Treating Head and Neck Cancer Without Overtreating Patients
In This Article
- Function-preserving transoral robotic surgery, combined with early swallowing rehabilitation, helps patients with HPV-associated head and neck cancer recover more quickly and maintain quality of life.
- Researchers have developed an ultra-sensitive liquid biopsy that may help identify which patients can safely avoid unnecessary radiation or chemotherapy after surgery.
- Comprehensive survivorship care helps patients manage the long-term physical, functional and psychosocial effects of treatment and reduce the lasting consequences of overtreatment.
According to the U.S. Centers for Disease Control and Prevention, human papillomavirus (HPV) causes up to 70 percent of oropharyngeal cancers in the United States. Transoral robotic surgery (TORS) has become a standard surgical approach for treating HPV-associated oropharyngeal cancer (HPV+OPC), enabling surgeons to remove tumors of the tonsil and base of the tongue through the mouth, without external incisions.
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While TORS has transformed the surgical management of HPV+OPC, surgery alone does not define patient experience or outcomes. Postoperative management decisions—including early recovery of swallowing function and the selection of appropriate adjuvant therapy (observation versus radiation and/or chemotherapy)—are critical to individualized care, minimizing treatment-related toxicity and optimizing long-term outcomes.
Function-preserving surgical care
When Jeremy D. Richmon, MD, Associate Professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School, arrived at Mass Eye and Ear in 2016, he was tasked with growing a world-class head and neck robotic program. Having helped launch one of the earliest TORS programs in the country during his years at Johns Hopkins, he returned to his alma mater to take the program to the next level. “We did the first head and neck robotic cases at both Mass Eye and Ear and Mass General,” Dr. Richmon recalled. Since then, the team has grown into one of the highest-volume TORS centers in the nation, performing well over 100 robotic cases annually, with patients traveling from across the country for care.
What distinguishes Mass General Brigham Cancer Institute's approach is how protocolized and multidisciplinary the perioperative pathway has become—especially around swallowing. All patients undergo a preoperative evaluation by a specialized speech-language pathologist (SLP), including a baseline swallow assessment, swallow education and expectation-setting for the postoperative course.
“There’s a lot of work that goes into preparing patients before we ever get to the OR,” said Dr. Richmon, who serves as Director of Head and Neck Robotic Surgery at Mass Eye and Ear. “The team makes sure patients understand pain trajectories, how swallowing may feel and what’s normal during healing.” On postoperative day one, patients receive a bedside swallow evaluation by the SLP, along with tailored strategies such as a chin tuck or head rotation to optimize safe swallowing.
Routine pre- and postoperative involvement of SLPs in the perioperative care of patients after TORS is critical for favorable patient outcomes; however, this population has not been comprehensively studied. To address this gap, Dr. Richmon led a retrospective cohort study of adults with OPC who underwent TORS at Mass Eye and Ear between 2017 and 2024, evaluating both objective swallowing physiology and patient-reported swallowing function across the perioperative period.
Patients completed objective videofluoroscopic swallow studies (VFSS) and validated patient-reported surveys preoperatively, then again early after surgery and during longitudinal follow-up. The results, published in JAMA Otolaryngology–Head & Neck Surgery, demonstrated that among the 212 patients included in the retrospective study, 207 patients (96.7 percent) were tolerating an oral diet by the time of discharge, which averaged one to two days. Only 14 patients (seven percent) required a feeding tube placement in the immediate postoperative period, although only four (two percent) were discharged from the hospital with a tube in place.
At six weeks postoperatively, 95 percent of patients were tolerating a regular diet. Although a majority of patients reported a subjective decline in swallowing immediately postoperatively, likely secondary to pain, VFSS scores demonstrated that most patients maintained near-normal swallow function or recovered within four to six weeks.
“Our study validates the comprehensive care model at Mass Eye and Ear, where surgery, rehabilitation and recovery are fully integrated. With early involvement from speech-language pathologists, patients recover swallowing sooner, leave the hospital safely, and rarely require prolonged tube feeding,” emphasized Dr. Richmon.
