Management of oropharyngeal cancer: a cross-sectional review of institutional practice at a large Canadian referral centre

BACKGROUND: Over the years, the treatment of oropharyngeal cancer has changed; in the past, first-line treatment consisted of surgery followed by adjuvant radiotherapy, today however, primary treatment typically involves concomitant chemoradiation, and reserves surgery for salvage. While chemoradiation is the modality of choice for primary management of oropharyngeal cancer, disease characteristics, institutional bias, and patient preferences influence treatment choice. This has lead to variation in the treatment of OPC, and has generated some uncertainly regarding the ideal therapeutic approach. The objective of this study was to describe the treatment of OPC a large Canadian referral center, highlighting trends in treatment choice and outcome. METHODS: This is a cross-sectional retrospective review of clinical practice at Sunnybrook Health Science Centre (Toronto, ON). This investigation documents type of first-line treatment, rates of treatment failure, rates of surgical salvage, and 5-year disease-free survival. This study also asses the therapeutic impact of free-flap reconstruction on the use of a postoperative tracheostomy and/or percutaneous endoscopic gastrostomy tube. RESULTS: The majority of oropharyngeal cancer patients presented with regionally metastatic disease (stage III-IV) and underwent concomitant chemoradiation as first-line treatment. Just over half of patients who failed chemoradiation were eligible for salvage surgery. Forty-six percent of salvage patients recurred at approximately 6 months, and died approximately 12 months following the first sign of disease recurrence. Five-year survival for salvage patients stage II, III, IVA, and IVB was 100%, 54.5%, 53.8%, and 50%, respectively. The incidence of percutaneous endoscopic gastrostomy tubes and tracheostomies was comparable between patients who underwent free-flap reconstruction and patients who did not. CONCLUSION: The modality of choice for first-line treatment of oropharyngeal cancer is concomitant chemoradiation. The moderate failure rate following chemoradiation and the modest survival rate following salvage surgery could indicate that selected patients may benefit from undergoing surgery as first-line treatment. While this study did not show that functional outcomes were better for free-flap patients, it is highly likely that those who received a free-flap did better then they would have had they not undergone reconstructive surgery. More research regarding the therapeutic effects of free-flaps in OPC survivors is needed.