Types of Treatment for Laryngeal and Hypopharyngeal Cancer

Executive Summary

Treatment (laryngeal and hypopharyngeal cancer) recommendations depend upon the size, grade, and type of tumor, metastasis, possible side effects, and patient’s preferences and overall health. The standard treatment techniques used to treat laryngeal and hypopharyngeal cancers are radiation therapy, surgery, and medication-based therapies, such as chemotherapy. The primary goal of treatment for nearly all patients, particularly those with early-stage (T1 or T2) laryngeal cancer, is to keep the larynx functioning. Surgery or radiation therapy can help to treat the malignancy while keeping the larynx functional in certain circumstances. Radiation therapy involves external beam radiation therapy and internal radiation therapy to treat laryngeal and hypopharyngeal cancers.

Chemoradiotherapy consists of chemotherapy and radiation therapy to help people avoid Surgery and keep their larynx and speaking ability intact. Surgery includes partial laryngectomy (supraglottic laryngectomy, cordectomy, vertical hemilaryngectomy, partial supracricoid laryngectomy), total laryngectomy, laryngopharyngectomy, dissection of the neck, laser surgery, tracheostomy, and reconstruction. Medication therapies include systemic or medicated therapy (immunotherapy, chemotherapy, and targeted therapy). Palliative care includes medication, nutritional changes, emotional and spiritual support, and other relaxation therapies. The treatment procedures for recurrent tumors include surgery, radiation therapy, etc. Many clinical trials test the viability of various treatment options for dealing with recurrent laryngeal and hypopharyngeal cancer.

Treatment for Laryngeal and Hypopharyngeal Cancer

With an early diagnosis, cancers such as larynx and hypopharynx has higher chances of successful treatment. Although the major goal of treatment is to eradicate cancer, it is equally critical to maintain the function of the damaged organs. When doctors arrange treatment, they think about how the treatment will influence their quality of life, such as how they feel, look, talk, eat, and breathe. Cancers of the larynx and hypopharynx and their treatments can significantly impact these functions. Therefore the treatment choices can influence the overall wellbeing to a large extend.

For treating a condition like laryngeal and hypopharyngeal cancer, doctors from different areas of expertise work together to design a suitable treatment plan. A multidisciplinary team will consist of different doctors to carry out the treatment. The team will consist of a variety of healthcare professionals starting from medical oncologists, radiation oncologists, surgeons, otolaryngologists (ear, nose, and throat doctors), maxillofacial prosthodontists (specialists who perform head and neck restorative surgery), dentists, physical therapists, speech pathologists, audiologists, and psychiatrists. Because they assist with diagnosis and staging, diagnostic radiologists and pathologists are also essential treatment team members. Physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, nutritionists, and other health care professionals are part of cancer treatment teams. In addition to treatment, the healthcare team will also focus on providing care and support to the family members associated with the patient. 

Clinical Trials

Doctors use different procedures and techniques to treat laryngeal and hypopharyngeal cancer patients. Doctors use the standard care (best possible treatment option) available to treat such tumors. While deciding on the treatment strategy, patients may also consider clinical trials as an option. A clinical trial refers to a detailed research study that focuses on testing new approaches to treat better and cure disease. Sometimes the treatment strategies approved in a clinical trial must be much better than the already existing treatment to treat a particular disease condition. The patients must seek the help and guidance of their doctors to arrive at an apt clinical trial or in considering all possible treatment options to cure the condition.  

Available Treatment Options

Radiation therapy, surgery, and medication-based therapies, such as chemotherapy, are the three main treatment choices for laryngeal and hypopharyngeal cancer ^​1​. One or more of these therapies might be necessary to treat cancer. The most common treatments are surgery and radiation therapy. Chemotherapy can be given before, during, or after radiation therapy and/or surgery to enhance the likelihood of destruction of cancer cells.

Patients should take time to learn about all the available treatment options for laryngeal and hypopharyngeal cancer and be sure to ask questions and clear doubts about things that are unclear and appears complex. Ask your doctor about the aim of each treatment and what outcome you can expect while receiving the treatment. This is what is called “shared decision making.” Shared decision-making helps the patients to have informed choices regarding treatment. This will help the healthcare team choose and plan a treatment strategy that best fits your aims and expectations.

