‘Survival’ to ‘Survivorship’ in Carcinoma Nasopharynx: are We Doing Enough?

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Sarbani Ghosh Laskar, Vaishnavi Pahwa, Anuj Kumar, Shwetabh Sinha, and 16 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8746379/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Nasopharyngeal cancer patients face various survivorship challenges like psychosocial disturbances, body dysmorphia, failure to Return to Work (RTW), etc. These issues are concerning due to relatively younger age at diagnosis. Our study aims to address RTW and martial issues faced by these patients. Methods 194 nasopharyngeal carcinoma patients treated with radical intent Intensity Modulated Radiotherapy (IMRT) between 2014–2023, on regular follow-up, were included in the study, after taking written informed consent. RTW and marital issues were studied using questionnaires. P-value < 0.05 was considered significant. Results Median age at diagnosis was 44 years (IQR = 32–57 years). Male:Female ratio was 2.3:1. 95.4% patients were literate. At diagnosis, 16.0% were students, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% had retired. At follow-up, 9.8% were students, 20.1% were homemakers, 42.3% were employed, 19.6% were unemployed, and 8.2% were retired. Thus, there was a 16.5% increase in number of unemployed patients post-treatment. Marital status, education, and ISCO-08 (International Standard Classification of Occupations) Broad Skill Level were significantly associated with Failure to RTW (P < 0.05). 71.6% patients were married at baseline. 2 female patients who were married at baseline, were widowed at follow-up. 1 male reported getting divorced from his spouse, following treatment. Only 6 patients who were unmarried at baseline, got married post-treatment. Conclusions & Implications for Cancer Survivors: Even after major improvements in disease control among carcinoma nasopharynx patients, survivorship issues remain areas of concern, and there is a dire need to shift focus on successful rehabilitation of these patients. Carcinoma nasopharynx survivorship Return to Work (RTW) Occupational Rehabilitation INTRODUCTION Nasopharyngeal carcinoma (NPC) is a rare epithelial carcinoma, arising from the mucosal lining of the nasopharynx, unique among all head and neck malignancies owing to its characteristic epidemiologic and geographic predilection[ 1 ], classic bimodal age distribution[ 2 ], association with Epstein Barr Virus (EBV)[ 3 ], a higher propensity for haematogenous spread, complex anatomy with a very limited role of surgery, and high sensitivity to radiation therapy as well as chemotherapy[ 4 ]. For decades, radiotherapy has been the primary treatment modality for nasopharyngeal carcinoma[ 5 ][ 6 ], however, it was the landmark Intergroup 0099 study[ 7 ], and other similar prospective randomized studies[ 8 ][ 9 ] conducted among endemic populations, which established chemoradiotherapy as the standard of care for locally advanced carcinoma nasopharynx. In recent times, taxane-based neoadjuvant chemotherapy followed by platinum-based concurrent chemoradiotherapy has been established as the preferred approach to treat locoregionally advanced NPC[ 10 ]. There has been a paradigm shift in the management of NPC, with Intensity Modulated Radiotherapy (IMRT) being established as the standard of care[ 11 ], as a result of the dual improvements in survival as well as reduction in adverse effects with IMRT, such as reduced rates of xerostomia, hearing loss, trismus, subcutaneous fibrosis, etc., as compared to conventional radiotherapy techniques[ 12 ][ 13 ][ 14 ]. Thus, with the advent of IMRT, radical improvements in Image Guided Radiotherapy (IGRT) techniques, and ever-evolving chemotherapy regimens, there has been an albeit but gradual, transition from improving patient outcomes, to reduction in treatment-related morbidity, to enhancing survivorship care in nasopharyngeal cancer patients. Although RT-related toxicities like hypothyroidism, xerostomia, hearing loss, etc. are well documented in literature, nasopharyngeal cancer survivors face a multitude of challenges like psychosocial issues, body dysmorphia, difficulty in occupational rehabilitation, fatigue, social isolation, etc[ 15 ]. All these survivorship needs more pertinent in these patients due to a relatively younger age at diagnosis as compared to other head and neck malignancies[ 2 ]. Difficulty in occupational rehabilitation is one of the major predicaments faced by NPC survivors, likely due to post-radiotherapy speech impairment, prolonged Nasogastric Tube (NGT) dependence, etc. Failure to Return to Work (RTW) is also associated with psychosocial implications like self-esteem issues, anxiety, depression, and social isolation[ 16 ]. Thus, we conducted this study to address the lacunae in literature on Return to Work (RTW) and marital issues faced by nasopharyngeal carcinoma survivors, especially from Low-and Middle-Income countries (LMIC) like India; and the socio-demographic, disease-related, and treatment-related factors which influence the same. MATERIALS AND METHODS After Institutional Ethics Committee (IEC) approval (IEC Project ID: 4119), all consecutive nasopharyngeal carcinoma patients ≥ 16 years of age, treated with curative intent IMRT (with or without chemotherapy) from 2014 till 2023, attending the Head and Neck Disease Management Group (DMG) Outpatient Department (OPD) clinic at Tata Memorial Hospital, Mumbai from April 2023 till December 2024, with at least 6 months of follow-up after completion of planned treatment, were eligible for the study. Patients who did not complete the planned course of treatment, received treatment with palliative intent, were not willing to sign the written Informed Consent Form (ICF), or those with synchronous or metachronous primaries were excluded from the study. Patients who fulfilled the inclusion criteria, were served questionnaires which included questions regarding sociodemographic aspects, disease, and treatment-related details; pre- and post-treatment employment and marital status. Sociodemographic details, disease, and treatment-related information were captured from the electronic medical records of the patient. Employment details included employment status, occupation, and monthly wages before diagnosis, and on the day of the survey. The broad skill levels of patients who were employed at baseline and follow-up, respectively were recorded using the International Standard Classification of Occupations (ISCO-08) provided by the International Labour Organization (ILO). Similarly, marital status and the number of children (if any) before diagnosis, and on the day of the survey, were also recorded. The ICH GCP (International Council for Harmonization Good Clinical Practice) guidelines were followed throughout the course of the study. Statistical analysis SPSS (Statistical Package for Social Sciences) Software Version 28.0.1.1 was used for data collection and statistical analysis. Demographic data was summarized with descriptive statistics. Continuous data was represented as mean (standard deviation) or median (interquartile range) and categorical data were reported in frequencies (percentage), respectively. Disease Free Survival (DFS) was defined as the time from the date of patient registration to the date of detection of any locoregional recurrence in the head and neck region, and/or distant metastases outside the head and neck region. Kaplan-Meier method was used for time-to-event analysis, including DFS analysis. Acute and late RT-related toxicities were recorded using the RTOG (Radiation Therapy Oncology Group) scale and CTCAE (Common Terminology Criteria for Adverse Events) v5.0, respectively. A univariate Cox proportional hazards model was used to test the factors influencing Return to Work (RTW) and change in marital status. A p-value of < 0.05 was considered statistically significant. RESULTS A total of 319 nasopharyngeal carcinoma patients treated with radical intent IMRT from 2014 to 2023 were eligible for the study. Out of these, 194 patients who were on regular follow-up and willing to sign the written ICF were included in the study. Patient, tumour, and treatment characteristics Table I summarizes the baseline sociodemographic, disease characteristics, as well as the treatment received by our study population. TABLE I: Sociodemographic, tumour and treatment-related characteristics of our study population at baseline CHARACTERISTICS NUMBER PERCENTAGE Median age (IQR; in years) 44 years (IQR = 32–57 years) Sex Male 136 70.1 Female 58 29.9 Endemicity Endemic areas 38 19.6 Non-endemic areas 156 80.4 Comorbidities (ACE-27 score) None 153 78.9 Mild 39 20.1 Moderate 2 1.0 Education Illiterate 9 4.6 Read and write 22 11.3 Formal < 10th grade 66 34.0 10th -12th grade 15 7.7 Vocational 6 3.0 Graduate/postgraduate 76 39.2 Employment Student 31 16.0 Homemaker 37 19.1 Employed 112 57.7 Unemployed 6 3.1 Retired 8 4.1 Marital status Married 139 71.6 Unmarried 55 28.4 8th AJCC Stage Stage I 4 2.1 Stage II 21 10.8 Stage III 50 25.8 Stage IVA 106 54.6 Stage IVB 13 6.7 Histopathology (2017 WHO classification) SCC NOS 22 11.3 Keratinizing SCC (WHO Type I) 3 1.5 Non-keratinizing differentiated (WHO Type II) 12 6.2 Undifferentiated (WHO Type III) 157 80.9 Radiotherapy dose 66Gy/30# 102 52.6 70Gy/35# 92 47.4 Chemotherapy Received 188 96.9 Did not receive 6 3.1 TOTAL 194 100.0 IQR- Interquartile range; ACE-27 score- Adult Comorbidity Evaluation-27 score; AJCC- American Joint Committee on Cancer; WHO- World Health Organization; SCC NOS- Squamous Cell Carcinoma Not Otherwise Specified The median age at diagnosis was 44 years (IQR = 32–57 years). 