Glottic cancer in Ontario, Canada and the SEER areas of the United States. Do different management philosophies produce different outcome profiles?

Effect of Radiological Tumor Thickness on Prognosis of Early Glottic-Squamous Cell Carcinoma Treated With Radiation

OBJECTIVES

Tumor depth of invasion is a known prognostic factor in several head and neck cancers, but data on early laryngeal squamous cell carcinoma (SCC) are sparse. In this study, we aim to determine whether radiological tumor thickness serves as a prognostic factor in early SCC of the glottis treated with radiation.

METHODS

One hundred thirty-two adult patients (age >18 years) underwent pretreatment computed tomography (CT) and were treated with radiation for pathologically proven early stage (T1 or T2) glottic SCC. Thirty-eight were excluded because the tumor could not be correctly identified on the CT scan, and an additional three patients because of insufficient data.

RESULTS

The final cohort consisted of 91 patients, 84 (90.3%) men and 7 (9.7%) women aged 39.86-86.53 (mean 65.55 ± 12.76) years. Mean tumor thickness was 0.59 ± 0.19 cm in patients with T1 tumors and 0.79 ± 0.21 cm in patients with T2 tumors. The optimal cutoff value for 5-year disease-free survival (DFS), using the Youden index (sensitivity: 81.2%, specificity 65.3%), was 0.7 cm. A significant advantage in 5-year overall survival (OAS) and 5-year DFS for tumor thickness of <0.7 cm (P = 0.01 and P < 0.01, respectively) was found, these findings were consistent also when each stage was examined separately (T1 vs T2).

CONCLUSION

Radiological tumor thickness appears to significantly predict OAS and DFS in early glottic SCC patients.

IMPLICATION FOR PRACTICE

Tumor thickness may be considered as an auxiliary aid in deciding follow-up time and frequency, proper treatment, and determining prognosis.

Multimodal Evaluation of Voice Outcome in Early Glottic Cancers Treated With Definitive Radiotherapy

BACKGROUND/AIM

We employed a multimodal evaluation of voice outcome (MEVO) model to assess long-term voice outcome in early glottic cancer (EGC) patients treated with primary radiotherapy (RT). The model consisted of objective and subjective vocal evaluation during follow-up, by a dedicated Speech Pathologist and Speech Therapist.

PATIENTS AND METHODS

MEVO methodology includes Self-perception Voice Handicap Index (VHI-30), evaluation of parameters Grade (G), Roughness (R), Breathiness (B), Asthenia (A) and Strain (S) according to GRBAS scale, objective analysis and aerodynamics using the PRAAT software and laryngeal evaluation with videostroboscope (VS).

RESULTS

The MEVO methodology was described and tested on a sample of 10 EGCs submitted to definitive RT (total dose 66-70 Gy). Mean follow-up was 48.9 months (range=9-115). VHI was mild-moderate in 90% of patients; overall voice function (GRBAS) was normal-mildly impaired in 70% of patients; VS evaluation showed normal vocal cord motion in 90% of patients, but complete glottic closure in 60%. PRAAT scores confirmed these findings.

CONCLUSION

A multidimensional voice evaluation is time consuming, but useful to objectify vocal impact of radiotherapy. The MEVO model allowed to quantify vocal dysfunction, showing a good objective vocal outcome.

KTP Laser Treatment of Early Glottic Cancer: A Multi-Institutional Retrospective Study

OBJECTIVES

The primary objectives were to report oncologic outcomes of transoral laser microsurgery with potassium-titanyl-phosphate (KTP) laser (TLM-KTP) ablation of early glottic cancer (EGC). The secondary objectives were to report vocal outcomes and to analyze factors that might influence outcomes.

METHODS

A multi-institutional, retrospective analysis of consecutive patients treated for T1 or T2 glottic squamous cell carcinoma undergoing TLM-KTP ablation with at least 2 years of follow-up was performed. Patients with prior radiation or surgery for laryngeal disease were excluded.

PRIMARY OUTCOME MEASURES INCLUDED

surgical failures requiring radiation or laryngectomy, disease-specific survival (DSS), and overall survival (OS). Secondary outcome measures included: pre- and postoperative Voice Handicap Index-10 (VHI-10) scores. The effects of smoking status, stage, and anterior commissure involvement on outcomes were analyzed.

RESULTS

Overall 88 patients met inclusion criteria (83% male, 79.5% current or former smokers). Mean age was 68 (standard deviation (SD): 12). Mean follow-up was 39.5 months (SD: 15.3). Staging included 50 T1a, 21 T1b, and 20 T2 tumors, including three metachronous second primaries. Radiation and/or laryngectomy avoidance was achieved in 87/88 (98.9%) of patients, inclusive of 24 patients requiring KTP re-treatments. Two patients had biopsy-proven recurrence (2.3%), but only 21 of 24 re-treated patients received a formal biopsy. No patients died from laryngeal cancer. DSS and OS were 100% and 92.3%, respectively. The mean VHI-10 scores were 19.3 preoperatively, 3.8 at 6-months postop, and 3.8 at 2-years postop. Smokers had a longer interval to re-treatment (P = .03), patients with T2 lesions had a shorter interval to re-treatment (0.02), and patients with T2 lesions presented with worse initial VHI-10 scores (0.002).

CONCLUSIONS

A multi-institutional, retrospective case series of TLM-KTP ablation of EGC demonstrated excellent oncologic outcomes when close surveillance and proactive re-treatments were utilized. Disease-specific survival, overall survival, and vocal function were excellent. Additional studies are necessary to further analyze the merits and risks of this treatment approach.

Voice outcomes for early laryngeal cancer

PURPOSE OF REVIEW

Treatment options for early laryngeal cancer are well established with good local control and 5-year survival. The commonest treatments are radiotherapy or transoral laser microsurgery (TLM). There are advantages and disadvantages of the different modalities, but debate continues regarding the voice outcomes posttreatment. This review will focus on early glottic carcinoma and voice outcomes following the different treatments.

