Who remembers the recent thought-provoking series of jaw osteoradionecrosis following head and neck proton therapy at MSKCC? We’re here to bring you more conjecture about how they may have reached the undesired incidence of 11% with this thoughtful reply from Indian oncologists. They primarily highlight that this nonrandomized series could be wrought with bias such as the potential for particularly high rates of any or all of the following: less than ideally-placed hot spots, use of outdated uniform scanning techniques (as opposed to pencil beam scanning), lack of prophylactic extractions, and/or extensive oncologic oral surgeries prior to radiation. Point is, this is all unknown and could provide some relatively easy-to-avoid factors using today’s proton therapy. The MSKCC authors reply with their own explanations, primarily that (1) this was an anecdotal (not consecutively treated) cohort that happened to be seen by MSKCC dentistry, creating inherent selection bias, (2) one of 13 cases was grade 0 meaning a case incidentally seen on imaging (i.e., mucosa was intact) and one that would not typically be included in other reported rates, and (3) yes, the majority of cases had prior oncologic resections and were treated with uniform scanning. | Nangia, JAMA Otolaryngol Head Neck Surg 2023 & Singh, JAMA Otolaryngol Head Neck Surg 2023
