Impact of Intensity-Modulated Proton Therapy vs. Intensity-Modulated Photon Therapy on Preserving Work and Productivity in Oropharyngeal Cancer Patients: Outcomes of a Multi-Institution Randomized Trial

Abstract

Oropharyngeal cancer (OPC) patients undergoing chemoradiation (CRT) are at high risk for “financial toxicity” from missed or lost work during and after treatment, as patients undergo intensive multimodality therapy impacting acute and long-term daily activities/function. Despite growing appreciation for the need to identify optimal CRT approaches that enable preserving work, productivity, and economic burden, no randomized studies have compared how treatments impact work outcomes in OPC. We compared the effect of intensity-modulated proton therapy (IMPT) vs intensity-modulated photon therapy (IMRT) on work and productivity outcomes in OPC patients receiving CRT on a randomized trial. From 2014-2018, 188 patients were randomized to IMPT vs. IMRT for stage II-IVB (7th ed) squamous cell carcinoma of the oropharynx, stratified by induction chemotherapy, HPV/p16 and smoking. A pre-specified aim compared patient-reported work outcomes using the validated Work Productivity and Activity Impairment (WPAI) questionnaire at baseline, end of CRT, 6 months, 1 year, and 2 years. Patients reported whether they were working, and working patients scored (0-100) levels of absenteeism, impairment while working, and productivity losses over the prior 7 days. Cochran-Armitage test analyzed differences in the proportion of patients working during follow-up. WPAI scores were compared using the Wilcoxon rank sum test. Mixed effects models tested longitudinal predictors. In 96 patients receiving IMPT and 92 IMRT, median age was 59. Baseline demographics, stage, employment, and insurance were balanced. 78% (n=147) participated in patient-reported outcomes aims, with evaluable responses in 79% of patients at 6 months, 67% at 1 year and 44% at 2 years. At baseline, there was no difference in the proportion of working IMPT patients (61%) vs. IMRT patients (58%) (P=0.71). However, among IMPT patients, the proportion who returned to/maintained work after treatment significantly increased over time, from 63%-78% (P=0.02). In contrast, among IMRT patients, the proportion working was unchanged over time, from 48%-55% (P=0.58). Among working patients, absenteeism, impaired work, and productivity loss ascribed to cancer did not differ by treatment arms, approaching baseline scores by 2 years (P= 0.17 to 0.80 for IMPT vs. IMRT scores at end of CRT, 6 months, 1 year, and 2 years). Adjusted scores were comparable in multivariate models. After CRT for OPC, patients undergoing IMPT were more frequently able to return to work with comparable productivity vs. those undergoing IMRT, demonstrating an absolute benefit of 26% at 2 years. Results provide Level 1 evidence in a randomized setting, using novel outcomes measures to demonstrate favorable societal- and patient-level economic impacts of IMPT for patients with OPC.Abstract 2977; Table 1Proportion of patients working (%)RandomizationPre-CRTEnd of CRT6 Months1 Year2 YearsPPBT61%63%71%71%78%0.02IMRT58%48%55%54%52%0.58 Open table in a new tab