Increase in primary surgical treatment of T1 and T2 oropharyngeal squamous cell carcinoma and rates of adverse pathologic features: National Cancer Data Base

Abstract

Background There has been increasing interest in primary surgical treatment of patients with early T classification (T1–T2) oropharyngeal squamous cell carcinoma (OPSCC), with the stated goal of de-escalating or avoiding adjuvant treatment. We sought to determine the degree to which this interest has translated into changes in practice patterns, and the rates of adverse post-operative pathologic features. Methods Patients with T1–T2 OPSCC in the National Cancer Database (NCDB) treated from 2004–2013 were categorized as receiving primary surgical or primary radiation-based treatment. Trends in treatment selection and factors related to selection of primary surgery were examined. The rates of adverse pathologic features including positive margins, extracapsular spread (ECS), and advanced T and N stage following surgery were analyzed. Results Of 8,768 patients with T1–T2 OPSCC, 68% received primary surgical treatment, increasing from 56% in 2004 to 82% in 2013 (p<0.0001). The highest versus lowest volume hospitals treated 78% versus 59% of patients with primary surgery (O.R. 2.23 C.I. 1.55–3.22, p<0.0001). Higher nodal stage predicted lower rates of primary surgery, but the majority of patients with clinical N2/N3 disease underwent primary surgery. Among surgical patients, positive margins were present in 24% and ECS in 25%. Positive margins decreased over time (p<0.0001) and were seen less often at high volume centers (p<0.0001). Among candidates for single modality therapy (clinical T1–T2/N0–N1), 33% had positive margins and/or ECS, and 47% had at least one adverse feature (T3–T4, N2–N3, positive margins, and/or ECS). Conclusion Primary surgical treatment for early T-stage OPSCC has become more widespread.

Current Role of Surgery in the Management of Oropharyngeal Cancer

“…31 High rates of adjuvant chemoradiotherapy are attributable to the elevated incidence of nodal metastases and extracapsular spread in HPV-positive pathologic specimens. 46,47 Extracapsular spread was originally identified as a poor prognostic indicator in two randomized controlled trials of advanced head and neck cancer that have made it an indication for adjuvant chemoradiotherapy under the current standard of care. 51 However, these studies were flawed because they grouped all head and neck subsites together, the majority of patients had OPSCC, and results were not stratified by HPV status.…”

“…The incidence of extracapsular spread in surgically treated OPSCC has been studied using the National Cancer and SEER databases and is estimated at 23% to 25%, increasing with higher N stages. 46,47 Recent retrospective studies by Sinha et al 48 and Maxwell et al 46 demonstrate that this feature does not negatively affect survival in HPV-positive OPSCC and may not require adjuvant chemoradiotherapy for successful treatment of this population. In 2013, the ADEPT (Adjuvant Deescalation, Extracapsular Spread, p16 Positive, Transoral) trial was launched to determine the benefit of chemotherapy in patients with HPV-positive OPSCC with extracapsular spread, using 2-year locoregional control and disease-free survival as end points.…”

De-intensification of adjuvant therapy in human papillomavirus-associated oropharyngeal cancer

“…eHNS consists of a minimally-invasive procedure using miniaturized instrumentation that avoids mandibulotomy and external incisions. eHNS is performed with carbon dioxide laser microsurgery or robotic surgical system and has been associated with a resurgence of primary surgical treatment for T1-T2 OPC [16]. Early reports have demonstrated that eHNS is associated with a lower complication rate and faster post-operative recovery [17,18].…”

Development of an Online, Patient-Centred Decision Aid for Patients with Oropharyngeal Cancer in the Transoral Robotic Surgery Era

“…The introduction of transoral robotic surgery (tors)-which offers patients with newly diagnosed opscc an innovative alternative to the standard of treatment with rt, potentially providing superior functional outcomes-is currently being used for most patients with early opscc in the United States 2,3 . The uptake of tors is increasing despite a lack of clear evidence about its oncologic or quality-of-life outcomes 3,4 . A randomized trial is currently underway to evaluate those questions by directly comparing tors with rt 5 .…”