This study is the first to explore the relationships of psychosocial, physical and neurocognitive health on different aspects of unemployment and occupational status for adult survivors of childhood cancer. Our findings suggest that multiple health domains influence unemployment and occupational status, and that these factors may be dissimilar among male and female survivors. Although comparisons by sex should be interpreted cautiously because males and females often have different attachments to the labor force, our findings suggest that interventions to improve employment outcomes for childhood cancer survivors may need to consider how limitations affect work status differentially for males and females. We also found that neurocognitive limitations are associated with a decreased likelihood of working in higher skill occupations for survivors. Additionally, survivors reporting health-related unemployment or being unemployed but seeking work are likely to have limitations in physical, mental and neurocognitive function at levels above comparison norms.
Childhood cancer survivors face health-related barriers to employment more often than sibling or population-based samples (2
), and our analyses suggest that limitations due to physical functioning may drive much of this difference. Survivors with poor physical health were almost eight times more likely to be unemployed due to health or disability, and this was consistent for both male and female survivors. Survivors with poor physical health were also more likely to work part-time, suggesting that even employed survivors could benefit from strategies to address physical limitations in the workplace. Physical limitations, however, were not significant for the seeking work group. Instead, both active depression and low mental health were associated with being unemployed but seeking work.
Survivors report more frequent executive functioning problems compared to siblings (11
). In our analyses male survivors with task efficiency and memory problems were more likely to report health-related unemployment or to work part-time. Female survivors with task efficiency problems also were at a higher risk for these outcomes. However, we found no association with neurocognitive deficits or for females or males who were retired, in school, or taking care of family – that is, survivors with neurocognitive problems may not be selecting themselves out of the labor force. Instead, survivors with neurocognitive problems may want to work, but face cognitive or health status barriers to gaining or maintaining employment.
Employed female survivors with task efficiency, emotional regulation and memory limitations were less likely to report working in higher-skilled professional or managerial occupations. Deficits in task efficiency (e.g., ability to finish work or multitask), emotional regulation (e.g., becoming easily frustrated or upset), and memory (e.g., forgetting instructions, difficulty with recall) may be more of an impediment for females in obtaining higher-skilled jobs than males. When we adjusted the models for education and cranial radiation, these associations for females attenuated or disappeared, suggesting that efforts to mitigate educational barriers or late effects from cranial radiation for female survivors could reduce the burden of neurocognitive deficits on their occupational achievement.
In our multivariable models, both female and male survivors with organization problems were more likely to work in professional occupations, compared to the other NCQ factors that conferred a decreased likelihood. The statements comprising the organizational factor – I am disorganized, I have trouble finding things in my bedroom, closet, or desk, and My desk/workspace is a mess – may indicate different things for survivors depending on their underlying health status or their type of occupation. Organizational problems may not become apparent until the survivor is confronted with a busy lifestyle that includes occupational or other higher level obligations. Additionally, fewer survivors report organizational limitations compared to the other NCQ factors, suggesting that deficits of task attention, emotion and memory may be more important to target in employment interventions for this population.
This study has limitations that should be considered when interpreting the results. Firstly, we did not postulate specific hypotheses regarding the relationship of the SF-36, BSI and NCQ on our outcomes, in particular by sex. Because of the multiple outcomes investigated, our results should be interpreted cautiously. Secondly, we did not have information on how long survivors had been unemployed or looking for work, which could differ substantially according a survivor’s limitations. Also, alternatives to the ≥63 T-score cut-point to indicate psychological distress using for the Global BSI have been suggested (30
). Because we were interested in the BSI subscales, we used this cut-point to be consistent with the current literature on cancer survivors and to be conservative in classifications of emotional distress.
These survivors were diagnosed during childhood. We have no information on when the psychosocial, physical and neurocognitive limitations first emerged nor do we know about their relationship with education or other social outcomes such as marriage, all which may impact adult work status over time. Finally, although the proportions missing employment status and occupation were minimal, comparison to the sample eligible for this analysis suggest that those missing employment and occupation may be at higher risk for poor employment outcomes due to having a lower education and higher levels of central nervous system tumors and cranial radiation. Our findings may underestimate the relationship between our measures of interest and unemployment.
In the general population, individuals with health limitations or disabilities are more likely to be unemployed (31
). With the recent economic downturn, such individuals may be increasingly vulnerable in the workplace (32
) and childhood cancer survivors may face additional risks due to neurocognitive, physical and mental deficits as a result of their treatment history. Unemployed survivors often lack the necessary resources, such as affordable health insurance, to obtain occupational services to address physical, mental and neurocognitive deficits that can hamper employment. Although there are legal protections that safeguard survivors from blatant employment discrimination and that obligate employers to provide reasonable accommodations for individuals with limitations (33
), childhood cancer survivors continue to be unemployed and underemployed.
Interventions to improve employment outcomes for childhood cancer survivors should target physical health barriers to employment coupled with screening for mental health and neurocognitive problems. Currently employed survivors, especially women reporting neurocognitive deficits, may need education or training services in order to maximize their occupational potential, whereas unemployed survivors could benefit from assistance in managing any physical barriers to work. Moreover, longitudinal research is needed to identify survivors at risk for physical, mental and neurocognitive limitations during important developmental periods, such as adolescence, to provide early occupational intervention. Information about the risk of neurocognitive and other deficits, their effect on employment, and survivors’ legal rights, as well as recommendations for strategies to improve employment success, need to be widely distributed to survivors, their families, primary care clinicians, and professionals involved in vocational and rehabilitation services.