Laryngeal and Hypopharyngeal Cancer

What is cancer?

The body is made up of hundreds of millions of living cells. Normal body cells grow, divide, and die in an orderly fashion. During the early years of a person's life, normal cells divide faster to allow the person to grow. After the person becomes an adult, most cells divide only to replace worn-out or dying cells or to repair injuries.

Cancer begins when cells in a part of the body start to grow out of control. There are many kinds of cancer, but they all start because of out-of-control growth of abnormal cells.

Cancer cell growth is different from normal cell growth. Instead of dying, cancer cells continue to grow and form new, abnormal cells. Cancer cells can also invade (grow into) other tissues, something that normal cells cannot do. Growing out of control and invading other tissues are what makes a cell a cancer cell.

Cells become cancer cells because of damage to DNA. DNA is in every cell and directs all its actions. In a normal cell, when DNA gets damaged the cell either repairs the damage or the cell dies. In cancer cells, the damaged DNA is not repaired, but the cell doesn’t die like it should. Instead, this cell goes on making new cells that the body does not need. These new cells will all have the same damaged DNA as the first cell does.

People can inherit damaged DNA, but most DNA damage is caused by mistakes that happen while the normal cell is reproducing or by something in our environment. Sometimes the cause of the DNA damage is something obvious, like cigarette smoking. But often no clear cause is found.

In most cases the cancer cells form a tumor. Some cancers, like leukemia, rarely form tumors. Instead, these cancer cells involve the blood and blood-forming organs and circulate through other tissues where they grow.

Cancer cells often travel to other parts of the body, where they begin to grow and form new tumors that replace normal tissue. This process is called metastasis. It happens when the cancer cells get into the bloodstream or lymph vessels of our body.

No matter where a cancer may spread, it is always named for the place where it started. For example, breast cancer that has spread to the liver is still called breast cancer, not liver cancer. Likewise, prostate cancer that has spread to the bone is metastatic prostate cancer, not bone cancer.

Different types of cancer can behave very differently. For example, lung cancer and breast cancer are very different diseases. They grow at different rates and respond to different treatments. That is why people with cancer need treatment that is aimed at their particular kind of cancer.

Not all tumors are cancerous. Tumors that aren’t cancer are called benign. Benign tumors can cause problems – they can grow very large and press on healthy organs and tissues. But they cannot grow into (invade) other tissues. Because they can’t invade, they also can’t spread to other parts of the body (metastasize). These tumors are almost never life threatening.

What are laryngeal and hypopharyngeal cancers?

What is the larynx?

The larynx, often called the "voice box," is one of the organs responsible for speech. It contains the vocal cords. It is located in the neck, at the opening of the trachea (windpipe). There, it helps protect the trachea from food and fluids. From the outside, the larynx can be seen on the front of your neck as the "Adam's apple." It is divided into 3 sections:

• The supraglottis (the area above the vocal cords); it contains the epiglottis, which closes off the larynx when you swallow to keep food from going into your lungs
• The glottis (the area containing the vocal cords)
• The subglottis (the area below the vocal cords)

Knowing these 3 different sections is important because the cancer is treated differently depending on where it starts.

Your larynx and vocal cords sit above your windpipe at the entrance into your lungs. They have several functions:

• The larynx produces sound for speaking.
• The larynx protects the airway during swallowing.
• The vocal cords come together to change the sound and pitch of your voice. They close tightly when you swallow to keep food and saliva from entering your lungs and causing pneumonia or blockage of breathing tubes.
• The vocal cords open naturally when you breathe so that air can get in and out of your lungs.

What is the hypopharynx?

The hypopharynx is the part of the throat that lies beside and behind the larynx. The hypopharynx is the entrance into the esophagus (the tube that connects the mouth and throat to the stomach). Food goes from the mouth and through the hypopharynx and esophagus where it then passes through the neck and chest into the stomach. The structure of the hypopharynx makes sure that food goes around the larynx and into the esophagus.

Cancers of the larynx and hypopharynx

Cancers that start in the larynx are called laryngeal cancers; cancers of the hypopharynx are called hypopharyngeal cancers. Cancers of these 2 separate structures are discussed in the same document because they are so close to each other.

Squamous cell carcinomas

Almost all of these cancers develop from the thin, flat cells (called squamous cells) that form the lining layer (called epithelium) of these 2 structures. Cancer beginning in this layer of cells is called squamous cell carcinoma or squamous cell cancer. Most squamous cell cancers of the larynx and hypopharynx begin as pre-cancerous conditions called dysplasia. Most of the time, dysplasia doesn't turn into actual cancer. It often goes away without any treatment, especially if the underlying cause (like smoking) is stopped. (See the section, "What are the risk factors for laryngeal and hypopharyngeal cancers?")

Some cases of dysplasia will progress into a condition called carcinoma in situ (CIS). In CIS, the cancer cells are only seen in the uppermost layer lining the larynx or hypopharynx. They have not grown into deeper areas of the tissue or spread to other parts of the body. CIS is the earliest form of cancer. Most of these early cancers can be cured. The usual treatment is to strip (cut away) the lining layer or destroy it with a laser beam. If CIS is not treated, most will develop into an invasive squamous cell cancer that will destroy the nearby tissues and can spread to other parts of the body.

Other cancers

Some areas of the larynx and hypopharynx have tiny glands beneath their lining layer, known as minor salivary glands. These glands produce mucus and saliva to lubricate and moisten the area. Cancer rarely develops from the cells of these glands, but when it does, these cancers have the following names:

• Adenocarcinoma
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma

These cancers are distinguished from squamous cell cancer and from one another by the kinds of cells they are made of and by the way these cells are arranged.

The shape of the larynx and hypopharynx depends on a framework of connective tissues and cartilage. Cancers such as chondrosarcomas or synovial sarcomas can develop from connective tissues of the larynx or hypopharynx, but this is extremely rare.

Because cancers forming in glands and connective tissues of the larynx or hypopharynx are so rare, they are not discussed further in this document.

The following information refers only to squamous cell cancer.

What are the key statistics about laryngeal and hypopharyngeal cancers?

The American Cancer Society's most recent estimates for laryngeal and hypopharyngeal cancer for the United States are for 2010:

• 12,720 new cases of laryngeal cancer (10,110 in men and 2,610 in women)
• 3,600 people (2,870 men and 730 women) will die from laryngeal cancer

For laryngeal cancer about 60% start in the glottis -- that is the vocal cords themselves, while 35% develop in the supraglottic region, and 5% occur in either the subglottis or overlap more than one area so that it is hard to tell where they started.

An estimated 2,850 cases of hypopharyngeal cancer are diagnosed each year (2,250 men and 600 women).

These numbers are falling about 2% to 3% a year, mainly because fewer people are smoking.

What are the risk factors for laryngeal and hypopharyngeal cancers?

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, smoking is a risk factor for many cancers including cancer of the lung. Exposing skin to strong sunlight is a risk factor for skin cancer.

But risk factors don't tell us everything. Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may not have had any known risk factors.

Laryngeal and hypopharyngeal cancers are often grouped together with other cancers of the mouth and throat into a group known as head and neck cancers. These cancers have many of the same risk factors, many of which are included below.

Tobacco and alcohol

Tobacco use is the most important risk factor for head and neck cancers (including cancers of the larynx and hypopharynx). The risk of developing cancer in these areas is much higher in smokers than in nonsmokers. These cancers are rare in people who have never smoked. Most people with these cancers have a history of smoking or other tobacco exposure. The more you smoke, the greater the risk. Smoke from cigarettes, pipes, and cigars all increase the chance of getting these cancers. Chewing tobacco also increases the risk of mouth (oral cavity) cancer.

Drinking alcohol also increases the risk of these cancers. Heavy drinkers have a risk that is several times that of nondrinkers.

People who use both tobacco and alcohol have the highest risk of all. Combining these 2 habits doesn't just add both risks together, it actually multiplies them. Some reports have found that people who smoke and drink are up to 100 times more likely to get head and neck cancer than are people with neither habit.

Nutrition

Poor nutrition may increase the risk of getting head and neck cancer. Poor nutrition and vitamin deficiencies often occur in those who abuse alcohol and may be partly responsible for alcohol's role in increased risk of these cancers. Not eating enough foods with B vitamins and vitamin A retinoids may play a role.

Human papilloma virus

The human papilloma virus (HPV) is a group of over 100 related viruses. They are called papilloma viruses because some of them cause a type of growth called a papilloma, which is more commonly known as a wart. Some types of HPV can cause cancers of the cervix, vagina, anus, vulva, or penis. HPV also seems to be a factor in some cases of throat cancer, such as cancer of the tonsils and cancers of the hypopharynx. It does not seem to be a factor in laryngeal cancer.

Weakened immune system

Laryngeal and hypopharyngeal cancers are more common in people who have a weak immune system. A weak immune system can be caused by certain diseases present at birth, the acquired immunodeficiency syndrome (AIDS), and certain medicines (such as those given after bone marrow and organ transplant).

Genetic syndromes

People with certain syndromes caused by inherited defects (mutations) in certain genes have a very high risk of throat cancer, including cancer of the hypopharynx.

Fanconi anemia is a condition that can be caused by inherited defects in several genes. People with this syndrome often have blood problems at an early age. These blood problems often lead to leukemia or aplastic anemia. They also have a high risk of cancer of the mouth and throat -- up to 500 times the risk of healthy people the same age.

Dyskeratosis congenita is another genetic syndrome that can cause aplastic anemia. People with this syndrome have a very high risk of developing cancer of the mouth and throat at an early age.

More information about Fanconi anemia and dyskeratosis congenita can be found in our document; Aplastic Anemia.

