Background: Laryngeal cancer accounts for roughly 3-4% of all newly diagnosed malignancies in the United States each year. Treatment paradigms for both early and advanced stage laryngeal cancer have shifted significantly toward non-surgical, organ sparing approaches, which utilize external beam radiotherapy (EBRT) with or without chemotherapy. As a result, the burden on patients is extensive, with treatment requiring daily visits for radiation, weekly visits for chemotherapy, and close follow up and surveillance. For patients who are under- or uninsured and may have limited financial means and family support, these requirements can pose a significant challenge.
Objective: We sought to evaluate laryngeal cancer treatment delivery and clinical outcomes in a large population of under- and uninsured patients treated within a large metropolitan area.
Methods: Ben Taub Hospital (Harris Health System, HHS) serves the under- and uninsured residents of Harris County, the third largest county in the United States. All patients are discussed at bimonthly multi-disciplinary tumor board meetings and are offered NCCN compliant treatment recommendations. Surgical and non-surgical treatment (EBRT, chemotherapy) is available within HHS and is delivered by physicians affiliated with the Baylor College of Medicine. In this retrospective review we examined treatment delivery and oncologic outcomes for laryngeal cancer patients diagnosed and treated between 2005 and 2015.
Results: We identified 233 patients who were diagnosed and/or received their treatment within HHS, with a mean follow up of 3.4 years. Of these, 43% presented with T4 tumors (T3- 28%, T2-16%, T1-12%). Cervical metastasis at the time of diagnosis was present in 45% of patients, and distant metastasis was present in 3% of patients. Approximately 42% of patients were treated with total laryngectomy, followed by adjuvant radiation in 34% and adjuvant chemo-radiation in 13% of patients, respectively. Primary radiation was offered to 44% of patients. All-cause mortality was 40%, while the average time from diagnosis to death was approximately 2 years. Nearly 25% of patients did not receive curative intent treatment; 7% of patients refused curative intent treatment or did not return for treatment initiation. An additional 25% of patients were unable to complete the prescribed treatment course or refused treatment completion. Over 90% of patients designated to undergo induction chemotherapy were unable or unwilling to complete the prescribed course of chemotherapy. Initiation of adjuvant radiation within the recommended 6-week interval, and completion of treatment package within 100 days of initiation occurred in only 7% of patients. In contrast time from diagnosis to curative intent surgical intervention was relatively rapid (mean 27days, median 10days).
Conclusions: Under- and uninsured patients often present with advanced laryngeal disease. Although surgical treatment can be initiated in a timely fashion, delivery of multi-modality treatment for advanced disease remains challenging. The ability to complete the prescribed course of chemo-EBRT, particularly for patients with advanced disease, remains low, despite resource availability. Prospective studies are required to determine whether delivery of chemo-EBRT for advanced laryngeal disease in this patient population can be optimized.