Introduction
The Department of Health National Health Service (NHS) Cancer Plan (2000) advocates more patient choice in the management of their cancer. 1 Patients with tumour stage T1 or T2 glottic cancer have multiple modalities of treatment options, all with good locoregional control. The aim of treatment is not simply to cure the patient; today treatments are also concerned with organ preservation and good functional outcomes, particularly with respect to voice and swallowing.
The UK National Institute for Health and Care Excellence guidance on improving outcomes in head and neck cancer identifies both transoral laser microsurgery and radiotherapy as acceptable treatments for early laryngeal cancer. 2
There are around 2000 new cases of laryngeal squamous cell carcinoma in the UK per annum. Males are 5 times more likely to develop laryngeal cancer than females, with an incidence rate of 5.9 per 100 000 and 1.2 per 100 000 respectively, 3 which has remained unchanged over the past few decades. Laryngeal cancer has a peak incidence around the age of 70 years, and up to 73 per cent of laryngeal cancers occur in people aged 60 years or more. 3
To date, there have been no published data examining preference when patients are offered choices between treatment modalities for early laryngeal cancer. Whilst we acknowledge that there are other centres in the UK that perform laser surgery for early laryngeal cancer, we believe we are the first to describe a series in which patients were offered a choice between transoral laser surgery and radiotherapy.
We wanted to know what treatment patients would choose when given a balanced choice between radiotherapy and transoral laser resection. Patients are offered a choice of treatment modalities to treat their glottic cancer wherever possible, as recommended by the NHS Cancer Plan. 1 We reviewed the choices that patients made in these circumstances (not previously reported in the literature) to determine whether transoral laser resection or radiotherapy is more popular.
Materials and methods
A prospective audit of established equal treatment methods was conducted, as advised by the multidisciplinary team (MDT). The project was registered with the local research and development department, and no further approval was required.
In December 2002, the senior author and clinical oncologist (MS), together with the MDT, decided to offer suitable patients a choice between radiotherapy and transoral laser resection with frozen section for the treatment of their laryngeal cancer. Each new patient with early laryngeal cancer was seen jointly by the clinical oncologist and senior author, and offered a choice between laser resection and radiotherapy if appropriate.
All patients received a copy of the MDT new patient summary, which summarised the points made by the senior author, clinical oncologist and clinical nurse specialist. They were advised that both modalities are effective treatments, with cure rates of 90 per cent five-year survival for T1 disease and 80 per cent five-year survival for T2 disease. The differences between the treatment options were highlighted (Table I).
Table I Patient information regarding procedures*
* Indicates what patients were told regarding the advantages and disadvantages of transoral laser surgery and radiotherapy. †Later patients were told that we had 1 tracheostomy case in our series, with an average of 16 oncological laser cases per year over 10 years. GP = general practitioner
Radiotherapy entailed a minimum four-week treatment period (55 Gy in 20 fractions), with daily Monday to Friday sessions, for a T1 lesion. Pre-treatment preparation for radiotherapy included the provision of a mask for patient immobilisation and pre-treatment appointments to obtain computed tomography images for treatment planning. Patients were informed about possible skin reactions and mouth dryness, which are the main side effects of radiotherapy. Other early side effects of radiotherapy, including tiredness, sore throat, painful swallowing, aspiration risk, thick secretions and hoarseness, were explained, and patients were advised that these usually settled within four to six weeks. Late side effects of hyperpigmentation, skin atrophia, underactive thyroid (a long-term complication affecting less than 3 per cent of patients), stricture formation, fistula and necrosis were also explained by the clinical oncologist.
Although laser resection with frozen section was typically a 2.5–3 hour procedure, patients were advised that one-third of them would require further surgery. The laser complications discussed included the 5 per cent risk of tracheostomy, the possibility of bleeding and the risk of breathy voice in T2 tumours. Patients within a 10 mile radius of the hospital were advised that they could undergo surgery as a day case; those living further away were kept overnight for logistical reasons.
Those with no initial decision preference were reviewed in the allied health professional clinic 1–3 days later so they could obtain more information from the clinical nurse specialist, with or without the speech and language therapist. A review appointment was scheduled with the senior author and oncologist for the following week, and at this time the patients were asked about their decision choice. On this basis, all patients were able to make a decision by the following week.
Radiotherapy was scheduled to start four weeks after the decision was made (because of treatment planning) and laser surgery was scheduled for three weeks after the decision date. Bias for either treatment modality was avoided by: (1) ensuring that each patient was seen jointly by the senior author and oncologist; (2) providing written material reiterating all information given; and (3) emphasising that the MDT team had no treatment ‘of choice’ – both were equally effective.
Transoral laser surgery usually entails a single general anaesthetic procedure with frozen section, and is carried out as a day-case procedure in approximately 80 per cent of patients. There is the option for subsequent transoral laser surgery, radiotherapy or open surgery in cases of recurrent or residual disease. The treatment is used for local control only. The voice outcomes are good in T1 but unpredictable in T2 disease.
