Treatment Results for Stage III Laryngeal Cancer: Analysis of a Populational Database Using Propensity Scores

Abstract

Introduction Treatment of stage III laryngeal cancer suffered a major paradigm change with surgery being substituted by radiation therapy with chemotherapy. Objective To evaluate the oncological outcome of different treatment modalities for stage III laryngeal cancer using a population database. Methods A population database representing patients treated in the state of São Paulo, Brazil, was analyzed. Demographic, clinical and treatment variables were included, and the outcomes of interest were disease-specific and overall survival. Propensity score with nearest neighbor matching was used to compensate for imbalances in treatment groups. Results We retrieved data from 1,804 patients. In multivariate analysis, age, female gender, payment source, clinical N stage (cN) stages, and treatment modality were significant for disease-specific and overall survival. Patients submitted to surgery treatment had a significantly better disease-specific (p < 0.001) and overall survival (p < 0.001) compared with chemoradiation. Propensity score matching was based on cN stage, gender, age, topography, and payment modality, and allowed the pairing of 685 patients from each treatment modality. There was a significant difference in disease-specific survival favoring surgery-based treatment (p = 0.017). Conclusion The treatment choice has a significant impact on survival in patients with stage III laryngeal cancer with surgery-based treatment being superior to chemoradiotherapy (CRT).

Overview of glottic laryngeal cancer treatment recommendation changes in the NCCN guidelines from 2011 to 2022

“…In this sense, the two previous modalities along with concomitant ST/RT or RT alone in patients whose performance status is not sufficient to tolerate this treatment, and surgery with or without adjuvant therapy, are the pathways provided by the last algorithm (2022) of the NCCN guideline. Although RCTs with a robust analysis between surgical and non‐surgical therapy comparing oncologic and functional outcomes in a homogeneous clinicopathological population are needed, retrospective studies performed in a population‐based database analyzing surgery with or without adjuvant treatment versus chemoradiation found superior oncological outcomes in those surgically treated 8,33 . Despite the controversies in the oncological results between studies comparing surgical and non‐surgical modalities, 13,67,69,87 it is noteworthy that induction chemotherapy, which has been gaining more evidence in recent years, is an excellent option for those patients with advanced cancer who are not candidates for surgery or those patients who, after careful evaluation by a multidisciplinary team, the decision to larynx preservation with dysfunction‐free survival through non‐surgical protocols is chosen according to good survival prognosis and patients' QoL.…”

“…5,7 Traditional oncological protocols for advanced (stage III-IV) glottic cancer include techniques such as total laryngectomy and postoperative RT or non-surgical therapy (chemotherapy). Overall and disease-specific survival rates have been better following total laryngectomy than after non-surgical therapy, 8 but current evidence shows that induction chemotherapy followed by RT yields superior clinical outcomes due to decreased morbidity and organ preservation. 7,9 The National Comprehensive Cancer Network (NCCN) has developed clinical practice guidelines for the screening, prevention, diagnosis, treatment, and follow-up of different types of cancer, including head and neck cancers.…”

“…The possibility of the occurrence of morbidities associated with essential functions, such as the loss of the natural voice, breathing, and airway protection during swallowing, should be evaluated carefully 13 . Divergent survival and clinical outcomes of various oncological protocols have been reported, creating controversy about treatment choices, especially regarding organ preservation in patients with advanced (T3–T4) glottic cancer and well‐documented reductions in survival rates 8,14–17 . Thus, the main goal of the present review was to describe the main changes made to the NCCN guidelines for glottic cancer treatment published between 2011 and 2022, as these guidelines serve as the reference in many institutions treating head and neck cancer worldwide.…”

“… 5 , 7 Traditional oncological protocols for advanced (stage III–IV) glottic cancer include techniques such as total laryngectomy and postoperative RT or non‐surgical therapy (chemotherapy). Overall and disease‐specific survival rates have been better following total laryngectomy than after non‐surgical therapy, 8 but current evidence shows that induction chemotherapy followed by RT yields superior clinical outcomes due to decreased morbidity and organ preservation. 7 , 9 …”

Peristomal recurrence following primary total laryngectomy: the enigma of the central compartment neck lymph nodes

“…Medical oncologists have expressed the opinion that primary surgery in terms of TL can be almost dispensed with as there has been shown no survival difference between surgical and nonsurgical treatments [14]. Clinicians have contested those selected patients with advanced laryngo-hypopharyngeal SCC (T4 category, high T-N volume, and significant pretreatment laryngeal dysfunction) fared better with reduced risk of recurrence rates and improved survival when treated with primary surgery [15][16][17][18].…”