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ASCO convened a multidisciplinary Expert Panel to develop a clinical practice guideline for treatment of laryngeal cancer, with the intent of preserving the larynx itself or its function (J Clin Oncol 24:3693-3704, 2006). The Panel conducted a review of the pertinent literature available through November 2005.
The ASCO Expert Panel summarized larynx-preservation treatment strategies by T-stage using the TNM system of the AJCC Cancer Staging Manual (6th edition). Based on available evidence, the larynx-preservation guideline is most applicable to supraglottic and glottic tumors. The guideline focuses only on invasive laryngeal cancers with squamous cell carcinoma histology, which represent more than 95% of laryngeal cancers. Table 1 presents a summary of treatment strategies, and Table 2, a summary of the guideline recommendations.
In 2005, it was estimated that approximately 9,880 new cases of laryngeal cancer would be diagnosed in the United States and account for 3,770 deaths. Given the fundamental role the larynx plays in human speech and communication, determining the optimal management of laryngeal cancers must involve consideration of both survival and the functional consequences of a given treatment approach. Larynx-preservation options include radiation therapy, chemoradiation therapy, and function-preserving partial laryngectomy procedures. Total laryngectomy is widely recognized as one of the surgical procedures most feared by patients. Social isolation, job loss, and depression are common sequelae. When total laryngectomy (either for primary therapy or as salvage treatment) is the recommendation, the potential morbidity of curative treatment is a special consideration. Effective application of larynx-preservation treatment requires special expertise and a specialized support team. A typical treatment team will include expertise in head and neck surgery, radiation therapy, medical oncology, pathology, nursing, speech and swallowing physiology/rehabilitation, audiology, social services, nutrition, tobacco cessation, and management of relevant medical comorbidities.
The Panel emphasized the results of randomized controlled trials that included larynx cancer only. Also considered were site-specific, single-arm studies and randomized trials that were not disease site–specific but that included patients with laryngeal cancer. Overall survival, rates of disease control and larynx preservation, and treatment toxicities were the primary outcomes assessed, as these were the end points most commonly provided in the clinical studies reviewed. With larynx-preservation therapies, however, rates of local control and larynx preservation are intermediate and imperfect markers for the more fundamental end points of treatment success: speech and swallowing function and quality of life. Despite improvement in these outcomes being a central goal of larynx-preservation therapy, more rigorous, site-specific data regarding functional and quality-of-life outcomes in this setting, derived from studies in which the compared therapies were randomly assigned, are limited. More information on the impact of therapy on symptoms, quality of life/function, and costs are needed.
The 2006 abridged guideline is available in the August 1, 2006, print edition of the JCO and also at http://www.jco.org; (J Clin Oncol 24:3693-3704, 2006, and published online ahead of print July 10, 2006). In addition to the abridged and unabridged (available online at http://www.asco.org/guidelines/larynx) full-text versions of the guideline recommendations, further resources from ASCO include a patient guide and PowerPoint slide set.
It is important to realize that many management questions have not been comprehensively addressed in randomized trials and guidelines cannot always account for individual variation among patients. A guideline is not intended to supplant physician judgment with respect to particular patients or special clinical situations and cannot be considered inclusive of all proper methods of care or exclusive of other treatments reasonably directed at obtaining the same results.
Accordingly, ASCO considers adherence to this guideline to be voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. In addition, the guideline describes administration of therapies in clinical practice; it cannot be assumed to apply to interventions performed in the context of clinical trials, given that clinical studies are designed to test innovative and novel therapies in a disease and setting for which better therapy is needed. Because guideline development involves a review and synthesis of the latest literature, a practice guideline also serves to identify important questions for further research and those settings in which investigational therapy should be considered.
ASCO Clinical Practice Guideline for the Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer was developed and written by David G. Pfister, Scott A. Laurie, Gregory S. Weinstein, William M. Mendenhall, David J. Adelstein, K. Kian Ang, Gary L. Clayman, Susan G. Fisher, Arlene A. Forastiere, Louis B. Harrison, Jean-Louis Lefebvre, Nancy Leupold, Marcy A. List, Bernard O. O'Malley, Snehal Patel, Marshall R. Posner, Michael A. Schwartz, and Gregory T. Wolf.