancerous
tissue, has an impact on both cancerous and normal tissues in the
larynx. Thus, voice quality will be abnormal in these cases, to a
greater or lesser degree depending on the patient, the size and
location of the tumor, and the dose of radiation used.
Radiation Therapy for T2 Tumor Can Be a Disadvantage
More importantly, radiation therapy is not available for further use
if another primary tumor grows in the same area (5 percent chance per
year), since radiation can only be delivered to a particular area of
the body once in a patient's life. Thus, failure of radiation therapy
more than likely results in total laryngectomy (removal of the entire
larynx), with a permanent windpipe brought out through the skin of the
neck.
Partial Laryngectomy Possible for T2 Tumors
Partial laryngectomies are possible for T2 laryngeal tumors. For
those T2 tumors arising on the vocal folds, surgical treatment involves
cutting out the tumor (surgical resection) on one or both vocal folds with either a vertical or horizontal transection (removal) of the thyroid cartilage. (See Anatomy & Physiology of Voice Production for more information and a picture of the thyroid cartilage.)
Quality of Life: Need for a Temporary Breathing Tube
A temporary plastic breathing tube placed below the tumor into the windpipe (tracheotomy) is necessary in these cases.
Tumor Control: Variable Success Rate for T2 Cancer of the Vocal Folds
The tumor control rate for T2 tumors with partial laryngectomy is
somewhat variable because of slight differences between surgeons and
medical centers in performing this procedure. The failure rate for
tumor control is reported to range between 5 and 25 percent.
Current Best Practice: Total Laryngectomy Not Recommended for T2 Cancer
According
to current best practice, a total laryngectomy is usually not
recommended for a T2 laryngeal cancer, unless the tumor was
"unfavorable" and/or had already been treated with chemotherapy and/or
radiation therapy.
 Key Information
Multidisciplinary Approach Important for Comprehensive Care
The
key to cancer therapy and recovery is a multidisciplinary approach,
often found in "team-oriented" environment at an academic medical
center. Results are best when speech and swallowing therapists are
involved in rehabilitation of speaking and swallowing after treatment
procedure(s). (For more information, see Voice Care Team.)
Combined Radiation Therapy and Chemotherapy
- Recent studies comparing radiation therapy alone
with chemoradiation (chemotherapy and radiation therapy delivered at
the same time rather than sequentially) have demonstrated that combined
chemoradiation is the optimal non-surgical treatment for larynx
preservation. However, there is no survival advantage of this
technique, and those for whom chemoradiation fails usually must have a
total laryngectomy.
- Quality of life studies are currently
underway that compare non-surgical (chemoradiotherapy) versus partial
laryngectomies or total laryngectomy.
Note: For laryngeal cancers with large and/or extensive neck
nodes containing cancer (N2-N3), combination chemoradiation therapy has
not been effective for tumor control in the lymph nodes, even if the
laryngeal cancer is controlled.
How do I select cancer treatment options?
Patients must be educated regarding different cancer treatment
options to make an informed decision. Informed decisions are depend on:
- Cooperative discussion with the treating physician otolaryngologist
- Realization
that one therapy or another might be more prevalent, or preferred, by a
particular physician at a particular medical center
The treating physician should be able to accurately describe the
likely success rate of a given, recommended treatment for each
particular tumor at that medical center.
Selecting the most appropriate therapy for a particular cancer of the larynx depends on many factors.
Factor 1: TNM Stage of the Tumor
- A patient with an early T2N0 (stage 2) tumor may choose single modality therapy, such as radiation alone or surgery
alone. Chemotherapy alone in this setting has not been proven to be
effective at this point in time.
- For more advanced cancers, such as T3 and T4
tumors, with or without evidence of spread to the neck, multi-modality
therapy is needed to improve the chances of tumor control and survival.
Additionally, patients with T3 and T4 tumors also receive treatment on
one or both sides of the neck with either surgery, radiation, or both.
