Quality of life preservation has become an essential goal of treatment in the management of laryngeal carcinoma. Although established treatments of reference such as total laryngectomy and chemoradiation protocols have focused on survival and anatomic preservation of the larynx, they still generate considerable functional morbidity with detrimental effects on quality of life. Transoral and transcervical partial laryngectomy techniques can offer significant advantages when used prudently after proper patient selection. The growing relevance of those techniques in the management of advanced and recurrent laryngeal carcinoma deserves particular attention, with potential for improved quality of life without compromising oncologic outcomes.
Key points
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Any treatment modality of laryngeal carcinoma can have effects on laryngeal function, and the impact of treatment on function has to be carefully weighed against its oncologic benefit.
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Quality of life (QOL) after treatment should be viewed as an independent outcome variable to be included in the management algorithm.
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Total laryngectomy (TL) is a radical procedure with significant QOL-related morbidity, and exploring alternative management possibilities has been the basis for the development of organ preservation strategies.
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Conservation laryngeal surgery has wide applications in the management of laryngeal cancer.
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Transoral laser microsurgery (TLM) and transcervical partial laryngectomy procedures offer significant QOL advantages when compared with total laryngectomy and should be considered as feasible treatment options in appropriately selected cases of early, advanced, and recurrent laryngeal cancer.
Overview
Laryngeal cancer has a singular position as a life-threatening condition affecting a complex organ of utmost functional importance. The critical role of the larynx in the maintenance of such cardinal physiologic functions as phonation, regulation of respiratory airflow, and airway protection during deglutition invariably prompts crucial dilemmas when a malignant neoplasm affects this organ. Although TL is still viewed as the ablative procedure of reference, it remains a radical procedure with significant consequences on various qualitative measures of human performance and considerable rehabilitation requirements.
Nonsurgical treatment modalities gained importance in the era of organ preservation protocols but demonstrated their own shortcomings with long-term morbidity issues and added difficulty in the management of treatment failure. After timid beginnings fraught by harsh criticism, transoral microlaryngeal surgery rapidly gained popularity as an oncologically valid alternative to radiation therapy for early glottic lesions, relegating time-honored open partial laryngectomy approaches to a status of quasi-irrelevance given their higher morbidity. The latter are now undergoing a genuine revival as alternative means to either address advanced-stage disease or propose salvage management after radiation failure.
After placing the emphasis of management strategies on oncologic outcomes, and subsequently, on raw functional outcomes, QOL assessments have only recently become a focus of attention. QOL does not necessarily correlate with adequacy of objective functional parameters or with the elementary indicators of oncologic control, but in fact embodies a less-tangible amalgamation of both objective and subjective factors. The increasing complexity of the decision-making process in the management of laryngeal cancer only underscores the importance of an individualized approach, tailored to the patient’s lesion, expectations, and overall health status.
Importance of Quality of Life in the Management Algorithm
The treatment of any malignancy relies primarily on an oncologically validated model of disease control, with a particular emphasis on local control or regional control while focusing on prolonged survival as the ultimate goal. This paradigm was historically the basis to justify the most radical therapeutic approaches, often sacrificing some or all function—and frequently QOL—to increased survival. In addition, a once paternalistic perspective of the practice of medicine served to contribute to substituting patient autonomy with expert clinical judgment.
In more recent times, QOL as reported by the patient, regardless of correlation with clinical or objective parameters of health, is viewed as a factor of paramount importance. In a survey of otolaryngologists, Demez and Moreau noted that most practitioners considered QOL, particularly relating to pain and breathing, to be at least as important as survival in the management of head and neck cancers, and that the physician’s perception of patient QOL had an influence on the proposed choice of treatment. In another survey of healthy professionals faced with a hypothetical personal diagnosis of advanced laryngeal cancer, 20% of respondents declared they would opt for a treatment modality that would provide them with a preserved voice quality over one that would provide improved survival at the detriment of voice function. These sporadic results may admittedly not be extrapolated into algorithms but reflect the importance of tailoring treatment strategies to each patient’s particular situation.
