Within a week or so after a partial laryngectomy, you will be able to talk in the usual way. After a total laryngectomy, however, you must learn to speak in a new way. A speech pathologist usually meets with you before surgery to explain the methods that can be used. In many cases, speech lessons start before you leave the hospital.

Until you begin to talk again, it is important to have other ways to communicate. Here are some ideas that you may find helpful:

Keep pads of paper and pens or pencils in your pocket or purse.

Use a typewriter, computer, or other electronic device. Your words can be printed on paper, displayed on a screen, or produced in a male or female voice.

Carry a small dictionary or a picture book and point to the words you need.

Write notes on a “magic slate” (a toy with a plastic sheet that covers black wax; lifting the plastic erases the sheet).

The health care team can help patients learn new ways to speak. It takes practice and patience to learn techniques such as esophageal speech or tracheoesophageal puncture speech, and not everyone is successful. How quickly a person learns, how understandable the speech is, and how natural the new voice sounds depend on the extent of the surgery on the larynx.

Esophageal Speech

A speech pathologist can teach you how to force air into the top of your esophagus and then push it out again. The puff of air is like a burp. It vibrates the walls of the throat, making sound for the new voice. The tongue, lips, and teeth form words as the sound passes through the mouth.

This type of speech sounds low pitched and gruff, but it usually sounds more like a natural voice than speech made by a mechanical larynx. There is also no device to carry around, so your hands are free.

Tracheoesophageal Puncture

For tracheoesophageal puncture (TEP), the surgeon makes an opening between the trachea and the esophagus. The opening is made at the time of initial surgery or later. A small plastic or silicone valve fits into this opening. The valve keeps food out of the trachea. After TEP, patients can cover their stoma with a finger and force air into the esophagus through the valve. The air produces sound by making the walls of the throat vibrate. The sound is a lot like natural speech.

Mechanical Speech

You may choose to use a mechanical larynx while you learn esophageal or TEP speech or if you are unable to use these methods. The device may be powered by batteries (electrolarynx) or by air (pneumatic larynx).

Many different mechanical devices are available. The speech pathologist will help you choose the best device for your needs and abilities and will train you to use it.

One kind of electrolarynx looks like a small flashlight. It makes a humming sound. You hold the device against your neck, and the sound travels through your neck to your mouth. Another type of electrolarynx has a flexible plastic tube that carries sound into your mouth from a hand-held device. There are also devices that are built into a denture or retainer and can be worn inside your mouth and operated by a hand-held remote control.

A pneumatic larynx is held over the stoma and uses air from the lungs instead of batteries to make it vibrate. The sound it makes travels to the mouth through a plastic tube.

Followup Care

Followup care is important after treatment for cancer of the larynx. Regular checkups ensure that any changes in health are noted. Problems can be found and treated as soon as possible. The doctor will check closely to be sure that the cancer has not returned. Checkups include exams of the stoma, neck, and throat. From time to time, the doctor may do a complete physical exam and take x-rays. If you had radiation therapy or a partial laryngectomy, the doctor will also examine you with a laryngoscope.

Treatments for laryngeal cancer can affect the thyroid. A blood test can tell if the thyroid is making enough thyroid hormone. If the level is low, you may need to take thyroid hormone pills.

People who have laryngeal cancer have a chance of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for those who are smokers or drink alcohol heavily. Most doctors strongly urge their patients to stop smoking and drinking to cut down the risk of a new cancer and other health problems.

The NCI has prepared a booklet for people who have completed their treatment to help answer questions about followup care and other concerns. Facing Forward Series: Life After Cancer Treatment 11 provides tips for getting the most out of medical visits. It describes the kinds of help people may need. Support for People with Cancer of the Larynx

Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, people living with cancer get together to share what they have learned about coping with the disease and the effects of treatment. People interested in finding a support group may want to talk with their health care provider for suggestions.

