Employment and work-related issues in cancer survivors

2.1. Search strategy 

A systematic literature review on return to work and employment in cancer survivors was undertaken. Criteria for considering studies for this review were original papers published in English in peer-reviewed journals between 01/2000 and 11/2009. The databases PubMed, Medline, Embase and PsycInfo/Psyndex were searched extensively using a search string of “cancer OR neoplasm OR carcinoma OR oncology” combined with each of the following terms: “work”, “employment/employed”, “occupation/occupational”, “labor”, “labor market”, “absenteeism”, “sick leave”, “sickness absence”, “retirement”, “pension”, “disability pension”, “rehabilitation”, “work ability”, “work disability”, “wages”, “job loss”, “job performance”, “career” and “employer accommodation”. The reference lists of the identified articles and literature reviews [3], [4], [5], [6], [7], [8], [9] were searched manually until no additional articles were found.

Inclusion criteria: Considered studies for this review had to (1) primarily focus on employment and work-related issues in cancer patients; (2) be an original article using quantitative methodology; and (3) including adults.1

Exclusion criteria: Articles were excluded if they (1) only reported incidence or measurement of employment status, work ability or economic costs; (2) only reported employment status or work-related aspects as a correlate to another outcome variable of interest (often as part of the sociodemographic characteristics); (3) focused on work-related cancer risk factors (e.g. industrial or environmental risk factors); (4) were articles using qualitative methodology (primarily non-numerical data collection such as qualitative interviews); (5) focused primarily on the assessment of caregivers, employers or co-workers instead of cancer patients; and (6) focused on childhood cancer survivors. Studies on childhood cancer survivors were excluded due to the fact that this population – although under researched in the psycho-oncological literature – has a variety of specific topics and problems that would be addressed adequately in an independent review.

Quality assessment: The search process was executed in duplicate with two additional reviewers. The abstracts of the identified articles were then searched manually by the author and the two reviewers for relevance and inclusion in the review.

3.1. Prevalence of employment and return to work 

Twenty-eight out of 64 studies reported data about rates of employment or return to work in cancer survivorship. Overall, on an average 63.5% of the participants (range 24–94%) managed to return to work depending on the period of time after cancer treatment. At six months following diagnosis, on an average 40% of patients had returned to work or had continued working during treatment (range 24–72%) [10], [11], [12], [13]; at 12 months a mean of 62% had returned to work or had continued working during treatment (range 50–81%) [10], [11], [12], [13], [14], [15], [16]; at 18 months a mean of 73% had returned to work (range 64–82%) [10], [12], [17], [18]; and at 24 months on an average 89% of patients had returned to work (range 84–94%) [19], [20]. One study reported that 82% of women who had worked before their breast cancer diagnosis returned to work at a median follow-up of 36 months [21]. Another study showed that 67% of cancer patients were able to work five years after cancer diagnosis [22]. Several studies did not specify the time since cancer diagnosis or treatment completion until return to work [2], [23], [24], [25], [26], [27], [28], [29], [30].

Overall, studies indicated a steady increase of return to work from on an average 40% at six months post diagnosis to 62% at 12 months, 73% at 18 months, and to 89% at 24 months after cancer diagnosis. Compared to non-cancer comparison groups, research showed slightly different findings, particularly when time since treatment had been considered. Sanchez et al. [27] showed that 81% of those patients who returned to work sustained employment five years after diagnosis. Prostate cancer patients were less likely to be working six months compared to controls, but at 12 months post diagnosis, the likelihood of employment for cancer patients and cancer-free control subjects was not significantly different [31]. In contrast, although Taskila et al. [32] found that the employment rate among cancer patients before diagnosis (78%) was the same as in the cancer-free population, however, about 2.5 years after diagnosis, the employment rate of cancer survivors was significantly lower (64%) than in matched referents (73%) [32]. Breast cancer patients were found to be significantly less likely to be employed six months following diagnosis compared to healthy controls [11], [33]. Ahn et al. [23] showed that employment decreased from 48% to 33% after breast cancer treatment and significantly less patients worked after treatment relative to the general population. Also among stomach cancer survivors, non-working was significantly higher (47%) than in the general population (37%) [34]. Similar findings were observed by Maunsell et al. [35] and Drolet et al. [36]: At three years after diagnosis, slightly more cancer survivors were unemployed or not working compared to cancer free comparison groups.