Figure 1
From the left: Jeremy D. Richmon, MD and Daniel Faden, MD, FACS
Biology-guided postoperative care
Despite favorable survival outcomes, postoperative decision-making regarding the need for radiation or chemoradiation after surgery remains challenging in HPV+OPC. Current guidelines rely on clinicopathologic risk factors, such as tumor size, nodal burden, extranodal extension and margin status, which do not directly indicate whether residual cancer is present. Rather, these measures provide an estimate of risk. As a result, some patients receive additional therapy based on risk profiles rather than evidence of remaining disease, exposing them to avoidable treatment-related toxicity.
Daniel Faden, MD, FACS, Associate Professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School and Principal Investigator in the Mike Toth Head and Neck Cancer Research Center and Director of the Head and Neck Cancer Genomics and Liquid Biopsy Program at the Mass General Brigham Cancer Institute, leads a laboratory focused on developing ultra-sensitive blood-based tests for HPV-associated cancers, with a particular emphasis on minimal residual disease (MRD) detection after surgery. “The goal of MRD detection is to directly and accurately determine whether microscopic residual cancer is present after surgery or not, allowing clinicians to safely withhold additional therapy when disease is no longer present,” explained Dr. Faden.
Previously, Dr. Faden and his team developed HPV-DeepSeek, a novel, ultrasensitive liquid biopsy for HPV-associated cancers, and demonstrated that the approach is significantly more sensitive than currently available liquid biopsy methods in studies published in Clinical Cancer Research in 2025 and 2026. Dr. Faden, in collaboration with Dr. Richmon and the full Head and Neck Cancer Surgery team at Mass Eye and Ear, recently published results from a clinical trial evaluating the ability of HPV-DeepSeek to detect MRD. The study enrolled 103 patients with stage I–III HPV-associated cancer treated at Mass Eye and Ear and followed them for an average of more than two years.
Detection of MRD by HPV-DeepSeek was strongly predictive of cancer recurrence, with zero patients who tested negative with HPV-DeepSeek having a recurrence by the two-year mark. HPV-DeepSeek outperformed the traditional clinicopathologic risk factors used to decide which additional treatments are recommended after surgery and was significantly more sensitive than existing liquid biopsy approaches available for clinical use, approximately doubling MRD detection and allowing for earlier detection of recurrence by about seven months.
These findings, published in Science Translational Medicine, suggest that decisions regarding the need for more treatment after surgery in HPV+OPC could be guided by MRD testing, rather than relying only on less specific clinicopathologic risk factors as is done at present.
HPV-DeepSeek will now be used in a large national clinical trial to test the ability to give patients who test negative less treatment after surgery. If successful, this could lead to new national guidelines for how HPV+OPC patients are treated after surgery.
These advances are transforming not only how patients are treated but how they recover. “A lot of what shapes patients’ lives years later comes from the treatments we add after surgery. If we can be more precise about who actually needs that therapy, we can reduce unnecessary toxicity and help patients move into survivorship with better quality of life,” said Dr. Faden.
Long-term survivorship support
As clinical care for HPV-associated head and neck cancer becomes increasingly precise, the focus of care is expanding beyond disease control to the long-term effects of treatment. Even with advances in minimally invasive surgery, rehabilitation and treatment personalization, many survivors experience persistent or delayed challenges from their radiation and/or chemotherapy that significantly affect quality of life, reinforcing the importance of survivorship care.
Survivors may experience life-altering physical, psychological and psychosocial effects that do not resolve when treatment ends and, in some cases, may emerge years after the cancer has been cured. To address these unmet needs, Mass General Brigham launched the Head and Neck Cancer Survivorship Program under the leadership of Tessa Goldsmith, MA, CCC-SLP, designed to support patients as they transition from active treatment to long-term recovery. Patients are typically referred three to six months after treatment, once acute toxicities have resolved.
During comprehensive, hour-long visits at Mass Eye and Ear, patients and their care partners meet with a multidisciplinary team that includes a head and neck–specialized physician assistant, speech-language pathologist, physical therapist and nutritionist. Together, the team addresses the full spectrum of survivorship concerns—including nutrition, swallowing and speech, neck and shoulder function, lymphedema and psychosocial well-being. Patients leave the appointment with individualized care plans and coordinating referrals are made to experienced community clinicians. Follow-up visits allow the team to monitor progress and address new or evolving challenges over time.
By aligning surgical precision with biologically informed decision-making and long-term survivorship support, head and neck cancer care at Mass Eye and Ear is continuing to advance toward a model that treats cancer effectively while avoiding the lifelong consequences of overtreatment.
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