Because TORS.

Top Line: Do patients who have trans-oral robotic surgery for T1-2 oropharyngeal cancer have better quality of life compared to those who have radiation?
The Study: Ok, we’re back at it again this morning discussing the evolving treatment paradigms for oropharyngeal cancer. Radiation has played a central role in the definitive treatment of even early stage oropharyngeal cancer due to the historical morbidity of surgical resection. Kinda surprising to us, though, was the NCDB data cited in this study of the rapidly rising rate (>80%) of upfront surgery for T1-2 oropharyngeal cancer with the emergence of trans-oral robotic surgery (TORS). That’s because TORS is much less invasive, right? Well, what's usually lacking when there are options for surgery or radiation for cancer treatment? Yep, data. In the ORATOR trial, 68 patients with T1-2, N0-2 (but 4cm or less and no radiographic ECE) oropharyngeal cancer were randomized to primary surgery (including neck dissection) or radiation (with chemo for node positive). Importantly, they did not have to be p16-positive. Primary radiation and chemo were the standard 70/56 Gy. Adjuvant radiation (60 Gy) was given for T3/4, N+, LVSI, close margins, and (with chemo) positive margins or ECE. Now, this was a phase II trial with a primary endpoint of MD Anderson Dysphagia Inventory (MDADI) score at 1 year. At 1 year, the MDADI was statistically worse after TORS as opposed to RT, although the authors deemed that difference not clinically meaningful. It’s important to note here that over 70% of the TORS patients received adjuvant radiation. While you’d think that obviously sunk the surgery group, even the patients with surgery alone had a worse MDADI than the RT alone group.
TBL: TORS for early stage oropharyngeal cancer doesn’t improve quality of life compared to definitive radiation. | Nichols, Lancet Oncol 2019

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