Workplace exposures

Long and intense exposures to wood dust, paint fumes, and certain chemicals used in the metalworking, petroleum, plastics, and textile industries can also increase the risk of laryngeal and hypopharyngeal cancers. Asbestos is a mineral fiber that was often used for insulation in the past. It is an important risk factor for 2 types of lung cancer called mesothelioma and bronchogenic carcinoma. Some studies have linked asbestos exposure to laryngeal cancer, but others have not shown an increased risk.

Gender

Cancers of the larynx and hypopharynx are about 4 times more common in men than women. This is because the 2 main risk factors -- smoking and alcohol abuse -- are more common in men. In recent years, however, as these habits have become more common among women, their risks for these cancers have increased as well.

Age

Cancers of the larynx and hypopharynx usually take many years to develop, so they are not common in young people. Over half of patients with these cancers are older than 65 when the cancers are first found.

Race

Cancers of the larynx and hypopharynx are more common among African Americans and whites than among Asians and Latinos.

Gastroesophageal reflux disease

When acid from the stomach comes up into the esophagus it is called gastroesophageal reflux disease (or GERD). GERD can cause heartburn and increase the chance of cancer of the esophagus. Whether or not it increases the risk of laryngeal and hypopharyngeal cancers is currently under study.

Do we know what causes laryngeal and hypopharyngeal cancers?

We don’t know what causes each case, but we do know many of the risk factors for these cancers and how some of them cause cells to become cancerous.

Recently, scientists have begun to understand how these risk factors produce certain changes in the DNA of cells, causing them to grow abnormally and form cancers. DNA is the genetic material that carries the instructions for nearly everything our cells do. We usually look like our parents because they passed their DNA on to us. But DNA affects more than our outward appearance. Some genes (parts of our DNA) contain instructions for controlling when cells grow and divide.

• Genes that promote cell division are called oncogenes.
• Genes that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes.

It is known that cancers can be caused by DNA mutations (defects) that activate (turn on) oncogenes or inactivate (turn off) tumor suppressor genes. Some people inherit DNA mutations from their parents that greatly increase their risk for developing breast, ovarian, colorectal and several other cancers. But inherited oncogene or tumor suppressor gene mutations are not believed to cause very many cancers of the larynx or hypopharynx.

Oncogene and tumor suppressor gene mutations related to these cancers usually start during life rather than before birth like an inherited mutation does. Every time a cell prepares to divide into 2 new cells, it must duplicate its DNA. This process is not perfect and copying errors occur.

Fortunately, cells have repair enzymes that proofread the DNA, but some errors may slip past. Some people may have faulty DNA repair mechanisms that make them especially vulnerable to cancer-causing chemicals and radiation. Acquired mutations in cells often result from exposure to cancer-causing chemicals -- like those found in tobacco smoke. Acquired changes in genes, such as the p53 tumor suppressor gene, are thought to be important in the development of larynx and hypopharynx cancer.

Inherited mutations of oncogenes or tumor suppressor genes rarely cause these cancers, but some people seem to inherit a reduced ability to detoxify (break down) certain types of cancer-causing chemicals and may be more susceptible to the cancer-causing effects of tobacco and alcohol.

Others may inherit an increased tendency to activate carcinogens, making them even more dangerous. These people are more sensitive to the cancer-causing effects of tobacco smoke and certain industrial chemicals. Researchers are developing tests that may help identify such people, but these tests are not yet reliable enough for routine use. Therefore, doctors recommend that all people avoid tobacco smoke and hazardous industrial chemicals.

With additional damage, the cells begin to invade (spread into neighboring tissue) and metastasize (spread to distant organs). See the section, "What's new in laryngeal and hypopharyngeal cancer research and treatment?" to learn more about recent genetic discoveries in this type of cancer.

Viruses, specifically some forms of Human papilloma virus (HPV) are emerging as important causes of some pharyngeal cancers (including cancers of the hypopharynx). Patients who develop HPV-associated hypopharyngeal cancers are less likely to have exposure to tobacco and alcohol. In addition, the outlook of HPV-associated head and neck cancers appears to be better than for HPV negative head and neck cancers.

Can laryngeal and hypopharyngeal cancers be prevented?

Most laryngeal and hypopharyngeal cancers can be prevented. The most effective way is to avoid known risk factors such as smoking and alcohol use.

Tobacco use is the most important cause of cancer in these areas. Avoiding exposure to tobacco (by not smoking and avoiding secondhand smoke) lowers the risk of these cancers. Alcohol abuse multiplies the cancer-causing effect of tobacco smoke, so it is especially important to avoid the combination of drinking and smoking.

Plenty of workplace ventilation and the use of industrial respirators when working with cancer-causing chemicals are important preventive measures.

Poor nutrition and vitamin deficiencies have been linked to laryngeal and hypopharyngeal cancers. Eating a balanced, healthy diet can help you avoid these cancers (and many others). Taking vitamins has not been shown to reduce the overall risk of these cancers and is not a substitute for a good diet.

The American Cancer Society recommends eating a variety of healthful foods, with an emphasis on plant sources. Eat at least 5 servings of fruits and vegetables every day, as well as servings of whole grain foods from plant sources such as breads, cereals, grain products, rice, pasta, or beans. Eat fewer red meats and processed meats (such as hot dogs, sausage, and lunch meat).

There are many doctors working on treatments that prevent these cancers. None have so far been successful enough to be recommended. These are discussed near the end of this document in the section, "What's new in laryngeal and hypopharyngeal cancer research and treatment?"

Can laryngeal and hypopharyngeal cancers be found early?

Many laryngeal and some hypopharyngeal cancers can be found early. They usually cause symptoms, which are described in the section, “How are laryngeal and hypopharyngeal cancers diagnosed?" Talk to your doctor if you have any of these symptoms. Many of these signs and symptoms may be caused by other cancers or by less serious, benign (non-cancerous) problems. Still, it is important to see a doctor to find out whether your symptoms are caused by a cancer or a non-cancerous condition. The sooner you receive a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.

There is no simple screening procedure to diagnose these cancers early. They are difficult to diagnose and require complex procedures. Because the cancers are not common, and the tests require specialized doctors, neither the American Cancer Society nor any other group recommends screening for these cancers.

How are laryngeal and hypopharyngeal cancers diagnosed?

Signs and symptoms

Hoarseness

Laryngeal cancers that form on the vocal cords (glottis) often cause hoarseness or a change in the voice. This can lead to them being found at a very early stage. Anyone who has voice changes (like hoarseness) that does not improve within 2 weeks should see their health care provider right away. For a complete evaluation, they may need to be referred to an ear, nose, and throat (ENT) specialist. These doctors are also known as otolaryngologists or as head and neck surgeons.

For cancers that don't start on the vocal cords, hoarseness occurs only after these cancers reach a later stage or have spread to the vocal cords. These cancers are sometimes not found until they have spread to the lymph nodes and the patient notices a growing mass in the neck.

Other problems

Cancers that start in the area of the larynx above the vocal cords (supraglottis), the area below the vocal cords (subglottis), or the hypopharynx do not generally cause hoarseness or other such clear symptoms, and are more often discovered at later stages.

Symptoms of these cancers may include:

• A sore throat that won’t go away
• Constant coughing
• Pain when swallowing
• Difficulty swallowing
• Ear pain that won’t go away
• Difficulty breathing
• Weight loss

A lump or mass in the neck

Exams and procedures for evaluating suspected laryngeal or hypopharyngeal cancer

If you have signs or symptoms that suggest a cancer of the larynx or hypopharynx might be present, your doctor will recommend 1 or more of the following tests or procedures.

Complete medical history and physical exam

The first step in any medical evaluation is for your doctor to gather information about symptoms, risk factors, and family history and medical conditions. A thorough physical exam will help uncover any signs of possible cancer or other diseases. In particular, your doctor will look for any signs that the cancer has spread, such as enlarged lymph nodes in your neck.

Blood tests

Blood tests do not help diagnose laryngeal or hypopharyngeal cancer. Still, blood may be drawn to check liver and kidney function, as well as look for blood diseases to help evaluate a patient's overall medical condition.

Consultation with a specialist

If your doctor suspects a cancer of the larynx or hypopharynx, you will be referred to an otolaryngologist (a specialist in diseases of the ear, nose, and throat).

Complete head and neck exam

Anyone suspected of having a laryngeal or hypopharyngeal cancer needs to have a thorough physical exam with special attention to the head and neck area. In order to examine the larynx and hypopharynx, special mirrors or a fiber-optic laryngoscope is needed. A fiberoptic laryngoscope is a thin, flexible, lighted tube that can be inserted through the mouth or nose to look at these areas. When the fiberoptic laryngoscope is used to look at the larynx it is called direct laryngoscopy. When mirrors are used, it is called indirect laryngoscopy. Both procedures can be done in the doctor's office to help find the cause of symptoms, such as hoarseness or throat pain.

Because patients with laryngeal or hypopharyngeal cancer have a higher risk for other cancers in the head and neck region, the nasopharynx (area behind the nose), mouth, tongue, and the neck are carefully looked at and felt for any evidence of cancer.

Panendoscopy

Panendoscopy is a procedure that combines laryngoscopy, esophagoscopy, and (at times) bronchoscopy. This allows the doctor to thoroughly examine the entire area containing the larynx and hypopharynx, including the esophagus and trachea (windpipe). This procedure is usually done in an operating room on an outpatient basis. The patient is given general anesthesia so that they are asleep for the procedure. The patient is examined for tumors in the larynx and hypopharynx, as well as other parts of the mouth, nose, and throat. If a tumor is found that is large or seems likely to spread, the doctor may also need to look into the esophagus or the trachea (windpipe).