70.1% of patients were males, and 29.9% were females. 19.6% of patients were from regions endemic for nasopharyngeal carcinoma in India i.e. the North-Eastern states. 4.6% of patients were illiterate, 11.3% of patients could only read and write, 34.0% of patients had studied only till the 10th grade, 7.7% of patients had studied only till the 12th grade, 3.0% of patients had received vocational training, and 39.2% of patients had completed graduation or post-graduation. 16.0% of patients were students at the time of diagnosis, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% of patients had retired from their respective jobs. 71.6% of patients were married at baseline, whereas 28.4% of patients were unmarried. Disease Free Survival (DFS) and Patterns of Recurrence At a median follow-up of 49 months (IQR = 24–75 months), the 5-year DFS (Disease Free Survival) was 89.6% (95% CI, 84.2–95.0%) (Supplementary Figure I). A total of 16 patients experienced disease recurrence. The most common patterns of failure are shown in Supplementary Figure II. Radiotherapy-related acute and late toxicities Supplementary Table I summarizes the most commonly reported acute as well as late radiotherapy-related toxicities among our patients. The most frequently reported acute ≥Grade III RTOG toxicities were dysphagia (14.9%), dermatitis (12.4%), and mucositis (7.7%). Return to Work (RTW) and factors influencing occupational rehabilitation Table II summarizes the employment status at baseline, and at follow-up respectively. At baseline, 16.0% of patients were students, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% were retired. On the other hand, at follow-up, 9.8% of patients were students, 20.1% were homemakers, 42.3% were employed, 19.6% were unemployed, and 8.2% were retired. TABLE II: Employment status at baseline and follow-up, respectively EMPLOYMENT ILO ISCO-08 BROAD SKILL LEVEL BASELINE [n (%)] FOLLOW-UP [n (%)] Student 31 (16.0) 19 (9.8) Homemaker 37 (19.1) 39 (20.1) Unemployed 6 (3.1) 38 (19.6) Retired 8 (4.1) 16 (8.2) Employed 112 (57.7) 82 (42.3) Skill Level 1 8 (4.1) 3 (1.5) Skill Level 2 41 (21.1) 25 (12.8) Skill Levels 3 and 4 63 (32.5) 55 (28.0) TOTAL 194 (100) 194 (100) Broad skill levels at baseline and follow-up As mentioned in Table II, 57.7% and 42.3% of patients were employed at baseline and follow-up, respectively. Table II also summarizes the broad skill levels of patients employed at baseline and follow-up, respectively, as per the International Standard Classification of Occupations (ISCO-08) provided by the International Labour Organization (ILO). At baseline, 4.1% of patients were Skill Level 1 workers, 21.1% were Skill Level 2 workers, and 32.5% were Skill Levels 3 and 4 workers; whereas at follow-up, 1.5% of patients were Skill Level 1 workers, 12.8% were Skill Level 2 workers, and 28.0% were Skill Levels 3 and 4 workers. Failure to Return to Work (RTW) As depicted in Table II, there was an increase of 16.5% in the number of unemployed patients at the time of follow-up, as compared to pre-treatment. This surge in rates of unemployment was accounted for by the fact that 30 patients (15.4%) who were employed at baseline, reported losing their jobs post-treatment; 3 patients (1.5%%) who were students at baseline, discontinued their higher education, and were unemployed at the time of follow-up; 6 (3.0%) patients who were unemployed at baseline, remained unemployed at the time of follow-up. 2 (1.0%) female patients reported quitting their jobs after their diagnosis, and continued to be homemakers. 8 (4.1%) patients retired from their jobs after completion of their service. Factors influencing Return to Work (RTW) We defined ‘Failure to Return to Work (RTW)’ as loss of employment post-treatment, as well as disruption in higher education, resulting in unemployment at the time of follow-up. Patients who were employed at baseline, or were students at baseline and employed at follow-up were deemed to have ‘Returned to Work’. Patients who were unemployed at baseline, and those who were homemakers, were not included for this analysis. Thus, a total of 135 patients were included in this analysis, out of which 34 (25.2%) patients experienced Failure to RTW, and 101 (74.8%) patients had returned to work at follow-up. We assessed various factors influencing Failure to Return to Work (RTW), as depicted in Table III. Marital status [Married vs. Unmarried; 31.0% vs. 14.6% (P = 0.035)], Education [Not graduate vs. At least graduate; 32.9% vs. 15.3% (P = 0.019)], and ISCO-08 Broad Skill Level [Students vs. Skill Level 1 vs. Skill Level 2 vs. Skill Level 3 and 4; 9.7% vs. 62.5% vs. 42.5% vs. 16.1%(P < 0.01)] were significantly associated with Failure to RTW. TABLE III: Factors influencing Failure to Return to Work (RTW) Covariates Returned to Work Failure to RTW Total P-value PATIENT-RELATED FACTORS Sex 0.985 Male 89 (74.8) 30 (25.2) 119 (88.1) Female 12 (75.0) 4 (25.0) 16 (11.9) Comorbidities (ACE-27) 0.708 None 85 (74.6) 29 (25.4) 114 (84.4) Mild 14 (73.7) 5 (26.3) 19 (14.1) Moderate 2 (100) 0 (0) 2 (1.5) Marital status 0.035 Married 60 (69.0) 27 (31.0) 87 (64.4) Unmarried 41 (85.4) 7 (14.6) 48 (35.6) Education 0.019 Not graduate 51 (67.1) 25 (32.9) 76(56.3) At least graduate 50 (84.7) 9 (15.3) 59 (43.7) ISCO-08 Broad Skill Level < 0.01 Students 28 (90.3) 3 (9.7) 31 (23.0) Skill Level 1 3 (37.5) 5 (62.5) 8 (5.9) Skill Level 2 23 (57.5) 17 (42.5) 40 (29.6) Skill Levels 3 and 4 47 (83.9) 9 (16.1) 56 (41.5) TUMOUR-RELATED FACTORS 8th AJCC Stage 0.655 I-III 36 (72.0) 14 (28.0) 50 (37.0) IVA 59 (77.6) 17 (22.4) 76 (56.3) IVB 6 (66.7) 3 (33.3) 9 (6.7) M0 vs. M1 0.560 M0 95 (75.4) 31 (24.6) 126 (93.3) M1 6 (66.7) 3 (33.3) 9 (6.7) Histopathology 0.273 Undifferentiated (WHO Type III) 88 (76.5) 27 (23.5) 115 (85.2) Other histologies 13 (65.0) 7 (35.0) 20 (14.8) Recurrence 0.168 Yes 5 (55.6) 4 (44.4) 9 (6.7) No 96 (76.2) 30 (23.8) 126 (93.3) TREATMENT-RELATED FACTORS Radiotherapy dose 0.150 66Gy/30# 51 (69.9) 22 (30.1) 73 (54.1) 70Gy/35# 50 (80.6) 12 (19.4) 62 (45.9) Chemotherapy 0.146 Received 95 (73.6) 34 (26.4) 129 (95.6) Did not receive 6 (100) 0 (0) 6 (4.4) ACUTE TOXICITIES Acute dermatitis 0.476 <Grade III 91 (74.0) 32 (26.0) 123 (91.1) ≥Grade III 10 (83.3) 2 (16.7) 12 (8.9) Acute mucositis 0.072 <Grade III 92 (73.0) 34 (27.0) 126 (93.3) ≥Grade III 9 (100) 0 (0) 9 (6.7) Acute dysphagia 0.903 <Grade III 87 (75.0) 29 (25.0) 116 (85.9) ≥Grade III 14 (73.7) 5 (26.3) 19 (14.1) LATE TOXICITIES Xerostomia 0.063 <Grade 2 88 (77.9) 25 (22.1) 113 (83.7) ≥Grade 2 13 (59.1) 9 (40.9) 22 (16.3) Hearing loss 0.591 <Grade 2 87 (75.7) 28 (24.3) 115 (85.2) ≥Grade 2 14 (70.0) 6 (30.0) 20 (14.8) Hypothyroidism 0.143 <Grade 2 39 (68.4) 18 (31.6) 57 (42.2) ≥Grade 2 62 (79.5) 16 (20.5) 78 (57.8) Cataract 0.560 <Grade 2 100 (74.6) 34 (25.4) 134 (99.3) ≥Grade 2 1 (100) 0 (0) 1 (0.7) Decreased vision 0.742 <Grade 2 99 (75.0) 33 (25.0) 132 (97.8) ≥Grade 2 2 (66.7) 1 (33.3) 3 (2.2) Subcutaneous fibrosis 0.889 <Grade 2 90 (75.0) 30 (25.0) 120 (88.9) ≥Grade 2 11 (73.3) 4 (26.7) 15 (11.1) Trismus 0.785 <Grade 2 97 (74.6) 33 (25.4) 130 (96.3) ≥Grade 2 4 (80.0) 1 (20.0) 5 (3.7) Dysphagia 0.408 <Grade 2 99 (74.4) 34 (25.6) 