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Throat Cancer

If an adult in your life has throat cancer, you may want to learn more about it. This page has information about throat cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease caused by abnormal cells that grow too rapidly. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer that can grow anywhere in the body.1 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.

The term “throat cancer” is not very specific. It includes cancers in many parts of the head and neck area. These areas include the nasopharynx located behind the nose, the oropharynx, which includes the tonsils and base of the tongue, as well as the voice box and the inlet to the esophagus.

Your loved one may have noticed a lump or swelling in or around the neck or throat, then brought it to the attention of a doctor. Not every lump or bump is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome.

It was the hoarseness and the overall feeling of tiredness that prompted me to seek out a doctor for some clue about what was going on.Gordon O. (laryngeal cancer survivor)

Understanding the anatomy

To understand throat cancer, you need a basic understanding of the anatomy (parts) of the head and neck.

Basically, the throat extends from the area behind the nose (nasal cavity) and mouth (oral cavity) down to the opening of the breathing tube (trachea) and the feeding tube (esophagus).

04a_throat_overview CROP

Causes of throat cancer

You may want to know what caused the throat cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

In most cases, it’s a combination of genetics and the environment.

By far the biggest contributor to throat cancer is using tobacco, particularly smoking it. Drinking too much alcohol also adds to the risk of developing throat cancer.

Major factors that increase the chance of developing throat cancer include:

  • Tobacco: Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase the chance of getting throat cancer.1 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.
  • Alcohol: Drinking too much alcohol is strongly linked to getting throat cancer. And if one both smokes and drinks heavily, the risk more than doubles.2 Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Cancer risk associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism. 2006;29(3):193-198.

Other factors that can increase the chance of getting throat cancer include:

  • Exposure to radiation in the past: Being exposed to radiation through previous treatment for another disease, certain working conditions or even a natural disaster can increase the chances of some throat cancers.3 Little MP. Cancer after exposure to radiation in the course of treatment for benign and malignant disease. The lancet oncology. Apr 2001;2(4):212-220.
  • Viruses: The details of this are still being studied. But clearly, exposure to certain strains of human papillomavirus (HPV) is associated with oropharynx cancer, and exposure to Epstein-Barr Virus (EBV) is linked with nasopharynx cancer.4 D'Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. The New England journal of medicine. May 10 2007;356(19):1944-1956.
  •  Genetic factors: This is important in all cancers, and details are still being determined.5 Hildesheim A, Berrington de Gonzalez A. Etiology and prevention of cervical adenocarcinomas. Journal of the National Cancer Institute. Mar 1 2006;98(5):292-293.
  • Certain foods: Lack of some vitamins, poor oral hygiene and even salted fish (for nasopharyngeal cancer) have been linked with certain throat cancers.6 Armstrong RW, Armstrong MJ, Yu MC, Henderson BE. Salted fish and inhalants as risk factors for nasopharyngeal carcinoma in Malaysian Chinese. Cancer research. Jun 1983;43(6):2967-2970.
  • Plummer-Vinson Syndrome (especially for hypopharyngeal and cervical esophageal cancer): This condition, more common in women, is associated with low iron and low blood counts (anemia), along with webs of tissues in the throat that cause difficulty with swallowing.7 Larsson LG, Sandstrom A, Westling P. Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden. Cancer research. Nov 1975;35(11 Pt. 2):3308-3316.
  • Asbestos exposure
  • A history of drinking poisons such as lye
  • Gastroesophageal reflux disease (GERD): Though GERD is not a proven cause of throat cancers, many studies have shown a link between “acid reflux” and throat cancer.8, El-Serag HB, Hepworth EJ, Lee P, Sonnenberg A. Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer. Am J Gastroenterol. Jul 2001;96(7):2013-8.9 Vaezi MF, Qadeer MA, Lopez R, Colabianchi N. Laryngeal cancer and gastroesophageal reflux disease: a case-control study. Am J Med. Sep 2006;119(9):768-76.

