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Minimally invasive surgery versus radiotherapy/chemoradiotherapy for small‐volume primary oropharyngeal carcinoma

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Referencias

References to studies excluded from this review

ADEPT {published data only}

Haughey B. Adjuvant de‐escalation, extracapsular spread, P16+, transoral (ADEPT) trial for oropharynx malignancy. clinicaltrials.gov/ct2/show/NCT01687413 2012 (accessed 22 June 2016). [NCT01687413]CENTRAL

ECOG‐E3311 {published data only}

Ferris R. Phase II randomized trial of transoral surgical resection followed by low‐dose or standard‐dose IMRT in resectable p16+ locally advanced oropharynx cancer. clinicaltrials.gov/ct2/show/NCT01898494 2013 (accessed 22 June 2016). [NCT01898494]CENTRAL

PATHOS {published data only}

Owadally W, Hurt C, Timmins H, Parsons E, Townsend S, Patterson J, et al. PATHOS: a phase II/III trial of risk‐stratified, reduced intensity adjuvant treatment in patients undergoing transoral surgery for human papillomavirus (HPV) positive oropharyngeal cancer. BMC Cancer 2015;15:602. [NCT02215265]CENTRAL

EORTC 1420 {published data only}

EORTC 1420‐HNCG‐ROG "The best of" trial. http://www.eortc.org/research‐groups/head‐and‐neck‐cancer‐group/ongoing‐projects/. [EORTC 1420‐HNGC‐ROG]CENTRAL

ORATOR {published data only}

Nichols AC, Yoo J, Hammond JA, Fung K, Winquist E, Read N, et al. Early‐stage squamous cell carcinoma of the oropharynx: radiotherapy vs. trans‐oral robotic surgery (ORATOR) ‐ study protocol for a randomized phase II trial. BMC Cancer 2013;13:133. [NCT01590355]CENTRAL

Adelstein 2012

Adelstein DJ, Ridge JA, Brizel DM, Holsinger FC, Haughey BH, O'Sullivan B, et al. Transoral resection of pharyngeal cancer: summary of a National Cancer Institute Head and Neck Cancer Steering Committee Clinical Trials Planning Meeting, November 6‐7, 2011, Arlington, Virginia. Head and Neck 2012;34(12):1681‐703.

Al‐Khudari 2013

Al‐Khudari S, Bendix S, Lindholm J, Simmerman E, Hall F, Ghanem T. Gastrostomy tube use after transoral robotic surgery for oropharyngeal cancer. ISRN Otolaryngology 2013;2013:190364. [PUBMED: 23936676]

Ang 2010

Ang KK, Harris J, Wheeler R, Weber R, Rosenthal DI, Nguyen‐Tân PF, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. New England Journal of Medicine 2010;363(1):24‐35.

Blanchard 2011

Blanchard P, Baujat B, Holostenco V, Bourredjem A, Baey C, Bourhis J, et al. Meta‐analysis of chemotherapy in head and neck cancer (MACH‐NC): a comprehensive analysis by tumour site. Radiotherapy Oncology 2011;100(1):33‐40.

Byrd 2016

Byrd JK, Ferris RL. Is there a role for robotic surgery in the treatment of head and neck cancer?. Current Treatment Options In Oncology 2016;17(6):29. [PUBMED: 27117980]

Chaturvedi 2011

Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. Journal of Clinical Oncology 2011;29(32):4294‐301.

Chaturvedi 2013

Chaturvedi AK, Anderson WF, Lortet‐Tieulent J, Curado MP, Ferlay J, Franceschi S, et al. Worldwide trends in incidence rates for oral cavity and oropharyngeal cancers. Journal of Clinical Oncology 2013;31(36):4550‐9.

Chen 2010

Chen AM, Li BQ, Jennelle RL, Lau DH, Yang CC, Courquin J, et al. Late esophageal toxicity after radiation therapy for head and neck cancer. Head and Neck 2010;32(2):178‐83.

Chen 2015

Chen AM, Daly ME, Luu Q, Donald PJ, Farwell DG. Comparison of functional outcomes and quality of life between transoral surgery and definitive chemoradiotherapy for oropharyngeal cancer. Head & Neck 2015;37(3):381‐5.