133 (98.5) ≥Grade 2 2 (100) 0 (0) 2 (1.5) Dermatitis 0.408 <Grade 2 99 (74.4) 34 (25.6) 133 (98.5) ≥Grade 2 2 (100) 0 (0) 2 (100) TOTAL 101 (74.8) 34 (25.2) 135 (100) Difference in monthly remuneration pre-treatment and post-treatment 45 (33.3%) patients reported a median increase in monthly remuneration of 15000 INR (167.05 USD) [IQR: 8000–48000 INR (89.09-534.54 USD)] at follow-up, compared to baseline; whereas, 46 (34.0%) patients reported a median decrease of 9500 INR (105.80 USD) [IQR: 4000–25000 INR (44.55-278.41 USD)]. Interestingly, there was a significant correlation between decrease in monthly remuneration and broad skill level (P < 0.001), with 64.5% of patients with Skill levels 1 and 2 reporting a decrease in monthly remuneration post-treatment, as compared to only 26.8% of patients with Skill levels 3 and 4. Marital status at baseline and follow-up Marital status of our patients at baseline, and at follow-up is depicted in Table IV. 136 (70.1%) patients who were married at baseline, continued to stay married at follow-up. 2 female patients (1.0%) who were married at baseline, were widowed at follow-up. 1 male (0.5%) reported getting divorced from his spouse, following treatment. On the other hand, only 6 (3.1%) patients who were unmarried at baseline, got married post-treatment; whereas 49 (25.3%) patients who were unmarried at baseline, remained unmarried at follow-up. Also, only 9 (4.6%) patients reported conceiving at least one child post-treatment. TABLE IV: Marital status of patients at baseline and at follow-up Marital status (Follow-up) TOTAL Married Unmarried Marital status (Baseline) Married 136 (70.1%) 3 (1.5%) 139 (71.6) Unmarried 6 (3.1%) 49 (25.3%) 55 (28.4) TOTAL 142 (73.2%) 52 (26.8%) 194 (100) Factors influencing marital status post-treatment As mentioned above, out of 55 patients who were unmarried at baseline, only 6 patients got married, and 49 patients remained unmarried at follow-up. The median age of patients who were still unmarried at follow-up was 26 years (IQR = 22–32 years). On the other hand, only 1 (0.5%) male patient who was married at baseline, reported getting divorced from his spouse post-treatment; whereas 2 (1.0%) female patients who were married at baseline, reported getting widowed at follow-up. Thus, we analysed the factors influencing marriage among the 55 patients who were unmarried at baseline, as summarized in Supplementary Table II. Only the 8th AJCC clinical stage correlated with the likelihood of staying unmarried post treatment [Stage I-III vs. IVA vs. IVB; 90.0% vs. 0% vs. 100% (P = 0.013)]. DISCUSSION Head and Neck cancers, particularly NPC are unique among all malignancies as the treatment-related adverse effects may extend years beyond treatment, owing to the proximity of critical normal structures which influence speech, swallowing, respiration, as well as physical appearance, which are all critical to daily functioning[ 17 ] as well as the bimodal age distribution. This could impede the Quality of Life (QoL) of these patients despite adequate tumour control, by negatively impacting their psychosocial, personal as well as professional domains of life. To add to their woes, many of these patients are the sole breadwinners of the family, for whom failure to resume their pre-radiotherapy jobs not only adds to the financial toxicity caused by the treatment itself, however, also pushes these patients as well as their families towards socio-economic vulnerability. [ 18 ] Return to Work (RTW) among Head and Neck Cancer survivors has been studied previously[ 19 ][ 20 ], however, there is a substantial vacuum in the literature with regards to survivorship issues among NPC survivors, especially among Low- and Middle-Income Countries (LMICs) like India. On the contrary, these survivorship issues are all the more important in a country like India, where adolescents and youth comprise 27% of its total population[ 21 ]. To the best of our knowledge, this is the first study from India, as well as the largest study overall to address survivorship intricacies like RTW and marital issues among nasopharyngeal carcinoma patients. The median age at diagnosis was 44 years (IQR = 32–57 years), and 70.1% of patients were males, whereas 29.9% were females. 78.9% of patients did not have any comorbidities, and only 4.6% of patients were illiterate. Thus, most of these patients were ‘employable’ in various economic sectors, and were capable of positively contributing towards the society. 87.1% of patients were diagnosed with ≥Stage III NPC, and 96.9% of them received chemotherapy. Only 16 patients experienced disease recurrence at a median follow-up of 49 months (IQR = 24–75 months). None of them defaulted for treatment, or were treated inadequately. However, despite adequate disease control, there was a staggering increase in the proportion of unemployed patients from 3.1% at baseline to 19.6% post-treatment. This surge in unemployment was largely attributed to 30 (15.4%) patients losing their jobs post-treatment, and 3 (1.5%) students discontinuing higher education. Being unmarried at baseline, [Married vs. Unmarried; 31.0% vs. 14.6% (P = 0.035)], higher education [Not graduate vs. At least graduate; 32.9% vs. 15.3% (P = 0.019)], and a higher ISCO-08 Broad Skill Level [Students vs. Skill Level 1 vs. Skill Level 2 vs. Skill Level 3 and 4; 9.7% vs. 62.5% vs. 42.5% vs. 16.1%(P < 0.01)] were associated with higher rates of RTW. Moreover, a lower broad skill level was also associated significantly with decrease in monthly remuneration (P < 0.001). These statistics are deeply concerning as patients employed in Skill Level 1 and 2 industries are prone to socio-economic vulnerabilities, and the added financial toxicities associated with cancer diagnosis, treatment, and follow-up, only seem to make matters worse for them. The potential reasons behind this disparity in rates of RTW among various broad skill levels could be attributed to the increased physical demands associated with manual labour; lack of legislation with respect to paid leaves for treatment and follow-up visits, regular medical check-ups, insurance coverage in the unorganized economic sector; hesitancy among employers while employing NPC survivors due to stigma, lack of awareness about the disease, etc. Another retrospective study on occupational rehabilitation among NPC survivors conducted at Princess Margaret Hospital (PMH) reported a median reduction of 12 hours/week among 31% of patients who were employed. Also, age, change in baseline neurobehavioral function, and private health benefits were all independent predictors of RTW[ 22 ]. Psychosocial support from family members, especially from the spouse is known to improve self-efficacy and reduce stigma among NPC survivors[ 23 ]. Moreover, marital status is also strongly associated with Quality of Life (QoL) among these patients [ 24 ]. Among our study population, one male (0.1%) patient reported getting divorced from his spouse post-treatment. However, whether the disease itself, the treatment, or the treatment-related morbidity have any negative impact on the marital life of these patients, or difficulty in finding a prospective spouse for patients who are unmarried at the time of diagnosis, has not been studied before. Among our study population, 55 (28.4%) patients were unmarried at baseline, out of which only 6 (3.1%) patients reported getting married post-treatment. Thus, out of those unmarried at baseline, 49 patients continued to remain unmarried post-treatment. Only a higher 8th AJCC clinical stage correlated with the likelihood of staying unmarried post treatment [Stage I-III vs. IVA vs. IVB; 90.0% vs. 0% vs. 100% (P = 0.013)]; however similar results were not replicated when we analysed change in marital status with respect to the M stage [M0 vs. M1; 92.7% vs. 100%; P = 0.467]. Although, the probable reasons behind the inability to find a suitable match could be body dysmorphia, social stigma, or other psychosocial issues. These need to be studied further in detail and are potential areas of research among nasopharyngeal cancer survivors. Both Return to Work (RTW)[ 22 ] as well as marriage[ 24 ] have been proven to be associated with a better quality of life (QoL). On one hand psychological support from family members, especially the spouse is of paramount importance in reducing stigma[ 23 ], and it plays a vital role in sustained recovery and rehabilitation of