RECENT FINDINGS

TLM and radiotherapy are both likely to affect voice quality, but the extent of voice change depends on different factors. These factors can be divided into patient, tumour and treatment factors. Recent meta-analyses data show similar voice outcomes for either modality in the treatment of early glottic carcinoma. However, larger tumours and those involving the anterior commissure are associated with worse voice outcomes.

SUMMARY

There are various considerations for the patient and clinician before deciding on the preferred treatment for early glottic carcinoma. Although both TLM and radiotherapy will affect voice outcomes, the recent meta-analyses show similar voice outcomes for either modality in the treatment of early glottic carcinoma. There are numerous variables in the published studies hindering direct comparisons. These include heterogeneous patient groups, different treatment standardization and methods of voice analysis.

Do Lower-Risk Thyroid Cancer Patients Who Live in Regions with More Aggressive Treatments Have Better Outcomes?

BACKGROUND

The management of differentiated thyroid cancer has traditionally consisted of total thyroidectomy with or without adjuvant radioactive iodine. However, in the last two decades, this approach has been challenged, with the consideration of more conservative approaches such as less radical surgery and deferring adjuvant treatment, especially in lower-risk patients. The objective of this study was to consider the effectiveness of current treatment options by comparing the survival outcomes from different geographic regions with different treatment philosophies. This study design was based on the concept of natural experiments in patient care that occur when physicians in different regions treat the spectrum of typical patients with varying treatments.

METHOD

This population-based retrospective cohort study investigated 2444 patients with differentiated thyroid cancer ≤4 cm between 1990 and 2001 from Ontario, Canada. Extent of disease and extent of surgery were abstracted from pathology reports and were linked to downstream administrative medical information on treatments and outcomes. Patient demographics, tumor characteristics, treatments, and outcomes were compared between those geographic regions with more aggressive treatments and those regions with less aggressive treatments.

RESULTS

Treatment varied across the province. When comparing outcomes in regions where patients had more extensive treatment to those in regions where patients had less extensive therapy, similar rates were found for 15-year survival, recurrence, and survival after recurrence.

CONCLUSION

There were significant variations in treatment but no differences in outcomes for regions with more versus less aggressive approaches. These findings support the trend toward more conservative management approaches in the treatment of thyroid cancer.

Risk factors for radiation failure in early-stage glottic carcinoma: A systematic review and meta-analysis

BACKGROUND

Radiotherapy is one of the main treatment modalities for early-stage glottic carcinoma. Unfortunately, local failure may occur in a group of cases with T1-T2 glottic carcinoma. This meta-analysis sought to determine risk factors for radiation failure in patients with early-stage glottic carcinoma.

METHODS

A systematic and comprehensive search was performed for related studies published between 1995 and 2014. The primary end-point was 5-year local control. Data extraction and analysis were performed using the software STATA/SE 13.1 for Windows.

RESULTS

Twenty-seven studies were eligible. A higher risk of radiation failure was demonstrated in male patients [relative risk (RR): 0.927, p<0.001] and those with low hemoglobin level (RR: 0.891, p<0.001) with a high agreement between studies (I-squared=0.0%). Moreover, T2 tumors (RR: 0.795, p<0.001), tumors with anterior commissure involvement (RR: 0.904, p<0.001), tobacco use during/after therapy (RR: 0.824, p<0.001), and "bulky" tumors (RR: 1.270, p<0.001] or tumors bigger in size (RR: 1.332, p<0.001]. Poorly differentiated tumors had a questionable risk of local failure, although a moderate to high interstudy heterogeneity was determined. A statistically significant contribution was not detected for age, presence of comorbidity, alcohol use or subglottic extension.

CONCLUSION

This is the first meta-analysis which assessed the potential risk factors for radiation failure in patients with early-stage glottic carcinoma. Gender and pretreatment hemoglobin level are major influential factors associated with radiation failure in patients with early-stage glottic carcinoma. However, prospective, randomized clinical trials may permit better stratification of their relative contributions, and those who may benefit more from upfront surgery.

Management of primary T1-T4 glottic squamous cell carcinoma by transoral laser microsurgery

OBJECTIVES/HYPOTHESIS

Evaluate the oncologic outcomes of patients with early and select advanced primary glottic squamous cell carcinoma (SCCa) managed by transoral laser microsurgery (TLM).

STUDY DESIGN

Retrospective cohort study.

METHODS

Ninety cases of TLM-managed primary glottic SCCa were identified retrospectively using a prospectively collected database.

RESULTS

Outcomes of patients with pTis-pT2a disease (n = 65) and pT2b-pT4a disease (n = 25) were, respectively: 5-year local control, 86.2% and 67.5%; 5-year disease-free survival, 64.9% and 44.9%; 5-year disease-specific survival, 96.4% and 59.0%; laryngeal preservation, 96.9% and 80%. Five of nine patients (56%) with supraglottic-glottic-subglottic tumors were local recurrence-free compared to the 70 of 81 (86%) patients with glottic, supraglottic-glottic, and glottic-subglottic tumors. Seven of 13 patients (54%) with positive or indeterminate margins were local recurrence-free compared to 68 of 77 (88%) patients with negative margins.

CONCLUSIONS

Given sample size considerations, this study highlights the satisfactory oncologic outcomes of TLM-treated glottic cancer and the potential importance of margin management and disease extension within the larynx.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:597-604, 2017.

Partial laryngectomy in glottic cancer: complications and oncological results

Introduction

Most patients with laryngeal carcinoma present tumors in the glottis that can be treated by different treatment modalities. Some authors consider open partial laryngectomy as obsolete, while others still deem this as a viable and cost-efficient option.

