Voice-box (larynx) cancer

Cancer of the vocal cords (glottic) causes hoarseness early, so it is often found early and cured with voice preserved.

Supraglottic and subglottic cancers are found later and more often spread to neck nodes.

Often found at a later stage, with neck nodes. Treated similarly to locally advanced larynx cancer.

A camera through the nose or mouth to see the larynx, with a biopsy under anaesthesia. Shows vocal cord movement.

Show cartilage involvement, neck nodes and spread. Cartilage destruction affects whether the voice-box can be saved.

A dental check before radiotherapy, and a dietitian review. Many patients have lost weight; a feeding tube may be advised before treatment.

Before starting chemotherapy, immunotherapy or targeted therapy, these tests check that you are fit for treatment, and give a starting point to compare with later.

Before immunotherapy, also:

Sometimes needed, depending on your treatment:

• Pregnancy test for women who could be pregnant.
• Calcium and magnesium: for example before cisplatin or bone-strengthening injections.
• Dental check-up before bone-strengthening injections (zoledronic acid or denosumab), as they can rarely affect the jaw bone.
• Hearing test before cisplatin, in some patients.
• Clotting tests (PT/INR) before a biopsy or chemoport.

Your doctor will choose the tests that apply to you. Some of them are repeated during treatment.

• The scans and cord movement decide whether the voice-box can be preserved with radiotherapy, or needs surgery.
• If breathing is difficult, a tracheostomy may be done first.

Limited to the larynx, vocal cords still moving (or slightly reduced). Cure rates are high.

Vocal cord fixed, cartilage involved, or neck nodes involved. Still curable in many.

Spread to the lungs or elsewhere.

1. Radiotherapy (about 4 to 6 weeks), or laser surgery through the mouth.
2. Both usually preserve a good voice.

Side effects: radiotherapy

1. Larynx preservation: chemoradiotherapy with cisplatin, or induction chemotherapy (docetaxel, cisplatin and 5-FU) followed by radiotherapy if it responds well.
2. Total laryngectomy (removal of the voice-box) with neck dissection, then radiotherapy: for cancers that have destroyed cartilage, or when the larynx no longer works well.
3. After laryngectomy, breathing is through a permanent opening in the neck (stoma), and speech can be restored with a voice prosthesis.

Side effects: chemoradiotherapy · laryngectomy

1. If the cancer comes back only in the head and neck: surgery or re-irradiation may still cure some patients.
2. Otherwise, depending on the PD-L1 (CPS) result: pembrolizumab alone, or pembrolizumab with chemotherapy.
3. Other options: chemotherapy with cetuximab; in India, low-dose nivolumab with metronomic chemotherapy (oral methotrexate with celecoxib) is an affordable option.
4. Palliative radiotherapy for pain or bleeding.

Side effects: immunotherapy · chemotherapy

• After laryngectomy: breathing through a neck stoma; the stoma is kept covered and moist. Speech therapy teaches voice prosthesis use.
• Loss of smell and changes in taste are common after laryngectomy.

• From the 2nd or 3rd week: sore mouth and throat (mucositis), painful swallowing, thick saliva and loss of taste. Pain medicines, mouthwashes and soft food help; a feeding tube is used if eating becomes difficult.
• Skin redness on the neck, like sunburn.
• Weight loss: a dietitian review is important.
• Long-term: dry mouth, tooth decay, stiffness of the jaw, neck stiffness, and an underactive thyroid (check TSH yearly).
• Most early side effects settle 4 to 8 weeks after treatment.

• Nausea and vomiting: well controlled with medicines given before and after chemotherapy.
• Low blood counts and infection risk: fever of 38°C or more needs urgent care.
• Tiredness, mouth sores, loose stools or constipation.
• Cisplatin: nausea, kidney effects, ringing in the ears or hearing loss; plenty of fluids are given.

More about chemotherapy · Side effects of your regimen

• The immune system can affect normal organs: thyroid, skin (rash, itching), bowel (loose stools), lungs (cough, breathlessness) and liver.
• These can happen months after starting, or even after stopping. Report any new symptom, even if it seems small.
• Thyroid, cortisol and liver blood tests are checked regularly.

More about immunotherapy · Side effects of your regimen

• Dental check-up before radiotherapy; unhealthy teeth may need removal first.
• After radiotherapy: soft toothbrush, fluoride toothpaste or gel daily, and regular dental visits for life.
• Tell any dentist you had radiotherapy before a tooth extraction: the jaw bone heals poorly (risk of osteoradionecrosis).
• Mouth-opening and jaw exercises every day help prevent stiffness.

• Soft, moist, high-protein food and nutritional supplements during treatment.
• Keep swallowing small sips or soft food even with a feeding tube, so the swallowing muscles stay active.
• Speech and swallowing therapy helps recovery. Nutrition and diet

• Stop all tobacco (smoking, gutka, khaini, betel quid) and alcohol completely.
• Continuing tobacco makes treatment less effective, increases side effects, and greatly increases the risk of a second cancer.
• Ask us for help; medicines and counselling make quitting easier.

• Every 1 to 3 months in the first year, then less often, for at least 5 years.
• A PET-CT or MRI about 3 months after treatment to check the response.
• Thyroid test (TSH) every year after neck radiotherapy.
• Mind and emotions

Bleeding from the mouth, throat or neck, difficulty breathing or noisy breathing, inability to swallow even liquids, or fever of 38°C or more need urgent care. With a laryngectomy stoma: blockage of the stoma or breathing difficulty is an emergency.

When to seek help urgently