3.2. Factors related to employment and return to work 

A previous review by Spelten et al. [3] documented that 62% of cancer patients (range 24–93%) manage to return to work depending on the period of time following treatment. Perceived employer accommodation for cancer and treatments was a strong and significant predictor for return to work. Recent studies seem to strengthen the findings by Spelten et al. [3]. Pryce et al. [13] found a return to work meeting with the employer as well as advice from doctor about work as factors significantly positive associated with return to work in cancer survivors. Moreover, counseling, miscellaneous training services, job replacement services, job search assistance and maintenance services [24] as well as perceived employer accommodation [18] were significantly associated with a greater likelihood of being employed.

Further factors related to return to work were younger age and cancer sites of younger individuals [25], [32], [37], [38], higher levels of education [25], continuity of care [15], absence of surgery [17], less physical symptoms [13], the length of sick leave [17] as well as male gender and ethnicity [38]. Higher employment levels in cancer survivors correlated with being single or separated, divorced or widowed [23]. Cancer types with a greater proportion of survivors working were genitourinary, melanoma and Hodgkin's disease [38]. Several studies reported the impact of physical and psychological symptoms on return to work. Pryce et al. [13] found higher levels of fatigue and overall stress significantly associated with return to work whereas Villaverde et al. [30] showed that the sequelae of the disease, cancer treatment and disease stage were independently associated with the ability to work after the end of treatment. Factors associated with working during treatment were the possibility of flexible working, cancer disclosure to colleagues and difficulties managing fatigue [13]. The findings by Chan et al. [24] indicated that 52% cancer survivors were successful employed after receiving vocational rehabilitation services.

3.3. Barriers related to not returning to work and to job loss 

Non-supportive work environment, manual work, cancer types associated with an unfavorable prognosis, the presence of fatigue and physical symptoms, and perceived employer discrimination because of cancer and treatment have been previously reported as barriers for returning to work [3], [35], [39]. In the current review, a range of similar employment barriers and risk factors for unemployment and job loss in cancer patients was detected.

Overall, cancer survivors were found to have a significantly increased risk for unemployment [40], [41], [42] and were less likely to be re-employed [43], [44]. A projected 13% of all survivors had quit working for cancer-related reasons within four years post diagnosis [45]. Amir et al. [17] found about 10% of cancer patients in a UK region stopped working after diagnosis. Peuckmann et al. [46] showed that 11% of patients stopped working or changed their job due to breast cancer; and findings by Stewart et al. [29] revealed that 41% of breast cancer patients were no longer working at on an average 9 years post diagnosis.

Several findings showed that between 47% and 53% of cancer survivors lost their job or quit working over a 12-month, 72-month period, respectively; and 26–50% of survivors lost their job or quit working within the first year post diagnosis [45], [47], [48]. However, between 23% and 75% of patients who lost their job were re-employed. Park et al. [48] showed that the mean time to job loss was 41 months, significantly lower in cancer patients than in non-cancer controls (50 months). The mean time to re-employment was 46 months [44]. Likewise, the mean time to re-employment was significantly longer in cancer patients than in the non-cancer comparison group (47 months vs. 32 months) [44].

Use of endocrine therapy was associated with a twofold increase risk of not having returned to work after two years post diagnosis [20]. Risk for unemployment was associated with extensive surgery [23], advanced tumor stage [2], [11], [18], [20], [23], [45], [47], chemo- and radiotherapy [21], higher age [21], [34], [40], [48], [49], female gender [24], [34], [48] and lower levels of education [2], [21], [24], [28], [32], [47]. A range of cancer sites had been associated with a higher risk for unemployment and job loss. These cancer sites include liver cancer [2], [44], [47], [48], lung cancer [32], [38], [44], [48], advanced blood and lymph malignancies [32], [44], [45], [48], brain and CNS cancer sites [32], [44], [45], [48], gastrointestinal cancers [38], [44], [48], pancreatic cancer [44], [48], head and neck cancers [38], [45] as well as gynecological cancers [38].

