Cancer Survivors Returning to Work: Barriers and Interventions

In a session at the National Comprehensive Cancer Network Virtual Annual Conference, Amye J. Tevaarwerk, MD, director of the Survivorship Program at the University of Wisconsin Carbone Cancer Center, discussed the impact that cancer diagnosis and treatment can have on survivors when it comes to work status and outcomes, as well as potential interventions and lifestyle habits that might help patients transition back to work.

The Impact of Cancer on Employment

Tevaarwerk noted that roughly 46% of people diagnosed with cancer are between the ages of 20 and 64, although it isn’t clear what portions of that population are working, in school, or not in the workforce prior to diagnosis. Even so, given the fact that work provides not just income, but also insurance, a sense of normalcy, social contact, and other benefits for this population, overall work impairment can have a significant effect on health-related quality of life for cancer survivors.

It is also important to consider that “returning to work” will be a different experience from patient to patient, she said, since cancer is not necessarily a linear journey.

“The truth is that cancer patients may not ever stop working, so they might work during their entire diagnosis with only some short breaks; they may stop or start more than once; and they may stop and then restart at a very different level or job,” she said. “And so we just have to be a little bit careful of some of the implications of that term.” Especially in the metastatic setting, patients often undergo multiple lines of treatment in the same year and can face intensive treatments that may drive up costs at the end of life.

Still, measuring outcomes by employment, meaning a patient completes any work for pay or profit, is a straightforward method that is easy to track.

Describing employment as “the tip of the iceberg,” Tevaarwerk said that a key aspect of work outcomes that is more difficult to measure is work limitations, whether physical or mental, that change someone’s ability or productivity at work. Those limitations can lead to employment instability, under-employment, cause patients to struggle to maintain productivity at work, or lead to non-employment via early retirement or job loss.

Given employment is most often tied to health insurance coverage in the United States, financial toxicity is a potential occurrence when patients cannot sustain employment due to cancer treatment.

Potential Interventions to Aid Cancer Patients Returning to Work

Proactive interventions and guidance from clinicians can provide the support patients need on their cancer journeys. And when relevant and possible, taking the impact of a treatment into consideration prior to starting a patient on a therapy regimen can help physicians select the appropriate agent for specific patient lifestyle factors.

Tevaarwerk pointed to Lance Armstrong, a famous professional cyclist and testicular cancer survivor, as an example of the latter situation. At the time of his diagnosis, the most studied regimen carried a risk of pulmonary toxicity because it contained bleomycin. Given the potential impact on his career, he opted for an alternative, more experimental and expensive treatment regimen in an effort to avoid pulmonary toxicity. Although a situation like his is a luxury and is contingent on the existence of alternative therapies, it speaks to the potential for physicians to discuss and determine the treatment option best suited for a patient’s livelihood.

Patient surveys have shown that priorities and preferences also change, Tevaarwerk said, meaning the issue has to be readdressed regularly. She cited a study in which Williams et al. interviewed patients with metastatic breast cancer, discussing their priorities in regard to treatment and its impact on daily life, including work.

“They were able to divide on the basis of response to that question patients into two groups. There was a cost-prioritizing group, which was actually among the largest group; but there was a group that sort of prized the ability to work, and that was reported as their top concern. So, talking to our patients about this proactively may be very important and is something that I want to emphasize doing,” she said.

At clinics with the resources, patient navigators or social workers can also be a significant piece of the puzzle in terms of patient concerns about financial toxicity or employment. More complex multidisciplinary interventions that involve physical, educational, and vocational components have showed modest impacts on return to work rates in trials, but Tevaarwerk noted that she has not yet seen them implemented outside of the trial setting in a standardized way.

Based on available research, the NCCN Guidelines for Survivorship now includes an algorithm to address employment-related concerns. One question was added to the NCCN Survivorship Assessment survey: “Do you have concerns about how cancer and/or cancer therapy has affected your ability to work?” The update highlights the importance of discussing stressors related to employment with cancer patients, addressing concerns and barriers regarding work.