Laryngeal Cancer

The Causes, Symptoms, Causes, and Treatment of Laryngeal Cancer

Human larynx cancer, illustration
What is laryngeal cancer, what are the symptoms, and how is it diagnosed and treated?. SEBASTIAN KAULITZKI/Science Photo Library/Getty Images

What is Laryngeal Cancer?

Laryngeal cancer (cancer of the "voice box") is a type of cancer that affects the larynx—an organ that plays an important role in breathing and communicating. It contains the vocal cords, which give us the sound needed to speak. Above the larynx is the pharynx and below the larynx lies the trachea.

The larynx is composed of three different parts:

  • Glottis - The part of the larynx that contains the vocal cords (the true vocal folds) - Around 60 percent of laryngeal cancers begin in the glottis
  • Supraglottis - The area above the glottis, including the epiglottis - This area is the origin of around 35 percent of laryngeal cancers
  • Subglottis - The area below the glottis

Cancer can develop in each of these three areas and these cancers are unique from one another. They each produce different symptoms, require different treatment methods, and vary in prognosis.

How Common is Laryngeal Cancer?

About 13,000 people are diagnosed in the United States with laryngeal cancer each year, and around 3500 people die from the disease. It affects men much more often than women. The difference in the number of men and woman with laryngeal cancer is likely related to differences in tobacco use. The incidence of laryngeal cancer has been dropping two to three percent each year, and this reduction is thought to be the result of fewer people smoking.

Causes of Laryngeal Cancer

We don't know exactly what causes laryngeal cancer, but we are familiar with the most common risk factors.

Laryngeal cancer is one of many cancers related to smoking, and smoking appears to be the largest risk factor. It's important to note, however, that laryngeal cancer can and does occur in people who have never smoked. Heavy alcohol consumption also increases your risk of developing laryngeal cancer.

Those who use tobacco products and consume alcohol together are at the greatest risk.

Risk Factors for Laryngeal Cancer

  • Age - The risk of laryngeal cancer increases with age, and is uncommon in people under the age of 45.
  • Male sex - Men are four to five times as likely to develop laryngeal cancer than women.
  • Race - African Americans are more likely to develop laryngeal cancer that whites,
  • A history of head and neck cancer - People who have had one head or neck cancer are much more likely to develop a second primary cancer.
  • Smoking - Smoking is clearly the leading risk factor for laryngeal cancer, especially smoking which is combined with excess alcohol intake.
  • Alcohol use - Alcohol use alone increases risk, especially when combined with smoking. (Alcohol is now considered a known human carcinogen.)
  • Occupational exposures - Some on-the-job exposures are linked with an increased risk including exposure to asbestos, coal, and formaldehyde. (Learn more about occupational cancers.)
  • HPV infection - We are learning that human papillomavirus (HPV) is involved in cancers other than cervical cancer. It's thought at this time that around half of head and neck cancers (especially cancers such as that of the tonsils) are related to HPV infection. With laryngeal cancer it's not clear if HPV is a risk factor. HPV has been found in roughly 25 percent of laryngeal cancers, but this does not mean that it causes laryngeal cancer. It could be, instead, that cancer is a risk factor for HPV in some cases.
  • Diet - A diet high in fruits and vegetables is linked with a lower risk of developing laryngeal cancer whereas a diet high in meat—especially processed meats—is correlated with a lower risk of laryngeal cancer. Since people who consume large amounts of alcohol tend to eat fewer fruits and vegetables, it's not clear whether it is diet or instead alcohol use.
  • Heredity - A family history of laryngeal cancer increases risk. If you have a first-degree relative with the disease (father, mother, sibling, or child) you are roughly twice as likely to develop laryngeal cancer. (Learn more about the genetics of cancer.)
  • Immunosuppression - People who have compromised immune systems, such as those with HIV or those who are taking immunosuppressive drugs after an organ transplant, have an increased risk.
  • Head and neck radiation - Radiation to the head and neck region, such as that often given in the past for Hodgkin's disease, may increase risk.

GERD and Laryngeal Cancer

Studies have shown a link between those who suffer from gastroesophageal reflux disease (GERD) and laryngeal cancer. More studies are being done to understand GERD's influence on the development of cancer and what may be done reduce the risk. It is a small risk and not everyone who has GERD will develop laryngeal cancer. There is also ongoing research looking at whether proton pump inhibitors used for GERD increase the risk for recurrence of laryngeal cancer.

Types of Laryngeal Cancer

Around 90 percent of laryngeal cancers are squamous cell carcinomas, with less than 10 percent of these cancers being adenocarcinomas. Lymphomas may also sometimes occur in the larynx.

