With improvement in surgical techniques, including minimally invasive procedures, there is a need to revisit various treatment options and look at the overall survival of different treatment groups.
—Chih-Tao Cheng, MD, DrPH
A large study presented at the 2015 European Cancer Congress in Vienna found that patients with advanced oropharyngeal or hypopharyngeal cancer had improved survival if their primary treatment included surgery.1 The caveat is that these patients were treated in Taiwan, and the results may not be generalizable to the United States or elsewhere.
“Primary surgery is associated with better overall survival and disease-free survival, even after controlling for potential confounders. Surgery should be the treatment of choice for stage IVA oropharyngeal and stage III and IVA hypopharyngeal cancers,” stated lead author Chih-Tao Cheng, MD, DrPH, a medical researcher at the Koo Foundation Sun Yat-Sen Cancer Center in Taipei City, Taiwan.
“There has been a paradigm shift regarding treatment of oropharyngeal and hypopharyngeal cancers. Concurrent chemoradiotherapy has become the standard of care for unresectable head and neck cancers, and it is being used alone, even where surgery is possible,” Dr. Cheng explained.
“Several studies have shown that nonsurgical approaches such as concurrent chemoradiotherapy can achieve comparable results to surgery and also achieve organ preservation. But many patients treated without surgery still develop long-lasting comorbidities, including difficulty in swallowing and speech. With improvement in surgical techniques, including minimally invasive procedures, there is a need to revisit various treatment options and look at the overall survival of different treatment groups,” he elaborated.
“It is difficult to conduct a prospective study on surgical vs nonsurgical approaches,” he pointed out. Therefore, Dr. Cheng and coauthors conducted a retrospective study based on national registry databases for cancers diagnosed between 2004 and 2009, health insurance, and death. They also conducted an adjusted analysis to account for potential confounding factors. Patients were followed until 2012.
The study identified 2,482 patients diagnosed with oropharyngeal cancer and 2,322 diagnosed with hypopharygeal cancers. Of them, patients with clinical stage III and IV disease could potentially benefit from surgery, and this is the group they focused on in their study: 1,698 with stage III or IV oropharyngeal cancers and 1,619 with stage III or IV hypopharyngeal cancers.
Radical surgery was performed on 35% of stage III oropharyngeal patients and 38% of stage IV oropharyngeal patients. About half of both stage III and IV hypopharyngeal cancer patients had radical surgery (55% and 49% of stage IVA patients, respectively).
Outcomes in surgical and nonsurgical groups were compared, irrespective of whether patients were treated with concurrent chemoradiotherapy. For both types of cancer, surgically treated patients were significantly more likely to survive at 5 years than those who did not have surgery. Five-year overall survival rates were 59% of the surgery group vs 48% of the nonsurgery group. Among patients with stage IVA oropharyngeal cancer, 5-year overall survival rates were 51% for the surgery group vs 40% for the nonsurgery group.
The 5-year survival rate for stage III hypopharyngeal cancer was 54% among the surgical group and 33% among the nonsurgical group. For stage IV disease, overall survival rates were 39% and 26%, respectively.
“Surgery had a somewhat greater survival benefit in the hypopharyngeal cancers compared with oropharyngeal cancers,” Dr. Cheng reported.
Due to the potential for selection bias, an adjusted analysis was performed to control for gender, age, comorbidity, tumor site, lymph node invasion, and radiation.
“After controlling for potential confounders, our conclusion still stands. We found significantly improved overall and disease-free survival [in surgically treated patients], with the exception of stage III oropharyngeal cancer,” he said.
At the presentation, several audience members took issue with the study. Critiques included the fact that patients were not stratified according to whether or not they were surgical candidates, and no details were provided for treatments in the nonsurgery group. ■
Disclosure: Dr. Cheng reported no potential conflicts of interest.
1. Cheng CT, Terng SD, Lin CY, et al: Primary surgery for advanced oropharyngeal and hypopharyngeal cancers: A nationwide study in Taiwan. 2015 European Cancer Congress. Abstract 2804. Presented September 26, 2015.
After presentation of the study by Cheng and colleagues at the 2015 European Cancer Congress, formal discussant Vincent Grégoire, MD, PhD, Department of Radiation Oncology, UCL St-Luc University Hospital, Brussels, Belgium, was cautious in endorsing a surgical approach for stage III and IV...