Laryngeal (larynx) cancer
Laryngeal cancer, or cancer of the larynx, is an uncommon type of cancer that develops inside the tissue of the larynx (voice box).
Symptoms of laryngeal cancer can include:
changes in the voice, such as sounding hoarse
pain when swallowing or difficulty swallowing
a persistent cough
a lump or swelling in your neck
When to seek medical advice
You should visit your GP if you have had any of the symptoms listed above for more than three weeks.
As these symptoms are similar to those of many other conditions, it's unlikely they are caused by cancer. However, it's a good idea to rule out all possible causes of your symptoms by visiting your GP.
Why it happens
It's not clear exactly what causes laryngeal cancer, but factors that can increase your risk have been identified. They include:
regularly drinking large amounts of alcohol
having a family history of head and neck cancer
exposure to certain chemicals and substances, such as coal dust and diesel fumes
By adopting a healthy lifestyle, including avoiding alcohol and tobacco, you can significantly reduce your chances of developing laryngeal cancer.
Who is affected
Laryngeal cancer is an uncommon type of cancer. In the UK, there are about 2,300 new cases of laryngeal cancer each year.
The condition is rare in people under 40, with most cases affecting people aged 60 years or over.
Laryngeal cancer is about four times more common in men than women.
How laryngeal cancer is treated
The main treatments for laryngeal cancer are radiotherapy, surgery and chemotherapy.
Radiotherapy and surgery to remove the cancerous cells from the larynx can often cure laryngeal cancer if it is diagnosed early.
If the cancer is diagnosed after it has started to spread, a combination of surgery to remove part or all of the larynx, radiotherapy and chemotherapy can be used.
If you have surgery to remove all of your larynx, you will 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 to help restore your voice. This may include an implant in your throat, or an electrical device you hold against your throat to produce sound.
The outlook for laryngeal cancer depends on how far the cancer has spread before it is diagnosed and treated. This is known as the stage of the cancer. See diagnosing laryngeal cancer for more information about staging.
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 after diagnosis and about 57 out of every 100 people will live for at least 10 years.
If you smoke, stopping smoking after being diagnosed with laryngeal cancer may help improve your outlook.
Symptoms of laryngeal cancer
Most laryngeal cancers develop near the vocal cords, so one of the first noticeable symptoms is often a change in the sound of your voice. For example, your voice may be unusually hoarse.
Other symptoms include:
pain when swallowing or difficulty swallowing
a lump or swelling in your neck
a high-pitched wheezing noise when breathing
unexplained weight loss
fatigue and weakness
When to seek medical advice
You should visit your GP if you experience any of the symptoms listed above for more than three weeks.
As these symptoms are the same as those for many other conditions, it's unlikely they are caused by cancer. However, it's a good idea to find out the cause of your symptoms by visiting your GP.
Causes of laryngeal cancer
Laryngeal cancer is caused by changes in the cells or the larynx, although it is not clear exactly why this happens.
All cancers begin with a change in the structure of DNA. DNA provides our cells with a basic set of instructions, such as when to grow and reproduce.
A change in DNA structure is known as a mutation. It can alter the instructions that control cell growth. This 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 and how the DNA inside the cells of the larynx is affected in cases of laryngeal cancer. However, it appears that exposure to anything that can damage the cells and tissue of the larynx increases the risk of cancer developing.
There are a number of factors that can increase your chances of developing laryngeal cancer, the most common of which are outlined below.
Alcohol and tobacco
Evidence shows that alcohol and tobacco are the two biggest risk factors for laryngeal cancer. Alcohol and tobacco are thought to contain chemicals that affect the cells of the larynx, triggering mutations that can lead to cancer.
The more you drink or smoke, the higher your risk of developing laryngeal cancer.
Compared to people who don't drink, people who regularly drink large amounts of alcohol are about three times more likely to develop laryngeal cancer.
People who smoke more than 25 cigarettes a day, or people who have smoked for more than 40 years, are estimated to be about 40 times more likely to develop laryngeal cancer than people who don't smoke.
If you drink and smoke, your risk of laryngeal cancer increases even further. By stopping drinking and smoking, you can significantly reduce your risk of developing the condition.
Your risk of developing laryngeal cancer increases with age. The condition is rare in people under 40 and most common in people over 60.
People who have a first-degree relative (parent, sibling or child) who has been diagnosed with head or neck cancer are estimated to be twice as likely to develop laryngeal cancer as someone without a family history.
Laryngeal cancer affects about four times as many men as women.
There's evidence to suggest that a diet high in red meat, processed food and fried food can increase your risk of developing laryngeal cancer.
Human papilloma virus (HPV)
Human papilloma virus (HPV) is the name given to a family 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.
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 pharynx (the cavity connecting the back of the nose and mouth with the larynx and oesophagus). HPV is often spread during sex, including oral sex.
