Let's Talk About Throat Cancer
From the causes to the cures, we've got everything you need to know on this less common but growing category of cancers making headlines. by Stephanie Wood Health Writer
The expression “I’ve got a lump in my throat,” can mean you’re feeling a heart-tugging emotion in a good way—or it can spell big trouble when there’s a legit bump that shouldn’t be there and doesn’t go away. Once thought to be a disease of old men and heavy smokers, that scenario is changing as we learn more about new causes of throat cancer—we’re lookin’ at you HPV—and who is vulnerable. At the same time, incredible advances in surgery, radiation, and medical treatments are improving not just survival rates, but quality of life for people who’ve battled cancers of the throat and won.
Our Pro Panel
We went to some of the nation’s top experts on head and neck cancers to bring you the most up-to-date information possible.
Salvatore M. Caruana, M.D.
Director of the Division of Head and Neck Surgery
New York-Presbyterian Hospital Columbia University Medical Center
New York, NY
Nadia Mohyuddin, M.D.
Head and Neck Surgical Oncologist, Associate Professor of Clinical Otolaryngology
Houston Methodist Hospital
J. Kenneth Byrd, M.D.
Chief of Head and Neck Surgery, Medical Director and Research Director
Georgia Cancer Center at Augusta University
As an adult, the best things you can do are not use tobacco—and quit now if you do—and limit or avoid alcohol. If you’re a parent, consider have your tween or teen vaccinated for HPV. The vaccine isn’t helpful once someone has become sexually active and likely acquired HPV, which is a virus the body mostly fights off—except when it doesn’t.
A sore throat that doesn’t go away is one of the most common early symptoms, along with a lump in your neck, trouble swallowing, and hoarseness or other changes in your voice. Of course, all of these symptoms can occur for other reasons, so pay attention to how long they last. If any these symptoms persist for more than two weeks, have a doctor take a look.
If a lump on your neck is a tumor it will feel hard and firm from the outside and may be immovable. From the inside it can be painful all the time, but especially when swallowing. A hard mass on the side of your neck could also be due to a swollen lymph node, where throat cancer often spreads.
One of the main goals of treating laryngeal cancer is to preserve as much of your natural voice as possible. In more advanced cases when removing the entire larynx is necessary, you will no longer be able to speak using your vocal cords. You can work with a speech pathologist, however, to learn other ways to speak.
What Is Throat Cancer, Actually?
Most days we just chew, swallow, talk, and breathe without giving much thought to the critical body part that makes it all happen. Except when it starts to hurt. A sore throat is never fun, but at least it’s usually temporary. It’s when a sore throat hangs on like a toddler wrapped around your legs that you need to get it checked out. Because although head and neck cancers are uncommon and most are on the decline in the U.S., some forms of throat cancer are actually on the rise—and a chronic sore throat is one potential indicator. Let’s take a deeper dive into what could be going on.
First, some Throat Anatomy 101. Your throat is made up of—in medical lingo—the pharynx and the larynx. The pharynx is a hollow tube that’s about five inches long. It begins behind your nose and travels down to the esophagus, another hollow tube that helps food and drink journey on to your stomach. The pharynx has three parts:
the nasopharynx, or the upper part behind your nose
the oropharynx in the middle, which starts where the oral cavity (mouth) ends and includes the soft palate at the back of your mouth, the base of the tongue, and the tonsils
the hypopharynx, or the lower part of the throat
The larynx, more commonly known as your voice box, is a short passageway formed by cartilage between the base of the tongue and the trachea (windpipe). The larynx contains your vocal cords which vibrate and make sound when air hits them. That sound then echoes through the pharynx, mouth, and nose to create your voice. The larynx also includes a small piece of tissue, called the epiglottis, which shifts to cover the opening when you swallow so that food can’t enter the air passages. Like the pharynx, the larynx also has three parts:
The supraglottis and epiglottis make up the upper area above the vocal cords.
The glottis make up the middle part where the vocal cords are located.
The subglottis is the lower part between the vocal cords and trachea.