PRESERVING THE LARYNX

The primary goal of treatment for nearly all patients, particularly those with early-stage (T1 or T2) laryngeal cancer, is to keep the larynx functioning. Surgery or radiation therapy can help to treat the malignancy while keeping the larynx functional in certain circumstances.

We can appropriately preserve the larynx in most people with a T3 laryngeal tumour. And also for some people with a T4 laryngeal tumour who receives a combination of chemotherapy and radiation therapy. Total laryngectomy may be the preferable therapeutic choice for massive laryngeal tumours.

Before deciding on a treatment plan, talk to your doctor about having your voice and swallowing abilities tested.

RADIATION THERAPY

Radiation therapy is the use of high-energy x-rays or other particles to eliminate cancer cells. A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy ^​2​.

External–beam radiation therapy

External-beam radiation therapy, in which radiation is delivered from a machine outside the body, is the most prevalent radiation treatment method.

Intensity-modulated radiation treatment (IMRT), a new technique of external-beam radiation therapy, allows for effective doses of radiation therapy while minimizing damage to healthy cells.

Internal radiation therapy

Internal radiation therapy, also known as brachytherapy, is a type of radiation therapy that uses implants to deliver radiation. Radiation therapy is the use of high-energy x-rays or other particles to eliminate cancer cells. A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy.

Proton beam therapy

Clinical trials are currently testing proton beam therapy to check whether it lessens the damage to healthy tissues during treatment. It is a sort of external-beam radiation therapy that destroys cancer cells using protons rather than x-rays (photons). A radiation therapy regimen, often known as a schedule, comprises a defined number of treatments administered over a set amount of time. Radiation therapy can also be a stand-alone treatment for head and neck cancer or administered after surgery to kill small cancerous spots that surgery did not reach. A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy.

BEFORE RADIATION TREATMENT STARTS

Before starting radiation therapy for any head and neck cancer, patients should see an oncologic dentist for a complete evaluation. An oncologic dentist is a dentist who specializes in the dental and oral health of cancer patients. It is important to remove the damaged teeth before the treatment begins because radiation therapy can induce tooth decay. Tooth decay is frequently preventable with adequate dental treatment. It is necessary to continue the dental care after radiation therapy for laryngeal and hypopharyngeal cancer to help prevent additional dental issues. Fluoride treatment can also be effective to avoid tooth decay.

A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy.

It is also critical that people get counseling and evaluation from a speech pathologist who has previously worked with people with head and neck cancer. Radiation therapy can induce swelling and scarring, which affects the voice and swallowing. Speech pathologists can teach people exercises and procedures to help them avoid speech and swallowing issues in the long run.

CHEMORADIOTHERAPY

A combination of chemotherapy and radiation therapy may be employed, depending on the cancer stage. Concomitant chemoradiotherapy is another term for this ^​3​. Chemotherapy makes radiation therapy more effective. Chemoradiotherapy can help people avoid surgery and keep their larynx and speaking ability intact. This is the preferred conventional treatment option for many patients. Combining chemotherapy and radiation therapy, on the other hand, can result in more side effects than radiation therapy alone.

SIDE EFFECTS OF RADIATION TREATMENT

Radiation therapy to the head and neck can cause skin irritation on the treated area, dry mouth or thicker saliva due to damage to the salivary glands (which can be temporary or permanent), bone discomfort, nausea, exhaustion, mouth sores, and/or sore throat, trouble opening the mouth, and dental difficulties.

SURGERY

A surgical oncologist removes the dangerous tumour and some healthy tissue around it, known as a margin, during surgery. A surgical oncologist is a physician who specializes in the surgical treatment of cancer. The surgery aims to remove the entire tumour while leaving negative margins. Negative margins indicate no cancer was detected in the healthy tissue removed during the operation. It is not always feasible to entirely eradicate cancer. In this case, other treatments might be more effective.

Before surgery, talk to your doctor about the potential adverse effects of the procedure you’ll be having.

