Palliative radiotherapy for patients with advanced laryngeal cancer: A case sharing
Laryngeal cancer is one of the most common types of head and neck cancers worldwide, with 5-year survival rates as high as 80%-90% for patients with early-stage tumors (i.e., stage I or II), and decrease sharply to 40% among those at advanced stage.1,2 Multimodal therapy combining surgery, radiotherapy and/or chemotherapy is often necessary for patients with advanced disease (i.e., stage III or IV).2 Certain patients such as the elderly may not be able to tolerate standard therapy well.2,3 However, these patients may need palliative treatment, which aims to improve their quality of life (QoL) and provide symptom relief.4 In this interview with Omnihealth Practice, Dr. Choy, Tim-Shing discussed the use of palliative radiotherapy among elderly patients with advanced laryngeal cancer and shared a clinical case todemonstrate its real-world applications.
Advance in laryngeal cancer treatment
Laryngeal cancer is a challenging disease to manage since there can be many debilitating impairments caused by the tumor, affecting breathing, speech, and swallowing.2 In recent decades, laryngeal cancer management has evolved from radical surgery followed by radiotherapy or chemoradiotherapy to a more conservative surgical approach such as endoscopic resection or open partial laryngectomy, with the aim of preserving laryngeal function and improving QoL, without sacrificing survival rates.2 With modern treatment approaches, patients in whom laryngeal cancer was diagnosed early could achieve high cure rates of 80%-90%.2
Unmet needs in the elderly laryngeal cancer patients
Elderly patients with laryngeal cancer aged ≥80 years are typically associated with lower 5-year survival rates at around 58%.4 These patients may have difficulty tolerating standard treatment. For such patients, treatment with curative intent is associated with significant treatment-related toxicity, impairing their QoL.5 Indeed, the use of supportive measures, also known as palliative care, may be more appropriate. Palliative care takes an approach aiming to prevent suffering of patients by relieving their symptoms and maintaining QoL.4 The common forms of care in this setting include pain management with analgesic medications, controlling airway secretions and tracheostomy for airway protection, as well as feeding tube placement for nutritional supplementation.5 For certain patients, palliative tumor-directed radiation therapy is a viable treatment option for improving cancer-related symptoms and minimizing suffering as much as possible.5
Palliative radiotherapy for symptomatic relief and improvement of QoL
Many studies have demonstrated the effectiveness of palliative radiotherapy among patients with advanced head and neck cancers, in terms of improving speech, swallowing, breathing, pain, bleeding, and symptoms from tumor ulceration.5 When compared with radiotherapy, which is often delivered with chemotherapy (as it is often the case in active treatment), palliative radiotherapy aims to administer relatively lower doses to avoid severe side effects, while still achieving sufficient control of symptoms.5 In short, maintaining a delicate balance is the key consideration when it comes to the selection of treatment regimen for these patients. In this article, Dr. Choy shared a clinical case to demonstrate the effectiveness of palliative radiotherapy and discussed the practical considerations involved.
Local case sharing
A 91-year-old man with type II diabetes, hypertension, and Alzheimer’s disease developed a hoarse voice in April 2021. Initial laryngoscopy showed the presence of a vocal cord polyp, the hoarseness worsened over time, and with coughing up of blood (hemoptysis). In November 2021, further examination by laryngoscopy identified a large lesion which had grown beyond the larynx into the thyroid cartilage, highly suggestive of a vocal cord tumor. The patient’s right vocal cord retained some mobility, but the left cord had become immobile, limiting his ability to speak. Although the tumor had not spread to the lymph nodes, the patient was classified as having stage IVa laryngeal cancer (i.e., advanced stage), according to the American Joint Committee on Cancer (AJCC) Staging System (8th edition).
Given the patient’s advanced age and comorbidities, he was considered unable to tolerate surgery or full-course radiotherapy. Therefore, palliative fractionated radiotherapy was adopted and performed in January 2022 to alleviate his hemoptysis and breathlessness. A total of 10 fractions were administered, and bleeding from the suspected tumor stopped. Other symptoms such as throat discomfort and tightness improved as well. Overall, the patient tolerated the treatment well and only experienced short-term difficulties with swallowing.
About 5 months later, the tumor recurred further in the patient’s neck. Nevertheless, it was suggested to proceed with palliative radiotherapy to ensure continual control of symptoms.
Palliative management of elderly patients with advanced laryngeal cancer is a considerable challenge to clinicians, given the complexity and severity of most symptoms. Although literature supports the use of radiotherapy in the palliative setting, there is still no international consensus to guide the selection of appropriate treatment regimens for individual patients. The currently available regimens vary in the doses from 2,000-7,000cGy in 3-20 fractions and treatment length varies from 3-day to conventional 7-week courses.5 Clinicians are advised to select a regimen based on the patient’s prognosis.5 Other factors, including performance status, comorbidities, disease burden and the risk of radiotoxicity should also be considered.5
The National Comprehensive Cancer Network (NCCN) guidelines recommend the use of the QUAD shot regimen (4,440cGy in 12 fractions over 3 cycles, with each cycle separated by 2-3 weeks) for patients with limited life expectancy.5,6 Specifically, symptomatic patients with a poor prognosis of less than 4 months can benefit from this regimen for symptom palliation with lower risk of toxicity.5 Patients with satisfactory responses to the initial cycle of QUAD shot may proceed with additional cycles.5
A conventional palliative course of 2,000cGy in 5 fractions could be beneficial to patients with an intermediate prognosis of 4-12 months, allowing for treatment completion within a relatively short period of time, in addition to offering tumor and symptom control with less toxicity than higher-dose regimens.5
For patients with a prognosis of more than 1 year, a protracted regimen of 7,000cGy in 35 fractions may be appropriate so as to achieve aggressive palliation.5 Other regimens including QUAD shot and 3,000cGy in 10 fractions may also be used, but these regimens are less likely to produce persistent responses, and additional treatments may be required in the future.5
Comorbidities and advanced age may render patients with advanced laryngeal cancer ineligible for the standard multimodal treatment, thus limiting their potential for cure. These patients require supportive care to minimize their suffering and maintain QoL, and palliative radiotherapy is a viable option. A cautious selection of radiotherapy regimen is warranted to achieve optimal outcomes given each patient’s clinical circumstances.