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Original Investigation |

Oncologic and Functional Outcomes of Surgical and Nonsurgical Treatment of Advanced Squamous Cell Carcinoma of the Supraglottic Larynx

Adekunle I. Elegbede, PhD1; Lisa A. Rybicki, MS2; David J. Adelstein, MD3; James A. Kaltenbach, PhD4,5; Robert R. Lorenz, MD5; Joseph Scharpf, MD5; Brian B. Burkey, MD5
[+] Author Affiliations
1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
2Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
3Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
4Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
5Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio
JAMA Otolaryngol Head Neck Surg. 2015;141(12):1111-1117. doi:10.1001/jamaoto.2015.0663.
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Importance  Nonsurgical treatment of advanced supraglottic laryngeal cancer is widely used as part of a larynx preservation protocol. However, recent studies have suggested that nonsurgical treatment may be associated with inferior survival. Furthermore, it is not clear whether preservation of the larynx provides superior voice or swallowing function in the long term.

Objective  To test the hypothesis that surgical treatment of advanced-stage squamous cell carcinoma of the supraglottic larynx is associated with superior overall survival (OS), freedom from recurrence (FFR), and noninferior voice and swallowing function.

Design, Setting, and Participants  Retrospective medical record review of patients treated for stage III or IV squamous cell carcinoma of the supraglottic larynx between January 1990 and June 2013 at a tertiary referral center: 97 patients underwent surgical treatment and 138, nonsurgical treatment. Exclusion criteria included prior definitive treatment for laryngeal cancer or evidence of distant metastatic disease at presentation. The median follow-up for all 235 patients was 63 months.

Interventions  Surgical or nonsurgical therapy.

Main Outcomes and Measures  Freedom from recurrence (FFR), OS, larynx preservation, voice graded from 1 to 5, and swallowing graded from 1 to 6 using our voice and swallowing function scales.

Results  Surgical treatment was associated with superior FFR (5-year FFR: 75% vs 55%; P = .006) but not OS (5-year OS: 52% vs 52%; P = .61). The larynx was preserved in 83% of patients in the nonsurgical group vs 42% of patients in the surgical group (P < .001). Voice function was superior in the nonsurgical group at all time points through 5 years after treatment (mean voice score, 3.8 vs 2.6; P < .001). Swallowing function was comparable between surgical and nonsurgical groups. Multivariable analysis revealed that advanced age (hazard ratio [HR], 1.43 per 10-year increment; 95% CI, 1.19-1.72) and clinical N stage (HR, 1.17 per 1-level increment; 95% CI, 1.05-1.30) were associated with worse OS, while treatment with chemotherapy was associated with superior OS (HR, 0.61; 95% CI, 0.41-0.92).

Conclusions and Relevance  Compared with surgical treatment, nonsurgical treatment as part of a larynx preservation protocol is associated with a higher likelihood of recurrence but has similar OS and should continue to be viewed as a viable alternative for the treatment of advanced supraglottic laryngeal cancer.

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Figures

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Figure 1.
Overall Survival in the Nonsurgical and Surgical Treatment Groups

Patients in the nonsurgical treatment group experienced overall survival that was equivalent to those in the surgical treatment group.

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Figure 2.
Voice and Swallowing Scores for Nonsurgical and Surgical Groups as a Function of Time

A, The mean voice scores beginning from date of first definitive treatment. Nonsurgical patients had better voice function through 5 years after treatment. B, The mean swallowing scores beginning from date of first definitive treatment. Swallowing function was not different between surgical and nonsurgical groups through 5 years after treatment. Error bars indicate SE.

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