Aims. For patients with T4aM0 HPSCC, the guidelines of the National Comprehensive Cancer Network recommend TPL (as category 2A), induction chemotherapy followed by TPL or CRT (as category 3), and CRT (as category 3). 8 However, a previous report described that treatment of T4aM0 HPSCC with CRT results in a low laryngeal preservation rate compared with T1-3 disease. 9 A prospective randomized trial to compare these treatments is practically impossible because of the patientfs request for laryngeal preservation. The purpose of this study is to elucidate whether total pharyngolaryngectomy (TPL) or chemoradiotherapy (CRT) provides a better prognostic outcome in patients with T4aM0 hypopharyngeal carcinoma (HPSCC) using a nationwide database. Methodology. All data were obtained from the Head and Neck Cancer Registry of Japan, and information from patients who were newly diagnosed with T4aM0 HPSCC between 2011 and 2015 was extracted. The primary endpoint was disease-specific survival (DSS), and the secondary endpoint was overall survival (OS). The inverse probability of treatment weighting (IPTW) adjustments was used for survival analyses. Results. Our cohort included 1,143 patients. The TPL and CRT groups included 724 and 419 patients, respectively. Following IPTW adjustments, both the OS and DSS of the TPL group were significantly longer than those of the CRT group (P = .02 and P = .002, respectively). Conclusions. Survival superiority was demonstrated for patients with T4aM0 HPSCC treated with TPL compared with those treated with CRT.