The treatment of cancer of the larynx has changed dramatically in recent years. With organ preservation now possible in many cases, it is more important than ever for patients to receive guidance from every corner of the field. In a recent article in the Journal of Oncology Practice (JOP),1 a specialist in the field, Ezra Cohen, MD, of the University of California, San Diego, outlined his approach to the emerging and complex management of laryngeal cancer. Dr. Cohen, who is Professor of Hematology/Oncology at the University of California San Diego (UCSD) and Associate Director for Translational Science at the UCSD Moores Cancer Center, spoke to The ASCO Post about the key issues involved in caring for patients with this type of cancer.
Not All Patients Receive Optimal Care
Why are you writing about laryngeal cancer now?
The treatment of laryngeal cancer is a topic that is still somewhat controversial, despite the fact that evidence has established at least some standard of care for treatment. But perhaps more important, this is a disease that, if managed properly, can be cured in the majority of patients, with function preserved. It is an area in which we as oncologists—including those in oncology subspecialties and services—can have a dramatic impact not only on a patient’s length of life but on his or her quality of life. Judging from the patients I see who have had poor outcomes, I believe there is still a substantial number of patients who are not receiving optimal care. This pertains to both undertreatment and overtreatment.
Optimal Tumor Board
You’ve advocated the involvement of a multidisciplinary team. Can you speak to this?
The emphasis on a multidisciplinary approach is probably the most important point we made in the JOP article. The advice of a multidisciplinary tumor board, especially for patients with stage III and IV disease, has been shown to result in better outcomes for patients. Although this is usually what happens in large institutions and academic centers, whether this is also the case in the community is not clear.
Community oncologists have busy practices, and this tumor is not seen that often. Most community centers are not going to see a large enough volume of head and neck cancer to have a dedicated tumor board for these cases. It is more likely these patients will see only one oncologist—and we are just talking about a physician here. They may never see a speech and swallowing specialist, nutritionist, pharmacist, social worker, or dental practitioner. It is not easy to assemble this team for a small population of patients. These services, along with other oncology subspecialties, comprise the optimal tumor board, but many of the critical services do not exist in the community setting. Sometimes tumor boards can be conducted by video conferencing, but this has its own challenges—you are not meeting face to face, reviewing films and pathology slides.
There is also now good evidence that patients have longer survival and higher functional outcomes when seen by a multidisciplinary tumor board and treated at experienced centers.
This is important because laryngeal cancer can have truly negative consequences. If we intervene correctly, our treatments can have dramatic implications for the patient’s life. If we do not do so correctly, we cannot go back and redo it. Once you have treated these patients with surgery or radiation, you cannot undo it.
What are the factors necessary for patients to be considered candidates for organ preservation?
Organ preservation is possible for many patients with locoregionally advanced disease. It usually involves a combination of chemotherapy and radiotherapy, although laryngeal preservation surgery could be an alternative in carefully selected patients with early-stage disease. Patient-related factors are clearly important. When attempting organ preservation, patients need to be able to adhere to therapy and return for frequent follow-up visits. We understand that for some patients, this is challenging because of issues related to distance or for economic or psychological reasons. If they are unable to handle this, we may have to question whether organ preservation is the best strategy for them.
Also, from the physician’s side, you have to consider your practice setting. I have the luxury of having multidisciplinary personnel and services at the disposal of my patients, but if you do not, organ preservation may not be a good idea.
In simple terms, by stage, what modalities are most often used?
For earlier-stage disease, it is usually a single-modality approach, either radiotherapy or surgery. I suspect only about one-quarter of patients are undergoing surgery upfront these days. For patients with stage III and IV disease, we usually do surgery followed by radiotherapy or chemoradiation. Chemoradiation is the approach for organ preservation. Our preference is to combine chemotherapy and radiation in a concurrent approach, but if we think the patient will only marginally be able to tolerate the combination, we can give them sequentially.
Cetuximab (Erbitux) is approved in head and neck cancer. Which patients receive this drug?
For the most part, we give cetuximab to patients who we believe cannot tolerate cytotoxic chemotherapy, mostly the cisplatin. When chemotherapy is contraindicated, we use cetuximab. These approaches have not been compared head to head, but retrospective data suggest cetuximab may be inferior to chemotherapy. We have no prospective studies, however.
How are immunotherapies looking in laryngeal cancer?
Pembrolizumab (Keytruda) is approved for recurrent or metastatic head and neck cancer. For locoregionally advanced disease, we are just beginning to study the antibodies against PD-1/PD-L1 (programmed cell death protein 1/ligand), and we won’t have these results for a few years.
What is the main message you are offering in your JOP paper?
Our main message is that many patients with laryngeal cancer are good candidates for organ preservation, so it should be discussed and considered. We believe patients should receive an opinion from a multidisciplinary tumor board at a high-volume center, whether or not they can be managed there. It is very important to involve not only the oncology subspecialists, but also the many other critical members of the treatment team. ■
Disclosure: Dr. Cohen reported no potential conflicts of interest.