It’s a mouthful to be sure, but you need to know all this because throat cancers can have different causes, symptoms, and outcomes depending on which area they’re located in.
One thing that most throat cancers do have in common, however, is that 90% to 95% of them are squamous cell carcinomas, meaning they begin in the flat squamous cells that make up the thin layer of tissue that lines the interior surfaces of your head and neck.
Directly beneath this lining is a layer of moist tissue called the mucosa. If there are abnormal findings only in the squamous layer of cells, it is called carcinoma in situ, meaning that these cells have not turned into full-blown cancer yet, but they could be on their way. If the cancer has traveled beyond this first layer into the deeper tissue, then it is called invasive squamous cell carcinoma.
From there, depending on the exact location of the cancerous cells, your cancer will get its own name.
What Are the Types of Throat Cancer?
To friends and family, you have throat cancer. But technically speaking, you’ll be diagnosed with one of four possible types, three named after parts of your pharynx, plus one for your larynx. The cancers you can get are named after the part of the throat they’re in.
Nasopharyngeal Cancer. Forming in the air passageway at the upper part of the throat behind the nose, NPC is diagnosed in fewer than one person per 100,000 annually. About half the people with NPC are under age 55, and men are two times more likely than women to be affected. The five-year survival rate is 61%.
Oropharyngeal Cancer. Forming in the middle of the throat, 70% of oropharyngeal cancers are caused by the sexually-transmitted human papillomavirus (HPV). While this type of cancer is on the rise—men are four times more likely to get it and the average age of diagnosis is 62—it’s also considered one of the more curable types. The five-year survival rate is about 65%.
Hypopharyngeal Cancer. Affecting 3,000 people annually, this cancer forms in the area at the bottom part of your throat. Its deeper location and minimal symptoms mean it is often not diagnosed until a later stage and has a worse prognosis (the overall five-year survival rate is only 32%). It affects men four to five times more often than women.
Laryngeal Cancer. Forming in the tissues of your voice box, this cancer affects men four to five times more than women. About 12,370 adults in the U.S. are diagnosed with laryngeal cancer every year and the overall five-year survival rate is 60%.
What Causes Throat Cancer?
Like all head and neck cancers, the primary culprits for this disease are tobacco and alcohol use, and for oropharyngeal cancer (and, rarely, laryngeal cancer), HPV. Beyond that, there are a few specific risk factors for each type. They include:
Ancestry. Being of Asian descent, and especially Chinese ancestry, is a risk factor for nasopharyngeal cancer. Black and white people are more likely to develop hypopharyngeal and laryngeal cancer.
Epstein-Barr virus. Contracting this virus, which causes mononucleosis or “mono” for short, is a risk factor for nasopharyngeal cancer.
Nutrition. A diet low in vitamins A and E may raise a person’s risk of laryngeal and hypopharyngeal cancer, although more research is needed.
Occupation. Exposure to wood dust is a risk factor for nasopharyngeal cancer. Exposure to asbestos, wood dust, paint fumes, and certain chemicals may increase a person’s risk of developing hypopharyngeal cancer. Exposure to asbestos and synthetic fibers have been associated with cancer of the larynx (voice box). People who work in construction, metal, textile, ceramic, logging, and food industries may also have an increased risk of cancer of the larynx.
Oral health. Poor dental health and irritation from dentures that don’t fit properly increase the risk of head and neck cancers.
Paan (betel quid). This chewable combo of betal leaf and areca nut, popular among Southeast Asians for its stimulant and psychoactive effects, has been strongly associated with an increased risk of oral and oropharyngeal cancer.
Plummer-Vinson syndrome. This rare condition, which involves iron deficiency and causes difficulty swallowing, increases the risk of hypopharyngeal cancer.
Preserved or salted fish. Also popular in Asia, these foods have historically been linked to nasopharyngeal cancer when consumed in childhood, but recent studies suggest they may play a smaller role than originally thought.
Signs Something May Be Up
Okay, a lump is never normal, but many of the other symptoms of throat cancer are easy to dismiss. Don’t. Your odds of beating this disease rise significantly when it’s caught early. While symptoms vary by throat cancer type, if you experience any of the following for more than two weeks, see your primary care doctor.