Overview
Laryngeal cancer has a singular position as a life-threatening condition affecting a complex organ of utmost functional importance. The critical role of the larynx in the maintenance of such cardinal physiologic functions as phonation, regulation of respiratory airflow, and airway protection during deglutition invariably prompts crucial dilemmas when a malignant neoplasm affects this organ. Although TL is still viewed as the ablative procedure of reference, it remains a radical procedure with significant consequences on various qualitative measures of human performance and considerable rehabilitation requirements.
Nonsurgical treatment modalities gained importance in the era of organ preservation protocols but demonstrated their own shortcomings with long-term morbidity issues and added difficulty in the management of treatment failure. After timid beginnings fraught by harsh criticism, transoral microlaryngeal surgery rapidly gained popularity as an oncologically valid alternative to radiation therapy for early glottic lesions, relegating time-honored open partial laryngectomy approaches to a status of quasi-irrelevance given their higher morbidity. The latter are now undergoing a genuine revival as alternative means to either address advanced-stage disease or propose salvage management after radiation failure.
After placing the emphasis of management strategies on oncologic outcomes, and subsequently, on raw functional outcomes, QOL assessments have only recently become a focus of attention. QOL does not necessarily correlate with adequacy of objective functional parameters or with the elementary indicators of oncologic control, but in fact embodies a less-tangible amalgamation of both objective and subjective factors. The increasing complexity of the decision-making process in the management of laryngeal cancer only underscores the importance of an individualized approach, tailored to the patient’s lesion, expectations, and overall health status.
Importance of Quality of Life in the Management Algorithm
The treatment of any malignancy relies primarily on an oncologically validated model of disease control, with a particular emphasis on local control or regional control while focusing on prolonged survival as the ultimate goal. This paradigm was historically the basis to justify the most radical therapeutic approaches, often sacrificing some or all function—and frequently QOL—to increased survival. In addition, a once paternalistic perspective of the practice of medicine served to contribute to substituting patient autonomy with expert clinical judgment.
In more recent times, QOL as reported by the patient, regardless of correlation with clinical or objective parameters of health, is viewed as a factor of paramount importance. In a survey of otolaryngologists, Demez and Moreau noted that most practitioners considered QOL, particularly relating to pain and breathing, to be at least as important as survival in the management of head and neck cancers, and that the physician’s perception of patient QOL had an influence on the proposed choice of treatment. In another survey of healthy professionals faced with a hypothetical personal diagnosis of advanced laryngeal cancer, 20% of respondents declared they would opt for a treatment modality that would provide them with a preserved voice quality over one that would provide improved survival at the detriment of voice function. These sporadic results may admittedly not be extrapolated into algorithms but reflect the importance of tailoring treatment strategies to each patient’s particular situation.
Relevant problems
Impact of Total Laryngectomy on Quality of Life
The decision to undergo a TL implies the creation of an irreversible diversion of the tracheal airway to a permanent cervical stoma, resulting in the inability to use the remaining upper airway structures (oral, nasal, and pharyngeal cavities) for respiratory exchanges. As a consequence, the laryngectomee also becomes dependent on routine stomal care measures and devices to prevent excessive bronchorrhea, airway obstruction, and pulmonary complications. An often-overlooked complaint that ensues is the loss of olfactory faculties. Although this deficit can be addressed through simple rehabilitation measures, caregivers commonly dismiss it as a minor and inevitable outcome of TL.
The negative effects of TL on QOL are difficult to mitigate. Despite the eventual adjustment of patients to their new status, a TL is commonly experienced as a form of physical mutilation associated with severe psychosocial effects that do not seem to improve over time. The adjunction of radiation therapy seems to amplify the detrimental effects of TL on QOL.
The mere need for a permanent stoma plays a significant role in the deterioration of perceptual QOL measures, presumably because of the heavy social stigma and psychological adaptation needs associated with it. Potter and Birchall queried a population of laryngectomees on their interest in a possible restoration of function by laryngeal transplant and found that 75% of respondents would be agreeable to a transplant under ideal circumstances. However, the proportion of potential volunteers dropped to 58.9% if a stoma was to be retained after transplant, illustrating the significant contribution of the stoma to the perceived morbidity of TL.
