The area of your neck you are referring to contains the following structures: thyroid gland, larynx (voice box) and trachea (windpipe). Any condition that affects these structures can cause pain when you touch the area. For example, an enlargement or inflammation of the thyroid gland can cause pain with pressure. More common conditions, such as acid reflux, can also do this. Acid churning up from the stomach can irritate the back of the larynx, which can then be felt as a throat pain. An infection of the trachea, which could be part of an upper respiratory infection, can also cause pain. Cancers of the larynx can cause pain as well. If you have other risk factors for cancer and the pain has persisted for more than two to three weeks, a visit to your doctor is warranted. Without a thorough head and neck exam, I’d be taking a shot in the dark as to your diagnosis. Q2. My husband will need a stoma after his laryngectomy. We’re anxious about the impact that will have on our lives and his ability to enjoy things like going out for dinner, exercise, etc. Is it hard to take care of? Does it limit your life very much? Laryngectomy is a surgery where the entire voice box (larynx) is removed for advanced cancer. After the reconstruction, the esophagus is still attached to the mouth, so swallowing is unchanged. But the windpipe (trachea) is now brought out through the middle of the neck just above the collar bone and this opening is called a stoma. A very, very rough analogy is a blowhole seen in dolphins. So while you swallow the same, patients with a stoma now breathe directly into the lungs, bypassing the mouth and nose. Taking care of the stoma is relatively minor after healing is complete. In general, speech, dust, water, and sense of smell are all long-term issues with this surgery. As you breathe, your nose and mouth warm, humidify and filter the air. So the lack of relative humidity can cause crusting around the opening of the stoma. This needs to be regularly cleaned out. Most patients wear a small ascot that conceals the stoma and filters out dust. Since the stoma is open all the time, in addition to keeping dust and other particulate matter out, showering can require an adjustment in order to keep the water out. Though there are some devices that allow patients to swim and even snorkel, patients with stomas must think twice before boating or other activities where they can fall into the water as this poses a very serious risk. Your sense of smell and taste are diminished due to the lack of air flowing through your nose and mouth, so smoke detectors and devices that detect natural gas are needed. You will also not be able to blow your nose. I find most patients adjust very well to life after laryngectomy, especially after speech rehabilitation. Several excellent support groups exist for laryngectomy patients, including WebWhispers and local chapters of the Chatterbox laryngectomy support groups. Several other resources for patients and families are listed in the link below. Q3. I’ve had mild throat discomfort for several months — not really a sore throat but more like swollen glands. I am a smoker, and my father died a year ago from esophageal cancer. I’m scared that I might have cancer. What symptoms should I look out for? When should I see a doctor? Some signs of head and neck cancer include persistent cough, difficulty or pain with swallowing, persistent hoarseness or changes in voice, coughing up blood (hemoptysis), ulcers or sores that won’t heal, and lumps in the neck. Additional risk factors include a history of smoking and drinking, and in some cases, a family history of head and neck cancer. These are some things to look for, but by no means does it mean you have cancer if you have any of these symptoms or findings. As a general rule of thumb, symptoms like those you describe should be addressed with your physician if they have persisted for several months. Since you are a smoker and have a family history, a thorough head and neck examination is in your best interest. Q4. With cancer of the larynx, what determines whether or not you have to have your voice box removed? Should I start learning sign language? The treatment for cancer of the larynx can include surgery, radiation, chemotherapy or combinations of all three treatments. Surgery can involve removing a part or all of the voice box (larynx). The amount of surgery needed will depend on the site and stage of the cancer. For example, small cancers of the vocal cords can be treated surgically by removing the vocal cords without removing the entire voice box. Alternatively, radiation therapy can be used to treat these cancers without surgery. However, advanced cancers of the larynx will often require all three treatment options and can often require the removal of the voice box (an operation called a laryngectomy) followed by postoperative radiation and chemotherapy. Accurate staging of the cancer will require imaging (CT scan or MRI) and an evaluation of the larynx by the surgeon under general anesthesia. In this way, the size, location and extent of involvement of the voice box can be assessed. If a laryngectomy is recommended, there are many ways to rehabilitate speech. These include various prostheses that allow the development of an esophageal speech that, with practice, is almost 100 percent intelligible by most people. I would discuss these options with your doctor. Both the American Cancer Society and National Cancer Institute have excellent information about what to expect after laryngectomy, and there are many local support groups for laryngectomy patients. Q5. My husband has throat cancer. He’s a nonsmoker. He tested positive for HPV-16. Should I be tested for HPV? Do I need to worry about getting cancer too? Thanks. Human papilloma virus (HPV) has been linked to cervical cancer and some types of oral cancers. HPV-16 is one of several subtypes of the virus that has a link to oral cancer. But many people harbor HPV in their mouths and not everyone develops oral cancer. Currently, only about 25 percent to 50 percent of oral cancers are associated with HPV-16, and the risk of having HPV-16 and developing oral cancer is not clear. So it is difficult to make definitive recommendations. If you feel you are at risk, I would start with a thorough head and neck exam