Christiansen 2006

Christiansen H, Hermann RM, Martin A, Florez R, Kahler E, Nitsche M, et al. Long‐term follow‐up after transoral laser microsurgery and adjuvant radiotherapy for advanced recurrent squamous cell carcinoma of the head and neck. International Journal of Radiation Oncology, Biology, Physics 2006;65(4):1067‐74.

Chung 2009

Chung CH, Gillison ML. Human papillomavirus in head and neck cancer: its role in pathogenesis and clinical implications. Clinical Cancer Research 2009;15:6758‐62.

Cracchiolo 2016

Cracchiolo JR, Baxi SS, Morris LG, Ganly I, Patel SG, Cohen MA, et al. Increase in primary surgical treatment of T1 and T2 oropharyngeal squamous cell carcinoma and rates of adverse pathologic features: National Cancer Data Base. Cancer 2016;122(10):1523‐32. [PUBMED: 26970050]

CTCAE 2010

National Institutes of Health, National Cancer Institute. Cancer Therapy Evaluation Program, Common Terminology Criteria for Adverse Events. 4th Edition. US Department of Health and Human Services, 2010.

de Almeida 2014

de Almeida JR, Byrd JK, Wu R, Stucken CL, Duvvuri U, Goldstein DP, et al. A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review. Laryngoscope 2014;124:2096‐102.

de Martel 2012

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Dwivedi 2013

Masterson L, Dwivedi RC, Allam M, Jani P. An adult with a neck lump. BMJ 2013;347:f5473.

Evans 2010

Evans M, Powell NG. The changing aetiology of head and neck cancer: the role of human papillomavirus. Clinical Oncology 2010;22:538‐46.

Fakhry 2008

Fakhry C, Westra WH, Li S, Cmelak A, Ridge JA, Pinto H, et al. Improved survival of patients with human papillomavirus‐positive head and neck squamous cell carcinoma in a prospective clinical trial. Journal of the National Cancer Institute 2008;100(4):261‐9.

Genden 2012

Genden EM, O'Malley BW, Weinstein GS, Stucken CL, Selber JC, Rinaldo A, et al. Transoral robotic surgery: role in the management of upper aerodigestive tract tumors. Head and Neck 2012;34(6):886‐93.

Gillison 2015

Gillison ML, Chaturvedi AK, Anderson WF, Fakhry C. Epidemiology of human papillomavirus‐positive head and neck squamous cell carcinoma. Journal of Clinical Oncology 2015;33(29):3235‐42.

Grant 2009

Grant DG, Hinni ML, Salassa JR, Perry WC, Hayden RE, Casler JD. Oropharyngeal cancer: a case for single modality treatment with transoral laser microsurgery. Archives of Otolaryngology ‐‐ Head and Neck Surgery 2009;135(12):1225‐30. [DOI: 10.1001/archoto.2009.185]

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Haughey 2011

Haughey BH, Hinni ML, Salassa JR, Hayden RE, Grant DG, Rich JT, et al. Transoral laser microsurgery as primary treatment for advanced stage oropharyngeal cancer: a United States Multicentre Study. Head and Neck 2011;33(12):1683‐94. [DOI: 10.1002/hed.21669]

Hee 2016

Hee LY, Kim YS, Chung MJ, Yu M, Jung SL, Yoo IR, et al. Soft tissue necrosis in head and neck cancer patients after transoral robotic surgery or wide excision with primary closure followed by radiation therapy. Medicine 2016;95(9):e2852.

Holsinger 2015

Holsinger FC, Ferris RL. Transoral endoscopic head and neck surgery and its role within the multidisciplinary treatment paradigm of oropharynx cancer: robotics, lasers and clinical trials. Journal of Clinical Oncology 2015;33(29):3285‐92.

Huang 2015

Huang SH, Hansen A, Rathod S, O'Sullivan B. Primary surgery versus (chemo)radiotherapy in oropharyngeal cancer: the radiation oncologist's and medical oncologist's perspectives. Current Opinion in Otolaryngology & Head and Neck Surgery 2015;23:139‐47.

