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In HPV-positive oropharyngeal cancer removed by transoral robotic surgery, patients with intermediate-risk pathology did just as well with a reduced 50 Gy dose of radiotherapy as with the standard 60 Gy, supporting surgery-based de-escalation.
Phase 2 trial of 495 patients with resectable HPV-positive oropharyngeal cancer treated with transoral surgery and neck dissection, then allocated by pathology: observation for low risk, randomisation to 50 or 60 Gy radiotherapy for intermediate risk, and chemoradiotherapy for high risk.
Two-year progression-free survival was 96.9 percent with observation, 94.9 percent with 50 Gy and 96.0 percent with 60 Gy, and 90.7 percent with chemoradiation, with better swallowing outcomes at lower doses.
Transoral surgery with pathology-guided reduced-dose radiotherapy is a validated de-escalation pathway for HPV-positive oropharyngeal cancer in experienced centres.