People living with cancer may worry about caring for their families, keeping their jobs, or continuing daily activities. Concerns about tests, treatments, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful for those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for help with rehabilitation, emotional support, financial aid, transportation, or home care.

The Cancer Information Service (1-800-4-CANCER) can provide printed materials on coping, as well as information to help patients and their families locate programs and services.

The Promise of Cancer Research

Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Studies include new ways to treat cancer of the larynx. Research already has led to advances, and researchers continue to search for more effective approaches.

People who join these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.

People with laryngeal cancer are participating in several types of treatment studies:

Radiation therapy. Researchers are studying a new approach to radiation therapy. Patients receive radiation three times a day, 5 days a week, for just over 2 weeks, instead of once a day for 5 to 7 weeks.

Drugs that reduce side effects. Researchers are testing therapies that reduce the side effects of radiation therapy. They are testing drugs that may help patients maintain their weight or help lessen damage to the skin during radiation therapy.

Chemotherapy. Scientists are studying drugs that kill cancer cells. These drugs are used alone or in combination with radiation therapy to spare the larynx from surgery.

Biological therapy. Scientists are studying monoclonal antibodies that slow or stop the growth of cancer.

If you are interested in learning more about joining a clinical trial, you may want to talk with your doctor.

Cancer of the larynx can occur on the glottis (most laryngeal cancers are there), the supraglottis (the area above the vocal cords, which includes the epiglottis), or the subglottis (the area that connects the larynx to the trachea).

Cancer of the larynx affects more men then women, although more women are developing it today due to an increase in smoking in the female population.

Causes of Cancer of the Larynx

Although the exact cause of cancer is unknown, some known risk factors for cancer of the larynx include:

smoking: The risk of laryngeal cancer increases up to 30 times forsmokers. The heavier the person smokes, the higher the risk. Second-hand smoke is also considered a hazard.

alcohol: Heavy drinkers more than double their risk for this type of cancer, and combining smoking with alcohol can increase the risks even more than either drinking or smoking alone.

GERD (gastroesophageal reflux disease): Constant heartburn could actually be GERD. In GERD, the stomach acid backs up into the esophagus, causing a burning pain. Researchers have found that the irritation from long-standing GERD can increase the chances of cancer in both the esophagus and the larynx.

poor nutrition: Many people who abuse alcohol also have poor nutritional habits, but some research also suggests that not getting enough vitamins might be a risk factor.

human papillomavirus (HPV): The virus that can cause genital warts can also develop into certain cancers. Mothers may pass the virus on to their children when they’re born. It settles in the larynx, developing into growths called laryngeal papillomas later on in life. These growths may develop into cancer.

race: Laryngeal cancer is found twice as often among people of African descent than among Caucasians.

gender: More men than women are diagnosed with cancer of the larynx.

age: This type of cancer is usually detected in people between 50 and 75 years old.

weakened immune systems: People with weak immune systems (due to diseases such as AIDS or medications that lower immunity to viruses) are more susceptible to laryngeal cancer.

toxic exposure: These risk factors include being exposed to wood dust, asbestos, or many types of chemicals, which can increase the chances of cancer.

voice overuse: People who use their voices a lot, such as singers, may develop polyps (lumps of tissue) that can become cancerous if not removed.

Symptoms and Complications of Cancer of the Larynx

The symptoms of laryngeal cancer depend on where in the larynx the tumour is located. Cancer on the vocal cords can often be detected early because the main symptom is hoarseness. Most people go hoarse from time to time, but if the hoarseness doesn’t go away in two weeks, it should be checked.

Symptoms that the cancer has spread or is occurring in another part of the larynx include:

a cough that doesn’t go away

persistent sore throat

breathing difficulties, feeling that something is catching in the throat

ear pain (pain from deep in the throat can be felt in the ear)

a lump or mass in the neck or throat

coughing up of blood

There are a few complications that can result from laryngeal cancer.