Results furthermore revealed the significant impact of socioeconomic and work-related factors on unemployment such as low income [23], [40], [48], [49], manual and non-sedentary work [40], [47], [49], company employment [48], union membership [36] and perceived employer discrimination, psychological or self-perceived constraints [18], [21]. Working environment, physically exhaustion and deterioration were found as the most frequent reasons for not returning to work [20]. Findings by Bradley and Bednarek [22] revealed that poor health and disablement as frequent cause to stop working. Overall, the presence of comorbid diseases, a poor health status and depression have been found as risk factor for unemployment [18], [23], [40].

A higher percentage of cancer patients retired from their jobs post diagnosis compared to non-cancer controls [31], [50]. A Danish study showed that patients had a significantly increased risk of early retirement pension compared to cancer-free controls [51]. Risk factors for early retirement included older age; dissimilated disease, manual job, and sickness leave the year before taking early retirement pension, physical and psychological comorbidity, low education and low income as well as cancer sites containing leukemia, prostate cancer and ovary cancer.

3.4. Sick leave and length of absence from work 

Merely few studies have investigated the length of sickness absence in cancer, indicating a wide range from on an average 27 days in prostate cancer patients [52] to on an average 11 months in early-stage breast cancer survivors [19], [21]. On the basis of the reported sick leave periods, the mean duration of absence from work was 151 days [17], [19], [27], [49], [52]. However, a recent study by Roelen et al. [53] reported that the mean duration of sickness absence due to breast cancer was 349 days and another study by Ohguri et al. [54] showed a mean duration of sick leave of 86 days (range 11–929 days). Balak et al. [19] reported that 35% of breast cancer patients were absent longer than one year.

Short et al. [45] reported that 41% of male and 39% female patients with mixed cancer sites who were working at the time of diagnosis stopped working during cancer treatment. Patients older than 60 years reported a higher prevalence of sick leave [46]. At the end of cancer treatment, Molina et al. [37] found an age over 44 years, elementary school education, comorbidity, disease stage IV, presence of sequelae and having lung cancer significantly associated with sick leave. In contrast, compared with survivors belonging to a union, those patients who did not belong to a union and those who were self-employed were more likely to report no work absence [49].

No significant differences in current sick leave between cancer survivors and non-cancer controls were found by Gudbergson et al. [55] and by Drolet et al. [49]. The latter study showed that disease-free women had no longer length of sickness absence than women in the comparison group three years post diagnosis. Duration of absence from work was significantly longer in patients who underwent chemotherapy or multimodal treatment [10], [19], [21], [27], [37], [49], who belonged to the most economically deprived group [17], who reported higher levels of fatigue, physical complaints, and higher workload [10], who were older and who reported work changes due to cancer [56].

3.5. Reduction in work hours, wages and work changes 

The majority of studies that concentrated on working time reported a reduction in work hours – at least partially or over a time limited period – in cancer survivors [34]. Slightly more than 50% of survivors reduced their work schedule at least one time, although 86% of survivors returned to former work schedules [22]. Working women with breast cancer reduced their weekly hours worked by nearly 18% at six months following diagnosis [11]. Compared with the general population, cancer survivors reported reduced working hours significantly more difficulties with reduced working hours [23].

For both genders, significant effects of survivorship on the probability of full-time employment and hours were found [57]. However, it is noteworthy that again for both genders, these effects were primarily attributable to new cancers. There were no significant effects on the employment of cancer-free survivors [57]. Likewise, Peuckmann et al. [46] found a similar extent of employment (paid by the hour, temporary work, and average weekly hours) between patients and the general women population. However, cancer survivors of both genders worked an average of 3–5h less per week than non-cancer controls [57]. The findings by Steiner et al. [28] showed that 57% of cancer survivors who remained employed after treatment, reduced work by more than 4h per week with a mean reduction of 16h per week. In a further study, the mean hours per week were 49h for full-time workers, and 20h for part time workers [22]. In contrast, Bradley et al. [33] showed that employed breast cancer survivors were even estimated to work 3.4h more a week than other employed women. A reduction in work hours was significantly associated with advanced stages [11] more physical (e.g. lack of energy) and psychological symptoms (feeling useless, anxiety, depression) [28].

