Black patients with laryngeal cancer are less likely to get larynx preservation treatments than white patients, a new study shows (Archives of Otolaryngology -- Head & Neck Surgery, July 2012, Vol. 138:7, pp. 644-649).
Although the use of nonsurgical larynx preservation therapy seems to be increasing, racial disparities continue to exist, most notably among black patients with stage IV disease, according to researchers at the University of California, Davis and the Memorial Sloan-Kettering Cancer Center.
Approximately 12,000 cases of laryngeal cancer are diagnosed in the U.S. annually, the study authors noted. Historically, the standard of care for patients with locally advanced laryngeal cancer consisted of total laryngectomy followed by adjuvant radiation therapy.
However, a 1991 study demonstrated that when compared with total laryngectomy followed by adjuvant radiation, the use of radiation therapy in patients who responded to induction chemotherapy conferred a high rate of larynx preservation without compromising survival (New England Journal of Medicine, June 13, 1991, Vol. 324:24, pp. 1685-1690).
In 2003, another study in the New England Journal of Medicine demonstrated that concurrent chemoradiation is superior to induction chemotherapy, followed by radiation or radiation alone for larynx preservation (November 27, 2003, Vol. 349:22, pp. 2091-2098).
These studies have resulted in the wide acceptance of larynx preservation using radiation therapy with concurrent chemotherapy as the initial treatment for locally advanced laryngeal cancer, with total laryngectomy reserved for salvage therapy, the researchers noted.
For this study the researchers used the Surveillance Epidemiology and End Results (SEER) database to identify white, black, Hispanic, and Asian patients with stage III and IV laryngeal cancers diagnosed during 1991 through 2008. A total of 3,862 patients met their selection criteria, including 2,808 white patients, 648 black patients, 287 Hispanic patients, and 119 Asian patients.
The mean age of the patient population was 63 years. The racial distribution was 72.7% white, 16.8% black, 7.4% Hispanic, and 3.1% Asian. Male patients composed 73.9% of the study population.
Patients predominantly had T3 disease (64.4%), followed by T2 (24.2%) and T1 diseases (11.4%). The majority (79.0%) of patients received larynx preservation as the initial treatment strategy. More than 90% received radiation as a component of their cancer treatment with no significant differences among racial/ethnic groups (p = 0.69).
Racial disparities evident
However, black patients were less likely to undergo larynx preservation than white patients: Among white patients, 2,254 (80.3%) had larynx preservation, while among black patients, 483 (74.5%) had larynx preservation. The odds ratios for Hispanic and Asian patients to receive larynx preservation were not significantly different from that of white patients.
Larynx preservation was less likely among those with stage IV disease and in black patients. It was also less common in patients with T2 or T3 disease.
The researchers offered several possible explanations for their findings:
- Larynx preservation therapy involves an intensive and prolonged course of radiation therapy with chemotherapy, and physicians may deem a patient unreliable to complete radiation therapy and recommend surgical options.
- Lack of health literacy may prevent a patient from full comprehension of management options.
- Patients may decline radiation therapy if they are unable to complete treatment due to lack of social or familial support.
- Racial disparities in referral to oncology specialists can contribute to the difference.
- Other social factors including financial barriers, health insurance, and transportation may potentially influence treatment modalities available to patients.
However, racial differences in treatment may be decreasing, the study authors noted.
"Following the trend within the general population, the use of larynx preservation has also increased among black patients over time, and our data suggest that the observed racial disparity may in fact be narrowing," they wrote.
Quality of life
The study's results are noteworthy, the researchers pointed out, because larynx preservation with chemoradiation therapy has been shown to improve quality of life by retaining a functional larynx.
"Patients treated with total laryngectomy experience worse social functioning and isolation from speech impairment and body disfigurement," they wrote. Thus, "choice of initial therapy (total laryngectomy versus radiation therapy) has a dramatic impact on post-therapy quality of life."
Although nonsurgical larynx preservation therapy appears to be increasing among the general population, racial disparities remain, most notably among black patients with stage IV disease, the researchers noted.
"Acknowledging that socioeconomic and nonethnicity-related variables have the potential to confound our observed findings, we believe that future research should focus on identifying and eliminating barriers to the use of larynx preservation for all medically suitable patients, with a particular focus on black patients with stage IV disease," they concluded.