the patient. On the other hand, successful RTW not only provides financial security, but also ensures a sense of psychosocial well-being, bringing normalcy to the survivor’s life, and aids in his/her rehabilitation in the society. Needless to say, occupational reintegration of these patients is beneficial both to the patient as well as to the society and economy. The major strength of our study is a predominantly young population among whom RTW and marital issues are relevant issues. The weaknesses of our study are its retrospective nature and the possibility of recall bias. Further areas of potential research include surveys on probable reasons behind unsuccessful RTW, and/or NPC survivors not getting married post-treatment; prospective follow-up of these patients to study the temporal relationship between treatment and Return to Work (RTW), etc. CONCLUSION To conclude, even after major improvements in survival and disease control among NPC patients, survivorship issues remain a matter of concern, and there is a dire need to shift focus on successful reintegration of these patients into the society to ensure the overall health of the patient, as well as the society as a whole. Declarations COMPETING INTERESTS The authors have no relevant financial or non-financial interests to disclose. ETHICS APPROVAL This is an observational study approved by the Institutional Ethics Committee (IEC) at Tata Memorial Hospital, Mumbai, India (IEC Project ID: 4119). The ICH GCP (International Council for Harmonization Good Clinical Practice) guidelines were followed throughout the course of the study, and the study was conducted in accordance with the Declaration of Helsinki. CONSENT TO PARTICIPATE Written informed consent was obtained from all individual participants included in the study. FUNDING The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sarbani Ghosh Laskar, Vaishnavi Pahwa and Shwetabh Sinha. The first draft of the manuscript was written by Sarbani Ghosh Laskar and Vaishnavi Pahwa, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References X. Niu, F. Xue, P. Liu, C. Hu, and X. 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Anema, and A. J. Van Der Beek, “Physical and psychosocial problems in cancer survivors beyond return to work: A systematic review,” Psychooncology. , vol. 23, no. 5, pp. 481–492, 2014, doi: 10.1002/pon.3467 . D. N. Margalit et al. , “Interventions for head and neck cancer survivors: Systematic review,” Head Neck , vol. 44, no. 11, pp. 2579–2599, 2022, doi: 10.1002/hed.27142 . A. Pearce et al. , “Financial toxicity is more than costs of care: the relationship between employment and financial toxicity in long-term cancer survivors,” J. Cancer Surviv. , vol. 13, no. 1, pp. 10–20, 2019, doi: 10.1007/s11764-018-0723-7 . J. Yu, J. Smith, R. Marwah, and O. Edkins, “Return to work in patients with head and neck cancer: Systematic review and meta-analysis,” Head Neck , vol. 44, no. 12, pp. 2904–2924, 2022, doi: 10.1002/hed.27197 . J. Agarwal et al. , “Survey of return to work of head and neck cancer survivors: A report from a tertiary cancer center in India,” Head Neck , vol. 39, no. 5, pp. 893–899, May 2017, doi: https://doi.org/10.1002/hed.24703 . “Gender, youth and demographic shifts in India 1 Shireen J Jejeebhoy 2 and Sanjay Kumar 3,” vol. 51, no. 2, pp. 1–24, 2022. N. So et al. , “The Prevalence and Determinants of Return to Work in Nasopharyngeal Carcinoma Survivors,” Int. J. Radiat. Oncol. Biol. Phys. , vol. 106, no. 1, pp. 134–145, 2020, doi: 10.1016/j.ijrobp.2019.09.008 . M.-H. Yan, Y.-Y. Fan, and J.-E. Zhang, “Stigma, self-efficacy and late toxicities among Chinese nasopharyngeal carcinoma survivors.,” Eur. J. Cancer Care (Engl). , vol. 31, no. 1, p. e13528, Jan. 2022, doi: 10.1111/ecc.13528 . L. J. McDowell et al. , “Long-Term Late Toxicity, Quality of Life, and Emotional Distress in Patients With Nasopharyngeal Carcinoma Treated With Intensity Modulated Radiation Therapy,” Int. J. Radiat. Oncol. Biol. Phys. , vol. 102, no. 2, pp. 340–352, 2018, doi: 10.1016/j.ijrobp.2018.05.060 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableI.docx SupplementaryTableII.docx SupplementaryFigureI.png Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 05 May, 2026 Reviewers invited by journal 03 Mar, 2026 Editor assigned by journal 03 Mar, 2026 Submission checks completed at journal 06 Feb, 2026 First submitted to journal 30 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8746379","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600196851,"identity":"0da808c8-1bcc-4b45-aeee-0abfbb50984e","order_by":0,"name":"Sarbani Ghosh 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12:20:46","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":161594,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigureI.png","url":"https://assets-eu.researchsquare.com/files/rs-8746379/v1/7e8b26ae4f5c1e1882577137.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e‘Survival’ to ‘Survivorship’ in Carcinoma Nasopharynx: are We Doing Enough?\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNasopharyngeal carcinoma (NPC) is a rare epithelial carcinoma, arising from the mucosal lining of the nasopharynx, unique among all head and neck malignancies owing to its characteristic epidemiologic and geographic predilection[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], classic bimodal age distribution[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], association with Epstein Barr Virus (EBV)[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], a higher propensity for haematogenous spread, complex anatomy with a very limited role of surgery, and high sensitivity to radiation therapy as well as chemotherapy[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor decades, radiotherapy has been the primary treatment modality for nasopharyngeal carcinoma[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], however, it was the landmark Intergroup 0099 study[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and other similar prospective randomized studies[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] conducted among endemic populations, which established chemoradiotherapy as the standard of care for locally advanced carcinoma nasopharynx. In recent times, taxane-based neoadjuvant chemotherapy followed by platinum-based concurrent chemoradiotherapy has been established as the preferred approach to treat locoregionally advanced NPC[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere has been a paradigm shift in the management of NPC, with Intensity Modulated Radiotherapy (IMRT) being established as the standard of care[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], as a result of the dual improvements in survival as well as reduction in adverse effects with IMRT, such as reduced rates of xerostomia, hearing loss, trismus, subcutaneous fibrosis, etc., as compared to conventional radiotherapy techniques[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, with the advent of IMRT, radical improvements in Image Guided Radiotherapy (IGRT) techniques, and ever-evolving chemotherapy regimens, there has been an albeit but gradual, transition from improving patient outcomes, to reduction in treatment-related morbidity, to enhancing survivorship care in nasopharyngeal cancer patients. Although RT-related toxicities like hypothyroidism, xerostomia, hearing loss, etc. are well documented in literature, nasopharyngeal cancer survivors face a multitude of challenges like psychosocial issues, body dysmorphia, difficulty in occupational rehabilitation, fatigue, social isolation, etc[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. All these survivorship needs more pertinent in these patients due to a relatively younger age at diagnosis as compared to other head and neck malignancies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifficulty in occupational rehabilitation is one of the major predicaments faced by NPC survivors, likely due to post-radiotherapy speech impairment, prolonged Nasogastric Tube (NGT) dependence, etc. Failure to Return to Work (RTW) is also associated with psychosocial implications like self-esteem issues, anxiety, depression, and social isolation[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Thus, we conducted this study to address the lacunae in literature on Return to Work (RTW) and marital issues faced by nasopharyngeal carcinoma survivors, especially from Low-and Middle-Income countries (LMIC) like India; and the socio-demographic, disease-related, and treatment-related factors which influence the same.