Cancer has a massive impact globally, with an estimated 1.8 million cases per year in the U.S. The advances in screening, early diagnosis, and treatment modalities have greatly improved cancer-related morbidity and mortality. With approximately 16.9 million cancer survivors as of January 2019 in the U.S. alone, this number is only expected to grow. When diagnosed, many of these survivors were probably working, thus needing to adapt their lifestyle and work ability around their diagnosis and upcoming treatment. However, this aspect of cancer survival receives very little coverage in research and modern-day media.

The National Comprehensive Cancer Network’s (NCCN) 2021 Virtual Annual Conference highlighted many important aspects of cancer survivorship. Speaker, Anna J. Tevaarwerk, M.D., from the University of Wisconsin Carbone Cancer Centre, highlighted the importance of accommodating cancer survivors returning to work. Her talk, titled, ‘Helping Cancer Survivors Return to Work,’ discussed the impact of cancer and its treatment on a survivor’s work ethic, performance, and/or employment satisfaction and how employers can better assimilate survivors who choose to or need to work during or after their treatment.

 

The ‘Return to Work’ Issue

During her presentation, Dr. Tevaarwerk shared that around 46% of those diagnosed with cancer are in the 20-64 age group—the ‘working age group’ in the U.S. So, most are either in the workforce, in school, or not in the workforce. Additionally, the average retirement age in the U.S. is 64, but this is predicted to rise. This highlights how cancer survivors may have to undergo and recover from treatment while remaining within the working age group.

This also means, that the majority of patients or survivors will either want or need to continue working after their diagnosis. But evidence indicates that their successful return to work post-diagnosis is much more challenging than it should be. Some of these work limitations are physical and are likely to impair their ability to work:

  • Increased fatigue
  • Decreased stamina
  • Lack of productivity and the persistent side effects of the treatment itself Additionally, the numerous appointments and frequent sick leave associated with cancer treatments can interfere with daily tasks, resulting in unpredictable absences from work. Psychosocial, mental, and/or emotional issues may also emerge when a person is diagnosed with cancer, leading to:
    • Decreased confidence in being able to work
    • Reduced self-esteem
    • Increase anxiety about being shunned at work
    • Fear of being a burden on your colleagues or employer

While most survivors appear ‘normal’ on the outside, many of these psychological and psychosocial stressors associated with cancer treatment and self-confidence/body dysmorphia anxiety (e.g., hair loss associated with chemotherapy), can often make it very hard for survivors to return to work. Unfortunately, many are unable to stop working or reducing their work hours even during active treatment – especially with patients receiving palliative (treatment targeting the symptoms rather than the cancer itself) or non-curative (treatments that slow progression and tumour growth) treatments that are ongoing and need to remain in the workforce.

 

Consequences of Work Limitations

Explaining the impact of the above stressors on patients who need to work, Dr. Tevaarwerk said, “Cancer treatment creates demands on patient time that may impact employment and may require job accommodation such as increased personal calls or messages during work hours, perioding breaks for rest, reduced physical exertion, job restructuring and/or modification, provision or mobility assistance, improved building access and parking close to your work area, or modified office temperatures.

As a survivor with, undergoing, or recovering from cancer and its treatment it can be quite challenging to ask for these adjustments from your employer and can leave survivors feeling productively inadequate. Additionally, the impact of reducing work hours may lead to financial toxicity that culminates in treatment delays/lack of treatment adherence, treatment discontinuation, health insurance threat (becoming uninsured/paying for increased out-of-pocket expenses), lack of stable income, and psychosocial distress.

For many survivors, work also means a lot more than income—survivors may continue or want to return to work because, as Dr. Tevaarwerk says it creates a sense of normalcy, distraction, need for activity, and social contacts.” While there is no direct line between these concepts, it is important to highlight that work is important for a lot of reasons outside of income, and many survivors may find a sense of purpose that encourages them to continue to return to work.

 

Post-Diagnosis Work Outcomes

Cancer employment support varies widely in the U.S. depending on the system you are operating in, according to Dr. Tevaarwerk. Work-related productivity due to loss of health may change significantly, with lower levels of productivity happening after diagnosis and at the end of treatment, she said, with the main driver being absenteeism, which includes a loss of working days due to treatment. Additionally, patients receiving curative treatment have shown increased work ability, decreased work limitations, and a steady rise in hours worked when compared to their counterparts receiving palliative cancer therapy.

Dr. Tevaarwerk added that due to the stigma surrounding cancer, and the possibility of being laid off or misrepresented at work, patients find it extremely difficult to share their diagnosis and treatment plans with their employer. Thus, a majority of the time the type of treatment a cancer patient is receiving is unclear, meaning that employment facilities tend to be inadequately prepared to support a cancer patient either during (if they decide that they are in the position where they are able to comfortably continue working) or after their treatment. She added that the phrase ‘return to work’ is misleading as it “implies that a cancer survivor stops working and then re-starts only once at the exact same job,” when in reality a cancer survivor may never stop working, or may stop and start more than once, or may take up a very different level or job.

 

Overcoming Work Limitations and Barriers

To make returning to work successful, it is important for employers and their employees who are survivors to work together to create an accommodative environment that supports both their needs. A proactive discussion between both parties can help establish physical and emotion boundaries. Dr. Tevaarwerk highlighted several key things an employer can do to support the successful return of a cancer survivor to work:

  • A proactive discussion between the employer and employee to establish work-related boundaries (performance adjustments, work intensity etc.)
  • Increasing the availability of emotional support options within the workplace (physical work-place adjustments, increased work-from home hours, staggering schedules etc.)
  • Making shared decisions to mitigate work impact

Conclusion

Overall, the return to work of a survivor is complicated and influenced by numerous factors and the work ability and performance of a survivor or patient often depends on survivor characteristics, work conditions (flexibility/climate), and the interplay between complex employee-employer social systems. Being at work is considered both necessary and fulfilling, and is strongly associated with mental, emotional, physical, and therapeutic benefits for those suffering from chronic conditions like cancer. Therefore, understanding the ‘return-to-work’ dilemma that cancer survivors face and adjusting it to be more accommodative would open up a range of opportunities that could benefit both the employer and the survivor.

 

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