LARYNGEAL CANCER TREATMENT : REVIEW OF LITERATURE PUBLISHED OVER THE LAST TEN YEARS Tratamento do câncer de laringe : revisão da literatura publicada nos últimos dez anos

(1) Clinica Dedicare, Porto Alegre, RS, Brasil. (2) Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil. Conflict of interest: non-existent One of the reasons why this procedure is sometimes necessary when a person remains without these important structures is when cancer occurs1. According to data from INCA-National Cancer Institute, Brazil has a high incidence of laryngeal malignant tumors, the second most frequent being the upper aerodigestive tract, accounting for 25% of head and neck malignant tumors and 2% of malignant neoplasms. Moreover, it is the sixth most common location in the male population of 40 years in average, with 3,369 deaths recorded in 2011. The treatment of laryngeal cancer depends on the location and extent, it can be treated with surgery and/or radiotherapy and chemotherapy combined with radiotherapy.  INTRODUCTION


INTRODUCTION
Laryngectomy is a surgical procedure in which sometimes all the structures that produce laryngeal sound and from neighboring muscles are removed, transferring nasal flow to tracheostoma.Laryngectomies may be partial or total and tracheostomy may be temporary or definitive.
Total laryngectomy consists in removing the larynx, it implies the loss of physiological voice and in definitive tracheostomy an artificial hole is made in the trachea, below the larynx 1 .

ABSTRACT
The purpose of this study was to analyze the characteristics of the scientific bibliographic production about the larynx cancer treatment in the last ten years.It was followed the Cochrane Handbook precepts, that involved the formulation of the question to investigate, the localization, the studies selection and the critical assessment of the articles.The articles published between 2002 and 2011 were shortlisted by the data base LILACS e ScIELO, using the laringect$ descriptor and in the data base PubMed, using the laringect* descriptor.It was analyzed the full texts, potentially relevant for the review, using a standardized form, when the following data were collected: goals, research design, characteristics of the research group, findings and discussion about the larynx cancer treatment.Initially it was identified 299 studies.After the tittles and abstracts review, consideration of inclusion and exclusion test, coherence check with the researched thematic and elimination of the studies which were at the same time in more than one data base, 72 were sure enough analyzed to be larynx related to the topic in its descriptors and/or in the abstracts.From this research it is possible to verify gaps and opportunities for the development of studies that verify standardized techniques of larynx cancer treatment with the increasing of analytical and interventional studies based on clinical trials randomized, considering especially guidelines as CONSORT, STROBE e GRADE for its planning and publication.
ScIELO and PubMed database.The following parameters were used: laringect$, for LILACS and ScIELO database (for abstract and title); and laringect* (abstract and title) for PubMed database.

Selection of the Articles
In this study articles published between 2002 and 2011 in journals indexed in LILACS, ScIELO and PubMed database available in full were included.This enabled a more detailed analysis of the characteristics of bibliographic productions on the treatment of laryngeal cancer.
For the selected articles the criteria for inclusion was the term used in the search, at least in one of the places: key-words, abstract and/or title.In addition, it was used as criteria for inclusion: complete articles published in Portuguese between the years 2002 and 2011, in LILACS, PudMed and/ or Scielo database on the research theme.
Criteria for exclusion considered: texts with insufficient data for the study, studies not related to the objective of the research, texts found in more than one database and studies published outside the period related to the objective of the research.

Analysis of the Articles
Only those studies which abstract had a relationship with the objective of the study were evaluated and selected, and later the full articles were obtained.The complete texts were analyzed, potentially relevant for review, using a standardized form in which the following data was collected: objectives, research design, findings and discussion on the treatment of laryngeal cancer.
Initially, 299 studies were identified.After reviewing the titles and abstracts, as well as reviewing the studies considering the criteria for inclusion and exclusion, 72 studies were actually analyzed as they referred in their results and/or in their conclusions to the theme of laryngeal cancer (Figure 1).
Due to the great importance of preserving the voice for the patient's quality of life, sometimes radiation therapy can be used first, leaving surgery for the salvage.In addition, even in patients who were submitted to total laryngectomy the rehabilitation of voice is possible through the esophageal voice, tracheo-esophageal phonation prosthesis 1 and the use of eletrolarynx 2 .
Currently, many studies demonstrate the impact severity of laryngectomy on patients' quality of life.More precisely in the physical aspects (comfort and pain), personal, family, social and professional 2 .
Communication ability is a fundamental element to the quality of life and all preventive action in this area will contribute significantly to promoting global health 3 .
Speech therapy has been trying to build its knowledge, directing its practices not only for the technological development, but also to widen formal content, social and political responsibility, contributing for the improvement of conditions of life in the population 3 .
The speech therapist who works in the public health needs updates that meet the guidelines and principles of the NHS, turning not only for rehabilitation therapy, but also for the promotion and prevention 4 .
In view of the need to know the topic, the advancements and gaps in the scientific knowledge accumulated in terms of laryngeal cancer the objective of the study is to analyze the bibliographic production indexed on partial and total laryngectomies in the last ten years.