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e After Institutional Ethics Committee (IEC) approval (IEC Project ID: 4119), all consecutive nasopharyngeal carcinoma patients\u0026thinsp;\u0026ge;\u0026thinsp;16 years of age, treated with curative intent IMRT (with or without chemotherapy) from 2014 till 2023, attending the Head and Neck Disease Management Group (DMG) Outpatient Department (OPD) clinic at Tata Memorial Hospital, Mumbai from April 2023 till December 2024, with at least 6 months of follow-up after completion of planned treatment, were eligible for the study. Patients who did not complete the planned course of treatment, received treatment with palliative intent, were not willing to sign the written Informed Consent Form (ICF), or those with synchronous or metachronous primaries were excluded from the study.\u003c/p\u003e \u003cp\u003ePatients who fulfilled the inclusion criteria, were served questionnaires which included questions regarding sociodemographic aspects, disease, and treatment-related details; pre- and post-treatment employment and marital status. Sociodemographic details, disease, and treatment-related information were captured from the electronic medical records of the patient. Employment details included employment status, occupation, and monthly wages before diagnosis, and on the day of the survey. The broad skill levels of patients who were employed at baseline and follow-up, respectively were recorded using the International Standard Classification of Occupations (ISCO-08) provided by the International Labour Organization (ILO). Similarly, marital status and the number of children (if any) before diagnosis, and on the day of the survey, were also recorded. The ICH GCP (International Council for Harmonization Good Clinical Practice) guidelines were followed throughout the course of the study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eSPSS (Statistical Package for Social Sciences) Software Version 28.0.1.1 was used for data collection and statistical analysis. Demographic data was summarized with descriptive statistics. Continuous data was represented as mean (standard deviation) or median (interquartile range) and categorical data were reported in frequencies (percentage), respectively. Disease Free Survival (DFS) was defined as the time from the date of patient registration to the date of detection of any locoregional recurrence in the head and neck region, and/or distant metastases outside the head and neck region. Kaplan-Meier method was used for time-to-event analysis, including DFS analysis. Acute and late RT-related toxicities were recorded using the RTOG (Radiation Therapy Oncology Group) scale and CTCAE (Common Terminology Criteria for Adverse Events) v5.0, respectively. A univariate Cox proportional hazards model was used to test the factors influencing Return to Work (RTW) and change in marital status. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 319 nasopharyngeal carcinoma patients treated with radical intent IMRT from 2014 to 2023 were eligible for the study. Out of these, 194 patients who were on regular follow-up and willing to sign the written ICF were included in the study.\u003c/p\u003e\n\u003ch3\u003ePatient, tumour, and treatment characteristics\u003c/h3\u003e\n\u003cp\u003eTable I summarizes the baseline sociodemographic, disease characteristics, as well as the treatment received by our study population.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTABLE I: Sociodemographic, tumour and treatment-related characteristics of our study population at baseline\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCHARACTERISTICS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNUMBER\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePERCENTAGE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian age\u003c/b\u003e (IQR; in years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 years (IQR\u0026thinsp;=\u0026thinsp;32\u0026ndash;57 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndemicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndemic areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-endemic areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities (ACE-27 score)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRead and write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal \u0026lt;\u0026thinsp;10th grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10th -12th grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate/postgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8th AJCC Stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistopathology (2017 WHO classification)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSCC NOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeratinizing SCC (WHO Type I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-keratinizing differentiated (WHO Type II)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndifferentiated (WHO Type III)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiotherapy dose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66Gy/30#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70Gy/35#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChemotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not receive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e194\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eIQR- Interquartile range; ACE-27 score- Adult Comorbidity Evaluation-27 score; AJCC- American Joint Committee on Cancer; WHO- World Health Organization; SCC NOS- Squamous Cell Carcinoma Not Otherwise Specified\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe median age at diagnosis was 44 years (IQR\u0026thinsp;=\u0026thinsp;32\u0026ndash;57 years). 70.1% of patients were males, and 29.9% were females. 19.6% of patients were from regions endemic for nasopharyngeal carcinoma in India i.e. the North-Eastern states.\u003c/p\u003e \u003cp\u003e4.6% of patients were illiterate, 11.3% of patients could only read and write, 34.0% of patients had studied only till the 10th grade, 7.7% of patients had studied only till the 12th grade, 3.0% of patients had received vocational training, and 39.2% of patients had completed graduation or post-graduation. 16.0% of patients were students at the time of diagnosis, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% of patients had retired from their respective jobs. 71.6% of patients were married at baseline, whereas 28.4% of patients were unmarried.\u003c/p\u003e\n\u003ch3\u003eDisease Free Survival (DFS) and Patterns of Recurrence\u003c/h3\u003e\n\u003cp\u003eAt a median follow-up of 49 months (IQR\u0026thinsp;=\u0026thinsp;24\u0026ndash;75 months), the 5-year DFS (Disease Free Survival) was 89.6% (95% CI, 84.2\u0026ndash;95.0%) (Supplementary Figure I). A total of 16 patients experienced disease recurrence. The most common patterns of failure are shown in Supplementary Figure II.\u003c/p\u003e\n\u003ch3\u003eRadiotherapy-related acute and late toxicities\u003c/h3\u003e\n\u003cp\u003eSupplementary Table I summarizes the most commonly reported acute as well as late radiotherapy-related toxicities among our patients. The most frequently reported acute \u0026ge;Grade III RTOG toxicities were dysphagia (14.9%), dermatitis (12.4%), and mucositis (7.7%).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eReturn to Work (RTW) and factors influencing occupational rehabilitation\u003c/h2\u003e \u003cp\u003eTable II summarizes the employment status at baseline, and at follow-up respectively. At baseline, 16.0% of patients were students, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% were retired. On the other hand, at follow-up, 9.8% of patients were students, 20.1% were homemakers, 42.3% were employed, 19.6% were unemployed, and 8.2% were retired.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTABLE II: Employment status at baseline and follow-up, respectively\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEMPLOYMENT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eILO ISCO-08 BROAD SKILL LEVEL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBASELINE [n (%)]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFOLLOW-UP [n (%)]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHomemaker\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (20.