Your doctor will look at these areas through the scope to find any tumor, see how large it is, and see how far it may have spread to surrounding areas. A small piece of tissue from the tumor or other abnormal area may be removed so that it can be looked at under the microscope to see if cancer is present. This is called a biopsy, and it can be performed with a special instrument operated through the scope. Most often, biopsies of the hypopharynx or larynx are performed in the operating room under general anesthesia.

Imaging tests

Once a tumor is detected by examination, imaging studies may be useful to determine the extent of spread.

Computed tomography scan

The computed tomography (CT) scan (also known as a CAT scan) is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture like a standard x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image that represents a "slice" of your body. The machine takes pictures of multiple slices of the part of your body being studied. This test can help your doctor determine the size of the tumor, whether it is growing into nearby tissues, and if it has spread to lymph nodes in the neck.

Depending on the areas being scanned, you may be asked to drink 1 to 2 pints of a liquid called "oral contrast" before any pictures are taken. This helps outline the intestine so that certain areas are not mistaken for tumors.

You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body. Some people are allergic to the dye and get hives, a flushed feeling, or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays.

CT scans take longer than regular x-rays, and you need to lie still on a table while they are being done. But the newest machines only take a few minutes, so your scan might be pleasantly short.

Magnetic resonance imaging

Magnetic resonance imaging (MRI) scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of your body. Not only does this produce cross-sectional slices of the body like a CT scanner, it also produces slices that are parallel with the length of your body.

A contrast material may be injected just as with CT scans. This is not the same contrast that is used for CT scans, so being allergic to one does not mean that you are allergic to the other type. MRI scans are often used to examine the neck. They are also very useful in providing pictures of the brain and spinal cord. They are sometimes more helpful than CT scans for other areas of the body as well.

MRI scans take longer than CT scans -- often up to an hour. Also, you are placed inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces (claustrophobia). Special, "open" MRI machines can help with this if needed. The machine makes a thumping noise, and some places will provide headphones with music to block out the noise.

Barium swallow

This is a series of x-rays taken while the patient swallows a liquid containing barium. Barium can be seen on the x-rays as it coats the throat. It is useful to see how your throat looks as you swallow. It also shows what your hypopharynx looks like and how it functions.

Chest x-ray

A chest x-ray may be done to see if cancer is present in the lungs. Since smoking causes lung cancer as well as laryngeal and hypopharyngeal cancers, people with these latter 2 cancers have a high risk of lung cancer. Also, laryngeal and hypopharyngeal cancers can spread to the lungs. If any suspicious spots are noted on the chest x-ray, a CT scan of the chest may be needed.

Positron emission tomography

In a positron emission tomography (PET) scan, radioactive glucose (sugar) is injected into the patient's vein to look for cancer cells. Cancers use glucose (sugar) at a higher rate than normal tissues, so the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful for spotting small collections of cancer cells. It may also help tell if a tumor is benign or malignant. Your doctor may use this test to see if the cancer has spread to lymph nodes or elsewhere. PET scans can be used instead of several different x-rays because they can scan your whole body. Some machines combine a CT scan with a PET scan to even better pinpoint the tumor.

For more information on these tests, see our document, Imaging (Radiology) Tests.

Types of biopsies used to diagnose laryngeal and hypopharyngeal cancers

A biopsy is a procedure that removes a sample of tissue for examination under the microscope. It is the only way to confirm the diagnosis of cancer.

Endoscopic biopsy

The larynx and hypopharynx are located deep inside the neck, so biopsies of these areas are not done in the doctor's office. These are performed in the operating room while you are under general anesthesia (asleep). The surgeon uses special instruments through the endoscope to remove small tissue samples.

Fine needle aspiration biopsy

For a fine needle aspiration (FNA) biopsy, a thin needle is placed into the mass (or tumor) to obtain cells for a biopsy. The cells are looked at under a microscope to see if the swelling is caused by something benign (like an infection), or if it is cancer. This is often done to find the cause of an enlarged lymph node. FNA is not used to biopsy the larynx or hypopharynx.

If the FNA finds cancer, the pathologist (a doctor specializing in diagnosing disease by examining tissues with a microscope) examining the specimen can often tell what type of cancer it is. If the type of cancer seen is consistent with cancers that begin in the larynx or hypopharynx, these areas are examined also.

FNA biopsies may be useful in other situations as well. If a patient with laryngeal or hypopharyngeal cancer has a neck mass that can be felt, an FNA can help determine if the mass is due to the spread of the cancer. FNA may also be used in patients whose laryngeal or hypopharyngeal cancer has been treated by surgery and/or radiation therapy, to find out if a new neck mass in the treated area is scar tissue, or to find out if your cancer has come back (recurred).

If FNA is used to look at a lymph node and the results are benign, it only means that cancer was not found in that lymph node. Cancer could still be present in other places. If you are having symptoms suggesting a laryngeal or hypopharyngeal cancer, you will need other procedures to find the cause of the symptoms.

How are laryngeal and hypopharyngeal cancers staged?

Staging is the process of finding out how far a cancer has spread. The extent of spread of laryngeal or hypopharyngeal cancer is the most important factor in selecting treatment options and estimating the course of a patient’s illness and their outlook for recovery and survival (prognosis). A staging system is a way for members of the cancer care team to summarize the extent of a cancer's spread.

If you have laryngeal or hypopharyngeal cancer, ask your cancer care team to explain the staging of your cancer in a way that you understand. Knowing all you can about staging lets you take a more active role in making informed decisions about your treatment.

The American Joint Committee on Cancer (AJCC) TNM System

The most common system used to describe the stages of cancers is the American Joint Committee on Cancer (AJCC) TNM system.

• T stands for tumor (its size and how far it has spread within the larynx and hypopharynx and to nearby organs).
• N stands for spread to nearby lymph nodes in the neck (lymph nodes are bean-sized collections of immune system cells that help fight infections and cancers).
• M is for metastasis (spread to distant organs).

Using the TNM staging system, information about the tumor, lymph nodes, and metastasis is combined to assign a stage. This process is called stage grouping. The stage is described in Roman numerals from I to IV. Patients with lower stage cancers have a better outlook for a cure or long-term survival.

The T stage of cancers of the larynx and hypopharynx depends on how far it has spread to the surrounding tissues from its origin. Spread may be evaluated by indirect examinations using mirrors, by direct endoscopy using scopes, and, if your doctor can reach it, by feeling the texture of the area.

The T stage of laryngeal cancer also depends upon the movement of the vocal cords. The doctor will watch the vocal cords with an endoscope or special mirrors while the patient makes certain sounds. If the vocal cords move normally, the cancer likely has not affected deeper tissues. Vocal cord fixation (lack of movement) suggests involvement by cancer. Imaging studies such as CT or MRI scans may be used to add more detailed information.

T staging of laryngeal and hypopharyngeal cancers describes spread of the cancer precisely in relation to specific areas of the larynx, hypopharynx, and the surrounding structures. Higher T stage numbers indicate more spread within the larynx or hypopharynx and to other nearby areas in the neck.

The features used to assign the T stage of laryngeal cancer vary according to the area of the larynx involved -- supraglottis, glottis, or subglottis. T staging for hypopharyngeal cancer differs from T staging for cancer of the larynx.

You may want to talk to your doctor about the stage of your cancer. It will be important that the doctor illustrate it using a diagram of the larynx.

T stages common to all laryngeal and hypopharyngeal cancers

TX: not enough information available to stage the tumor

T0: No tumor can be found

Tis: Carcinoma in situ. The cancer cells are only growing in the most superficial layer (the epithelium), with no cancer growing into the underlying connective tissue of the larynx or hypopharynx. (Very few hypopharyngeal and larynx cancers are found at this early stage.)

T stages of supraglottic cancer

For cancer of the supraglottis, the T stage is based on how many different parts (or sites) of the larynx are involved and how far outside the larynx the cancer has spread. The 5 subsites of the supraglottic part of the larynx are:

• The false vocal cords (or ventricular bands)
• Arytenoids
• Suprahyoid epiglottis
• Infrahyoid epiglottis
• Aryepiglottic folds

Whether or not the vocal cords move normally is also considered. When the vocal cords do not move normally it often means that the cancer is growing into them. This is a more advanced T stage.

T1: The vocal cords move normally and the tumor is only growing in 1 subsite of the supraglottis.

T2: The tumor is growing into at least 2 subsites of the supraglottis (or glottis); the vocal cords still move normally.

T3: Either:

1) The tumor is growing only in the larynx and has caused the vocal cords to stop moving.

OR

2) The tumor is growing into the postcricoid area, paraglottic space, or pre-epiglottic (in front of the epiglottis) tissues.

OR

3) Both #1 and #2 are true.

T4a: The tumor is growing through thyroid cartilage (firm tissue that separates the thyroid gland from the front of the larynx) and/or is growing into tissues beyond the larynx (such as the thyroid gland, trachea, esophagus, tongue muscles, or neck muscles). This is known as moderately advanced local disease.

T4b: The tumor is growing into the tissue in front of the spine in the neck (the prevertebral space), is growing around a carotid artery, or is growing down into the front of the chest cavity. T4b tumors are also known as very advanced local disease.

T stages of glottic cancer

T1: The tumor is growing only in the vocal cord(s); the vocal cords move normally.

• T1a: The tumor is only growing in 1 vocal cord.
• T1b: The tumor is on both vocal cords.

T2: The tumor is growing into the supraglottis and/or subglottis, and/or the vocal cords move only a little.

T3: The tumor is growing only in the larynx and the vocal cords don’t move and/or the tumor is growing into the paraglottic space, and/or the tumor has started growing into the thyroid cartilage (firm tissue that separates the thyroid gland from the front of the larynx).