METHODS
Cochrane Handbook precepts were followed that involved the formulation of the question to be investigated, the location, the studies selection and the critical assessment of the articles.The question in the investigation that subsidized the review was: "Which are the characteristics of the scientific bibliographic productions on the laryngeal cancer treatment?".
In formulating the question for investigation, there was an attempt to do the bibliographic research on the central theme of this paper, based on LILACS, regarding the use of surgical techniques for the treatment of laryngeal cancer.Many studies [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] have been done with the aim to investigate the efficiency of different surgical methods with a view to the most satisfactory possible prognostic in these patients affected by cancer.

RESULTS AND DISCUSSION
Analyzing all the articles selected for the research (Figure 2) it was found a large percentage from the medical sector that deals with the concern of these researchers, especially after the year 2007,

Case-control
Assess using surface electromyography behavior of the sternocleidomastoid and cervical paraspinal muscles bilaterally in patients who communicate through the esophageal and artificial larynx speech, to determine if the type of voice used changes the behavior of the cervical muscles.
In phonation there was no alteration in the pattern of muscle activation in individuals that use esophageal speech and artificial larynx, compared to the control group.However, there was significant difference at rest.

Series of cases
Characterize the muscle electrical activity of the masseter muscle during swallowing in total laryngectomized patients.
There is moderate electrical activity of the masseter muscle during swallowing, with higher averages on the left side.There are no differences between swallowing 14.5 ml and 20 ml.

Systematic review
Systematically review the changes in the functions of smell and taste in patients submitted to total laryngectomy and identify aspects in the literature involved in the evaluation of these functions in this population.
Most studies attested decrease in sensory functions of smell and taste in patients who were submitted to total laryngectomy.
Quality of life aspects.

Case report
Describe the process of voice rehabilitation of a 61-year male patient submitted to fronto-lateral laryngectomy without arytenoidectomy in a Speech School Clinic.
Returned to the social life and consequent improvement in the patient's quality of life.
Quality of life aspects.

Series of cases
Perform perceptual and acoustic evaluation in this group of patients.
All patients had some degree of dysphonia, increased fundamental frequency and altered acoustic measurements.
Voice and swallowing aspects.

Retrospective
Retrospectively evaluate the results of patients submitted to partial laryngectomy for laryngeal squamous cell carcinoma in HMCP service.
In all total and/or radiotherapy were performed, and two died from the disease.Twenty four patients (84%) had their voice preserved.
Medical treatment aspects and voice and swallowing aspects.

Series of cases
To evaluate the influence of using the humidifier tracheostoma (heat moisture exchanger -HME) in the control of lung secretion and esophageal and tracheoesophageal voice quality of patients submitted to total laryngectomy.
No statistically significant difference in esophageal or trachea-esophagic vocal quality parameters.There were statistically significant differences for the variables of cough and forced sputum, during the day, after a period of using HME.

Coorte histórica longitudinal
The evaluation of the subsites in spreading of carcinoma and its influence on the surgical treatment of larynx, in local control and survival rate.
Posterior comissure and subglottis, respectively, were significant for total laryngectomy.

Series of cases
Identify the extent and evolution of dysphagia and dysphonia in patients submitted to supracricoid laryngectomy and verify the association of these findings with clinical and surgical variables.
Dysphagia and dysphonia showed an association between them related to the degrees of severity, a greater number of patients had better evolution of dysphagia compared to the evolution of dysphonia.There was no significant statistics in the other associations.
Voice and swallowing aspects.

Series of cases
Identify nursing diagnoses in the late postoperative period of total laryngectomy and develop a plan of nursing interventions for identified diagnoses.
Assistance to the laryngectomized must be done not only in biological dimension but also social and psychological.
Quality of life aspects.

Series of cases
Evaluate the behavior of total laryngectomized patients facing their body image.
The identified behavior of the patients showed that they look at themselves in the mirror (93%), avoid touching the operated area (73%), feel older (80%), like their appearance (100%), take care of themselves better (73%) and pay more attention to the body (87%).
Quality of life aspects.

Descriptive
Describe the experience of patients submitted to laryngectomy and family in dealing with the reactions of radiotherapy.

The most frequent reactions and considered
the worst were skin burning and reaction in oropharynx; some actions used to minimize them are derived from cultural beliefs around the treatment.
Quality of life aspects.