A lump in the mouth, throat, or neck
A persistent sore throat
A red or white patch on the tongue, tonsils, or lining of the mouth that does not go away
Coughing up blood
Difficulty opening your mouth
Ear or jaw pain
Hoarseness or voice changes
Toothache or loose teeth
Trouble breathing, speaking, or swallowing
How Do Doctors Diagnose Throat Cancer?
Getting to a diagnosis begins with discussing your overall health and lifestyle with your doc, including your smoking and drinking habits, sexual history, and family medical history. You’ll also get a physical exam that will include:
feeling your neck thoroughly to check for any lumps, bumps, or swelling
seeing how wide you can open your mouth, then looking and feeling inside it
looking inside your ears
looking inside your nose
At this point, if your doctor suspects throat cancer, one or more of the following tests will likely be ordered to determine if it has spread.
For this test, a sample of throat tissue or cells will be removed and examined under a microscope to confirm the presence and type of cancer. Different methods are used to obtain tissue, depending on where the tumor is located. They include:
Incisional biopsy: During this most common type of biopsy, your doctor surgically removes a small piece of the suspected tissue while you’re in an operating room under general anesthesia.
Excisional biopsy: This type of biopsy is also done under general anesthesia and removes most or all of the tissue suspected of having cancer.
Fine-needle-aspiration biopsy (FNA): Often accompanied by an ultrasound to verify location, during FNA a thin needle is inserted into the area suspected of cancer. Cells are withdrawn and examined under a microscope.
During this procedure, a long, thin tube with a light and lens on the end called an endoscope is inserted through your mouth, nose, or an incision to get a look at the harder-to-see areas for abnormalities. Don’t panic—you’ll be given an anesthetic spray to numb the area and keep you comfortable during the test. The endoscope also has a tool to remove tissue samples for a biopsy.
Your doctor may refer to this test by different names depending on the area being examined: laryngoscopy to view the larynx, pharyngoscopy to view the pharynx, or nasopharyngoscopy to view the nasopharynx.
A variety of scans may be used to help determine the size of the cancer and look for additional tumors in the area or spread to other parts of the body, including:
Chest and dental X-rays
Computed tomography or computed axial tomography (CT or CAT) scans
Magnetic resonance imaging (MRI)
Positron emission tomography (PET) scans
All patients with newly diagnosed oropharyngeal squamous cell carcinoma will have also HPV testing done on the biopsy tissue sample, to help determine the cancer’s stage and the most effective treatment options.
Your doctor may recommend laboratory tests on a tumor sample to identify specific genes, proteins, and other factors that may lead to more targeted treatment options.
For this test, you’ll be given a chalky liquid containing barium to drink, which improves the visibility of abnormal structures on an x-ray image. You may also be given a modified barium swallow test, which allows your medical team to observe your swallow in real-time so they can evaluate the structures and movements associated with swallowing.
This test involves putting a lighted tube in the mouth or nose to check the overall appearance and movements of the voice box (larynx) and vocal cords (folds) during sound production (phonation).
Fiberoptic Endoscopic Examination of Swallowing (FEES)
A small, flexible endoscope is inserted through the nose, allowing the doctor or speech pathologist to examine swallowing.
Throat Cancer Staging
Once it’s been determined that you have a head or neck cancer, the next step is staging, a way of describing where the cancer is located, the size of it, and whether or not it has spread and is affecting other parts of the body. Your doctor will use the results from your diagnostic tests and scans to see where your cancer falls in the TNM staging system, which stands for:
Tumor (T): Where is it and how large is it?
Node (N): Has the cancer spread to any lymph nodes—tiny, bean-shaped organs that help fight infection—and if so, where and how many?
Metastasis (M): Has the cancer spread to other parts of the body, and if so, where and how much?
The results are then combined to determine the stage and the best course of treatment. There may be four or five different stages, ranging from stage 0 (pre-cancer or cancer in situ) to stage 4, which is a cancer that has metastasized to another part (or parts) of the body. Each type of throat cancer has a different staging system, depending on the location.