Exposure to certain substances
Having a job where you're exposed to high levels of certain substances may also increase your risk of developing laryngeal cancer. These substances include:
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
Diagnosing laryngeal cancer
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 main tests that may be carried out in hospital are described below.
A nasendoscopy is a procedure used to enable medical staff to get a clearer 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 into the back of your throat. The images from the endoscope are displayed on a monitor.
The procedure isn't painful but can sometimes feel uncomfortable, so an anaesthetic spray is often used to numb your nose and throat.
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 medical staff to see the larynx in greater detail.
A laryngoscopy can be very uncomfortable, so is usually carried out under general anaesthetic (where you will be 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 as the procedure or the day after.
During a biopsy, a small sample of tissue is removed and sent to a laboratory to be examined for cancerous cells. A biopsy can usually be done at the same time as a nasendoscopy or laryngoscopy. Small instruments are passed down the endoscope and used to remove a tissue sample.
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.
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 produce an image of the larynx and surrounding tissue
Staging and grading
After these tests have been completed, the doctor in charge of your care should be able to tell you how far the cancer has spread and how fast it is likely to spread. These are 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 of laryngeal cancer 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 of laryngeal cancer is given as a number from 0-3. N0 means the lymph nodes are not affected, whereas stages N2 to N3 mean that the lymph nodes are affected.
The M stage of laryngeal cancer 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 three different grades used to describe the cancerous cells in the larynx, these are:
grade 1 - the cancer cells look a lot like the normal cells in the larynx
grade 2 - the cancer cells look a little like the normal cells in the larynx
grade 3 - the cancer cells look very different to the normal cells in the larynx
Lower grade cancers, such as grade one, tend to grow more slowly and are less likely to spread, whereas higher grade cancers, such as grade three, grow quickly and are more likely to spread.
Treating laryngeal cancer
The treatment for laryngeal cancer largely depends on how far the cancer has spread.
Most hospitals use multidisciplinary teams (MDTs) of specialists that work together to decide the best way to proceed with your treatment.
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 advantages and disadvantages of particular treatments.
Your treatment plan
Your recommended treatment plan will depend on the stage of the cancer (see diagnosing laryngeal cancer for more information about staging).
If you have early stage laryngeal cancer, it may be possible to remove the cancer using laser 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 particularly severe cases, the entire larynx may have to be removed.
A medication called cetuximab may be used in cases where chemotherapy is not suitable.
These treatments are described below.
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 before or after surgery to stop cancerous cells returning.
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. During your first visit to the radiotherapist, a mould of your face will be taken to make the mask.
Radiotherapy is usually given in short daily sessions from Monday to Friday, with a break from treatment at the weekend. As well as killing cancerous cells, radiotherapy can affect healthy tissue and has a number of side effects, including:
sore, red skin (similar in appearance to sunburn)
sore mouth and throat
loss of taste
loss of appetite
Your MDT will monitor any side effects and, where possible, treat them. 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. Contact your key worker or visit your local accident and emergency (A&E) department as soon as possible if you have difficulty breathing.
Most side effects should pass after your course of radiotherapy has been completed, although symptoms such as tiredness and dry mouth can last for several months following treatment.
There are three types of surgery that can be used to treat laryngeal cancer. They are:
These are discussed below.
Endoscopic resection can be used in early stage laryngeal cancer.
During the procedure, a surgeon uses a 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 unconcious 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 is a risk of your voice changing as a result of the procedure, which can be permanent.
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. If this is the case, the surgeon will 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 in the UK nowadays, as endoscopic resection is preferred when suitable.
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 restore your speech. See recovering from laryngeal cancer for more information about this.
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'll be given training about 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 recovering from laryngeal cancer - recovery for more information about adjusting to life after a laryngectomy.
Chemotherapy uses powerful cancer-killing medicines to damage the DNA of the cancerous cells and stop them reproducing.
Chemotherapy is often used in combination with radiotherapy before or after surgery to treat advanced laryngeal cancer.
Chemotherapy can sometimes damage healthy tissue as well as the cancerous tissue. This, unfortunately, means side effects are common, such as:
Chemotherapy can also weaken your immune system, making you more vulnerable to infection and illness.
It's therefore important that you report any symptoms of a potential infection to your MDT, such as a high temperature, persistent cough or reddening of the skin. Also avoid close contact with people known to have an infection.
The side effects of chemotherapy should improve after your treatment has finished.
Cetuximab is a type of medication called a biological therapy. These medications target and disrupt the processes that cancerous cells use to grow and reproduce.
Cetuximab specifically targets special proteins called epidermal growth factor receptors (EGFRs), which are found on the surface of cancerous cells. EGFRs help the cancer to grow, so by disrupting them cetuximab can prevent the cancer from spreading.