The following are the most common surgical methods for treating laryngeal or hypopharyngeal cancer ^​4​:

Partial laryngectomy

A partial laryngectomy is a surgical procedure that removes part of the vocal cords. This procedure involves removing a portion of the larynx, to preserve the natural voice of the patient. Some of the numerous types of partial laryngectomies include:

• Supraglottic laryngectomy is a type of laryngectomy that removes the upper part of the voice. The surgeon eliminates the area above the vocal folds during this operation. A partial pharyngectomy occurs when a portion of the hypopharynx is removed along with the malignancy.
• Cordectomy: A vocal fold is removed.
• Vertical Hemilaryngectomy: One side of the larynx is removed.
• Partial supracricoid laryngectomy: The vocal folds and regions around them are removed.

Total laryngectom

A total laryngectomy is a surgical procedure that removes the entire voice box ^​5​. The entire larynx is removed during this treatment. A stoma is created in the front of the neck through the windpipe, allowing the patient to breathe during the process. A tracheostomy is a medical term for this procedure (see below). After a total laryngectomy, patients can not talk using their vocal folds because the vocal folds have been removed. On the other hand, a speech pathologist can train people to speak differently following surgery.

LARYNGOPHARYNGECTOMY

The entire larynx, including the vocal folds and part or all of the pharynx, is removed during a laryngopharyngectomy. Doctors must repair the pharynx using skin flaps from the forearm, other regions of the body, or a portion of the intestine after this surgery. After a laryngopharyngectomy, people can no longer speak using their vocal folds, just as they can after a total laryngectomy. They could also have trouble swallowing. On the other hand, a speech pathologist can assist people in learning to speak and swallow again after that.

Dissection of the neck

If cancer has spread to the lymph nodes in the neck, surgery may be necessary to remove part of the lymph nodes. A neck dissection is a medical term for this procedure. A partial neck dissection, a modified neck dissection, or a selective neck dissection are all examples of neck dissections. Depending on the stage and location of the malignancy, we might have to remove some or all of the lymph nodes in the neck. Patients with laryngeal cancer treated with radiation or chemoradiotherapy do not usually require a neck dissection. After this sort of surgery, a patient may experience varying degrees of stiffness in the shoulder and neck and loss of sensation in the neck.

Laser surgery

Laser surgery is a procedure that involves the use of Laser surgery to remove a tiny tumour in the larynx or perform a partial laryngectomy using a beam of light. This is a very new therapy method that a qualified physician should only use.

Other surgeries for treating laryngeal or hypopharyngeal cancer include:

Tracheostomy

A stoma is a hole at the front of the neck that the surgeon makes into the windpipe or trachea as part of a partial or total laryngectomy. A tracheostomy is another name for this surgical operation. To maintain the opening open, a tube is frequently introduced. Air enters and leaves the trachea and lungs through the stoma, allowing the person to breathe.

The stoma is usually transient for persons who have had a partial laryngectomy. After a partial laryngectomy, the tube is withdrawn. And when the hole heals, the patient can breathe and speak normally again. The voice may be hoarse or weak in some situations, but it normally improves as someone heals after surgery.

The stoma is permanent in those who have had a total laryngectomy. The tube is withdrawn, but the person must learn to talk in a new way and continue to breathe via the stoma.

Reconstruction

Plastic surgery, often known as reconstruction, aims to restore a person’s appearance and function of the damaged area. If extensive tissue removal is necessary during surgery, reconstructive or plastic surgery may replace the lost tissue.

SIDE EFFECTS OF SURGERY

Swelling the lips and throat is common after surgery, making breathing difficult. The lungs and windpipe create a lot of mucus after the procedure. The mucus is removed with a little suction tube until the person learns to cough through the stoma. Similarly, because swelling in the throat might inhibit swallowing, saliva may need to be suctioned from the mouth. Discuss your post-surgery expectations with your doctor.

Furthermore, surgery may result in a permanent loss of voice or poor speech, trouble eating or talking, lymphedema, facial deformity, numbness in portions of the neck and throat, and decreased movement in the shoulder and neck region. Surgery can also affect thyroid gland function, particularly after a total laryngectomy.

