Transoral robotic surgery linked to survival benefit in early-stage oropharyngeal cancer
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Transoral robotic surgery appeared associated with improved surgical and long-term survival outcomes compared with nonrobotic surgery for patients with early-stage oropharyngeal cancer, according to study results published in JAMA Oncology.
“At a minimum, robotic surgery for patients with oropharyngeal cancer seems safe and effective compared to what’s been the standard of care for many years,” Zachary S. Zumsteg, MD, assistant professor of radiation oncology at Cedars-Sinai, said in a press release. “Our purpose in doing this study was to see how this new technology, which has never been tested in a randomized, controlled trial, has influenced patterns of treatment and outcomes since its FDA approval.”
Patients with early-stage oropharyngeal squamous cell carcinoma (OPSCC) usually receive definitive radiotherapy over surgery because historical studies have shown higher morbidity with surgical approaches. The development of minimally invasive approaches via transoral robotic surgery, however, has the potential to change this risk-benefit equation, according to researchers.
Previous studies have shown that transoral robotic surgery, approved by the FDA in 2009 for treatment of OPSCC, has decreased operative time, shortened hospitalizations and improved post-surgical quality of life compared with open surgery.
Zumsteg and colleagues conducted a retrospective cohort comparative effectiveness analysis to compare long-term outcomes of transoral robotic surgery vs. nonrobotic surgery among 9,745 patients (mean age, 58.8 years; 78.5% men) with early-stage OPSCC. Among these patients 27.6% (n = 2,694) underwent robotic surgery.
Researchers conducted a multivariable Cox proportional hazards regression analysis and propensity score matching among patients with known HPV status (n = 4,071) to adjust for patient- and disease-related covariates.
OS served as the primary endpoint.
From 2010 to 2015, the use of robotic surgery for clinical T1 and T2 OPSCC increased from 18.3% (240 of 1,309) to 35.5% (654 of 1,831) of all surgical procedures (P = .003).
Results showed associations between robotic surgery and lower rates of positive surgical margins (12.5% vs. 20.3%; P < .001) and adjuvant chemoradiotherapy use (28.6% vs. 35.7%; P < .001) compared with nonrobotic surgery.
Among the subset of patients with known HPV status, robotic surgery appeared associated with improved OS vs. nonrobotic surgery (HR = 0.74; 95% CI, 0.61-0.9). Those who received robotic vs. nonrobotic surgery had a higher 5-year OS rate (84.8% vs. 80.3%) in propensity score-matched cohorts (P = .002).
Researchers also compared survival after robotic and nonrobotic surgery among patients with prostate, endometrial and cervical cancers. Results showed no evidence that robotic surgery improved survival in prostate cancer (HR = 0.92; 95% CI, 0.79-1.07), endometrial cancer (HR = 0.97; 95% CI, 0.9-1.04) and cervical cancer (HR = 1.27; 95% CI, 0.96-1.69).
The results are hypothesis-generating and hopefully will inform future randomized, controlled clinical trials, according to Anthony T. Nguyen, MD, PhD, lead study author and resident in the department of radiation oncology at Cedars-Sinai.
“Meanwhile, it’s reassuring to our patients that their survival rate is still the same if not better with robotic surgery and they have the potential for a better quality of life,” he said in the release.
There is little doubt that robotic surgery is here to stay, Yinin Hu, MD, surgical oncologist at University of Virginia, and Vivian E. Strong, MD, FACS, surgeon at Memorial Sloan Kettering Cancer Center, wrote in an accompanying editorial.
“Broadly, robotic surgery trades higher cost and longer operating time for lower morbidity and faster recovery compared with an open approach,” Hu and Strong wrote. “In experienced hands, robotic surgery can achieve excellent short-term outcomes, but rigorous research into long-term survival is sorely needed.
“Ultimately, the reality for most solid tumors is that survival is rarely dictated solely by local control and the robot serves as a technical tool to improve operative intervention,” they added. “Thus, the key questions in cancer surgery always remain who should undergo resection and when, not how. These techniques, and future improvements, will augment our capabilities as surgeons, but rigorous attention to the primary goals of safety and oncologic principles must remain the most important priorities.”
References:
Hu Yinin and Strong VE, et al. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2020.2996.
Nguyen AT, et al. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2020.3172.
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