Jackel 2007

Jackel MC, Martin A, Steiner W. Twenty five years experience with laser surgery for head and neck tumors. European Archives of Oto‐Rhino‐Laryngology 2007;264(6):577–85.

Lawson 2011

Lawson G, Matar N, Remacle M, Jamart J, Bachy V. Transoral robotic surgery for the management of head and neck tumors: learning curve. European Archives of Oto‐Rhino‐Laryngology 2011;268(12):1795–801. [DOI: 10.1007/s00405‐011‐1537‐7]

Luckens 2014

Luckens JN, Lin A, Gamerman V, Mitra N, Grover S, McMenamin EM, et al. Late consequential surgical bed soft tissue necrosis in advanced oropharyngeal squamous cell carcinomas treated with transoral robotic surgery and postoperative radiation therapy. International Journal of Radiation Oncology, Biology, Physics 2014;89(5):981‐8. [PUBMED: 24928257]

Masterson 2014a

Masterson L, Moualed D, Liu ZW, Howard JE, Dwivedi RC, Tysome JR, et al. De‐escalation treatment protocols for human papillomavirus‐associated oropharyngeal squamous cell carcinoma: a systematic review and meta‐analysis of current clinical trials. European Journal of Cancer 2014;50(15):2636‐48. [DOI: 10.1016/j.ejca.2014.07.001.]

Masterson 2014b

Masterson L, Moualed D, Masood A, Dwivedi RC, Benson R, Sterling JC, et al. De‐escalation treatment protocols for human papillomavirus‐associated oropharyngeal squamous cell carcinoma. Cochrane Database of Systematic Reviews 2014, Issue 2. [DOI: 10.1002/14651858.CD010271.pub2]

Masterson 2015

Masterson L, Sorgeloos F, Winder D, Lechner M, Marker A, Malhotra S, et al. Deregulation of SYCP2 predicts early stage HPV+ oropharyngeal carcinoma – a prospective whole transcriptome analysis. Cancer Science 2015;106(11):1568‐75.

Masterson 2016

Masterson L, Winder D, Ball SLR, Vaughan K, Lehmann M, Scholtz LU, et al. Molecular analyses of unselected head and neck cancer cases demonstrates that human papillomavirus transcriptional activity is positively associated with survival and prognosis. BMC Cancer 2016;16:367. [DOI: 10.1186/s12885‐016‐2398‐7]

Mehanna 2012

Mehanna H, Beech T, Nicholson T, El‐Hariry I, McConkey C, Paleri V, et al. The prevalence of human papillomavirus in oropharyngeal and nonoropharyngeal head and neck cancer: a systematic review and meta‐analysis of trends by time and region. Head and Neck 2013;35(5):747‐55. [DOI: 10.1002/hed.22015]

Moore 2009

Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope 2009;119(11):2156–64. [DOI: 10.1002/lary.20647]

Moore 2013

Moore EJ, Hinni ML. Critical review: transoral laser microsurgery and robotic‐assisted surgery for oropharynx cancer including human papillomavirus‐related cancer. International Journal of Radiation Oncology, Biology, Physics 2013;85(5):1163‐7. [PUBMED: 23182390]

More 2013

More YI, Tsue TT, Girod DA, Harbison J, Sykes KJ, Williams C, et al. Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced‐stage oropharynx and supraglottis cancers. JAMA Otolaryngology Head & Neck Surgery 2013;139(1):43‐8.

Morisod 2016

Morisod B, Simon C. Meta‐analysis on survival of patients treated with transoral surgery versus radiotherapy for early‐stage squamous cell carcinoma of the oropharynx. Head & Neck 2016;38 Suppl 1:E2143‐50.

NCCN 2015

Pfister DG, Spencer S, Brizel DM, Burtness BA, Busse PM, Caudell JJ, et al. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Head and Neck Cancers. http://www.nccn.org2015:1‐187.

Parmar 1998

Parmar MK, Torri V, Stewart L. Extracting summary statistics to perform meta‐analyses of the published literature for survival endpoints. Statistics in Medicine 1998;17(24):2815‐34.

