Return to Work in Survivors of Human Papillomavirus–Associated Oropharyngeal Cancer: An Australian Experience

Purpose

Human papillomavirus (HPV)–associated oropharyngeal cancer (OPC) commonly affects people of working age, yet there is limited data regarding the return-to-work experience in this cohort. This study aimed to investigate the proportion of survivors currently working after completion of radiation therapy and to explore potential facilitators and barriers to working after treatment.

Methods

A cross-sectional, single-institutional study was undertaken at the Peter MacCallum Cancer Centre, a comprehensive cancer center in Melbourne, Victoria, Australia. Eligible participants were 18 to 65 years old at diagnosis, were employed at or within the 3 months before diagnosis, and had completed curative treatment for HPV-associated OPC ≥4 months before enrollment. Participants completed a paper-based survey to assess baseline demographics, employment status, and quality of life (QOL; Functional Assessment of Cancer Therapy Head and Neck). Open-ended questions explored factors affecting return to work. Associations between current employment status and various disease, treatment, and demographic variables and with QOL were examined. Free-text items were analyzed by summarizing content analysis.

Results

Of 93 participants approached, 68 responded (73.1%). Mean age was 54.1 years (range, 39-64 years), and 89.7% were male. Most participants (67.6%) had stage II disease and were treated with chemoradiation (85.3%). Mean time after treatment was 2.6 years (range, 0.3-9.1 years). Fifty-eight of 68 participants (85.3%) were working at enrollment; median time to return to work was 6.0 months (interquartile range, 4-10 months); 45 (77.6%) were in the same role and 35 (60.3%) worked the same number of hours. Ten participants were not working, 3 had retired, 5 reported persistent and significant treatment toxicity preventing employment. Survivors currently working reported higher physical, functional, and global QOL scores. Access to leave and support from treating doctors were facilitators for return to work, whereas fatigue was frequently reported as a barrier to returning to work.

Conclusion

With time, the majority of participants with HPV-associated OPC will return to work after radiation therapy. Attention to symptom management and support from the workplace may enable more successful return to work.

Introduction

Head and neck cancer (HNC) is the seventh most common cancer in Australia¹ and the eighth most common cancer in male patients in the United States.² Historically, oropharyngeal cancer (OPC) most commonly affected men who were older than 60 years, were of low socioeconomic status, and had a history of heavy tobacco and alcohol use.³ The rising incidence of human papillomavirus (HPV)-associated OPC has resulted in a rapid increase in the number of younger, fitter, and employed patients with HNC.3, 4, 5

A consequence of this shifting demographic is the higher proportion of survivors of HNC expressing a strong desire to return to work (RTW) after treatment. Although employment after cancer treatment provides many benefits to cancer survivors, including a sense of identity, control, a sense of capacity, belonging, and financial security,6, 7, 8, 9, 10 many survivors face difficulties in retaining or returning to employment after treatment.¹¹ A meta-analysis by De Boer et al¹² reported that cancer survivors are 1.37 times more likely to be unemployed compared with healthy individuals. According to data from 2008 to 2010 in the United States, the total annual per capita lost productivity was US$3,593 (diagnosed >1 year ago) and US$4,694 (diagnosed <1 year ago) in cancer survivors of working age.¹³ In a recent Australian study, unemployment in cancer survivors was estimated to result in a loss of A$1.7 billion (at January 2018, approximately US$1.22 billion or €1.06 billion) in gross domestic product.¹⁴ Unemployed cancer survivors are more likely to experience financial toxicity compared with employed cancer survivors, including psychological distress associated with finances.¹⁵ Compared with other cancer types, survivors of HNC experience higher rates of unemployment.16, 17, 18, 19

To date, studies reporting RTW in HNC populations have largely focused on surgical cohorts or have had heterogeneous inclusion criteria, with limited relevance to HPV-associated OPC survivors who are younger and thus likely have a greater need to RTW. Published data on RTW in this group is extremely limited, with only one US-based study identified.²⁰ Given the differences between the US and Australian contexts—importantly that Australia has a universal health care system and employees are legally entitled to paid sick leave—a study investigating the Australian experience is warranted. The aims of the present study were to understand the RTW experience of patients with HPV-associated OPC treated primarily with radiation, specifically in the Australian context.