Airway obstruction: Any tumour or swelling in the airway can cause a blockage, making breathing difficult. If treatment involves total removal of the larynx, a tracheostomy (surgery to create an artificial airway in the trachea) is then performed to improve breathing.

Disfigurement: Removing the tumour and surrounding tissue could leave some disfigurement of the throat and neck. Muscles might be removed as well, making neck movement more difficult. If a tracheostomy was performed, the stoma (opening in the throat) is usually permanent.

Difficulty eating: After surgery, it may become difficult to swallow certain consistencies of food. Those undergoing radiotherapy may have trouble swallowing or even chewing. Chemotherapy can cause nausea and vomiting. A good, healthy diet is vital when recuperating from cancer, so it’s important that adequate nutrition be maintained throughout the treatment.

Cancer spread: It’s possible that the cancer may spread to other areas of the body.

Voice loss: Treatment that involves removing the entire larynx makes normal speech impossible. In this case, alternate methods of speaking need to be learned. These are:

esophageal speech: This is the most basic form of alternate speech, which is done by swallowing air and creating sound by expelling it.

tracheoesophageal puncture (TEP): A small one-way valve is placed between the trachea and esophagus. By taking in air through their stoma into the lungs, then covering their stoma (from the tracheostomy), sounds can be made through the mouth.

electrolarynx: When you hold this electronic device next to the skin of the throat or the corner of the mouth it produces a mechanical voice. Muscle movements stimulate the machine to make sounds.

While these new methods of speech are being learned, other ways of communicating will be needed. This might mean keeping a “magic slate” or pad and pencils easily available. It’s important to plan ahead to help avoid frustration after surgery.

WebWhispers is an on-line group for anyone with access to a computer. The address is www.webwhispers.org and there is a lot of helpful information on the site. You can join for free and get on their e-mail list. You can ask any question about your laryngectomy and many people will answer from their own experience. It is a very caring group –makes you feel not so alone.

There is also a monthly meeting held the 3rd Wednesday of each month at Walgreen’s Health Initiative building at 1435 No. 113th St. in Wauwatosa, WI from noon to 1:15 PM. We are a group of laryngectomees — usually led by speech therapists. I believe it is sponsored by the American Cancer Society. Quite often we have speakers (I believe Dr. Bruce Campbell spoke once). Other times, we just discuss with the group about our situation and how we have handled problems. We support and help each other. A few of us speak with an electrolarynx, a few with transesophageal puncture (TEP), and a very few with esophageal speech. It’s a fairly small group — usually about 10 or so attending each month.

A:  I do hope the reader who had his larynx (voice box) removed because of cancer and is not able to speak will see your very helpful suggestions for gaining support and information. For more, try the American Cancer Society, and the International Association of Laryngectomees, which lists local larygenctomee clubs and other helpful resources.

“Controlling for the other included factors, the radiotherapy and chemo-radiotherapy groups had lower odds of survival than did the total laryngectomy group,” the authors write. “The increased risk associated with death is approximately 30 percent for the chemo-radiotherapy group and 60 percent for the radiotherapy group.”

In addition, men were less likely to survive than women, those with stage IV disease were less likely to survive than those at stage III, black patients were more likely to die than white patients and uninsured patients and those with Medicaid, Medicare or other government health plan coverage were more likely to die than those with private insurance. “We do not believe that insurance status in this analysis represents differential treatment or quality of care for patients with advanced laryngeal cancer,” the authors write. “Rather, insurance status is likely a proxy for multiple medical care issues, including usual source of medical care, participation in screening and preventive care activities and exposure to related risk factors, including alcohol and/or tobacco use and poor diet, all of which can influence overall survival.”

“In conclusion, this analysis demonstrates that total laryngectomy yields the highest likelihood of survival for patients with advanced laryngeal cancer,” the authors write. “These results differ from those of previous analyses comparing total laryngectomy and chemo-radiotherapy, suggesting that caution is needed when applying clinical trial findings to broader medical care settings and populations.”

