Surgery Versus Radiotherapy in Older Adults with Oral Cavity Cancer: A Nationwide Comparative Effectiveness Study

Importance: Older adults with oral cavity squamous cell carcinoma (OCSCC) are underrepresented in clinical trials, and the comparative effectiveness of surgery versus definitive radiotherapy with or without chemotherapy (RT ± CT) remains uncertain. Objective: To compare all-cause and OCSCC-specific mortality after curative-intent surgery versus definitive RT ± CT in older adults with newly diagnosed OCSCC. Design: Nationwide, population-based retrospective cohort study using linked registry and claims data. Propensity score fine stratification weighting (PS-FSW) and multivariable Cox proportional hazards models were used to reduce treatment selection bias. Setting: Taiwan Cancer Registry, National Health Insurance Research Database, and Taiwan Death Registry. Participants: Patients aged ≥65 years with newly diagnosed, nonmetastatic, pathologically confirmed OCSCC between January 1, 2009, and December 31, 2022. Intervention or Exposures: Curative-intent surgery, with or without adjuvant therapy, compared with definitive RT ± CT delivered with curative-intent. Main Outcome Measures: All-cause mortality and OCSCC-specific mortality. Results: Among 1275 eligible patients, 492 underwent curative-intent surgery and 783 received definitive RT ± CT. After PS-FSW, baseline characteristics were well balanced. Surgery was associated with lower all-cause mortality (adjusted hazard ratio [aHR] 0.59; 95% confidence interval [CI] 0.51, 0.69; P < .0001) and lower OCSCC-specific mortality (aHR 0.63; 95% CI 0.51, 0.78; P < .0001) compared with definitive RT ± CT. The survival benefit persisted across age strata, including patients aged ≥85 years. Conclusions: Curative-intent surgery was associated with superior all-cause and cancer-specific survival compared with definitive RT ± CT among older adults with OCSCC. Relevance: Chronological age alone should not preclude surgical consideration in older adults with OCSCC. Treatment decisions should incorporate physiologic fitness, comorbidity burden, geriatric assessment, and multidisciplinary evaluation; future studies should further evaluate treatment-related toxicity, functional outcomes, and quality-of-life.