Causes of Throat Cancer

As with most cancers, doctors can’t tell you with certainty what causes throat cancer. It’s a combination of genetic factors and factors in your environment.

By far the most common factor contributing to throat cancer is using tobacco, particularly smoking it. Drinking excessive amounts of alcohol also contributes to the risk of developing throat cancer.

• Tobacco:Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase your chance of getting throat cancer.
• Alcohol:Drinking excessive amounts of alcohol is also very strongly related to getting throat cancer. Moreover, if you both smoke and drink heavily, the risk more than doubles.

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

• Exposure to radiation in the past:Being exposed to radiation as part of a natural disaster, treatment for another disease a long time ago or even through work can increase the chances of some throat cancers.
• Viruses: The details of this are still being studied. Clearly, though, exposure to certain strains of Human Papilloma Virus (HPV) is associated with oropharynx cancer, and exposure to Epstein-Barr Virus (EBV) is associated with nasopharynx cancer.
• Genetic factors: This is important in all cancers, and the details are still being worked out. Genetics clearly plays a major role in nasopharyngeal cancer.
• Certain foods:Deficiencies in some vitamins, poor oral hygiene and even salted fish (for nasopharyngeal cancer) have been associated with certain throat cancers.
• Plummer-Vinson Syndrome(especially for hypopharyngeal and cervical esophageal cancer): This is a condition, more common in women, that is associated with low iron and low blood counts (anaemia), along with webs of tissues in the throat that cause difficulty with swallowing.
• Asbestos exposure
• A history of drinking poisons such as lye
• Gastroesophageal reflux disease (GERD): Though GERD has not been proven to be a cause of throat cancers, multiple studies have shown an association between “acid reflux” and throat cancer.

Signs and Symptoms of Throat Cancer

Since throat cancer is such a general term for cancers in many different locations, the signs and symptoms are 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 you should investigate specific types of throat cancer 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 typically less likely to be cancer.

Some symptoms that might be related to a throat cancer include:

• 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 your throat
• Bleeding from the throat
• Coughing or choking every time you drink liquid
• Difficult or noisy breathing
• Numbness in a certain part of the face
• A change in speech or tongue movement
• Unexplained weight loss

But don’t jump to any conclusions. You could have one or more of these symptoms but NOT have a throat cancer. There are several non-cancerous causes of the same symptoms. That’s why you need to see a specialist.

What to Expect at Your Doctor’s Visit?

 Step 1: History

First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.

Your doctor might ask questions such as:

• 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, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern.

You should also expect the doctor to:

• Feel your neck to carefully check for any lumps or bumps
• Look inside your ears
• Look inside the front of your nose
• Check your cranial nerves by asking you to move your face, stick your tongue out, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face

Your doctor might even put a camera in through your nose using a fibreoptic scope to take a look at the back of your throat.

 Step 3: Reviewing Tests

After getting your history and performing a physical exam, your doctor will review any imaging, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

 Step 4: Recommendations

Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. Once your doctor has all the necessary information, you should be given a preliminary stage and discuss treatment plans.

If the tumour is very large and is putting your breathing at risk, your doctor might recommend you undergo a tracheotomy, which is a breathing tube placed into the front part of your neck directly into your windpipe.

Also, if you are just not able to get enough nutrition by mouth because of the tumour, your doctor might recommend that you receive a feeding tube. This will help make sure you are in good shape to undergo the treatment that you will need to beat the cancer. If you have lost weight, your doctor may give you a choice of getting enough nutrition by mouth by increasing the number of calories in your diet or by undergoing placement of a feeding tube. There are a variety of nutritional supplements that you can eat or drink that can help to achieve that goal. You may want to meet with a nutrition expert early during your treatment. Note that for esophageal cancers, your doctor will probably recommend a special type of feeding tube called a J-tube (or jejunal feeding tube). This is different from a G-tube (gastric tube). This is important because if surgical resection is a possible treatment for your cancer, sometimes your stomach is used as a new esophagus, and it is better if the stomach doesn’t have a feeding tube in it. The J-tube is placed in the jejunum, which is the organ further down the GI tract from the stomach.

Diagnosing Throat Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer. You might undergo some anti-reflux medications, try changing your diet, try speech therapy or receive special tests like video stroboscope.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like with most cancers in the head and neck, this will include some combination of biopsy and imaging tests.

Be sure to bring all reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

 Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumours that are easily evaluated on physical examination, imaging might not be necessary. For larger tumours, or tumours in locations that are difficult to examine (including most tumours of the hypopharynx), your doctor will probably order some sort of imaging to get more information about the tumour location and possible spread to regional lymph nodes.

