In addition, the demographics of HPV-positive cancers are different. “The patients are younger and healthier. They’re not smokers or heavy drinkers,” said Jeremy Richmon, MD, director of the head and neck surgery robotic program and assistant professor of otolaryngology-head and neck surgery at Johns Hopkins University in Baltimore. “They tend to do much better; their tumors respond better to treatment of any kind.”
Explore This IssueApril 2014
Benefits of TORS
Open surgeries were the standard of care in the 1980s, said Dr. Ferris. Then, in the 1990s, chemotherapy and radiation began to replace surgical resection, and the combination remains the standard today. In the early 2000s, a team of researchers at the University of Pennsylvania developed a method for using the daVinci robot to access tumors through the mouth. The key was using a mouth retractor so that surgeons could get three arms into the open mouth, said Gregory Weinstein, MD, co-
director of The Center for Head and Neck Cancer at the University of Pennsylvania. One arm held the camera, and the other two worked as surgeons’ hands. Together with Bert O’Malley, Dr. Weinstein developed a research program, invited surgeons to train with their method, and generated enough data to submit the procedure to the FDA. Approval came in 2009.
Now, with oropharyngeal cancers presenting more often in younger patients with smaller primary tumors and the advent of minimally invasive transoral robotic surgery (TORS), the field has an opportunity to revisit treatment options. “These two things have dovetailed,” said Eric Moore, MD, professor of otolaryngology at the Mayo Clinic in Rochester, Minn. He points out that chemotherapy and radiation became favored over surgery and radiation for all the reasons discussed: difficult surgery, serious morbidity, long hospital stays, and long-term consequences. But now, he said, “TORS allows us to revisit this choice.”
A recent study, co-authored by Dr. Richmon, provided early data that if surgery is indicated, patients undergoing TORS have shorter hospital stays than those undergoing traditional open surgical procedures. In this nationwide inpatient study comparing TORS to open surgery, researchers looked retrospectively at more than 9,000 surgical operations for oropharyngeal cancer performed from 2008 to 2009, when the TORS procedure was still very new. A scant 116 of these cases used TORS, and yet none of those patients required either a tracheotomy or a gastrostomy tube. Total hospital costs were more than $4,000 less for TORS than non-TORS procedures (Laryngoscope. 2014;124:164-171).