Studies of adult CCS have increasingly sought to identify and explain the impact of late effects on their social, economic and demographic outcomes. We found that adult survivors were less likely to be employed in higher-skill occupations when compared to siblings. Survivors, particularly those with a history of CNS tumors and leukemia, reported jobs that were non-physical more often than siblings. Because of the physical late effects from cancer, we hypothesized that CCS would be less likely to report occupations that required high levels of physical activity, but this was only significant for bone cancer survivors.
Our results that suggest survivors are more often employed in lower skill occupations have implications for their economic status throughout their lifetimes. The average yearly income from the 2003 Bureau of Labor Statistics for our Professional/Managerial category was approximately $49,000 (range: $32,400–$70,870) compared to less than $24,000 (range: $15,390–$34,290) for Service/Blue Collar.26
Within occupational categories, personal income was lower for survivors compared to siblings even when adjusted for education. Future studies should examine more detailed assessment of survivors’ career decisions and occupations and the effect on income. There may be work experiences or lifestyle decisions that differ between the survivors and siblings not captured in our categories. Additionally, survivors with chronic health problems may be intermittently employed, affecting their income potential despite working in similar fields as siblings.
Certain cancer and treatment-related factors were linked to occupational differences. CNS tumor resection was associated with decreased Professional employment, and all surgery types were associated with unemployment. Platinum chemotherapy, which was primarily used in the CCSS cohort for osteosarcoma patients, conferred a 66% decreased likelihood of reporting Physical work, although due to the small number in this category, this finding should be interpreted with caution. Conversely, the bone cancer diagnosis group was the only diagnosis group more likely to be working in Professional jobs than siblings. Among CCS, a younger diagnosis age is associated with cognitive impairment and learning disabilities requiring special education7, 11
and an increased risk of specific medical conditions.27
We found as age of diagnosis increased, the likelihood of Professional employment increased, while survivors diagnosed at a younger age were more likely to hold Service/Blue Collar jobs.
Fewer survivors were employed in Professional jobs and more survivors were in Non-Physical jobs with increasing doses of cranial radiation. Mid-range doses (18–25 Gy) were the only cranial radiation dose associated with an increased likelihood of Physical work, suggesting that survivors with a history of higher doses may not be physically able to work in certain occupations. Patients receiving cranial radiation – typically CNS and leukemia patients – often face neurocognitive deficits, including motor skill limitations and decreased abilities in acquiring new skills and information, although the risk decreases with lower doses.5, 6, 28
Not only are these survivors at a higher risk for poor health outcomes and unemployment,8, 18
but if they are working, our findings suggest they may be disproportionately employed in lower skill positions.
Black survivors were less likely to be employed in Professional and more often in Non-Physical occupations than white survivors, while no racial/ethnic differences were found for siblings. Black survivors report similar health status as white survivors when adjusting for socioeconomic status,29
and when we controlled for socioeconomic variables, such as education, our racial and ethnic occupational differences persisted, suggesting that there may be factors beyond health status influencing racial/ethnic employment differences. CCS report difficulties obtaining employment,30
and minority race survivors may face differential discrimination by employers for hiring or providing access to training or career advancement opportunities.
The differences in our results depending on the inclusion of unemployed or only employed survivors demonstrates the necessity in comparing both groups due to the high proportion of unemployed female survivors. In analyses limited to employed survivors, female survivors were more likely than male survivors to be employed in Professional occupations. However, when we considered the proportion unemployed in the denominator, female survivors were less likely to work in these occupations and more likely to be unemployed compared to male survivors and male and female siblings. These results suggest that future studies should investigate how the cancer experience differentially affects career decisions for female survivors, including the decision to work, and whether to work full- or part-time. Coupled with our earlier analyses that found female survivors at an increased risk of health-related unemployment,31
female survivors may particularly vulnerable for poor labor force outcomes.
There are certain limitations with this study. Aggregating occupations may obscure further job skill differences between survivors and siblings. Although there are well-known indicators of occupational status and social class available, such as the Duncan Socioeconomic Index, we hypothesized that occupational groupings tied to potential differences in skills and physical ability would best describe our population and our sensitivity analyses showed the robustness of our classifications. Using cross-sectional occupational information limited our ability to detect further differences if we had been able to summarize years of experience in specific occupations or other longitudinal occupational measures. Also, we did not have information on comorbidities beyond cancer recurrence and secondary cancers, which may impact on CCS occupational outcomes.
Childhood socioeconomic status and parental occupation are predictive of adult employment and occupational status, and were not available in the current study. However, by comparing the survivors to a sibling cohort, we provided some control for childhood socioeconomic status, although not all survivors had a sibling pair (N=1,592 pairs in the full sample). Additionally, 24% of survivors and 19% of siblings have been lost to follow-up or refused participation since baseline; because individuals with lower socicoeconomic status are less likely to participate in health surveys, our estimates of the proportion of survivors in low-skill jobs may be conservative.
CCS are less often employed in higher-skill occupations. Future studies are needed to determine why survivors make specific career decisions, to elucidate what survivors need to be successful in the workplace, and to assess the barriers survivors face in developing their careers. Long-term survivorship programs should offer vocational assistance to CCS from the point of initial treatment throughout their careers, and may need to provide a broad array of services depending on a survivor’ s psychosocial or health status to maximize their occupational potential. High-risk survivors, due to their treatment history or demographic background, may also need additional resource assistance from community vocational or educational services.
Barriers exist to getting occupational services to the neediest survivors. Uninsured CCS may not be able to obtain survivorship services, and, even for insured survivors, occupational rehabilitation services may not be covered. Furthermore, current national policies that encourage workforce participation for individuals with disabilities should be extended to provide those employed in low-skill and entry-level jobs – such as many adult survivors of childhood cancer – opportunities to advance their careers.12
As research continues to acknowledge the social, psychological and financial impacts of childhood cancer, identifying survivors for occupational intervention will help to improve their quality of life.