The two main imaging techniques used are computed tomography (CT) scans and magnetic resonance imaging (MRI) scans. Ultrasound is a quick and inexpensive way to get information about disease that is in lymph nodes in the neck. PET scans are studies that look at the function of cells in the body, and they are being used more and more in oncology. PET scans can be combined with other imaging methods such as CT scans to get more detailed information.

CT Scan: This is a quick series of X-rays that can show very good detail of the anatomy. It is helpful in seeing the extent of the main tumour mass and what structures it has invaded. It can also help detect spread into the neck.

• Advantages: A CT scan is a quick test that is readily available and gives a great deal of useful information.
• Disadvantages: A CT scan involves radiation, and the images can be degraded by movement and dental work. It only shows late changes associated with invasion into nerves (such as destruction of the bone where the nerve enters the skull).
• Important points: A CT scan looking for throat tumours should be done with a contrast dye that is injected into your veins, unless there is some reason that you cannot receive contrast. Allergies to iodine and shellfish are common indications that a patient may be allergic to contrast dye.
• What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. CT scans are typically open, so you shouldn’t feel enclosed. You will then get an injection of contrast, and soon after, the scanner will start moving and taking pictures; this part should only take one or two minutes. Try not to swallow, speak or move during this quick test.

 MRI: This test uses magnets to create a picture of the inside of the neck. It is good for showing more subtle details of how extensive the main tumour mass is. It can also help pick up spread of cancer to lymph nodes in the neck.

• Advantages: There is no radiation involved, and the details of the soft tissues are better than that of a CT scan.
• Disadvantages: An MRI takes much longer than a CT scan and is more expensive. Some people feel enclosed inside the MRI machine and may require sedation to get through the study.
• Important points: This test should be done with and without contrast injected into your veins, unless there is some reason you can’t have contrast. Closed MRI machines usually give better pictures than open MRI machines.
• What to expect: First, a nurse will insert an intravenous line into a vein to allow for contrast injection. Then you will have to lie flat on a table with your head in a little holster to help keep it totally still. Due to the strength of the magnets, you will be instructed to remove any metallic objects and to change into a hospital gown before entering the room where the scanner is located. You will then enter the scanner, and the MRI machine will start moving and taking pictures. This can take 30 to 60 minutes, depending on how the scan is done. Try to stay as still as possible throughout the test.

 Positron Emission Tomography (PET): Doctors are still studying the most appropriate uses of PET scans for head and neck cancer. The main uses of PET scans at this point are to see if there is spread to sites in the neck or other parts of the body or to help find a primary tumour when the only evidence of cancer is a lymph node that has cancer in it. It is often combined with a CT scan (or in some cases an MRI) to help pinpoint the location of active cells.

 Neck ultrasound: An ultrasound is a way to look at vessels, structures and lymph nodes all over the body, particularly in the neck and thyroid gland. You are not exposed to any radiation, and it doesn’t hurt. Basically, a technician or a radiologist will place some cold jelly over the area that is being examined and rub a plastic probe over the area to take pictures.

The technician can see enlarged lymph nodes and nodules deep in the neck and describe details about them such as whether they have fluid inside, have a lot of blood vessels around and so on. While the ultrasound is being performed, a doctor can place a needle into a lymph node or nodule and draw off cells (this is an ultrasound-guided biopsy).

 Chest X-ray: This is a quick, inexpensive and easy way to look for signs of spread of cancer into the lungs or the possibility of a different cancer in the lungs. Some doctors will recommend a chest X-ray every year as follow-up if you have had a head and neck cancer. This is because patients who have had head and neck cancer are at a higher risk of getting lung cancer as well.

Finally, some special considerations with esophageal cancer that are different from other head and neck cancers are that you will probably get a chest and abdominal CT scan with both IV contrast as well as contrast for you to drink. You may also be referred for a pelvic CT scan.

 Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your throat. The biopsy report is extremely important for determining your diagnosis and treatment plan.

When performing a biopsy on a neck mass, your doctors should test for certain viruses such as human papillomavirus (HPV) and Epstein-Barr Virus (EBV). They can also test for proteins related to these viruses (e.g. P16 as it relates to HPV infection). Cancerous lymph nodes that have the HPV virus (or P16 protein) are very likely to be related to a primary cancer in the oropharynx. A positive HPV or P16 test should make your doctor spend extra time and effort looking for a small or hidden tumour somewhere in the oropharynx.