T4a: The tumor has grown through the thyroid cartilage and/or is growing into tissues beyond the larynx (such as the thyroid gland, trachea, esophagus, tongue muscles, or neck muscles). This is known as moderately advanced local disease.

T4b: The tumor is growing into the tissue in front of the spine in the neck (the prevertebral space), surrounds a carotid artery, or is growing down into the front of the chest cavity. T4b tumors are also known as very advanced local disease.

T stages of subglottic cancer

T1: The tumor is only growing in the subglottis.

T2: The tumor has grown from the subglottis to the vocal cords, with normal or reduced vocal cord movement.

T3: The tumor is l growing only in the larynx and the vocal cords don’t move.

T4a: The tumor is growing through the cricoid or thyroid cartilage and/or is growing into tissues beyond the larynx (such as the thyroid gland, trachea, esophagus, tongue muscles, or neck muscles). This is known as moderately advanced local disease.

T4b: The tumor is growing into the tissue in front of the spine in the neck (the prevertebral space), surrounds a carotid artery, is growing down into the front of the chest cavity. T4b tumors are also known as very advanced local disease.

T stages of hypopharyngeal cancer

Spread of cancer within the hypopharynx is described according to the size of the tumor and how many areas (subsites) of the hypopharynx are involved by the cancer. The 3 subsites of the hypopharynx are the:

• Pharyngo-esophageal junction
• Pyriform sinus
• Posterior pharyngeal wall

T1: The tumor is growing only in 1 subsite of the hypopharynx and it is smaller than 2 centimeters (cm) (about 3/4 of an inch) across.

T2: Either

• The tumor in growing in 2 or more subsites of the hypopharynx.

OR

• The tumor is growing in 1 subsite plus an area nearby.

OR

• The tumor is 2 to 4 cm in size with normal movement of the vocal cords.

T3: Either:

• The tumor is larger than 4 cm (about 1 1/2 inches) across.

OR

• The tumor is affecting the movement of vocal cords.

T4a: The tumor is growing into the cricoid or thyroid cartilage, hyoid bone, thyroid gland, esophagus, or the strap muscles in front of the larynx. This is known as moderately advanced local disease.

T4b: The tumor is growing into the space in front of the spine in the neck, is growing around a carotid artery, or is growing down into the front of the chest cavity. T4b tumors are also known as very advanced local disease.

N (regional lymph node) stages of laryngeal and hypopharyngeal cancers

The N staging is the same for laryngeal and hypopharyngeal cancers. The stages are as follows:

NX: The lymph nodes cannot be assessed (information not available).

N0: There is no evidence of spread to the lymph nodes.

N1: The cancer has spread to a single lymph node on the same side of the neck as the tumor is. The lymph node is not larger than 3 cm (about 1¼ inch) across.

N2: Separated into 3 sub-stages:

• N2a: The cancer has spread to a single lymph node on the same side of the neck as the tumor is. The lymph node is between 3 cm and 6 cm across.
• N2b: The cancer has spread to 2 or more lymph nodes on the same side of the neck as the tumor is. None of these lymph nodes is larger than 6 cm across.
• N2c: The cancer has spread to lymph nodes on both sides of neck or on the side opposite the tumor. None of these lymph nodes is larger than 6 cm across.

N3: The cancer has spread to at least 1 lymph node that is larger than 6 cm.

M (distant metastasis) stages of laryngeal and hypopharyngeal cancers

The M staging for all head and neck cancers, including laryngeal and hypopharyngeal cancers, is the same. The stages are as follows:

M0: The cancer has not spread to distant sites.

M1: The cancer has spread to distant sites.

Stage grouping

Once the T, N, and M stages have been assigned, this information is combined to assign an overall stage for the cancer. This process is called stage grouping. Stage grouping rules are the same for all cancers of the hypopharynx and the supraglottic, glottic, and subglottic areas of the larynx.

Stage 0: Tis, N0, M0

Stage I: T1, N0, M0

Stage II: T2, N0, M0

Stage III: T3, N0, M0, OR T1 to T3, N1, M0

Stage IVA: T4a, N0 or N1, M0, OR T1 to T4a, N2, M0

Stage IVB: T4b, Any N, M0, OR Any T, N3, M0

Stage IVC: Any T, Any N, M1

Survival rates by stage

Survival rates are often used by doctors as a standard way of discussing a person's prognosis (outlook). Some patients with cancer may want to know the survival statistics for people in similar situations, while others may not find the numbers helpful, or may even not want to know them. Whether or not you want to read about the survival statistics below for laryngeal and hypopharyngeal cancer is up to you.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, many people live much longer than 5 years (and many are cured).

Five-year relative survival rates assume that some people will die of other causes and compare the observed survival with that expected for people without the cancer. This is a more accurate way to describe the prognosis for patients with a particular type and stage of cancer.

In order to get 5-year survival rates, doctors have to look at people who were treated at least 5 years ago. Improvements in treatment since then may result in a more favorable outlook for people now being diagnosed with this type of cancer.

Survival rates are often based on previous outcomes of large numbers of people who had the disease, but they cannot predict what will happen in any particular person's case. Many other factors may affect a person's outlook, such as their general health and how well the cancer responds to treatment. Your doctor can tell you how the numbers below may apply to you, as he or she is familiar with the aspects of your particular situation.

These are data from the National Cancer Data Base, based on patients diagnosed from 1998-1999, and published in the AJCC staging manual (see the “References” section).

Supraglottis

Stage	5-year relative survival (percent)
I	59%
II	59%
III	54%
IV	34%

Glottis

Stage	5-year relative survival (percent)
I	90%
II	74%
III	56%
IV	44%

Subglottis (These numbers are less accurate because of the small number of patients.)

Stage	5-year relative survival (percent)
I	65%
II	56%
III	47%
IV	32%

Hypopharynx

Stage	5-year relative survival (percent)
I	53%
II	39%
III	36%
IV	24%

If you have any questions about the stage of your cancer or how it affects your treatment, do not hesitate to ask your doctor.

How are laryngeal and hypopharyngeal cancers treated?

General treatment information

After your cancer is diagnosed and staged, your cancer care team can recommend 1 or more treatment options. Choosing a treatment plan is an important decision, so it is important to take time and think about all of the choices.

In creating your treatment plan, the most important factors to consider are the site of the cancer and the stage (extent) of the cancer. Your cancer care team will also take into account your age, general state of health, and personal preferences.

It is often a good idea to seek a second opinion, especially with doctors experienced in treating this type of cancer. A second opinion can provide more information and help you feel more confident about the treatment plan being considered. Some insurance companies require a second opinion before they will agree to pay for certain treatments. Even if they don't require a second opinion, almost all insurance companies will pay for one.

There are 3 main methods of cancer treatment:

• Surgery
• Radiation therapy
• Chemotherapy

Sometimes the best treatment approach uses 2 or more of these methods. Your recovery is the goal of your cancer care team. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible to prevent the tumor from growing, spreading, or returning for as long as possible.

A major consideration in all treatment is to save your larynx and voice. People who lose their voice can suffer from social isolation and depression. Most experts don’t recommend surgery that will totally remove the larynx unless there are no other options.

Sometimes treatment is aimed at relieving symptoms. This is called palliative treatment.

Surgery

Several operations are commonly used in treating patients with laryngeal and hypopharyngeal cancers. Depending on the stage of the cancer and its location, one or more of these may be used to remove the cancer and some of the surrounding laryngeal or hypopharyngeal tissue and to help restore the appearance and function of the tissues affected by the treatment.

Vocal cord stripping

This technique involves using a long instrument to strip away the superficial layers of tissue on the vocal cords. This can be a way to biopsy and treat stage 0 (carcinoma in situ) cancer of the larynx. Most people can speak normally again after recovering from this operation.

Laser surgery

Lasers can be used to treat some stage 0 (carcinoma in situ) and T1 cancers. An endoscope is used to locate the tumor, which is then either vaporized or excised (cut out) using a high-intensity laser. A drawback of using vaporization is that it destroys the tissue being treated leaving nothing behind that can be sampled to look at under the microscope. If the laser is used to remove part of a vocal cord, it may result in hoarse speech.

Cordectomy

Cordectomy involves removing all or part of the vocal cords. It can be used to treat very limited or superficial glottic cancers. The effect of this procedure on speech varies depending on how much of the vocal cords are removed. Removing part of a vocal cord may result in hoarse speech. Normal speech is no longer possible after both vocal cords are removed.

Laryngectomy

Partial laryngectomy: Smaller cancers of the larynx often can be treated by removing only part of the voice box. This is called partial laryngectomy (removing the entire voice box is called total larygectomy). There are different types of partial laryngectomy procedures, but they all have the same goal: to remove the entire cancer while leaving behind as much of the natural larynx as possible. In a supraglottic laryngectomy, only the portion of the larynx above the vocal cords is removed. This procedure can be used to treat some supraglottic cancers, and allows the patient to retain normal speech. For small cancers of the vocal cords (glottis), the surgeon may be able to remove the cancer by taking out only one vocal cord and leaving the other behind. This allows for some speech to remain.

Total laryngectomy: In this procedure, the entire larynx (voice box) is removed. The voice box is removed and the windpipe is then brought up to the skin of the front of the neck as a stoma (or hole) that you breathe through (see the illustration below). Once the entire larynx is removed, normal speech is no longer possible.

Total or partial pharyngectomy

Surgery to remove all or part of the pharynx is called a pharyngectomy. This operation may be needed to treat cancers of the hypopharynx. Often, the larynx is removed along with the hypopharynx. After surgery, you may need a reconstructive procedure to rebuild the pharynx and improve your ability to swallow.

