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What Patients Should Know in Decision Making for Cancer of the Larynx

Written by Gregory T. Wolf, M.D.,
Head and Neck Oncology Program; Department of Otolaryngology

Table of Contents:

Overview

Cancers arising in the larynx (voice box) are devastating malignancies that account for roughly 200,000 deaths annually worldwide. Although this only represents 2-5% of all malignancies, these cancers have special importance because of their significant effects on voice, swallowing and quality of life. In the United States, it is estimated that over 12,000 new cases are diagnosed each year and that this incidence is increasing during a time that many other cancers are decreasing.

Tobacco use is known to be the major predisposing factor for laryngeal cancer. However, alcohol use, nutritional deficiencies, genetic predisposition and viral factors may also play a role. The vast majority (85-90%) of cancers of the larynx are squamous cell carcinomas that arise from the covering of the vocal cords.

Common Symptoms

Common symptoms are hoarseness, painful swallowing, earache or development of a mass in the neck. When diagnosed early, these cancers are readily curable. Modern treatment approaches have become increasingly complex, as sophisticated methods have been developed to try and preserve vocal function. Because of this, a variety of treatment options are available and selecting the optimal treatment has become a complex and often confusing process for patients. In making these decisions, patients and their families can benefit greatly from understanding how various cancer treatments will affect vocal function and quality of life and how cancer staging and tumor location influence treatment recommendations. This brief article will outline some of the essential considerations that impact treatment decision-making for patients with cancer of the larynx.

How Cancer Affects Vocal Function

As tumors grow they encroach on the airway and affect the muscles of the voice box. These muscles are vitally important in providing protection of the trachea (windpipe) during swallowing of solids, liquids and saliva. When interfered with, closure of the larynx is incomplete and can lead to severe coughing, choking or even chronic pneumonia. The structure of the voice box also provides rigid support for the trachea (windpipe) to facilitate respiration. Compromise of this function causes shortness of breath, noisy and labored breathing. Finally, the larynx is important in communication. The voice box consists of upper and lower components. The upper part is called the supraglottic larynx and consists of the epiglottis; false vocal cords and supporting muscles within the framework of the cartilaginous "box" called the thyroid cartilage. When cancers grow here, they interfere with swallowing and cause pain in the ear, but only affect the voice in a minor way, leading to "thick" speech, "hot potato" voice or change in timbre. The lower part of the voice box contains the true vocal cords and extends down to the top of the windpipe, the cricoid cartilage. Cancer in this region, termed the glottis, causes significant hoarseness as the primary symptom.

There are natural cartilage and fibrous barriers to spread of cancer within the larynx that are well understood by head and neck surgeons. These barriers prevent the spread and invasion of malignant cells so that cancer of the glottis (true vocal cords) tends to remain localized for long periods of time, often six to eight months, before they are discovered. Because there is a sparse lymphatic drainage system in this region, spread of cancer to adjacent lymph nodes in the neck is generally a late stage of malignant growth. In the supraglottic larynx (false vocal cords and epiglottis), however, the tissues are looser, lymphatics more abundant and spread to lymph nodes occurs early and often. Thus, most treatment approaches for cancer, even early ones arising in the supraglottic larynx, include treatment of the lymph nodes in the neck, while treatment of early vocal cord (glottic) cancer is focused on the primary tumor in the larynx.

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Cancer Evaluation and Staging

The 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. (Table 1) 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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