Many cancer survivors face challenges that extend beyond strictly medical issues, including their ability to continue working and maintain insurance coverage. Prior research on this topic is dominated by cross-sectional or retrospective studies.18
Prospective studies like ours have focused mainly on patients with breast cancer and have shown that most employed patients return to work19
and that some are able to work through cancer treatment.4
This study adds to the literature by exploring these issues in patients with lung or colorectal cancer and presenting estimates of workforce departures that can be attributed to patients' cancer.
In our study, 74% of patients employed at diagnosis were also employed at follow-up. This compares favorably to the rate of 62% found by Spelten et al19
in their review of the employment literature related to cancer. When adjusted for age-related workforce departure, the excess rate of workforce departure was 17%. Moreover, we found little evidence that cancer survivors experience overt discrimination at work. In our study, younger, less educated, and lower income patients were particularly prone to depart from the workforce. If a young cancer survivor departs the workforce permanently because of cancer, the cumulative loss of potential earnings is enormous.3
Bradley et al20
found the effect of breast cancer on labor force departure to be twice as great in African American women than in white women. Our study did not find conclusive evidence of racial differences after adjusting for factors such as age, education level, and income, although we had only limited statistical power to investigate this effect in all subgroups, particularly among older patients. The finding that wage loss is associated with lower sociodemographic status has been reported in other contexts.21
For example, Lauzier et al6
found that lower education, shorter tenure in a job, part-time work, and self-employment were all associated with wage loss in a prospective cohort of women with breast cancer in Quebec, Canada. Rothstein et al22
found manual laborers to be most likely and professionals least likely to have their job duties reassigned on return to work. Drolet et al13
reported that being unionized was protective for these workers.
We did not find an association between receipt of chemotherapy and workforce departure. However, more advanced disease is understandably a barrier to work that has also been observed in other studies.2
Cancer and its treatment often leave patients with disabilities that may be subtle or pronounced, such as difficulty with memory and concentration (so-called chemo-brain) or fatigue that can interfere with the ability to perform work-related tasks. In one survey of working-age cancer survivors, 17% reported that they were unable to work because of physical, mental, or emotional problems.23
Although data on cancers other than breast cancer are limited, survivors of brain tumors, leukemia, and head and neck cancers may be particularly vulnerable.2
In addition to the direct effects of cancer, logistical burdens related to care may also lead to workforce departure.
Insurance loss did not seem to be a significant problem for CanCORS participants. This may have been partly related to selection into the cohort for some patients, such as those in the Veterans Affairs sites. Married women of lower incomes were significantly more likely than unmarried women to stop working,24
possibly because they may have a spouse who is the primary source of health insurance or income in their households, resulting in more flexibility to leave the workforce. Similarly, patients near age 65 years may be more likely to leave work as they become eligible for Medicare insurance. Patients who exited the workforce seem to have either obtained public insurance (ie, those age > 65 years) or insurance through a family member (ie, married women). Patients younger than age 65, unmarried patients, and patients who are the primary breadwinners may not be able to do so as easily.
A recent study found that workers with health coverage at cancer diagnosis were no more likely to alter employment after treatment than similar insured workers without cancer but that cancer survivors with no employer-related health insurance were more likely to stop working, switch jobs, or cut back from full-time to part-time work than other workers with health insurance.25
There are some protections in place for patients who depart the workforce. Examples include the Consolidated Omnibus Budget Reconciliation Act, which allows workers to maintain their health insurance for 18 months after losing or leaving a job, and the Health Insurance Portability and Accountability Act (HIPAA), which prohibits insurers from denying or limiting coverage because of pre-existing conditions. However, Consolidated Omnibus Budget Reconciliation Act premium surcharges are not controlled and can be insurmountable for patients who are unemployed, and the HIPAA provisions do not apply to employers with less than 20 workers.
Our study has some limitations. Although the goal of CanCORS was to create a population-based cohort of patients, nonparticipants may have differed from participants. Nonetheless, participants in CanCORS have been shown to be demographically similar to population-based samples with these cancers in Surveillance, Epidemiology, and End Results registries.26
However, the older age distribution of the cohort resulted in less than half of the patients being employed at diagnosis and somewhat limits the power to study employment trends. Among participants, there was further attrition between the baseline and follow-up surveys for a variety of reasons, including death, and these patients may have experienced even greater rates of workforce departure than patients able to complete the follow-up survey. We did not have information on the specific types of jobs patients had. We also did not know whether patients had other sources of support, such as disability benefits, which may have affected their decision making regarding returning to work. Finally, insurance loss was an uncommon problem in our study cohort, so we were unable to explore this issue in great depth.
We found that approximately 80% of patients with colorectal and lung cancer who survive their cancer are able to return to work. However, patients who are most vulnerable to the negative economic consequences of cancer are those with the most need of support—those with the fewest resources and the most advanced disease. These findings are worthy of consideration in several types of policy decisions. For example, employers have an interest in choosing health plans with adequate resources to assist survivors to return to work. Moreover, because primary cancer treatment often takes longer than 12 weeks to complete, federal and state governments should consider lengthening the duration of guaranteed medical leaves in the workplace. Finally, patients may benefit from discussions with clinicians about the possibility that their cancer could impact their ability to work. Ultimately, new strategies to limit cancer-related disability will be important to minimize disruptions in employment.