Validation of the use of the lognormal model for predicting long-term survival rates using short-term follow-up data.

Methods

907 cases of laryngeal cancer were treated from 1973–1977 by radiation and surgery (248), radiation alone (345), and surgery alone (314), in registries of Connecticut and Metropolitan Detroit of the SEER database, with known survival status up to 1999. Phase 1 of this study used the minimum chi-square test to assess the goodness of fit of the survival times of those who died with disease to a lognormal distribution. Phase 2 used the maximum likelihood method to estimate long-term survival rates using short-term follow-up data. In order to validate the lognormal model, the estimated long-term cancer-specific survival rates (CSSR) were compared with the values calculated by the Kaplan-Meier (KM) method using long-term data.

Results

The 25-year CSSR were predicted to be 72%, 68% and 65% for treatments by radiation and surgery, by radiation alone, and by surgery alone respectively, using short-term follow-up data by the lognormal model. Corresponding results calculated by the KM method were: 72+/-3%, 68+/-3% and 66+/-4% respectively.

Conclusions

The lognormal model was validated for the prediction of the long-term survival rates of laryngeal cancer patients treated by these different methods. The lognormal model may become a useful tool in research on outcomes.

Background

Literature review [1] indicated that local control, laryngeal preservation, and survival rates of larynegeal cancer patients were similar after transoral laser resection, open partial laryngectomy, and radiotherapy. Open partial laryngectomy was reserved for patients with locally recurrent tumors. There are still some unanswered questions. Will radiation combined with surgery give a better result than single modality treatment alone? Will treatment results from the community centers follow published data from prestigious centers? After radiotherapy, radio-resistant cells theoretically may take some time to grow before recurrence. Short-term data may not reflect long-term local control and survival rates. We attempt to address these questions in the present study.

The lognormal distribution is defined as the distribution of a random variable whose logarithm is normally distributed. The purpose of this study is to validate the use of the lognormal model [2-4] by estimating the long-term survival from short-term follow-up data of laryngeal cancer treated by three different treatment methods: radiation and surgery, radiation alone, and surgery alone. We have previously validated the application of the lognormal model for small cell lung cancer [5], glottic laryngeal cancer [6], prostate cancer [7] and breast cancer [8].

This model may be useful for randomized clinical trials because it allows the prediction of long-term survival rates several years earlier than is possible by using the standard actuarial life table/Kaplan-Meier method of calculation [9].

The idea that long-term survival rates can be estimated from short-term follow-up data is attractive because this method shortens the delay in further research to improve cancer treatment. The validation of the lognormal model has two phases. Phase 1 tests the goodness of fit to a lognormal distribution of the survival times of those cancer patients who died with disease.

Phase 2 attempts to verify the lognormal model, which uses short-term follow-up data to predict long-term survival rates. These survival rates are then compared with values calculated by the Kaplan-Meier life table method from available long-term data. The second phase has been difficult to implement because of the general lack of large number of patients with sufficiently long follow-up information. With the SEER database [10], the validation of the lognormal model is now possible.

Between 1993 and 1995, a prospective longitudinal multicenter study of HRQL was performed in Sweden and Norway, including 357 newly diagnosed head-and-neck cancer patients. Patients were included consecutively, and therefore the patient group could be regarded as a convenience sample. The patients’ HRQL was assessed repeatedly during one year using three standardized questionnaires: the European Organization for Research and Treatment of Cancer (EORTC), Quality of Life Questionnaire-Core30 (QLQ-C30) (18), the EORTC Head and Neck Cancer Module (EORTC QLQ-H&N35), and the Hospital Anxiety and Depression Scale (HADS).

