Early Laryngeal Cancer Timeline: Radiation

Radiation is a main treatment for early (stage I or II) laryngeal cancer. Treatments are given once a day, Monday through Friday, for about 3 to 7 weeks without surgery, and the voice usually improves over the following 6 to 12 months.

This page is one of three treatment-track timelines for early laryngeal cancer. The steps before treatment, how a track is chosen and the follow-up schedule are covered on the early laryngeal cancer treatment timelines page.

Who follows this track

Radiation is a main option for nearly all early laryngeal cancers. It is often favored when the tumor involves both vocal cords or their front junction (anterior commissure) and a laser removal would have to be large, when the larynx is hard to see through the mouth, when anesthesia carries extra risk, or when a person prefers to avoid surgery. For a small cancer on one vocal cord, transoral laser surgery gives similar cure and survival, so the choice often depends on voice, convenience and the person's priorities. Chemotherapy is not usually added for stage I or II laryngeal cancer.

Before radiation (weeks 0 to 5)

The scope exam, biopsy, scans, meetings with the care team, voice and swallowing baseline and the tumor board's recommendation are the same on every track and are described on the overview page. Steps specific to radiation:

• Dental visit: an exam and X-rays of all the teeth. Any teeth that need to be removed come out at least 2 weeks before radiation starts, so the gums can heal; this lowers the risk of a serious jawbone problem called osteoradionecrosis. A prescription fluoride gel or toothpaste may be started for daily use, and a soft mouth guard may be made for people with metal fillings or crowns. For radiation to the vocal cords alone, the mouth and jaw receive very little radiation, so dental effects are usually much smaller than when the neck is treated.

• Simulation (planning) visit, about 1 to 2 weeks before treatment: a custom mesh mask is molded to the head and shoulders to hold perfectly still during treatment, and a planning CT scan is used to design a precise plan, usually with intensity-modulated radiation therapy (IMRT), which shapes the radiation to the target.

Radiation (about weeks 5 to 11)

• Treatments are given once a day, Monday through Friday (see radiation therapy). Each visit takes about 15 to 30 minutes, and the radiation itself only a few minutes. The treatment does not hurt, and no one becomes radioactive.

• T1 vocal cord cancer: most often 28 treatments (about 5½ weeks). Some centers use 25 treatments (5 weeks), up to 33 (about 6½ weeks), or a shorter course of about 16 treatments (about 3 weeks).

• T2 vocal cord cancer: about 27 to 35 treatments (about 5½ to 7 weeks); a common schedule is 29.

• Supraglottic cancer: about 33 to 35 treatments (about 6½ to 7 weeks), covering the tumor and the neck lymph nodes on both sides.

• For vocal cord cancer, only the larynx is treated, because the chance of spread to the neck is very low.

• Missed treatments matter: gaps in radiation make it work less well, so care teams work hard to avoid interruptions.

• The radiation oncologist sees the person at least once a week during treatment.

The follow-up clock starts on the last day of radiation.

Side effects week by week

• Serious short-term side effects are uncommon with radiation for early vocal cord cancer; fewer than about 1 in 20 people have severe effects.

• Radiation to the vocal cords alone causes much less dry mouth and swallowing trouble than the larger fields used for throat cancers. When the neck is treated (supraglottic cancer), side effects are stronger: more sore throat and painful swallowing, dry mouth, taste changes, thick saliva and mouth and throat soreness, with help from a dietitian and a speech-language pathologist (see swallowing problem treatments). A temporary feeding tube is needed by only a few people, more often when the neck is treated.

• Things that help during treatment: no smoking or vaping (people who keep smoking during radiation are much more likely to have the cancer come back), avoiding alcohol, plenty of fluids and soft, moist, high-protein foods, only the skin products the team approves, keeping sun off the neck, gentle voice use without shouting or forceful whispering, pain medicine as prescribed, and a weekly weight check.

• Voice therapy after treatment can help the voice recover (see voice problems).

Checking the result

The first check is usually 4 to 8 weeks after treatment, with a scope exam of the larynx. If a scan is used, a PET-CT is usually done at least 12 weeks after radiation, because earlier scans can show false alarms from normal healing. For small vocal cord cancers, a careful scope exam may be enough. When the 3-month check is clear, routine repeat scans are usually not needed unless symptoms appear.

Quality of life on this track

The first scores ("at diagnosis") were collected after the cancer was diagnosed and before treatment began, so they already reflect some of the burden of the cancer itself, not a person's quality of life before the cancer developed.

Typical or average scores before radiation and afterward (0 to 100, higher is better):

• Overall: in a large British study of cancer on one vocal cord (T1a), the typical overall score was 83 at diagnosis, 75 at 4 months, 83 at 1 year and 83 at 3 years, with no meaningful difference from surgery after the first months. The 3-year score matches the general population. In a Swedish study of 54 men with vocal cord cancer treated with radiation alone (almost all stage I or II), the average was 71 at diagnosis and 66 about a month after it ended, while side effects were still healing.

