Transoral robotic surgery for head and neck cancer feels a lot better than chemoradiation—but is it?

With FDA approval early this year to market robotic surgery applied through the open mouth for oral and throat cancers, there's a new element in the surgery-versus-chemoradiotherapy debate surrounding these malignancies. As yet there's little evidence that robotic surgery offers oncologic outcomes comparable to chemoradiation, according to a recent review by the surgeons who pioneered the technique at the University of Pennsylvania.
(Current Opinion in Otolaryngology & Head and Neck Surgery 2009, 17:126–131)

Functional outcomes (postoperative pain, swallowing ability, and the like) are clearly better than traditional surgery or chemoradiation, but does the patient risk survival in the interests of comfort?A preliminary study from New York's Mount Sinai Hospital begins to address that question. Comparing 25 patients treated with transoral robotic surgery (TORS) for oropharyngeal cancer and 12 treated with standard chemoradiation, the TORS group showed "equivalent or near-equivalent" one-year outcomes to the chemoradiation patients in terms of disease-free survival and overall survival (86% for both measures in the TORS group). The results were reported late last month at the Multidisciplinary Head and Neck Cancer Symposium in Chandler, Arizona.

It's crucial to confirm by endoscopy beforehand that a patient's anatomy and the tumor itself are amenable to the robotic approach, according to the University of Pennsylvania surgeons. When feasible, the robotic approach is clearly easier than traditional surgery for both surgeon and patient.

For instance, "to remove a tonsil cancer, surgeons frequently have to split the lip and the jaw in order to gain surgical access to that area to safely remove the tonsil cancer. With the use of the robot, we avoid the splitting of the lip and the jaw, the surgery is shorter, and the patient recovers much faster," says Ho-Sheng Lin, MD, chief of otolaryngologic surgery at Detroit's VA Medical Center, one of several surgeons conducting clinical trials of TORS. "Most importantly, patient's function is better following the surgery."

However, the comparison with other kinds of surgery is no longer the topic of much discussion. The issue is whether TORS is the best solution to the "substantial" risk of adverse effects from chemoradiation, as documented in Archives of Otoloaryngology—Head and Neck Surgery last December in a study from the University of Iowa.

The New York Mt. Sinai group reported better initial eating ability and dietary quality in the TORS group than in the chemoradiotherapy group, although these measures were similar a year after surgery. Better targeting of radiotherapy has already improved outcomes for these patients, and further improvements are still possible. For instance, a shorter course of radiation could reduce the amount of chemotherapy required to treat oropharyngeal cancers, according to a report from the University of Montreal also presented at the Arizona symposium.

Only a few centers in the United States are able to offer TORS, although the University of Pennsylvania team began a concerted effort to train other surgeons in the technique in 2006. But nearly 800 facilities in the United States (and many in other countries) have purchased the Da Vinci robotic surgical system, which is used for many other indications. Given that the initial investment for the equipment has already been made, hospitals have an incentive to increase their use of robotic surgery, and the FDA approval leaves the Pennsylvania surgeons free to expand their training program for TORS.

With numerous clinical trials of TORS already underway, expect an intensive effort to substantiate the clinical value of this procedure for head and neck cancers—now that its safety, convenience, and comparatively mild sequelae are more or less taken for granted.

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