Treatment Options for Laryngeal and Hypopharyngeal Cancers by Stage

Laryngeal cancer at this stage is almost always a glottic (vocal cord) cancer that was found early because of voice changes.

These cancers are nearly always curable with either endoscopic surgery or radiation therapy. After treatment, a person is watched closely to see if the cancer returns. If the cancer comes back, radiation can be used.

At this stage, almost all cancers can be cured without major surgery. But it's important to know that continuing to smoke makes treatment less likely to work and increases the chance that another tumor will develop.

Most stage I and II laryngeal cancers can be treated successfully without removing the whole larynx.

Most people can get either radiation alone or surgery with a partial laryngectomy. Many doctors use radiation therapy for smaller cancers. Voice problems tend to be less with radiation therapy than with partial laryngectomy.

Treatment at this stage is slightly different depending on where in the larynx the cancer started.

Glottic cancer (vocal cords)

Some early glottic cancers might be treated by removing the vocal cord with cancer (cordectomy) or even by laser surgery.

Radiation or surgery is usually enough to treat most glottic cancers unless there are signs that the treatment might not have cured the cancer. For example, if cancer cells are found at the edge of the removed tumor.

Supraglottic cancer (above the vocal cords)

Supraglottic cancers are more likely to spread to the lymph nodes in the neck.

• If you have a supraglottic laryngectomy surgery, the surgeon might also remove lymph nodes from your neck (lymph node dissection).
• If your treatment is radiation therapy alone, you will also get radiation to the lymph nodes in your neck.

After surgery, your doctor will have more information about your cancer. If the cancer has features that make it more likely to come back, you might need more treatment. This could involve radiation therapy, chemoradiation, or more extensive surgery.

The main options for initial treatment of these cancers are:

• Surgery
• Chemotherapy with radiation (chemoradiation)
• Immunotherapy followed by surgery

Radiation therapy alone may be an option for people who can not tolerate more intensive treatments. This radiation might be given along with the targeted drug cetuximab.

Surgery

Surgery for these tumors is almost always a complete removal of the larynx, called a total laryngectomy. A small number of these cancers might be treated by partial laryngectomy. Immunotherapy might be given both before and after surgery. Radiation therapy or chemoradiation might be given after surgery as well.

These cancers have a high risk of spreading to nearby lymph nodes in the neck, if they have not spread already. During surgery to remove the tumor, these lymph nodes are often removed as well.

Radiation therapy, often given with chemo, might be needed after surgery. This is especially true if the cancer has spread to the lymph nodes or has other features that make it more likely to come back.

Chemoradiation

Instead of using surgery as the first step, many doctors now prefer to start treatment with chemoradiation. This is radiation and chemotherapy given together. If any cancer remains after treatment, surgery can then be done to try to remove it.

Chemoradiation can be hard to tolerate. But it often works as well as total laryngectomy, and it gives a chance to save the larynx.

Immunotherapy followed by surgery

Another option for some people is to take a medication called pembrolizumab before surgery. This is called induction therapy, which is treatment given before the main treatment to help shrink the tumor.

Pembrolizumab is an immunotherapy drug. It works by helping your immune system find and attack cancer cells. Based on results from a large clinical trial called Keynote-689, pembrolizumab before surgery has become a standard treatment option for people whose tumors test positive for a protein called PDL1.

Your cancer care team will test your tumor to see if this treatment may be right for you.

Other situations

Sometimes, the thyroid cartilage or other framework of the larynx has been destroyed by the cancer. When this happens, the larynx may never work normally again, no matter what treatment is chosen. In these cases, the best treatment may be surgery to remove the larynx and nearby tissues with cancer, such as the thyroid gland.

Cancers that are too big or have spread too far to be completely removed by surgery are often treated with radiation. This is usually combined with chemotherapy or the targeted drug cetuximab.

