also on the tumor site. For example, while surgery for glottic cancer can sometimes result in voice changes, there is no voice alteration following TLM for supraglottic cancer. Finally, patients and their physicians should consider the available technical expertise for any of the procedures dis- cussed here. “TLM, for example, requires study, practice, and treating lots of cases,” Dr. Weber said. “It’s not a procedure one can excel at by doing it on an occasional basis.” Like- wise, radiation therapy of the head and neck is complex. The National Comprehensive Cancer Network recommends a team consisting of a radiation oncologist, a radiation physi- cist, a dosimetrist, and a radiation technologist to achieve optimal results from radiation therapy, particularly 3-D con- formal techniques. This recommendation is even more im- portant to consider when the patient will not be receiving treatment at a comprehensive cancer center or a facility where multidisciplinary treatment decisions are made. ● 1 Viani L, Stell PM, Dalby JE. Recurrence after radiotherapy for glottic carcinoma. Cancer . 1991;67(3):577–584 2 Holsinger FC, Funk E, Roberts DB, et al. Conservation laryngeal surgery versus total laryngectomy for radiation failure in laryngeal cancer. Head Neck . 2006;28(9):779–784
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professor in and chair of the Department of Head and Neck Surgery. Despite those advantages, however, Dr. Weber pointed out that TLM may not be an option for all early- stage laryngeal cancer patients, including those with limited neck mobility or spinal issues that prevent the positioning necessary for the surgery. If a patient has a full set of natural teeth or cannot fully extend the jaw, the surgeon may not be able to use transoral instruments. Treatment decisions The goal of treatment for patients with early-stage laryn- geal cancer is optimal cancer control with functional preser- vation of the larynx, said Dr. Rosenthal. The chosen treatment should be the one that is the easiest on the patient, he add- ed. “Functional preservation” must take into consideration the jobs of this intricate organ: breathing, safe swallowing without aspiration, and voice. Ideally, early-stage laryngeal cancers should be treated with a single modality, either sur- gery or radiation therapy. The choice between surgery and radiation therapy should be based first on the patient’s medical considerations . For ex- ample, patients with a significant comorbid illness are often better served by radiation therapy than major surgery. As noted earlier, anatomical factors may preclude TLM, and comorbidities that cause pulmonary insufficiency or poor healing may preclude all surgical options. The other significant medical variables are tumor size and location. Tumors that are small and localized lend them- selves to surgery; for larger lesions, radiation therapy and chemotherapy may provide superior voice results. Patient preferences should also be considered, especially when the patient has no compelling medical considerations besides the tumor itself. More patients have opted for radia- tion therapy as it has become medically equivalent to surgery. Radiation therapy allows patients to avoid the substantial recovery and rehabilitation periods that follow surgery. Also, radiation therapy generally causes less deterioration in voice than surgery. For larger tumors that involve more structures, radiation therapy may have a significant effect on swallowing function. However, some patients are more comfortable with surgery than radiation therapy, and surgery offers a one-time treatment when it is not feasible to receive daily radiation treatments for up to 7 weeks. The emergence of TLM has significantly altered the deci- sion process for patients who are candidates for surgery or radi- ation therapy because it is noninvasive, requiring no surgical incision, tracheostomy, or complicated recovery—all reasons that some patients decided against surgery in the past. Patients whose voice quality is important in their work or personal life may prefer radiation therapy to retain the best possible voice after treatment. For others, the time re- quired for radiation therapy weighs more heavily than voice changes, and they may prefer TLM or conventional surgery, both one-time procedures. However, risk to voice depends
SUGGESTED READING
• Holsinger FC, Weber RS. Swing of the surgical pendulum: a return to surgery for treatment of head-and-neck cancer in the 21st centu- ry? Int J Radiat Oncol Biol Phys. 2007;60(suppl):s129–s131 • National Comprehensive Cancer Network: Practice Guidelines in Oncology—v.2.2008; Head and Neck Cancer. http://www.nccn.org • Pfister DG, Laurie SA, Weinstein GS, et al. American Society of Clinical Oncology clinical practice guideline for the use of laryn- geal-preservation strategies in the treatment of laryngeal cancer. J Clin Oncol . 2006;24:3693 – 3704 • Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. J Clin Oncol. 2006;24:2636–2643. Contributing Faculty The University of Texas M. D. Anderson Cancer Center
F. Christopher Holsinger, M.D., F.A.C.S. Assistant Professor, Department of Head and Neck Surgery
Jan S. Lewin, Ph.D. Associate Professor, Department of Head and Neck Surgery Director, Section of Speech Pathology and Audiology
David I. Rosenthal, M.D., F.A.C.R. Professor, Division of Radiation Oncology Director, Head and Neck Translational Research
Randal S. Weber, M.D., F.A.C.S. Professor and Chair, Department of Head and Neck Surgery
6 OncoLog • January 2009
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