 Biopsy of hypopharynx lesions

Typically, you will undergo endoscopy with biopsy. Exactly how the endoscopy is done will be up to your physician. The three general ways to biopsy a suspicious area in the hypopharynx are:

• Transnasal flexible endoscopy with biopsy:If your doctor sees a suspicious lesion that he or she might be able to biopsy in the office, this method is a possibility. This is just like having a transnasal flexible laryngoscopy, except the camera used in this case has a special attachment through which your doctor can spray medicine directly onto the area of interest to numb it. Through that same attachment, your doctor can pass a thin biopsy forceps and clip off a tiny piece of the suspicious growth.

The main advantage of transnasal flexible endoscopy with biopsy is that it is usually quick and easy, and you don’t need to go to an operating room or go under general anesthesia. However, your doctor can only get a tiny piece of tissue this way, and it might not lead to the correct diagnosis. Also, it’s not as good a view as a direct examination in the operating room. Finally, your doctor can’t feel around or get as good a look as with a direct laryngoscopy.

• Direct laryngoscopy with biopsy:Your doctor might choose this technique if he or she can’t get a good biopsy in the office or wants to get a better look all around your throat in the operating room.

For select hypopharynx tumours, your doctor might either take a small piece in the operating room to confirm the diagnosis or remove the entire mass (this is called an excisional biopsy). Also, your surgeon will take the opportunity to thoroughly feel all around your neck, mouth and throat while you are asleep. Finally, he or she will look for any additional suspicious lesions (called second primaries). One of the other advantages of this technique is that frozen section pathology is usually available in the operating room to make certain that enough tissue has been sampled in order to make a definitive diagnosis.

For this to be done, you will go to sleep with anaesthesia in an operating room with a small breathing tube placed through your mouth into your windpipe. Then your surgeon will place an instrument called a laryngoscope through your mouth and look all over your throat. He or she can even use a longer scope, called an esophagoscope, to look at the upper part of your esophagus. The surgeon will then use small forceps to take a piece of tissue from any suspicious looking area. In some cases, the doctor might remove the entire lesion, for which he or she may use a variety of different instruments, including a laser.

If needed, your doctor might talk to you in advance about doing a tracheotomy or a feeding tube during this procedure while you are asleep.

CT-guided needle biopsy: This is used quite rarely for throat and esophagus tumours. It is usually required only if your surgeon cannot get to the suspicious area despite trying the standard ways. CT-guided needle biopsies are typically done by a radiologist. Most often this technique is used to evaluate lesions in remote locations, such as suspicious nodules in the chest.

The advantages are that you can avoid a trip to the operating room, and the needle can reach some areas more easily than your surgeon could through the mouth, throat or neck.

The disadvantages are:

• Your doctor can only get a tiny piece of tissue this way, and it might not lead to the correct diagnosis.
• It does not provide as good a view as a direct examination in the operating room.
• Your doctor can’t palpate (or feel) around for other suspicious lumps and bumps.
• Your doctor can’t examine the entire throat and hypopharynx directly.

For a CT-guided needle biopsy to be done, you will be placed into a CT scanner, and a few low-dose CT scans will be performed to identify where the tumour is located. You will get a tiny injection of medicine to numb the skin. Then a small needle will be passed through the numb area towards the tumour that was located earlier. This may require a few low-dose CT scans as the needle is adjusted to make sure it gets into the area of interest.

There is some emerging technology such as fluoroscopic CT scanning, by which the radiologist can quickly take a few scans without leaving the room as he or she moves the needle around to get it into the right place.

Biopsy of neck masses

If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck.

Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumour and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. Several “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

 DIFFERENT TYPES OF FINE NEEDLE ASPIRATION BIOPSIES

 Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumour rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.

Open neck biopsy: An open biopsy involves making an incision over the tumour and removing a piece or all the tumour to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumour is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.

Determining the Type of Throat Cancer

Almost all throat cancers are squamous cell carcinomas. These are tumours that start from cancer cells on the surface lining of the throat. There are several different types and classifications of squamous cell carcinomas that you can talk to your doctor about.

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

Squamous cell cancers of the throat are typically given a grade by a pathologist after looking at the cells under a microscope. Grade means that the tumour falls on a scale from well differentiated (Grade I) to poorly differentiated (Grade IV). It is generally felt that the prognosis for a more well-differentiated cancer is more favourable.

More rarely, other cancers can be found in the throat as well. Some of them include:

• Salivary gland cancers:There are minor salivary glands located under the lining of the throat. Therefore, cancers that we typically see in salivary glands can arise 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: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. Therefore, lymphoma might appear as a lump in the throat area.
• Mucosal melanoma:These cancers come from skin cells that give skin its colour. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat.