Note: The most appropriate treatment
is chosen after a thorough discussion between the patient and the
physician once an accurate diagnosis is obtained, including pathologic
biopsies to confirm the tissue type of the tumor. When considering
which therapy is most appropriate, the patient does play an important role in guiding the advice of the surgeon.
Key Information
Recently,
some clinical studies have directly compared the use of surgery (total
laryngectomy) and postoperative radiation therapy with non-surgical
treatment (combined chemotherapy and radiation therapy). These studies
suggest that although there is no survival advantage from the addition
of chemotherapy to radiation therapy for T3 and T4 tumors, the number
of individuals who were cured while avoiding the need for laryngectomy
(surgical removal of the voice box) was significant.
- Therefore,
some physicians recommend that chemoradiotherapy is a viable
alternative to total laryngectomy for advanced tumors, such as T3 and
T4 cancers.
- However, of the patients who avoided laryngectomy, some
experienced a recurrence of the tumor and were not able to have
subsequent surgery to remove the tumor after chemoradiation therapy.
Follow-Up Surveillance Is Important in Cancer Management
Response to chemoradiotherapy, either immediate or in the long-term,
is currently impossible to determine. Therefore, close follow-up for
tumor surveillance is necessary every month or two for the first two
years after treatment.
Total Laryngectomy: A Treatment Trade-Off
- Patients who wish to avoid surgery assume the risk
that, if the tumor comes back after non-surgical therapy, they may no
longer be a candidate for surgery and may later die from the cancer.
- On
the other hand, those who undergo total laryngectomy for advanced
cancers of the larynx may have an equal or better survival rate than
those who choose non-surgical therapy, but must learn to live without
their larynx (voice box) and will need to learn new techniques for
communicating through extralaryngeal speech techniques.
Other factors play a role in the decision made jointly by the physician and patient to maximize the benefit of the treatment.
- The general medical condition of patients affects
their ability to undergo major surgery or to receive chemotherapy and
radiation therapy, which can have side effects on certain organ systems
such as the kidneys.
- Radiation therapy for advanced
laryngeal cancer requires treatments by a radiation therapist five days
per week, for approximately six weeks consecutively. Occasionally, a
one-week break may be recommended by the radiation therapist.
- Surgery
typically entails a stay in the hospital of between five to eight days
for recovery, as well as swallowing and speech therapy.
What are the frontiers/controversies of treatment?
Emphasis on Tumor Control and Quality of Life
The goal of organ preservation is to emphasize quality of life
issues, providing grounds for a healthy debate on the best treatment
approaches for patients with advanced laryngeal cancer.
Combination Chemotherapy and Radiation Therapy for Larynx Preservation in Advanced Cancer Treatment
The introduction of combined chemotherapy and radiation therapy as
an alternative to total laryngectomy for patients with advanced
laryngeal cancer has led to a new perspective on treatment for
laryngeal cancer, referred to as "larynx preservation."
Limitations of Combination Chemotherapy and Radiotherapy for Larynx Preservation
- The combination of chemotherapy and radiotherapy
for organ preservation is appropriate only for patients otherwise
facing total laryngectomy.
- Although the structure and the
tissues of the larynx are preserved in those patients whose tumor is
successfully treated by chemoradiotherapy, the function of the
remaining larynx is no longer normal in terms of speaking and
swallowing.
- Furthermore, some patients receiving
non-surgical therapy will not be successfully treated and will still
need total laryngectomy.
- Because radiation therapy can
only be delivered once to a particular area of the body, the use of
non-surgical treatment (chemoradiotherapy) up front means that
radiation cannot be used later if another primary tumor is found (5
percent chance per year).
Key Information
Patient Counseling and Education Regarding Treatment Options
Patients
considering organ-preserving treatment must be adequately counseled and
educated regarding all treatment options, side effects, and failure
rates.
Key Role of Otolaryngologist
The
otolaryngologist assists the patient in making an appropriate decision
in conjunction with the advice of a medical oncologist and radiation
oncologist, whose practices are limited to head and neck cancer.
