[Skip to Content]
[Skip to Content Landing]
Views 1,206
Citations 0
Original Investigation
September 26, 2019

Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Author Affiliations
  • 1Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
  • 2Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
  • 3Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
  • 4Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
JAMA Otolaryngol Head Neck Surg. Published online September 26, 2019. doi:10.1001/jamaoto.2019.2725
Key Points

Questions  What is the prevalence of acute dysphagia and the rate of dysphagia recovery after transoral robotic surgery for oropharyngeal cancer, and how do outcomes after transoral robotic surgery compare with those after primary radiotherapy?

Findings  In this cases series study of 257 patients with human papillomavirus–associated oropharyngeal cancer, the prevalence of moderate-severe acute dysphagia after transoral robotic surgery (per Dynamic Imaging Grade of Swallowing Toxicity grade ≥2) was 22.7%, with partial recovery that did not return to baseline by 3 to 6 months. Dysphagia profiles between patients with primary transoral robotic surgery and the groups that received primary radiotherapy differed in the short term but not by 3 to 6 months of subacute recovery.

Meaning  Subacute swallowing outcomes were similar regardless of primary treatment modality among patients with low- to intermediate-risk oropharyngeal squamous cell carcinoma.

Abstract

Importance  A major goal of primary transoral robotic surgery (TORS) for oropharyngeal cancer is to optimize swallowing outcomes by personalized treatment based on pathologic staging. However, swallowing outcomes after TORS are uncertain, as are the outcomes compared with nonsurgical options.

Objectives  To estimate rates of acute dysphagia and recovery after TORS and to compare swallowing outcomes by primary treatment modality (TORS or radiotherapy).

Design, Setting, and Participants  This case series study was a secondary analysis of prospective registry data from 257 patients enrolled from March 1, 2015, to February 28, 2018, at a single academic institution who, according to the AJCC Staging Manual, 7th edition TNM classification, had low- to intermediate-risk human papillomavirus–related oropharyngeal squamous cell carcinoma possibly resectable by TORS.

Exposure  Patients were stratified by primary treatment (75 underwent TORS and 182 received radiotherapy).

Main Outcomes and Measures  Modified barium swallow (MBS) studies graded per Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the MD Anderson Symptom Inventory–Head and Neck Module (MDASI-HN) questionnaires were administered at standard intervals. Prevalence and severity of dysphagia were estimated per DIGEST before and after TORS and 3 to 6 months after treatment. Moderate-severe dysphagia (DIGEST grade ≥2) was assessed using logistic regression and compared by primary treatment group. The MDASI swallowing symptom severity item scores during and after radiotherapy were compared using generalized estimating equations by treatment status at the start of radiotherapy, after induction, and after TORS.

Results  A total of 257 patients (mean [SD] age, 59.54 [9.07] years; 222 [86.4%] male) were included in the study. Dysphagia severity (per DIGEST) was significantly worse after TORS (r=0.63; 95% CI, −0.78 to −0.44): 17 patients (22.7%; 95% CI, 13.8%-33.8%) had moderate-severe (DIGEST grade ≥2) acute post-TORS dysphagia significantly associated with primary tumor volume (odds ratio, 1.43; 95% CI, 1.11-1.84). DIGEST improved by 3 to 6 months but remained worse than that at baseline; at 3 to 6 months, the number of patients with DIGEST grade 2 or higher dysphagia was 5 (6.7%; 95% CI, 2.2%-14.9%) after primary TORS and 29 (15.9%; 95% CI, 10.9%-22.1%) after radiotherapy. At the start of radiotherapy, MDASI swallowing symptom severity item scores were significantly worse in the post-TORS group compared with postinduction (mean [SD] change, 2.6 [1.1]) and treatment-naive (mean [SD] change, 1.7 [0.3]) patients. This result inverted at radiotherapy end, and all groups converged at 3 to 6 months.

Conclusions and Relevance  Subacute swallowing outcomes were similar regardless of primary treatment modality among patients with low- to intermediate-risk oropharyngeal squamous cell carcinoma.

Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×