Treatment for cancer of the larynx depends on a number of factors. Among these are the exact location and size of the tumor and whether the cancer has spread. To develop a treatment plan to fit each patient's needs, the doctor also considers the person's age, general health, and feelings about the possible treatments.

Many patients want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care. When discussing treatment options, the patient may want to talk with the doctor about taking part in a research study of new treatment methods.

The patient and the doctor should discuss the treatment choices very carefully because treatments for this disease may change the way a person looks and the way he or she breathes and talks. In many cases, the patient meets with both the doctor and a speech pathologist to talk about treatment options and possible changes in voice and appearance.

People with cancer of the larynx have many important questions. The doctor and other members of the health care team are the best ones to answer them. Most patients want to know the extent of their cancer, how it can be treated, how successful the treatment is expected to be, and how much it is likely to cost.

These are some questions patients may want to ask the doctor:

• What are my treatment choices?
• Would a clinical trial be appropriate for me?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• How will I speak after treatment?
• How will I look?
• Will I need to change my normal activities? If so, for how long?
• When will I be able to return to work?
• How often will I need to have checkups?
  

When a person is diagnosed as having cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

Getting a Second Opinion

Treatment decisions are complex. Before starting treatment, the patient might want a second doctor to review the diagnosis and treatment plan. It may take a week or two to arrange for a second opinion. A short delay will not reduce the chance that treatment will be successful. Some insurance companies require a second opinion; others cover a second opinion if the patient requests it.

There are a number of ways to find a doctor who can give a second opinion:

• The patient's doctor may be able to suggest a specialist to consult.
• Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.

Treatment Methods

Cancer of the larynx is usually treated with radiation therapy (also called radiotherapy) or surgery. These are types of local therapy; this means they affect cancer cells only in the treated area. Some patients may receive chemotherapy, which is called systemic therapy, meaning that drugs travel through the bloodstream. They can reach cancer cells all over the body. The doctor may use just one method or combine them, depending on the patient's needs.

In some cases, the patient is referred to doctors who specialize in different kinds of cancer treatment. Often several specialists work together as a team. The medical team may include a surgeon; ear, nose, and throat specialist; cancer specialist oncologist; radiation oncologist; speech pathologist; nurse; and dietitian. A dentist may also be an important member of the team, especially for patients who will have radiation therapy.

Radiation therapy uses high-energy rays to damage cancer cells and stop them from growing. The rays are aimed at the tumor and the area close to it. Whenever possible, doctors suggest this type of treatment because it can destroy the tumor and the patient does not lose his or her voice. Radiation therapy may be combined with surgery; it can be used to shrink a large tumor before surgery or to destroy cancer cells that may remain in the area after surgery. Also, radiation therapy may be used for tumors that cannot be removed with surgery or for patients who cannot have surgery for other reasons. If a tumor grows back after surgery, it is generally treated with radiation.

Radiation therapy is usually given 5 days a week for 5 to 6 weeks. At the end of that time, the tumor site very often gets an extra "boost" of radiation.
Surgery or surgery combined with radiation is suggested for some newly diagnosed patients. Also, surgery is the usual treatment if a tumor does not respond to radiation therapy or grows back after radiation therapy. When patients need surgery, the type of operation depends mainly on the size and exact location of the tumor.

If a tumor on the vocal cord is very small, the surgeon may use a laser, a powerful beam of light. The beam can remove the tumor in much the same way that a scalpel does.
Surgery to remove part or all of the larynx is a partial or total laryngectomy. In either operation, the surgeon performs a tracheostomy, creating an opening called a stoma in the front of the neck. (The stoma may be temporary or permanent.) Air enters and leaves the trachea and lungs through this opening. A tracheostomy tube, also called a trach ("trake") tube, keeps the new airway open.

A partial laryngectomy preserves the voice. The surgeon removes only part of the voice box--just one vocal cord, part of a cord, or just the epiglottis--and the stoma is temporary. After a brief recovery period, the trach tube is removed, and the stoma closes up. The patient can then breathe and talk in the usual way. In some cases, however, the voice may be hoarse or weak.

In a total laryngectomy, the whole voice box is removed, and the stoma is permanent. The patient, called a laryngectomee, breathes through the stoma. A laryngectomee must learn to talk in a new way.
If the doctor thinks that the cancer may have started to spread, the lymph nodes in the neck and some of the tissue around them are removed. These nodes are often the first place to which laryngeal cancer spreads.

Chemotherapy is the use of drugs to kill cancer cells. The doctor may suggest one drug or a combination of drugs. In some cases, anticancer drugs are given to shrink a large tumor before the patient has radiation therapy or surgery. Also, chemotherapy may be used for cancers that have spread.