• Swallowing: in two Swedish studies of stage I and II laryngeal cancer treated with radiation alone, the swallowing score averaged 94 at diagnosis, fell to 50 about a month into radiation, when the throat is sorest, was back to 88 about a month after radiation ended, and was 88 a year later. In the British study the typical person reported no swallowing trouble at any point, although swallowing and sticky saliva were somewhat worse after radiation than after surgery at 4 months, and these differences faded.

• Voice: in the British study the typical speech score was 56 at diagnosis, 89 at 4 months, 89 at 1 year and 94 at 3 years, slightly better than after surgery. In the Swedish study of 54 men, the speech score averaged 64 at diagnosis and 68 a month after it ended, and most measurements of the voice itself had moved toward those of healthy men of the same age by then. On the Voice Handicap Index (0 to 120, where lower is better), people with a cancer on one vocal cord averaged 34 at diagnosis, 22 at 3 months, 23 at 6 months, 24 at 1 year and 21 at 2 years; people with T2 cancer averaged 41 at diagnosis and about 26 to 29 afterward. Voice handicap is usually worst at the end of treatment and then improves quickly. Smoking made a large difference: 4 years after treatment, the average was 11 in people who quit and 33 in people who kept smoking. A small randomized trial in men with T1a cancer found that, 2 years later, the effect of the voice on everyday life was rated milder after radiation than after laser surgery.

• Mood: in the Swedish studies the mood score averaged 73 at diagnosis, 78 a month into radiation, 80 a month after radiation ended and 78 at 1 year. About a third of people screened as possibly anxious or depressed at diagnosis and again at 1 year, and about a quarter in between.

Where the numbers come from: the British study followed people with T1a vocal cord cancer treated with radiation alone (68 people) or surgery alone (55 people), with questionnaires before treatment and at 4 months, 1 year and 3 years or more; its scores are medians (the middle person), so they move in steps. One Swedish study followed 24 people with stage I or II laryngeal cancer through a year of standard radiation in the 1990s, with questionnaires at diagnosis, a month into treatment and at 1 year; its swallowing score comes from a question about swallowing food. The other, from Gothenburg, measured 54 men with vocal cord cancer before radiation and about a month after it ended; the same study followed 13 men with cancer above the vocal cords, who had more swallowing trouble and nausea after radiation and more often needed a feeding tube. The Swedish scores are averages. Averages describe groups of people, not what any one person will feel. The questionnaires are described on the quality-of-life questionnaires page.

Survival on this track

About 5 years after radiation for vocal cord cancer, about 97 to 99 percent of people with T1a, about 95 percent with T1b and about 90 to 94 percent with T2 do not die of laryngeal cancer (disease-specific survival). The cancer is controlled in the larynx by radiation alone in about 94 percent of T1a, 93 percent of T1b, 80 percent of T2 with normal vocal cord movement and 70 percent of T2 with reduced movement, and most of the rest are cured with surgery. Overall survival, from any cause, is about 80 to 90 percent for T1 and 75 to 80 percent for T2.

Check-ups and long-term care

• Check-ups follow the usual schedule counted from the end of treatment: every 1 to 3 months in the first year, every 2 to 6 months in the second, every 4 to 8 months in years 3 to 5, then yearly.

• Each visit includes a scope exam of the larynx in the office (see fiberoptic laryngoscopy). Hoarseness that gets worse after it had been improving, new pain or ear pain is reported promptly; pain can signal either a recurrence or a rare radiation injury to the cartilage, and a biopsy may be needed to tell them apart.

• Thyroid: when the neck received radiation, a thyroid blood test (TSH) every 6 to 12 months is common for the first 3 years and beyond. A slow thyroid affects about 1 in 5 people by 5 years after neck radiation and is treated with a daily pill; it is rare after radiation to the vocal cords alone.

• Dental visits and possible fluoride treatments: dental care continues at least every 6 months when the mouth or jaw received significant radiation, fluoride is used daily if prescribed, and any dentist is told about the radiation before a tooth extraction or implant. Dry mouth care helps when the neck was treated.

• Carotid arteries: radiation to the neck can speed narrowing of the neck arteries; about 1 in 4 people treated with head and neck radiation have significant narrowing years later, and stroke risk is modestly higher. A neck ultrasound about every 3 years may be suggested, along with control of blood pressure, cholesterol and blood sugar. Small vocal cord fields expose the arteries less.

• Rare late effects: lasting swelling of the larynx, damage to the cartilage, the need for a breathing tube or a long-term feeding tube occur in about 0 to 2 percent after radiation for early vocal cord cancer. Some people notice slow voice changes years later as tissues stiffen.

• If the cancer comes back after radiation, surgery is the main treatment. Sometimes a partial laryngectomy is possible; often removal of the whole larynx is needed (see the advanced laryngeal cancer timelines page).

• Staying tobacco-free improves the chance of cure and lowers the chance of a new cancer in the lungs, mouth, throat or esophagus.