Abstract
This study aimed to compare the efficacy and safety of transoral robotic surgery (TORS) versus radical radiotherapy (RT) following neoadjuvant therapy in patients with oropharyngeal carcinoma (OPC). OPC patients who received neoadjuvant therapy followed by either transoral robotic surgery(TORS) or radiotherapy (RT) between 2018 and 2024 across two centers were included in this study. To address potential confounding and ensure comparability, the overlap weighting (OW) method was employed. Progression-free survival (PFS), overall survival (OS), locoregional relapse-free survival (LRRFS), distant metastasis-free survival (DMFS), and adverse events were evaluated. A total of 367 eligible patients were included (264 in the RT group and 103 in the TORS group). Over a median follow-up of 41 months in the OW-adjusted cohort, no significant differences were observed between TORS and RT groups in 3-year PFS (75.6% vs. 74.4%, p = 0.834), OS (80.5% vs. 84.8%, p = 0.703), LRRFS (76.1% vs. 75.0%, p = 0.909), or DMFS (80.0% vs. 82.0%, p = 0.941). Subgroup analyses demonstrated that the treatment effect remained highly consistent across all subgroups, without significant statistical interactions (all P for interaction > 0.05). Toxicity patterns differed: the RT group had higher rates of xerostomia, mucositis, and leukopenia, while the TORS group had more hemorrhage (including one fatal case) and infection. Following neoadjuvant therapy, survival outcomes were comparable between TORS and RT in the OW-adjusted cohort. Toxicity patterns differ between the groups, underscoring the importance of personalized, multidisciplinary treatment decisions.