Morbidity of Radiation Therapy
The classic alternative to radical surgical management of laryngeal cancer is external beam radiation therapy, with the option of concurrent radiosensitizing systemic chemotherapy. A seminal 1991 Veterans Affairs study brought the concept of organ preservation into the spotlight, by proposing an ingenuous selection protocol of candidates for curative nonsurgical treatment modalities. Two decades later, the vast adoption of nonsurgical treatment of laryngeal cancer has revealed significant shortcomings with respect to the suboptimal residual function of an otherwise anatomically intact organ, and the difficulty in addressing persistent or recurrent disease with non radical surgical treatment once radiation is delivered. Thus, the term ‘organ preservation’ bears only relative value and should be interpreted with caution, because the functional status of an organ is just as important as its mere presence.
When used as an adjuvant modality after surgical management, radiation therapy has independent supplemental impact on QOL: Vilaseca and colleagues noted a negative influence of radiation therapy and neck dissection on disease-specific QOL after TLM for early to intermediate laryngeal carcinoma; similarly, the QOL relating to voice and swallowing functions after TL was noted to be negatively affected by radiotherapy.
The transoral alternative
Transoral Laser Microsurgery
TLM rapidly emerged as an alternative, minimally invasive surgical modality offering excellent oncologic outcomes and ease of recovery. Aside from cases in which anatomic or technical limitations render TLM unfeasible, the main reservation associated with the technique lies in deterioration of voice function, directly linked to the extent of glottic tissue resected. Nevertheless, despite variable outcomes with respect to voice quality, TLM seems to retain notable advantages in QOL outcomes. When compared with radiotherapy, Luo and colleagues found that although TLM resulted in an increase in the fundamental frequency of the voice, the voice-related QOL was similar and patients undergoing TLM enjoyed better overall communication abilities; Oridate and colleagues had previously observed similar reported voice-related QOL measures, with significantly worse scores after TL compared with TLM or radiotherapy.
One specific drawback of TLM is a prolonged postoperative interval of recovery of voice stability, estimated to range from 3 to 6 months. Therefore any assessment or comparison of definitive functional outcomes after TLM should not take place before this recovery period has elapsed.
Early Glottic Carcinoma
Early malignancy of the glottis certainly exemplifies a domain in which the purported QOL benefits of minimally invasive surgery have their most remarkable illustration. Oncologic outcomes and voice-related QOL were found to be comparable between TLM and external beam therapy in stage I and II glottic carcinoma. Similarly, a systematic review performed by Spielmann and colleagues concluded that the voice quality and QOL were comparable between TLM and radiotherapy, although the statistical power of the review was noted to be fairly low. Another systematic review by van Loon and colleagues also recognized the difficulty to attain sufficient statistical power in comparing the modalities and acknowledged the need to standardize methodology to improve the reliability of comparative studies.
The minimally invasive characteristic of TLM is of particular interest when the patient’s general state of health or comorbidities prompt concerns as to their amenability to radiation therapy or radical surgery. For instance, excellent oncologic outcomes and ease of recovery have been noted to make TLM a beneficial alternative to radiation therapy in the elderly. Furthermore, although there have been anecdotal reports of robot-assisted transoral partial laryngectomy, those were limited to supraglottic resections due to the spatial constraints associated with the cumbersome robotic systems currently available. It is reasonable to anticipate that robotic surgery will hold greater promises for laryngeal surgery as increasingly miniaturized systems are developed in the future.
Finally, cost considerations may also weigh in the choice of modality. In a Canadian retrospective study, the treatment of early glottic carcinoma with definitive external beam radiation therapy was found to be 4 times as costly as single-modality management with TLM. Although that absolute ratio may not be exactly representative of every health care system worldwide, it is safe to presume that, universally, the requisite resources, equipment, time, and personnel commitments of a complete modern radiation treatment regimen represent significantly greater expenditures than what is needed to perform a single TLM procedure followed by a brief hospital admission. However the in-depth economic analysis that is required to corroborate this hypothesis is beyond the scope of this article.