Another option might be treatment with an immunotherapy drug, either alone or with chemotherapy. If the tumor shrinks enough, surgery of the tumor and the lymph nodes in the neck is sometimes an option. But for many advanced cancers, the goal of treatment is often to stop or slow the growth of the cancer for as long as possible and to help relieve any symptoms it may be causing.

Most experts agree that treatment in a clinical trial should be considered if you have advanced-stage laryngeal cancer.

Surgery is the main option for initial treatment of these cancers. This could be with or without radiation to the lymph nodes.

Surgery includes removing all or part of the pharynx (throat) as well as lymph nodes on one or both sides of the neck (lymph node dissection). The larynx (voice box) often needs to be removed as well.

After surgery, your doctor will have more information about your cancer. If this information suggests the cancer has a high chance of returning, you might then be treated with radiation or chemotherapy combined with radiation (chemoradiation).

Some people with small tumors might get radiation as their main treatment. After treatment is complete, doctors will check to see if any cancer is left. Surgery will be done if any cancer remains.

The main options for initial treatment of these cancers are:

• Surgery
• Chemotherapy with radiation (chemoradiation)
• Immunotherapy followed by surgery

Surgery

One option to treat these cancers is surgery to remove the pharynx, larynx, thyroid gland, and lymph nodes in the neck.

Immunotherapy might be given both before and after this surgery. Radiation therapy, alone or with chemo, is usually given after surgery as well. This is especially true if there is a high chance that the cancer will come back based on what is found during surgery.

Chemoradiation

Another option is to first treat with both radiation and chemo (chemoradiation). If any cancer remains after treatment, surgery can try to remove it.

Immunotherapy followed by surgery

Another option for some people is to take a medication called pembrolizumab before surgery. This is called induction therapy, which is treatment given before the main treatment to help shrink the tumor.

Pembrolizumab is an immunotherapy drug. It works by helping your immune system find and attack cancer cells. Based on results from a large clinical trial called Keynote-689, pembrolizumab before surgery has become a standard treatment option for people whose tumors test positive for a protein called PDL1.

Your cancer care team will test your tumor to see if this treatment may be right for you.

If the cancer cannot be completely removed with surgery

Cancers that are too big or have spread too far to be completely removed by surgery are often treated with radiation, usually combined with chemo or the targeted drug cetuximab.

Another option might be treatment with an immunotherapy drug, either alone or with chemotherapy. If the tumor shrinks enough, surgery to remove the tumor and the lymph nodes in the neck is sometimes an option. But for many advanced cancers, the goal of treatment is often to stop or slow the growth of the cancer for as long as possible and to help relieve any symptoms it may be causing.

Most experts agree that treatment in a clinical trial should be considered if you have advanced-stage hypopharyngeal cancers.

If cancer comes back near where it started and limited surgery has already been done, it can often be treated with more extensive surgery. For example, if it comes back after a partial laryngectomy, a total laryngectomy may be done. This might be followed by radiation therapy or chemoradiation. Chemoradiation is radiation and chemo given at the same time.

Local recurrence might also be treated with immunotherapy alone or combined with chemotherapy. In some cases, chemotherapy might be given along with the targeted drug cetuximab. Or chemoradiation may be used.

If cancer comes back locally after radiation therapy, the usual treatment is total laryngectomy, but more radiation therapy is sometimes used.

If surgery cannot be done, palliative or supportive care might be an option. This is treatment to help control the cancer and ease any problems it causes. It could include immunotherapy, alone or in combination with chemotherapy, or chemoradiation.

If cancer spreads to distant parts of the body but radiation therapy and surgery are not an option, it can be treated with immunotherapy alone or immunotherapy combined with chemotherapy.

Another option might be targeted therapy, either alone or with chemotherapy. Chemoradiation might also be used if you can physically tolerate it.

If there are only a few tumors, surgery may be done. Radiation or chemo are also options.

Chemotherapy, immunotherapy, or chemoradiation can be used to help control the cancer and ease any problems it might be causing. This is called palliative or supportive care.