Patients treated with radiotherapy for early laryngeal cancers during the study period were given 55 Gy in 20 fractions over 4 weeks. The radiotherapy clinical target volume includes the whole larynx, and this is expanded by 4 mm to create the planning target volume, with 95 per cent isodose covering the planning target volume. In the event of recurrence, there is a likelihood of subsequent transoral laser surgery or open surgery. Radiotherapy is perceived to have better voice outcomes, but is associated with potentially significant side effects (as mentioned above).
The tumour-related criteria for excluding patients from transoral laser surgery changed during the seven years of data collection. This was a result of the learning curve with carbon dioxide (CO2) laser use within the department, and following evidence presented in the literature and at MDT conferences on laser surgery. We were increasingly able to offer laser resection to patients with anterior commissure or bilateral vocal fold disease (T1b), who were initially directed towards radiotherapy on the grounds of voice preservation.
Transoral laser surgery was not offered if: difficult surgical access was observed at the time of biopsy, which would prevent adequate resection (e.g. prominent incisors, limited neck extension); there was subglottic tumour extension preventing adequate clear margin resections; there was supraglottic tumour extension increasing the risk of nodal metastasis and necessitating neck dissection; there were large areas of field change requiring extensive resection; or patients were unsuitable for prolonged general anaesthesia.
Radiotherapy was not offered if: histological type was radiologically resistant (e.g. spindle cell carcinoma); the patient was unable to lie flat (this is particularly relevant in patient groups with a high incidence of smoking-related lung disease); or there were synchronous primaries that would delay treatment (patients were typically offered transoral laser surgery for a larynx primary, with radiotherapy or surgery for a second primary).
Results
A total of 411 patients with primary laryngeal cancer were seen by the Leeds head and neck MDT between December 2002 and September 2009; 209 patients (51 per cent) had early laryngeal cancer (i.e. T1 or T2 disease, with no nodal metastases). More than half of the patients in our series were aged over 70 years; 6 per cent of patients were aged over 85 years.
Of the 209 patients with T1 or T2 disease, 47.4 per cent (n = 99) were given a choice of treatment, whilst 51.2 per cent (n = 107) were not. Of those given a choice, 59.6 per cent (n = 59) chose transoral laser surgery (p < 0.02, two-tailed test), 35.4 per cent (n = 35) chose radiotherapy and 5.1 per cent (n = 5) opted for open surgery. There was no documentation regarding whether a choice was offered for 1.4 per cent of patients (n = 3).
Of those with T1 or T2 disease, 31.1 per cent (n = 65) underwent laser treatment as their primary treatment modality, 64.6 per cent had radiotherapy (n = 135) and 4.3 per cent (n = 9) were classified as receiving ‘other’ treatment, which included no treatment or open surgery alone.
Of those not offered a choice, 6 were treated with CO2 laser surgery and 97 with radiotherapy. The criteria for excluding one or more treatment modality are described in Tables II and III.
Table II Rationale for only offering transoral laser surgery
Table III Rationale for only offering radiotherapy
*This would require significant resection, which would cause poor voice and increase risk of aspiration.
We do not have detailed pre- and post-swallowing and speech data for all patients in the series; however, we do have a representative cohort from our speech and language therapy records. During the study period, only around one-third of the patients with early laryngeal cancer underwent both pre- and post-operative swallowing and voice assessment by a speech and language therapist because of staffing issues.
All patients presented with hoarseness, but many had an improved voice after the diagnostic biopsy. Our speech and language therapists used the Grade, Roughness, Breathiness, Asthenia, Strain (‘GRBAS’) voice rating scale for the assessments. Following laser resection, our patients were instructed to adhere to one week of voice rest. None of the laser resection patients required enteral feeding, and all were able to eat and drink at discharge (within 48 hours of surgery), indicating no long-term, significant swallowing problems. Tables IV and V show the findings for speech and swallowing quality in those who underwent pre- and post-laser surgery assessments.
Table IV Pre- and post-voice assessment in patients undergoing transoral laser surgery
Data represent percentages of patients. *Telephone conversation is possible; voice may be deeper than normal.
Table V Pre- and post-swallowing assessment in patients undergoing transoral laser surgery
Data represent percentages of patients. PEG = percutaneous endoscopic gastrostomy tube
Discussion
Radiotherapy is the most frequently used treatment for early glottic cancers in the USA, Canada and Northern Europe.Reference Preuss, Cramer, Klussmann, Eckel and Guntinas-Lichius 4 Historically, it was thought to yield better voice outcomes than surgery for early disease.Reference Preuss, Cramer, Klussmann, Eckel and Guntinas-Lichius 4 , Reference Higgins, Shah, Ogaick and Enepekides 5 However, radiotherapy has many disadvantages, such as protracted treatment regimens and significant side effects, including xerostomia, photosensitisation and skin burns. In cases of tumour recurrence, further treatment options are usually limited to surgery. It is widely accepted that many ‘small’ tumours are completely resected during the excisional diagnostic biopsy;Reference Ambrosch 6 hence, there is an inherent risk of over-treatment with radiotherapy.
