Treating Laryngeal and Hypopharyngeal Cancers by Stage

Treatment of laryngeal or hypopharyngeal cancer is based largely on the stage (extent) of the cancer, but other factors are also important, such as your overall health and your personal preferences.

Talk to your doctor if you have any questions about the recommended treatment plan. Ask if the treatment will change how you look, talk, breathe, and eat.

Smoking during cancer treatment is linked to more side effects, worse outcomes, and reduced benefit of treatment. It is best to stop smoking completely before starting treatment. Smoking also increases the risk of the cancer coming back after treatment as well as the risk of getting a new cancer.  Quitting smoking for good is the best way to improve your survival.

Laryngeal cancers

Stage 0

These cancers are almost always glottic (vocal cord) cancers that are found early because of voice changes. They are nearly always curable with either endoscopic surgery or radiation therapy. The patient is then watched closely to see if the cancer returns. If the cancer does comes back, radiation can be used.

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

Stage I and II laryngeal cancers

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

Either radiation alone or surgery with a partial laryngectomy can be used in most people. Many doctors use radiation therapy for smaller cancers. Voice problems tend to be less with radiation therapy than with partial laryngectomy, and there tend to be fewer problems with radiation treatment.

The treatment for glottic (vocal cord) cancers and supraglottic cancers (those starting above the vocal cords) is slightly different.

Glottic cancer: 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 (such as finding cancer cells at the edge of the removed tumor). If you need more treatment after surgery, your options might include radiation therapy, chemoradiation, or surgery to remove more of the larynx.

Supraglottic cancer: Supraglottic cancers are more likely to spread to the lymph nodes in the neck. If you're having surgery for supraglottic laryngectomy, the surgeon might also remove lymph nodes from your neck (called a lymph node dissection). If your treatment is radiation therapy alone, you will also get radiation to the lymph nodes in the neck. If, after surgery, the cancer is found to have features that make it more likely to come back, more treatment (such as radiation therapy, chemoradiation, or more extensive surgery) might be needed.

Stage III and IV laryngeal cancers

The main options for initial treatment for these cancers are surgery, chemotherapy followed by chemoradiation, or chemotherapy with radiation. Radiation therapy alone (or with the targeted drug cetuximab) may be an option for people who cannot tolerate more intensive treatments. Immunotherapy might be another option for some people with stage IV cancer.

Surgery for these tumors is almost always complete removal of the larynx (total laryngectomy), but a small number of these cancers might be treated by partial laryngectomy.

If they haven't spread already, these cancers have a high risk of spreading to nearby lymph nodes in the neck, so these lymph nodes are often removed along with the tumor if surgery is being done. Radiation therapy, often given with chemo, might be needed after surgery, especially if the cancer has spread to the lymph nodes or has other features that make it more likely to come back.

Instead of using surgery as the first step, many doctors now prefer to start treatment with chemoradiation (radiation and chemotherapy given together). If any cancer remains after treatment, surgery can then be done to try to remove it. Chemoradiation can be difficult to tolerate, but it often works as well as total laryngectomy and gives a 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, the best treatment may be surgery to remove the larynx and nearby tissues with cancer (such as the thyroid gland).

Another option may be to start with just chemotherapy, which is called induction chemotherapy. If the tumor shrinks, radiation therapy or chemoradiation is then given. If the tumor doesn’t shrink, surgery is usually the next treatment.

Cancers that are too big or have spread too far to be completely removed by surgery are often treated with radiation, usually combined with chemotherapy or cetuximab. Another option might be treatment with an immunotherapy drug, either alone or with chemotherapy. Sometimes, if the tumor shrinks enough, surgery of the tumor and the lymph nodes in the neck might be 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.

Hypopharyngeal cancers

These cancers are often harder to treat than laryngeal cancers. Because they don't cause symptoms when they're small, most are already at an advanced stage when they're diagnosed. Tumors in this area also tend to spread to the lymph nodes, even when there's no obvious mass in the neck. Because of this, treatment of the lymph nodes in the neck is often recommended.

Stage I hypopharyngeal cancers

The main options for initial treatment of these cancers are surgery 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. People who have a high chance of the cancer returning (based on what's found during surgery) might then be treated with radiation or chemotherapy combined with radiation (chemoradiation).

Some patients with small tumors may get radiation as their main treatment. The cancer is assessed again after the treatment is complete and if there's any cancer left, surgery is done.

Stage II, III, and IV hypopharyngeal cancers

One option to treat these cancers is surgery to remove the pharynx, larynx, thyroid gland, and lymph nodes in the neck. This is usually followed by radiation alone or radiation with chemo, especially if there's a high chance that the cancer will come back based on what is found during surgery.

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

A third option is to get chemotherapy as the first treatment, called induction chemotherapy. This is usually followed by radiation therapy or chemoradiation, depending on how much the tumor shrinks. If the tumor does not shrink, surgery might be done. If the lymph nodes in the neck are still enlarged after treatment, surgery can be done to remove them (lymph node dissection).

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 cetuximab. Another option might be treatment with an immunotherapy drug, either alone or with chemotherapy. Sometimes, if the tumor shrinks enough, surgery to remove the tumor and the lymph nodes in the neck may be 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.

Laryngeal and hypopharyngeal cancers that progress or recur after treatment 

If cancer continues to grow during treatment (progress) or comes back (recur), further treatment will depend on the location and extent of the cancer, what treatments have been used and when, and also on the person’s health and desire for more treatment. Recurrence can be local (in or near the same place it started) or distant (spread to other parts of the body, like the lungs or bone). It’s important to understand the goal of any further treatment – if it is to try to cure the cancer, to slow its growth, or to help relieve symptoms. It is also important to understand the benefits and risks of more treatment.

Because cancer recurrence is hard to treat, patients might want to think about taking part in clinical trials of newer treatments.

Local recurrence

Local recurrence in people who have already had limited surgery such as partial laryngectomy, can often be treated with more extensive surgery (such as a total laryngectomy). This may be followed by radiation therapy or chemoradiation (radiation and chemo are 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 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 can't be done, immunotherapy alone or in combination with chemotherapy 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.)

Distant recurrence

A distant recurrence, where radiation therapy and surgery are not options, can be treated with immunotherapy alone or immunotherapy combined with chemotherapy. Another option might be treatment with a targeted agent, either alone or with chemotherapy. Chemoradiation might also be used, if a person 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.)