Laryngeal (Voice Box) Cancer: What Patients Should Know in Decision Making
Written by Gregory T. Wolf, M.D.,
Head and Neck Oncology Program; Department of Otolaryngology
Early Disease:Early cancer of the glottis (vocal cords) or supraglottis (false vocal cords) can be effectively treated with either surgery alone or radiation therapy. Most surgical procedures can spare major portions of the voice box and with modern techniques, reconstruction of the voice box can be accomplished with preservation of reasonable voice quality and swallowing. The past ten years have seen the introduction of laser resections for many of these cancers thereby avoiding external neck incisions. In general, cancers that are superficial or limited in extent are best treated with laser removal. Similar tumors are also easily cured with 6-7 weeks of radiation treatment. Many physicians feel that voice quality may be better following radiation compared to surgery, but side effects of dry mouth and risks of some long-term swallowing problems are associated with radiation. Decision making as to treatment of choice also depends on availability of skilled surgeons or radiation therapists and the depth of invasion (extent) and the overall size (volume) of cancer.
Intermediate Disease:For those cancers that are of intermediate size (T2, small T3), treatment decisions are more difficult. Deeply invasive cancers are best treated with surgical excision, often combined with modified or selective neck dissection (removal of lymph nodes). Most of these procedures can preserve some vocal function without permanent tracheostomy. More extensive surgical resections are associated with significant problems with voice and swallowing. A recent advancement, pioneered in Europe, includes near total laryngectomy (supracricoid partial laryngectomy) which has achieved excellent results in young, properly selected patients. Superficial cancers or those of smaller volume can be effectively treated with radiation alone, but local recurrence rates are higher than with primary surgery. Overall cure rates are similar, however, with radiation when subsequent surgical salvage of these radiation failures is successful. Unfortunately, many of the patients suffering recurrences after radiation must undergo total laryngectomy in order to be cured.
Advanced Disease:Standard treatment for patients with advanced laryngeal cancer has historically consisted of total laryngectomy, often combined with modified neck dissection. When metastatic cancer is present in the lymphatics of the neck, surgery is combined with radiation therapy. Five-year cure rates vary from 40-60%. The major sequelae of total laryngectomy include loss of natural voice and problems associated with living with a permanent tracheal stoma (hole in the neck). Modern voice restoration techniques with tracheoesophageal puncture (Blom-Singer prosthesis) has significantly reduced loss of voice as a result of total laryngectomy since the majority of patients are able to speak with a naturally sounding, lung powered voice and fewer patients must rely on the electrolarynx or esophageal speech.
Many patients and physicians will select primary radiation for treatment of advanced laryngeal cancers. When there is no clinical evidence of regional (neck) metastases, cure rates are acceptable even though local tumor control is not as good as with surgery. This is because of the possibility of successful surgical salvage of radiation failures. When clinical metastases have occurred, cure rates with radiation alone are not good and optimal treatment incorporates surgery followed by radiation.
One of the most exciting advances in the treatment of patients with advanced laryngeal cancer has been the introduction of chemotherapy as initial treatment. \In pioneering work, the Veterans Affairs Laryngeal Cancer Study Group demonstrated that several cycles of initial chemotherapy combined with radiation can be as successful as total laryngectomy in curing patients with advanced cancer when the tumor responds to initial chemotherapy. For such patients, laryngeal function, voice, swallowing and quality of life are preserved. This approach has now been extended to patients with pharyngeal (throat) cancers that would normally also require total laryngectomy. More recent studies have shown the feasibility of using a single treatment of initial chemotherapy to determine which cancers will respond and then treating these patients with combined, simultaneous chemotherapy and radiation. Unfortunately, patients who have cancer, which is unresponsive to \initial chemotherapy, must undergo total laryngectomy with its resultant side effects. Fortunately, cure rates are the same in both groups of treated patients. Typically, nearly 2/3 of patients will be able to avoid surgery with this new approach. Five-year cure rates for patients with advanced disease remain in the 40--60% range. There is increasing evidence that combined (concurrent) chemotherapy and radiation may be better treatment than radiation alone. These combined approaches have substantially increased toxicity and make subsequent surgery for cancer recurrences more difficult.
None of the newer treatment approaches have demonstrated improvements in survival rates compared to total laryngectomy. Therefore, all patients should be informed about the effects of total laryngectomy and the chances of subsequent total laryngectomy if either radiation or radiation and chemotherapy are offered as initial treatment. The selection of treatment therefore depends on a balance between side effects, experience of the treating physicians, cost and patient desire. Currently, larynx preservation techniques using chemotherapy and radiation can be offered as alternatives to total laryngectomy if the treatment team has experience with these special techniques or is participating in controlled clinical trials of these approaches.