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Objectives/hypothesis: Primary curative treatment of advanced laryngeal cancer may include surgery or chemoradiation, although recommendations vary and both are associated with complications. We evaluated predictors and trends in the use of these modalities and compared rates of complications and overall survival in a population-based cohort of older adults., Study Design: Retrospective population-based cohort study., Methods: Using Surveillance Epidemiology and End Results (SEER) cancer registry data linked with Medicare claims, we identified patients over 65 with advanced laryngeal cancer diagnosed 1999 to 2007 who had total laryngectomy (TL) or chemoradiation (CTRT) within 6 months following diagnosis. We identified complications and estimated the impact of treatment on overall survival, using propensity score methods., Results: The proportion of patients receiving TL declined from 74% in 1999 to 26% in 2007 (P < 0.0001). Almost 20% of the CTRT patients had a tracheostomy following treatment, and 57% had a feeding tube. TL was associated with an 18% lower risk of death, adjusting for patient and disease characteristics. The benefit of TL was greatest in patients with the highest propensity to receive surgery., Conclusion: TL remains an important treatment option in well selected older patients. However, treatment selection is complex; and factors such as functional status, patient preference, surgeon expertise, and post-treatment support services should play a role in treatment decisions., Level of Evidence: 2b. Laryngoscope, 124:2707-2713, 2014., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)