This research focused on the 86 patients with laryngeal carcinoma who were included in the initial study group of 357 patients and performed a five-year follow-up, both of clinical data and their HRQL, using the same questionnaires. The aims of the study were to: (1) assess changes in HRQL between diagnosis and the five-year follow-up, as well as between the one-year follow-up and the five-year follow-up; (2) analyze HRQL results in relation to anatomic location within the larynx, i.e., supraglottic and glottic carcinoma; (3) analyze HRQL results in relation to the treatment given, i.e., conventional radiotherapy, hyperfractionated accelerated radiotherapy, combined treatment, and laryngectomy; (4) explore whether HRQL at diagnosis may predict the HRQL and the survival rate five years after diagnosis.

The authors of “Health-Related Quality of Life Five Years after Diagnosis of Laryngeal Carcinoma,” are Mats Nordgren MD, Magnus Jannert MD PhD, and Marianne Ahlner-Elmqvist RN, from the Department of Otorhinolaryngology, Malmo¨ University Hospital, Lund University, Malmo¨, Sweden; Helmut Abendstein MD, at the Department of Otolaryngology and Head and Neck Surgery, St. Olav’s Hospital, Trondheim, University, Trondheim, Norway; Morten Boysen MD PhD, at the Department of Otolaryngology and Head and Neck Surgery, Rikshospitalet, Oslo University, Oslo, Norway; Ewa Silander RD, and Eva Hammerlid MD PhD, both from the Department of Otolaryngology and Head and Neck Surgery, Sahlgrenska University Hospital, Goteborg University, Goteborg, Sweden; and Kristin Bjordal MD PhD, at the Department of Radiation Oncology, The Norwegian Radium Hospital, Oslo, Norway. Their findings were presented September 24, 2003, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation http://www.entnet.org Annual Meeting and OTO EXPO, being held September 21-24, 2003, at the Orange County Convention Center, Orlando, FL. (note: This study has been accepted for publication in the International Journal of Radiation Oncology, Biology, Physics)

Methodology: The original cohort of 357 patients were asked to answer HRQL questionnaires on six occasions during one year: at diagnosis, and one, two, three, six, and 12 months after the start of treatment. The 86 patients taking part in the study and who were still alive were asked, five years after diagnosis, to fill in the same HRQL questionnaires again. Laryngeal cancer patients who dropped out during the first study year but were alive at the five-year follow-up were also asked to answer the questionnaires. Clinical data related to the treatment given, relapse, and survival rate were collected at the one and five year follow-ups. Comorbidity including other cancers, other serious illnesses as well as heart and pulmonary diseases were recorded at the same time-points.

The HRQL questionnaires used were the EORTC QLQ-C30, a 30-item questionnaire widely used cancer-specific, patient-based measure designed for self-administration. The questionnaire comprises five functional scales—physical, emotional, role, cognitive, and social functioning; three symptom scales—fatigue, nausea-vomiting, and pain; six single items concerning dyspnea, sleep disturbance, loss of appetite, constipation, diarrhea, and financial difficulties; and a global quality of life scale; EORTC QLQ-H&N35. This 35-item head-and-neck cancer specific module consists of questions related to problems due to the tumor location and treatment; and HADS., the Hospital Anxiety and Depression Scale.

Eighty-six patients were included, of whom 84 percent were male. The patients were divided into subgroups according to stage, tumor location, and treatment. Forty-nine of 62 patients (79 percent) were diagnosed with Stage I /II glottic carcinoma and 6/24 patients (25 percent) with Stage I /II supraglottic carcinoma. Twelve patients underwent laryngectomy during the first year and one patient after 2 1⁄2 years. Eight of the 13 laryngectomized patients had glottic carcinoma, and five had supraglottic carcinoma. Chemotherapy was given to eight patients with Stage III/IV tumors; seven were given the combination of cis-platinum and 5-fluorouracil and one carbo platinum and 5-fluorouracil.