Parsons 2002

Parsons JT, Mendenhall WM, Stringer SP, Amdur RJ, Hinerman RW, Villaret DB, et al. Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both. Cancer 2002;94(11):2967‐80. [PUBMED: 12115386]

Pyeon 2007

Pyeon D, Newton MA, Lambert PF, den Boon JA, Sengupta S, Marsit CJ, et al. Fundamental differences in cell cycle deregulation in human papillomavirus‐positive and human papillomavirus‐negative head/neck and cervical cancers. Cancer Research 2007;67:4605‐19.

Rathod 2015

Rathod S, Livergant J, Klein J, Witterick I, Ringash J. A systematic review of quality of life in head and neck cancer treated with surgery with or without adjuvant treatment. Oral Oncology 2015;51:888‐900.

RevMan 2014 [Computer program]

The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Rich 2011

Rich JT, Liu J, Haughey BH. Swallowing function after transoral laser microsurgery ± adjuvant therapy of advanced stage oropharyngeal cancer. Laryngoscope 2011;121(11):2381–90. [DOI: 10.1002/lary.21406]

Richmon 2014

Richmon JD, Quon H, Gourin CG. The effect of transoral robotic surgery on short‐term outcomes and cost of care after oropharyngeal cancer surgery. Laryngoscope 2014;124:165‐71. [PUBMED: 23945993]

Schache 2011

Schache AG, Liloglou T, Risk JM, Filia A, Jones TM, Sheard J, et al. Evaluation of human papilloma virus diagnostic testing in oropharyngeal squamous cell carcinoma: sensitivity, specificity, and prognostic discrimination. Clinical Cancer Research 2011;17:6262‐71. [PUBMED: 21969383]

Schache 2016

Schache AG, Powell N, Cuschieri K, Robinson M, Leary S, Mehanna H, et al. HPV‐related oropharynx cancer in the United Kingdom ‐ an evolution in the understanding of disease aetiology. Cancer Research 2016;76:1‐9. [DOI: 10.1158/0008‐5472.CAN‐16‐0633; PUBMED: 27569214]

Siegel 2016

Siegel RL, Miller KD, Jemal A. Cancer Statistics 2016. CA: a Cancer Journal for Clinicians 2016;66(1):7‐30.

Singer 2013

Singer S, Arraras J, Baumann I, Boehm A, Chie WC, Galalae R, et al. Quality of life in patients with head and neck cancer receiving targeted or multimodal therapy‐‐update of the EORTC QLQ‐H&N35, Phase I. Head and Neck 2013;35(9):1331‐8.

Sinha 2012

Sinha P, Lewis Jr JS, Piccirillo JF, Kallogjeri D, Haughey BH. Extracapsular spread and adjuvant therapy in human papillomavirus‐related, p16 positive oropharyngeal carcinoma. Cancer 2012;118(14):3519‐30.

Slebos 2006

Slebos RJ, Yi Y, Ely K, Carter J, Evjen A, Zhang X, et al. Gene expression differences associated with human papillomavirus status in head and neck squamous cell carcinoma. Clinical Cancer Research 2006;12(3):701‐9.

Solares 2007

Solares CA, Strome M. Transoral robot‐assisted CO2 laser supraglottic laryngectomy: experimental and clinical data. Laryngoscope 2007;117:817‐20.

Steiner 1988

Steiner W. Experience in endoscopic laser surgery of malignant tumours of the upper aero‐digestive tract. Advances in Oto‐Rhino‐Laryngology 1988;39:135‐44. [PUBMED: 2455969]

Sudhoff 2011

Sudhoff HH, Schwarze HP, Winder D, Steinstraesser L, Gormer M, Stanley M, et al. Evidence for a causal association for HPV in head and neck cancers. European Archives of Oto‐Rhino‐Laryngology 2011;268:1541–7.

Van Abel 2012

Van Abel KM, Moore EJ, Carlson ML, Davidson JA, Garcia JJ, Olsen SM, et al. Transoral robotic surgery using the thulium:YAG laser: a prospective study. Archives of Otolaryngology‐‐Head & Neck Surgery 2012;138(2):158‐66.