Objectives

To compare the oncological and functional results of a series of patients undergoing partial laryngectomy vs. external radiotherapy for the treatment of glottic cancer.

Methods

Historical cohort study with a series of glottic carcinoma patients undergoing partial laryngectomy or external radiotherapy during a period of ten years.

Results

Sixty-two patients with glottic carcinoma were included. Group A comprised those submitted to partial laryngectomy (n = 30), and Group B, those who underwent radiotherapy (n = 32). They were homogeneous in the comparison of mean age, 56.4 vs. 60.4 years (p = 0.12) and distribution in pathological stage (p = 0.91). With regard to oncological outcome, there were no differences in distant metastasis rates, or second primary tumor between groups (p = 1.0), as well as in disease-free time, laryngeal rescue-free time, and overall five-year survival. Severe complication rates were also similar between groups.

Conclusion

Open partial laryngectomy had complication rates and oncological results similar to those of radiotherapy for patients with glottic carcinomas and should still be considered among the main available therapeutic options.

The DAHANCA 6 randomized trial: Effect of 6 vs 5 weekly fractions of radiotherapy in patients with glottic squamous cell carcinoma

PURPOSE

The DAHANCA 6 trial evaluated tumor response and morbidity after moderate accelerated radiotherapy compared to conventional fractionated radiotherapy in patients treated for glottic squamous cell carcinoma (SCC). Further, the failure pattern and incidence of new primary tumors were explored.

PATIENTS AND METHODS

Six hundred and ninety-four patients with non-metastatic glottic SCC were randomized between six or five weekly fractions (fx/w) of radiotherapy to the same total dose. The median treatment time was 38 and 46days, respectively. The primary endpoint was loco-regional failure.

RESULTS

Median follow-up time was 14.5years. Of the 177 failures, 167 involved T-site. The cumulative incidence of loco-regional failure (LRF) was 21.6% in the 6fx/w group and 29.3% in the 5fx/w group and the corresponding hazard rate (HR) of LRF was 0.72 (CI: 0.53-0.97, p=0.04). The effect of acceleration on LRF was especially evident in well differentiated tumors (HR=0.42 (CI: 0.23-0.75) and in T1-2 tumors (HR=0.60 (CI: 0.41-0.89)). The HR of laryngectomy was 0.72 (CI: 0.50-1.04) in the 6fx/w group compared to the 5fx/w group. The hazards of disease-specific death, event-free survival, and overall survival were comparable between the two groups. Significantly more patients experienced severe acute mucositis in the 6fx/w group but the incidence of late morbidity was comparable between the groups. New primary tumors occurred in 22.5% of the patients.

CONCLUSION

Moderate accelerated radiotherapy significantly improved loco-regional control in patients with glottic SCC.

Voice outcomes following radiation versus laser microsurgery for T1 glottic carcinoma: systematic review and meta-analysis

OBJECTIVE

Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy.

DATA SOURCES

PubMed, Web of Science, and Scopus (1997-2013).

REVIEW METHODS

These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results.

RESULTS

Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, -5.52; 95% confidence interval, -11.40, 0.36; heterogeneity I (2) = 61%, P = .01).

CONCLUSION

VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Long-term outcomes after surgical or nonsurgical initial therapy for patients with T4 squamous cell carcinoma of the larynx: A 3-decade survey

BACKGROUND

The current study was conducted to evaluate long-term disease control, survival, and functional outcomes after surgical and nonsurgical initial treatment for patients with T4 larynx cancer.

METHODS

Demographics, disease stage, and treatment characteristics were reviewed for 221 sequential patients treated for T4 laryngeal squamous cell cancer at a single institution between 1983 and 2011. Survival and disease control outcomes were calculated.

RESULTS

The median follow-up time was 47 months (71 months for patients still alive at the time of analysis). The overall 5-year and 10-year overall survival rates were 52% and 29%, respectively, and the corresponding disease-free survival rates were 57% and 48%, respectively. Overall 5-year and 10-year locoregional control rates were 78% and 67%, respectively, and the corresponding rates for freedom from distant metastasis were 76% and 74%, respectively. On both univariate and multivariate analyses, lymph node-positive disease at the time of presentation was associated with overall mortality (P<.0001). Patients treated with laryngectomy followed by postlaryngectomy radiotherapy (161 patients) achieved better initial locoregional control than patients treated with a laryngeal preservation (LP) approach (60 patients) throughout the follow-up period (log-rank P<.007) yet the median overall survival times were equal for both groups (64 months; 95% confidence interval 47-87 months and 38-87 months, respectively [P =.7]). Patients treated with an LP approach had a tracheostomy rate of 45% and an any-event aspiration rate of 23%. Rates of high-grade dysphagia at the time of last follow-up were worse for patients treated with an LP approach (P<.01).

CONCLUSIONS

Surgery and postoperative radiotherapy can produce substantial long-term cancer control and survival rates for patients with T4 larynx cancer. Caution should be taken when selecting patients for initial nonsurgical treatment because of significant rates of functional impairment despite survival equivalence.

Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2002 and previously updated in 2004, 2007 and 2010.Radiotherapy, open surgery and endolaryngeal excision (with or without laser) are all accepted modalities of treatment for early-stage glottic cancer. Case series suggest that they confer a similar survival advantage, however radiotherapy and endolaryngeal surgery offer the advantage of voice preservation. There has been an observed trend away from open surgery in recent years, however equipoise remains between radiotherapy and endolaryngeal surgery as both treatment modalities offer laryngeal preservation with similar survival rates. Opinions on optimal therapy vary across disciplines and between countries.

OBJECTIVES

To compare the effectiveness of open surgery, endolaryngeal excision (with or without laser) and radiotherapy in the management of early glottic laryngeal cancer.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 8); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 18 September 2014.

