Background: Despite recommendations for upfront total laryngectomy (TL), many patients with cT4a laryngeal cancer (LC) instead undergo definitive chemoradiation, which is associated with inferior survival. Sociodemographic and oncologic characteristics associated with TL utilization in this population are understudied. Methods: This retrospective cohort study utilized hospital registry data from the National Cancer Database to analyze patients diagnosed with cT4a LC from 2004 to 2017. Patients were stratified by receipt of TL, and patient and facility characteristics were compared between the two groups. Logistic regression analyses and Cox proportional hazards methodology were performed to determine variables associated with receipt of TL and with overall survival (OS), respectively. OS was estimated using the Kaplan–Meier method and compared between treatment groups using log-rank testing. TL usage over time was assessed. Results: There were 11,149 patients identified. TL utilization increased from 36% in 2004 to 55% in 2017. Treatment at an academic/research program (OR 3.06) or integrated network cancer program (OR 1.50), male sex (OR 1.19), and Medicaid insurance (OR 1.31) were associated with increased likelihood of undergoing TL on multivariate analysis (MVA), whereas age > 61 (OR 0.81), Charlson–Deyo comorbidity score ≥ 3 (OR 0.74), and clinically positive regional nodes (OR 0.78 [cN1], OR 0.67 [cN2], OR 0.21 [cN3]) were associated with decreased likelihood. Those undergoing TL with post-operative radiotherapy (+/− chemotherapy) had better survival than those receiving chemoradiation (median OS 121 vs. 97 months;p= 0.003), and TL + PORT was associated with lower risk of death compared to chemoradiation on MVA (HR 0.72;p= 0.024). Conclusions: Usage of TL for cT4a LC is increasing over time but remains below 60%. Patients seeking care at academic/research centers are significantly more likely to undergo TL, highlighting the importance of decreasing barriers to accessing these centers. Increased focus should be placed on understanding and addressing the additional patient-, physician-, and system-level factors that lead to decreased utilization of surgery.
背景：尽管指南推荐对cT4a期喉癌患者行前期全喉切除术，但许多患者仍选择根治性放化疗，而后者与较差的生存率相关。目前针对该人群接受全喉切除术的社会人口学及肿瘤学特征相关因素研究尚不充分。方法：本回顾性队列研究利用美国国家癌症数据库的医院登记数据，分析了2004年至2017年诊断为cT4a期喉癌的患者。根据是否接受全喉切除术对患者进行分层，并比较两组间的患者特征和医疗机构特征。采用逻辑回归分析和Cox比例风险模型分别评估与接受全喉切除术及总生存期相关的变量。使用Kaplan-Meier法估计总生存期，并通过时序检验比较治疗组间的差异。同时评估了全喉切除术随时间推移的使用趋势。结果：共纳入11,149例患者。全喉切除术使用率从2004年的36%上升至2017年的55%。多变量分析显示，在学术/研究型医疗机构（OR 3.06）或综合网络癌症诊疗机构（OR 1.50）接受治疗、男性（OR 1.19）及享有医疗补助保险（OR 1.31）与更高的全喉切除术实施可能性相关；而年龄>61岁（OR 0.81）、Charlson-Deyo合并症评分≥3分（OR 0.74）以及临床区域淋巴结阳性（cN1期OR 0.78，cN2期OR 0.67，cN3期OR 0.21）则与较低的实施可能性相关。接受全喉切除术联合术后放疗（±化疗）的患者比接受放化疗的患者生存期更长（中位总生存期121个月 vs 97个月；p=0.003），多变量分析显示全喉切除术联合术后放疗相较于放化疗可降低死亡风险（HR 0.72；p=0.024）。结论：cT4a期喉癌的全喉切除术使用率随时间推移逐渐上升，但仍低于60%。在学术/研究型医疗机构就诊的患者接受全喉切除术的可能性显著更高，这凸显了降低此类医疗中心就医壁垒的重要性。未来应更深入地理解和解决导致手术使用率降低的患者层面、医师层面及系统层面的多重因素。
Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer
肿瘤(癌症)患者之家