Treatment of Laryngeal Cancer
Treatment depends on the stage laryngeal cancer has reached at the time of diagnosis. The effects of treatment will depend on where the cancer is located in the larynx and how big it is. The treatment may result in temporary or permanent alterations to the functions of the larynx. The main permanent effect of treatment is problems with the voice which may mild, moderate or severe. If a permanent tracheostomy is needed it will require care to maintain health and speech will be affected.
Most people with large or advanced cancers will have a combination of treatments, e.g. chemoradiation therapy or radiotherapy and surgery.
In general, surgery is used for either very early or advanced tumours especially those involving the lymph nodes. Surgery for early cancer may be performed endoscopically. Surgery for advanced disease is more likely to be open surgery involving a partial, subtotal or total laryngectomy. Surgery for advanced disease is likely to have an effect on the voice. Radiotherapy when it is used either alone or with chemotherapy often preserves the ability to speak and is used for early cancers, the quality of the voice may not return to normal after the treatment.
Surgery
This treatment is used to remove cancer of the larynx and may be combined with other treatments especially radiotherapy. These operations range from “minimally invasive surgery” with preservation of the normal voice to removal of part of the larynx, leaving a hoarse and quiet or breathy voice (partial and subtotal laryngectomy), to removal of the whole larynx (total laryngectomy) with the result that a person will need to learn to speak again using other techniques. The type of surgery chosen will depend on the location and extent (stage) of the tumour. These are the names of some of the operations used and their likely disabling effects.
For early cancer of the larynx minimally invasive surgery can be used including:
- LASER treatment – this uses an endoscopic LASER surgical technique to excise small/medium cancers of the larynx. There are no external skin scars because the tumour is accessed through the throat. The voice is preserved but may be altered.
- Endoscopic resection – this is similar to LASER resection, but uses scissors and blades to excise tumours. There are no scars because the tumour is accessed through the throat and removed by operating through the endoscope. The voice is preserved.
More advanced tumours can still be cured by surgery but the operations affect the vocal cords thus affecting the voice. The voice is affected because it is usually necessary to remove part of the larynx (partial laryngectomy). This means the voice may be much quieter, hoarser or “tire easily” after surgery. These operations have different names depending on which part of the larynx is removed.
Partial Laryngectomy operations:
- Horizontal partial laryngectomy or Supraglottic laryngectomy – removal of the larynx above the vocal cords
- Vertical Partial laryngectomy including
- Cordectomy – removal of one vocal cord (there are two of these)
- Frontolateral laryngectomy – removal of part of both cords
- Anterior frontal laryngectomy - removal of part of both cords
- Hemilaryngectomy – removal of one half of the larynx
These operations are all major surgery. After the operation a temporary tracheostomy is in place. This will usually be closed by the time a person leaves hospital, the wound on the neck may require dressings for a few weeks. Speech will be possible with remnant of the larynx, the voice is likely to be hoarse, speaking loudly is likely to be difficult or impossible and the voice may tire easily especially at first. Total recovery time is about six weeks with continued improvements in the voice for many months afterwards.
Subtotal laryngectomy – removal of most of the larynx. This operation leaves a small part or portion of the larynx to enable speech with a hoarse voice. A person who has had this may also have a permanent tracheostomy because of their inability to breathe normally when their tracheostomy is closed. This means they will always breathe air through a hole in the neck; to speak they will have to close the hole in the neck to force air into the remnant of the larynx to speak. Their voice will be hoarse and may be weak. They will need to care for their tracheostomy stoma.
Total laryngectomy – the whole of the larynx is removed, this means a person has a permanent tracheostomy. They will need to learn how to use oesophageal speech or use a special device/speech aid to enable speech. There is more information about learning to speak again after total laryngectomy under care and mobility considerations
Neck dissection – this operation removes lymph nodes, fat and sometimes muscles and large blood vessels from the neck. It is an operation usually carried out in addition to removal of part of or the entire larynx. It leaves a visible scar and it can make the neck look asymmetrical. Neck dissection may be done on both sides of the neck. If the Spinal Accessory nerve is removed as part of the neck dissection, reduced shoulder movement, stiffness and pain are likely to result on the affected side.
Chemotherapy
This is not used for early laryngeal cancer, it is used more for the advanced cancers that have been treated before but have come back. When chemotherapy is being given without other treatments this is likely to be palliative treatment. Chemotherapy is likely to be given over 6 three or four week cycles. Side effects are likely to be more severe if radiation therapy is being given at the same time.
Chemotherapy may be used with radiotherapy – ‘chemoradiation’:
- As an alternative to surgery in selected cases.
- After surgery to reduce the risk of cancer coming back in high risk cases
Cisplatin or carboplatin are the chemotherapy drugs most likely to be used. Cisplatin is given at the same time as the radiotherapy. Side effects during treatment may be severe and recovery from the treatment is likely to take a further 6 weeks. Tiredness following this treatment may be persistent. The advantage of this treatment is the voice is preserved, although speaking may be difficult because of throat soreness during treatment. The voice may be weak and or hoarse after treatment.
Chemotherapy drugs used are likely to include two of the following:
- Cisplatin
- 5FU
- Carboplatin
- Taxol
- Taxotere
Radiotherapy
This treatment is used by itself in the treatment of early laryngeal cancer. Treatment lasts 6-7 weeks, or if a short treatment is used – 3-4 weeks. During treatment the voice may be hoarse and the throat sore, these problems usually resolve quickly at the end of treatment. The voice is preserved although it may sound different to how it did before. Long term side effects for some include dry mouth (xerostomia), difficulty swallowing, difficulty tasting food, food aversion and subsequent malnutrition. Maintaining nutrition by mouth may be so difficult during the treatment, due to throat soreness, that a feeding tube may be inserted through the skin into the stomach, this is called a Gastrostomy feeding tube or PEG (Percutaneous Gastrostomy) tube or RIG (Radiologically Inserted Gastrostomy) tube.
Treatment of recurrent / metastatic laryngeal cancer
Local Recurrence
For many people with laryngeal cancer one of the above treatments will control disease for life but in others it comes back in the neck or was not eradicated by the first treatment. For example someone who has had radiotherapy treatment a year ago may develop recurrence or have persistent disease in the neck and have a total laryngectomy a year later. If disease recurs locally in the neck this may be controlled by further local treatment including surgery e.g. laryngectomy and/or neck dissection or radiotherapy sometimes combined with systemic chemotherapy treatment.
Metastatic disease
Metastatic disease may occur elsewhere in the body, the most common site for this is the chest. Treatment is palliative.
Amended November 2008