Otolaryngologists have the understanding, tumor staging skills, and
expertise to accurately represent both the surgical and non-surgical
approaches to organ preservation.
Surgical Approaches and Larynx Preservation – Emerging Importance
The use of organ preserving surgical approaches has the added
benefit of keeping radiation therapy in reserve if a recurrence or
another primary cancer in the head and neck area develop. This added
benefit is significant since the chance of recurrence or development of
another primary cancer in the head and neck area is not small.
Note:
- Development of another cancer in the
throat area in an individual with advanced laryngeal cancer is
approximately 4 to 5 percent per year for the rest of that person's
life.
- The increased risk of second tumors in the larynx or
other locations within the mouth, throat, swallowing tube, or lungs is
most likely related to the exposure of those tissues to the same
cigarette and tobacco substances that induced the first cancer.
New Research on Inherited Susceptibility to Cancer Development
Newer information is being discovered that a small fraction of
patients with head and neck cancer may have some inherited problem with
repairing their DNA that makes them more susceptible to cancer in
general. The cancer can develop on its own and be even more likely in
someone with an inherited DNA problem who also smokes and drinks
heavily.
How can treatment options affect voice and swallowing?
Treatment of advanced cancer of the larynx often results in moderate
to severe effects on laryngeal functions (voice, breathing, and
swallowing).
Surgical Treatment for Advanced Cancer
- Surgical treatment, involving the removal of any
part of the vocal folds, will cause the voice to be rough, gravelly,
and hoarse. Taking a significant amount of tissue away from the larynx
can also result in a breathy, quiet, and whispered voice.
- The
advantage of surgery in the treatment of laryngeal cancer is that only
the areas involved with tumor are subjected to treatment. Larger, more
advanced laryngeal tumors (some T3 and most T4) usually are treated
with total laryngectomy.
Impact of Total Laryngectomy–Removal of Entire Larynx
Total laryngectomy involves the removal of the entire larynx (voice box). After the
removal of the larynx, the breathing tube and swallowing tube are
separated.
- Swallowing: The swallowing portion of the throat is reconnected with the esophagus so the patient can swallow food and liquid normally.
- Breathing: The breathing tube (wind pipe or trachea)
is brought out to the front, lower part of the neck and will be
visible. Therefore, the patient will no longer breathe through the
mouth and the nose, but rather through the surgically created hole in
the neck attached to the windpipe (laryngectomy stoma). Although this
is somewhat discouraging for patients initially, and is often the part
of a laryngectomy that patients dislike the most, this is actually a
quite effective method of breathing.
- However, the
humidification that our mouth, nasal cavity, and sinuses give to the
air we breathe no longer occurs after laryngectomy. Without this
humidification, normal secretions and mucous may become crusty and
difficult to care for. Therefore, after a total laryngectomy, a
humidifier is often used to prevent the air breathed into the lungs
from being too dry.
Impact of Partial Laryngectomy – Removal of Part of Larynx
- Voice: Because some bulk of tissue has
been removed during partial laryngectomy, the voice becomes gravelly,
weak, or breathy. However, surgical techniques can add tissue or bulk
to improve voice quality and strength.
One possibility is to push one side of the larynx over so that
the other unaffected vocal fold can move to meet it and better create
voice. This sort of procedure is called a thyroplasty or laryngoplasty,
and it entails inserting a material – such as silastic (soft black
plastic) or Gore-tex™ strips – into the larynx to restore some of the
fullness and bulk to the side of the larynx where tissue was removed.
Other procedures can also be combined to improve how the remaining
vocal folds meet the excised side of the larynx.
-
Swallowing: After partial laryngectomy swallowing is different, and the cooperation
of the surgeon with an experienced speech/language pathologist (SLP) is
critical to providing rehabilitation, teaching new swallowing
techniques, and giving voice therapy. The SLP can teach patients many
different maneuvers to improve swallowing and to prevent swallowed
materials from going through your larynx into the lungs ("aspiration").