Anticancer drugs for cancer of the larynx are usually given by injection into the bloodstream. Often the drugs are given in cycles--a treatment period followed by a rest period, then another treatment and rest period, and so on. Some patients have their chemotherapy in the outpatient part of the hospital, at the doctor's office, or at home. However, depending on the drugs, the treatment plan, and the patient's general health, a hospital stay may be needed.

Treatment Studies

Researchers are looking for treatment methods that are more effective against cancer of the larynx and have fewer side effects. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.

Many clinical trials of new treatments for cancer of the larynx are under way. Doctors are studying new types and schedules of radiation therapy, new drugs, new drug combinations, and new ways of combining various types of treatment. Scientists are trying to increase the effectiveness of radiation therapy by giving treatments twice a day instead of once. Also, they are studying drugs called "radiosensitizers." These drugs make the cancer cells more sensitive to radiation.

People who have had cancer of the larynx have an increased risk of getting a new cancer in the larynx or in the lungs, mouth, or throat. Doctors are looking for ways to prevent these new cancers. Some research has shown that a drug related to vitamin A may protect people from new cancers.

Patients who are interested in taking part in a trial should talk with their doctor.

Side Effects of Treatment

The methods used to treat cancer are very powerful. It is hard to limit the effects of therapy so that only cancer cells are removed or destroyed; healthy cells also may be damaged. That's why treatment often causes unpleasant side effects.

The side effects of cancer treatment vary. They depend mainly on the type and extent of the treatment. Also, each person reacts differently. Doctors try to plan the patient's therapy to keep problems to a minimum. Doctors, nurses, dietitians, and speech pathologists can explain the side effects of treatment and suggest ways to deal with them. It may also help to talk with another patient. In many cases, a social worker or another member of the medical team can arrange a visit with someone who has had the same treatment.

Radiation Therapy

During radiation therapy, healing after dental treatment may be a problem. That's why doctors want their patients to begin treatment with their teeth and gums as healthy as possible. They often recommend that patients have a complete dental exam and get any needed dental work done before the radiation therapy begins. It's also important to continue to see the dentist regularly because the mouth may be sensitive and easily irritated during cancer therapy.

In many cases, the mouth is tender during treatment, and some patients may get mouth sores. The doctor may suggest a special rinse to numb the mouth and reduce the discomfort.

Radiation to the larynx causes changes in the saliva and may reduce the amount of saliva. Because saliva normally protects the teeth, tooth decay can be a problem after treatment. Good mouth care can help keep the teeth and gums healthy and can make the patient feel more comfortable. Patients should do their best to keep their teeth clean. If it's hard to floss or brush the teeth in the usual way, patients can use gauze, a soft toothbrush, or a special toothbrush that has a spongy tip instead of bristles. A mouthwash made with diluted peroxide, salt water, and baking soda can keep the mouth fresh and help protect the teeth from decay. It may also be helpful to use a fluoride toothpaste and/or a fluoride rinse to reduce the risk of cavities. The dentist may suggest a special fluoride program to keep the mouth healthy.

If reduced saliva makes the mouth uncomfortably dry, drinking plenty of liquids is helpful. Some patients use a special spray (artificial saliva) to relieve the dryness.
Patients who have radiation therapy instead of surgery do not have a stoma. They breathe and talk in the usual way, although the treatment can change the way their voice sounds. Also, their voice may be weak at the end of the day, and it is not unusual for the voice to be affected by changes in the weather. Voice changes and the feeling of a lump in the throat may come from swelling in the larynx caused by the radiation. The treatment can also cause a sore throat. The doctor may suggest medicine to reduce swelling or relieve pain.

During radiation therapy, patients may become very tired, especially in the later weeks. Resting is important, but doctors usually advise their patients to try to stay as active as they can. It's also common for the skin in the treated area to become red or dry. The skin should be exposed to the air but protected from the sun, and patients should avoid wearing clothes that rub the area. During radiation therapy, hair usually does not grow in the treated area; if it does, men should not shave. Good skin care is important at this time. Patients will be shown how to keep the area clean, and they should not put anything on the skin before their radiation treatments. Also, they should not use any lotion or cream at other times without the doctor's advice.

Some patients complain that radiation therapy makes their tongue sensitive. They may lose their sense of taste or smell or may have a bitter taste in their mouth. Drinking plenty of liquids may lessen the bitter taste. Often, the doctor or nurse can suggest other ways to ease these problems. And it helps to keep in mind that, although the side effects of radiation therapy may not go away completely, most of them gradually become less troublesome and patients feel better when the treatment is over.

Surgery

Keeping the patient comfortable is an important part of routine hospital care. If pain occurs, it can be relieved with medicine. Patients should feel free to discuss pain control with the doctor.