After surgery, rehabilitation of lost or altered physical functions and mental support services are critical components of care. This may take some time and will necessitate the input of several treatment team members. Before having any form of surgery, patients should speak with their health care team about what to expect and how to handle the recovery.

THERAPIES USING MEDICATION

Systemic or medicated therapy refers to medication or drugs to eliminate cancer cells. These drugs or medications are administered through the bloodstream to reach tumor growths or cells throughout the body. A medical oncologist usually prescribes such therapies. Systemic therapies are commonly given in two ways:

• Using an intravenous (IV) tube to administer medication into the vein using a needle.
• A capsule or pill that is swallowed or administered orally.

These are some among the types of medicated therapies to treat laryngeal and hypopharyngeal cancer:

• Immunotherapy
• Chemotherapy
• Targeted therapy

A patient may receive one of these, or sometimes a combination of all these therapies simultaneously. Systemic therapies can also be a part of the overall treatment plan, including surgery or radiation. These therapies can also be a first-line treatment when a surgical procedure is impossible.

Many studies focus on developing efficient medications that can help treat and cure tumor conditions. Patients are must to talk with their doctor about the prescribed medicines and learn and understand more about them. Ask them questions regarding the purpose, possible side effects, and their possible interactions with other treatments and medications. One should also let their doctor know about any additional treatment or medicines they are taking well before cancer treatment. This is because certain herbs can interact with cancer medications and cause complications.

IMMUNOTHERAPY

Immunotherapy, also known as biologic therapy, is a cancer treatment that boosts the body’s natural defenses. It improves, targets, or restores immune system function by using materials created by the body or laboratory. Nivolumab (Opdivo) and pembrolizumab (Keytruda) are two immunotherapy medicines licensed to treat individuals with recurrent or metastatic squamous cell carcinoma. Clinical studies may also use immunotherapy in conjunction with chemotherapy and radiation therapy. Various forms of immunotherapy can have a variety of adverse effects. Skin rashes, flu-like symptoms, diarrhea, and weight fluctuations are common adverse effects. Consult your doctor in case of any potential adverse effects from the immunotherapy.

CHEMOTHERAPY

Chemotherapy uses medications to kill cancer cells by preventing them from growing, dividing, and producing new ones.

A chemotherapy regimen, often known as a schedule, consists of a defined number of cycles administered over a set length of time. A patient may receive a single medicine at a time or a mixture of drugs simultaneously.

Chemotherapy, radiation treatment, or combination may treat laryngeal and hypopharyngeal cancer. Neoadjuvant therapy is the term for this type of treatment. Chemotherapy and radiation therapy may be delivered at the same time. This is referred to as concurrent chemoradiation.

Chemotherapy can cause many side effects. These side effects depend on the type of drug and the dose used. Some side effects include nausea and vomiting, fatigue, hair loss, risk of infection, loss of appetite, and diarrhoea. These side effects usually go away once the treatment finishes. In some rare cases, chemotherapy can cause long-term problems that can affect the kidneys heart and can even cause cancer.

TARGETED THERAPY

Targeted therapy is a type of treatment that focuses on the genes, proteins, or tissue environment that contribute to cancer growth and survival. This treatment method stops cancer cells from growing and spreading while limiting damage to healthy cells.

The targets of all cancers are not the same. Your doctor may do tests to determine the genes, proteins, and other variables in your tumour to find the most effective treatment. This allows doctors better to match each patient with the most appropriate treatment when possible. Furthermore, research studies continue to uncover new information about specific molecular targets and new treatments aimed at them. 

Cetuximab (Erbitux) is a targeted medicine that has been approved for use in combination with radiation therapy in the treatment of non-metastatic head and neck cancer. It is also approved for use with chemotherapy to treat metastatic cancer patients.

Please consult your doctor about any potential adverse effects from targeted therapy and how to deal with them.