Reconstructive procedures

Myocutaneous flaps: Sometimes a muscle and area of skin may be rotated from an area close to your throat, such as the chest (pectoralis major flap), to reconstruct the throat.

Free flaps: With the advances of microvascular surgery (sewing together small blood vessels under a microscope), surgeons have many more options to reconstruct the area of your throat. Tissues from other areas of your body such as a piece of intestine or a piece of arm muscle can be used to replace parts of your throat.

Lymph node removal

Cancers of the supraglottic larynx and hypopharynx often spread to the lymph nodes in the neck. If, based on the stage and exact location of the tumor, your doctor thinks that lymph node spread is likely, it may be necessary to remove lymph nodes from your neck. This operation is called a neck dissection.

There are several forms of neck dissections ranging from the radical neck dissection to a less extensive selective neck dissection. They differ in the amount of tissue removed from the neck. The amount of tissue to be removed depends on the size and extent of cancer spread. In a full radical dissection, nerves and muscles responsible for full neck and shoulder movement are removed along with the lymph nodes. This may be needed in order to be sure that all of the lymph nodes likely to contain metastatic cancer are removed. Sometimes doctors will try to remove less normal tissue in order to keep the shoulder and neck functioning normally.

Tracheotomy

If a laryngeal or hypopharyngeal cancer is blocking the windpipe and is too large to remove completely, an opening may be made in your neck to bypass the tumor and allow you to breathe more comfortably. The new opening is called a tracheotomy. Often, a tracheotomy is only needed to protect the airway during recovery after a partial laryngectomy or pharyngectomy. It stays in place for a short time, and is removed later when it is no longer needed.

Gastrostomy tube

Cancers in the larynx and hypopharynx may prevent you from swallowing enough food to maintain good nutrition. This can make you weak and make it harder to complete treatment. A gastrostomy tube is a feeding tube that is placed through the skin and muscle of your abdomen directly into your stomach. Sometimes this tube is placed during an operation, but often it is placed endoscopically, with the patient sedated. When it is placed through endoscopy, it is called a percutaneous endoscopic gastrostomy or PEG. Once in place, it can be used to deliver extra nutrition directly into the stomach. Often, the gastrostomy tube is only needed temporarily to help you get adequate nutrition during radiation and/or chemotherapy. The feeding tube can be removed once your swallowing function improves after treatment.

Possible complications of surgery

Any surgery can lead to complications such as bleeding and infection. Laryngectomy and pharyngectomy can also lead to the development of a fistula (an abnormal opening between 2 areas that are not normally connected) or narrowing of the throat (a pharyngeal stricture). Rarely, these operations can lead to problems with the thyroid and/or parathyroid glands. Damage to the thyroid gland can lead to hypothyroidism, were the patient feels very tired and sluggish. Hypothyroidism can be relieved by taking thyroid hormone pills. Damage to the parathyroid gland can lead to problems with low calcium levels, which can cause muscle spasms and irregular heart beat. These problems are treated with calcium and vitamin D pills. A very rare but serious complication of neck surgery is rupture of the carotid artery (the large artery in the neck).

Partial laryngectomy can lead to paralysis of the remaining vocal cord, problems swallowing (called dysphagia), and narrowing of the larynx (laryngeal stenosis). The trouble swallowing can be severe enough to require the patient to use a feeding tube permanently. If the larynx becomes too narrow, a tracheostomy may be needed.

Radiation therapy

Radiation therapy uses high-energy x-rays (generated by a linear accelerator) or gamma rays (produced by radioactive cobalt isotope) and particles (such as electrons) to kill cancer cells.

Types of radiation therapy

External beam radiation therapy

Radiation delivered from outside the body is focused on the cancer. This type of radiation therapy is most often used to treat laryngeal and hypopharyngeal cancer. External beam radiation therapy for laryngeal and hypopharyngeal cancer is usually given in daily fractions (doses), 5 days per week, for about 7 weeks. Other schedules for radiation doses have been studied in clinical trials.

Hyperfractionation refers to dividing the total radiation dose over a larger number of doses (2 treatments per day instead of 1, for example). Accelerated fractionation indicates that the radiation treatment is completed faster (6 weeks instead of 7 weeks, for instance).

Several studies have found that hyperfractionation and accelerated fractionation schedules reduce the risk of laryngeal and hypopharyngeal cancer coming back in or near the place it started (called local recurrence). A recent study found that these types of radiation can also help some patients live slightly longer. The drawback is that these schedules also have more severe side effects.

Three-dimensional conformal radiation therapy (3D-CRT) is a type of external beam radiation therapy in which shaped beams are aimed at the cancer from different directions. Patients are fitted with a mold or cast to keep the body part still so the radiation can be aimed more accurately. By aiming the radiation more precisely, it may be possible to reduce radiation damage to normal tissues and better kill the cancer by increasing the radiation dose to the tumor.

Intensity modulated radiation therapy (IMRT) is a newer method much like 3D-CRT. It conforms to the tumor shape like 3D-CRT, but also allows the strength of the beams to be changed in some areas to lessen damage to normal body tissues. This gives even more control in reducing the radiation that reaches normal tissue and allows a higher dose to the tumor. It may result in fewer effects on nearby sensitive tissues. This type of radiation therapy is used often in treating some throat cancers, and may also be used for some cancers of the larynx.

Brachytherapy

Internal radiation therapy, also known as brachytherapy, uses radioactive material placed directly into or near the cancer. Brachytherapy may be used alone or in combination with external beam radiation therapy. It is rarely used to treat laryngeal and hypopharyngeal cancer.

The role of radiation therapy in treatment

Radiation may be used as the main (primary) treatment of laryngeal and hypopharyngeal cancer. If the cancer is small, it can often be destroyed by radiation without surgery. Radiation therapy can be done instead of partial laryngectomy for treating small cancers. This treatment can help to preserve better voice quality. It is also used to treat patients whose general health is too poor to undergo surgery. Often, chemotherapy is given with the radiation. This combination, called chemoradiation, can be more effective than radiation alone, but it also has more side effects. (See the “Chemotherapy” section for more details.)

After the cancer is removed with surgery, radiation therapy may be used to kill very small deposits of cancer that cannot be seen and removed during surgery. This is called adjuvant treatment.

Radiation therapy is also used to ease symptoms of laryngeal and hypopharyngeal cancer such as pain, bleeding, difficulty swallowing, and problems caused by bone metastases.

Side effects

Many people treated with radiation to the neck and throat area have problems with painful sores in the mouth and throat. These sores can make eating and drinking very difficult, and can lead to weight loss and malnutrition. The sores heal with time after the radiation has stopped.

Some less severe side effects of radiation therapy may include mild skin problems, dry mouth, sore throat, initial worsening of hoarseness, difficulty swallowing, decreased taste, possible breathing difficulty from swelling of the larynx, and tiredness. Most of these side effects go away after a short while. Side effects of radiation tend to be worse if chemotherapy is given at the same time. Talk with your doctor about these because there are ways to help.

When radiation is used as the main treatment for cancer of the larynx, it may very rarely lead to breakdown of the cartilage (called chondronecrosis). If this occurs, the patient may need to be treated with a tracheostomy or laryngectomy.

Radiation can worsen any tooth problems that already exist. Depending on the expected radiation plan and the condition of your teeth, it may be necessary to remove some or all of your teeth before starting treatment.

Radiation aimed at areas near the salivary glands may permanent damage, leading to dry mouth that does not improve with time. In addition to discomfort, a dry mouth can promote tooth decay. People with dry mouth after radiation must pay close attention to their oral health.

Chemotherapy

Systemic chemotherapy (chemo) uses anti-cancer drugs that are injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancers that have metastasized (spread) to organs beyond the head and neck.

Chemo is often given along with radiation as the main treatment for more advanced cancers of the larynx. This treatment, called chemoradiation, can allow the patient to avoid laryngectomy and retain the ability to speak. Chemotherapy is also sometimes used to help relieve symptoms from cancers that are too large to be completely removed with surgery.

Conventional chemotherapy

The chemo drugs that have been used most often for cancers of the larynx and hypopharynx are cisplatin (or carboplatin) and 5-fluorouracil (5-FU). Using these 2 drugs together may be better at shrinking tumors than when either drug is used alone. Adding a 3rd drug, docetaxel (Taxotere®), may help even more. Other drugs that may be used include bleomycin, carboplatin, methotrexate, and paclitaxel (Taxol®). These drugs may be used as single agents or in combination.

Chemotherapy drugs kill cancer cells but they also damage some normal cells, which can lead to some of their side effects. Common side effects of chemotherapy can include:

• Nausea and vomiting
• Loss of appetite
• Loss of hair
• Mouth sores
• Low blood counts

Because chemotherapy can damage the blood-producing cells of the bone marrow, the blood cell counts might become low. This can result in:

• An increased chance of infection (due to a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets)
• Shortness of breath (due to low red blood cell counts)

Fatigue is also quite common and may be caused by low red blood counts, by other reasons related to the chemotherapy, or by the cancer itself.

Some side effects are seen more often with certain chemo drugs. For example, 5-FU often causes diarrhea. Cisplatin can cause nerve damage (called neuropathy), leading to hearing loss as well as numbness and tingling in the hands and feet. This often improves once treatment is stopped, but it can persist a long time in some cases.

Most side effects disappear once treatment is stopped. Patients who have problems with side effects should talk with their cancer care team. Many side effects can be lessened or even prevented. For example, very good drugs are available to prevent or reduce nausea and vomiting.

