Adjuvant treatment decisions for oropharyngeal cancer – is it time for a change?

Transoral laser microsurgery for oropharyngeal squamous cell carcinoma: A paradigm shift in therapeutic approach

“…Although the use of IMRT certainly seems to have improved the situation, for example, a recent large-scale U.S. multi-institution pooled analysis demonstrated a 1-year dependence of 8.6% in those treated with concurrent chemotherapy and IMRT (n 5 1238), 39 results from our experience with TLM remain favorable by comparison (1-year G-tube dependency of 1.3%). HPV-driven disease is associated with excellent long-term oncologic outcomes irrespective of treatment modality used, 1,[4][5][6][7][8]42 something also observed incontrovertibly in our study group, with HPV positivity conferring a 76.6% reduction in risk of death and/or disease recurrence. 13,32,33 Unfortunately, although such favorable G-tube dependency rates are compelling, our series, and indeed the previous TLM series, lack more comprehensive data regarding swallowing function pretreatment and posttreatment, and, more importantly, lack a direct comparator group treated nonsurgically to allow for a more robust analysis of swallowing outcomes.…”

“…8,37 Although there is no doubt that previous major open surgical approaches carried significant risks of posttreatment morbidity and mortality, it is now apparent that use of chemotherapy in conjunction with RT to the head and neck is also associated with high rates of acute and late toxicity in the majority of patients, particularly with respect to deglutition, over and above those seen with RT alone. Indeed, the belief that "organ-preserving" primary nonsurgical treatment regimens offered favorable functional outcomes in comparison with traditional en bloc surgical approaches was a principal motivating factor in the widespread shift toward primary nonsurgical management of SCCHN, oropharyngeal SCC included.…”

“…Indeed, the belief that "organ-preserving" primary nonsurgical treatment regimens offered favorable functional outcomes in comparison with traditional en bloc surgical approaches was a principal motivating factor in the widespread shift toward primary nonsurgical management of SCCHN, oropharyngeal SCC included. 8,37 Although there is no doubt that previous major open surgical approaches carried significant risks of posttreatment morbidity and mortality, it is now apparent that use of chemotherapy in conjunction with RT to the head and neck is also associated with high rates of acute and late toxicity in the majority of patients, particularly with respect to deglutition, over and above those seen with RT alone. 11,[15][16][17][18][19][20][21][22][23][24][25] Although, when assessing swallowing function there is no universally recognized single method of measuring outcome, 38 it is apparent that primary CRT regimes often necessitate protracted or permanent nonoral feeding, with high rates of G-tube dependency reported -a crude but objective measure of swallowing outcome.…”

“…1,[4][5][6][7] Indeed, HPV status has been demonstrated to be a strong and independent prognostic factor for survival, with HPV-positive oropharyngeal SCC carrying a 58% reduction in the risk of death compared to HPV-negative oropharyngeal SCC (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.27-0.66). 1,8 This practice is largely predicated on the recognition of the significant morbidity associated with open surgical approaches and the enhanced survival noted with concurrent CRT over radiotherapy (RT) alone in the treatment of SCC of the head and neck (SCCHN) in general, and in particular of the larynx and oropharynx. 1,8 This practice is largely predicated on the recognition of the significant morbidity associated with open surgical approaches and the enhanced survival noted with concurrent CRT over radiotherapy (RT) alone in the treatment of SCC of the head and neck (SCCHN) in general, and in particular of the larynx and oropharynx.…”

“…4 Despite the absence of level I evidence comparing surgical and nonsurgical approaches in the management of oropharyngeal SCC, cisplatin-based chemoradiotherapy (CRT) is generally considered the current standard of care for intermediate and advanced stage (American Joint Committee on Cancer [AJCC] stage III/IVa) oropharyngeal SCC in the majority of centers in the United Kingdom, Northern Europe, and the United States. 1,8 This practice is largely predicated on the recognition of the significant morbidity associated with open surgical approaches and the enhanced survival noted with concurrent CRT over radiotherapy (RT) alone in the treatment of SCC of the head and neck (SCCHN) in general, and in particular of the larynx and oropharynx. 1,[9][10][11][12][13][14][15][16] However, the use of concurrent CRT or open surgery (involving mandibulotomy and reconstruction) followed by adjuvant RT for the treatment of oropharyngeal SCC results in significant long-term dysphagia.…”