Treatments for Throat Cancer
There is no single best treatment for the disease because so much depends on the location and stage of the tumor, as well as your age and general health. Options may include surgery, radiation therapy, chemotherapy, targeted therapy (medications that target a tumor’s specific makeup), immunotherapy (drugs that empower the immune system), or a combination of some or all of these. If your cancer is HPV-related, that will be factored in because evidence is mounting that HPV-positive tumors may require less intense treatment.
Let’s take a closer look at throat cancer treatments.
Head and neck cancer surgeries have come a long way thanks to the advent of transoral procedures, which can be done through the mouth either robotically or via laser microsurgery. These procedures last about two hours compared to 10 hours for traditional surgeries that required large incisions in the neck. Patients spend significantly less time in the hospital, experience less pain, recover faster, have fewer side effects, and may be less likely to need radiation and chemotherapy, especially if the cancer is caught early.
In addition to surgeries to remove the cancer, many patients will also require neck dissection, which is done at the same time, to remove some or all of the lymph nodes in the neck if the cancer has spread to them. Reconstructive (plastic) surgery procedures are also often necessary to replace tissue or bone in the area.
These are some types of surgery you may need:
Oropharyngeal cancer surgery: This may involve primary tumor surgery, where the tumor and a margin of healthy tissue around it are removed to decrease the chance that any cancerous cells will be left behind, or a mandibulectomy, in which a piece of or entire jawbone is removed if a tumor approaches or invades the jawbone. You may also need a tracheostomy—a hole cut in the neck if cancer is blocking the airway or is too large to completely remove—or a gastrostomy tube—a feeding tube placed into the stomach through the skin and muscle of the abdomen if the cancer is preventing you from swallowing.
Hypopharyngeal and laryngeal cancer surgery: Although these are two different types of cancer, the surgical options are similar and may include partial laryngectomy (removing part of the larynx) or total laryngectomy (removing the entire larynx, which will make it impossible to speak like before). A speech pathologist will help you learn new ways to talk after surgery. Patients are also given a tracheostomy for breathing with this procedure. You may also need a laryngopharyngectomy, or removal of the entire larynx, including the vocal folds and part or all of the pharynx. (The pharynx may be reconstructed using flaps of skin or a segment of the intestine.) Like a total laryngectomy, you’ll need a speech pathologist to re-learn how to talk and swallow.
Like surgery, radiation is considered a local treatment because it affects only the cancerous areas. Your doctor may recommend radiation therapy—which uses high-energy rays to kill cancer cells—to shrink a tumor so it’s easier to remove via surgery, or to kill any cancer cells that the surgery may have missed. It may also be used to ease symptoms or complications caused by the cancer. Radiation therapy is the main form of treatment for NPC, which usually can’t be removed surgically because of its location. The types of radiation therapy that your doctor may recommend are:
External-beam radiation therapy. This treatment aims radiation from a machine outside the body at the tumor. A method of external-beam radiation therapy known as intensity-modulated radiation therapy (IMRT) delivers more effective doses of radiation while reducing side effects and damage to healthy cells.
Proton therapy. This is a type of external-beam radiation therapy that uses protons rather than x-rays. It may be used for some tumors at the base of the skull to lower the radiation dose to nearby areas, such as the eye and the brainstem.
Stereotactic radiosurgery. This method delivers radiation therapy precisely to the tumor and can be an option for masses that have grown into the base of the skull, which may occur with NPC.
Brachytherapy. This type of radiation is received through tiny pellets or rods containing radioactive materials that are surgically implanted in or near the cancer location.
Like all treatments, radiation is not without side effects, including: Pain, swelling, scarring, dry mouth, nausea, fatigue, sore throat, and mouth sores. Fortunately, many of them will clear up when your treatment is finished.
Medications are a systemic form of treatment, meaning they travel through your bloodstream to your entire body, not just the cancer area. Because of this, they can cause collateral damage to your body, but they are used for treatment because they also can be highly effective at killing the cancer cells. These meds may be given intravenously or swallowed in pill form. There are three types of systemic therapy you may be given, separately or in combo. They include:
Chemotherapy: Like radiation, chemo can shrink a tumor before surgery, or kill any cancer cells that the surgery may have missed. It may also be used as a palliative treatment. Chemo is often given to head and neck cancer patients at the same time as radiation because research shows chemo can actually make the radiation work better.