For a few days after surgery, the patient isn't able to eat or drink. At first an intravenous (IV) tube supplies fluids. Within a day or two, the digestive tract is getting back to normal, but the patient still cannot swallow because the throat has not healed. Fluids and nutrition are given through a feeding tube (put in place during surgery) that goes through the nose and throat to the stomach. As the swelling in the throat goes away and the area begins to heal, the feeding tube is removed. Swallowing may be difficult at first, and the patient may need the guidance of a nurse or speech pathologist. Little by little, the patient returns to a regular diet.

After the operation, the lungs and windpipe produce a great deal of mucus, also called sputum. To remove it, the nurse applies gentle suction with a small plastic tube placed in the stoma. Soon, the patient learns to cough and to suction mucus through the stoma without the nurse's help. For a short time, it may also be necessary to suction saliva from the mouth because swelling in the throat prevents swallowing.

Normally, air is moistened by the tissues of the nose and throat before it reaches the windpipe. After surgery, air enters the trachea directly through the stoma and cannot be moistened in the same way. In the hospital, patients are kept comfortable with a special device that adds moisture to the air.
For several days after a partial laryngectomy, the patient breathes through the stoma. Soon the trach tube is removed; within the next few weeks, the stoma closes. The patient then breathes and speaks in the usual way, although the voice may not sound exactly the same as before.

After a complete laryngectomy, the stoma is permanent. The patient breathes, coughs, and "sneezes" through the stoma and has to learn to talk in a new way. The trach tube stays in place for at least several weeks (until the skin around the stoma heals), and some people continue to use the tube all or part of the time. If the tube is removed, it is usually replaced by a smaller tracheostomy button (also called a stoma button). After a while, some laryngectomees get along without either a tube or a button.

After a laryngectomy, parts of the neck and throat may be numb because nerves have been cut. Also, following surgery to remove lymph nodes in the neck, the shoulder and neck may be weak and stiff.

Chemotherapy

The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, such as blood cells that fight infection, cells that line the digestive tract, and cells in hair follicles. As a result, patients may have side effects such as lower resistance to infection, loss of appetite, nausea, vomiting, or mouth sores. They may also have less energy and may lose their hair.

Effects of Treatment on Eating

Loss of appetite can be a problem for patients treated for laryngeal cancer. People may not feel hungry when they are uncomfortable or tired.
Patients who have had a laryngectomy may lose their interest in food because the operation changes the way things smell and taste. Radiation therapy also tends to affect the sense of taste. The side effects of chemotherapy can also make it hard to eat. Yet good nutrition is important. Eating well means getting enough calories and protein to prevent weight loss, regain strength, and rebuild normal tissues.

After surgery, learning to swallow again may take some practice with the help of a nurse or speech pathologist. Some patients find liquids easier to swallow; others do better with solid foods. If eating is difficult because the mouth is dry from radiation therapy, patients may want to try soft, bland foods moistened with sauces or gravies. Others enjoy thick soups, puddings, and high-protein milkshakes. The nurse and the dietitian will help the patient choose the right kinds of food. Also, many patients find that eating several small meals and snacks during the day works better than trying to have three large meals.

Rehabilitation

Learning to live with the changes brought about by cancer of the larynx is a special challenge. Rehabilitation is a very important part of the treatment plan. The medical team makes every effort to help patients return to their normal activities as soon as possible.

Each laryngectomee must be able to care for the stoma. Before leaving the hospital, the patient learns to remove and clean the trach tube or stoma button, suction the trach, and care for the area around the stoma. The skin is less likely to become irritated if it is kept clean.

When shaving, men should keep in mind that the neck may be numb for several months after surgery. To avoid nicks and cuts, it may be best to use an electric shaver until normal feeling returns.

Most people continue to use a stoma cover after the area heals. Stoma covers--such as scarves, neckties, ascots, and special bibs--can be attractive as well as useful. They help keep moisture in and around the stoma. Also, laryngectomees may be sensitive to dust and smoke, and the cover filters the air that enters the stoma. The cover also catches any discharge from the windpipe when the person coughs or sneezes.

Whenever the air is too dry, as it may be in heated buildings in the winter, the tissues of the windpipe and lungs may react by producing extra mucus. Also, the skin around the stoma may get crusty and bleed. Using a humidifier at home or in the office can lessen these problems.

A person who has had neck surgery may find that the neck is somewhat smaller. Also, the neck, shoulder, and arm may not be able to move as well as before. The doctor may advise physical therapy to help the person move more normally.

After surgery, laryngectomees work in almost every type of business and can do nearly all of the things they did before. However, they cannot hold their breath, so straining and heavy lifting may be difficult. Also, laryngectomees have to give up swimming and water skiing unless they have special instruction and equipment because it would be very dangerous for water to get into the windpipe and lungs through the stoma. Wearing a special plastic stoma shield or holding a washcloth over the stoma keeps water out when showering or shaving.