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnemployed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (19.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRetired\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployed\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e112 (57.7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e82 (42.3)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSkill Level 1\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e8 (4.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e3 (1.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSkill Level 2\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e41 (21.1)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e25 (12.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSkill Levels 3 and 4\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e63 (32.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e55 (28.0)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e194 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e194 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBroad skill levels at baseline and follow-up\u003c/h3\u003e\n\u003cp\u003eAs mentioned in Table II, 57.7% and 42.3% of patients were employed at baseline and follow-up, respectively. Table II also summarizes the broad skill levels of patients employed at baseline and follow-up, respectively, as per the International Standard Classification of Occupations (ISCO-08) provided by the International Labour Organization (ILO). At baseline, 4.1% of patients were Skill Level 1 workers, 21.1% were Skill Level 2 workers, and 32.5% were Skill Levels 3 and 4 workers; whereas at follow-up, 1.5% of patients were Skill Level 1 workers, 12.8% were Skill Level 2 workers, and 28.0% were Skill Levels 3 and 4 workers.\u003c/p\u003e\n\u003ch3\u003eFailure to Return to Work (RTW)\u003c/h3\u003e\n\u003cp\u003eAs depicted in Table II, there was an increase of 16.5% in the number of unemployed patients at the time of follow-up, as compared to pre-treatment. This surge in rates of unemployment was accounted for by the fact that 30 patients (15.4%) who were employed at baseline, reported losing their jobs post-treatment; 3 patients (1.5%%) who were students at baseline, discontinued their higher education, and were unemployed at the time of follow-up; 6 (3.0%) patients who were unemployed at baseline, remained unemployed at the time of follow-up. 2 (1.0%) female patients reported quitting their jobs after their diagnosis, and continued to be homemakers. 8 (4.1%) patients retired from their jobs after completion of their service.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing Return to Work (RTW)\u003c/h2\u003e \u003cp\u003eWe defined \u0026lsquo;Failure to Return to Work (RTW)\u0026rsquo; as loss of employment post-treatment, as well as disruption in higher education, resulting in unemployment at the time of follow-up. Patients who were employed at baseline, or were students at baseline and employed at follow-up were deemed to have \u0026lsquo;Returned to Work\u0026rsquo;. Patients who were unemployed at baseline, and those who were homemakers, were not included for this analysis. Thus, a total of 135 patients were included in this analysis, out of which 34 (25.2%) patients experienced Failure to RTW, and 101 (74.8%) patients had returned to work at follow-up. We assessed various factors influencing Failure to Return to Work (RTW), as depicted in Table III. Marital status [Married vs. Unmarried; 31.0% vs. 14.6% (P\u0026thinsp;=\u0026thinsp;0.035)], Education [Not graduate vs. At least graduate; 32.9% vs. 15.3% (P\u0026thinsp;=\u0026thinsp;0.019)], and ISCO-08 Broad Skill Level [Students vs. Skill Level 1 vs. Skill Level 2 vs. Skill Level 3 and 4; 9.7% vs. 62.5% vs. 42.5% vs. 16.1%(P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)] were significantly associated with Failure to RTW.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTABLE III: Factors influencing Failure to Return to Work (RTW)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReturned to Work\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFailure to RTW\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePATIENT-RELATED FACTORS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119 (88.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidities (ACE-27)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.708\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114 (84.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87 (64.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (85.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48 (35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (67.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76(56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (84.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eISCO-08 Broad Skill Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (90.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkill Level 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkill Level 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (57.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkill Levels 3 and 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (83.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTUMOUR-RELATED FACTORS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8th AJCC Stage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.655\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI-III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (37.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (77.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (22.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76 (56.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIVB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM0 vs. M1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (75.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (24.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistopathology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndifferentiated (WHO Type III)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (76.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (85.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther histologies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (65.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTREATMENT-RELATED FACTORS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRadiotherapy dose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66Gy/30#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (69.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70Gy/35#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChemotherapy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (73.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e129 (95.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not receive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eACUTE TOXICITIES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcute dermatitis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e123 (91.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcute mucositis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (73.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e126 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (6.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAcute dysphagia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116 (85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLATE TOXICITIES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eXerostomia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (77.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113 (83.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHearing loss\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (85.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypothyroidism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCataract\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134 (99.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDecreased vision\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132 (97.