Originally published by 2 Minute Medicine^® (view original article). Reused on AccessMedicine with permission.

1. Primary treatment with chemoradiotherapy when treating oropharyngeal squamous cell carcinoma had improved progression-free survival and distant metastasis-free survival compared to when treated with upfront surgery.

2. There was no significant difference in mortality during the study period in the upfront surgical treatment versus chemoradiotherapy groups.

Evidence Rating Level: 2 (Good)

Study Rundown:

Advanced stage oropharyngeal squamous cell carcinoma (OPSCC) is primarily treated with concurrent chemoradiotherapy or surgical treatment with adjuvant therapy. The decision, however, is often decided based on site of carcinoma, sex, clinical stage, and patient age as the optimal primary treatment modality is still unclear. This retrospective comparative effectiveness analysis was done to determine the superior primary treatment modality between surgical pharyngectomy and definitive chemoradiotherapy when treating advanced stage OPSCC. The study examined 1180 patients, 694 patients treated with definitive chemoradiotherapy and 486 patients with surgery. Statistical analysis after patient follow-up, when adjusted for the discrepancies between populations which negatively affect survival such as clinical stage, sex, and subsite of carcinoma, demonstrated a comparable overall survival. Although both treatments have comparable risk of death, concurrent chemotherapy had significantly improved progression-free survival, as individuals were more likely to be progression free at 12 months since OPSCC diagnosis. Patients were also more likely to be distant metastasis free. These findings suggest chemotherapy should be considered first if surgical treatment likely requires adjuvant therapy, due to chemoradiotherapy having superior recovery and comparable overall survival. The findings also suggest that when considering treatments prognosis it is important to consider various demographical factors, as seen by the importance of individual characteristics in this study. These findings are limited, however, as 143 individuals from the 1180 individuals reviewed in this study did not have data pertaining to their site of OPSCC, and adjuvant therapy regiments were not controlled in surgery-treated individuals.

Click to read the study in JAMA Network Open

Relevant Reading: Commercial Claims–Based Comparison of Survival and Toxic Effects of Definitive Radiotherapy vs Primary Surgery in Patients With Oropharyngeal Squamous Cell Carcinoma

In-Depth [retrospective cohort]:

This retrospective analysis used data from the Taiwan Cancer Registry from 2007 to 2015. It examined 1180 individuals 20 and over with a history of stage III or IVA OPSCC and no other history of malignant neoplasm. The review consisted of 1180 individuals, 486 treated with surgical pharyngectomy and 694 treated with chemoradiotherapy equal or over 60 Gy. The two cohorts differed in individual characteristics. Individuals treated with surgery had a median age of 53.49, and a median tumor size of 30mm with 65.4% of carcinomas being located at the tonsil level and 23.9% being located at the base of tongue. Individuals treated with chemoradiotherapy had an older median population of 55.36 years, and a median tumor size of 39mm with 56.8% of carcinomas being located at the tonsil level and 30.1% being located at the base of tongue. Surgically treated carcinomas were also more poorly histologically differentiated. These differences are important to consider as studies have found these factors influence survival, such as tonsil carcinomas being associated with better survival than base of tongue carcinomas. The results with this study support this conclusion, as surgically treated individuals had higher overall survival, until baseline characteristics were adjusted for. Following statistical adjustment, the two treatment modalities had comparable overall survival, as surgical treatment had a hazard ratio score of 0.96 (95% CI, 0.80-1.16, P=0.70) indicating the risk of death in the surgical group was not significantly different to the risk of death in the chemoradiotherapy group. However, when comparing how well patients recovered and responded to treatment, surgically treated patients had inferior recovery with a progression -free survival hazard risk score of 1.72 (95% CI, 1.12-2.66, P=0.01) after adjusting for prognostic factors. Future studies should be done comparing patients of similar characteristics with controlled adjuvant therapy to add support to the results found in this study.

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