Functional impact of transoral surgery and risk-based adjuvant therapy in human papillomavirus-associated oropharyngeal cancer: swallowing outcomes from ECOG-ACRIN E3311.

Abstract

The ECOG-ACRIN E3311 Phase II trial demonstrated outstanding disease control (90.6% 54-month PFS) following transoral surgery (TOS) with de-escalated, risk-based postoperative management in resectable HPV-associated oropharyngeal cancer (OPC). The goal of de-escalation was functional preservation. The objective of this work was to evaluate clinician-graded modified barium swallow (MBS) studies from E3311 over time and across arms for: (i) aspiration and high-grade pharyngeal residue rates, (ii) differences in swallow safety and efficiency, and (iii) accuracy of site clinician reporting against central MBS review. 885 MBS studies were performed on 314 patients from 50/59 sites at baseline, post-TOS, and 6- and 24-months post-RT. Swallow outcomes (aspiration, high-grade residue) were recorded by site clinicians. A subset of 414 MBS studies was centrally graded using penetration-aspiration scale (PAS) scores and Dynamic Imaging Grade of Swallowing Toxicit<b>y (</b>DIGEST) scale. Aspiration, residue and dysphagia rates significantly increased from baseline to post-TOS (p<0.01) and then decreased modestly at 6- and 24-months. At 6 months, swallow outcomes favored the 50Gy vs. 60Gy arm, with significantly lower aspiration and high-grade dysphagia rates but this difference was not maintained at 24-months. MBS results reported by site clinicians demonstrated substantial agreement with the central laboratory (PABAK: 0.75-0.84, p<0.01). Swallowing worsened after TOS but improved by 6 and 24 months despite adjuvant therapy. De-escalated adjuvant RT at 50 Gy reduced acute aspiration. Site-reported MBS metrics strongly aligned with DIGEST, showing potential as an accessible metric in cooperative group settings.