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Nearly 12 years after its approval, use of TORS for oropharyngeal cancer still varies among institutions, according to Dr. Holsinger. Part of the reason may be the difficulty of comparing outcomes between treatment regimens—that is, between frontline surgery and frontline radiation. Oftentimes, with TORS, a lower dose of radiation therapy can be given postoperatively; sometimes radiation therapy is omitted completely. Dr. Holsinger explained that the postoperative dose of radiation after TORS might be reduced by 15% from the traditional dose of 70 Gray used when radiation is administered as a definitive treatment with chemotherapy. Lowering or eliminating radiation therapy has been shown to prevent or drastically reduce late radiation-associated dysphagia (RAD) and other complications, but the data are largely retrospective.
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September 2021According to Dr. Holsinger, however, more evidence is coming soon. He believes compelling evidence from prospective trials funded by the National Institutes of Health will be available in the next couple of years. “We’re going to have level A evidence-based medicine to justify the use of TORS, and that will really transform the conversation among all otolaryngologists—even ones who don’t frequently see patients with oropharyngeal cancer,” he said. He noted that this higher level of evidence will be discussed at tumor boards just as Phase II/III clinical trials are now discussed when talking about chemoradiation. “We’ll have the same high-level evidence advocating the use of robotic surgery in appropriate patients,” he said.
Further data on the use of TORS in more advanced oropharyngeal cancers may expand the candidates for this surgery (Cancer Manag Res. 2018;10:839-846). Dr. Weinstein and his colleagues at the University of Pennsylvania are starting to publish excellent results, he said, using TORS for treating larger T3 and T4 oropharyngeal tumors while simultaneously reconstructing the oropharyngeal defect with free flap reconstruction (J Clin Oncol. 2020;38:15_suppl:6500-6500).
Critical for Dr. Weinstein and his colleagues is sharing their techniques with other surgeons through publications, online videos, and other forms of education to expand TORS use to institutions worldwide. Since its FDA clearance in 2009, Dr. Weinstein pointed out, the Robotic Surgery Laboratory in the department of otorhinolaryngology–head and neck surgery at the University of Pennsylvania has hosted over 500 international and national trainees for two-day didactic, hands-on cadaver and case observation courses. Prerequisites for participating in the courses include online training and participating in a full-day live porcine robotics lab. This training course for postgraduate trainees, he believes, is one of the important reasons behind the rapid adoption of TORS.