Easy to swallow.

Top Line: We got a taste of ORATOR-2 at ASTRO 2021 where we learned the oncologic and survival outcomes were excellent following definitive radiation to 60 Gy for early-stage HPV+ oropharyngeal cancer.

The Study: We now have the long term results of its predecessor ORATOR. To recap, this phase 2 trial randomized 68 patients with T1-T2N0-2 HPV+ oropharyngeal cancer to upfront transoral robotic surgery (TORS) with neck dissection versus definitive radiation to the standard 70 Gy in 30 fractions. Let’s back up for a minute, why this design? Because a randomized trial is always better than the same conjecture on repeat every week at multi-D tumor board. Everyone agrees these patients do great and should receive the least toxic treatment that doesn’t compromise outcomes. What they don’t agree on is just what that treatment strategy is. On the one hand, surgery has the inherent benefit of being a one-day treatment. On the other hand, a majority (70% on this trial) consistently merit post-TORS adjuvant radiation, anyway, and are left with bi- or even tri-modality toxicity. Note: here adjuvant radiation was received in the setting of lymphovascular invasion, margins < 2 mm, and pT3-T4 or pN1 disease and adjuvant chemoradiation with positive margins or extranodal extension. The primary outcome of MDADI scores, a validated measure of swallowing function, remains statistically superior in the radiation arm at not only year one but also years two and three. The caveat being that these differences are clinically quite small. Other trade-offs included more ototoxicity and neutropenia with definitive radiation and more pain, trismus, and bleeding with TORS. Finally, exploratory analyses suggest poorer swallowing outcomes after TORS may be more explained by primary tumor location (i.e., base of tongue versus lateralized tonsil) more so than +/- receipt of adjuvant radiation.

TBL: Quality of life is pretty good after either upfront TORS or radiation for early-stage HPV+ oropharyngeal cancer, but swallowing outcomes are technically slightly better after radiation. | Nichols, J Clin Oncol 2022