Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Program Number: AHNS35
Session Name: Scientific Session 7 - HPV-negative Mucosal Disease
Session Date: Thursday, May 15, 2025
Session Time: 3:15 PM - 4:15 PM
Trends in Initial Management of T4 Laryngeal Squamous Cell Carcinoma
Annie J Orr, MD1; Michael C Topf, MD, MSCI2; Robert P Zitsch III, MD1; Patrick T Tassone, MD, MSAM, FACS1; 1University of Missouri; 2Vanderbilt University Medical CenterIntroduction: Patients with locally advanced laryngeal squamous cell carcinoma may be treated with either upfront surgery or definitive non-surgical therapy. Initial non-surgical management was widely adopted after the landmark VA and 91-11 trials. Later analyses, however, suggested a survival benefit with upfront surgery for patients with T4 primary tumors. It is not well studied whether initial treatment has changed over time, factors associated with initial treatment type, or whether initial treatment type is associated with survival.
Methods: The National Cancer Database (NCDB) was used to identify initial management strategy for patients with cT4 laryngeal squamous cell carcinoma from 2004 to 2019. Relationship between initial management and year as well as 2-year overall survival and year were compared by Mann-Kendall test. Logistic regression was used to identify factors associated with upfront surgery. Cox proportional hazard analysis was used to examine associations between patient and treatment factors with overall survival.
Results: In total, 11,626 patients were included. Over the entire study period, 52.7% of patients underwent upfront surgery, and this proportion increased significantly over time from 45.6% in 2004 to 63.5% in 2019 (Kendall’s tau 0.78, p<0.001). Two-year overall survival improved over the study period, from 55.4% in 2004 to 69.7% in 2018 (Kendall’s tau 0.85, p<0.001). On multivariable analysis, upfront surgery was associated with younger age (OR 0.99 / year, 95% CI 0.99-1.00, p=0.007), male sex (OR 1.31, 95% CI 1.19-1.45, p<0.001), academic center treatment (OR 2.41, 95% CI 2.23-2.61, p<0.001), Medicaid insurance (OR 1.24, 95% CI 1.11-1.38, p<0.001), later year of diagnosis (OR 1.06 / year, 95% CI 1.05-1.07, p<0.001), and less advanced N stage disease (N3 vs. N0 OR 0.19, 95% CI 0.15-0.25). Improved overall survival was independently associated with upfront surgical treatment (HR 0.77, 95% CI 0.74-0.81, p<0.001) on multivariable analysis controlling for age, sex, race, facility type, insurance status, year of diagnosis, and N stage.
Conclusion: From 2004 to 2019, an increasing proportion of patients with T4 laryngeal squamous cell carcinoma have been treated with upfront surgery, which has been accompanied by an increase in overall survival. Patient selection and shared decision making are important when considering treatment modality for locally advanced laryngeal cancer, however upfront surgery likely offers improved oncologic outcomes in patients with T4 disease.
Figure 1: Mann-Kendall test demonstrating proportion of patients with T4 laryngeal squamous cell carcinoma treated with upfront surgery increased from 2004-2019 (Kendall's tau 0.78, p<0.001).
Figure 2: Mann-Kendall test demonstrating 2-year overall survival of patients with T4 laryngeal squamous cell carcinoma increased from 2004-2018 (Kendall's tau 0.85, p<0.001).