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. 2019 Nov 1;145(11):1053-1063.
doi: 10.1001/jamaoto.2019.2725.

Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Katherine A Hutcheson  1   2 , Carla L Warneke  3 , Christopher M K L Yao  1 , Jhankruti Zaveri  1 , Baher E Elgohari  1   2 , Ryan Goepfert  1 , Amy C Hessel  1 , Michael E Kupferman  1 , Stephen Y Lai  1   2 , C David Fuller  2 , G Brandon Gunn  2 , Adam S Garden  2 , Faye Johnson  4 , Renata Ferrarotto  4 , Jan S Lewin  1 , Neil D Gross  1 ; MD Anderson Head and Neck Cancer Symptom Working Group
Affiliations

Dysphagia After Primary Transoral Robotic Surgery With Neck Dissection vs Nonsurgical Therapy in Patients With Low- to Intermediate-Risk Oropharyngeal Cancer

Katherine A Hutcheson et al. JAMA Otolaryngol Head Neck Surg. .

Abstract

Importance: A major goal of primary transoral robotic surgery (TORS) for oropharyngeal cancer is to optimize swallowing outcomes by personalized treatment based on pathologic staging. However, swallowing outcomes after TORS are uncertain, as are the outcomes compared with nonsurgical options.

Objectives: To estimate rates of acute dysphagia and recovery after TORS and to compare swallowing outcomes by primary treatment modality (TORS or radiotherapy).

Design, setting, and participants: This case series study was a secondary analysis of prospective registry data from 257 patients enrolled from March 1, 2015, to February 28, 2018, at a single academic institution who, according to the AJCC Staging Manual, 7th edition TNM classification, had low- to intermediate-risk human papillomavirus-related oropharyngeal squamous cell carcinoma possibly resectable by TORS.

Exposure: Patients were stratified by primary treatment (75 underwent TORS and 182 received radiotherapy).

Main outcomes and measures: Modified barium swallow (MBS) studies graded per Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) questionnaires were administered at standard intervals. Prevalence and severity of dysphagia were estimated per DIGEST before and after TORS and 3 to 6 months after treatment. Moderate-severe dysphagia (DIGEST grade ≥2) was assessed using logistic regression and compared by primary treatment group. The MDASI swallowing symptom severity item scores during and after radiotherapy were compared using generalized estimating equations by treatment status at the start of radiotherapy, after induction, and after TORS.

Results: A total of 257 patients (mean [SD] age, 59.54 [9.07] years; 222 [86.4%] male) were included in the study. Dysphagia severity (per DIGEST) was significantly worse after TORS (r = -0.63; 95% CI, -0.78 to -0.44): 17 patients (22.7%; 95% CI, 13.8%-33.8%) had moderate-severe (DIGEST grade ≥2) acute post-TORS dysphagia significantly associated with primary tumor volume (odds ratio, 1.43; 95% CI, 1.11-1.84). DIGEST improved by 3 to 6 months but remained worse than that at baseline; at 3 to 6 months, the number of patients with DIGEST grade 2 or higher dysphagia was 5 (6.7%; 95% CI, 2.2%-14.9%) after primary TORS and 29 (15.9%; 95% CI, 10.9%-22.1%) after radiotherapy. At the start of radiotherapy, MDASI swallowing symptom severity item scores were significantly worse in the post-TORS group compared with postinduction (mean [SD] change, 2.6 [1.1]) and treatment-naive (mean [SD] change, 1.7 [0.3]) patients. This result inverted at radiotherapy end, and all groups converged at 3 to 6 months.

Conclusions and relevance: Subacute swallowing outcomes were similar regardless of primary treatment modality among patients with low- to intermediate-risk oropharyngeal squamous cell carcinoma.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hutcheson reported receiving research grants and contracts from the National Institutes of Health and the Patient Centered Outcomes Research Institute. Dr Lai reported receiving personal fees from Cardinal Health outside the submitted work. Dr Fuller reported receiving grants and personal fees from the National Institutes of Health, grants and personal fees from Elekta AB, and personal fees from Greater Baltimore Medical Center, Tianjin Memorial Hospital, and the American Association of Physicists in Medicine outside the submitted work. Dr Johnson reported receiving grants from Trovagene and PIQUR outside the submitted work. Dr Ferrarotto reported receiving consulting fees from Ayala Pharmaceuticals, Regeneron Sanofi, and Klus. Dr Gross reported receiving personal fees from Intuitive Surgical and nonfinancial support from MedRobotics outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart
Cohort sampling from the MD Anderson Oropharynx Cancer Registry. HPV indicates human papillomavirus; TORS, transoral robotic surgery.
Figure 2.
Figure 2.. Longitudinal Swallowing Outcomes by Modified Barium Swallow (MBS) Study Graded per Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and MD Anderson Symptom Inventory–Head and Neck Module (MDASI-HN) Swallowing Symptom Severity Item Among Patients With Low- to Intermediate-Risk Oropharyngeal Squamous Cell Carcinoma
A, Longitudinal prevalence and severity of pharyngeal dysphagia among the primary transoral robotic surgery (TORS) group per MBS DIGEST (n = 75). B, Least-square means of MDASI-HN swallowing symptom severity item adjusted for baseline item score, age, and concurrent chemotherapy (n = 219). C, Difference in prevalence of moderate to severe dysphagia (MBS DIGEST grade ≥2) at 3 to 6 months by primary treatment group. D, Prevalence of moderate to severe dysphagia (MBS DIGEST grade ≥2) at 3 to 6 months by treatment group (n = 257) and by treatment subgroup. Error bars indicate 95% CIs.
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Comment in

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