Double Whammy: Unemployment After Breast Cancer Diagnosis

Ron Zimmerman

December 09, 2011

December 9, 2011 (San Antonio, Texas) — Five years after a diagnosis of breast cancer, the unemployment rate among these women was nearly 30%, more than 3 times the national unemployment rate.

A diagnosis of breast cancer can financially destroy a family, not only because of the cost of treating the underlying medical condition but also because the cancer patient may lose her job and then may be unable to re-enter the workforce, researchers announced here at the 34th Annual San Antonio Breast Cancer Conference (SABCS).

That's the common perception, but is it accurate? Investigators at Memorial Sloan-Kettering Cancer Center in New York City and the David Geffen School of Medicine at the University of California at Los Angeles have put numbers to this hypothesis.

In a 5-year longitudinal study, they surveyed 921 survivors of breast cancer in California about their employment status after their cancer diagnoses. One surprising finding was that the unemployment rate among this group 5 years later was still nearly 30%. This is more than 3 times higher than the national unemployment rate.

Why is it important to study and put numbers to this issue? According to lead author Victoria Blinder, MD, MSc, from the Health Outcomes Research Group in the Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, most of the prior unemployment studies of cancer survivors have focused on middle- to upper-income white women, who had return-to-work rates of 70% to 80% within 1 year of diagnosis.

Dr. Victoria Blinder

As she told Medscape Medical News, "I was interested in lower-income groups and seeing if they were worse off. Our first study looked at this same sample of women but only for the first 3 years. That first study showed that only 60% had gone back to work. But it took them a while to get there. So it seems that there is an income-related disparity in terms of the overall rate of returning to work. I'm interested in finding out why that is. I think we need to find interventions to help them; that's the ultimate goal."

The research team did telephone surveys with their participants at 6, 18, 36, and 60 months after diagnosis. The study was controlled for age (median age, 50 years), income (98% made less than $40,000 annually), education, marital status, cancer stage, and therapy mode, and also job type at diagnosis.

Participants eligible for inclusion in the study were California residents with a recent diagnosis of breast cancer who spoke English or Spanish and had an income less than 200% of the federal poverty level (approximately $22,000 annually for a family of 4). The participants must have been employed before cancer diagnosis, and they had to be both free of cancer recurrence and currently not in treatment.

Of the 315 women who were employed before diagnosis, 54% (n = 169) did return to work and 19% (n = 61) worked during at least 1 survey point but were not working at the study's conclusion at 60 months. Those women were excluded from the analysis of prolonged employment, which compared only those who were out of work at every survey point.

The investigators found that 27% (n = 85) of the women had "prolonged unemployment" — that is, no work at all — during the study period.

In this subgroup, those with the lowest incomes before diagnosis were especially vulnerable to prolonged unemployment.

"One thing that troubles and surprises me is that even among this uniformly low-income sample, the women with the very lowest incomes were the most vulnerable," said Dr. Blinder. "Women whose household incomes are below $10,000 a year — which is really, really low — were the least likely to go back to work."

Likewise, women who had the greatest medical burdens (that is, those with the highest comorbidity burden and those treated with chemotherapy) were much more likely to fall out of the workforce.

The most statistically significant predictors of prolonged unemployment after diagnosis, according to the study findings, were lower education (P = .04), higher comorbidity burden (P = .006), higher cancer stage at diagnosis (P =.001), and receiving chemotherapy (P = .008). Education and ethnicity were not significant predictors.

"The chemotherapy issue is controversial," said Dr. Blinder. "Other researchers have not shown that chemotherapy was associated with impaired ability to return to work. But the issue with chemotherapy is related to the time spent getting the therapy. If you take time off, will your job be waiting for you when you get back? For those of us who work in a larger work setting, where we're able to take time off to go in for infusions, and/or go home early if we're not feeling well, that's much less a concern. But for people who don't have those kinds of supportive work settings, getting chemotherapy is going to be a barrier."

Dr. Blinder hopes her study will spur oncologists to bring up the issue of employment with their patients.

"A lot of patients are not aware that their clinicians and nurses can help them with this and they may not want to burden them with these issues," she says. "But I think it's our responsibility when we're taking care of patients to bring it up. I ask my patients 'How are things going at work?' And just bringing it up tells my patients that it's okay to talk about it."

One oncologist, Mary Crow, MD, from Millennium Oncology in The Woodlands, Texas, appreciated the study's numbers. "It confirms what we've been concerned about in all of our cancer patients, their future employability, their insurability," she told Medscape Medical News. "Employment is always part of the discussions with my patients because it's part of their decision-making. Knowing who is in our at-risk groups is important because perhaps they're the ones who will say, 'I don't want to be treated, because I'm going to lose my job,' which I've heard more than once. It's tragic."

Dr. Crow continued, "I'm surprised at [the prolonged unemployment figure] of only 27%. It always helps to have numbers, both from a patient-to-doctor level, and also from a policy level. What programs can we bring to bear to help these people reenter the workforce?"

Another oncologist, Barry Brooks, MD, from Texas Oncology, Dallas, had some patient counseling suggestions for his fellow oncologists. "The first thing we can do is to tell them, 'Don't quit work.' Even with chemotherapy, in the vast majority of the cases, they don't need to quit work. In all ways they do better if they continue to work."

Dr. Brooks told Medscape Medical News that only patients undergoing the most debilitating treatment should radically change their work routines. "Now if they're taking dosages of TAC [taxotere, adriamycin, and cyclophosphamide] and things like that," he said, "and you're ground down to the ground and cannot continue, that's a different circumstance. But I think a lot of oncologists say, 'Dear, you're going to have to take off work,' and I think that sets up a bad mindset. It's not just for financial reasons, which are important, but also for better preserving their social, emotional, and financial situation to continue to do what they normally do. I think oncologists need to rethink their advice for women to quit once they've had a diagnosis."

Dr. Blinder concluded, "One thing we as healthcare providers can do is educate people about their rights. If you work in a company with at least 15 employees you qualify under the American Disabilities Act for your needs to be accommodated during times of unemployment. If you need time off from work, that's something you should be able to negotiate. Also phone calls and letters from us as doctors to the employer can be very helpful."

Dr. Blinder, Dr. Crowe, and Dr. Brooks have disclosed no relevant financial relationships.

34th San Antonio Breast Cancer Symposium (SABCS); Abstract #PD06-09. Presented December 9, 2011.

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