Weinstein 2007

Weinstein GS, O'Malley Jr BW, Snyder W, Hockstein NG. Transoral robotic surgery: supraglottic partial laryngectomy. Annals of Otology, Rhinology and Laryngology 2007;116:19‐23.

Weinstein 2012

Weinstein GS, O'Malley BW, Magnuson JS, Carroll WR, Olsen KD, Daio L, et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope 2012;122(8):1701‐7.

Westra 2009

Westra WH. The changing face of head and neck cancer in the 21st century: the impact of HPV on the epidemiology and pathology of oral cancer. Head and Neck Pathology 2009;3:78–81.

White 2013

White H, Ford S, Bush B, Holsinger C, Moore E, Ghanem T, et al. Salvage surgery for recurrent cancers of the oropharynx comparing TORS with standard open surgical approaches. JAMA Otolaryngology Head & Neck Surgery 2013;139(8):773‐8.

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Williams 2013

Williams CE, Kinshuck AJ, Derbyshire SG, Upile N, Tandon S, Roland NJ, et al. Transoral laser resection versus lip‐split mandibulotomy in the management of oropharyngeal squamous cell carcinoma (OPSCC): a case match study. European Archives of Oto‐Rhino‐Laryngology 2013 May 4 [Epub ahead of print]. [PUBMED: 23644937]

Yeh 2015

Yeh DH, Tam S, Fung K, MacNeil SD, Yoo J, Winquist E, et al. Transoral robotic surgery vs. radiotherapy for management of oropharyngeal squamous cell carcinoma ‐ a systematic review of the literature. European Journal of Surgical Oncology 2015;41:1603‐14.

References to other published versions of this review

Howard 2014

Howard J, Masterson L, Dwivedi RC, Riffat F, Benson R, Jefferies S, et al. Minimally invasive surgery versus radiotherapy/chemoradiotherapy for early‐stage oropharyngeal carcinoma. Cochrane Database of Systematic Reviews 2014, Issue 2. [DOI: 10.1002/14651858.CD010963]

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

ADEPT

1) PARTICIPANTS: T1‐4a tumours; all have positive neck disease with extracapsular spread

2) INTERVENTION: all patients have endoscopic head and neck surgery

ECOG‐E3311

1) PARTICIPANTS: advanced (T3‐4) tumours only

2) INTERVENTION: all patients receive endoscopic head and neck surgery/surgical intervention

PATHOS

1) ALLOCATION: randomisation only after stratification by stage/high‐risk features of excised tumour/neck nodes

2) PARTICIPANTS: T1‐3, N0‐2b

3) INTERVENTION: all patients receive endoscopic head and neck surgery/surgical intervention

Characteristics of ongoing studies [ordered by study ID]

EORTC 1420

Trial name or title

EORTC 1420‐HNCG‐ROG "The best of" trial

Methods

Parallel‐group randomised controlled trial

Participants

Exact details awaited

Interventions

Experimental:

Endoscopic head and neck surgery

Comparator:

Radiotherapy

Exact details awaited

Outcomes

Primary:

  • Swallowing function (using the MDADI score) (time frame: within the first year after the 2 treatment strategies)

Secondary:

  • Locoregional tumour control rate (time frame: at the end of 1 and 2 years)

  • Overall survival (time frame: at the end of 1, 2 and 5 years)

  • Functional assessment (time frame: at the end of 2 years)

  • Complication rate (time frame: at the end of 2 years)

  • QOL (time frame: up to 2 years)

  • Cost‐effectiveness

Starting date

Mid 2016

Contact information

Co‐ordinator: Prof Christian Simon

Notes

http://www.eortc.org/research‐groups/head‐and‐neck‐cancer‐group/ongoing‐projects/

ORATOR

Trial name or title

A phase II randomised trial for early‐stage squamous cell carcinoma of the oropharynx: radiotherapy vs trans‐oral robotic surgery (ORATOR)

Methods

Parallel‐group randomised controlled trial

Participants

Inclusion criteria:

  • Age 18 or older

  • Willing to provide informed consent

  • ECOG performance status 0‐2

  • Histologically confirmed squamous cell carcinoma primary tumour site in the oropharynx (includes tonsil, soft palate, base of tongue, walls of oropharynx)

