Chemo-radiation Offers Better Post-treatment Voice Quality for Laryngeal Cancer
Researchers find that laryngeal cancer patients treated with chemo-radiation have a similar survival rate and better speech after treatment than those who had their voice box removed.
This finding could be important for the 10,000 patients who will be diagnosed with laryngeal cancer in 2004. Many treatment options exist: surgery, radiation, chemotherapy, chemo-radiotherapy (chemo-radiation), or a combination thereof. Depending on the extent of disease, surgery may involve removal of the entire larynx, a permanent tracheostoma (a hole in the neck that allows the patient to breathe), and vocal impairment. Preservation of the larynx and voice is important, but becomes more difficult in the advanced stages of disease.
Non-surgical treatment options such as chemo-radiation can often preserve the laryngeal structure. Chemo-radiation and other non-surgical techniques are known to cause destruction of tissue surrounding the cancer site, possibly rendering the organ dysfunctional. The present study is the first to ask the question: Is the voice box worth preserving after chemo-radiation treatment?
This question may be answered in the study, ¡°Voice and swallowing outcomes of an organ preservation trial for advanced laryngeal cancer¡± to be presented by study authors Kevin Fung, MD, Teresa Lyden, MA, Julia Lee, MS, MPH, Susan G. Urba, MD, Frank Worden, MD, Avraham Eisbruch, MD, Christina Tsien, MD, Carol R. Bradford, MD, Douglas B. Chepeha, MD, Norman D. Hogikyan, MD, Mark E. P. Prince, MD, Theodoros N. Teknos, MD, Gregory T. Wolf, MD, Head and Neck Oncology Program, all of the Department of Otolaryngology ¨C Head & Neck Surgery, University of Michigan, Ann Arbor, MI, at the 6th International Conference on Head and Neck Cancer being held August 7-11, 2004, at the Marriott Wardman Park in Washington, DC.
Methodology: A prospective phase II clinical trial was conducted in 97 patients with advanced squamous cell carcinoma of the larynx or hypopharynx (Stage III and IV) that was previously untreated, surgically resectable, and curable with conventional surgery and radiotherapy.
All patients were given a single course of induction chemotherapy followed by assessment of response by direct laryngoscopy. Patients who achieved <50 percent response underwent early salvage laryngectomy, and patients who achieved ¡Ý50 percent response underwent concurrent chemo-radiation followed by adjuvant chemotherapy. Assessments were made by direct laryngoscopy and biopsy; late salvage surgery was performed on patients with persistent or recurrent disease. Survey data was obtained from patients who were alive and free of disease. Voice and swallowing function was measured using validated quality of life instruments (Voice-Related Quality of Life Measure ¨C V-RQOL, and Performance Status Scale for Head and Neck Cancer Patients ¨C PSS-HN), and nutritional mode: (i) Nothing by mouth, (ii) Tube feeds, trial oral intake, (iii) Combined oral and tube feeds, (iv) Nutritional supplements only taken by mouth, (v) Oral intake with nutritional supplements, and (vi) Oral intake alone; no supplements.
Results: Completed V-RQOL survey data were obtained from 56 patients who were alive and free of disease at the time of survey. Completed PSS-HN data were available from 41 of 56 patients. In this cohort, partial (¡Ý50 percent) response after induction chemotherapy was achieved in 78.6 percent of patients. Overall, organ preservation was achieved in 66.1 percent of patients. Laryngectomy was performed on 19 patients (33.9 percent), of which 12 (63.2 percent) were done after induction chemotherapy (early) and seven (36.8 percent) were done after persistent or recurrent disease (late). The overall three-year survival rate was 86 percent.
V-RQOL scores in the study patients were lower compared to normal patients, but higher compared to patients who had had their larynx removed. No differences were detected between patients grouped by early and late laryngectomy. Significant predictors of higher total V-RQOL scores are lower cancer stage, organ preservation, and length of time since treatment. Speech scores were lower in those without a voice box, but eating in public and normalcy of diet were similar for both groups.
Conclusion: Voice-related quality of life is better in larynx cancer patients who are treated with chemo-radiation therapy than those who have their voice box removed. These findings indicate that a chemo-radiated voice box is worth preserving. However, longer follow-up of larynx preservation patients is needed to evaluated late toxicity and organ function since fibrosis after aggressive radiation regimes increases over time.