Decisional Conflict in Advanced Larynx Cancer | 105 4 Introduction Decision-making for patients with locally advanced laryngeal carcinoma (T3 and T4) can be challenging. Whereas historically these patients were treated with a total laryngectomy (TL)1, larynx preservation became more popular over the years for trying to avoid permanent tracheostomy and loss of natural voice2. In selected cases, concurrent chemoradiotherapy (CRT) and radiotherapy (RT) have been proven to yield almost similar survival rates whilst sparing the larynx3. Only in very advanced tumors, several retrospective studies have shown that upfront laryngectomy probably has a survival advantage4. However, larynx preservation does not always lead to function preservation and can have significant long-term morbidity5. Research has shown that global quality of life (QoL) does not differ between patients who received larynx preservation treatments or TL, however, functionality does; TL patients have more speech-related problems, while CRT patients experience more swallowing-related problems6,7. For some patients with limited T3 primaries partial laryngectomies can be an alternative, although this modality is relatively rarely used in the Netherlands. After TL, patients often experience social and adaptation problems, and associated distress. Therefore, They are sometimes willing to tradeoff survival percentages to preserve their larynx2,8,9. However, when choosing CRT or RT, patients and physicians should keep in mind that these treatments might fail. The potential risk of the need for a salvage TL (STL) after (C)RT failure is reported to be 16% for patients treated with concurrent CRT, and 31% for RT10–12. Compared to upfront TL, STL is associated with higher complication rates 13,14. Therefore, decision-making on initial primary treatment is crucial, preferably through a shared decision-making approach, to enhance patients’ knowledge, values and preferences15. The complexity of these treatment modalities and their possible consequences might lead to decisional conflict (DC). DC is defined as a state of uncertainty and difficulty experienced by an individual about the course of action to take16. The risk of DC is increased when patients have to weigh the pros and cons of multiple options, have inadequate knowledge, unclear personal values, and a perceived lack of support17,18. DC can lead to a range of negative consequences, such as postponed decision-making, selection of treatments misaligned with patient preferences, decisional regret and depression19,20. There is limited research on DC in head-and-neck cancer and specifically advanced laryngeal cancer. We therefore aimed to explore the level of DC, using a validated DC scale (DCS) in patients with locally advanced laryngeal cancer who are facing decision-making for treatment with the intent to cure. Additionally, we aimed to identify factors associated with DC.
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