Laryngeal (Voice Box) Cancer: What Patients Should Know in Decision Making
Written by Gregory T. Wolf, M.D.,
Head and Neck Oncology Program; Department of Otolaryngology
Cancer Evaluation and StagingThe first step in decision-making for patients with cancer of the larynx is accurate diagnosis and staging. This requires adequate tissue biopsy and histologic interpretation by a pathologist. Generally, these cancers are not difficult to diagnose by the pathologist, but if the clinical presentation is unusual (i.e. cancer in a younger person or non-smoker), or if the appearance is not typical or the growth is too slow or too fast, a second interpretation or re-biopsy may be warranted.
Because most treatment decisions are based on the size and extent of the cancer, precise direct visualization of the cancer is required. This usually involves examination with an endoscope in the physician's office, which allows determination of vocal cord mobility and other dynamic features and also direct laryngoscopy with a microscope under anesthesia. The exact size, shape and depth of invasion can be better determined and a search for adjacent areas of pre-malignant or malignant change can be assessed in other areas such as the oral cavity, pharynx and esophagus. The larynx is connected with the back of the tongue and the lower swallowing passageways and so these areas must also be examined thoroughly.
Radiologic imaging studies such as computerized tomographic (CAT) scans and magnetic resonance imaging (MRI) are often used to examine the neck for cancer spread outside the larynx or involvement of lymph nodes. Chest x-ray and barium swallow x-rays of the esophagus are routinely obtained looking for cancer involving the lungs or the esophagus (swallowing passage). Using information derived from these assessments, the cancer is "staged", i.e. descriptive numbers are assigned that categorize the cancer's size and potential for curability.
The AJCC has established guidelines for staging of cancer of the larynx that assign a description for the tumor (T), the regional or neck lymph nodes (N) and presence of distant metastases (spread of cancer) (M). Cancer of the larynx is often grouped into early (Stage I), intermediate (Stage II) or advanced (Stages III & IV) disease groups. Early cancers are remarkably curable with five-year survival or "cure rates" of 80-95% compared to advanced stages that have five-year survival rates of 25-50%.
Important elements of prognosis that are not represented in such a staging system include a patient's general health, age, immune function, and co-morbidities such as weight loss, heart disease, hypertension or diabetes. Because these cancers usually occur in patients in the sixth or seventh decade of life, as many as 15-20% die of causes other than the cancer itself.
Many factors enter into decision-making when it comes to the treatment or laryngeal cancer. Perhaps more than any other type of cancer, a patient's wishes are a significant element in every decision because of the wide variety of treatments available, the differences in how each treatment affects voice, swallowing and quality of life and the similarities in cure rates among the various treatments. Many of the decisions are influenced by subtle variations in the size or location of the cancer such that patients should seek out the most knowledgeable head and neck oncologists to get information specific to their individual cancer.
A skilled practitioner experienced in the diagnosis and staging of these cancers can only provide such advice. These cancers are usually slow growing and so, if necessary, there is ample time for consultation with both surgical, radiation and medical oncologists. Usually the surgical oncologist will "stage" the cancer and outline various treatment options and often will consult the specialists in the other disciplines.
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