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubcutaneous fibrosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTrismus\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDysphagia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.408\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133 (98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDermatitis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.408\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133 (98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e101 (74.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e34 (25.2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e135 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDifference in monthly remuneration pre-treatment and post-treatment\u003c/h2\u003e \u003cp\u003e45 (33.3%) patients reported a median increase in monthly remuneration of 15000 INR (167.05 USD) [IQR: 8000\u0026ndash;48000 INR (89.09-534.54 USD)] at follow-up, compared to baseline; whereas, 46 (34.0%) patients reported a median decrease of 9500 INR (105.80 USD) [IQR: 4000\u0026ndash;25000 INR (44.55-278.41 USD)]. Interestingly, there was a significant correlation between decrease in monthly remuneration and broad skill level (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 64.5% of patients with Skill levels 1 and 2 reporting a decrease in monthly remuneration post-treatment, as compared to only 26.8% of patients with Skill levels 3 and 4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMarital status at baseline and follow-up\u003c/h2\u003e \u003cp\u003eMarital status of our patients at baseline, and at follow-up is depicted in Table IV. 136 (70.1%) patients who were married at baseline, continued to stay married at follow-up. 2 female patients (1.0%) who were married at baseline, were widowed at follow-up. 1 male (0.5%) reported getting divorced from his spouse, following treatment. On the other hand, only 6 (3.1%) patients who were unmarried at baseline, got married post-treatment; whereas 49 (25.3%) patients who were unmarried at baseline, remained unmarried at follow-up. Also, only 9 (4.6%) patients reported conceiving at least one child post-treatment.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTABLE IV: Marital status of patients at baseline and at follow-up\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMarital status (Follow-up)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMarital status (Baseline)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMarried\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e136 (70.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e139 (71.6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnmarried\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e55 (28.4)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTOTAL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e142 (73.2%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e52 (26.8%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e194 (100)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing marital status post-treatment\u003c/h2\u003e \u003cp\u003eAs mentioned above, out of 55 patients who were unmarried at baseline, only 6 patients got married, and 49 patients remained unmarried at follow-up. The median age of patients who were still unmarried at follow-up was 26 years (IQR\u0026thinsp;=\u0026thinsp;22\u0026ndash;32 years). On the other hand, only 1 (0.5%) male patient who was married at baseline, reported getting divorced from his spouse post-treatment; whereas 2 (1.0%) female patients who were married at baseline, reported getting widowed at follow-up. Thus, we analysed the factors influencing marriage among the 55 patients who were unmarried at baseline, as summarized in Supplementary Table II. Only the 8th AJCC clinical stage correlated with the likelihood of staying unmarried post treatment [Stage I-III vs. IVA vs. IVB; 90.0% vs. 0% vs. 100% (P\u0026thinsp;=\u0026thinsp;0.013)].\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eHead and Neck cancers, particularly NPC are unique among all malignancies as the treatment-related adverse effects may extend years beyond treatment, owing to the proximity of critical normal structures which influence speech, swallowing, respiration, as well as physical appearance, which are all critical to daily functioning[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] as well as the bimodal age distribution. This could impede the Quality of Life (QoL) of these patients despite adequate tumour control, by negatively impacting their psychosocial, personal as well as professional domains of life. To add to their woes, many of these patients are the sole breadwinners of the family, for whom failure to resume their pre-radiotherapy jobs not only adds to the financial toxicity caused by the treatment itself, however, also pushes these patients as well as their families towards socio-economic vulnerability. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eReturn to Work (RTW) among Head and Neck Cancer survivors has been studied previously[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e][\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], however, there is a substantial vacuum in the literature with regards to survivorship issues among NPC survivors, especially among Low- and Middle-Income Countries (LMICs) like India. On the contrary, these survivorship issues are all the more important in a country like India, where adolescents and youth comprise 27% of its total population[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. To the best of our knowledge, this is the first study from India, as well as the largest study overall to address survivorship intricacies like RTW and marital issues among nasopharyngeal carcinoma patients.\u003c/p\u003e \u003cp\u003eThe median age at diagnosis was 44 years (IQR\u0026thinsp;=\u0026thinsp;32\u0026ndash;57 years), and 70.1% of patients were males, whereas 29.9% were females. 78.9% of patients did not have any comorbidities, and only 4.6% of patients were illiterate. Thus, most of these patients were \u0026lsquo;employable\u0026rsquo; in various economic sectors, and were capable of positively contributing towards the society. 87.1% of patients were diagnosed with \u0026ge;Stage III NPC, and 96.9% of them received chemotherapy. Only 16 patients experienced disease recurrence at a median follow-up of 49 months (IQR\u0026thinsp;=\u0026thinsp;24\u0026ndash;75 months). None of them defaulted for treatment, or were treated inadequately. However, despite adequate disease control, there was a staggering increase in the proportion of unemployed patients from 3.1% at baseline to 19.6% post-treatment. This surge in unemployment was largely attributed to 30 (15.4%) patients losing their jobs post-treatment, and 3 (1.5%) students discontinuing higher education. Being unmarried at baseline, [Married vs. Unmarried; 31.0% vs. 14.6% (P\u0026thinsp;=\u0026thinsp;0.035)], higher education [Not graduate vs. At least graduate; 32.9% vs. 15.3% (P\u0026thinsp;=\u0026thinsp;0.019)], and a higher ISCO-08 Broad Skill Level [Students vs. Skill Level 1 vs. Skill Level 2 vs. Skill Level 3 and 4; 9.7% vs. 62.5% vs. 42.5% vs. 16.1%(P\u0026thinsp;\u0026lt;\u0026thinsp;0.01)] were associated with higher rates of RTW. Moreover, a lower broad skill level was also associated significantly with decrease in monthly remuneration (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThese statistics are deeply concerning as patients employed in Skill Level 1 and 2 industries are prone to socio-economic vulnerabilities, and the added financial toxicities associated with cancer diagnosis, treatment, and follow-up, only seem to make matters worse for them. The potential reasons behind this disparity in rates of RTW among various broad skill levels could be attributed to the increased physical demands associated with manual labour; lack of legislation with respect to paid leaves for treatment and follow-up visits, regular medical check-ups, insurance coverage in the unorganized economic sector; hesitancy among employers while employing NPC survivors due to stigma, lack of awareness about the disease, etc.