Practice Patterns in Human Papilloma Virus-Associated Oropharyngeal Cancer and Strategies for Deintensification of Therapy: A Nationwide Survey of Radiation Oncologists

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In the absence of large clinical trial results, practice patterns have varied as to utilization of deintensification strategies in human papilloma virus-associated oropharyngeal cancer (HPV-OPC) and as to up-front management of these malignancies. We hypothesized that there is substantial heterogeneity amongst radiation oncologists as to treatment recommendations for HPV-OPC. An institutional review board-approved survey was developed and distributed electronically through a third-party website. Survey questions focused on demographics of respondents, setting of clinical practice, region of practice, preferred deintensification strategies, recommendations based on extent of extracapsular extension (ECE) in resected HPV+ nodes, institutional use of transoral robotic surgery (TORS), and 2 clinical vignettes highlighting controversial cases. A Pearson’s correlation test was utilized for statistical analysis. A total of 111 radiation oncologists (105 attendings/practicing physicians, 6 residents) responded (100 complete, 11 partial) to the survey. Respondents identified their current positions as at major academic hospitals (40.5%), non-academic hospitals (27.9%), satellite/community sites of major academic facilities (17.1%), and private practices (14.4%). Respondents were divided as to the “ideal” form of deintensification in HPV-OPC. While 40.6% felt that chemoradiation (ChemoRT) with reduced RT dose to 60 Gy best served patients, 35.9% preferred TORS followed by adjuvant therapy as indicated. The remaining practitioners selected altered fractionation RT (AFX-RT) (60 Gy/5 weeks, 10.4%), induction chemotherapy followed by ChemoRT (4.7%), or other (8.5%). Respondents were more likely to recommend TORS with neck dissection in HPV-OPC than in HPV-negative disease regardless of radiographic lymph node size (47.5% vs 40.6%) or with nodes <6 cm (21.8% vs 16.8%); nodes <3cm (25.7% vs 38.6%). There was also significant consideration of omission of chemotherapy in postoperative patients with HPV-OPC and minimal ECE (<2mm) (31.7%), while 64.4% still regularly prescribe ChemoRT. Others (3.8%) consider RT alone regardless of ECE extent. In a patient with cT2N2aM0 HPV-OPC of the base of tongue, preferred respondent up-front approaches were ChemoRT (55%), TORS with adjuvant therapy as indicated (37%), AFX-RT (6%), and other (2%). In a patient with pT1N1MX HPV-OPC of the tonsil after TORS (3mm margin, no ECE/LVSI/PNI), practitioners were evenly split as to whether to offer adjuvant RT: observation 51%, RT 47%, other 2%. Optimal management and therapy deintensification strategies for patients with HPV-OPC remain controversial. Forthcoming clinical trial data should substantially inform therapeutic recommendations and practice guidelines.