Signs and symptoms of throat cancer

Since throat cancer is a general term for cancers in many locations, the signs and symptoms are fairly broad. A cancer in the nasopharynx (behind the nose) will probably have different symptoms than a cancer in the larynx (the voice box). There are certainly some similarities, but certain types of throat cancer should be investigated further to learn about symptoms specific to a certain part of the throat.

In general, symptoms that come for a while and then go away are less likely to be cancer.

Some symptoms that might be related to a throat cancer include10, Wei WI, Sham JS. Nasopharyngeal carcinoma. Lancet. Jun 11-17 2005;365(9476):2041-2054.11Hoare TJ, Thomson HG, Proops DW. Detection of laryngeal cancer--the case for early specialist assessment. Journal of the Royal Society of Medicine. Jul 1993;86(7):390-392.:

  • A hoarse voice
  • Pain or difficulty with swallowing
  • A sore throat
  • A lump or a bump in the neck
  • Ear pain on one side with no other ear problems
  • Feeling like there’s something stuck in the throat
  • Bleeding from the throat
  • Coughing or choking when drinking liquids
  • Difficult or noisy breathing
  • Numbness in a certain part of the face
  • A change in speech or tongue movement
  • Unexplained weight loss

These symptoms sound scary, but don’t jump to conclusions. A person could have one or more of these symptoms but NOT have throat cancer. There are several non-cancerous causes of the same symptoms. That’s why the patient needs to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The throat typically requires a specialist to examine it because it is not easy for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Feel the neck to carefully check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing throat cancer

If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less worried that the lesion is cancer, the doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

However, if the doctor is worried, he or she may choose one or more of the following actions.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting some imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues as to whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous. The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit with very little risk.

Fortunately, biopsies of the skin are more straightforward than for other sites, mainly because they are easier to get to. Typically, skin cancers can be biopsied in the office with a little numbing medicine. It usually takes only a few seconds to do a biopsy. The tissue is then sent to a pathology doctor to see if it is cancer and, if so, what type and how far it has spread.

A biopsy can help the doctor plan the surgery if he or she decides it is needed. A biopsy can also prevent unnecessary surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false-positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Sometimes doctors can’t be completely sure a tumor is cancerous from a biopsy.7 Larsson LG, Sandstrom A, Westling P. Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden. Cancer research. Nov 1975;35(11 Pt. 2):3308-3316.

Serology

Serology involves checking the blood for certain proteins. It is sometimes used, if throat cancer is suspected or confirmed, to see if the body has made proteins to fight the Epstein-Barr Virus. In some cases, checking for DNA of the virus may also help with screening.

Determining the type of throat cancer

After the tumor has been closely looked at, the doctor will need to figure out what type of cancer it is. He or she may be able to tell from the biopsy results. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps inside the throat are cancer. Some growths are benign (non-cancerous), and some tumors are on the border between benign and malignant (cancerous).

Almost all throat cancers are squamous cell carcinomas. There are many different types and classifications of squamous cell carcinomas.

  • Squamous cell carcinoma: These are by far the most common throat cancers. They arise from cells lining the throat.

Rare cancers found in the throat include:

  • Salivary gland cancers: There are minor salivary glands located under the lining of the throat. This is why cancers we typically see in salivary glands can begin in this region. They include diagnoses such as mucoepidermoid carcinomas, adenocarcinomas and adenoid cystic carcinomas, to name a few. See Salivary Gland Cancer for more information.
  • Lymphoma: Lymphoma is cancer of the lymphatic system, which includes lymph nodes, lymph channels, lymphatic fluid and lymphoid tissue. The throat is lined with lymphoid cells. Some major sites of lymphoid tissue include the adenoids in the nasopharynx and palatine tonsils and lingual tonsils in the oropharynx. This is why lymphoma might appear as a lump in the throat area.
  • Mucosal melanoma: These cancers come from skin cells that give skin its color. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat.

Although extremely rare, these cancers can also develop in the throat:

  • Adenocarcinomas of the esophagus
  • Sarcomas such as chondsarcoma, liposarcoma and synovial sarcoma
  • Malignant fibrous histiocytoma
  • Peripheral Neuroectodermal Tumor (PNET)
  • Cancer spread from another site

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is a qualitative interpretation by the pathologist of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by studying the physical exam, imaging studies, laboratory work and biopsies.