Targeted therapy

Targeted therapy is term used for drugs that target certain parts of the cell changes and signals that are needed for a cancer to develop and keep growing. Targeted cancer therapies do not damage bone marrow or blood cells like most standard chemo drugs do. They can be used alone or along with other drugs and cancer treatments. Targeted therapy is still relatively new compared to other forms of cancer treatment, like surgery, radiation, or regular chemo.

Cetuximab (Erbitux®) is the first and only targeted therapy approved for use in laryngeal and hypopharyngeal cancers. This drug is an antibody that targets the epidermal growth factor receptor (EGFR). This receptor can be found on the surface of some normal cells, but laryngeal and hypopharyngeal cancer cells often have many more copies. EGFR takes in the signal telling the cell to grow and divide. When cetuximab blocks this signal, it can slow or stop cell growth. When cetuximab was added to radiation therapy it helped patients with advanced cancers (stages III and IV) live longer. It also has been shown to be helpful when added to cisplatin and 5-FU. This drug does not cause problems with nausea, vomiting or low blood counts like regular chemo drugs. The most common side effects of cetuximab are skin rash and more rarely, problems from allergic reactions that occur while the drug is being given into the vein.

Studies of other targeted therapy drugs to treat laryngeal and hypopharyngeal cancers are going on now.

Chemoradiotherapy

Chemoradiotherapy (also called chemoradiation) is chemotherapy given at the same time as radiation. This combination has been shown to shrink and eliminate tumors more effectively than either treatment alone. It is often used in place of laryngectomy to treat laryngeal cancer. A commonly used regimen is to give a dose of cisplatin every 3 weeks (for a total of 3 doses) during radiation. Another approach is to first give chemotherapy with a cisplatin plus other drugs (such as 5-FU or 5-FU and docetaxel). In patients who cannot tolerate cytotoxic chemotherapy in combination with radiation, cetuximab is often used instead.

If the cancer shrinks then chemoradiation is begun. If it doesn’t shrink, then surgery is recommended.

Clinical trials

You may have had to make a lot of decisions since you've been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know. You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.

Complementary and alternative therapies

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor's medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you consider your options, here are 3 important steps you can take:

• Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain providers or travel to another country?
• Talk to your doctor or nurse about any method you are thinking about using.
• Contact us at 1-800-227-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.

The choice is yours

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.

Treating laryngeal and hypopharyngeal cancers by stage

Laryngeal cancers

Stage 0

This stage is highly curable with either stripping to surgically remove the abnormal layer of cells or vaporizing the abnormal cell layer with a laser beam. The patient is then watched closely to see if the cancer returns.

If the cancer comes back, radiation will be used. Between 96% and 100% of patients at this stage will not need extensive surgery. It is important for these patients to realize that continuing to smoke increases the risk that a new cancer will develop.

Stages I and II laryngeal cancers

Most patients with stage I and II laryngeal cancer can be successfully treated without totally removing their larynx. Radiation alone (without surgery) is successful in treating 80% to 90% of patients with stage I laryngeal cancer and 70% to 80% of stage II patients.

Partial laryngectomy may also be used with similar survival results. However, voice results tend to be better with radiation therapy than with partial laryngectomy, and the complication rate for surgery tends to be greater than for radiation treatment alone. Many doctors choose to use radiation therapy for smaller cancers, only using surgery for cancers that come back after treatment. In either case, the treatment not chosen at first may be used later if initial treatment fails.

Selected superficial glottic cancers may be treated by removing the cancerous vocal cord, or even by laser excision.

Supraglottic cancers tend to spread to the neck lymph nodes. If you are having surgery for your tumor, then the surgeon will also likely remove lymph nodes from your neck. If your treatment is to be radiation therapy alone, you will also receive radiation therapy to these lymph nodes in the neck.

Stages III and IV laryngeal cancers

Stages III and IV laryngeal cancers generally require combined therapy of either surgery and radiation, or radiation and chemotherapy, or all 3 types of treatment. Surgical treatment of these tumors almost always requires complete removal of the larynx, although a small group of T3 laryngeal cancers may still be treated by partial laryngectomy.

More advanced stage cancers have a higher risk for spread to nearby lymph nodes. These lymph nodes are often removed along with the tumor if surgery is being used to treat the cancer. Radiation therapy, often given with chemo, may be required after surgery, particularly if there is lymph node metastasis.

Instead of using surgery as the first step, many doctors now prefer to start treatment with radiation and chemotherapy. Surgery can then be done to remove any remaining cancer. This approach works as well as surgery alone to treat the cancer, but it gives the patient the chance to save the larynx. If the framework of the larynx (such as the thyroid cartilage) has been destroyed by the cancer, the larynx may never work normally again – no matter what treatment is chosen. In these cases, surgery to remove the larynx may be the best treatment approach.

Cancers that are too large to be completely removed by surgery are often treated with radiation, usually combined with chemotherapy. Several studies continue to look at various methods of combined radiation and chemotherapy to improve outcomes and reduce the need for radical resection of advanced laryngeal cancer.

Hypopharyngeal cancers

These are more difficult to treat than laryngeal cancers. Because they do not cause symptoms early, most are diagnosed in an advanced stage. Tumors in this region have a high likelihood of lymph node metastasis, even when there is no obvious mass in the neck. Because of this risk, radiation therapy of the neck is recommended for patients who have had their hypopharyngeal cancer removed by surgery.

Stages I and II hypopharyngeal cancers

The 2 main options for treating small tumors are radiation and surgery. Larger tumors are treated with surgery.

Surgery would include removing all or part of the pharynx and lymph nodes in the neck. The larynx is sometimes removed as well. Patients who have a high chance of the cancer returning (based on what is found during surgery) may then be treated with radiation or chemoradiation.

Patients who receive radiation as their main treatment will be assessed after the treatment is complete. If there is still cancer in the hypopharynx, surgery will be done.

Stages III and IV hypopharyngeal cancers

These can be treated with extensive surgery followed by radiation alone or chemoradiation. Sometimes radiation is combined with the targeted therapy drug cetuximab (Erbitux). Another choice is to give chemotherapy as the first treatment. If the cancer goes away with chemo, radiation therapy is given. Lymph nodes in the neck may be removed after radiation. If the tumor shrinks without going away, the patient may receive chemoradiation or treatment with surgery. Further treatment depends upon the results of the prior therapy.

Recurrent laryngeal and hypopharyngeal cancers

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). Treatment options for patients whose laryngeal or hypopharyngeal cancers come back after treatment depend on what their initial treatment was and on the location of the recurrent cancer (local recurrence or distant recurrence).

Local recurrences in patients who have already had partial laryngectomy can be treated with total laryngectomy or with radiation therapy. If your cancer comes back locally after radiation therapy, the usual treatment is total laryngectomy, but additional radiation therapy is sometimes used. Chemotherapy (perhaps in a clinical trial) is the usual treatment for distant recurrences and for local recurrences that have not responded to combined radiation therapy and surgery.

More treatment information

For more details on treatment options -- including some that may not be addressed in this document -- the National Comprehensive Cancer Network (NCCN) and the National Cancer Institute (NCI) are good sources of information.

The NCCN, made up of experts from many of the nation's leading cancer centers, develops cancer treatment guidelines for doctors to use when treating patients. Those are available on the NCCN Web site (www.nccn.org).

The NCI provides treatment information via telephone (1-800-4-CANCER) and its Web site (www.cancer.gov). Information for patients as well as more detailed information intended for use by cancer care professionals is also available on www.cancer.gov.

What should you ask your doctor about laryngeal and hypopharyngeal cancer?

It is important to have frank, open discussions with your cancer care team. They want to answer all of your questions, no matter how trivial they might seem to you. For instance, consider these questions:

• What kind of laryngeal or hypopharyngeal cancer do I have?
• Has my cancer spread beyond the primary site?
• What is the stage of my cancer and what does that mean in my case?
• Is my cancer associated with HPV?
• What treatment choices do I have?
• Are you aware of any clinical trials I might be eligible for?
• What do you recommend and why?
• What risks or side effects are there to the treatments you suggest?
• How will this treatment affect my voice? If my larynx is removed, what are the options for restoring my voice?
• What are the chances of recurrence of my cancer with these treatment plans?
• What should I do to be ready for treatment?
• Based on what you've learned about my cancer, how long do you think I'll survive?

In addition to these sample questions, be sure to write down some of your own. For instance, you might want more information about recovery times so that you can plan your work schedule. Or you may want to ask about second opinions or about clinical trials for which you may qualify.

What happens after treatment for laryngeal and hypopharyngeal cancer?

Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.

It may take a while before your confidence in your own recovery begins to feel real and your fears are somewhat relieved. You can learn more about what to look for and how to learn to live with the possibility of cancer coming back in our document, Living with Uncertainty: The Fear of Cancer Recurrence, available at 1-800-227-2345.

Follow-up care

Patients with cancer of the larynx and hypopharynx are at risk for developing recurrences or new cancers in the head and neck area. Therefore, they must be observed closely after treatment. The health care team will decide which tests should be done and how often based on the patient's initial stage, type of treatment chosen, and response to that treatment.

These cancers recur most frequently in the first 2 years after treatment, so your head and neck will be examined (often including laryngoscopy) about every other month during the first year after treatment and quarterly during the second year. Follow-up may then be spread out to 3-, 6-, and 12-month intervals as time progresses and there is no evidence of recurrence. Chest x-rays and other imaging studies may be used to watch for a recurrence, metastasis, or a new tumor, especially if new symptoms develop. If your thyroid gland received radiation as part of your treatment, you may also need regular blood tests to check its function.

You should report any new symptoms right away because they may prompt your doctor to do tests that could help find recurrent cancer as early as possible, when the likelihood of successful treatment is greatest.

