I am not a cancer survivor, but I have taught singers who have dealt with the aftermath of chemotherapy and its effects on the voice. We have had to work as a team to find solutions to regain lost vocal function. This process has given me a much deeper understanding of how to realign the voice after such treatment, allowing the singer the ability to sing well once again.
These professional singers have kept their health issues confidential, and I will do the same. There are many people dealing with cancer in our population, including singers dealing with the side effects of this disease and the effects of chemotherapy and other drug treatments. It is not, however, a subject that is in the mainstream of discussion regarding the singer and vocal health. In fact, it can be difficult to find information about the side effects of chemotherapy on singing.
Chemotherapy may not stop the voice from functioning completely, but any singer who has experienced this kind of treatment will attest to the fact that some side effects ensue. The voice may have similar symptoms to menopause or andropause, depending upon the type of treatment. Using a slow and careful approach, these issues can be minimized, bringing the singer back to fuller vocal function.
As an instructor, it is critical to understand how to deal with not only the physical symptoms but also the emotional component when someone is dealing with such a situation. The purpose of this article is to share my personal experience as a vocal pedagogue in helping singers find their fullest possible vocal function during and after treatment. I will also offer more information about the vocalization process. And I will list some side effects that tend to come up with individuals who have been treated with cancer drugs—characteristics that several have had in common, although every singer’s voice responds slightly differently to instruction.
Singers have come to me in varying degrees of treatment, sometimes feeling as though their voice would never reappear. I cannot speak for everyone, of course, but only for the singers I have worked with. In my experience, the singer dealing with cancer treatments often suffers from the following symptoms:
1: Varying degrees of dryness of the vocal folds
2: Narrowing of the laryngeal muscles or a closed throat
3: Inability for the vocal folds to close completely after the preparatory breath, especially in the middle register
4: Less ability to sing longer phrases without running out of breath
5: Slight to chronic hoarseness in the middle register
6: Tension in the jaw, tongue, or larynx; an attempt to force phonation
7: Shortness of breath related to anemia
8: Frozen or locked larynx or the inability for the laryngeal tilt or pivot to function successfully
9: Imbalance in registration
Case Study #1:
Almost 20 years ago I had a soprano come to me suffering from dryness and thickness in the vocal folds in the middle register. We worked for approximately five years in total. I noticed that her voice was thick, and we worked on a lot of staccato exercises to help thin out the vocal folds in the middle register—which, in turn, lessened the vocal weight in that register. We also worked on exercises for integrating the chest register and the middle voice.
It was quite a period of time before she told me that she was on tamoxifen, a drug to help prevent the reoccurrence of cancer. When this singer was taken off the drug, her vocal folds weakened tremendously. This made it very difficult to vocalize in the middle register with any degree of volume. The cords simply could not take the breath pressure without cracking. We continued to work weekly on the Garcia “coup de glotte” exercises, which were the only ones that actually helped. It took a period of approximately six months before the cords strengthened once again.
This professional singer was successful in Europe and had sung a long career before her diagnosis. After her cancer and our work together, she went on to perform concerts successfully, singing very difficult repertoire to great critical acclaim. I have always said that the real joy in this business is helping singers to discover or rediscover their dream of singing well. This singer now teaches successfully at a conservatory.
Case Study #2
A tenor in the midst of a thriving European career was diagnosed with cancer when he was quite young, in his early 30s. His chemotherapy treatment was successful, but it left his middle voice with what some call “vocal weight.” This was due to the larynx having lost its ability to tilt properly, caused by residual laryngeal tension. This made it difficult for head voice to transition early enough in the scale, creating a registration imbalance in the pitch range of middle C and the D natural above. At times the vibrato would simply flutter or become somewhat irregular.
We worked slowly and thoroughly with the laryngeal tilt, helping him to discover the slow down-and-forward motion of the larynx in the upper-middle register. When this was accomplished, he had no problems with the vibrato or the resonance factor in the previously “questionable” pitch range. This realignment process took approximately six months of slow methodical work, but he returned to his career with great success. He currently has an ongoing singing career in Europe.