by a specialist. Any warts or growths in the mouth should be biopsied. Your doctor may also test for the presence of HPV subtypes. Beyond that, I would discuss your concerns with your doctor and to come up with a plan for cancer surveillance that you feel comfortable with. Q6. My doctor said we could try targeted therapy for my throat cancer. I don’t understand what that means. She said it wasn’t the same thing as traditional chemotherapy. In general, targeted therapy refers to a class of drugs that “target” a specific biologic pathway or a specific chemical, protein or cell important in the growth of cancer cells. One of these, the epidermal growth factor receptor (EGFR) is an important regulator of cancer cell growth and is found on the surface of many head and neck cancer cells. Targeted therapies such as cetuximab (Erbitux) can bind to these receptors and disrupt the cellular pathways that control cell growth. Other drugs in this class can target molecules associated with EGFR that disrupt the communication between these receptors and the nucleus of the cell. In simpler terms, if chemotherapyis a “dumb bomb” that kills both normal cells and cancer cells, targeted therapies are “smart bombs” that kill only cancer cells. Currently, targeted therapies for oral, head and neck cancer are used in conjunction with more conventional treatments such as chemotherapy and radiationtherapy and are not approved as stand-alone therapy. Q7. I was treated for stage II laryngeal cancer nearly six years ago and haven’t had a relapse. Does that mean I’m cured? If not, what are my chances that the cancer will come back? First of all, congratulations. Living through cancer treatment is truly an accomplishment, and I continue to be amazed at the resilience of my own patients who have persevered and have come out the other side — a little battered, perhaps — but cancer survivors. For most head and neck cancers, the first 12 months from the time you complete treatment is the most critical time, as most recurrences will occur during this period. Every year after the first year, your chance of recurrence goes down. After five years, many people will consider a patient “cured” because the odds of a recurrence at that point are so low. Having said all of this, if you have survived an advanced cancer, constant vigilance and follow-up are still warranted. Cancer can be a lifelong health issue for many patients. Depending on the type of cancer, recurrences can occur many years after initial treatment. Careful follow-up helps you and your doctor catch any recurrence early, and early detection is the key to long-term survival. So, keep up with your follow-up. If you are a former smoker, it is never safe to go back to smoking. Eat sensibly and well, and take care of your body with regular exercise. You may have to live with cancer, but you can choose to live well. Q8. My husband was diagnosed with larynx cancer (stage IV) this spring. He has had two sessions of chemotherapy (carboplatin), both of which have been horrific. He is almost incoherent, and the fatigue is incredible. I don’t know if he can take a third session. If you reduce the amount of chemotherapy to reduce side effects, do you still get the same benefit? Or are you just stuck with a certain amount if you want to get better? For some advanced laryngeal cancers, induction chemotherapy is used to shrink the tumor volume as to make it more amenable for surgery, or as a pretreatment for definitive chemo-radiation therapy. Due to the higher doses of chemotherapy needed in induction therapy, the side effects can be very pronounced. Unfortunately, these doses are also very important in killing the cancer. So in a very real way, there is a race between how much it takes to kill the cancer and how much your body can tolerate. If your husband has had two sessions of induction chemotherapy, and he is having significant problems, it may be time to re-evaluate the treatment plan. If there has been a significant response to the chemotherapy, surgery may now be an option. Alternatively, he may now be ready for definitive chemo-radiation. I would discuss these issues with your cancer treatment team. Q9. My oncologist told me about a new kind of chemotherapy called cetuximab for pharyngeal cancer. She said it has fewer side effects. Can I try it, or is it still considered experimental? Cetuximab is the generic name for the brand-name medication Erbitux, which is a monoclonal antibody that attaches itself to the epidermal growth factor receptor (EGFR) located on the surface of some cells. This is an important pathway in the growth of some cancer cells, including the most common type of head and neck cancer. Cetuximab is in a class of drugs best thought of as “targeted therapy.” Unlike more traditional chemotherapies that act broadly on many cell types, drugs like cetuximab target specific molecular pathways involved in cancer cell growth. These targeted therapies represent a potential future direction in the treatment of head and neck cancer and are usually given in conjunction with more traditional therapies such as radiation and chemotherapy. Their efficacy as stand-alone therapy is not proven. Cetuximab is approved by the Food and Drug Administration for use in combination with radiation therapy for the treatment of locally or regionally advanced squamous cell cancer of the head and neck. It is also approved for the treatment of recurrent or metastatic squamous cell cancer of the head and neck that has progressed after chemotherapy with platinum-based drugs. Cetuximab is given intravenously. Other drugs in this class are available in a pill form, an additional benefit. Studies have shown that cetuximab has its greatest benefits in cancers expressing high levels of EGFR, and your doctor may recommend that your cancer be tested for EGFR levels. Some side effects of this drug include a very severe skin rash and/or acne, because skin has high levels of EGFR. Cetuximab has moved from clinical trials into more mainstream treatment plans, and although I would not consider it experimental, it is not a “magic bullet” for cancer either. As always, I would thoroughly discuss the pros and cons of any treatment plan with your doctor before you start. Learn more in the Everyday Health Oral, Head, and Neck Cancer Center.