Chemo works by targeting cells that are rapidly dividing and growing—which is what cancer cells do—but the death of normal cells can occur too, causing hair loss, nausea, and other side effects. Chemo drugs may be given intravenously over several hours or taken in pill form. Usually two or more chemo drugs are given together, then the patient gets a break for two to three weeks before another round or “cycle” is given—a process that can last several months.
Targeted Therapy: These state-of-the art meds attack only the specific genes, proteins, and tissue that contribute to the cancer’s growth. Two examples in use for head and neck cancers are EGFR (epidermal growth factor receptor) inhibitors, which block the EGFR tumor protein, and Vitrakvi (larotrectinib), a drug that targets specific genetic changes that can occur in head and neck cancers (as well as other forms of cancer).
These therapies generally have fewer side effects than chemo and help chemo do its job better when given together, but they don’t work for everyone, may not be covered by insurance, and are expensive. Talk to your doctor about possibly participating in clinical trials that make use of these meds.
Immunotherapy: This category of drugs boosts the body’s natural defenses to fight the cancer by teaching the immune system to recognize and attack cancer cells. Keytruda (pembrolizumab) and Opdivo (nivolumab) are two immunotherapy drugs that are approved for people with recurrent or metastatic head and neck cancers, or who haven’t had good results with chemo. Again, they don’t work for everyone, but it’s worth a convo with your treatment team.
The side effects of throat cancer medications will go away when your treatment is completed and you’ve had some time to recover, but until then, these are some issues you may face:
Loss of appetite
Nausea and vomiting
Risk of infection due to lowered immunity
What’s Life Like With Throat Cancer?
It would be false to say that a throat cancer diagnosis is anything but challenging. Just about everything you do, 24/7, involves your throat, from eating to breathing to speaking. There’s always a chance that you could be one of the lucky ones, without any scars cosmetically or physically. On the other hand, you could have a more serious case that requires a tracheotomy and may lead to changes in your voice or difficulty speaking.
It sounds pretty darn scary, but know this: You are not alone. Your treatment dream team of physicians, surgeons, speech-language pathologists, physical therapists, audiologists, mental health experts, social workers, and nutritionists will be available to help you adapt to your new normal so you can get back to doing what you do best: living your life to the fullest.
- Throat Cancer and HPV Statistics: National Cancer Institute. (2020). “HPV and Cancer.” cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer
- Salted Fish Risk Factor: The Journal of Nutrition. (2019). “Past and Recent Salted Fish and Preserved Food Intakes Are Weakly Associated with Nasopharyngeal Carcinoma Risk in Adults in Southern China.” academic.oup.com/jn/article-abstract/149/9/1596/5498647?redirectedFrom=fulltext
- HPV and Prognosis: Oral Oncology. (2016). “Prognostic significance of non-HPV16 genotypes in oropharyngeal squamous cell carcinoma.” sciencedirect.com/science/article/abs/pii/S1368837516301476?via%3Dihub
- Combining Chemo and Radiation: ECCO: The European Cancer Organization. (2017). “Twice Daily Radiation Therapy Cuts Deaths from Head and Neck Cancer.” sciencedaily.com/releases/2017/01/170126190553.htm
- Targeted Therapy: Clinical Cancer Research. (2018). “Inhibition of EphB4-ephrin-B2 signaling enhances response to Cetuximab-radiation therapy in head and neck cancers.” clincancerres.aacrjournals.org/content/24/18/4539
- Immunotherapy Treatment: New England Journal of Medicine. (2016). “Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck.” ncbi.nlm.nih.gov/pubmed/27718784
- HPV Vaccination: American Society of Clinical Oncology. (2017). “Impact of HPV Vaccination on Oral HPV Infections Among Young Adults in the U.S.” meetinglibrary.asco.org/record/153036/abstract