Cetuximab can be used in combination with radiotherapy to treat more advanced laryngeal cancer where it's not possible to use chemotherapy. For example, people with kidney or heart disease, or people with an ongoing infection will not be able to have chemotherapy because it could make them very ill.
Cetuximab is given intravenously (through a drip into your vein) which slowly delivers the first dose over the course of a few hours. Further doses should take about an hour and are given weekly.
The side effects of cetuximab are usually mild and include:
Cetuximab can also trigger allergic reactions in some people, which can cause problems such as a swollen tongue or throat. In about 1 in 35 people who take cetuximab, the allergic reaction can be severe and life-threatening.
Most serious reactions occur within 24 hours 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, anti-allergy medicines can be used to relieve them (such as corticosteroids).
These measures mean that deaths resulting from severe reactions in people taking cetuximab are rare, occurring in less than 1 in every 1,000 cases.
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Your multidisciplinary team (MDT)
Members of your MDT may include:
a clinical oncologist (a specialist in the non-surgical treatment of cancer)
a pathologist (a specialist in diseased tissue)
a radiologist (a specialist in radiotherapy)
a specialist cancer nurse, who will be responsible for co-ordinating your care (key worker)
Recovering from laryngeal cancer
If you have had some or all of your larynx removed (laryngectomy), it's likely you'll need to spend one or two days in an intensive care unit (ICU) until you have recovered from the effects of the surgery.
You won't be able to eat until your throat has healed, which for most people takes 7-14 days. However, in a small number of people, recovery can take several months. While your throat heals, you'll need to be fed with a tube through your nose and into your stomach.
If you've had all of your larynx removed, you won't be able to speak normally because you will no longer have vocal cords. A number of techniques can be used to replicate the functions of your vocal cords (see below), although they can take weeks or months to learn.
Therefore, it's likely you'll need to use alternative methods of communicating, such as using a pen or paper, during the first few weeks or months after surgery. This can be a frustrating experience and the loss of an ability you've previously taken for granted can be difficult to cope with.
Prepare yourself for strangers reacting in unpredictable and possibly upsetting ways. Many people who have had a laryngectomy have reported that other people sometimes assume they're deaf or have a learning difficulty because of their inability to speak.
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.
This type of emotional disruption 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 enjoy.
Contact your GP for advice if you think you may be depressed. There are a range of effective treatments for depression, such as antidepressant medication and talking therapies such as cognitive behavioural therapy.
The National Association of Laryngectomee Clubs (NALC) is another useful resource for people trying to come to terms with living with a laryngectomy. NALC is a patient support group that provides advice about all aspects of living with a laryngectomy.
Looking after your stoma
If you've had all of your larynx removed (total laryngectomy) 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 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. This can be done using a cotton bud and freshly boiled water that's then cooled.
Alternatively, the ear nose and throat (ENT) department of your local hospital will be able to give you cleaning solutions. An ENT nurse will be able to teach you how to keep your stoma clean. Your ENT department also has filters that can help to keep your stoma moist and free of germs.
It's important to remember 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.
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.
Before your laryngectomy, you may meet a speech and language therapist (SLT) to discuss possible treatment options for restoring your voice. A SLT is a healthcare professional who specialises in helping people who have difficulties speaking and using language.
There are several different treatment options, briefly outlined below.
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 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.
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 an electrolarynx.
Preventing laryngeal cancer
It's thought 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:
snuff (powdered tobacco snorted through the nose)
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, your GP will be able to refer you to an NHS stop smoking service, which can help you give up. You can also call the NHS Smoking Helpline on 0300 123 1044. Specially trained helpline staff offer free expert advice and support.
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 recommended guidelines for alcohol consumption will also reduce your risk of developing laryngeal and liver cancers. Recommended daily limits of alcohol are:
3-4 units of alcohol for men
2-3 units of alcohol for women
A unit of alcohol is equal to about half a pint of normal-strength lager or a pub measure (25ml) or spirits.
Studies have found your risk of developing laryngeal cancer reduces significantly within 5-10 years of not drinking, and after 20-30 years your risk is about the same as someone who has never drunk alcohol.
Contact your GP if you're finding it difficult to reduce the amount of alcohol you drink. You may need additional treatment that could include counselling, group work or medication.
Research shows a diet that contains many fresh fruits and vegetables, particularly tomatoes, citrus fruit (such as oranges, grapefruits and lemons), olive oil and fish oil, can reduce your risk of getting laryngeal cancer. This type of diet is sometimes known as a Mediterranean-style diet.
Eating five portions a day of a variety of fruit and vegetables will also help prevent many types of cancer, including laryngeal cancer. Leafy vegetables such as lettuce, spinach and cabbage are thought to provide the most protection against cancer.
Your diet should also be low in fat and high in starchy foods (carbohydrates) such as wholemeal bread, cereals and potatoes.
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