Abstract
Transoral robotic surgery has been widely adopted since approval by the US Food and Drug Administration in December 2009, despite limited comparative data. To compare the long-term outcomes of transoral robotic surgery with those of nonrobotic surgery for patients with early-stage oropharyngeal cancer. A retrospective cohort comparative effectiveness analysis was performed of patients in the National Cancer Database with clinical T1 and T2 oropharyngeal squamous cell carcinoma diagnosed between January 1, 2010, and December 31, 2015, who underwent definitive robotic and nonrobotic surgery. Multivariable Cox proportional hazards regression analysis and propensity score matching were performed in patients with known human papillomavirus status to adjust for patient- and disease-related covariates. Survival after robotic and nonrobotic surgery was also compared in 3 unrelated cancers: prostate, endometrial, and cervical cancer. Statistical analysis was performed from April 10, 2019, to May 21, 2020. Overall survival. Of 9745 patients (7652 men [78.5%]; mean [SD] age, 58.8 [9.6] years) who met inclusion criteria, 2694 (27.6%) underwent transoral robotic surgery. There was a significant increase in the use of robotic surgery from 18.3% (240 of 1309) to 35.5% (654 of 1841) of all surgical procedures for T1 and T2 oropharyngeal cancers from 2010 to 2015 (P = .003). Robotic surgery was associated with lower rates of positive surgical margins (12.5% [218 of 1746] vs 20.3% [471 of 2325]; P < .001) and lower use of adjuvant chemoradiotherapy (28.6% [500 of 1746] vs 35.7% [831 of 2325]; P < .001). Among 4071 patients with known human papillomavirus status, robotic surgery was associated with improved overall survival compared with nonrobotic surgery in multivariable Cox proportional hazards regression (hazard ratio [HR], 0.74; 95 CI, 0.61-0.90; P = .002). Similar results were seen when analyzing only the subset of facilities offering both robotic and nonrobotic surgery. The 5-year overall survival was 84.8% vs 80.3% among patients undergoing robotic vs nonrobotic surgery in propensity score-matched cohorts (P = .001). By contrast, there was no evidence that robotic surgery was associated with improved survival in other cancers, such as prostate cancer (HR, 0.92; 95% CI, 0.79-1.07; P = .26), endometrial cancer (HR, 0.97; 95% CI, 0.90-1.04; P = .36), and cervical cancer (HR, 1.27; 95% CI, 0.96-1.69; P = .10). This study suggests that transoral robotic surgery was associated with improved surgical outcomes and survival compared with nonrobotic surgery in patients with early-stage oropharyngeal cancer. Evaluation in comparative randomized trials is warranted.
Highlights
Data Source Patient data were obtained from the National Cancer Database (NCDB), a registry sponsored by the American College of Surgeons and the American Cancer Society
In contrast to what was seen with transoral robotic surgery (TORS), there was no evidence that robotic surgery was associated with improved survival in prostate cancer (HR, 0.92; 95% CI, 0.791.07; P = .26), endometrial cancer (HR, 0.97; 95% CI, 0.901.04; P = .36), or cervical cancer (HR, 1.27; 95% CI, 0.96-1.69; P = .10) in multivariable analysis
To assess whether patients in real-world data sets undergoing robotic surgery for cancer are generally a more favorable cohort with improved survival owing to nononcologic factors, we examined 3 additional cancers for which robotic surgery is used: prostate, endometrial, and cervical cancer
Summary
Data Source Patient data were obtained from the National Cancer Database (NCDB), a registry sponsored by the American College of Surgeons and the American Cancer Society. The NCDB includes deidentified data from patients treated at more than 1500 Commission on Cancer–accredited facilities in the United States and encompasses more than 70% of newly diagnosed cancer cases nationwide.[29] Race/ethnicity and sex were abstracted from the medical record by coders working for the NCDB. Given that this study used deidentified data from a pub-
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