SELECTION CRITERIA

Randomised controlled trials comparing open surgery, endolaryngeal resection (with or without laser) and radiotherapy.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified only one randomised controlled trial, which compared open surgery and radiotherapy in 234 patients with early glottic laryngeal cancer. The overall risk of bias in this study was high.For T1 tumours, the five-year survival was 91.7% following radiotherapy and 100% following surgery and for T2 tumours, 88.8% following radiotherapy and 97.4% following surgery. There were no significant differences in survival between the two groups.For T1 tumours, the five-year disease-free survival rate was 71.1% following radiotherapy and 100.0% following surgery, and for the T2 tumours, 60.1% following radiotherapy and 78.7% following surgery. Only the latter comparison was statistically significant (P value = 0.036), but statistical significance would not have been achieved with a two-sided test.Data were not available on side effects, quality of life, voice outcomes or cost.We identified no randomised controlled trials that included endolaryngeal surgery. A number of trials comparing endolaryngeal resection and radiotherapy have terminated early because of difficulty recruiting participants. One randomised controlled trial is still ongoing.

AUTHORS' CONCLUSIONS

There is only one randomised controlled trial comparing open surgery and radiotherapy but its interpretation is limited because of concerns about the adequacy of treatment regimens and deficiencies in the reporting of the study design and analysis.

Treatment, comorbidity and survival in stage III laryngeal cancer

BACKGROUND

The purpose of this study was for us to identify factors associated with survival and laryngeal function in a contemporary, population-based study of stage III laryngeal carcinoma.

METHODS

Patients presenting to a tertiary center with stage III laryngeal carcinoma between 1999 and 2010 were included in the study. Kaplan-Meier and Cox proportional hazards analyses were utilized.

RESULTS

Of 137 patients receiving either surgery ± adjuvant therapy (SURG±Adj = 24.1%), chemoradiotherapy (CRT = 32.8%), or radiotherapy alone (RT = 36.5%), 5-year cause-specific survival (5-year CSS) was 81.0% and 2-year local relapse rate was 27.5%. RT had higher recurrence (p < .01), lower 5-year CSS (90.8% vs 87.8% vs 68.9%/SURG±Adj vs CRT vs RT/p = .0026) and lower overall survival (p = .001). Adjusting for excess of severe comorbidity in the RT group, there was no difference in 5-year CSS between treatment modality.

CONCLUSION

SURG±Adj and CRT had similar survival. Severe comorbidity was associated with selection bias to RT and reduced 5-year CSS. Comorbidity is a key prognostic variable and should be considered in the interpretation of treatment outcomes.

Practice patterns in the management of patients with differentiated thyroid cancer in Ontario Canada 2000-2008

BACKGROUND

The extent of treatment for differentiated thyroid cancer remains controversial. The objective of this study was to describe the variations in practice prior to diagnosis and for the first year after diagnosis, including the investigations, the extent of surgery and the use of RAI 131, for all patients with thyroid cancer (TC) treated Jan 1 2000 to Dec 2008 across Ontario Canada.

METHOD

Population-based study of all patients who had a therapeutic surgical procedure for TC based on the data holdings of the Institute of Clinical Investigative Sciences (ICES) linking the Ontario Cancer Registry to the Ontario Health Insurance Plan and to the Canadian Institutes of Health Information. The analysis includes comparisons between health care utilization/geographic regions and between treating specialties. The study population was 12957 patients.

RESULTS

There was a 112% increase in case detection over 9 years. Overall the initial (index) surgery was less-than-total thyroidectomy (LTT) in 37.6% and 63.4% of the patients who had total thyroidectomy (TT) as an index surgery went on to adjuvant RAI, however there was wide variation in all aspects of patient care across the province, between Local Health Networks and between surgical specialties.

CONCLUSION

In Ontario, there was wide variation for most aspects of the management of TC and, as the incidence of TC is increasing at least 7% per year in females, these data provide a foundation for future discussions, the provision of health care services and research.

Impact of the addition of chemotherapy to radiotherapy for oropharyngeal cancer in 2003-2004: Population-based study from the Province of Ontario, Canada

BACKGROUND

Concurrent chemoradiotherapy (CRT) became the standard of care for locoregionally advanced head and neck cancers based on clinical trials but its effectiveness at the community level is not reported.

METHODS

We conducted a population-based comparative effectiveness study of all 571 patients with oropharyngeal cancer in Ontario Canada (2003-2004) that describes the patients and the treatments and compares concurrent CRT to radiotherapy (RT) alone.

RESULTS

When comparing the outcomes (CRT vs RT) for all patients or patients eligible for either treatment, for patients of centers with the "higher use" of CRT to patients of the 'lower use' centers and comparing all centers, we found no overall or disease-specific advantage to CRT over RT alone. There was also no difference in recurrence-free survival, pattern of recurrences, or distant control.

CONCLUSION

In Ontario (2003-2004), in daily clinical practice, the addition of concurrent CRT to RT had little impact on survival in patients with oropharyngeal carcinoma.

Initial treatment for newly diagnosed elderly colorectal cancer patients: patterns of care in Italy and the United States

Cancer is a major component of health-care expenditures in most developed countries. The costs of cancer care are expected to increase due to rising incidence (as the population ages) and increasing use of targeted anticancer therapies. However, epidemiological analysis of patterns of care may be required prior to empirically well-grounded cost analyses. Additionally, comparisons of care between health-care delivery systems and countries can identify opportunities to improve practice. They can also increase understanding of patient outcomes and economic consequences of differences in policies related to cancer screening, treatment, and programs of care. In this study, we compared patterns of colorectal cancer treatment during the first year following diagnosis in two cohorts of elderly patients from some areas of Italy and the United States using cancer registry linked to administrative data. We evaluated hospital use, initial treatments (surgery, chemotherapy, and radiation), and timeliness of surgery and adjuvant therapy, taking into account patient characteristics and clinical features, such as stage at diagnosis and the cancer subsite. We observed greater use of adjuvant chemotherapy in stage III and IV colon cancer patients and adjuvant therapy in all stages of rectal cancer patients in the US cohort. We found a higher rate of open surgeries in the Italian cohort, a similar rate of hospitalization, but a higher number of hospital days in the Italian cohort. However, in spite of structural differences between the United States and Italy in health-care organization and delivery as well as in data collection, patterns of care and the timing of care in the year after diagnosis are generally similar among patients within stage of disease at diagnosis. Comparative studies of the costs associated with patterns of cancer care will be important for future research.

