My first option for the title of this post was “Implementing Evidence in a Reluctant Environment.” It is the title of the talk I am preparing for the upcoming meeting of the Asian Pacific Thyroid Society (APTS) in Singapore next month, on Active Surveillance for differentiated thyroid cancer.
Because the same feeling often arises in many Head&Neck tumor boards when discussing treatment for a patient with oropharyngeal squamous cell carcinoma (OPSCC).
I already addressed this debate a year ago, when the American Society of Clinical Oncology (ASCO) published its guideline on transoral robotic surgery in the multidisciplinary care of patients with OPSCC (see that post).
J Clin Oncol. 2025 Feb 11:JCO2402755. doi: 10.1200/JCO-24-02755
Today, however, I would like to keep it even simpler. Because in reality, the discussion can be reduced to three questions.
The Three-Question Algorithm
When evaluating a patient with oropharyngeal squamous cell carcinoma, the decision about primary surgery can be structured around three essential questions:
- Can I obtain negative margins?
- Will the functional outcome be good?
- Can I reasonably expect to avoid adjuvant treatment?
If the answer to all three is yes, the patient should undergo surgery. That is the decision-making algorithm. basically nothing more and nothing less.
Question 1: Can I Obtain Negative Margins?
With current tech for transoral approaches, particularly transoral robotic surgery (TORS), margin control in well-selected T1–T2 tonsillar and base of tongue tumors is no longer the challenge it once was. In experienced hands exposure is excellent, visualization surpasses traditional open approaches and en bloc resection is feasible and reproducible. If adequate exposure cannot be achieved, then the answer to Question 1 is no, and surgery might not be the best primary treatment. But in properly selected early-stage disease, the answer is very often yes.
Question 2: Will the Functional Outcome Be Good?
The objective of surgery is not simply tumor removal. It is oncologic control with preservation of swallowing and speech. Transoral surgery avoids mandibulotomy and routine free-flap reconstruction in early cases. When performed as single-modality treatment, functional outcomes are frequently excellent. If the anticipated resection implies major functional compromise (aspiration risk, prolonged feeding tube dependence, severe dysphagia), then the answer is no. And surgery might not be chosen. But in early OPSCC, the answer is often yes.
Question 3: Can I Avoid Adjuvant Treatment?
This is the decisive question. If surgery will inevitably be followed by chemoradiation, then the patient is exposed to trimodality therapy, and the functional advantage of surgery largely disappears. Before operating, we must realistically estimate nodal burden, the risk of extranodal extension, margin risk and other adverse pathological features. If postoperative radiotherapy, or worse, chemoradiotherapy, is highly likely, then the answer is no. And surgery might not be the primary modality. If we can reasonably expect single-modality treatment (surgery), the answer is yes.
And the patient should be operated on.
HPV Status: Relevant, but Not Determinant
HPV status does not change the algorithm. But it modifies probabilities, especially regarding Question 3, but it does not change the logic.
Under the AJCC 8th edition classification (see bellow), almost all HPV-positive OPSCC patients are Stage I or II. That is, early stages. We should be able to treat this patients with single therapy (surgery or radiation; chemoradiation is usually applied for advanced stages). These patients have excellent prognosis, are frequently younger and have long life expectancy. They are precisely the patients in whom we must actively try to limit long-term sequelae.
If the three answers are “yes,” surgery should be strongly considered as primary treatment. In many of these patients, single-modality treatment is achievable. And we should not forget: the only treatment with the potential for near-zero long-term sequelae is surgery alone. Radiation, even when de-escalated, is never biologically neutral.
In HPV-negative disease, the probability of answering “yes” to Question 3 is lower, particularly in node-positive necks. But the framework does not change. If free-margins are achievable, functional outcome will be good, and adjuvant therapy can likely be avoided, operate. If not, consider another primary treatment modality.
Also, surgery gives us a pathologic staging, which is always more accurate, and helps us better tailor the treatment for every patient. This is particularly relevant if we want to de-escalate HPV positive cases.
Why the Reluctance? Implementing Evidence
Because historical practice patterns are strong. Because we have decades of robust outcome data on chemoradiation (… biased by HPV status and old surgical techniques). Because institutional culture influences multidisciplinary discussions.
But the indication for surgery in OPSCC should not be ideological. It should be analytical. It requires answering three objective questions. If the answers are positive, surgery is evidence-based. Failing to offer it in that scenario is not prudence. It is resistance.
In oncology, a standard treatment is an option that provides appropriate outcomes and is accepted as such based on medical evidence. However, among standard options, there is usually a preferred treatment for a given clinical scenario: the modality that should be offered first when it fulfills oncologic and functional criteria.
Today, in appropriately selected early oropharyngeal cancer, surgery is that preferred option. If the answer to the three questions is “yes”, the discussion should conclude with surgery. If another treatment is preferred, it should be because surgery has been carefully evaluated and ruled out, not because it was never seriously considered. This is how the discussion should take place.
And de-escalation? This is probably not the most accurate term to describe what has been happening in the treatment of HPV-related OPSCC. We now recognize that many patients with HPV-related tumors have been overtreated. We applied standard treatment protocols designed for a biologically different tumor, to a disease with a distinct behavior and prognosis. We are not truly “de-escalating.” We are searching for the appropriate treatment. And we now understand that we started from a position that was too aggressive, often at the cost of unnecessary sequelae.
The role of surgery, including robotic approaches, in selected OPSCC patients is not controversial in the literature. The controversy lies in its implementation. Evidence-based medicine is not merely about publishing guidelines. It is about applying them thoughtfully and consistently.
Why would we avoid operating on a patient if the disease can be controlled with surgery alone and with a good functional outcome? In small base-of-tongue tumors, this is not only possible, it is frequently achievable, sometimes with virtually no long-term sequelae. Every oncologist would agree on surgery under this terms.
Three questions. Three answers. One decision.
J Granell. March 4, 2026
References
Holsinger FC, Ismaila N, Adkins DR, Barber BR, Burnette G, Fakhry C, Galloway TJ, Goepfert RP, Miles BA, Paleri V, Patel AA, Roof SA, Starmer HM, Yom SS, Saba NF, Li R, Ku JA. Transoral Robotic Surgery in the Multidisciplinary Care of Patients With Oropharyngeal Squamous Cell Carcinoma: ASCO Guideline. J Clin Oncol. 2025 Feb 11:JCO2402755. doi: 10.1200/JCO-24-02755.
Costantino A, Haughey B, Zhu J, Alamoudi U, Magnuson JS. Transoral Surgery Versus Radiotherapy as Primary Treatment for HPV-Related Oropharyngeal Cancer in the Elderly. Head Neck. 2025 Jul;47(7):1867-1877. doi: 10.1002/hed.28097. Epub 2025 Feb 7. PMID: 39917816.
Lechien JR, Paleri V, Baudouin R, Brunet A, Chiesa-Estomba CM, Crosetti E, De Vito A, Cammaroto G, De Virgilio A, Fakhry N, Golusinski W, Irjala H, Lang S, Leemans CR, Moriniere S, Saibene AM, Sampieri C, Siddiq S, Vander Poorten V, Viros Porcuna D, Vergez S, Briganti G, Maniaci A, Remacle M, Simon C, Hans S. European surgical guidelines: transoral robotic surgery for head and neck cancers. Oral Oncol. 2026 Feb;173:107826. doi: 10.1016/j.oraloncology.2025.107826. Epub 2025 Dec 26. PMID: 41455326.