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Persistent sore throat may be a warning sign for laryngeal cancer, study suggests

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l435 (Published 29 January 2019) Cite this as: BMJ 2019;364:l435

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Re: Persistent sore throat may be a warning sign for laryngeal cancer, more likely to be a "Throat Cancer" - Oropharynx or Hypopharynx

Dear Editor,

The head and neck clinicians are grateful to Shephard E et al for their recent publication on “recognising laryngeal cancer in primary care”. [1] The incidence of laryngeal cancer in the UK has declined by nearly 20% but has levelled off since 2002. [2]. This decline is considered to be linked with the reduction in smoking rather than alcohol. [3]

Shephard et al [1] it is unclear which symptoms from the “disparate range” reported in previous research are associated with laryngeal cancer in primary care. The larynx has three anatomical sub-sites : the glottis or vocal cords – involved in vocalisation resulting in constant hoarseness [4], the supraglottic – above the vocal cords – involved in laryngeal protect (solids and fluids) and maintaining an airway. The third - subglottis rarely involved in primary cancer.[5]

Analysis of laryngeal cancer in England/Wales 2013 – 2014 [6] allowed for 1051 to be studied; 844 early stage disease (T1/T2NO) – glottic 774 (>90%) and supraglottic 70 – the majority presented with hoarseness, and <10% had other symptoms. The advanced stage disease (T3/4 N0 – N+) was recorded in 607; glottic involvement was T3N0 167 and T40 99 = 266/378 – 70.2% would have hoarseness. The remaining advanced glottic had hoarseness and a neck mass (104/378) - 27.5% whereas (136/229) 59% advanced supraglottic had a palpable neck mass in (136/229) 59% and the remainder (31/229) 13.5% would have presented with non-specific throat symptoms.

A diagnosis of laryngeal cancer can only be made by inspection of the larynx and confirmed by tissue biopsy reported by a histopathologists confirming a malignant process most commonly squamous cell carcinoma. A patient who present with throat pain without any hoarseness should be referred to a head and neck clinic as a suspected “throat cancer” as pain alone or with a neck mass is more suggestive that the primary malignancy is located in the oropharynx/ hypopharynx or the supraglottic.

To conclude: patients who have persistent throat symptoms are best referred sooner than later, and more so men who are or have been smokers!

1. Shephard E A, Parkinson MAL, Hamilton W T Recognising laryngeal cancer in primary care. Br J Gen Pract 2019; DOI:https://doi.org/10.3399/bjgp19X700997
2. Cancer Research UK. Cancer statistics for the UK [Internet}. [cited 2019. Feb 12]. Available from: http://www.cancerresearchuk.org/health-professional/cancer-statistics.
3. Thomas S J, Penfold C M, Waylen A, Ness A R., The changing aetiology of head and neck squamous cell cancer: A tale of three cancers?
4. Tikka T, Pracy P, Paleri V., Refining the head and neck guidelines referral guidelines: a two-centre analysis of 4715 referrals. Clin Otoaryngology 2016;41(1):66 - 75
5. Brierley J D, Gospodarowicz M K, Wittekind C., TNM Classification of malignant tumours, Union for International Cancer Control (UICC). 8th Edition. Larynx p31 – 35. Wiley Blackwell 2017.
6. DAHNO 10th Report 2014 National Head and Neck Cancer Audit 2014, Health and Social Care Information Centre, National Head and Neck Audit.

Competing interests: No competing interests

12 February 2019
Patrick J Bradley
Emeritus Honorary Professor of Head and Neck Oncologic Surgery
Nottingham University Hospital
Queens Medical Centre Campus, Nottingham NG7 2UH