“One of the most important changes in our tumor board that’s occurred over the last decade or so is we bring patients to tumor board who have failed, who have persistent, recurrent disease,” he said. It was, in part, a practical consideration, he added, because patients would ask the surgeon, who would say that no more surgery should be done; then they would see the radiation therapist, who would say there were no more options. This way, everyone is talking about a case together.
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June 2015
The collaboration is how we really improve care for our patients.—Carol Bradford, MD
“The patients and their families need to be part of the decision to treat,” he said. “The elephant in the room is this business of treating people with interventions that are potentially harmful, which you just can’t expect to work. The patient needs to understand the potential for harm. We need to recognize this and move on to symptom relief.”
“There are patients who we see every week who can’t be helped by any [non-palliative] intervention. And this is the intervention that helps: Somebody should help at home. Somebody should help them with their nutritional needs and their pain needs and their anxiety needs…. It is so essential to multidisciplinary care.”
Total Laryngectomy
Cherie-Ann Nathan, MD, professor and chair of the department of otolaryngology-head and neck surgery at Louisiana State University in Shreveport, called total laryngectomy “the most feared surgical procedure.” A team approach to the care of patients who face this procedure is vital, with surgery, radiation, oncology, pathology, nursing, social work, tobacco cessation, nutrition, speech, and swallow rehabilitation all represented, she said.
The choice of laryngeal preservation or laryngectomy should involve a variety of factors, she said. Her group’s research has found that tumor size, co-morbidities, and malnutrition are independent significant risk factors for disease recurrence in patients who undergo chemo-radiotherapy for laryngeal squamous cell carcinoma (Laryngoscope. 2012;122:565-571).
In a study published this year, patients at her center had better overall survival compared with those in the National Cancer Data Base, even though her center’s patient population had inferior socioeconomic factors and more advanced tumor stage (JAMA Otolaryngol Head Neck Surg. 2015;141:169-173). “We believe that this was because we continued to perform total laryngectomies for T4 disease patients,” Dr. Nathan said.
“Laryngeal preservation [should be chosen] only if it offers improved function and quality of life without compromising survival,” she said. Selection should depend on patient factors and co-morbidities, local expertise, and support and rehab services, she added.