Cochrane · intervention · CD006205
Interventions for the treatment of oral cavity and oropharyngeal cancers: surgical treatment
Worthington, HV, Bulsara, VM, Glenny, A-M, et al. · Cochrane Database of Systematic Reviews · 2023 · Cochrane Library
Full textEvery question was extracted from the full review (methods and results), not only its Summary of Findings table.
Questions
45
current version
GRADE rated
28
No studies
12
Included studies
15
as reported
No studies 12 · 26.7%Ungraded 5 · 11.1%Very low 15 · 33.3%Low 6 · 13.3%Moderate 7 · 15.6%High 0 · 0%
Ungraded means an effect was reported without a GRADE rating; it is not a gap. No studies means the review found nothing to answer the question. The six categories are a display order, not a score.
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | People with oral cancer (ICD-O C01-C06) or oropharyngeal cancer (C09, C10) with primary squamous cell carcinoma (including histological variants and carcinoma in situ); head and neck cancer studies included if >50% oral cavity/oropharyngeal or separable data; excluded hypopharynx (C13), nasopharynx (C11), larynx (C32), lip (C00), salivary gland malignancies, odontogenic tumours, sarcomas and lymphomas | 2820 participants randomised (2583 evaluated); approximately 2074 oral cavity cancers; 14 trials reported TNM stage; nine trials oral cavity only; earliest recruitment 1985 |
| Intervention | Surgical treatment of the primary tumour (scalpel-based surgery, laser cutting/ablation, or harmonic scalpel); surgical management of the cervical (neck) lymph nodes as part of primary tumour treatment | Elective neck dissection; elective radical neck dissection; superselective neck dissection; supraomohyoid neck dissection; sentinel node biopsy; PET-CT following chemoradiotherapy; surgery plus radiotherapy; surgery (transoral robotic surgery); surgery plus adjuvant radiotherapy |
| Comparison | One surgical treatment modality versus another; other treatment interventions (radiotherapy, chemotherapy, immunotherapy/biotherapy or combinations) with versus without surgery; surgery versus no surgery (salvage/palliative surgery excluded) | Therapeutic (delayed) neck dissection; elective selective neck dissection; selective neck dissection; modified radical neck dissection; elective neck dissection; planned neck dissection; radiotherapy alone; chemotherapy |
| Outcomes | Primary: overall survival (or total mortality); disease-free survival (new disease, progression and mortality); locoregional recurrence; recurrence. Secondary: adverse events associated with treatment; quality of life; direct and indirect costs; participant satisfaction | Overall survival (12 trials); disease-free survival (10 trials); locoregional recurrence (11 trials); recurrence (11 trials); adverse events (10 trials); quality of life and costs in a few trials |
| Study designs | Randomised controlled trials, including cluster-RCTs | Randomised controlled trials |
| Timing | Not specified | Not reported |
Search date: 2022-02. Databases: Cochrane Oral Health's Trials Register (to 9 February 2022); CENTRAL (2022, Issue 1); MEDLINE Ovid (1946 to 9 February 2022); Embase Ovid (1980 to 9 February 2022); ClinicalTrials.gov; WHO ICTRP
Questions and results
Show all 5 versionsSurgery vs Radiotherapy alone
Population: Adults with oropharyngeal cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Total mortality 3 years | HR 0.83 [0.09, 7.46] 500 per 1000 (Warnakulasuriya 2009) vs 437 per 1000 (60 to 994) | 1 study · 68 participants | Low Downgraded: imprecision |
Locoregional recurrence | Locoregional recurrence: not reported. | 0 studies | No studies |
Adverse events associated with treatment | Adverse events: grade 2+ treatment-related events similar (31/34 radiotherapy vs 33/34 surgery; RR 0.94, 0.83 to 1.06); more hearing loss/neutropenia/constipation/tinnitus with radiotherapy, more oral bleeding/trismus… | 1 study · 68 participants | Very low Downgraded: risk of bias, imprecision |
Disease-free survival (new disease, progression, and mortality) 3 years | HR 1.07 [0.27, 4.22] 600 per 1000 vs 625 per 1000 (219 to 979) | 1 study · 68 participants | Low Downgraded: imprecision |
Recurrence | Recurrence: not reported. | 0 studies | No studies |
Surgery plus radiotherapy vs Radiotherapy alone
Population: Adults with oral cavity or oropharyngeal cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Locoregional recurrence | Locoregional recurrence: not reported. | 0 studies | No studies |