Transoral laser resection is not appropriate for all patients, but gives equivocal cure rates to radiotherapy and increasingly the evidence points towards similar post-treatment voice quality. A meta-analysis by Feng et al. revealed no significance differences in voice quality following radiotherapy or transoral laser surgery.Reference Feng, Wang and Wen 7 Although voice outcomes may be perceived as better following radiotherapy, a number of studies have found that practically there may be no significant difference when it comes to voice use and after outweighing the co-morbidity associated with radiotherapy.Reference Osborn, Hu, Venkatesan, Nichols, Franklin and Yoo 8 – Reference Abdurehim, Hua, Yasin, Xukurhan, Imam and Yuqin 10 Previous studies have reported the reduced cost of transoral laser resection, with comparable disease-free survival results.Reference Feng, Wang and Wen 7 , Reference Higgins 11 Compared to open surgery, laser resection is associated with reduced post-operative hospital stay, a reduced need for tracheostomy, and reduced physical and psychological trauma.Reference Silver, Beitler, Shaha, Rinaldo and Ferlito 12
The ENT-UK head and neck guidelines recommend that all patients in the UK with early laryngeal cancer be given the choice of radiotherapy or transoral laser surgery where appropriate. (Previous Data for Head and Neck Oncology (‘DAHNO’) reports (seventh and eighth annual reports) have investigated the availability of laser surgery in England and Wales, and there have been no documented reports of where combined modality treatment is offered). To date, there has been no documented series in the UK detailing how choice is offered by individual MDT teams, and we believe we are the first to provide this information.
The latest Data for Head and Neck Oncology report (ninth edition) 13 found wide variation in the practice of radiotherapy versus endoscopic laryngeal resection amongst cancer networks in documented cases of early laryngeal cancer, defined as tumour–nodal stages T1N0 and T2N0. This suggests a bias between networks, with a preference for either radiotherapy or transoral laser surgery. Of 712 early glottic cancer cases covered by the report period, 44.9 per cent received surgery as the primary treatment, whilst 51.6 per cent received radiotherapy as the primary treatment.
Five cancer networks reported using radiotherapy as the primary treatment in more than 60 per cent of cases, 13 including Kent and Medway, at 81.5 per cent. Two networks, Sussex, and Humber and Yorkshire Coast, utilised endoscopic surgery in 66.7 per cent of early laryngeal cancer cases. Rates of radiotherapy use varied between 0 and 81.5 per cent in documented cases, with a median of around 42.2 per cent in England and Wales. The use of endoscopic primary surgical treatment varied between 0 and 66.7 per cent in England and Wales, with a median of 29.4 per cent. In the Yorkshire and Humber region, endoscopic surgery represented 66.7 per cent of all primary treatment for early laryngeal cancer. 13
This study has shown that when appropriate and given the choice, more patients choose transoral laser surgery over radiotherapy. All patients in the study were seen by both the clinical oncologist and head and neck surgeon, and were given an unbiased, fair and balanced choice. The national Cancer Patient Experience Survey does not specifically refer to patient choice regarding treatment options; however, the results from 2010/2011 and 2011/2012 showed excellent results with regard to patient satisfaction with treatment at our centre. 14 Initially, we could not offer all patients laser surgery, and more patients were excluded at the beginning of the study period. As experience with laser surgery grew within the department, an increasing number of patients were given the choice of treatments.
We believe we are the first centre to provide current findings regarding treatment choice in head and neck oncology. We think it is important that cancer centres offer treatment choice. Our patients were able to form a choice when given the opportunity. Most patients chose laser surgery; patient preferences were based mainly on the offer of a single day of treatment, rather than four to six weeks. Others that chose radiotherapy were often told by the referring physician that they would undergo this course of treatment and hence this was their expectation.
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• The UK Cancer Plan (2000) advocates more patient choice in the management of cancer
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• Patients with early laryngeal cancer have multiple treatment options
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• Transoral laser microsurgery and radiotherapy are considered appropriate, effective treatments for early laryngeal cancer
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• To date, there have been no published data examining patient preference of treatment for this condition
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• This study shows that when offered the choice, patients can make balanced decisions on treatment options
Anecdotal evidence suggests that both surgeons and clinical oncologists underrepresent the side effects of the treatment they offer. We therefore felt that having a representative of each treatment speak to patients at the same time would provide a more balanced view. Clinical nurse specialists in head and neck cancer involved in the management of such patients seemed to agree with this.
We were unable to identify any published studies examining patient choice in the treatment of glottic cancer. We found documented evidence of patient choice in stage D prostate cancer when the outcomes of different treatment modalities were similar.Reference Cassileth, Soloway, Vogelzang, Schellhammer, Seidmon and Hait 15 The patients in that study were able to formulate choice when given the option.
At present in the UK, most early laryngeal cancers are treated by radiotherapy and 18 per cent 13 are treated with laser. Nationally, UK surgeons are treating around one-third of such cancers with laser surgery. Most patients are not given a choice. We appreciate that surgical experience is necessary in order to offer patients the choice of treatment.
Acknowledgements
The senior author would like to thank our head and neck consultant clinical oncologist colleagues, Drs Catherine Coyle, Dan Ash (now retired) and Mehmet Sen, who agreed with the philosophy of patient choice and thus facilitated our laser surgery practice.
