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Original Investigation
October 29, 2020

Oncologic Outcomes Following Transoral Robotic Surgery for Human Papillomavirus–Associated Oropharyngeal Carcinoma in Older Patients

Author Affiliations
  • 1Department of Otorhinolaryngology–Head & Neck Surgery, University of Pennsylvania, Philadelphia
  • 2Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
  • 3Department of Radiation Oncology, University of Pennsylvania, Philadelphia
JAMA Otolaryngol Head Neck Surg. 2020;146(12):1167-1175. doi:10.1001/jamaoto.2020.3787
Key Points

Question  What are the oncologic outcomes of an upfront transoral robotic surgery approach to human papillomavirus–associated oropharyngeal carcinoma in older adults?

Findings  In a cohort study including 77 older patients with oropharyngeal carcinoma, 3-year estimated survival outcomes were 92.4% for disease-specific, 90.0% for overall, and 84.3% for disease-free survival over a median follow-up period of 39.6 months. Twenty-seven patients (35.1%) underwent postoperative radiotherapy and 20 patients (26.0%) underwent postoperative chemoradiotherapy.

Meaning  The findings of this study suggest that the transoral robotic surgery approach can provide positive survival outcomes for carefully selected older adults with oropharyngeal carcinoma and, in many of these patients, obviate the need for chemotherapy.


Importance  While early epidemiologic studies ascribed increases in the incidence of human papillomavirus–associated oropharyngeal cancers to middle-aged patients, recent analyses have demonstrated an increasing median age of diagnosis. Treatment of patients older than 70 years is controversial as their inclusion in the practice-defining clinical trials has been limited and the survival benefit conferred by chemotherapy may be outweighed by treatment toxic effects.

Objective  To assess the oncologic outcomes of older adults with human papillomavirus–associated oropharyngeal cancer who underwent upfront transoral robotic surgery and pathologic characteristics–guided adjuvant therapy in a large cohort of patients with close follow-up.

Design, Setting, and Participants  A retrospective cohort analysis was conducted in a tertiary care academic medical center between January 1, 2010, and December 30, 2017. Patients aged 70 years or older at time of diagnosis with biopsy-proven and surgically resectable p16-positive oropharyngeal cancers were included. Data analysis was conducted from March 1 to June 1, 2020.

Exposures  Transoral robotic surgery oropharyngeal resection and neck dissection with pathologic characteristic-guided adjuvant therapy.

Main Outcomes and Measures  Three-year estimates of disease-specific survival, overall survival, and disease-free survival, as well as rates of adjuvant therapy (radiotherapy and chemoradiotherapy) and perioperative complications.

Results  Seventy-seven patients were included (median age, 73.0; interquartile range, 71.0-76.0; range, 70-89 years); of these, 58 were men (75.3%). Perioperative mortality was 1.3% and the rate of oropharyngeal hemorrhage was 2.6%. Twenty-seven patients (35.1%) underwent postoperative radiotherapy and 20 patients (26.0%) underwent postoperative chemoradiotherapy. The median length of follow-up was 39.6 (range, 0.1-96.2) months, and the 3-year estimates of survival were 92.4% (95% CI, 82.4%-96.9%) for disease-specific survival, 90.0% (95% CI, 79.4%-95.0%) for overall survival, and 84.3% (95% CI, 73.4%-91.0%) for disease-free survival.

Conclusions and Relevance  The findings of this cohort study suggest that transoral robotic surgery and pathologic characteristic–guided adjuvant therapy can provide beneficial survival outcomes, infrequent perioperative mortality, and, for most carefully selected older adults, obviate the need for chemotherapy.

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