Total mortality 3 years | HR 0.24 [0.10, 0.59] 500 per 1000 (Warnakulasuriya 2009) vs 153 per 1000 (67 to 336) | 1 study · 35 participants | Very low Downgraded: risk of bias, imprecision |
Recurrence | Recurrence: not reported. | 0 studies | No studies |
Disease-free survival | Disease-free survival: not reported. | 0 studies | No studies |
Adverse events associated with treatment | Adverse events: severe acute effects in both groups (subcutaneous fibrosis, telangiectasia, moderate-to-severe oedema, xerostomia, trismus, dysphagia); subcutaneous fibrosis more prevalent with surgery + radiotherapy… | 1 study · 35 participants | Very low Downgraded: risk of bias, imprecision |
Elective neck dissection (at time of primary tumour resection) vs Therapeutic (delayed) neck dissection
Population: Adults with oral cavity cancer (tongue or floor of mouth) and clinically negative neck nodes
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Recurrence 3 years | RR 0.58 [0.48, 0.70] 600 per 1000 (D'Cruz 2015) vs 348 per 1000 (288 to 420) | 3 studies · 633 participants | Moderate Downgraded: risk of bias |
Adverse events associated with treatment | RR 1.31 [1.11, 1.54] | 2 studies · 746 participants | Moderate Downgraded: risk of bias |
Locoregional recurrence 3 years | HR 0.58 [0.43, 0.78] 300 per 1000 (Hutchison 2019) vs 187 per 1000 (142 to 243) | 4 studies · 458 participants | Moderate Downgraded: risk of bias |
Mortality (overall survival) 3 years | HR 0.64 [0.50, 0.83] 350 per 1000 (D'Cruz 2015); 250 per 1000 (Hutchison 2019) vs 241 per 1000 (194 to 301); 168 per 1000 (134 to 212) | 4 studies · 883 participants | Moderate Downgraded: risk of bias |
Disease-free survival (new disease, progression, and mortality) 3 years | HR 0.56 [0.45, 0.70] 550 per 1000 (D'Cruz 2015); 450 per 1000 (Hutchison 2019) vs 361 per 1000 (302 to 428); 285 per 1000 (236 to 342) | 5 studies · 954 participants | Moderate Downgraded: risk of bias |
Elective radical (comprehensive) neck dissection vs Elective selective neck dissection
Population: Adults with oral cavity cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Total mortality | Total mortality: 2 trials reported HR but could not be pooled (different surgical procedures); neither indicated a difference (BHNCSG 1998 HR 1.14, 0.70 to 1.86; Bier 1994 HR 0.87, 0.41 to 1.83); 252 participants (2… | 2 studies · 252 participants | Very low Downgraded: risk of bias, inconsistency |
Adverse events associated with treatment | Adverse events (BHNCSG 1998): flap necrosis, wound infection, fistula, vascular rupture, haematoma, seroma, chyle fistula; no complications in 45/76 modified radical ND and 54/72 supraomohyoid ND; 2 vs 1 postoperative… | 1 study · 148 participants | Low Downgraded: risk of bias |
Locoregional recurrence | Locoregional recurrence: not reported. | 0 studies | No studies |
Recurrence 5 years | RR 1.21 [0.63, 2.33] 250 per 1000 (BHNCSG 1998) vs 303 per 1000 (158 to 583) | 1 study · 143 participants | Very low Downgraded: risk of bias, imprecision |
Disease-free survival (new disease, progression, and mortality) 5 years | HR 0.57 [0.29, 1.11] 300 per 1000 (D'Cruz 2015/Hutchison 2019) vs 184 per 1000 (142 to 243) | 1 study · 104 participants | Very low Downgraded: risk of bias, imprecision |
PET-CT following chemoradiotherapy (neck dissection only if no/incomplete response) vs Planned neck dissection before or after chemoradiotherapy
Population: Adults with oral cavity or oropharyngeal cancer with nodal disease (stage N2 or N3)
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Recurrence | Recurrence: outcome not reported in a usable way (Mehanna 2017: nodal recurrence 3 vs 1; distant metastases 21 vs 23). | 1 study | Ungraded |
Total mortality 3 years | HR 0.92 [0.65, 1.31] 200 per 1000 (D'Cruz 2015/Hutchison 2019) vs 186 per 1000 (135 to 253) | 1 study · 564 participants | Moderate Downgraded: imprecision |
Locoregional recurrence 3 years | HR 1.00 [0.94, 1.06] 200 per 1000 (Hutchison 2019) vs 200 per 1000 (189 to 211) | 1 study · 564 participants | Moderate Downgraded: imprecision |
Adverse events associated with treatment | Adverse events: 22 surgical complications in the PET-CT group vs 83 in the planned-surgery group (Mehanna 2017). | 1 study · 564 participants | Very low Downgraded: risk of bias, imprecision |
Disease-free survival | Disease-free survival: outcome not reported in a usable way (Mehanna 2017: disease-specific and other-cause mortality did not differ, P=0.80 and 0.41). | 1 study | Ungraded |
Surgery plus adjuvant radiotherapy vs Chemotherapy (chemoradiotherapy)