Case Study #3
In 2001, a professional mezzo-soprano came to study with me in Europe. She had suffered from several vocal issues and was looking for technical answers. Her cancer diagnosis happened approximately six years after we met. After each chemotherapy treatment, she would travel to my New York studio to work on the voice. Her reoccurring symptoms were dryness, laryngeal squeeze (narrowing of the lower laryngeal muscles), slight hoarseness in the middle register, and inability of the cords to come together healthfully on transitional pitches between register changes. This case was perhaps my biggest challenge as an instructor, because we were working during active treatment.
The best medicine is a nurturing attitude, an open mind, and the ability to embrace experimentation using a group of therapeutic vocal exercises. These lessons went on for approximately nine months, and at the end of treatment, her voice was in fantastic condition.
Again I remind the reader that some of the symptoms are similar to those of menopause, something that I work with frequently in helping singers to realign registration. We worked on the laryngeal tilt and thinning the vocal folds in the middle register, and we continued to use exercises that encouraged registration balance. This singer now works in a large opera house in Europe and teaches at a conservatory.
Case Study #4
Several years ago I received an e-mail from a young soprano in a city I was traveling to who had been told by a voice therapist that she would never sing again. In this singer’s case, she had been taught a technique that was based on more forward placement than on an open acoustical space, so it was difficult to know how much of her vocal dysfunction was set before her cancer treatment. But certainly the treatment made it more difficult for the old technique to function.
Two days after I arrived, we had our first session. Phonation was difficult at first, and I noticed that she was thrusting her jaw forward. When she corrected this, the phonation began to balance. Her emotional response was that of “overwhelmed.” When we feel that we cannot do something and then are given a small key, this can be surprising and shocking, especially when we have been told that we should find another profession.
This soprano continues to sing and has a large voice studio in a metropolitan area, teaching mainly young professional singers. She has developed a tremendous knowledge of the voice and works with local laryngologists and voice therapists, offering joint public presentations.
Solutions and Recovery
The solutions for these singers were based on old Italian exercises, scientifically proven to be therapeutic in working with vocal damage by Dr. Barbara Mathis. Dr. Mathis performed her research years ago in the office of Dr. Van Lawrence, then laryngologist for the Houston Grand Opera. It is amazing how such old vocal concepts can be so healthful for the voice.
It is difficult to tell how much of these singers’ laryngeal, jaw, and tongue tension was from the emotional distress and how much was from the treatment. Isolating the vocal fold function from the tongue was one important part of recovering healthy vocal fold adduction. I used the [ae] vowel in the chest register with the tongue extended out over the bottom lip. This inspires the lower laryngeal muscles to widen (as in the pre-vomit reflex) and the cords to come together more efficiently. The singer can then begin to feel the sensation of healthy vocal fold adduction as opposed to a dysfunctional tone.
Once the healthy closure was established, I used the concept that Caruso shared with my teacher Allan Lindquest in 1914—the feeling of strength of the vowel below the vocal folds. This can be extremely helpful in recovering vocal function after chemotherapy. I also used the laryngeal tilt in my sessions with the singers, having them ascend a major 3rd on a closed vowel feeling the thyroid cartilage tilt down and forward. This begins to re-establish the healthy head voice registration transition (for an example, see pp. 54 and 55 of William Vennard’s book, Singing: The Mechanism and the Technique). In each session I would do the following with the singer: 1) laryngeal tilt exercises, 2) thin-edge closure exercises, 3) registration balance exercises, and 4) pharyngeal vocal stretch exercises.
What the human spirit can accomplish during great distress is amazing to me. In the end, we all want to find our voice in the world—our expression or ability to communicate. These individuals had the courage to continue their journey under extremely stressful conditions. I applaud their courage and determination, and I feel honored to have worked with them and to know them.