Survival Differences between Organ Preservation Surgery and Definitive Radiotherapy in Early Supraglottic Squamous Cell Carcinoma

Objective

Single-modality treatment, either with organ preservation surgery (OPS) or definitive radiation (RT), is the treatment of choice for patients with early supraglottic squamous cell carcinoma (SGC). However, studies comparing the effectiveness of these 2 techniques are lacking. This study compares the survival outcomes in early SGC patients treated with OPS versus RT.

Study Design

Secondary data analysis.

Setting

Surveillance, Epidemiology and End Results database.

Subjects and Methods

This study included adult patients with early-stage (T1N0, T2N0) SGC undergoing single-modality treatment with either OPS (with or without neck dissection [ND]) or RT between 1988 and 2008. Survival analysis was used to compare the overall survival (OS) and disease-specific survival (DSS) between patients treated with OPS+ND, OPS alone, and RT.

Results

A total of 2631 T1/T2 N0 SGC patients were identified, of whom 167 (6%) were treated with OPS+ND, 186 (7%) with OPS only, and 2278 patients (87%) with definitive RT only. In stage I (T1N0) SGC patients, a significantly better 5-year DSS was noted for both OPS+ND (81% vs 68%, hazard ratio [HR] = 0.61, P = .03) and OPS only (82% vs 68%, HR = 0.70, P = .05) when compared with definitive RT. For stage II (T2N0) patients, only OPS+ND resulted in a significantly better 5-year DSS (86% vs 60%, HR = 0.31, P < .001) when compared with patients treated with RT.

Conclusions

Patients with early SGC who underwent OPS+ND had better OS and DSS than patients undergoing RT alone. OPS+ND may be considered a viable and preferred treatment option in these patients.

End-of-life care for lung cancer patients in the United States and Ontario

BACKGROUND

Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems.

METHODS

We identified care for non-small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999-2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)-Medicare data (N = 13,533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided.

RESULTS

Rates of chemotherapy use were statistically significantly higher for SEER-Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER-Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER-Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER-Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001).

CONCLUSIONS

NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns.

Economic burden of resected squamous cell carcinoma of the head and neck in a US managed-care population

BACKGROUND

Squamous cell carcinoma of the head and neck (SCCHN) places a high burden on society and poses complex challenges to healthcare providers.

METHODS

Retrospective claims-based analysis of commercially insured patients identified between 01-31-04 and 12-31-07 with diagnostic evidence of cancer of the lip, tongue, oral cavity, pharynx, or larynx who underwent surgical resection during identification period. Outcomes included treatment patterns, healthcare utilization, and costs. All study variables were analyzed descriptively.

RESULTS

Among the 1104 patients in the final study sample, 71.9% were male, with mean age 56.6 years. On average, patients were followed for 830 days (range of mean days: 805 for lip or tongue cancer to 847 for pharyngeal cancer). About half received radiation therapy during follow-up, whereas only 16.2% received chemotherapy. Patients with pharyngeal cancer were most likely to undergo chemotherapy. After their index surgery, 57.9% of patients had ≥1 inpatient stay, 44.9% had ≥1 ER visit, and all had ≥1 ambulatory visit. The percentage with ≥1 inpatient stay post-index was highest among patients with pharyngeal cancer (73.0%) and lowest in the laryngeal cancer cohort (49.5%). Mean number of hospitalized days, ER visits, and ambulatory visits was 0.45, 0.69, and 27.4, respectively, per-patient per-year. Overall, patients incurred ~$94 million in cost following index surgery ($85,000 per-person, on average). Mean total healthcare cost was $34,450 per-patient per-year, the bulk of which comprised medical expenses ($32,401). The highest mean healthcare cost was incurred by the pharyngeal cancer cohort ($40,214).

CONCLUSIONS

Patients with resected SCCHN incur substantial healthcare costs and have high utilization rates. Results of this analysis are primarily applicable to resected SCCHN in a managed-care setting, and therefore may not be generalizable to the entire US population. Furthermore, disease stage is an important factor impacting outcomes, but these analyses did not stratify patients according to disease stage.

Impact of surveillance on survival after laryngeal cancer in the medicare population

OBJECTIVES/HYPOTHESIS

Routine surveillance is advocated to detect recurrent disease after treatment for laryngeal cancer. This aim of this study was to determine the 1- and 5-year postrecurrence mortality for laryngeal cancers and evaluate whether more intensive surveillance improved survival.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients with recurrent cancers (1992-1999) were identified in a national cancer clinical database. Multivariate analysis was used to evaluate the effect of surveillance on postrecurrence survival.

RESULTS

Of 2,121 recurrent cancers identified, 913 were laryngeal. Patients with laryngeal cancer recurrence had 27% (P = .001) and 22% (P = .007) better odds of 1- and 5-year survival than other sites. The 1- and 5-year postrecurrence survival rates for laryngeal cancer patients were 72.4% and 41.3%, respectively. Glottic cancer cases had the best postrecurrence life expectancy. Multivariate regression revealed that clinical surveillance intensity had no independent impact on their survival (P < .05). However, patients with recurrent glottic cancer seen in surveillance had 23% improved odds of survival (P = .037).

