Combo Therapy Can Save Larynx

Chemo and radiation best chance to save voice box in treating laryngeal cancer

WEDNESDAY, Nov. 26, 2003 (HealthDayNews) -- Administering chemotherapy and radiation at the same time to people who have laryngeal cancer provides the best chance of saving the larynx or voice box.

That's the conclusion of a study appearing in the Nov. 27 issue of the New England Journal of Medicine. Researchers found the combination proved superior both to chemotherapy followed by radiation and to radiation alone.

But this powerful therapy does come with a high price in terms of side effects.

"If you want to keep your larynx, this is the best way. But on the other hand, you're going to suffer," says Dr. Herman Kattlove, medical editor at the American Cancer Society.

However, patients facing the ravages of this type of cancer seem to think it's worth it, experts say they've found.

"I think that there's no question that the patients view it as worthwhile, mainly because it is by-and-large reversible," says Dr. Arlene Forastiere, the lead author of the study and an oncology professor at Johns Hopkins' Sidney Kimmel Cancer Center in Baltimore.

Each year, 9,500 Americans are diagnosed with laryngeal cancer and 3,800 people die of it.

Small tumors can be treated with radiation or surgery without loss of voice. More advanced tumors have proved more difficult to treat without losing the larynx.

Until the early 1990s, those advanced tumors, which extended beyond the actual vocal cords, were usually treated by removing the larynx (and thus the voice) followed by radiation.

In 1991, the treatment landscape changed dramatically when a clinical trial by the U.S. Department of Veterans Affairs found that chemotherapy followed by radiation was just as effective and managed to preserve the larynx in about two-thirds of the cases. That is now the standard therapy.

The current study has gone a step further by comparing three different therapies head-to-head: chemotherapy followed by radiation; chemotherapy concurrent with radiation; and radiation alone. In all, 547 patients were randomized to one of the three groups and were followed for a median of about four years to see if the larynx could be saved.

After two years, 88 percent of patients who had had radiation and chemo concurrently still had an intact larynx, compared to 75 percent in the group that received chemo followed by radiation and 70 percent in the group that received radiation alone.

Although both of the chemotherapy-based regimens helped control the spread of cancer, overall survival rates were similar in all three groups (about 75 percent at one year and about 55 percent at two years). Many patients with laryngeal cancer have other risk factors, however, such as smoking and drinking, which could affect their survival.

"They may have died from something else," Kattlove says. "These people are sick. They have been through all this chemo, radiation, they're malnourished because they can't eat or swallow very well. They're smokers, usually heavy drinkers. These aren't 30-year-old Olympic athletes."

In fact, patients in the group that received chemo and radiation at the same time had a harder time swallowing a year after the treatment.

Individuals receiving chemotherapy had higher rates of toxic effects (81 percent for the concurrent and 82 percent for the sequential) than those receiving radiation (61 percent). Individuals receiving the concurrent treatment had twice the frequency of mouth sores than the other two groups. "Think of your worst oral sore and double it. That's what they had," Kattlove says.

"There was definitely more toxicity, mouth sores, redness to the throat and mouth, and skin reaction," Forastiere adds. "These are things that are reversible but uncomfortable."

The patients are supported with pain medication and most have a tube in the stomach to provide nutrition, Forastiere says.

An editorial appearing in the same issue of the New England Journal of Medicine recommends concurrent therapy and if that can't be tolerated, radiation alone rather than chemo followed by radiation.

"What we did learn that was important was that giving chemo in sequence with radiation really was no better than giving radiation," Forastiere says. Radiation, however, carries a higher risk than the concurrent therapy of eventually needing to have the larynx removed.

The concurrent therapy, she adds, "is not an easy treatment by any means, and that's why we also feel very strongly that if a person isn't strong enough to take this on or they just don't have the support system at home, we recommend radiation alone. The concurrent therapy is an alternative."

More information

The National Cancer Institute has more on cancer of the larynx, as does the University of Maryland.

SOURCES: Arlene Forastiere, M.D., professor of oncology, Johns Hopkins' Sidney Kimmel Cancer Center, Baltimore; Herman Kattlove, M.D., medical editor, American Cancer Society, Los Angeles; Nov. 27, 2003, New England Journal of Medicine
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