De-escalation strategies in the treatment of oral squamous cell carcinoma: A cross-sectional study in oral and maxillofacial surgery in Germany, Austria, and Switzerland.

Evidence for de-escalating oral squamous cell carcinoma (OSCC) treatment is growing, but real-world adoption remains unclear in German-speaking countries. A nationwide web-based survey (SurveyMonkey®), developed by the German-Austrian-Swiss Working Group on Tumors of the Maxillofacial Region (DÖSAK) and distributed to department heads of oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland, assessed surgical and adjuvant de-escalation practices across 33 items. Participation was voluntary and anonymous; data were analyzed descriptively. Forty-two of 92 OMFS departments participated in the study (45.7 %). Sentinel lymph node biopsy (SLNB) was used by 38.1 % and planned by 26.2 %, yet fewer than half regard it as a future standard. For strictly lateral tongue cT1/2 cN0 carcinoma, unilateral elective neck dissection (ND) was reported by 73.5 %, although a minority reported more extensive procedures. Bone management shows a shift toward function preservation. Many centers favor marginal resection when cortical/medullary invasion is not demonstrated, though segmental resections persist in borderline scenarios. For maxillary OSCC, early-stage strategies varied; elective ND was widely supported in cT3/4 OSCC. Adjuvant therapy patterns are heterogeneous: most recommend radiotherapy (RT) for advanced primary or nodal disease (e.g., >pT2: 71 %; pN1: 74 %; >pN1: 68 %) and radiochemotherapy (RCT) for high-risk features (pR2: 94 %; pR1: 81 %; extranodal extension (ENE+): 81 %). Notably, ∼20 % would not recommend RCT despite pR1 or ENE+. In contrast, more than 40 % would escalate to RCT for isolated intermediate-risk factors (e.g., perineural (Pn1), lymphatic (L1), or venous invasion (V1)). Nearly half support individualized omission of adjuvant RT in pN1 when no additional adverse pathological features are present, such as Pn1, L1, or V1. De-escalation in OSCC is gaining traction but remains inconsistently implemented, with signals of both under- and overtreatment. Standardized definitions (e.g., bone invasion), more precise risk-adapted adjuvant algorithms, and prospective multicenter studies are needed to balance oncologic safety with functional outcomes and patient preferences.