Primary Surgical Therapy Results in Higher 5-Year Survival for Patients With Advanced-Stage Disease

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Bucking national trends toward preserving the larynx in patients with advanced laryngeal cancer, treatment of patients for stage IV disease at Louisiana State University (LSU) Health-Shreveport were more likely to involve primary surgical therapy, including total laryngectomy, and more likely to achieve 5-year survival than the national average. “This contributes to a growing body of literature that suggests that initial surgical therapy for advanced-stage disease may result in increased survival compared with organ-preservation protocols,” Blake Joseph LeBlanc, MD, and colleagues from LSU-Health Shreveport stated in JAMA Otolaryngology–Head & Neck Surgery.

The authors compared survival outcomes for initial surgical treatment of advanced-stage primary tumors in the Louisiana health system with outcomes in the National Cancer Database (NCDB), a joint program of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. At LSU-Health, an academic tertiary referral hospital, 117 of 165 patients (70.9%) with laryngeal cancer in the tumor registry from 1998 to 2007 presented with advanced-stage (III/IV) disease, compared with 46.7% nationwide (P < .01). Among the LSU patients with advanced disease, 64 patients (54.70%) underwent primary surgical therapy, including total laryngectomy or pharyngolaryngectomy. “Data from the NCDB indicate that the rate of laryngectomy declined from 40% to 60% in the 1980s to 32% in 2007,” the investigators noted.

“For stage IV disease, our 5-year survival rate was 55.54% (95% CI, 43.4%–66.1%) compared with 31.6% (95% CI, 30.4%–32.9%) nationally (P < .05). Our proportion of uninsured patients was 23.7% vs 5.1% of patients nationally (P < .001), and our patients traveled farther distances for care, with 60.5% traveling 50 miles or more, compared with 15.9% nationally (P < .001),” Dr. LeBlanc and coauthors reported. “We believe that upfront laryngectomy may explain our higher survival rates for advanced-stage laryngeal cancer,” the authors stated.

“While it seems logical that triple-modality therapy would confer improved survival at the expense of increased morbidity, the question arises as to whether we should be advising upfront surgical therapy more frequently for the advanced T-stage tumors,” the researchers wrote. “Current National Comprehensive Cancer Network guidelines display the options of concurrent systemic therapy vs laryngectomy vs induction chemotherapy for advanced T-stage glottic and supraglottic carcinomas. At our institution, [patients with] T4 tumors with cartilage and extralaryngeal involvement are uniformly offered total laryngectomy in favor of organ preservation, which resulted in a higher percentage of primary surgical patients at LSU-Health when compared with the NCDB.”

LSU-Health Shreveport “is a public hospital with a large proportion of uninsured and Medicaid [patients] and those with low socioeconomic status,” the authors noted. “Our data suggest that despite disparities in insurance and socioeconomic status, improvements in survival can be achieved with primary surgical
treatment.” ■

LeBlanc BJ, et al: JAMA Otolaryngol Head Neck Surg. November 27, 2014 (early release online).