Restoring speech after total laryngectomy

After a total laryngectomy, you will not be able to speak using your vocal cords. However, there are several options for restoring speech after total laryngectomy. Losing your voice box to cancer no longer means losing your ability to talk. Learning to speak again will take time and effort. You will need to see a speech therapist who is trained in the rehabilitation of people who have had a laryngectomy. The speech therapist will play a major role in helping you to learn to speak.

Esophageal speech: After a laryngectomy, your windpipe (or trachea) has been separated from the mouth and food pipe, and therefore, you can no longer expel air from the lungs through your mouth to speak. With training, some patients can swallow air and force it through their mouth. As the air passes through the throat it will cause vibrations which, with training, people can turn into speech. This is the most basic form of speech rehabilitation. With the advent of new devices and surgical techniques, learning esophageal speech is often not necessary.

Tracheoesophageal puncture (TEP): This is the most common way that surgeons try to restore speech. TEP is done either at the time of surgery or later. This procedure creates a connection between the windpipe and food pipe through a small puncture at the stoma site. A small one-way shunt valve placed into this puncture restores your ability to force air from the lungs into the mouth. After this operation, you can cover your stoma with a finger to force air out of your mouth, producing sustained speech. This takes practice, but after surgery you can work closely with speech pathologists to learn this technique.

Electrolarynx: If you cannot have a TEP because of certain medical reasons, or while you are learning to use your TEP voice, you may use electrical devices to produce a mechanical voice. These battery-operated devices are either placed in the corner of the mouth or against the skin of the neck. When you press a button on the device, it will make a vibrating sound. By moving your mouth and tongue, you can form this sound into words. You will need training with a speech therapist to learn to use it properly.

Stoma care following total laryngectomy

Having a stoma instead of a larynx means that the air you breathe in and out will not pass through your nose or mouth. As air passes through the nose or mouth, it is humidified, warmed, and filtered (dust and other particles are removed). After a laryngectomy and tracheostomy, the air reaching the lungs will be dryer and cooler. This may irritate the lining of the breathing tubes and cause thick or crusty mucus to accumulate.

For this reason, you should learn how to take care of your stoma (periodic suctioning, cleaning, and use of a humidifier). Your doctors, nurses, and other health care professionals can teach you how to care for and protect your stoma, which includes precautions to keep water or small particles from falling into the windpipe. Support groups formed by other patients who have also had a laryngectomy can provide essential information on stoma care and use of products for protecting and cleaning the stoma.

Sexual impact of laryngectomy

Laryngectomy changes not only your physical appearance with the stoma but also your speech and breathing. Sexual intimacy may be affected because of uncomfortable feelings about appearance and awkwardness. However, there are things you can do to decrease these feelings during intimacy.

A scarf, ascot, or turtleneck shirt can look nice and hide the stoma cover. Even during sexual activity, a stoma cover may look more appealing than a bare stoma.

During sexual activity, a partner may be startled at first by breath that hits at a strange spot. On the positive side, one patient quipped, "Now when I kiss, I never have to come up for air!"

You can lessen odors from the stoma by avoiding garlic or spicy foods and by wearing perfume, cologne, after-shave, or lotion.

Sometimes problems in speaking interfere with the communication for some couples. If you have learned esophageal speech, talking during lovemaking is not a big problem. It does take more effort, though, and you lose some of the emotional overtones. A speech aid built into the stoma might also work well. However, neither method lets you whisper romantically in your partner's ear.

If you use a hand-held speech aid, communication during sex is likely to be awkward and distracting. You can say a great deal sexually, however, by guiding your partner's hand or using body language.

Talking is not needed in many sexual situations. With a new partner, you may want to discuss the kinds of touching and positions you like before you start making love.

Smoking and alcohol use

If you smoke or drink, it is very important to quit. Quitting can reduce your chance of developing a new cancer, which is a serious problem among laryngeal and hypopharyngeal cancer survivors. It can also help improve your appetite and your overall health.

Because these cancers develop in smokers, other smoking-related cancers such as lung and oral cancers are often seen later. Avoiding risk factors like smoking and drinking is the best way to prevent these cancers. Also, the high risk of developing a new cancer is one reason that people with cancers of the larynx and hypopharynx will need to continue follow-up exams for the rest of their lives.

Seeing a new doctor

At some point after your cancer diagnosis and treatment, you may find yourself in the office of a new doctor. Your original doctor may have moved or retired, or you may have moved or changed doctors for some reason. It is important that you be able to give your new doctor the exact details of your diagnosis and treatment. Make sure you have the following information handy:

• A copy of your pathology report from any biopsy or surgery
• If you had surgery, a copy of your operative report
• If you were hospitalized, a copy of the discharge summary that every doctor must prepare when patients are sent home from the hospital
• If you were treated with radiation, a copy of your treatment summary
• Finally, since some drugs can have long-term side effects, a list of your drugs, drug doses, and when you took them

It is also important to keep medical insurance. Even though no one wants to think of their cancer coming back, it is always a possibility. If it happens, the last thing you want is to have to worry about paying for treatment. Should your cancer come back, our document, When Your Cancer Comes Back: Cancer Recurrence gives you information on how to manage and cope with this phase of your treatment. You can get this document by calling 1-800-227-2345.

Lifestyle changes to consider during and after treatment

Having cancer and dealing with treatment can be time-consuming and emotionally draining, but it can also be a time to look at your life in new ways. Maybe you are thinking about how to improve your health over the long term. Some people even begin this process during cancer treatment.

Make healthier choices

Think about your life before you learned you had cancer. Were there things you did that might have made you less healthy? Maybe you drank too much alcohol, or ate more than you needed, or smoked, or didn’t exercise very often. Emotionally, maybe you kept your feelings bottled up, or maybe you let stressful situations go on too long.

Now is not the time to feel guilty or to blame yourself. However, you can start making changes today that can have positive effects for the rest of your life. Not only will you feel better but you will also be healthier. What better time than now to take advantage of the motivation you have as a result of going through a life-changing experience like having cancer?

You can start by working on those things that you feel most concerned about. Get help with those that are harder for you. For instance, if you are thinking about quitting smoking and need help, call the American Cancer Society at 1-800-227-2345.

Diet and nutrition

Eating right can be a challenge for anyone, but it can get even tougher during and after cancer treatment. For instance, treatment often may change your sense of taste. Nausea can be a problem. You may lose your appetite for a while and lose weight when you don’t want to. On the other hand, some people gain weight even without eating more. This can be frustrating, too.

If you are losing weight or have taste problems during treatment, do the best you can with eating and remember that these problems usually improve over time. You may want to ask your cancer team for a referral to a dietitian, an expert in nutrition who can give you ideas on how to fight some of the side effects of your treatment. You may also find it helps to eat small portions every 2 to 3 hours until you feel better and can go back to a more normal schedule.

One of the best things you can do after treatment is to put healthy eating habits into place. You will be surprised at the long-term benefits of some simple changes, like increasing the variety of healthy foods you eat. Try to eat 5 or more servings of vegetables and fruits each day. Choose whole grain foods instead of white flour and sugars. Try to limit meats that are high in fat. Cut back on processed meats like hot dogs, bologna, and bacon. Get rid of them altogether if you can. If you drink alcohol, limit yourself to 1 or 2 drinks a day at the most. And don't forget to get some type of regular exercise. The combination of a good diet and regular exercise will help you maintain a healthy weight and keep you feeling more energetic.

Rest, fatigue, work, and exercise

Fatigue is a very common symptom in people being treated for cancer. This is often not an ordinary type of tiredness but a “bone-weary” exhaustion that doesn’t get better with rest. For some, this fatigue lasts a long time after treatment, and can discourage them from physical activity.

However, exercise can actually help you reduce fatigue. Studies have shown that patients who follow an exercise program tailored to their personal needs feel physically and emotionally improved and can cope better.

If you are ill and need to be on bed rest during treatment, it is normal to expect your fitness, endurance, and muscle strength to decline some. Physical therapy can help you maintain strength and range of motion in your muscles, which can help fight fatigue and the sense of depression that sometimes comes with feeling so tired.

Any program of physical activity should fit your own situation. An older person who has never exercised will not be able to take on the same amount of exercise as a 20-year-old who plays tennis 3 times a week. If you haven’t exercised in a few years but can still get around, you may want to think about taking short walks.

Talk with your health care team before starting, and get their opinion about your exercise plans. Then, try to get an exercise buddy so that you’re not doing it alone. Having family or friends involved when starting a new exercise program can give you that extra boost of support to keep you going when the push just isn’t there.

If you are very tired, though, you will need to balance activity with rest. It is okay to rest when you need to. It is really hard for some people to allow themselves to do that when they are used to working all day or taking care of a household. (For more information about fatigue, please see the publication, Cancer Related Fatigue and Anemia Treatment Guidelines for Patients.)

Exercise can improve your physical and emotional health.

• It improves your cardiovascular (heart and circulation) fitness.
• It strengthens your muscles.
• It reduces fatigue.
• It lowers anxiety and depression.
• It makes you feel generally happier.
• It helps you feel better about yourself.

And long term, we know that exercise plays a role in preventing some cancers. The American Cancer Society, in its guidelines on physical activity for cancer prevention, recommends that adults take part in at least 30 minutes of moderate to vigorous physical activity, above usual activities, on 5 or more days of the week; 45 to 60 minutes of intentional physical activity are preferable. Children and teens are encouraged to try for at least 60 minutes a day of moderate to vigorous physical activity on at least 5 days a week.

How about your emotional health?

Once your treatment ends, you may find yourself overwhelmed by emotions. This happens to a lot of people. You may have been going through so much during treatment that you could only focus on getting through your treatment.