Learning To Speak Again

It's natural to be fearful and upset if the voice box must be removed. Talking is part of nearly everything we do, and losing the ability to talk--even temporarily--can be frightening. Patients and their families and friends need understanding and support during this very difficult time.

Until patients learn to talk again, it is important for them to be able to communicate in other ways. In the beginning, everyone who has had a laryngectomy has to communicate by writing, gesturing, or pointing to pictures, words, or letters. Some people like to use a "magic slate" for writing notes. Others use pads of paper and pens or pencils. It's handy to have a supply of pads that fit easily in a pocket or purse. In addition, some patients use a typewriter or computer. Others carry a small dictionary or a picture book (sometimes called a picture dictionary) and point to the words they need. Patients may want to select some of these items before the operation.

Within a week or so after a partial laryngectomy, most people can talk in the usual way. After a total laryngectomy, patients must learn to speak in a new way. A speech pathologist usually meets with the patient before surgery to explain the methods that can be used. In many cases, speech lessons can begin before the person leaves the hospital.
Patients may try out various new ways of talking. One way is to use air forced into the esophagus to produce the new voice (esophageal speech). Or the voice can come from some type of mechanical larynx. Some people rely on a mechanical larynx only until they learn esophageal speech, some decide to use this device instead of esophageal speech, and some use both.

Even though esophageal speech may sound low-pitched and gruff, many people want to use this method instead of a mechanical larynx because it sounds more like regular speech. Also, there's nothing to carry around, and the person's hands are free. A speech pathologist teaches the laryngectomee how to force air into the top of the esophagus and then push it out again. The puff of air is like a burp. It vibrates the walls of the throat, producing sound for the new voice. The tongue, lips, and teeth form words as the sound passes through the mouth.

For some laryngectomees, air for esophageal speech comes through a tracheoesophageal puncture. The surgeon creates a small opening between the trachea and the esophagus. A plastic or silicone valve is inserted into this opening through the stoma. The valve keeps food out of the trachea. When the stoma is covered, air from the lungs is forced into the esophagus through the valve. The air produces sound by making the walls of the throat vibrate. Words are formed in the mouth.

It takes practice and patience to learn esophageal speech, and not everyone is successful. How quickly a person learns, how natural the new voice sounds, and how understandable the speech is depend partly on the type and extent of the surgery. Other important factors are the patient's desire to learn and the help that's available. Patience and support from loved ones are important, too.

A mechanical larynx may be used until the person learns esophageal speech or if esophageal speech is too difficult. The device may be powered by batteries (electrolarynx) or by air (pneumatic larynx). The speech pathologist can help the patient choose a device and learn to use it.

One kind of electrolarynx looks like a small flashlight. It has a disk that makes a humming sound. The device is held against the neck, and the sound travels through the neck to the mouth. (This device may not be suitable for people who have had radiation therapy.) Another type of electrolarynx has a flexible plastic tube that carries sound to the person's mouth from a hand-held device.

A pneumatic larynx is held over the stoma and uses air from the lungs instead of batteries to make it vibrate. The sound it makes travels to the mouth through a plastic tube.

Followup Care

Regular followup is very important after treatment for cancer of the larynx. The doctor will check closely to be sure that the cancer has not returned. Checkups include exams of the stoma, neck, and throat. From time to time, the doctor does a complete physical exam, blood and urine tests, and x-rays. People treated with radiation therapy or partial laryngectomy will have a laryngoscopy.

People who have been treated for cancer of the larynx have a higher-than-average risk of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who smoke. Most doctors strongly urge their patients to stop smoking to cut down the risk of a new cancer and to reduce other problems, such as coughing.

Cause and Prevention

Cancer of the larynx occurs most often in people over the age of 55. In the United States, it is four times more common in men than in women and is more common among black Americans than among whites. Scientists at hospitals and medical centers all across the country are studying this disease to learn more about what causes it and how to prevent it.

Doctors cannot explain why one person gets cancer of the larynx and another does not, but we are sure that no one can "catch" cancer from another person. Cancer is not contagious.

One known cause of cancer of the larynx is cigarette smoking. Smokers are far more likely than nonsmokers to develop this disease. The risk is even higher for smokers who drink alcohol heavily.

People who stop smoking can greatly reduce their risk of cancer of the larynx, as well as cancer of the lung, mouth, pancreas, bladder, and esophagus. Also, by quitting, those who have already had cancer of the larynx can cut down the risk of getting a second cancer of the larynx or a new cancer in another area. Special counseling or self-help groups are useful for some people who are trying to stop smoking. Some hospitals have groups for people who want to quit.

Working with asbestos can increase the risk of getting cancer of the larynx. Asbestos workers should follow work and safety rules to avoid inhaling asbestos fibers.
People who think they might be at risk for developing cancer of the larynx should discuss this concern with their doctor. The doctor may be able to suggest ways to reduce the risk and can suggest an appropriate schedule for checkups

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