Symptoms of Laryngeal Cancer

One of the most commonly experienced symptoms of laryngeal cancer is persistent hoarseness of the voice. Hoarseness that does not go away after two weeks should be reported to your doctor. Keep in mind that hoarseness is extremely common and much more likely to be caused by something other than laryngeal cancer, but hoarseness that persists should always be evaluated. Common culprits of a hoarse voice include smoking, seasonal allergies and laryngitis.

Other symptoms of laryngeal cancer include:

  • Difficulty swallowing (dysphagia)
  • Pain or burning sensation when swallowing
  • Sensation of food being stuck in the throat when swallowing
  • Persistent cough that is unrelated to common cold or allergies (A persistent cough is defined as a cough which lasts longer than eight weeks. There are many causes of a chronic cough, but many people who are diagnosed with laryngeal cancer, lung cancer, or esophageal cancer look back and realize that they had an unexplained cough for a long period of time)
  • Lump in the neck
  • Sore throat
  • Earaches
  • Choking on food
  • Halitosis (bad breath)
  • Unintentional weight loss (Weight loss of five percent of body weight over a period of six to twelve months)

Tumor size and location are the greatest factors in what symptoms a person may experience. If a tumor develops in the vocal cords, typical symptoms may present with a change in the voice such as hoarseness. When tumors develop above or below the vocal cords, although much less common, different symptoms such as an earache or breathing difficulties may occur.

People with these type of persistent symptoms may be referred to an ear, nose, and throat (ENT) doctor called an otolaryngologist for further evaluation.

Diagnosing Laryngeal Cancer

Laryngeal cancer is most often diagnosed when a person seeks medical care for one or more of the above symptoms. The doctor will first perform a routine physical exam during which she will feel the throat area for any lumps or other abnormalities.

To get a better view of the inside of the throat, the doctor may recommend either an indirect or a direct larygngoscopy. In an indirect laryngoscopy, a long handled instrument with a mirror is inserted in the mouth in order to get an indirect look at your larynx. In a direct laryngoscopy, a spray is used to numb the throat and a thin, fiber-optic scope is fed down your throat allowing the doctor to see the back of your throat, larynx and vocal cords. This procedure may sound uncomfortable, but is usually tolerated very well. During a direct laryngoscopy, a sample of tissue may be taken if any suspicious areas are discovered. This is called a biopsy and it either confirms or rules out cancer. Other studies used to evaluate possible laryngeal cancer symptoms include:

  • CT scan
  • MRI studies
  • Barium swallow
  • PET scan

Staging of Laryngeal Cancer

If cancer is found, it is then necessary to determine the extent of the cancer. This process is called staging. The doctor will want to see if the cancer has spread to nearby tissue or organs. The stage of laryngeal cancer will affect what treatment method will be recommended for you.

You may hear your oncologist talk about the TNM system when staging your cancer. In this system:

  • T - Stands for tumor, and represents the size of your tumor. A T1 tumor is present in only one part of the larynx and the vocal cords are able to move freely. A T2 tumor has extended into another part of the larynx. For example, a tumor in the supraglottis may have grown down into the glottis. A T3 tumor involves all of the larynx and one of the vocal cords has become paralyzed due to the tumor. A T4 tumor has spread beyond the larynx and may extend down into the trachea or through to the esophagus or into the thyroid gland.
  • N - Stands for lymph nodes. NO (N zero) would mean that a tumor has not spread to lymph nodes. N2 and N3 refer to cancers that have spread to the lymph nodes and are further broken down depending on the location of the lymph nodes and the size of the cancer in the lymph nodes.
  • M - Stands for metastases. If a cancer has not spread to distant regions it is called M0, M1 would mean metastases were found.

Based on TNM letters, a cancer is given a stage.

Stage 0 or carcinoma in situ - The cancer cells are present only in the cells lining the larynx and has not spread beyond the basement membrane. At this stage cancer is considered non-invasive and should theoretically be 100 percent curable with surgery.

Stage I to stage IV cancers are considered invasive. These stages and sub-stages are related to a combination of the T, N, and M designations above, with stage I being the earliest stage of invasive cancer, and stage IV referring to laryngeal cancer which has spread beyond the larynx and is metastatic.

Tumor grade - Laryngeal cancers, like many cancers, are also given a grade, based on how aggressive the tumor looks underneath a microscope. A grade of 1 means that the tumor is not very aggressive (low grade) and that the cells look fairly similar to normal laryngeal cells. In contrast a tumor grade of 3 (high grade) usually means an aggressive tumor with the cells appearing very abnormal (undifferentiated) under the microscope.

