Transoral robotic surgery with pathologic characteristics-guided adjuvant therapy may improve survival outcomes in older patients with human papillomavirus (HPV)-related oropharyngeal carcinoma (OPSCC), according to a retrospective cohort analysis now published in JAMA Otolaryngology–Head & Neck Surgery.
Because patients over 70 years of age are underrepresented in clinical trials for HPV-related oropharyngeal cancers, the optimal way to treat these patients remains controversial. Additionally, the toxicity of chemotherapy may outweigh the survival benefit in older patients. The investigators, led by Harman Parhar, MD, MPH, an otolaryngologist at Abramson Cancer Center of the University of Pennsylvania in Philadelphia, investigated the efficacy of transoral robotic surgery in this patient population in a study that enrolled 77 patients ages 70 and older with biopsy-proven and surgically resectable p16-positive oropharyngeal cancers. The primary end points were three-year estimated overall, disease-specific, and disease-free survival.
At a median follow-up of 39.6 months, the authors found three-year estimated survival rates of 92.4% for disease-specific survival, 90% for overall survival, and 84.3% for disease-free survival. Twenty-seven patients (35.1%) underwent postoperative radiotherapy, and 20 patients (26%) underwent postoperative chemoradiotherapy. The authors recorded a perioperative mortality rate of 1.3%, and 2.6% of patients experienced an oropharyngeal hemorrhage.
Eight patients experienced a locoregional recurrence and four patients experienced a distant recurrence during the follow-up period. Eleven patients died during the follow-up period, five from events unrelated to oropharyngeal cancer. One patient died from leukemia, one patient from sepsis and multiorgan failure, one patient from intracranial hemorrhage, and three patients from unknown causes without evidence of cancer recurrence. In a subgroup analysis, the authors did not find statistically significant differences in outcomes based on treatment approach. Additionally, the authors found that age negatively impacted overall survival outcomes but did not negatively impact disease-specific or disease-free survival.
For future studies on HPV-related OPSCC, the authors suggested placing greater emphasis on patient selection using a formal geriatric assessment to determine which patients could benefit from and tolerate a multimodality treatment plan.
"In this analysis, a TORS, neck dissection, and pathologic findings–guided adjuvant therapy approach demonstrated positive oncologic and survival outcomes among patients 70 years or older with HPV-associated OPSCC. Perioperative mortality was rare and postoperative oropharyngeal hemorrhages occurred infrequently. For carefully selected older adults, this approach may be safe and obviate the need for chemotherapy," conclude the authors.
For More Information
Parhar HS, Shimunov D, Newman JG, et al (2020). Oncologic outcomes following transoral robotic surgery for human papillomavirus–associated oropharyngeal carcinoma in older patients. JAMA Otolaryngol Head Neck Surg. [Epub ahead of print] DOI:10.1001/jamaoto.2020.3787
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