Radiation Therapy for Advanced Cancer
Radiation Therapy Side Effects Variable, but Usually Progressive
Radiation therapy cannot distinguish normal from cancerous tissue
and therefore affects all of the tissues in the treated area, including
the parts of the larynx that are not involved with tumor. Radiation
therapy can have variable effects on the voice and swallowing. These
effects are progressive, meaning that they develop over time (up to
several years after the treatment). The effects of radiation therapy
include a rough, hoarse voice.
Dryness – a Frequent Side Effect of Radiation Therapy
The main negative effect of radiation therapy is that it destroys
salivary tissues which secrete lubricating mucous. Therefore, any area
that has received radiation therapy will be very dry.
Swelling After Radiation Therapy
Another side effect of radiation therapy is swelling and a decrease
in the ability of fluid to drain out of the tissues normally and
recirculate around the body. This leads to swelling in the vocal folds
and swallowing areas, reducing the functions of voice and food intake.
Key Information
Side Effects from Radiation and Chemotherapy Can Be Severe – Making the Larynx Non-Functional
Different
patients react to radiation and chemotherapy in different ways. Some
individuals do quite well with this non-surgical therapy, while others
have so much dryness, swelling, and scarring (fibrosis) that the larynx
is essentially rendered non-functional following treatment.
Total Laryngectomy After Non-Surgical Treatment of Advanced Cancer
In
large studies of patients undergoing non-surgical treatment
(chemoradiotherapy) for advanced laryngeal cancer, a small fraction (5
percent) lose all functioning of the larynx, resulting in poor voice,
difficulty breathing, an inability to swallow enough food to maintain
nutrition, and/or an inability to protect the lungs from saliva or food
that leaks through the vocal folds into the windpipe (aspiration).
These patients may need to undergo a total laryngectomy, even though
the tumor no longer present.
If I Lose My Voice Box (from Total Laryngectomy)
Restoration of voice after laryngectomy has improved significantly
over the past 10 to 20 years. There are three main ways to restore
voice after total laryngectomy.
- The first way to
restore speech after laryngectomy is the use of pharyngo-esophageal
speech, which can be learned with the assistance of an SLP. Patients
learn to swallow air and bring it back up again (similar to a belch) to
vibrate throat membranes to create sound. Pharyngo-esophageal speech
can be remarkably intelligible.
- The second way to restore
speech is the use of a vibrating instrument that the patient holds up
to the throat or places along the cheek, called an electrolarynx. This is the vibrating device that most people associate with a patient who has had a total laryngectomy.
- The
third technique, called a tracheoesophageal puncture (TEP), is most
effective at restoring speech after laryngectomy. Placement of a TEP
prosthesis, which is a one-way valve going from the windpipe into the
esophagus (swallowing tube), requires a very minor surgical procedure.
Patients speak by taking a deep breath and putting their thumb over the
stoma (windpipe hole in the neck) or by using a plastic valve called a
stoma vent to enable air to go through the TEP valve and out through
the mouth. Although this is not a normal sounding voice, many patients
function quite adequately and can even talk on the telephone well. Most
patients can be taught to care for their TEP prosthesis.
- When necessary, replacement of an old prosthesis can be done in the clinic by a doctor or a speech pathologist.
- Although the TEP is effective, the patient should know how to use an electrolarynx if the TEP ever malfunctions.
After total laryngectomy, breathing is quite easy because the
windpipe comes out directly from the neck instead of being connected to
the mouth and throat. Although breathing is not difficult, the air that
someone breathes after a laryngectomy must have humidity added to it or
the mucous will become crusty and block the windpipe. While this is
frustrating to some patients, they soon realize that is just like
brushing their hair or teeth or other aspects of self-care; caring for
the breathing tube becomes quite routine and simple.
Most patients can eat normally after a laryngectomy.
- The new throat will take some time to heal (up
to several weeks), but usually liquids can be started by mouth within a
week or so after surgery.