Results: Seventy-four of the 86 patients (85 percent) were alive after one year, and 53 patients (62 percent) were alive after 5 years. The disease-specific survival rate was 73 percent. At the five-year follow-up, 33 patients were dead, 20 due to the laryngeal carcinoma and one due to another form of malignancy. Eleven patients died from other diseases and one from unknown causes. Patients treated with hyperfractionated radiotherapy had a five-year survival rate of 90 percent, whereas patients treated with laryngectomy had a 31 percent survival rate at five years. Key findings included:

Change in HRQL scores for all patients between diagnosis and the five -year follow-ups. A clinically and statistically significant improvement between the score at diagnosis and the five-year follow-up was found in the speech scale. Five scales and single items showed both clinical and statistical deterioration (physical functioning scale, role functioning scale, problems with dyspnea, dry mouth, and sticky saliva).

Change in HRQL scores for all patients between the one-year and the five-year follow-up. None of the variables showed both clinically and statistically significant improvement in HRQL, but one scale showed statistical improvement (diarrhea). A few scales showed deterioration both clinically and statistically (physical functioning scale, role functioning scale, and problems with social eating).

Comparison of HRQL at diagnosis between survivors and patients who died during follow-up. Patients who survived five years had better HRQL at diagnosis than those who died during the first year after treatment. The largest differences were seen in the speech scale, social eating scale, physical functioning scale, role functioning scale, coughing, appetite loss sticky saliva, fatigue scale, feeling ill, and pain scale

Conclusions: Comparing cancer subsites showed that patients with glottic carcinoma had better HRQL values at diagnosis and after one year. After five years the supraglottic carcinoma group had better quality of life, but the number of patients was small and the five-year results are therefore inconclusive. Patients with supraglottic carcinoma not surviving five years had worse HRQL already at diagnosis compared with supraglottic survivors. The patients with supraglottic carcinoma had lower survival rates compared with patients with glottic carcinoma (25 vs. 75 percent), and they were often diagnosed at a later stage due to the differences in symptomatology.

The laryngectomized patients showed an unexpected improvement in speech at the five-year follow-up, with scores comparable to those of patients grouped as “all other treatments.” Previous studies have shown that laryngectomized patients experienced severe problems with speech or at least no improvement compared with diagnosis.

Patients with laryngeal carcinoma had better speech after five years compared with the time of diagnosis. However, physical function and role function deteriorated during the same period, and treatment-related side effects, such as dyspnea, dry mouth, and sticky saliva, became worse. From the first year to five years after diagnosis, a few scales deteriorated, such as physical function and role function, and problems with social eating increased.

Amy Y. Chen, M.D., M.P.H., of Emory University and the American Cancer Society, Atlanta, and Michael Halpern, M.D., Ph.D., also of the American Cancer Society, analyzed data from a national cancer registry containing 7,019 patients diagnosed with advanced laryngeal cancer between 1995 and 1998. Of these, 53.6 percent underwent total laryngectomy, 30.6 percent radiation therapy (radiotherapy) alone and 15.8 percent combined chemotherapy and radiotherapy.

“Controlling for the other included factors, the radiotherapy and chemo-radiotherapy groups had lower odds of survival than did the total laryngectomy group,” the authors write. “The increased risk associated with death is approximately 30 percent for the chemo-radiotherapy group and 60 percent for the radiotherapy group.”

In addition, men were less likely to survive than women, those with stage IV disease were less likely to survive than those at stage III, black patients were more likely to die than white patients and uninsured patients and those with Medicaid, Medicare or other government health plan coverage were more likely to die than those with private insurance. “We do not believe that insurance status in this analysis represents differential treatment or quality of care for patients with advanced laryngeal cancer,” the authors write. “Rather, insurance status is likely a proxy for multiple medical care issues, including usual source of medical care, participation in screening and preventive care activities and exposure to related risk factors, including alcohol and/or tobacco use and poor diet, all of which can influence overall survival.”

“In conclusion, this analysis demonstrates that total laryngectomy yields the highest likelihood of survival for patients with advanced laryngeal cancer,” the authors write. “These results differ from those of previous analyses comparing total laryngectomy and chemo-radiotherapy, suggesting that caution is needed when applying clinical trial findings to broader medical care settings and populations.”