CONCLUSIONS

More frequent surveillance visits was not associated with a survival advantage in the overall population. Patients with glottic cancer had a postrecurrence survival advantage if seen during the surveillance period. Laryngeal cancer patients had better postrecurrence survival than other head and neck sites.

Challenging a dogma – Surgery yields superior long-term results for T1a squamous cell carcinoma of the glottic larynx compared to radiotherapy

AIMS

The aim of this study was to compare laser surgery, conventional endoscopic surgery and radiotherapy in the treatment of early T1a glottic cancer.

METHODS

We conducted a retrospective analysis of patients with early vocal cord cancer (who underwent either conventional surgery via endoscopy or laryngofissur, or primary radiotherapy) at the Medical University of Vienna. By univariate and multivariate Cox regression models the influence of treatment and other parameters on survival and locoregional control were analysed.

RESULTS

337 Patients were analyzed with a mean follow-up period of 133.8 months. Overall survival rates where similar in all three treatment groups. Five-year, 10-year and 15-year estimates of disease specific survival for laser-treated patients were 100%, for conventional surgery were 100%, 98% and 98%, and for radiotherapy were 96%, 92% and 91%, respectively. Locoregional recurrences were observed after laser surgery in 10%, after conventional surgery in 13% and after radiotherapy in 30% of the patients treated. According to the log-rank test, time to relapse was significantly shorter for irradiated patients compared to patients who underwent surgery (p < 0.0001). Mortality caused by the laryngeal tumour was significantly higher in the radiotherapy group (p = 0.003).

CONCLUSION

Patients undergoing laser or conventional surgery have a significantly lower incidence of locoregional recurrences and longer disease-free intervals when compared to patients treated by radiotherapy.

Interrater reliability of measurements of comorbid illness should be reported

OBJECTIVE

Comorbidity indices are commonly used to stratify patients to control for treatment selection bias. The objectives here were to review the reporting of interrater reliability when studies use comorbidity indices in clinical research publications and to report the interrater reliability of four common indices in a particular research setting.

STUDY DESIGN AND SETTING

Four trained abstractors reviewed the same 40 charts of patients with squamous cell carcinoma of the head and neck from a regional cancer center. Scores for the Charlson Index, the Index of Co-existent Disease, the Cumulative Illness Rating Scale, and the Kaplan-Feinstein Classification were calculated, and the intraclass correlation coefficient was used to assess interrater reliability.

RESULTS

The details on the training of abstractors and the results of interrater reliability tests are not commonly reported. In our study setting, the Charlson Index had excellent reliability and the others had acceptable reliability.

CONCLUSION

If the quality of a study using an index or scale is to be assessed, the reliability and interrater reliability of the score assignment process should be reported.

Compromised local control due to treatment interruptions and late treatment breaks in early glottic cancer: Population-based outcomes study supporting need for intensified treatment schedules

PURPOSE

This population-based study describes the treatment of early glottic cancer in Ontario, Canada and assesses whether treatment variations were associated with treatment effectiveness.

METHODS AND MATERIALS

We studied 491 T1N0 and 213 T2N0 patients. Data abstracted from charts included age, sex, stage, treatment details, disease control, and survival.

RESULTS

The total dose ranged from 50 to 70 Gy, and the daily dose ranged from 1.9 to 2.8 Gy. In 90%, treatment duration was between 25 and 50 days. Field sizes, field reductions, beam arrangement, and beam energy varied. Late treatment breaks occurred in 13.6% of T1N0 and 27.1% of T2N0 cases. Local control was comparable to other reports for T1N0 (82% at 5 years), but was only 63.2% in T2N0. Variables associated with local failure in T1N0 were age less than 49 years (relative risk [RR], 3.21; 95% confidence interval [CI], 1.49-6.90) and >3 treatment interruption days (RR, 2.43; 95% CI, 1.00-5.91). In T2N0, these were field reduction (RR, 2.33; 95% CI, 1.23-4.42) and late treatment breaks (RR, 2.19; 95% CI, 1.09-4.41).

CONCLUSION

Some aspects of treatment for early glottic cancer were associated with worse local control. Problems with protracted treatment are of particular concern, underscoring the need for randomized studies to intensify radiotherapy.

Using cancer registry data for survival studies: the example of the Ontario Cancer Registry

BACKGROUND AND OBJECTIVES

The Ontario Cancer Registry (OCR) is a population-based tumor registry created to provide data for epidemiologic research and for cancer surveillance. Recently it has been used for health services research. The objective of this project was to assess the quality of the OCR data that is used in survival analysis.

METHODS AND DESIGN

Clinical information for 898 patients with squamous carcinoma of the head and neck including index tumor site, date of diagnosis, vital status, date of death, and cause of death from a prospective database at the Kingston Regional Cancer Center is compared to the same data elements in the OCR for the same patients.

RESULTS

There is no statistically significant difference in disease-specific survival between the information from the two databases (log rank P = .89). The OCR captured and correctly assigned index tumor site for 81.4% (detection rate). The site assignment was accurate 90.9% of the time (confirmation rate), there was agreement on vital status (dead vs. alive) for all but one patient, and there was excellent agreement on date of death. However, cause of death (cancer vs. noncancer) based on death certificates had a 31% error rate.

CONCLUSION

Researchers can be confident in the survival analysis generated from data in this registry, but need to be aware of potential sources of error.

The management of early laryngeal cancer: options for patients and therapists

PURPOSE OF REVIEW

To evaluate the optimal treatment of early laryngeal cancer and to highlight new developments.