  • Tumour stage: T1 or T2, with likely negative resections at surgery

  • Nodal stage: N0, N1 (<= 3 cm) or N2 (up to 2 nodes between 1 cm and 3 cm, on either side of the neck), without extranodal extension on pre‐randomisation imaging

  • Patient assessed at head and neck multidisciplinary clinic (with assessment by radiation oncologist and surgeon) and presented at multidisciplinary tumour board prior to randomisation

Exclusion criteria:

  • Serious medical comorbidities or other contraindications to radiotherapy, chemotherapy or surgery

  • Prior history of head and neck cancer within 5 years

  • Prior head and neck radiation at any time

  • Metastatic disease

  • Inability to attend full course of radiotherapy or follow‐up visits

  • Neck disease with unknown primary site

  • Prior invasive malignant disease unless disease‐free for at least 5 years or more, with the exception of non‐melanoma skin cancer

  • Unable or unwilling to complete QOL questionnaires

Interventions

Experimental:

TORS + neck dissection using Da Vinci Robot. Cautery spatula. 1 cm margins. Frozen sections + proceed until negative margins if feasible.

Comparator:

Radiotherapy ± chemotherapy

Gross tumour and nodes: 70 Gy in 35 fractions over 7 weeks. High‐risk nodal areas: 63 Gy in 35 fractions over 7 weeks. Low‐risk nodal areas: 56 Gy in 35 fractions over 7 weeks

Outcomes

Primary:

  • QOL (time frame: 1 year post‐treatment)

Secondary:

  • Overall survival (time frame: at the end of 3 years and at the end of 5 years)

  • Progression‐free survival (time frame: at the end of 3 years and at the end of 5 years)

  • Quality of life at other time points (time frame: every 6 months for 5 years from 1st date of treatment)

  • Toxicity (time frame: 5 years from date of first treatment)

  • Swallowing function (time frame: 5 years from date of first treatment)

Starting date

June 2012

Contact information

Primary Investigator: David Palma, MD, PhD; [email protected]

London Regional Cancer Program of the Lawson Health Research Institute

London, Ontario, Canada, N6A 4L6

Primary Investigator: Anthony Nichols, MD

Same address

Notes

https://clinicaltrials.gov/ct2/show/NCT01590355

ECOG: Eastern Cooperative Oncology Group
MDADI: MD Anderson Dysphagia Inventory
QOL: quality of life
TORS: transoral robotic surgery

Process for sifting search results and selecting studies for inclusion.
Figuras y tablas -
Figure 1

Process for sifting search results and selecting studies for inclusion.

Summary of findings for the main comparison. Minimally invasive surgery versus radiotherapy/chemoradiotherapy for small‐volume primary oropharyngeal carcinoma

Minimally invasive surgery versus radiotherapy/chemoradiotherapy for small‐volume primary oropharyngeal carcinoma

Patient or population: patients with small‐volume primary oropharyngeal carcinoma

Settings: inpatient

Intervention: transoral, minimally invasive surgery (transoral robotic surgery/transoral laser microsurgery) with or without adjuvant radiotherapy or adjuvant chemoradiotherapy

Comparison: primary radiotherapy with or without induction or concurrent chemotherapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Primary radiotherapy ± induction or concurrent chemotherapy

Transoral, minimally invasive surgery ± adjuvant radiotherapy or adjuvant chemoradiotherapy

Overall survival

No data

No data

No data

No data

Locoregional control

No data

No data

No data

No data

Progression‐free survival

No data

No data

No data

No data

Gastrostomy rate (at 1 year)

No data

No data

No data

No data

Tracheostomy rate

No data

No data

No data

No data

Swallowing function (MDADI)

No data

No data

No data

No data

Quality of life (EORTC QLQ‐C30 and H&N35)

No data

No data

No data

No data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; EORTC: European Organisation for Research and Treatment of Cancer; MDADI: MD Anderson Dysphagia Inventory

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Figuras y tablas -
Summary of findings for the main comparison. Minimally invasive surgery versus radiotherapy/chemoradiotherapy for small‐volume primary oropharyngeal carcinoma