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Concurrent Chemotherapy and Radiation Best for Cancer of the Vocal Cords

Researchers have found that giving chemotherapy along with radiation to patients with cancer of the vocal cords gives those patients their best chance for keeping their voice. The study, published in the New England Journal of Medicine (Vol. 349, No. 22: 2091-2098) reported on results with 518 patients.

Cancer of the vocal cords, or larynx, affects about 9,500 Americans each year. If caught early, it can be treated with radiation and often cured. More advanced cancers often require surgery. But surgery to remove the cancer leaves a person voiceless and breathing through an opening made in the neck.

To avoid this, doctors have used chemotherapy and radiation instead of surgery. This has led to about two-thirds of patients keeping their larynxes with no drop in their cure rate. But it wasn't clear if it was the radiation or the chemotherapy or the combination that was important.

In this study, the researchers divided patients with advanced cancers of the larynx into three groups: One group received only radiation therapy, a second received chemotherapy followed by radiation, and the third group received the chemotherapy and radiation therapy at the same time. The researchers were careful to screen out patients with tumors too big to be helped by this treatment.

After their treatment, patients were followed an average of almost four years. If the cancer wasn't completely destroyed by the treatment or came back, then they would need surgery.

By two years, it was clear that the best results were seen in patients given the chemotherapy and radiation at the same time. Eighty-eight percent of these people were able to avoid surgery. Patients who received chemotherapy followed by radiation had a no-surgery rate of 75%; only 70% of those who had radiation alone did not require surgery.

Another benefit of the chemotherapy was that it reduced the chance that the cancer would come back in a distant site. Patients who received only radiation therapy had a 16% distant recurrence rate, compared to 8%-9% for the groups that received chemotherapy. It didn't make any difference if the chemotherapy was given before or along with the radiation.

But the people who had the concurrent radiation and chemotherapy had more severe side effects. The treatment is very toxic to the mouth and throat. Twice as many of these patients had severe mouth and throat sores compared to the other two groups. Also, by the end of the first year, they weren't able to swallow as well. One-fourth of them needed to eat a diet of soft food or liquids, and a small number were unable to swallow at all. This was less of a problem for patients in the other groups.

By the end of two years, though, all the groups were equal in their swallowing problems, with about 15% in each group unable to take a normal diet.

Overall survival also was the same in all three groups. Nearly half the patients were expected to die by five years. It isn't clear, though, what were the causes of death.

But in an accompanying editorial, cancer experts pointed out that patients with cancer of the larynx are often heavy smokers and drinkers. Such patients may have poorer survival due to other conditions, such as heart disease or other cancers.

Even though survival didn't improve, the editorialists say that treatment to preserve the larynx ? and thus, the voice -- is "a realistic and feasible option" for most patients with intermediate or late-stage cancer.

The study authors say concurrent chemotherapy and radiation should be considered standard care for patients who want to save their voice.