Transversal Coorte
Assess laryngeal function in patients submitted to complete cordectomy (type IV), reconstructed with vestibular fold flap.
The results showed that there was no need to keep tracheostomy in late postop, as the rebuilt larynx light was permeable.The protection function was kept in all cases.They also showed that there was a vibratile sound source in 90% of the cases and that in all the vestibular fold participated in its composition.

Series of cases
Assess total laryngectomy for surgical salvage after treatment after chemoradiation therapy for advanced squamous carcinoma of the larynx.
The application of stapler lasted less than five minutes.There was no infecction, pharyngocutaneous fistula, complaint of dysphagia nor narrowing at X-Ray examination.Patients had success in the phonatory/sound rehabilitation of the prosthesis.

Case-control
Analyze whether there are significant differences between certain quantitative variables of acoustic voice parameters in three samples of individuals, using, discriminating analysis.
The method ofdiscriminant analysis is valid to differentiate the variables used between the three groups, thus, have some characteristics of the acoustic point of view.The study allowed us to affirm that no tracheoesophageal voice is close to normal esophageal speech.
Voice and swallowing aspects.

Figure 2 -List of studied articles published in LILACS and ScIELO on the treatment of larynx cancer
The articles were distributed from the point of view of the result studied: 39 articles included medical treatment aspects, 14 quality of life, 14 on voice and swallowing and 12 articles with more than one theme.
During the it was also verified a considerable percentage of publications from the nursing sector related with the bio-psycho-social aspects directly linked to the rehabilitation and/or postoperative handling/care which the patients must be submitted to [32][33][34][35][36][37][38][39] .
Few studies were found, from the psychology sector 36 , and these, most of a descriptive character, referring to psycho-social aspects involved in the rehabilitation of patients affected by laryngeal cancer, a characteristic that was evident in this research and that are similar to the studies from the nursing sector [32][33][34][35] , as described above.
It was noticed, mainly in the last five years, the concern of the authors  to verify the association between quality of life/voice and quality of life/ swallowing. It ws observed also the interest in investigating the correlations between conservative surgical techniques and radical surgeries in obtaining positive prognostics, as well as the concern with the bio-psycho-social aspects of each patient, fact that points to the increase in the interest of professionals to promote a holistic treatment considering the various aspects involved in the rehabilitation of patients exposed to such condition.
The literature studied  points to the importance of multidisciplinary interventions in the prevention and treatment of laryngeal cancer and highlights the importance of considering the patient's point of view when developing rehabilitation strategies, however, no article mentioned the multidisciplinary approach theme as their main focus.
Nevertheless, this review suggests some need regarding those publications that deal with the treatment of laryngeal cancer.From the analysis done it can be observed that the majority of papers are of a descriptive nature.
To analyze the effectiveness of the interventions it would be relevant that analytical studies were conducted and published, especially intervention studies, especially randomized clinical studies, considering the golden standard for the practice based on evidence regarding the attainment of standardized techniques of treatment, be it for rehabilitation using surgical techniques or not 37 .
Among the intervention studies published it was observed that the recommendations for planning and publication of intervention studies are not always considered, which would result in an improvement in the quality of articles published as well as qualifying the available information 37 .
An aspect that stood out in the literature research was the absence of mentioning the complications and adverse reactions, side effects and safety of treatments implemented both in the medical field as the techniques of voice rehabilitation.The mention of complications resulting from interventions or even adverse reactions is a relevant aspect in intervention studies of any nature, as normally these are present in a higher or lower rate in any type of intervention.

CONCLUSION
The characteristics of the publications related to the treatment of laryngeal cancer are mostly the result of medical and speech therapy areas, and guidelines such as CONSORT, STROBE and GRADE for planning and publication [37][38][39][40] .
The identification of characteristics and gaps in bibliographic productions on the theme contributes for the researchers of speech therapy disorders related to laryngeal cancer direct their studies to the solution of these demands.From this it will be possible to improve the strategies for the treatment already in existence and elaborate standardized techniques that contemplate the needs of the patient, contributing with subsidies that qualify the practice based on scientific evidence.
there is a considerable number of publications in Nursing and few in Psychology.
From this research it is possible to verify the absence to mention adverse reactions, side effects and safety of treatments implemented both in the medical area and techniques of speech therapy rehabilitation, which use to be present in a higher or lower rate in any type of intervention.

Figure 1 -
Figure 1 -Schematic representation of the research method and results obtained: excluded and included studies Exclusion criteria: Texts with insufficient data for the study, studies not related to the research objective, texts found in more than one database and studies published outside the period related to the objective of the research.