Page 39 - Functional impairment and cues for rehabilitation of head and neck cancer patients -

Swallowing function after treatment for early-stage OPC
The only randomized comparative study investigating differences in clinical outcomes after surgery or radiotherapy for early stage oropharyngeal carcinoma was the ORATOR- trial, including 68 patients, of which the results were published recently (11). Differences in swallowing related quality of life were not clinically meaningful and the authors concluded that both treatment options have different toxicity profiles. A recent retrospective study focusing on patient reported outcomes was performed by Amit et al. who compared symptom burden and quality of life of low-intermediate risk OPC treated either surgically or nonsurgically (32). Patients were analysed by received treatment rather than intended treatment. Results of the 24 patients treated with singly modality, a significantly smaller sample size than our current analyses, showed that surgery participants had less interference of symptoms on daily functioning at 6 month post treatment. Also, studies have focused on patient reported outcomes and swallowing in more advanced staged OPC and concluded that surgery seems beneficial over CRT . Many other studies have reported on outcomes after single-modality treatment for early-stage OPC, but most have focused on either surgery or RT separately (28, 35), or only examined survival and disease recurrence (5, 10, 36-39). Results from the systematic review of observational studies by de Almeida et al. (4) showed different adverse events after either surgery or RT for early-stage OPC including oesophageal stenosis and osteoradionecrosis after (adjuvant) RT, and haemorrhage and fistula after surgery. The review of Huang et al. (9) reported on a feeding tube dependency rate of 5% one-year post treatment for both surgery and RT in early-stage OPC, which was comparable to the 4% in our cohort.
Previous studies have shown that HPV-positive and -negative OPC are distinct diseases with respect to both aetiology and prognosis (40). Currently, treatment de-intensification trials are underway for early-stage oropharyngeal carcinoma that aim to reduce toxicity while maintaining excellent survival (31). In our study, although participant numbers were low within groups, functional outcomes between HPV-positive and -negative participants seemed comparable. Also, no substantial differences in survival were seen. The possible difference in survival in HPV-negative participants between those who were offered RT or surgery might be caused by differences in age, comorbidities, and tumour biology or it could be due to chance.
This study has several limitations. Firstly, 49% of those eligible were actually enrolled (n = 5511) (18). This may result in selection bias and a lack of generalisability. Secondly, of the 300 OPC participants offered single-modality treatment, only 163 patients had data on self-reported swallowing and secondary functional outcomes available at 12-month follow-up. These missing data reduced the sample size and there may have been differences in those that provided complete data and those with missing data. Thirdly, because data from an existing large UK- wide multicentre study HN5000 were used, collecting a broad range of data from participants, detailed data on treatment and the process of clinical decision making were not collected. So data on treatment characteristics (e.g., surgical approach, and RT details such as time to and reason for adjuvant RT) that would have been valuable to this study were not available. Also, since most swallowing problems occurred in eating solids, information on dental status would provide more insight in the aetiology of the swallowing difficulties. Fourthly, multiple
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