This study highlights three important aspects of employment in survivors of HPV-positive oropharyngeal cancer treated with definitive CTRT. The first is that the majority of patients will be able to return to work following treatment and will be satisfied with their ability to work. The second is that younger age may be associated with longer employment interruption following CTRT. And the third conclusion is that symptoms related to treatment linger well past treatment completion and are associated with dissatisfaction with ability to work after treatment completion. Notably, type of chemotherapy, primary tumor location, baseline functional status, and sociodemographic variables were not associated with whether the participant returned to work.
Employment and return to work after cancer treatment are important issues for patients, not only because of the financial implications but also due to the self-identity and emotional well-being which can be associated with a job [23, 27]. Depending on the cancer population, the effects of cancer and its treatment on employment appear to be transient for the majority of patients, like the participants in our study. However, the impact is more permanent for a subset of survivors, which is consistent with our findings where 8 patients never returned to work after treatment completion [28, 29]. In a meta-analysis and meta-regression of 36 studies, including 20,366 patients with many different cancers and 157,603 age-matched controls, de Boer and colleagues estimated a pooled relative risk (RR) of unemployment of 1.37 compared to age-matched cancer-free controls from the general population . Yet, there was a great deal of variability in employment status, treatments and toxicities associated with post-treatment unemployment across the studies included in the pooled analysis highlighting the heterogenous nature of cancer patients. Across cancer types, education and occupation appear to modify the effect of cancer on employment [20, 30]. For example, using the Finnish Cancer registry, Taskila-Abrant and colleagues reported that the rates of employment between cancer survivors 2–3 years after diagnosis was 9 % lower than matched cancer-free controls (RR 0.88, 95 % CI (0.86–0.90). However the difference was more pronounced in patients with only grade 1–9 education (RR 0.81, 95 % CI 0.78–0.84), and the difference was not significant in patients with university education (RR 0.96, 95 % CI 0.93–1.00) . While we did not explicitly ask for educational level in our survey, the occupations represented in our participants are generally associated with higher education and our findings of high return to work following treatment completion are consistent with these prior observations.
In prior studies in the United States and Europe, patients treated for head and neck cancer were more likely to stop working and less likely to return to work after treatment compared to most other solid tumors [20, 22, 23, 25]. The association between job type and employment seen in other cancers is present in head and neck cancer survivors as well . While we were unable to assess the association of job type on employment outcomes within our population, even in this study, where the majority of participants were employed in desk jobs, treatment was associated with some level of employment reduction, interruption, or discontinuation in all but 3 participants. Interestingly, younger age was associated with requiring longer employment interruption despite expected better physiologic tolerance to treatment than older patients. Although this study did not measure quality of life prospectively during treatment, others have reported that the acute toxicities of CTRT are more acutely experienced by younger patients with higher rates of depression and poor coping than older patients who might be physically less functional . Our findings suggest that the toxicity of CTRT is significant in all head and neck cancer patients, regardless of the fact that patients with HPV-positive disease present healthier than their HPV-negative counterparts. However, despite needing time off, it is possible that a younger and healthier population is more likely to eventually recover and be able to return to work than historical head and neck cancer patients with HPV-negative tumors, explaining at least some of the differences between our results and prior studies on employment outcomes in the head and neck cancer population. Wells et al. recently reported that independent predictors of poorer quality of life in long-term head and neck cancer survivors include unemployment and younger age, but the relationship between the two was not elucidated in this cross-sectional survey either .
Only a few studies have evaluated both health-related quality of life and employment outcomes among head and neck cancer survivors. They reported that a higher severity of fatigue and oral dysfunction were associated with unemployment [24, 25, 34, 35]. In our study population, while most participants were able to return to work, the presence of long-term toxicities of CTRT, including fatigue, oral and social interaction symptoms, more than a year after treatment completion were associated with dissatisfaction with ability to work, most commonly reported by those unemployed at time of survey [24, 25, 35].
A limitation of this study is the high proportion of high-level managers and professionals in our single-institution study cohort. However, the epidemiology of HPV-positive oropharyngeal cancer is emerging as a disease of patients from higher socioeconomic status, and the employment demographics of this population have not been previously described [36, 37]. Another possible limitation is that the study population was predominantly male (94 %) which can further limit the generalizability of our findings. Marino and colleagues found that both higher educational level and male sex predict for a more rapid return to work suggesting a possible underestimation in our study cohort.  Further, 80 % of head and neck cancers are treated at cancer centers nationally, suggesting the tertiary-referral center may not bias the results toward higher socioeconomic status as much as in other cancer sites . We did not ask for reasons for retirement; if some participants retired earlier than planned because of their health, this would increase the association between treatment toxicities and poor employment outcomes. In addition, while we asked about occupation, we did not explicitly ask about education which makes direct comparison against prior studies more difficult. Future studies should assess when participants began their time off from work and reasons for stopping work or retiring, which could further describe the trajectory of toxicity and subsequent recovery.
To our knowledge, this is the first study to look at employment outcomes specifically in patients with HPV-positive oropharynx cancer. Going into the survey, we expected to find that patients treated with cisplatin-based therapy would require more time to return to work given the higher toxicities generally attributed to this regimen. One possible explanation for our findings is that physicians are able to judge tolerability and each patient is pushed to their own extreme, and as a result, all are normalized in the end to very symptomatic, with no one regimen causing more harm in the end than another. Alternatively, it may be that CTRT, as a treatment, is simply toxic and requires time away from work and that differences between regimens are not detectable by a blunt instrument such as our retrospective analysis.
Unlike prior studies which have combined head and neck cancer disease sites and treatment, this study focused on a specific subset of patients who all underwent similar treatment with CTRT. Overall, the results of this study are reassuring in that the vast majority of patients are able to return to work compared to historical head and neck cancer patients. But even in this cohort, who generally is young and otherwise healthy at the time of diagnosis, there are areas for concern. Treatment toxicities, including dry mouth, sticky saliva, and weight changes, persist more than a year after treatment completion in many patients, and a subset of patients experiences prolonged employment interruption, an inability to return to work following CTRT, and dissatisfaction with ability to work. The results of this study will help patients and clinicians plan for the impact of cancer treatment on employment and highlight the on-going need for prevention, identification, and management of late toxicities.