\u003c/p\u003e \u003cp\u003eAnother retrospective study on occupational rehabilitation among NPC survivors conducted at Princess Margaret Hospital (PMH) reported a median reduction of 12 hours/week among 31% of patients who were employed. Also, age, change in baseline neurobehavioral function, and private health benefits were all independent predictors of RTW[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychosocial support from family members, especially from the spouse is known to improve self-efficacy and reduce stigma among NPC survivors[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, marital status is also strongly associated with Quality of Life (QoL) among these patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Among our study population, one male (0.1%) patient reported getting divorced from his spouse post-treatment. However, whether the disease itself, the treatment, or the treatment-related morbidity have any negative impact on the marital life of these patients, or difficulty in finding a prospective spouse for patients who are unmarried at the time of diagnosis, has not been studied before.\u003c/p\u003e \u003cp\u003eAmong our study population, 55 (28.4%) patients were unmarried at baseline, out of which only 6 (3.1%) patients reported getting married post-treatment. Thus, out of those unmarried at baseline, 49 patients continued to remain unmarried post-treatment. Only a higher 8th AJCC clinical stage correlated with the likelihood of staying unmarried post treatment [Stage I-III vs. IVA vs. IVB; 90.0% vs. 0% vs. 100% (P\u0026thinsp;=\u0026thinsp;0.013)]; however similar results were not replicated when we analysed change in marital status with respect to the M stage [M0 vs. M1; 92.7% vs. 100%; P\u0026thinsp;=\u0026thinsp;0.467]. Although, the probable reasons behind the inability to find a suitable match could be body dysmorphia, social stigma, or other psychosocial issues. These need to be studied further in detail and are potential areas of research among nasopharyngeal cancer survivors.\u003c/p\u003e \u003cp\u003eBoth Return to Work (RTW)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] as well as marriage[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] have been proven to be associated with a better quality of life (QoL). On one hand psychological support from family members, especially the spouse is of paramount importance in reducing stigma[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and it plays a vital role in sustained recovery and rehabilitation of the patient. On the other hand, successful RTW not only provides financial security, but also ensures a sense of psychosocial well-being, bringing normalcy to the survivor\u0026rsquo;s life, and aids in his/her rehabilitation in the society. Needless to say, occupational reintegration of these patients is beneficial both to the patient as well as to the society and economy.\u003c/p\u003e \u003cp\u003eThe major strength of our study is a predominantly young population among whom RTW and marital issues are relevant issues. The weaknesses of our study are its retrospective nature and the possibility of recall bias. Further areas of potential research include surveys on probable reasons behind unsuccessful RTW, and/or NPC survivors not getting married post-treatment; prospective follow-up of these patients to study the temporal relationship between treatment and Return to Work (RTW), etc.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eTo conclude, even after major improvements in survival and disease control among NPC patients, survivorship issues remain a matter of concern, and there is a dire need to shift focus on successful reintegration of these patients into the society to ensure the overall health of the patient, as well as the society as a whole.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCOMPETING INTERESTS\u003c/h2\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eETHICS APPROVAL\u003c/h2\u003e \u003cp\u003eThis is an observational study approved by the Institutional Ethics Committee (IEC) at Tata Memorial Hospital, Mumbai, India (IEC Project ID: 4119). The ICH GCP (International Council for Harmonization Good Clinical Practice) guidelines were followed throughout the course of the study, and the study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCONSENT TO PARTICIPATE\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sarbani Ghosh Laskar, Vaishnavi Pahwa and Shwetabh Sinha. The first draft of the manuscript was written by Sarbani Ghosh Laskar and Vaishnavi Pahwa, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eX. Niu, F. Xue, P. Liu, C. Hu, and X. He, \u0026ldquo;Long-term outcomes of induction chemotherapy followed by intensity-modulated radiotherapy and adjuvant chemotherapy in nasopharyngeal carcinoma patients with N3 disease,\u0026rdquo; \u003cem\u003eTransl. Oncol.\u003c/em\u003e, vol. 14, no. 12, p. 101216, 2021, doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tranon.2021.101216\u003c/span\u003e\u003cspan address=\"10.1016/j.tranon.2021.101216\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eE. T. Chang, W. Ye, Y. X. Zeng, and H. O. 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Phys.\u003c/em\u003e, vol. 102, no. 2, pp. 340\u0026ndash;352, 2018, doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijrobp.2018.05.060\u003c/span\u003e\u003cspan address=\"10.1016/j.ijrobp.2018.05.060\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Carcinoma nasopharynx, survivorship, Return to Work (RTW), Occupational Rehabilitation","lastPublishedDoi":"10.21203/rs.3.rs-8746379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8746379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eNasopharyngeal cancer patients face various survivorship challenges like psychosocial disturbances, body dysmorphia, failure to Return to Work (RTW), etc. These issues are concerning due to relatively younger age at diagnosis. Our study aims to address RTW and martial issues faced by these patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e194 nasopharyngeal carcinoma patients treated with radical intent Intensity Modulated Radiotherapy (IMRT) between 2014\u0026ndash;2023, on regular follow-up, were included in the study, after taking written informed consent. RTW and marital issues were studied using questionnaires. P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian age at diagnosis was 44 years (IQR\u0026thinsp;=\u0026thinsp;32\u0026ndash;57 years). Male:Female ratio was 2.3:1. 95.4% patients were literate. At diagnosis, 16.0% were students, 19.1% were homemakers, 57.7% were employed, 3.1% were unemployed, and 4.1% had retired. At follow-up, 9.8% were students, 20.1% were homemakers, 42.3% were employed, 19.6% were unemployed, and 8.2% were retired. Thus, there was a 16.5% increase in number of unemployed patients post-treatment. Marital status, education, and ISCO-08 (International Standard Classification of Occupations) Broad Skill Level were significantly associated with Failure to RTW (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). 71.6% patients were married at baseline. 2 female patients who were married at baseline, were widowed at follow-up. 1 male reported getting divorced from his spouse, following treatment. Only 6 patients who were unmarried at baseline, got married post-treatment.\u003c/p\u003e\u003ch2\u003eConclusions \u0026amp; Implications for Cancer Survivors:\u003c/h2\u003e \u003cp\u003eEven after major improvements in disease control among carcinoma nasopharynx patients, survivorship issues remain areas of concern, and there is a dire need to shift focus on successful rehabilitation of these patients.\u003c/p\u003e","manuscriptTitle":"‘Survival’ to ‘Survivorship’ in Carcinoma Nasopharynx: are We Doing Enough?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 11:28:41","doi":"10.21203/rs.3.rs-8746379/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"121029694428225888125252135979752135285","date":"2026-05-06T02:59:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T20:01:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-03T19:55:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-07T00:19:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2026-01-31T04:20:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"19a69637-5106-4e5e-8381-75504857ed5d","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"121029694428225888125252135979752135285","date":"2026-05-06T02:59:51+00:00","index":14,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-08T11:28:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 11:28:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8746379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8746379","identity":"rs-8746379","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}