FLEX October 2023

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anterior tumor location in the vocal cord is associated with a breathy voice when cancer is treated with TLS. TLS has the advantage of being completed within 1 day, which may also influence patient preference. A larger study is war ranted to compare the effects on survival. International Journal of Radiation Oncology Biology Physics

Aaltonen et al.

improvement in any of the 5 voice quality measures of the GRBAS scale occurred in the TLS group, suggesting that the vocal cord defect caused by carcinoma and TLS frequently causes long-lasting voice impairment. Yet, in dividual compensation is an important factor contributing to final voice quality, and it may sometimes lead to an excellent voice (11). Rehabilitative speech therapy facili tating functional compensation should therefore be considered. Self-rated voice quality and the level of perceived inconvenience are important to evaluate (12, 13) because they relate to occupational and social demands. A meta analysis of 6 studies in patients with T1 glottal cancer concluded that TLS with CO 2 laser and external beam ra diation therapy resulted in similar levels of voice handicap (14). The voice handicap has been considered mild (15) and comparable to that caused by benign glottal tumors (14, 16). Only 16 (29%) of the patients were employed at the time of entry into the study, and one could argue that for most patients a mildly or moderately breathy voice may not cause a substantial handicap, but the patient is likely the best judge. This trial has some limitations. A larger series could have identified further differences between the treatments. Yet, statistically significant differences emerged, suggesting that the trial was not underpowered with regard to the main endpoint despite its limited size. The study was not pow ered to compare recurrence-free or overall survival between the treatment groups. Such endpoints require a much larger study because of the generally good prognosis of small glottal carcinomas. Voice quality might change after the first 2 years of follow-up, and a longer follow-up time may be warranted. When the study began, the Voice Handicap Index (VHI) had not yet been validated in the Finnish language, and thus it could not serve as a subjective voice evaluation instrument. Female patients were excluded because of the infrequency of laryngeal cancer in women and to achieve a more homogenous study population, and therefore the results may not be applicable to female pa tients with laryngeal cancer. Smoking habits may influence the quality of voice, but these data were insufficient for analysis. In conclusion, radiation therapy results in less breathy voice than TLS, but the overall voice quality was similar. Radiation therapy may be the treatment of choice when the requirements for the voice quality are demanding. An

References

1. Abdurehim Y, Hua Z, Yasin Y, et al. Transoral laser surgery versus radiotherapy: Systematic review and meta-analysis for treatment op tions of T1a glottic cancer. Head Neck 2012;34:23-33. 2. Dey P, Arnold D, Wight R, et al. Radiotherapy versus open surgery versus endolaryngeal surgery (with or without laser) for early laryn geal squamous cell cancer. Cochrane Database Syst Rev 2010;2: CD002027. 3. Kanonier G, Fritsch E, Rainer T, et al. Radiotherapy in early glottic carcinoma. Ann Otol Rhinol Laryngol 1996;105:759-763. 4. Steiner W. Radiotherapy in early glottic carcinoma. Am J Otolaryngol 1993;14:116-121. 5. International Union Against Cancer on Cancer. In: Sobin L, Gospodarowicz M, Wittekind C, editors. TNM classification of ma lignant tumours. 7th ed. Chichester: Wiley-Blackwell; 2010. 6. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69-90. 7. International Commission on Radiation Units and Measurements Report 50: Prescribing, recording and reporting photon beam therapy . Washington, DC: International Commission on Radiation Units and Measurements; 1993. 8. Strong MS. Laser excision of carcinoma of the larynx. Laryngoscope 1975;85:1286-1289. 9. Remacle M, Eckel HE, Antonelli A, et al. Endoscopic cordectomy. A proposal for a classification by the Working Committee, Euro pean Laryngological Society. Eur Arch Otorhinlaryngol 2000;257: 227-231. 10. Hirano M. Clinical examination of voice. Wien, Austria: Springer Verlag; 1981. 11. Galletti B, Freni F, Cammaroto G, et al. Vocal outcome after CO 2 laser cordectomy performed on patients affected by early glottic carcinoma. J Voice 2012;26:801-805. 12. Hogikyan ND, Rosen CA. A review of outcome measurements for voice disorders. Arch Otolaryngol Head Neck Surg 2002;126:562-572. 13. Carding P. Evaluating voice therapy: Measuring the effectiveness of treatment. London: Whurr Publishers; 2000. 14. Cohen SM, Garrett G, Dupont WD, et al. Voice-related quality of life in T1 glottic cancer: Irradiation versus endoscopic excision. AnnOtol Rhinol Laryngol 2006;115:581-586. 15. Nu´n˜ez Batalla F, Caminero Cueva MJ, Sen˜aris Gonza´lez B, et al. Voice quality after endoscopic laser surgery and radiotherapy for early glottic cancer: Objective measurements emphasizing the Voice Handicap Index. Eur Arch Otorhinolaryngol 2008;265:543-548. 16. Van Gogh CD, Mahieu HF, Kuik DJ, et al. Voice in early glottic cancer compared to benign voice pathology. Eur Arch Otorhinolaryngol 2007;264:1033-1038.