Clinical outcomes of open partial laryngectomy
Oncologic Outcomes
The rapid expansion of nonsurgical organ preservation protocols in the 1990s induced a decrease in the use of open partial laryngectomy in the management of laryngeal carcinoma. The broad adoption of the TLM approach generated further momentum for the decline of transcervical partial resection in the early 2000s.
While one might have anticipated a gradual disappearance of open partial laryngectomy, the technique has instead been enjoying an actual resurgence in the past few years, albeit limited to select specialized centers. On one hand, this trend can be explained by growing numbers of postradiation treatment failures and the often suboptimal efficacy of nonsurgical treatment regimens bearing severe toxicity. Some even expressed concern about presumably decreasing survival rates with nonsurgical treatment being illustrative of missed opportunities for conservation surgery approaches, facing strong rebuttals from advocates of nonsurgical treatment.
On the other hand, higher patient and provider expectations with respect to QOL outcomes have also driven a reevaluation of TL alternatives, whether in the management of advanced laryngeal carcinoma or for salvage ablation of recurrent carcinoma. The latter situation has become the preferred indication of open partial laryngectomy, which is no longer justified in the setting of its original applications. A typical example would be a T1 or T2 lesion of the anterior glottic commissure, which would nowadays be better addressed transorally than by supracricoid partial laryngectomy (SCPL) as it used to be. The use of SCPL for T3 and T4 laryngeal lesions has been noted to produce adequate oncologic outcomes, and open partial laryngectomy has been deemed equivalent to radiation therapy with respect to overall survival, voice quality, and stoma avoidance rate when used to manage T3N0 lesions of the glottis. Lastly, a retrospective analysis of TL surgical specimens by Weinstein and colleagues demonstrated that a nonnegligible subset of the examined tumors would have been possible candidates for SCPL and thus, organ conservation treatment, implying that TL is probably an overused procedure.
Another phenomenon suspected to be an effect of the development of nonsurgical modalities for laryngeal cancer has been a notable decline in survival rates. In a multicenter study by Bussu and colleagues, SCPL with cricohyoidopexy was able to produce survival rates similar to concurrent chemoradiation and greater rates of laryngeal preservation, albeit with the recognition that the procedure was only feasible in selected cases and that concurrent chemoradiation still enjoyed vast applicability. Qian and colleagues noted that the judicious use of adjuvant therapy after partial laryngectomy afforded greater survival than nonsurgical multimodality treatment of advanced tumors.
Quality of Life Outcomes
After decades of controversy, open partial laryngectomy eventually gained definitive acceptance as a safe oncologic alternative to TL in the right indications. However, several factors have precluded widespread adoption of partial laryngectomy as a routine tool in the armamentarium of the head and neck surgical oncologist.
First, when posing a surgical indication, the obligation to follow strict patient selection criteria naturally makes partial laryngectomy the exception rather than the rule; remarkably, although the setting of open partial laryngectomy may be shifting from a primary ablative approach to an alternative or salvage approach, the principal selection criteria remain largely unchanged in either context with respect to amenable tumor boundaries, as well as anatomic and functional contraindications; notably, preserving the cricoid cartilage and at least 1 functional cricoarytenoid unit is of paramount importance ( Box 1 ). In addition, transcervical partial laryngectomy procedures entail significant technical challenges at all levels: initial patient and lesion evaluation, discussion of risks and alternatives, skillful execution of the procedure, and postoperative management needs present daunting pitfalls and complexity to the head and neck surgeon lacking relevant experience. This aspect is amplified by an ongoing attrition of surgeons well versed in conservation surgery of the larynx, which, in turn, results in the virtual absence of these techniques in modern otolaryngology–head and neck surgery training curricula, thereby turning transcervical partial laryngectomy into a lost art. However, such issues are alleviated by the fact that laryngeal cancer is a steadily declining disease entity and its management would probably be adequately served by a limited number of highly specialized centers.
