Concurrent Chemoradiation as a Treatment Option for Advanced-Stage Laryngeal Cancers

Abstract

There is little doubt that concurrent CRT has a valuable role in the management of advanced-stage laryngeal carcinoma.TheresultsofboththeVA laryngeal trialaswellas theRTOG9111trialhavegivenusgreat insight into theutilityofCRTin themanagement of thisdisease. Enepekideshasthoroughly reviewed the pertinent literature on the use of both partial laryngeal surgery and CRT for advancedstage laryngeal carcinoma. To establish the T classification as T3 for a patient with a laryngeal carcinoma, the findings on physical examination as well as cross-sectional imagingof theneckare required.But, many others factors unrelated to tumor stage are critical in making decisionsregardingtherapy.Theseinclude both functional and social issues unique to each patient. Does the patient require a tracheostomy for respiration?Doesthepatientaspiratewith or without a history of pneumonia? Does thepatient reside inanarea that has CRT available as a treatment optionand,more importantly,does this facilityhaveexperiencedeliveringsuch therapy?Otherconsiderationsthatare more difficult to accurately assess include the patient’s perspectives in regard toposttherapyspeech, swallowing, and physical appearance. The data from the large clinical trials show that survival is not deleteriously affected by use of CRT for advanced-stagelaryngealcarcinoma. These data represent the application of intense therapy by subspecialized physicians in a highly monitored environment following the most vigorously scrutinized staging assessment possible.Are theseresultsuniversally obtainable?Datafromlargecancerregistries (Surveillance, Epidemiology, andEndResults [SEER]andNational CancerDatabase[NCDB])revealapotentially alarming trend with a slight decrease inoverall survivalduringthe last 15 years for laryngeal cancer, whereasalmostallothermalignancies have shown an improvement in survival (unpublished data from NCDB throughcommunicationswithHenry T. Hoffman, MD, University of Iowa, asamemberoftheHeadandNeckSite of the Commission on Cancer, January5,2005). Duringthistime,theuse of chemoradiation as the primary therapy for laryngeal cancer has increased,whiletheuseofsurgeryaspart of the therapy has decreased. The intuitive concept that laryngeal preservation results in improved function and quality of life has alsonotbeenestablished.Limiteddata on function and quality of life is available from the VA laryngeal and RTOG 91-11 trials. The data published from the RTOG 91-11 trial suggest no differences in speech and slightly worse swallowing function after concurrent CRT. At the University of Iowa, it is our experience that there are no significant differences in quality-oflife scores in patients with both laryngeal and hypopharyngeal carcinomas treated with radiation alone, CRT, or surgery with postoperative radiation therapy. In addition, the patients who were treated with CRT showed a trend of having the worst swallowing scores and highest depression rating by the Beck Depression Inventory. IbelievethatconcurrentCRTmust be discussed as one of the treatment options for all patients who have T3 laryngeal cancer. But in addition to concurrent CRT, both conventional and altered fractionation radiation therapyshouldbeincludedasnonsurgical options for patients. As Enepekideshasclearlydelineated,partial laryngeal surgery (eitheropenor laser) shouldalsobeoffered,butinmanypatients these options are not possible becauseof theextentofdisease. I also believe that total laryngectomy with or without postoperative radiation therapyshouldbe includedinthediscussion as a treatment option. It remains one of the most oncologically sound operations performed in head and neck oncology and is likely the best option for some patients.