Laryngeal cancer management: Voice, communication and quality of life outcomes following non-surgical treatment

Abstract

Organ-preservation treatments, such as radiotherapy + chemotherapy ([C]RT), are used to manage laryngeal cancer with the dual aim of achieving cancer cure, whilst enabling preservation of the larynx for improved functional outcomes post treatment. Research, however, has shown that organ-preservation is not synonymous with function-preservation. It is now recognised that vocal impairments often remain after organ-preservation treatment and that a return to normal voice function does not occur for all patients. Consequently, further research is needed to investigate the varying sequelae of laryngeal cancer management, specifically the impact on function and quality of life (QOL) over time, and the efficacy of rehabilitation. Positive benefits following rehabilitation have been reported within the greater head and neck cancer (HNC) population, however, research specifically exploring laryngeal cancer management, impact on voice function, communication, QOL and patient well-being is comparatively sparse. Hence, the aims of the current thesis are to (1) investigate voice function, communication and QOL for patients treated with (C)RT, and (2) examine the impact of voice rehabilitation on function, patient perceptions and psychological well-being. The first three studies of this thesis (Chapters 2-4) address the first aim, while studies 4 and 5 (Chapters 5-6) address the second. Data used in the current thesis were derived from (a) a large, randomised controlled trial (RCT), (b) a normative cohort, (c) a community listener group, and (d) speech-language pathology (SLP) clinicians. The first study (Chapter 2) investigates the potential impact of laryngeal biopsy on voice outcomes in a pilot group of 15 patients, and a matched control cohort (n=15). Voice outcomes were collected via voice recordings for both groups with the patient group undergoing recordings pre and post biopsy. No significant difference was observed pre-post biopsy, however examination of individual data suggested that multiple punch biopsies may negatively impact functional outcomes. Although the biopsy is a necessary component of cancer diagnosis, this pilot study concluded that type of biopsy may influence functional outcomes and that this is in an area requiring further research. Chapter 3 presents a longitudinal study investigating voice characteristics, communication and QOL outcomes for a cohort of patients (n=40) who received radiotherapy for laryngeal cancer. Voice function, patient reported communication and QOL outcomes were recorded pre treatment, then again at 1, 6 and 12 months post treatment. Results indicated that patients with laryngeal cancer demonstrated impaired and/or reduced perceptual, acoustic, patient reported communication and QOL outcomes pre radiotherapy, which persisted up to 12 months post. Results also documented patterns of change during the 12 month follow-up period. The implications for the nature and timing of voice rehabilitation are discussed. Chapter 4 investigates community listeners’ perceptions of voice function post radiotherapy, and compares their perceptions with those of clinicians and the patients themselves. Sixty-six patients, six months post radiotherapy, underwent voice recordings and self-rated their voice quality and voice acceptability. Ten community members and three SLPs later provided their perceptions of the irradiated voice, including perceived function of the voice across different vocally demanding environments and gender perception. There were significant differences between rater groups’ perception of voice quality and, in more vocally demanding communication environments, the voice was perceived to be significantly poorer. Additionally, 25% of females were incorrectly gender identified. Results suggest that community communication partners identify functional voice changes post radiotherapy, particularly across more vocally demanding environments and for female speakers. Implications for voice rehabilitation including appropriate patient selection are highlighted. The final two studies examine the effects of voice rehabilitation (VR) and its impact on voice function, patient voice perceptions and psychological well-being in a RCT design. Eighty-nine patients with Tis-T4 size laryngeal cancers (glottic, supraglottic and subglottic cancers) were randomised into a VR group (Study 4, n=30; Study 5, n=31) or a control group (Study 4, n=31; Study 5, n=32). In Study 4, voice outcomes from pre VR and up to 12 months post, were evaluated using SLP auditory-perceptual and patient voice perception assessment measures. Study 5 investigated voice rehabilitation and the associated effect on patient well-being, indicated by anxiety and depression scores. Results demonstrated that there were statistically significant differences between the VR group and controls. The VR group (1) did not experience vocal decline as per controls, (2) perceived their voice function to improve to a greater extent and (3) reported significantly less cases of anxiety and depression at 12 months compared to controls. The series of investigations within this thesis indicate that the voice, its function and impact on QOL are negatively and variably affected by laryngeal cancer and its management, at different time-points pre-post treatment. Furthermore, voice rehabilitation following laryngeal cancer treatment is associated with improved voice function, better patient reported voice outcomes and psychological well-being. This thesis highlights the impacts and implications for patient survivorship care and further underscores the importance of function rehabilitation in management for selected patients post (C)RT.