Population: Adults with oral cavity or oropharyngeal cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Adverse events associated with treatment | Adverse events: not reported for any participants (Iyer 2015). | 0 studies | No studies |
Disease-free survival oral cavity | Disease-free survival: not reported (Iyer 2015). | 0 studies | No studies |
Total mortality oral cavity | Total mortality: study reported survival significantly better with surgery and RT vs chemoradiotherapy, but no useable data; 32 participants (1 RCT, Iyer 2015 oral cavity subgroup). | 1 study · 32 participants | Very low Downgraded: risk of bias, imprecision |
Recurrence oral cavity | Recurrence: not reported for the oral cancer subgroup (Iyer 2015). | 0 studies | No studies |
Locoregional recurrence oral cavity | Locoregional recurrence: reported difference between groups not statistically significant (P=0.355), but no useable data; 32 participants (1 RCT, Iyer 2015). | 1 study · 32 participants | Very low Downgraded: risk of bias, imprecision |
Supraomohyoid neck dissection vs Modified radical neck dissection
Population: Adults with oral cavity or oropharyngeal cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Locoregional recurrence | Locoregional recurrence: reported but not usable (variable follow-up) (Guo 2014). | 1 study | Ungraded |
Disease-free survival | Disease-free survival: not reported (Guo 2014 reported disease-specific survival, not a review outcome). | 0 studies | No studies |
Adverse events associated with treatment | Adverse events: significant difference in complication rates, lower for supraomohyoid (SOND 13.0% vs MRND 21.9%, P=0.040). UW-QOL at 1 year: supraomohyoid superior in pain relief (78.8% vs 75.2%, P=0.013) and shoulder… | 1 study · 332 participants | Very low Downgraded: risk of bias, imprecision |
Total mortality | Total mortality: reported but not usable (Guo 2014: during follow-up 113/322 (35.1%) died; SOND 53, MRND 60). No GRADE rating. | 1 study | Ungraded |
Recurrence | Recurrence: reported but not usable (variable follow-up) (Guo 2014). | 1 study | Ungraded |
Superselective neck dissection vs Selective neck dissection
Population: Adults with oral cavity cancer (tongue or floor of mouth) and clinically negative neck nodes
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Disease-free survival (new disease, progression, and mortality) 36 months | Disease-free survival: Pandey 2018 reported 83% (superselective) vs 91% (selective) at median 36 months, not significant (P=0.69); unable to analyse (variable follow-up); 32 participants (1 RCT). | 1 study · 32 participants | Very low Downgraded: risk of bias, imprecision |
Total mortality | Total mortality: not reported. | 0 studies | No studies |
Adverse events associated with treatment | Adverse events: no adverse events reported; 72 participants (2 RCTs). | 2 studies · 72 participants | Very low Downgraded: risk of bias, imprecision |
Recurrence | Recurrence: outcome not reported in a usable way in either study. | 0 studies | No studies |
Locoregional recurrence | Locoregional recurrence: data not presented usably and inconsistent; Pandey 2018 no difference (3/12 vs 3/20); Rastogi 2018 lower recurrence with superselective (Kaplan-Meier P<0.05); 72 participants (2 RCTs). | 2 studies · 72 participants | Very low Downgraded: risk of bias, imprecision |
Sentinel node biopsy (neck dissection only if biopsy positive) vs Elective neck dissection
Population: Adults with oral cavity or oropharyngeal cancer
| Outcome | Effect | Evidence | Status / GRADE |
|---|---|---|---|
Locoregional recurrence 3 years | HR 1.04 [0.91, 1.19] 200 per 1000 vs 207 per 1000 (184 to 233) | 1 study · 279 participants | Low Downgraded: risk of bias, imprecision |
Adverse events associated with treatment | Adverse events: no adverse events were reported (Garrel 2020). | 1 study · 279 participants | Very low Downgraded: risk of bias, imprecision |
Recurrence | Recurrence: Garrel 2020 reported that the number of patients with recurrences in both arms was almost identical; unable to use the data (variable follow-up); 279 participants (1 RCT). | 1 study · 279 participants | Very low Downgraded: risk of bias, imprecision |
Total mortality 3 years | HR 1.00 [0.90, 1.11] 200 per 1000 (D'Cruz 2015/Hutchison 2019) vs 200 per 1000 (182 to 219) | 1 study · 279 participants | Low Downgraded: risk of bias, imprecision |
Disease-free survival (new disease, progression, and mortality) 3 years | HR 0.98 [0.90, 1.07] 300 per 1000 vs 295 per 1000 (275 to 317) | 1 study · 279 participants | Low Downgraded: risk of bias, imprecision |