Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer.
Factors Associated with Total Laryngectomy Utilization in Patients with cT4a Laryngeal Cancer.
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DOI：
10.3390/cancers15225447
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发表时间：
2023-11-16
期刊：
影响因子：
5.2
通讯作者：
Mitchell, Darrion
中科院分区：
文献类型：
--
作者：
Ritter, Alex R.;Yildiz, Vedat O.;Koirala, Nischal;Baliga, Sujith;Gogineni, Emile;Konieczkowski, David J.;Grecula, John;Blakaj, Dukagjin M.;Jhawar, Sachin R.;Vankoevering, Kyle K.;Mitchell, Darrion
全喉切除术（TL）联合术后放疗（PORT）被推荐用于临床晚期（cT 4a）喉癌患者，与非手术放化疗治疗相比，其结局具有上级优势。尽管如此，许多诊断为喉癌的患者并没有接受TL作为其治疗过程的一部分，这使他们处于较差的肿瘤学结局的风险中，并且与在这种情况下使用TL相关的因素仍然知之甚少。因此，这项利用国家癌症数据库（NCDB）的观察性队列研究的目的是阐明与cT 4a喉癌患者中TL利用相关的患者和治疗机构特征，并评估其使用如何随时间变化。背景资料：尽管建议进行前期全喉切除术（TL），但许多cT 4a喉癌（LC）患者反而接受了明确的放化疗，这与较差的生存率相关。社会人口学和肿瘤学特征与TL利用在这一人群中的研究不足。研究方法：这项回顾性队列研究利用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cT 4a LC的患者。患者按接受TL进行分层，并比较两组之间的患者和机构特征。采用Logistic回归分析和考克斯比例风险法分别确定与接受TL和总生存期（OS）相关的变量。使用Kaplan-Meier方法估计OS，并使用对数秩检验比较治疗组之间的OS。评估了TL随时间推移的使用情况。结果：共有11，149名患者被确定。TL利用率从2004年的36%上升到2017年的55%。在学术/研究项目中的治疗（OR 3.06）或综合网络癌症计划（OR 1.50），男性（OR 1.19）和医疗保险多变量分析（MVA）显示，年龄> 61岁（OR 1.31）的患者发生TL的可能性增加，（OR 0.81）、Charlson-Deyo合并症评分≥ 3（OR 0.74）和临床阳性区域淋巴结（OR 0.78 [cN 1]、OR 0.67 [cN2]、OR 0.21 [cN 3]）与可能性降低相关。接受TL+术后放疗（+/−化疗）的患者的生存率高于接受放化疗的患者（中位OS 121 vs. 97个月; p = 0.003），与MVA放化疗相比，TL + PORT的死亡风险较低（HR 0.72; p = 0.024）。结论：TL在cT 4a LC中的使用随时间推移而增加，但仍低于60%。在学术/研究中心寻求治疗的患者更有可能接受TL，这突出了减少进入这些中心的障碍的重要性。应更多地关注了解和解决导致手术利用率下降的其他患者、医生和系统层面因素。
Total laryngectomy (TL) with post-operative radiotherapy (PORT) is recommended for patients with clinically advanced (cT4a) laryngeal cancer and is associated with superior outcomes compared to non-operative treatment with chemoradiation. Despite this, many patients with a diagnosis of laryngeal cancer do not receive TL as part of their treatment course, which places them at risk for inferior oncologic outcomes, and the factors associated with the utilization of TL in this setting remain poorly understood. Thus, the aims of this observational cohort study utilizing the National Cancer Database (NCDB) were both to elucidate the patient and treatment facility characteristics associated with TL utilization in patients with cT4a laryngeal cancer and to evaluate how its usage has changes over time. 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.
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