Swallowing and Speech Outcomes After Transoral Robotic Surgery +/- Adjuvant Therapy for HPV(+) Oropharyngeal Squamous Cell Carcinoma

Presentation: C061
Topic: Pharynx / Larynx Cancer
Type: Poster
Date: Thursday, April 19, 2018
Session: 9:00 AM - 7:00 PM
Authors: K M Van Abel, MD1, M H Quick1, D E Graner, CCCSLP2, C M Lohse, MS3, D J Ma, MD4, K P Price, MD5, D L Price, MD1, E J Moore, MD1
Institution(s): 1Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA, 2Division of Speech Pathology, Mayo Clinic, Rochester, Minnesota, USA, 3Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA, 4Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA, 5Department of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA

IMPORTANCE: Understanding functional swallowing and speech outcomes for HPV(+) oropharyngeal squamous cell carcinoma (OPSCC) patients beyond the binary PEG/no PEG, tracheostomy/no tracheostomy is important for patient counseling and further validation of the need for treatment de-escalation strategies.

OBJECTIVE: To compare measures of swallowing and speech outcomes in HPV(+)OPSCC patients undergoing TORS-based therapy with neck dissection (ND) +/- radiation(RT) or chemoradiation(CRT).

DESIGN: Retrospective chart review.

SETTING: Academic hospital.

PARTICIPANTS: We identified patients with primary HPV(+)OPSCC of the base of tongue and tonsil who underwent TORS-based therapy with intent-to-cure at our institution from 05/01/2007-05/31/2015. No patients receiving adjuvant de-escalation were included.

MAIN OUTCOMES & MEASURES: Clinical data were retrieved from diagnosis to study end. A study-ending event was defined as last follow up, new tumor, metastasis, or death. Formal speech evaluations were collected when available, most commonly prior to and following adjuvant therapy. Scored evaluations included the Functional Oral Intake Scale (FOIS), Performance Status Scale for Head & Neck Cancer Patients (PSS-HN), Functional Contextual Speech Intelligibility, hoarseness and hypernasality.

RESULTS: A total of 267 patients (median 58yrs old, 89% male, 66% tonsil, 90% T1/T2, 70% N2) met criteria. Most were never smokers (48%) with an ACE-27 score of 0 (42%). Treatment included TORS+ND in 25%, TORS+ND+RT in 30% and TORS+ND+CRT in 45%. ND was most commonly ipsilateral (88%), no patient received a free flap, the median total gray was 60 (range 48-70), and high dose cisplatin was used in 55% (55/100).

PEG was placed in 28% and was more common for TORS+ND+CRT (p<0.001). At study end, 259 (97%) reported a full oral diet with two patients fully PEG tube dependent. A tracheostomy was placed prior to or during treatment in 30 patients (11%) with all but two tracheostomy-free at study end. FOIS scores were rated at 5/6/7 for 73% (69/94) of patients before adjuvant therapy and 69% (60/87) at study end a median of 6.3 months following treatment. PSS-HN was 75-100% for public eating in 81% (26/32) and normalcy of diet in 55% (17/31) before adjuvant therapy. At study end this dropped to 67% (30/45) and 27% (12/44), respectively. PSS-HN for speech understandability was 75-100% in 100% (32/32) and PSS-HNS functional contextual speech intelligibility was 100% at both time points. Hoarseness and hypernasality were present in 27% (26/98) and 7% (7/98) prior to adjuvant and in 42% (38/91) and 9% (8/91) at study end, respectively.

CONCLUSIONS & RELEVANCE: We found a 97% return to full oral diet and <1% risk of long term tracheostomy dependence for TORS-based therapy. While encouraging, these outcomes are not a surrogate for normal swallowing and speech. Although the relatively lower number of patients undergoing speech evaluation represents a study bias, validated swallowing and speech measures associated with quality of life demonstrated worsening function in almost all measures following standard adjuvant therapy. Further prospective studies are needed, and currently underway, to investigate the impact of treatment de-escalation on swallowing and speech outcomes.