Several studies have compared the 7th and 8th editions of the TNM manual in the same group of OPSCC patients, with the stage modified according to HPV status. Park et al. re-evaluated 188 patients with HPV-positive OPSCC. In that study, using the 7th edition criteria, more than 85% of patients were classified as stage III and IV (19.1% and 67.6%, respectively) whereas most patients were classified as stage I and II using the criteria in the 8th edition (76.1% and 20.7%, respectively). Only eight patients (4.3%) were classified as stage I according to the 7th edition criteria. By contrast, none of the patients were classified as stage IV under the criteria of the 8th edition [
23]. The same study compared both groups in terms of the recurrence rates: under the 7th edition criteria, these rates were 0%, 11.8%, 2.8%, and 11.8%, respectively, for stage I, II, III, and IV patients; in contrast, following the criteria of the 8th edition, recurrence rates were 8.4%, 10.3%, and 33.3%, respectively, for stages I, II, and III. These findings show that use of the 8th edition criteria resulted in a higher recurrence rate, which implies better between-group discrimination. Similar results were reported by Sharma et al., who also classified a group of OPSCC patients (
n = 621) using criteria from both the 7th and 8th editions. Using the 7th edition criteria, only 7.9% of patients were stage I or II; by contrast, when the 8th edition criteria were applied, this percentage rose to 62.9% [
24]. Jacobi et al. re-evaluated 137 patients with OPSCC treated with primary surgery. Under the 7th edition criteria, most patients were classified as stage III and IV (19% and 62%, respectively); however, when the criteria from the 8th edition were applied, 95% of HPV-positive patients were categorized as stage I or II [
25]. Zhan et al. evaluated 3745 patients with OPSCC. Following the criteria in the 7th edition, only 10.2% of patients were classified as stage I and II (3.6% and 6.6%, respectively) while more than 95% of cases were classified as early stage (I or II) when the 8th edition criteria were applied (80.2% and 17.7%, respectively). Interestingly, the percentage of patients with pN1 disease increased from 17.3% (7th edition criteria) to 75.9% in the 8th edition [
26].
As those studies show, the change in criteria resulted in patients being reassigned to different stages, resulting in improved discrimination. However, survival rates also differed widely when the two set of criteria were compared. Mizumachi et al. analyzed 195 patients with OPSCC, showing that no survival differences (7th edition) between stage I–II and stage III–IV patients with p-16 positive oropharyngeal cancer. By contrast, when the 8th edition criteria were applied, patients with stage III disease presented significantly worse survival—as would be expected—than stage I–II patients. In that study, of the 80 stage IV patients (7th edition criteria), 45 were reassigned to stage I and 16 to stage II when the criteria from the 8th edition were applied [
27]. Similarly, Haughey and Sinha found that pathologic TNM staging was a prognostic factor for both disease-free survival (DFS) and disease-specific survival when the 8th edition criteria were used, but not prognostic when the 7th edition criteria were applied [
28, [
29].