NEW YORK (Reuters Health) - For patients with oropharyngeal squamous cell carcinoma (OPSCC) receiving transoral robotic surgery (TORS), adjuvant radiotherapy or chemoradiotherapy (CRT) should be avoided if possible, according to a long-term functional and quality-of-life (QOL) outcomes study.
TORS alone gave the best long-term functional outcomes in swallowing and speech, with QOL metrics returning to near baseline. Patients who received adjuvant therapy did not recover as quickly, and those who received TORS and CRT had the greatest risk for poor long-term outcomes, the study team found.
Dr. Daniel Clayburgh from Oregon Health and Science University in Portland and colleagues reported their findings in JAMA Otolaryngology - Head & Neck Surgery, online October 26.
TORS has emerged as a useful treatment option for OPSCC, with more centers now offering it. In appropriately selected patients, adjuvant RT or CRT may not be necessary, thereby avoiding the long-term adverse effects of these therapies, they point out.
In a cohort of OPSCC patients, they compared functional speech, swallowing and QOL outcomes in 20 patients who had TORS only, 31 who had TORS+RT and 23 who had TORS+CRT. Median follow-up was 21 months (range, 7 to 36 months).
In the first seven to 21 days after surgery, all three groups experienced significant worsening in pain and swallowing-related measures. They experienced subsequent improvement over time albeit with different trajectories across groups, with the TORS only group having the greatest recovery with the least weight loss and best swallowing-related outcomes at long-term follow up (>12 months).
These findings suggest that patients who undergo TORS+CRT are at increased risk of significantly poorer long-term function. “Triple-modality intervention in this patient population should be avoided,” Dr. Clayburgh and colleagues advise in their paper.
They note that, currently, the primary driver of adjuvant CRT in these patients is the presence of extranodal extension on pathologic assessment of cervical lymph nodes.
“It can be challenging to detect extranodal extension preoperatively; however, a study by Geltzeiler et al. determined that the presence of 3 or more radiologically suspicious lymph nodes on computed tomography has a 91% positive predictive value for any histologic evidence of extranodal extension. In the short term, for patients with a high likelihood of requiring adjuvant CRT, TORS should be avoided and definitive CRT should be administered,” the authors note.
Down the road, extranodal extension may no longer be an absolute indication for adjuvant CRT, they say. “Recent evidence suggests that in HPV-positive OPSCC, extranodal extension is not a significant prognostic indicator, and these data have been incorporated in the upcoming eighth edition of the American Joint Committee on Cancer staging manual,” they explain.
“Most important, results from the Eastern Cooperative Oncology Trial 3311 and Abnormal Doppler Enteral Prescription trials will better define which patients with HPV-positive OPSCC truly need adjuvant CRT. Our data support the drive toward deintensification of treatment in HPV-positive OPSCC and highlight the importance of including robust QOL measures during a long period of follow-up in future clinical trials,” they conclude.
The study had no specific funding, and the authors have disclosed no conflicts of interest.
JAMA Otolaryngol Head Neck Surg 2017.
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