A recent study comparing surgery and radiation therapy (RT) as treatment options for oropharyngeal cancer found advantages and disadvantages for both approaches. However, the study ultimately concluded that surgery appeared to be the better choice. The study, presented at the American Head & Neck Society (AHNS) annual meeting by Dr. Dev Amin and colleagues from Thomas Jefferson University Hospital, examined patients with T1-T2 oropharyngeal squamous cell carcinoma (OPSCC) in a database. The patients underwent either primary transoral robotic surgery (TORS) or primary RT and/or chemoRT (RT/CRT). The findings, published in JAMA Otolaryngology-Head & Neck Surgery, revealed that while primary TORS was associated with an increased risk of short-term dysphagia, patients treated with primary RT/CRT had a higher risk of long-term gastrostomy tube dependence and worse 5-year overall survival (OS) compared to those who underwent surgery.
The Risk of Dysphagia
The study found that primary TORS was linked to a clinically significant increase in the risk of dysphagia at 6 months and 1 year post-treatment, compared to primary RT/CRT. On the other hand, patients who received surgery were less likely to be dependent on a gastrostomy tube at 6 months and 5 years post-treatment. The researchers explained that the placement of gastrostomy tubes after treatment was likely reactive rather than prophylactic. They also highlighted the rarity of reports on the increased risk of gastrostomy tube placement at 5 years post-treatment in the radiochemotherapy cohort. This finding emphasizes the importance of considering late-stage toxic effects, such as radiation fibrosis, which can affect swallowing structures and contribute to severe late dysphagia events. These events, including fatal aspiration pneumonia, have been associated with other head and neck cancers and may contribute to late noncancer deaths.
The Need for Combination Treatment
Dr. Pierre Lavertu, a participant at the AHNS meeting, commented that in his practice, he treats patients with both radiation and surgery. He suggested that the study would have benefited from including a third group of patients who received both treatments. However, Dr. Amin explained that the retrospective study used population-level data, making it impossible to include a combination-treatment group. Another participant, Dr. C. Burton Wood, noted that the majority of patients who undergo surgery may also require radiation due to anatomical factors. He emphasized the need to determine the rate of feeding tube requirements for patients who receive both surgery and radiation.
The Study’s Limitations
The study included patients who underwent primary TORS or RT/CRT between 2002 and 2022. After propensity matching, 726 patients met the inclusion criteria. In the TORS group, 50% received primary surgery, while in the RT/CRT group, 50% underwent primary RT/CRT. The researchers reported that among unmatched patients with OPSCC, those who received RT/CRT had worse 5-year OS compared to those who underwent primary surgery. However, the researchers cautioned that they were unable to match patients for HPV tumor status or N stage due to the limitations of the data platform used. They acknowledged that the results favoring TORS for OPSCC management may be influenced by the nonradiosensitive HPV-negative OPSCC population. The study concluded that further randomized controlled trials are necessary to determine survival rates in patients with HPV-mediated vs HPV-negative OPSCC treated with TORS vs RT/CRT.
In summary, the study comparing surgery and radiation therapy for oropharyngeal cancer revealed the advantages and disadvantages of both approaches. While surgery was associated with an increased risk of short-term dysphagia, it offered better long-term outcomes in terms of gastrostomy tube dependence and overall survival. However, the study’s limitations and the need for further research highlight the ongoing debate and the importance of personalized treatment decisions for patients with oropharyngeal cancer.