Dear Editor,

I read with great interest the recent article by Kai Ping Ong et al. published in the Journal of Contemporary Brachytherapy, which compared swallowing outcomes between upfront high-dose-rate interstitial brachytherapy followed by IMRT (HyBIRT) and surgery in patients with oral tongue squamous cell carcinoma (OTSCC) [1]. The authors should be commended for addressing often underexplored yet clinically crucial endpoint: post-treatment swallowing function.

The integration of both objective (FEES with penetration-aspiration scale) and subjective (Malay EAT-10 and swallowing capacity scale) assessments strengthens the study design and provides a multidimensional evaluation of dysphagia. Importantly, the finding that HyBIRT was associated with superior swallowing outcomes, particularly in liquid and semisolid boluses, highlights the potential functional advantages of organ-preserving strategies. This observation is consistent with prior evidence demonstrating favorable functional and oncologic outcomes of interstitial brachytherapy in early oral tongue cancers [2] as well as guideline recommendations supporting its role in head and neck malignancies [3]. In an era, where survivorship and quality of life are increasingly emphasized, such data are highly relevant. Furthermore, recent reviews have highlighted the expanding role and technical evolution of brachytherapy in head and neck oncology, reinforcing its clinical value [4].

Nevertheless, several issues merit further discussion. First, the cross-sectional design and relatively small sample size, especially in the HyBIRT cohort, limit the generalizability of conclusions. The shorter follow-up duration in the HyBIRT group may also underestimate late radiation-related toxicities, such as progressive fibrosis, which could affect long-term swallowing outcomes. Given that dose distribution and exposure to critical structures are known to influence toxicity profiles in brachytherapy [5], longer follow-up is essential to fully evaluate functional durability. Second, the surgical cohort was heterogeneous, with a substantial proportion undergoing extensive resections and pedicled flap reconstruction as well as adjuvant radiotherapy. These factors independently influence swallowing and may confound direct comparisons between modalities. In addition, variability in institutional experience and implementation of interstitial brachytherapy may further affect outcomes, as emphasized in recent clinical reports [6].

Future prospective, longitudinal studies with stratification by tumor stage, reconstruction type, and adjuvant treatment are warranted. Incorporating patient-reported outcome measures alongside instrumental assessments over extended follow-up would further clarify the durability of functional preservation. Also, comparative evaluation with other advanced radiotherapeutic approaches, such as stereotactic ablative brachytherapy in selected cases, may provide further insights into optimal treatment selection [7].

Overall, this study contributes valuable preliminary evidence supporting HyBIRT as a function-preserving alternative in selected OTSCC patients, and stimulates important discussion regarding the balance between oncologic control and patient quality of life.

Funding

No external funding was provided.

Disclosures

Approval of the Bioethics Committee was not required.

The author declares no conflict of interest.