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Total laryngectomy may be underused in advanced larynx cancer
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A majority of patients with T4a larynx cancer received larynx preservation chemoradiation rather than the guideline-recommended total laryngectomy, according to study results.
Further, patients who underwent larynx preservation tended to have more advanced nodal disease and experienced worse OS, results showed.
National Comprehensive Cancer Network guidelines recommend patients with T4a larynx cancer undergo total laryngectomy (Pfister DG, et al. J Natl Compr Canc Netw. 2014;12:1454-87). Although larynx preservation may be appropriate for select patients with T4a disease, declining survival rates may suggest larynx perseveration is used too frequently over total laryngectomy, according to study background.
"Larynx preservation via chemoradiation is an excellent, organ-preserving option to total laryngectomy for many patients with less advanced larynx cancers,” Alexander Lin, MD, assistant professor and chief of head and neck service at The University of Pennsylvania’s Perelman School of Medicine, said in a press release. “But it is inferior for patients with the most locally-advanced cancers. These patients should be treated with a total laryngectomy — and our study shows that most of them are not.”
Lin and colleagues used the National Cancer Data Base to identify 969 patients (mean age, 59 years; 79% men) with T4a squamous cell larynx cancer who received definitive treatment between 2003 and 2006. The researchers conducted univariate and multivariable analyses to assess predictors for undergoing surgery.
Sixty-four percent of patients (n = 616) received larynx preservation chemoradiation and 36% (n = 353) underwent total laryngectomy. According to a multivariable analysis, total laryngectomy occurred less frequently in patients with advanced nodal disease. Compared with patients with N0 disease — 43.4% of whom underwent total laryngectomy — patients were less likely to undergo the procedure if they had N2 disease (26.6%; OR = 0.52; 95% CI, 0.37-0.73) or N3 disease (19.1%; OR = 0.23; 95% CI, 0.07-0.77).
Further, total laryngectomy occurred more frequently at high case-volume facilities (46.1% vs. 31.5%; OR = 1.78; 95% CI, 1.27-2.48).
Total laryngectomy receipt decreased significantly during the course of the study years, from 49.5% in 2003 to 27% in 2006 (OR = 0.36; 95% CI, 0.24-0.54).
Patients who underwent total laryngectomy experienced significantly longer OS compared with patients who received larynx preservation chemoradiation (61 months vs. 39 months; P < .001).
In analyses adjusted for confounding factors, larynx preservation significantly increased the risk for death (HR = 1.31; 95% CI, 1.1-1.57).
The researchers acknowledged limitations of their study, including the inability to ascertain disease-specific survival and local recurrence data from the National Cancer Data Base and potential selection bias related to medically inoperable patients.
“Patients and providers need to be aware of and educated on the proper indications for both larynx preservation and total laryngectomy, so that the best medical treatment options can be discussed and offered for each patient,” Lin said. “There may be select cases where patients with this serious form of cancer can be successfully treated with chemoradiation, but those cases will be far fewer in number than the figure we uncovered in our study.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Cristina Rodriguez, MD
Larynx preservation using chemoradiation is a standard of care for locally advanced laryngeal carcinomas established by two large landmark North American studies (VALCSG and RTOG 91-11). Grover and colleagues present an analysis of a large observational dataset obtained from the National Cancer Data Base (NCDB) showing inferior oncologic outcomes among patients with T4a larynx cancer (an exclusion criteria for RTOG 91-11) treated with larynx preservation compared with those treated with upfront laryngectomy. The researchers, recognizing the limitations of nonrandomized comparisons, attempted to control for confounding variables using statistical methods.This observation complements a previously published NCDB report by Hoffman and colleagues. These two papers attribute the temporal decline in survival among patients with larynx cancer to the increasing trend of larynx preservation in patients who may be poor candidates for this approach.
Although single-institution reports have published encouraging functional and oncologic outcomes with larynx preservation approaches for T4 larynx cancer, the paper from Grover and colleagues is a sobering reminder that these results are often difficult to replicate in the real-world scenario of less-carefully selected patients. The success of surgical salvage for larynx preservation failures demonstrated in RTOG 91-11 may not be applicable to patients with T4a disease. The researchers mention that patient preference for avoiding laryngectomy may be contributing to this trend. The limited literature describing patient preferences when faced with the prospect of laryngectomy suggests that patients with cancer (as opposed to healthy individuals) may be more accepting of laryngectomy if it was associated with a survival benefit. It was interesting to note that high-volume centers appeared associated with increased likelihood of total laryngectomy for T4a larynx patients. This may be a reflection of increased expertise in counseling patients regarding both surgical and nonsurgical approaches, and the availability of ancillary rehabilitation services after laryngectomy.
My two take-home points from this paper are:
- Appropriate patient selection — keeping in mind the exclusion criteria in larynx preservation studies; and
- Comprehensive patient evaluation and counseling. A multidisciplinary evaluation is a necessary and critical component of decision-making in these difficult clinical scenarios. Counseling patients not only about survival outcomes, but also about rehabilitation options, is crucial to leading patients to an informed decision.
References:
The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991;doi:10.1056/NEJM199106133242402.Forastiere AA, et al. N Engl J Med. 2003;doi:10.1056/NEJMoa031317.
Hoffman HT, et al. Laryngoscope. 2006;116:1-13.
Knab BR, et al. Ann Oncol. 2008;doi:10.1093/annonc/mdn173.
Laccourreye O, et al. Ann Otol Rhinol Laryngol. 2012;121(9):570-575.
McNeil BJ, et al. N Engl J Med. 1981;305:982-987.
Stenson KM, et al. Head Neck. 2012;34:1162-1167.
Weber RS, et al. Arch Otolaryngol Head Neck Surg. 2003;129:44-49.
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