Now you may find that you think about the potential of your own death, or the effect of your cancer on your family, friends, and career. You may also begin to re-evaluate your relationship with your spouse or partner. Unexpected issues may also cause concern -- for instance, as you become healthier and have fewer doctor visits, you will see your health care team less often. That can be a source of anxiety for some.

This is an ideal time to seek out emotional and social support. You need people you can turn to for strength and comfort. Support can come in many forms: family, friends, cancer support groups, church or spiritual groups, online support communities, or individual counselors.

Almost everyone who has been through cancer can benefit from getting some type of support. What's best for you depends on your situation and personality. Some people feel safe in peer-support groups or education groups. Others would rather talk in an informal setting, such as church. Others may feel more at ease talking one-on-one with a trusted friend or counselor. Whatever your source of strength or comfort, make sure you have a place to go with your concerns.

The cancer journey can feel very lonely. It is not necessary or realistic to go it all by yourself. And your friends and family may feel shut out if you decide not include them. Let them in -- and let in anyone else who you feel may help. If you aren’t sure who can help, call your American Cancer Society at 1-800-227-2345 and we can put you in touch with an appropriate group or resource.

You can’t change the fact that you have had cancer. What you can change is how you live the rest of your life -- making healthy choices and feeling as well as possible, physically and emotionally.

What happens if treatment is no longer working?

If cancer continues to grow after one kind of treatment, or if it returns, it is often possible to try another treatment plan that might still cure the cancer, or at least shrink the tumors enough to help you live longer and feel better. On the other hand, when a person has received several different medical treatments and the cancer has not been cured, over time the cancer tends to become resistant to all treatment. At this time it’s important to weigh the possible limited benefit of a new treatment against the possible downsides, including continued doctor visits and treatment side effects.

Everyone has his or her own way of looking at this. Some people may want to focus on remaining comfortable during their limited time left.

This is likely to be the most difficult time in your battle with cancer -- when you have tried everything medically within reason and it’s just not working anymore. Although your doctor may offer you new treatment, you need to consider that at some point, continuing treatment is not likely to improve your health or change your prognosis or survival.

If you want to continue treatment to fight your cancer as long as you can, you still need to consider the odds of more treatment having any benefit. In many cases, your doctor can estimate the response rate for the treatment you are considering. Some people are tempted to try more chemotherapy or radiation, for example, even when their doctors say that the odds of benefit are less than 1%. In this situation, you need to think about and understand your reasons for choosing this plan.

No matter what you decide to do, it is important that you be as comfortable as possible. Make sure you are asking for and getting treatment for any symptoms you might have, such as pain. This type of treatment is called “palliative” treatment.

Palliative treatment helps relieve these symptoms, but is not expected to cure the disease; its main purpose is to improve your quality of life. Sometimes, the treatments you get to control your symptoms are similar to the treatments used to treat cancer. For example, radiation therapy might be given to help relieve bone pain from bone metastasis. Or chemotherapy might be given to help shrink a tumor and keep it from causing a bowel obstruction. But this is not the same as receiving treatment to try to cure the cancer.

At some point, you may benefit from hospice care. Most of the time, this is given at home. Your cancer may be causing symptoms or problems that need attention, and hospice focuses on your comfort. You should know that receiving hospice care doesn’t mean you can’t have treatment for the problems caused by your cancer or other health conditions. It just means that the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult stage of your cancer.

Remember also that maintaining hope is important. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that are filled with happiness and meaning. In a way, pausing at this time in your cancer treatment is an opportunity to refocus on the most important things in your life. This is the time to do some things you’ve always wanted to do and to stop doing the things you no longer want to do.

What's new in laryngeal and hypopharyngeal cancer research and treatment?

Studies are ongoing in the area of head and neck cancers. Researchers are looking for causes of laryngeal and hypopharyngeal cancers and ways to prevent them and are working to improve treatments -- all in a major effort to reduce the number of laryngeal and hypopharyngeal cancer cases and improve the outlook for patients with these cancers.

DNA changes in laryngeal and hypopharyngeal cancer

A great deal of research is being done to better understand how changes in the DNA of certain genes cause cells in the larynx or hypopharynx to become cancerous. The p53 tumor suppressor gene has received attention. Changes in this gene contribute to the aggressiveness of many head and neck cancers.

Tests to detect p53 gene alterations may allow early detection of laryngeal and hypopharyngeal tumors. These tests may also be used to better define surgical margins (check to see if all cancer cells have been removed) and to determine which tumors may respond better to surgery or radiation therapy. These tests are still experimental and not used in the routine care of cancer patients.

Changes in several other genes of have recently been found in cancers of the larynx or hypopharynx. These include the p16 gene and the cyclin D1 gene. Researchers are hopeful that this information might lead to better tests for early detection and to ideas for new targeted treatments.

Chemoprevention

Chemoprevention is the use of drugs to stop cancer from developing. This may involve preventing precancerous lesions from becoming cancerous or preventing cancer from recurring once it has been treated.

Researchers are now focusing on several drugs to try to prevent precancerous lesions such as dysplasia (abnormal development or growth of tissues, organs, or cells) from developing into cancers.

With improvements in surgery and radiation therapy, the ability to control a patient's main cancer mass has improved. However, development of a second tumor in the head and neck area remains an important risk. Various chemopreventive agents are being tested to see if they can reduce the risk of developing a new cancer. Retinoid analogs (chemicals related to vitamin A) have been heavily studied for this purpose, but the results have been disappointing.

New treatments

Due to the nature of laryngeal and hypopharyngeal cancers, several promising new forms of treatment are likely to make therapy more effective and less burdensome in the coming years.

Chemotherapy and chemoradiotherapy

For advanced laryngeal and hypopharyngeal cancers, new chemotherapy delivery systems, such as direct injection into arteries feeding the cancer, are being tested in combination with radiation therapy in an attempt to improve their effectiveness. Newer chemotherapy drugs and drugs already shown to be effective against other cancers are also being tested.

Clinical trials are also studying ways to best combine several chemotherapy drugs together and to combine chemotherapy with radiation therapy. For example, studies are comparing the effectiveness of chemotherapy given before, during, and/or after radiation therapy.

Targeted therapy

EGFR inhibitors: Squamous cell cancers of the larynx (and other head and neck locations) often have abnormally high levels of growth factor receptors. Growth factors are hormone-like substances that attach to these receptors to signal cells to grow and divide. Having too many receptors may be a cause of abnormal cell growth in some cancers. The growth factor receptor that has received the most study is known as epidermal growth factor receptor (EGFR). Cetuximab (Erbitux) is an antibody that blocks this receptor. It is already approved by the FDA for the treatment of cancers of the head and neck region, including cancer of larynx and hypopharynx. Other EGFR blockers are under study for the treatment of head and neck cancers: These include the drugs panitumumab (Vectibix®), lapatinib (Tykerb®), gefitinib (Iressa®) and erlotinib (Tarceva®).

These drugs seem to work best when combined with other treatments, such as radiation and chemotherapy.

Angiogenesis inhibitors: Tumors need a large blood supply to grow, so they release chemicals that cause new blood vessels to form. Drugs that turn off these signals are called angiogenesis inhibitors. These drugs, such as bevacizumab (Avastin®) and sunitinib (Sutent®), have been helpful in the treatment of other cancers. They are now under study for the treatment of head and neck cancers.

Therapeutic viruses

Changes in certain genes are often seen in cancer cells. Viruses can be made that are genetically engineered with a normal copy of the gene. The virus is then injected to correct the abnormal gene and hopefully transform the cancer cells into normal ones.

Photodynamic therapy

In this treatment, the patient is given a substance that makes the cancer cells more sensitive to light, and then the cancer is exposed to laser light a day later. This is being studied as a treatment for very early stage laryngeal cancer.

Additional resources

We have selected some related information that may also be helpful to you. These materials may be viewed on our Web site or ordered from our toll-free number, 1-800-227-2345.

After Diagnosis: A Guide for Patients and Families (also available in Spanish)

Caring for the Patient With Cancer at Home: A Guide for Patients and Families (also available in Spanish)

Living With Uncertainty: The Fear of Cancer Recurrence

Pain Control: A Guide for People With Cancer and Their Families (also available in Spanish)

Questions About Smoking, Tobacco, and Health (also available in Spanish)

Targeted Therapy

Understanding Chemotherapy: A Guide for Patients and Families (also available in Spanish)

Understanding Radiation Therapy: A Guide for Patients and Families (also available in Spanish)

When Your Cancer Comes Back: Cancer Recurrence

Books

The following books are available from the American Cancer Society. Call us at 1-800-227-2345 to ask about cost or to place your order.

American Cancer Society's Guide to Pain Control: Understanding and Managing Cancer Pain

Caregiving: A Step-By-Step Resource for Caring for the Person With Cancer at Home

Couples Confronting Cancer: Keeping Your Relationship Strong

What Helped Get Me Through: Cancer Survivors Share Wisdom and Hope

National organizations and Web sites*

In addition to the American Cancer Society, other sources of patient information and support include:

International Association of Laryngectomees (IAL)
Toll-free number: 1-866-425-3678 (1-866-IAL-FORU)
Web site: www.theial.com

National Cancer Institute
Toll-free number: 1-800-422-6237 (1-800-4-CANCER) TYY: 1-800-332-8615
Web site: www.cancer.gov

Support for People with Oral and Head, Neck Cancer, Inc. (SPOHNC)
Toll-free number: 1-800-377-0928
Web site: www.spohnc.org

WebWhispers Nu-Voice Club
Telephone: 301-588-2352
Web site: webwhispers.org

No matter who you are, we can help. Contact us anytime, day or night, for information and support. Call us at 1-800-227-2345 or visit cancer.org.

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