RECENT FINDINGS

The use of hyperfractionation and acceleration of radiotherapy may result in improved outcomes for patients with respect to cancer cure and preservation of the larynx. Options for surgical treatment include endoscopic resection and open partial laryngectomy. The use of endoscopic vertical partial laryngectomy may overcome the difficulties encountered in exposure with transoral laser resection of anterior commissure tumors. The microdebrider may be a useful alternative to CO(2) laser in endoscopic resection in selected cases. A further treatment option that shows promising results is photodynamic therapy, which has some important advantages over the other treatment modalities. Further larger studies are needed to assess the efficacy of these treatment modalities to ascertain the treatment modality of choice.

SUMMARY

Different treatment modalities are available for early laryngeal cancer. The treatment choice should take into account the likely post-treatment morbidity, quality of life, patient preference, and voice quality. The cost of treatment, not only to the treating institution but also to the patient and those involved in the patient's care at home, is also an important issue. Well-designed randomized multicenter controlled trials are now necessary to influence patients' and clinicians' decision in the choice of the most effective and predictable treatment plan.

Radiotherapy patterns of practice: T1N0 glottic cancer in Ontario, Canada

AIMS

To describe the variation in the delivery of radiation therapy to patients with T1N0 glottic cancer who were diagnosed in Ontario, Canada, between 1982 and 1995.

MATERIALS AND METHODS

The patient population consisted of a random sample of 461 patients treated with curative intent from the nine cancer centres that administer radiation therapy in the province. Abstracted variables included prescribed dose (Gy) and fractionation (f), beam energy and arrangement, set-up, field size, beam modifiers, positioning and treatment interruptions.

RESULTS

Thirteen prescribed dose-fractionation schemes (> or = four cases each) were identified, including 50.0-53.0 Gy/20 f (54.5%), 55.0-61.0 Gy/25 f (30.3%), and 60.0-66.0 Gy/30-33 f (7.7%). All regimens used one fraction per day, 5 days per week. An isocentric set-up was used (94.3%), with megavoltage (MV) beam energies of Cobalt-60 (87.9%), 6 MV (6.1%) and 4 MV (6.1%). A lateral parallel-opposed pair of beams was the predominant technique (76.4%) versus an anterior oblique pair (17.2%) or angle-down pair (caudally directed fields to achieve shoulder clearance, 5.7%). Wedging (96.3%) and bolus (11.8%) were used as beam-modifying devices. Predominant field-width dimensions were 5.0-6.0 cm (43.4%) and 6.5-7.0 cm (43.1%), and field length dimensions were 5.0-6.0 cm (49.5%) and 6.5-7.0 cm (35.0%). Head, neck or chin immobilisation was used in 86.9% of the cases, with 94.6% of these being custom-made. We found that radiotherapy practice was stable over time, except for a trend of increasing field size and increasing use of immobilisation. In contrast, we found practice variations among the province's cancer centres. On the basis of our findings, we defined a predominant technical practice consisting of Cobalt-60 (reflecting machine availability during the period of the study), an isocentric set-up, a lateral parallel-opposed pair technique with wedging, and supine-head neutral positioning with custom immobilisation. Forty-two per cent of the cases had one or more components of treatment that differed from this definition.

CONCLUSIONS

Description of practice variation can provoke discussion about unrecognised differences in practice policies, perhaps identifying the need for better evidence, treatment guidelines, or both.

Cancer of the larynx

In Europe, laryngeal cancer accounts for only 2-5% of all cancers, the incidence being much higher among males than among females. Smoke and alcohol represent the major behavioural risk factors. Several carcinogens, occupations and vitamin deficiencies have been associated with laryngeal cancer. A genetic susceptibility to environmental risk factors and carcinogens is recognized. Hoarseness is the main symptom for which patients call for medical consultation. Mucosa is the most common histologic site of the primary lesions considered in the present chapter. Nodal involvement, the site and volume of the primary tumour, and some genes expression represent the major prognostic factors. A high death rate for not cancer-related events is to be pointed out. The loco-regional extent of the disease determines the success of cure. Surgery and radiotherapy represent the main therapeutic options. The choice between these two procedures is often controversial.

Squamous cell carcinoma of the head and neck in Ontario, Canada, and in southeastern Norway

OBJECTIVES/HYPOTHESIS

Reports comparing case mix, treatments, and outcomes between different countries are uncommon in head and neck oncology. Prospective databases of unselected patients from regional cancer centers in southeastern Ontario, Canada, and southeastern Norway were compared.

STUDY DESIGN

Retrospective comparative study of two prospective databases.

METHODS

The case mix, treatments, and disease-specific mortality were compared using frequency tables, Kaplan-Meier survival curves, and the log rank test. RESULTSThe case mix, except for differences in oral cavity, oropharynx, and the recorded tumor (T) category, was similar, and the treatments were different. There was no statistical difference in overall survival for all patients, as well as for some sites.

CONCLUSIONS

The results of treatments, based on different overall treatment polices, for all patients were similar. The differences in recorded T category with no statistical difference in overall survival suggest a difference in staging assignment and raises a question about the reliability of the TNM staging process.

Management and outcome differences in supraglottic cancer between Ontario, Canada, and the Surveillance, Epidemiology, and End Results areas of the United States

PURPOSE

We compared the management and outcome of supraglottic cancer in Ontario, Canada, with that in the Surveillance, Epidemiology, and End Results (SEER) Program areas in the United States.

METHODS

Electronic, clinical, and hospital data were linked to cancer registry data and supplemented by chart review where necessary. Stage-stratified analyses compared initial treatment and survival in the SEER areas (n = 1,643) with a random sample from Ontario (n = 265). We also compared laryngectomy rates at 3 years in those patients 65 years and older at diagnosis.