A significant proportion of patients had changed work due to cancer. Amir et al. [17] found 8% of breast cancer patients had changed to a different work place and Gudbergson et al. [56] showed that 17% of the sample reported work changes due to cancer. Similar results with regard to the percentage (15%) of women who reported work changes were found by Fantoni et al. [21]. Patients who reported work changes were significantly more frequently female and worked part time. Moreover, patients who had changed work had significantly poorer current work ability, reduced physical and mental work ability as well as significantly higher anxiety and depression [56].

Overall contrary findings have been found related to earnings and wages in cancer patients. No differences in annual household income levels as well as in the number of paid hours per week and in working time each week (full-time, part-time) between cancer survivors and non-cancer control subjects could be observed by Gudbergson et al. [58].

In contrast, recent studies found cancer to be associated with a 12% decline in overall earnings [41]. Breast cancer patients reported a 16% decrease in wages [23]. On average, working women lost 27% of their projected usual annual wages (median=19%) after compensations received had been taken into account [59]. A higher percentage of lost wages was significantly associated with a lower level of education [41], [59], lower social support, chemotherapy, self-employment, shorter tenure in the job, and part-time work. Furthermore, Syse et al. [41] found that leukemia, lymphomas, lung, brain, bone, colorectal, and head-and neck cancer resulted in the largest reductions in employment and earnings. One study showed significantly higher earnings in breast cancer survivors than among the non-cancer comparison group [33].

3.6. Work ability and perceived job strain 

The concept of work ability emphasizes that individual work ability is a process of human resources in relation to work [60]. Thus, work ability can be defined as an individual's physical, psychological, and social resources for participation in any kind of paid work or self-employment. Work ability is dependent on mental and somatic health status as well as on social skills, level of education, motivation, work demands, the work environment, and the organization of the work [57], [60].

Several studies investigated work ability following diagnosis and treatment, and found a reduction in physical or mental work ability up to 26% [23], [31], [34], [57], [58], [61], [62], [63]. Even four years post diagnosis, Hansen et al. [64] showed that breast cancer survivors reported higher levels of age-adjusted work limitations compared to a non-cancer group of employed workers. In contrast, the current work ability improved significantly over time in a study by De Boer et al. [12]. In this study, work ability of women improved more over time compared to male employees. Also, Taskila et al. [62] did not observe difference in the mean of work ability between cancer survivors and their referents for both genders. Work ability at six months after sick leave strongly predicted return to work at 18 months [12].

Risk for reduced work ability was associated with hematological neoplasias [12], chemotherapy and multimodal therapy [12], [62], [63] older age among women, diseases or injuries [62], as well as with work changes due to cancer [57]. In contrast, better work ability was found to be related to genitourological and gastrointestinal cancers [12], to a higher level of education [62], to better social climate at work and greater commitment to the work organization among both genders [62]. In comparison to non-cancer controls, cancer survivors did not differ significantly in their job or work strain [55]. However, female patients were found to experience more job strain than male patients [55]. Furthermore, cancer survivors who had changed their work due to cancer reported significantly higher demands caused by tasks of work and overall work load [56].

3.7. Career changes, job satisfaction, and employer accommodation 

Following a diagnosis of cancer, 56% of patients who returned to work reported changes in occupational role [28]. In a study of 378 women with breast cancer, who were assessed nine years post diagnosis, about one forth of patients reported a career change, 12.5% retired early as a result of cancer, 41% felt the cancer had altered their priorities and ambitions at work, and 12% reported that they were unable to fulfill their work or career potential [29]. However, another 26% of the women felt that cancer had made them more goal focused and 6.5% reported a positive career change [29]. A study by Gudbergson et al. [61] revealed no differences in work engagement between cancer patients and the comparison group.

