Protons for Oropharyngeal Cancer Have Not Yet Justified Their Promise.

Our colleagues had a tough job to do. Using patientreported outcomes (PRO) instruments that may have lacked sensitivity to elicit subtle differences in outcomes important to patients, they compared PROs in oropharyngeal cancer patients treated with intensity modulated proton therapy (IMPT) versus those in patients treated with intensity modulated photon therapy (IMRT) (1). Sio et al hypothesized that because IMPT reduces the low-dose bath to the anterior oral cavity, brainstem, and posterior neck, IMPT could result in less symptom burden and better quality of life (QOL). In the end, this hypothesis was not clearly proven, in part owing to challenges such as a small sample size, treatment across different eras, variance in systemic therapies, and unequal follow-up. This research was developed in an environment in which their institution had invested a fortune in the IMPT, a pressure we must acknowledge. This article focused exclusively on the potential QOL benefits promised by the new technology. We all appreciate the suffering the current standard of chemoradiation inflicts on our patients (2-4). However, when introducing a new modality into the cancer armamentarium, it would be optimal to introduce change within the context of the standard of care. Despite timely phase 3 data failing to show the effectiveness of induction chemotherapy in improving survival (5, 6), as the authors point out, 77% of the patients in the IMPT group received induction chemotherapy. This was a serious confounding variable, particularly in a QOL study. As has been