RESULTS

Radical surgery was more commonly used in SEER, with absolute differences increasing with increasing stage: I/II, 17%; III, 36%; and IV, 45%. The 5-year survival rates were 74% in Ontario and 56% in SEER for stage I/II disease (P =.01), 55.7% in Ontario and 46.8% in SEER for stage III disease (P =.40), and 28.5% in Ontario and 29.1% in SEER for stage IV disease (P =.28). Cancer-specific survival results mirrored the overall survival results with the exception of stage IV disease, for which 34.6% of Ontario patients survived their cancer compared with 38.1% in SEER (P =.10). This stage IV difference was more pronounced when we further controlled for possible cause of death errors by restricting the comparison to patients with a single primary cancer (P =.01). Three-year actuarial laryngectomy rates differed. In stage I/II, these rates were 3% in Ontario compared with 35% in SEER (P < 10(-3)). In stage III disease, the rates were 30% and 54%, respectively (P =.03), and in stage IV disease they were 33% and 64% (P =.002).

CONCLUSION

There are large differences in the management of supraglottic cancer between the SEER areas of the United States and Ontario. Long-term larynx retention was higher in Ontario, where radiotherapy is widely regarded as the treatment of choice and surgery is reserved for salvage. In stages I to III, survival was similar in the two regions despite the differences in treatment policy. In stage IV, there may be a small survival advantage in the U.S. SEER areas related to the higher use of primary surgery.

An international comparison of breast cancer survival: Winnipeg, Manitoba and Des Moines, Iowa, metropolitan areas

PURPOSE

Extending previous Canadian-United States cancer survival comparisons in large metropolitan areas, this study compares breast cancer survival in smaller metropolitan areas: Winnipeg, Manitoba and Des Moines, Iowa.

METHODS

Manitoba and Iowa cancer registries, respectively, provided a total of 2,383 and 1,545 women with breast cancer (1984 to 1992, followed until December 31, 1997). Socioeconomic data for each person's residence at the time of diagnosis was taken from population censuses.

RESULTS

Socioeconomic status and breast cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Des Moines, residents of the lowest fifth of income areas in Winnipeg experienced a significant 5-year survival advantage (survival rate ratio [SRR] = 1.14). In these lowest income areas, the Canadian survival advantage was larger among women aged 25 to 64 years (SRR = 1.23), and this was observed in the middle fifth of income areas among this younger cohort (SRR = 1.11). The Canadian survival advantage even seemed apparent in the poorest neighborhoods with relatively high representations of Aboriginal people (SRR = 1.16).

CONCLUSION

This study replicated the finding of advantaged Canadian cancer survival in smaller metropolitan areas that had been consistently observed in larger metropolitan areas. Canada's single payer health care system seems to offer similar advantages across a number of diverse urban contexts.

Glottic carcinoma--patterns of failure and salvage treatment after curative radiotherapy in 861 consecutive patients

BACKGROUND AND PURPOSE

The aim of this study was to evaluate the patterns of failure and the treatment of recurrences, in a series of primary irradiated patients with squamous cell carcinoma of the glottic larynx.

MATERIALS AND METHODS

Eight hundred and sixty-one consecutive patients were included in this study from 1963 to 1991, out of which 74 were females and 787 males. The stages were: I 56, II 26, III 15, and IV 3%. In 847 of 861 cases (98%) the primary treatment was delivered with curative intent, and out of these 834 patients received primary radical radiotherapy.

RESULTS

With a minimum follow up of 5 years, 274/861(32%) patients had persistent or recurrent disease; in 91% of these the persistent or recurrent disease was in the T-position, 15% in the N-position, and 5% developed distant metastases. Curative salvage attempt was possible in 207 patients, and 145 were subsequently controlled. A total of 718 (83%) patients obtained ultimate tumour control, 584 (68%) without a laryngectomy (134 of the controlled had a laryngectomy, 109 had a total laryngectomy and 25 had a partial laryngectomy). In the patients treated with curative intent, the overall 5-year local tumour control, loco-regional tumour control, disease specific survival rate and overall survival rate was 72, 70, 86 and 66%, respectively. For patients with small tumours the disease specific survival for T1a, T1b and T2 was 95, 93 and 83%, respectively. In the 718 patients cured for their glottic carcinoma, 204 new primary malignant tumours were detected.

CONCLUSIONS

The study shows that laryngeal glottic carcinoma can be effectively managed by primary radiotherapy and surgery salvage. The control is obtained with a high proportion of laryngeal preservation (68%). Recurrences treated with surgical salvage have a success rate of 70%. New primaries are a major problem.

Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryngeal squamous cell cancer

BACKGROUND

Radiotherapy, open surgery and endolaryngeal excision (with or without laser) are all accepted modalities of treatment for early stage glottic cancer. Case series suggest that they confer similar survival advantage. Opinions on optimal therapy vary across disciplines and between countries.

OBJECTIVES

To compare the effectiveness of open surgery, endolaryngeal excision (with or without laser) and radiotherapy in the management of early glottic laryngeal cancer

SEARCH STRATEGY

Electronic search of MEDLINE (from 1966 to October 2000), EMBASE (from 1980 to October 2000), CINAHL (from 1982 to October 2000) and CancerLit (from 1963 to October 2000) databases and the Cochrane Controlled Trials Register.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing open surgery, endolaryngeal resection and/or radiotherapy

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed RCTs identified from the electronic searches for eligibility and methodological quality. All authors of the review discussed the results of these assessments.

MAIN RESULTS

Only one RCT was identified which compared open surgery and radiotherapy among a substantial number of patients with early glottic laryngeal cancer.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence to guide management decisions on the most effective treatment. Interpretation of the only large scale RCT comparing open surgery and radiotherapy in patients with early glottic cancer is limited because of concerns about the adequacy of treatment regimens and deficiencies in the reporting of the study design and analysis. Endolaryngeal resection of early glottic tumours is becoming more common and a well designed multicentre RCT is warranted.