The majority of patients told employers and co-workers about the cancer disease [30], whereas Stewart et al. [29] reported that only 41% of the sample had told their cancer diagnosis to their boss or supervisor at work. Bouknight et al. [18] showed that 87% of breast cancer patients perceived their employer as accommodating to their cancer and treatment. Similar results found that cancer survivors reported only few workplace barriers on returning to work [28]. About 29% of patients noticed changes in their relation with co-workers and managers, however, usually in a supportive way [30]. Changes in patient's relationship with co-workers and managers were also found among 21% of survivors by Molina et al. [37]. Cancer patients had received most support from their co-workers [65], however, 39% of women and 29% of men hoped for more support particularly from the occupational health care personnel.

Few studies, however, reported difficulties in returning to work. Findings indicated that 2% of breast cancer survivors reported reduced opportunity for promotion [23]; and one fifth of those survivors who returned to work and stayed in the same employment reported deterioration in job satisfaction and career prospects [17]. Schultz et al. [38] reported that 7% of cancer survivors had experienced job discrimination such as getting fired or forced to quit, denied promotion, denied employment or the inability to obtain health insurance. Patients who changed their job due to cancer not only had higher demands caused by tasks of work and work load, but also lower support from colleagues [56]. Moreover, cancer survivors were more likely to file job loss claims and differential treatment related to workplace policies [66].

3.8. Physical and psychological disablement and quality of life 

The impact of cancer and cancer treatments may be particularly evident at the workplace. Cancer survivors were significantly more likely as non-cancer controls to report fair or poor health, psychological disabilities, limitations of activities of daily living, functional limitations, and, among those under the age of 65, being unable to work because of a health condition [67], [68].

Bradley and Bednarek [22] as well as Short et al. [45], [69] found cancer-related disabilities in 10%, 20% of the samples, respectively and half of the patients with disabilities were working [45]. In a recent study, 27% of male and 32% of female survivors reported work disabilities [69]. For both genders, the rate of work disability was significantly higher in the cancer sample compared to non-cancer controls [69]. The increase in disability for survivors with any new cancers was significantly greater than the increase in disability for cancer-free survivors [69]. Cancer survivors were found to be more likely to have comorbid diseases than controls, particularly evident among male patients, who had a significantly worse subjective health status and higher somatic symptom levels than non-cancer controls [58]. Gudbergson et al. [61] in addition found statistically lower rates of vigor domains among cancer patients, and a significantly poorer health status, greater numbers of disease symptoms, more anxiety, and reduced physical QoL. Limitations were most frequently reported by long term breast cancer survivors in the following activities: managing ‘heavier work at home, taking a short walk with a ‘rather healthy speed, climbing stairs, doing the grocery, and taking the bus [46]. In addition, going outside the house, walking around at home, taking a bath, getting dressed, and managing light work at home were reported by 65% of patients as troublesome [46].

Cancer-related fatigue is a profound fatigue related to cancer or its treatment and has been recognized as a common and debilitating complaint among cancer survivors [70]. Several studies have found fatigue and exhaustion to impact both housework and gainful work. In nearly half of the patients, fatigue and exhaustion were the most frequent problems reported and cancer survivors had more difficulties with fatigue and exhaustion compared to the general population [23]. Cancer survivors reported significantly more fatigue in performing both housework and gainful work compared to population-based control group [34]. Hansen et al. [64] showed that fatigue explained 71% of the contribution of overall symptom burden. However, a recent study revealed that fatigue was reported in 13% of patients and neither postponed partial return to work nor full return to work [19], although another study found that among women who had returned to work, 77% suffered from fatigue [21]. Few studies have focused upon psychosocial aspects in return to work. The lowest level of psychosocial distress and the highest levels of physical and mental functioning, and QoL were found in women who continued to work through treatment, followed by women who discontinued to work through treatment but returned to work [26]. Likewise, highest level of psychosocial distress and lowest levels of physical and mental functioning, and QoL were found in women who stopped working after the cancer diagnosis [26]. Among fully employed patients with hematological malignancies, 73% reported good QoL compared to 22% of those on disability insurance and 28% of those on part-time work. Age and employment status were significantly associated with QoL [14]. In contrast, being employed was found to be negatively associated with body changes, negative self-evaluation, negative outlook and life interference [71]. Furthermore, cancer survivors who had changed their work due to cancer had significantly higher levels of anxiety and depression as well as significantly poorer physical and mental QoL [58].