To TORS or not to TORS.

Headline: De-escalated definitive radiation to 60 Gy for HPV+ oropharyngeal cancer is better tolerated than upfront TORS.

The Study: Remember, the first ORATOR trial demonstrated a worse dysphagia score with upfront TORS (70% receiving adjuvant radiation) versus upfront definitive radiation +/- chemo. In ORATOR-2, 61 patients with T1-T2N0-1 HPV+ oropharyngeal cancer were again randomized to upfront TORS versus radiation, but this time radiation was slightly de-escalated to 60 Gy in 30 fractions à la HN002 with standard concurrent cisplatin in the case of nodal involvement.The most notable finding were two postoperative deaths due the hemorrhage and cervical osteomyelitis (following adjuvant radiation), which led to early closure to accrual. This also heavily influenced the primary outcome of overall survival among a cohort with an otherwise superb prognosis. At 2 years, overall survival was 100% after definitive radiation and 89% after surgery; progression-free survival was 100% after definitive radiation and 83.5% after surgery. Given the small numbers and what many would consider fluke grade 5 events, head and neck surgeons everywhere will be shaking their heads at the previous comparisons. Nonetheless, there's no denying the safety and effectiveness of the definitive 60 Gy approach.

TBL: Stopping at 60 Gy when definitively treating HPV+ oropharyngeal cancer remains promising - don’t miss our QuadCast interview with Dr. Palma for much more than the bottom line. | Palma, ASTRO 2021