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To the Editor We commend Hutcheson et al1 on their interesting study; however, a few points need to be addressed.
This study, being a retrospective toxic effects analysis, has various problems, chief among which is the lack of a priori decided end points. Although a 6-month period seems to be clinically meaningful, the lack of an a priori decided effect size remains an issue. Furthermore, the general dictum in oncologic care is to expose the patient to only 1 form of definitive treatment modality if it is deemed adequate.
In this study, nearly half of all patients in the surgery arm (49.3%) ended up receiving postoperative radiotherapy (PORT), about 20% receiving concurrent chemotherapy with PORT, and 26.7% receiving bilateral irradiation. All these factors are likely to contribute to increasing toxic effects in the transoral robotic surgery (TORS) group. On the other hand, the total dose received in the definitive radiotherapy (RT) group was higher, which is a significant contributory factor to RT-related dysphagia. The exact details of the dose-fractionation schedules used have not been mentioned, but would affect the highest dysphagia grade, especially if accelerated RT in any form had been used.2 Complicating this is the imbalance that 21.4% of patients receiving definitive RT did so via the more tissue-sparing proton therapy vs 13.5% in the PORT group.
Furthermore, the details of concurrent chemotherapy were not reported, and it is likely that it was not balanced between the 2 arms because the dose density and number of chemotherapy cycles would be higher for the definitive RT group vs the PORT group, which would also contribute to differences in dysphagia.3
Owing to all these unbalanced confounder variables between the groups, it is difficult to directly compare the 2 arms and draw firm conclusions regarding toxic effects patterns and rates. The data show that at 6 months posttreatment, as expected, the difference in dysphagia between the TORS vs TORS/PORT groups was significant; however, the difference between definitive RT vs TORS/PORT was not significant, despite the definitive RT group having larger tumors, with more patients being irradiated bilaterally and to higher doses. All this suggests that perhaps the true dysphagia benefits were seen in patients not receiving any PORT. Given the excellent locoregional control rates of definitive RT (with or without concurrent chemotherapy) in oropharyngeal carcinoma,4,5 this then fairly questions the rationale of not giving definitive RT (with or without concurrent chemotherapy) up front to these patients.
Prospective (preferably randomized) studies would be needed, with careful patient selection, to draw meaningful conclusions. In the meantime, we see a role for TORS mostly in T1-2 node-negative tumors, and it would be prudent to consider definitive RT (with or without concurrent chemotherapy) in all other cases, rather than subjecting patients to the nonoverlapping but additive toxic effects profiles of RT and surgery.
Corresponding Author: Shantanu Sapru, MD, Department of Radiation Oncology, Dr Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, UP 226010, India (firstname.lastname@example.org).
Published Online: March 12, 2020. doi:10.1001/jamaoto.2020.0089
Conflict of Interest Disclosures: None reported.
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Sapru S, Nanda SS. Radical Radiotherapy Should Remain the Standard of Care for Carcinoma Oropharynx. JAMA Otolaryngol Head Neck Surg. Published online March 12, 2020. doi:10.1001/jamaoto.2020.0089
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