Physical, emotional, and social effects of a tumour

A tumor and its treatment can cause many physical, emotional, and social effects. Tumour care doesn’t end with active treatment. Post-treatment care is as critical as active treatment. Palliative or supportive care focus on managing and relieving symptoms and side effects associated with cancer treatment. Along with an active treatment strategy, which helps in improving the treatment efficiency by slowing the cancer growth or destroying it.

Palliative care

Palliative care focuses on improving a patient’s condition by helping them to manage and relieve symptoms. The care extends support not just to the patients but also to their loved ones. It also focuses on the non-medical needs of cancer patients, like managing finances. Palliative care depends on the patient’s age, stage, or tumor type. Palliative care works best when it begins right after a cancer diagnosis. This helps prevent the cancer condition and its symptoms and side effects from aggravating. Palliative focuses on improving the comfort and quality of a patient’s life. Palliative care enhances the effectiveness of active treatment. Sometimes a patient may receive chemotherapy, surgery, or radiation therapy as palliative care.  

Patients should talk with their health care team about the aim of each treatment option, about the probable side effects and the available palliative care options before the active treatment begins.

The health care team will enquire about your medical history, symptoms and side effects during treatment. Be sure to communicate whatever you are feeling to the doctor. This helps them treat any symptoms or side effects that you are experiencing with ease. This will eventually help prevent your condition from becoming worse. 

Metastatic Cancer

Metastatic cancer refers to cancer or tumor that spreads from its origin to different body parts. If you are experiencing any signs or symptoms related to cancer metastasis, communicate it with your doctor. The doctor or the health care team will develop an active treatment plan to cure this condition. One can also go for clinical trial options. 

Metastasis can occur even after active treatment and removal of the cancer growth. Hence it can be stressful for the patient and their loved ones to bear the diagnosis. So, patients and their loved ones must have active communication with the doctor, nurses, social workers, or counselors regarding how they are feeling. Patients can also talk with other cancer survivors or join a support group.

Remission and the chance of recurrence

Remission refers to a stage where there are no signs or symptoms of a tumor in the body. The condition can be called NED or “no evidence of disease” in the body. Remission can be permanent or temporary. Cancer patients in remission are anxious about a probable cancer recurrence. Patients must continue tests, scans, and physical examinations even after successful treatment to look for recurrence. Patients with laryngeal and hypopharyngeal tumors should talk with their doctor about the chance of the tumor condition recurring back in the body. If cancer recurs in the same place as before, it is a local recurrence, and if it happens nearby the origin point, it is a regional recurrence. If it recurs in some distant place in the body, it is a distant recurrence.

The doctor will check for any signs of tumor recurrence. And if the tumor growth is back in the body, the doctor will list out the possible treatment options. In most cases, the treatment procedures for recurrent tumors include surgery, radiation therapy, etc. But the same kind of radiation procedure cannot be given more than once. These therapies in may be performed in different combinations.

Recurrence and Treatment

Many clinical trials are testing the viability of various treatment options for dealing with recurrent tumors. Patients are must talk to their doctor about any such possibilities. Whatever the treatment plan be, palliative care will always be an essential part that will primarily focus on managing and relieving symptoms and side effects of treatment.

When a tumor recurs back in the body or the disease worsens, it is quite natural and entirely ok for patients and their loved ones to feel upset and be in extreme fear. In such cases, both the patients and their caretakers are must talk to the healthcare team or counselors or seek support services or groups to cope with the circumstances. 

Care and Concern

Tumor recovery may not be successful at times. Any stage of cancer or tumor can be stressful to people. A diagnosis that states an advanced, aggressive tumor can cause even more stress and make people hopeless and uncertain about their lives. Patients should have open, honest communications with their doctor or health care team about their concerns, feelings, and preferences. Health care team members will support the patients and their caregivers. They will focus on improving the comfort and quality of the patient’s life by providing them physical, mental, and financial support.

People diagnosed with advanced tumors and the expected chance of survival is for less than six months can consider hospice care. Hospice care focuses on providing the best possible quality care for patients whose survival chance is low. Patients and their families can talk to the health care team about the available hospice options, including a unique hospice center,, hospice care at home or any other health care location. People can also avail nursing care options.

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