Over the past years, trans-oral robotic surgery (TORS) has gained momentum and wide applicability in the treatment of early-stage low-risk HPV-related oropharyngeal squamous cell carcinoma (OPSCC). This is in large part due to initial large single-institution series documenting good clinical outcomes using this approach. This culminated in the design and execution of the Eastern Cooperative Oncology Group trial 3311 (E3311) that provided a framework for applying this modality in the management of predominantly low-risk HPV-related OPSCC.

Even though results from E3311 have been widely adopted as the guide to implementing TORS in this disease, it is noteworthy that significant care in planning surgical aspects of the trial implementation took place. Namely, sites were mandated to implement a quality assurance process through documentation of surgical credentialing. Vetting the accruing ECOG3311 surgeons appeared to minimize complications related to critical aspects of the study. In addition, one has to account for a certain selection bias when patients are enrolled in a clinical trial. If an experienced TORS surgeon has not assessed the patient as a surgical candidate and documented eligibility, there is an increased likelihood of affecting the reported rate of complications.

Complications from TORS can be major, such as the rare and idiosyncratic yet real risk for severe postoperative bleeding, which puts patients at risk of death without feeding arterial vessel ligation. Among other complications that have not been systematically tracked in prior studies is reduced swallowing function, which may vary with volume and location of resected tissue, as well as availability and adherence to rehabilitation. Tumor volume is also related to the ability to achieve negative margins and thus may affect which patients are deemed to be surgical candidates. Furthermore, functional outcomes may be affected by the extent of adjuvant (chemo)radiation therapy, driven by the number of positive lymph nodes or extranodal extension of tumor cells outside of the lymph node capsule. Given interobserver variability in predicting pathological extranodal extension from preoperative radiographic studies, machine learning approaches hold promise for improved patient selection.

In this analysis from the US National Cancer Database published in this issue of the Journal, Trakimas et al. observed a higher rate of involved margins in lower vs higher volume TORS centers. Even though TORS use in community centers (CCs) was lower than both low- and high-volume academic centers (LVACs and HVACs), the TORS positive margin rate in CCs was higher than both LVACs and HVACs, with the lowest being at HVACs (P < .001). Irregularities in delivery of postoperative radiation were also higher in CCs. As sobering as these observations may be, they should come as no surprise, because they are in line with the factors we described, as well as the repeatedly documented observation that management of head and neck malignancies is a complex task that needs to be delivered in centers with high volume and expertise, and that survival is enhanced by high-volume care even within the same geographic neighborhoods. To take this 1 step further, 2 decades have elapsed between the first characterization of HPV-related disease and the needed changes in staging and surgical treatment. Proficiency in delivering definitive, nonsurgical therapy with 70 Gy of radiation + cisplatin or TORS with pathologically driven adjuvant therapy is an evolving process that requires efforts and resources that are likely more accessible in large-volume academic centers. Other examples of such resources include dedicated and experienced head and neck pathologists, who are available for real-time analysis of surgically resected specimens to help determine accurate margin status.

As is the case in overall cancer management, especially in the multimodality setting, the success of treatment and patient outcome is dependent to a great extent on the various skills of the treating medical team. The skill and attention to detail appear to be linked to the volume of patients evaluated and treated at the respective center, as has been demonstrated repeatedly. For example, when looking at patient outcomes within head and neck cancer clinical trials, the overall survival was worse for patients treated at LVACs vs HVACs, an observation accounted for at least partially by a higher rate of protocol deviations in LVACs. In esophageal cancer, the correlation between center volume and survival is striking and has been consistently reported in some series. Other unexplained observations, such as the increasing mortality in the application of organ preservation for larynx cancer, may suggest increased treatment-related toxicities of a widely adopted approach in centers with a lack of adequate expertise. Whether this is linked to volume of the treating centers is unknown and would need further confirmation. Similar findings applied to radiation therapy, the delivery of which appeared to be more excessive at times or prolonged in CCs and LVACs vs HVACs. Even though all the aforesaid appear to bolster the findings by Trakimas et al., some shortcomings in the analysis are worth mentioning, namely, the lack of clear justification for defining HVACs and LVACs as it pertains to TORS, lack of smoking data, as well as a noted discrepancy with other reports in what is considered an adequate nodal yield. It is also possible, yet unclear, as to whether these results were influenced by discrepancies in referral patterns and lack of access to HVACs for patients with increased comorbidities or a possibly higher disease stage at baseline. Regardless of these confounding variables, the overall findings support the notion that accessibility to therapies such as TORS only partially addresses the challenge of inequities in cancer care. Access to experienced high-volume centers with a good track record of success appears to be another necessary predictor of improved outcomes.

In conclusion, the availability of novel cancer treatment modalities, including TORS and their widespread use in various practice settings, is clearly a step in the right direction, assuming consistency in quality and adequate case volumes and experience. Assuring uniformity and reproducibility of these complex cancer treatment modalities is another, perhaps as challenging a goal without which bridging the inequities in cancer care could remain a noble yet unfulfilled ambition.

Author contributions

Mihir R. Patel, MD (Conceptualization; Writing—original draft; Writing—review & editing), Barbara Burtness, MD (Writing—review & editing), Robert L. Ferris, MD (Writing—review & editing), and Nabil F. Saba, MD (Conceptualization; Writing—original draft; Writing—review & editing).

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