Other rare cancers include:

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

Determining the Grade of the Tumour

Pathologists will typically report on the grade of the tumour. This is a qualitative interpretation by the pathologist of how much the cancerous cells resemble normal tissue from that site. There are several 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 tumour or lesion resemble normal cells from the healthy tissue surrounding the tumour.

“Well differentiated” means that the cells look like normal cells in that area.

“Undifferentiated” means the cells look nothing like normal cells in that area.

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

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. As with all cancers of the head and neck, in Australia it is mandatory for doctors to use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

At first, you will be given a clinical stage based on all of the available information.

 Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lowercase prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyse the tumour and any lymph nodes that may have been removed. You will then be assigned a pathological stage.

Pathological staging (pTNM) provides more data. Classification of pathology stage is described using the lowercase prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also several other lowercase prefixes that might be used in the staging of your cancer.

• The subscript y(yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (Posttherapy or Postneoadjuvant Stage). It is typically combined with either a clinical or pathological stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.
• The subscript r(rTNM) is used when the tumour has recurred after some period of time in which it was gone. This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a re-treatment stage.

Deciding on a Treatment Plan

Before starting treatment, your doctor will make sure that the following steps are completed.

 Pre-treatment evaluation

• A full history and physical examination, including a complete head and neck exam (mirror and fibreoptic exam if needed)
• An evaluation by the members of a head and neck cancer team
• A biopsy of the primary site or FNA of the neck to confirm a diagnosis of cancer
• Testing for HPV
• Imaging of the lungs to check for spread, if needed
• Imaging of the primary tumour and the neck with CT and/or MRI
• Maybe a PET-CT for advanced cancers
• A dental evaluation, with or without jaw X-rays
• Nutrition, speech and swallowing evaluation and maybe a hearing evaluation
• Examination under anaesthesia with endoscopy if needed
• Pre-treatment medical clearance and evaluation of medical conditions

Then your doctor will recommend a course of treatment for you, depending on several factors. Like with all cancers in the head and neck, there are three general therapeutic options to consider:

• Surgical removal (with or without reconstruction)
• Radiation (a few different types)
• Medications (chemotherapy and biologic medications)

The treatment recommendations for throat cancers can vary by subsite, so see the article about your particular type of cancer for more information.

Determining Your Prognosis

 Your prognosis is a prediction of the outcome of your disease. What is the risk of succumbing to the cancer or the risk of its coming back? These are the big questions on most people’s minds after receiving a diagnosis of throat cancer. Prognosis is based on many factors, and a survival rate is an estimate based on large populations of patients who have been given a similar stage of their throat cancer. There are many specific factors that are unique to each patient that may influence treatment success.

 It is very difficult to discuss prognosis without understanding all the details of your cancer, and this is a conversation you’re better off having in person with your doctor. To give you a percentage chance of cure is difficult because cancer research looks at all sorts of different types of cancers and may include patients from long ago.

 There are statistics that can give you some idea of your estimated disease-specific survival. Estimated Disease-Specific Survival is the percentage of people with a specific cancer who are alive at a given time point, such as five years after diagnosis. It excludes people who may have died from a disease other than their cancer. It is probably the best estimate we have in these large national databases as to the prognosis of a cancer at each stage. See the article on your cancer type for more information about estimated disease-specific survival rates that may apply to you.

What to Expect After Treatment is Completed?

Once you have made it through treatment, you need to have close follow-up with your doctor.

This follow-up plan is recommended after being treated for a throat cancer:

• Visit your head and neck specialist on a regular schedule (or earlier if you have any concerning symptoms). This allows your doctor to examine you for any signs that the cancer has come back.
  • For the first year, you should go every one to three months.
  • For the second year, you should go every two to six months.
  • For the third to fifth year, you should go every four to eight months.
  • After five years, you can start going every year.
• Your doctor should select a scan to be performed in the first six months after treatment. The first scan serves as a “baseline” study for the purpose of comparing future studies. This will depend on the type, stage and location of your cancer. Imaging may include CT scans, MRI scans and PET scans. If something suspicious comes up, you might need another biopsy.
• Consider chest imaging to check for any signs of lung cancer if you have an extensive smoking history.
• Check your thyroid function every six to twelve months if you have had radiation to the neck area.
• Get help with a therapist as needed for difficulties with speaking, hearing and swallowing.
• See a specialist about appropriate nutrition and diet.
• Alert your doctor if you experience any signs of depression.
• Stop smoking and stop drinking.
• See a dentist.
• For nasopharyngeal cancer:
  • Your doctor might consider monitoring you for a virus called Epstein-Barr virus with annual blood work or imaging.
  • Because it is difficult to view the nasopharynx without imaging, routine annual imaging may be necessary.