Like with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

Deciding on a treatment plan

Like all cancers in the head and neck, there are three general treatment options:

Let’s look at the types of treatments available.

Surgery

The main treatment for almost all throat cancers is complete surgical removal of the tumor. The surgeon will cut out the tumor plus a little bit of normal tissue around it to be sure to get all the cancer. Another doctor, called a pathologist, will look at the entire tumor under a microscope to identify a more exact stage for the tumor. This report, called the pathologic stage, can help the doctor decide if radiation and/or chemotherapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays. Radiation may be used as a main treatment for tumors that cannot be easily removed. The surgeon will use radiation alone or radiation with chemotherapy, depending on the characteristics of the tumor. Radiation is also often used after surgery to lower the chances that the tumor will come back.

Chemotherapy

Chemotherapy, or “chemo,” uses drugs to kill cancer cells. It is especially helpful when:

  • Cancer has spread beyond the head and neck.
  • There is a T3 or T4 tumor in which surgery cannot remove all of the tumor.
  • There is a T3 or T4 tumor that has certain bad features found under the microscope, such as intermediate or high grade.
  • There are close edges.
  • There is growth into nerves.
  • There is spread into lymph nodes.
  • There is growth into lymphatics or vessels.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will life change? These are the big questions on most people’s minds when they find out that someone they love has throat cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of tumor show how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of a cure.
The Tumor Margins (edges) Some say the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone has been shown to indicate a worse prognosis.

What to expect after treatment is completed

When the person in your life who has cancer has completed treatment, he or she will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, a person should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. In addition, the doctor will order scans to help in the monitoring process. After making it past the first five years, the person can then see the doctor once a year.


References

1 Moore C. Smoking and cancer of the mouth, pharynx, and larynx. JAMA: the journal of the American Medical Association. Jan 25 1965;191(4):283-286.

2 Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Cancer risk associated with alcohol and tobacco use: focus on upper aero-digestive tract and liver. Alcohol research & health: the journal of the National Institute on Alcohol Abuse and Alcoholism. 2006;29(3):193-198.

3 Little MP. Cancer after exposure to radiation in the course of treatment for benign and malignant disease. The lancet oncology. Apr 2001;2(4):212-220.

4 D'Souza G, Kreimer AR, Viscidi R, et al. Case-control study of human papillomavirus and oropharyngeal cancer. The New England journal of medicine. May 10 2007;356(19):1944-1956.

5 Hildesheim A, Berrington de Gonzalez A. Etiology and prevention of cervical adenocarcinomas. Journal of the National Cancer Institute. Mar 1 2006;98(5):292-293.

6 Armstrong RW, Armstrong MJ, Yu MC, Henderson BE. Salted fish and inhalants as risk factors for nasopharyngeal carcinoma in Malaysian Chinese. Cancer research. Jun 1983;43(6):2967-2970.

7 Larsson LG, Sandstrom A, Westling P. Relationship of Plummer-Vinson disease to cancer of the upper alimentary tract in Sweden. Cancer research. Nov 1975;35(11 Pt. 2):3308-3316.

8 El-Serag HB, Hepworth EJ, Lee P, Sonnenberg A. Gastroesophageal reflux disease is a risk factor for laryngeal and pharyngeal cancer. Am J Gastroenterol. Jul 2001;96(7):2013-8.

9 Vaezi MF, Qadeer MA, Lopez R, Colabianchi N. Laryngeal cancer and gastroesophageal reflux disease: a case-control study. Am J Med. Sep 2006;119(9):768-76.

10 Wei WI, Sham JS. Nasopharyngeal carcinoma. Lancet. Jun 11-17 2005;365(9476):2041-2054.

11 Hoare TJ, Thomson HG, Proops DW. Detection of laryngeal cancer--the case for early specialist assessment. Journal of the Royal Society of Medicine. Jul 1993;86(7):390-392.