Treatment of Laryngeal Cancer

Several factors are taken into consideration when a treatment plan is developed for someone with laryngeal cancer. Their age and overall general health are important, as well the stage and location of the cancer. Whether or not that cancer has spread plays a large role in determining what treatment method is best. Surgery and radiation therapy (RT) are standard methods of treatment for laryngeal cancer. When surgery is done, the surgeon also often does a "lymph node dissection" removing the lymph nodes nearest to the tumor where these cancers often first spread.

A link to the current recommendations for treatment based on the stage and location of laryngeal cancer is at the bottom of this section. Possible treatment options include:

Surgery - Surgery is very common in all stages of laryngeal cancer, and in the early stages can have a curative effect. Surgery can be as simple as user laser therapy to remove cancerous tissue to more aggressive surgical approaches such as a laryngectomy - the removal of the larynx. Types of surgery include:

  • Total laryngectomy - In this surgery the entire larynx is removed. This surgery requires a tracheostomy to be placed either temporarily or permanently. Following the surgery a person will be unable to speak, but options such as a mechanical larynx are available.
  • Partial laryngectomy
  • Supraglottic laryngectomy
  • Coredectomy - In this surgery, one or both vocal cords are removed.

Lymph node dissection - A lymph node dissection involves removing lymph nodes which lie near the larynx and is frequently done at the time of surgery in order to stage a tumor. The basis of checking lymph nodes is that when cancer spreads, it often spreads first to any lymph nodes near the tumor.

Radiation therapy - Radiation therapy is also commonly used with laryngeal cancer. It may be given as a primary treatment, or is sometimes given after surgery to eliminate any remaining cancer cells or to remove cancerous tissue that could not be removed during surgery.


Chemotherapy - Some people with laryngeal cancer may undergo chemotherapy to treat the disease. It is normally prescribed in conjunction with other treatment methods such as surgery and/or radiation therapy either as neoadjuvant therapy (neoadjuvant refers to chemotherapy or radiation therapy given before surgery to reduce the size of a tumor) or adjuvant therapy (adjuvant chemotherapy or radiation therapy is given after surgery to clean up any remaining cancer cells.)

Treatment Recommendations Based on Laryngeal Cancer Stage and Location

The specific treatment recommendations for laryngeal cancer depend significantly on the precise stage of the disease as well as the location. To learn more about treatment options based on a specific stage of the disease check out the evidence-based treatment recommendations for the stages of laryngeal cancer based on location in the larynx.

Making a Decision About Laryngectomy Surgery

Deciding to have surgery, and if so, the extent of surgery, is a very personal decision. Quality of life can be affected greatly, and it is important to spend time learning about all of your options. In a recent review, some people were willing to compromise their survival to avoid total larygnectomy. The most important thing is to make a decision which is best for you alone based on a thorough understanding of all options, and not what your loved ones or even physician would do themselves in the same situation.

Prognosis

Due to the symptom of hoarseness often occurring early, many laryngeal cancers are diagnosed when they are still in the early stages and can potentially be cured with treatment. Your individual prognosis will depend on many factors, including your age, general health, the stage of your cancer, its location, the tumor grade, and the treatments you choose.

If you smoke, quitting smoking can make a difference. If you're having difficulty taking this step, check out these 10 reasons to quit smoking after a diagnosis of cancer.

Coping with Laryngeal Cancer

Being diagnosed with cancer turns your life upside-down, even if your cancer was found in the early stages of the disease. Ask for help, and allow people to help you. Reach out to others. Consider joining one of the excellent support communities online.

Medicine is changing rapidly and we are learning that being your own advocate in your cancer care not only helps you feel more in control, but may affect your outcome as well. Learn as much as you can about your disease. Not only is the incidence of laryngeal cancer decreasing, but better treatments and improved surgical approaches are making life after laryngeal cancer treatment better each year.

Sources:

Blanchard, P., Volk, R., Ringash, J., Peterson, S., Hutcheson, K., and S. Frank. Assessing Head and Neck Cancer Patient Preferences and Expectations: A Systematic Review. Oral Oncology. 2016. 62:44-53.

National Cancer Institute. PDQ Cancer Information Summaries. Laryngeal Cancer Treatment (PDQ): Health Professional Version. 05/20/16. https://www.ncbi.nlm.nih.gov/pubmed/26389189

Salvador-Coloma, C., and E. Cohen. Multidisciplinary Care of Laryngeal Cancer. Journal of Oncology Practice. 2016. 12(8):717-24.

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