Similar Survival Shown With Radiation Versus Robotic Surgery in HNC

Treatment with radiation therapy or transoral robotic surgery plus neck dissection for patients with human papillomavirus (HPV)-related oropharyngeal cancer did not differ in survival outcomes but side effects and quality of life factors may differ.

These findings were demonstrated in the ORATOR trial, published in the Journal of Clinical Oncology. Of note, treatment decision-making should continue to be shared between the patient and their doctors, the researchers emphasized.

Oropharyngeal cancer is a head and neck cancer that starts in the oropharynx (middle part of the throat, beyond the mouth). An HPV infection may increase the risk of oropharyngeal cancer, according to the National Cancer Institute.

Transoral robotic surgery is a minimally invasive robotic surgery that helps doctors remove tumors in the mouth and throat, according to Penn Medicine.

“The patient is asleep, and they're positioned in such a way that their head is extended, which gives better access to the back of the throat. The surgeon is off to the side using a video console, and the video console has little handles on it that are almost like two joysticks that the surgeon can move,” study author Dr. David Palma, a radiation oncologist and professor at Western University in Canada, added during an interview with CURE®.

With this robotic surgery approach, it allows surgeons to operate an area that may be harder to reach without the surgical robot, Palma explained. This can prevent additional surgical cuts on the jaw that would be done previously in a traditional surgery.

Swallowing Quality of Life With Oropharyngeal Cancer

In the study, 68 patients were randomly assigned to receive either radiation therapy or transoral robotic surgery. The main goal of the study was to evaluate patients’ swallowing quality of life.

Researchers found that patients in the radiation group experienced worse dry mouth than patients in the surgery group. However, they also established that pain scores were worse in patients from the surgery group than those in the radiation group.

“Swallowing quality of life is really important,” Palma said. “If you're swallowing well, you don't think about it at all. Maybe you go to get your morning coffee and you have a muffin with it. You may take it for granted that you're going to drink that coffee or that the muffin is not going to get stuck in your throat … or that you could eat something in 10 or 15 minutes, and it doesn't take you an hour of chewing to get it down.”

Palma explained that patients’ quality of swallowing was evaluated based on a questionnaire, which included questions such as “How difficult is it to swallow?” “How much has it impacted your life?” and “How much has it impacted your social life?”

Survival Outcomes: Radiation Therapy Versus Transoral Robotic Surgery

Survival outcomes including progression-free survival (PFS; time patients live without their disease worsening) and overall survival (OS; time patients live, regardless of their disease status) were evaluated.

Of note, researchers concluded that there was no significant difference in PFS or OS outcomes in patients from either treatment group. At five years, the PFS was 84% versus 82.2% in the radiation and surgery groups, respectively. Similarly, at five years, the OS was 84% versus 85.1%.

Related, the grade 2 to 5 (serious to fatal) side effects did not significantly differ between patients in each treatment group, researchers noted. In the radiation group, the most common side effects included neutropenia (low levels of neutrophils, a type of white blood cell) and hearing loss, the researchers found. More patients from the surgery group experienced pain, they stated.

“Patients who had surgery needed more painkillers in the immediate postoperative period,” Palma said. “And sometimes patients after the surgery had some difficulty opening their mouth — we call that trismus. That means that you can't open your mouth very wide, maybe not enough to have a Jawbreaker or other big candy in there, but sometimes that can actually make it hard to eat a sandwich or a hamburger. And in the surgery [group], we had more of that.”

Shared Treatment Decision-Making for Patients With Oropharyngeal Cancer and Doctors

Discussions about treatment options should be had between patients with oropharyngeal cancer and their doctors, the researchers emphasized. Based on the results of the study, patients should discuss their specific risks and the potential side effects associated with treatments, according to the researchers.

“Medicine, years ago, used to be a one-size-fits-all thing where you come to your doctor and they tell you what you need and then you go and do it,” Palma added. “Our society has evolved so much since then. Patients are so unique, and they’re very individualized and they have different priorities.”

Reference

“Radiotherapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Final Results of the ORATOR Randomized Trial” by Dr. Anthony C. Nichols, et al. Journal of Clinical Oncology.

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