Transoral robotic surgery (TORS) can offer patients with oropharyngeal squamous cell carcinoma (OPSCC) improved survival while minimizing or avoiding late toxicities associated with the standard of care of radiation with cisplatin chemotherapy, according to a recent ASCO guideline.1
F. Christopher Holsinger, MD, FACS
“We show in a rigorous, evidence-based way that TORS is a great treatment option and is really the only way to de-escalate treatment for human papillomavirus [HPV]-mediated oropharyngeal cancer,” said Expert Panel Co-Chair F. Christopher Holsinger, MD, FACS, of Stanford University.
Responding to a Changing Patient Population
Up until about 25 years ago, head and neck cancers were largely diagnosed in older men and especially those who used tobacco, alcohol, or both. But since the late 1990s, epidemiologists have witnessed a trend toward these diseases developing increasingly in younger men and women as well as people who are relatively healthy.
“This surge in cases was due to HPV-mediated oropharyngeal cancer,” said Dr. Holsinger. “Head and neck cancer is no longer an orphan disease; all of a sudden, we are looking squarely in the face of a completely new disease.”
The shift in the demographics toward a younger, healthier population now developing HPV-related head and neck cancers—and primarily OPSCC—has spurred interest in finding less-toxic treatments than the current standard of care.
“Unlike the HPV-negative squamous cell cancer, which is linked to smoking and tobacco use, HPV-associated oropharyngeal cancer has a much better prognosis, which means an increasing number of long-term survivors,” said Expert Panel Co-Chair Jamie A. Ku, MD, FACS, of Cleveland Clinic.
Jamie A. Ku, MD, FACS
As a result, she said, there has been a burst of “excitement and research focused on deintensifying treatment” for this population.
TORS is one such approach that has been explored as a way to maintain good survival outcomes without exposing patients to the long-term side effects of chemoradiation (eg, dysphagia or difficulty swallowing) and disruptions in quality of life.2-5 As such, ASCO convened a multidisciplinary Expert Panel to assess the evidence for TORS in this population and provide recommendations for its use. Input was gathered from published clinical trials as well as both prospective and retrospective studies, alongside experts in surgical oncology, radiation oncology, medical oncology, and speech/language pathology.
Offering Reassurance
In addition to summarizing the trials reporting survival and quality-of-life outcomes, much of the guideline focuses on indications and patient selection. This includes a detailed description of what a “good” candidate patient might look like in terms of tumor size, lateralization, exposure, and surgical access.
However, Dr. Ku noted, the guideline’s recommendations around patient selection are “likely also the most controversial, as the quality of data for a surgical team’s decision-making around patient selection is not well studied in a prospective, rigorous manner.”
The panel also wanted to emphasize the fact that TORS is approved by the U.S. Food and Drug Administration for T1 to T2 cancers of the oral cavity, pharynx, and larynx, so oncologists understand there are robust data supporting this approach despite its novelty.6
However, some topics were considered too premature or lacked the consensus across the panel required to justify inclusion. For instance, Dr. Ku pointed to the need for more data to clearly define what is considered “adequate” surgical margins after TORS and the significance of extranodal extension as well as unanswered questions about the use of circulating tumor DNA as a biomarker in diagnosis, surveillance, and clinical decision-making in HPV-related disease.
“There are numerous deintensification strategies that are still to be explored in the clinical trial setting, and [some] ongoing [research] that will also further define the role of TORS in OPSCC,” she added. Common examples of other potential de-escalation approaches currently being investigated include decreasing the dose and/or field or volume of radiation as well as omitting chemotherapy, Dr. Ku noted.
Another area not addressed by the guideline concerns HPV vaccination, largely because the recommendations are focused on treatment rather than prevention. However, Dr. Holsinger explained that low vaccination rates are driving increases in OPSCC incidence, meaning the population of patients needing TORS will likely continue to increase as vaccine uptake continues to lag.
Accordingly, he and his colleagues recently published survey data about the lack of public awareness of HPV vaccination in the United States and its potential economic costs.7 Dr. Holsinger said similar public health efforts to improve public knowledge about HPV prevention will be critical going forward.
For those who do develop HPV-related head and neck tumors, the guideline emphasizes the importance of oncologists engaging patients in a multidisciplinary, collaborative treatment-planning process that considers both TORS and chemoradiation along with their unique upsides and risks. “[The guideline] makes the case that we need to engage patients in decision-making in a very structured way, through shared decision-making. That’s where we think this needs to go,” said Dr. Holsinger.
REFERENCES
1. Holsinger FC, Ismaila N, Do Adkins DR, et al: Transoral robotic surgery in the multidisciplinary care of patients with oropharyngeal squamous cell carcinoma: ASCO guideline. J Clin Oncol. February 11, 2025 (early release online).
2. Ferris RL, Flamand Y, Weinstein GS, et al: Phase II randomized trial of transoral surgery and low-dose intensity modulated radiation therapy in resectable p16+ locally advanced oropharynx cancer: An ECOG-ACRIN Cancer Research Group Trial (E3311). J Clin Oncol 40:138-149, 2022.
3. Meccariello G, Bianchi G, Calpona S, et al: Trans oral robotic surgery versus definitive chemoradiotherapy for oropharyngeal cancer: 10-Year institutional experience. Oral Oncol 110:104889, 2020.
4. Hargreaves S, Beasley M, Hurt C, et al: Deintensification of adjuvant treatment after transoral surgery in patients with human papillomavirus-positive oropharyngeal cancer: The conception of the PATHOS study and its development. Front Oncol 9:936, 2019.
5. Oliver JR, Persky MJ, Wang B, et al: Transoral robotic surgery adoption and safety in treatment of oropharyngeal cancers. Cancer 128:685-696, 2022.
6. Mella MH, Chabrillac E, Dupret-Bories A, et al: Transoral robotic surgery for head and neck cancer: Advances and residual knowledge gaps. J Clin Med 12:2303, 2023.
7. Lechner M, Masterson L, Mermelstein S, et al: Oropharyngeal cancer: Lack of human papillomavirus awareness and economic burden in the United States. Clin Transl Med 14:e70062, 2024.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, February 26, 2025. All rights reserved.