- A temporary tube to give
nutrition directly into the stomach may be placed through the nose or
directly through the abdominal skin into the stomach. This tube is
removed once swallowing improves and the patient can maintain nutrition
adequately. Some patients can eat a completely normal diet, while
others may eat some regular food and supplement their diet with tube
feeds such as Ensure or Jevity.
What can I expect for follow-up and for surveillance of recurrence?
Most surgeons and oncologists want to keep a very careful follow-up
schedule with patients who have been treated for advanced laryngeal
cancer.
Typical Schedule of Follow-Up
Follow-up visits are generally scheduled every four to six weeks for
the first year and then every six to eight weeks for the second year
after treatment. This schedule is based on observations from many
cases indicating that if a laryngeal cancer is going to return, there
is an 85 perecent chance it will do so within two years of the
definitive treatment.
- Follow-up for the first two years is critical to
detect any recurrent or persistent laryngeal cancer as quickly as
possible so that salvage treatment can be given.
- Follow-up
visits for subsequent years, which are generally every three to six
months for years three, four, and five after treatment, are scheduled
so that physicians can perform surveillance (detection) of a second
primary tumor elsewhere in the mouth, throat, or voice box.
What to Watch Out For – Monitoring for Cancer After Treatment
- Any change in symptoms of speaking, breathing, or swallowing
- If
any symptoms change or there is new pain or trouble speaking,
swallowing, or breathing that was not present after cancer treatment
finished, a visit with the physician should be scheduled immediately.
- Changes in every possible area that might harbor a persistent, recurrent, or second primary tumor
- The
patient can perform a self-directed neck examination (your doctor will
show you how), similar to the monthly self-breast examination that all
women should perform.
- A patient should seek medical
evaluation of any new mass, lump, or nodule, preferably by the surgeon
who took care of the patient initially or the doctor who made the
initial diagnosis. Returning to the same doctor is necessary because
after surgical or non-surgical treatment of advanced laryngeal cancer
the anatomy of the breathing and swallowing tubes, as well as the
appearance and feel of the neck, are quite different and can be best
assessed by someone capable of comparing previous and follow-up
examinations.
Key Information
- 85% or more of the cases of laryngeal cancer recurrence within two years of the completion of therapy.
- Follow-up
for the first two years is critical to detect any recurrent or
persistent laryngeal cancer as quickly as possible so salvage treatment
can be given.
- Follow-up visits in later years are also important to detect other types of cancers in the mouth, throat, or voice box.
What is it like to live with advanced cancer?
Patient-Physician Partnership Important
- Once you have been told that there is a tumor in
your larynx, you must cooperate fully with your physicians' advice.
Therefore, you need to find a doctor or doctors you trust.
- Doctors
who treat laryngeal cancer are used to dealing with the issues of
patients who are diagnosed with this disease. These doctors are very
interested in treating the cancer as soon as possible and maximizing
the quality of life before, during, and after tumor removal. Early
treatment requires a partnership between the doctor and the patient;
patients must have a real desire to assist and to be a part of their
medical team.
- A patient's positive attitude and an energetic approach to treatment maximize the likelihood of treatment success.
Psychiatric Consultation Helpful
Studies have shown that individuals with laryngeal cancer are often
depressed and may benefit from talking to a psychiatrist or receiving
medication for depression. Patients should realize that this is normal
and should feel comfortable bringing up these issues with their surgeon.
Near-Normal Lifestyles With Effective Talking, Breathing, and Eating Are Possible
Many patients are able to confront their cancer and, with
appropriate state-of-the-art medical care, successfully undergo
treatment. Frequently, these patients are able to return to normal or
near-normal lifestyles, with effective talking, breathing and eating.
Key Information
Multidisciplinary Approach Gives Optimal Comprehensive Care
The
key to any cancer therapy and recovery is a multidisciplinary approach,
often found in team-oriented settings in academic medical centers.
Treatment results are best when speech and swallowing therapists are
involved in rehabilitation of speaking and swallowing after treatment
procedure(s). (For more information, see Voice Care Team.)
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