## 4 Discussion
The majority of patients completed their prescribed cumulative radiation therapy dose (\(n\) = 94, 98%). The rate of treatment interruptions and hospitalizations were comparable between the two groups of patients when adjusted by systemic treatment choice (Table 2). Chronic narcotic use at 3 months did not differ between the two groups (32% at the main campus vs. 30% at the satellite sites, \(p\) = 0.98) (Table 2), demonstrating a significant number of patients persistently using narcotics after completing treatment. Chronic narcotic use was trending downwards at 6 months, and is in line with previously reported data in patients with OPSCC [22]. Our retrospective analysis demonstrated a significant difference in the rate of feeding tube placement between the main campus and satellite sites (24% vs. 55%, \(p\) = 0.002). Of those patients, four (33%) at the main campus and 20 (83%) at the satellite sites underwent prophylactic tube placement (\(p\) = 0.003). A trend towards significance in feeding tube persistence at 6 months was observed (17% vs. 46%, \(p\) = 0.08) (Table 2 and Figure 3). Figure 3: Feeding tube placement and 6-month dependency by treatment site. MBSS were more likely to be performed at the main campus versus satellite sites given the availability of on-site speech pathology at the main campus. Multiple studies have been conducted to determine the advantage of prophylactic versus reactive PEG tube placement and the results are controversial [23; 24; 25; 26; 27; 28; 29]. However, studies have reported the significance of prophylactic PEG tube placement on enteral feed dependency rates [23; 24; 29], consistent with our feeding tube outcomes. This difference highlights the need for supportive service availability at satellite sites that could be potentially reached with remote consultation with institutional dedicated nutritionists and speech pathologists at our COH satellite centers. There was no significant difference in the degree of weight loss between the two groups of patients with the majority maintaining a \(\leq\)10% baseline weight loss (75% vs. 59%, \(p\) = 0.12); however, this could be the result of a higher prophylactic feeding tube rate in the satellite centers than main campus (Table 2). Overall, patients who are at a higher risk of recurrence due to poor pathologic features, comorbidities, and nutritional status should be identified earlier during treatment so that they can have access to supportive services. At our institution, we are working on directing those patients earlier on to speech pathologists and nutritionists to eventually identify ones who might benefit from treatment modifications or early implementation of dietary needs. Furthermore, we are exploring the feasibility of implementing a program that allows for an initial comprehensive speech and nutrition evaluation at the main campus with continued telehealth follow-ups in the satellite sites and return to the main campus for repeat instrumental testing when necessary. This would reduce the need of in-person visits with speech pathologists and nutritionists and we plan to understand if this initiative could be effective in improving the 6 months feeding tube persistence rate. Due to the COVID-19 pandemic, numerous institutions have implemented telehealth services in order to accommodate patients and decrease needless exposure. Our institution offers outpatient telemedicine consults and follow-up visits via telephone or video call, and this service has been extended to our satellite sites. In the future, this implementation will greatly benefit patients undergoing treatment at satellite sites that need speech pathology and nutritionist oversight but do not have access to the main academic center, in order to minimize unnecessary feeding tube placements and ensure good functional outcomes. Precision medicine in oropharyngeal cancers is difficult to accomplish as we do not select treatment based on molecular targets other than HPV status.