Angela G. E. M. de Boer

Cancer Survivors and Unemployment : A Meta-analysis and Meta-regression

CONTEXT Nearly half of adult cancer survivors are younger than 65 years, but the association of cancer survivorship with employment status is unknown. OBJECTIVE To assess the association of cancer survivorship with unemployment compared with healthy controls. DATA SOURCES A systematic search of studies published between 1966 and June 2008 was conducted using MEDLINE, CINAHL, EMBASE, PsycINFO, and OSH-ROM databases. STUDY SELECTION Eligible studies included adult cancer survivors and a control group, and employment as an outcome. DATA EXTRACTION Pooled relative risks were calculated over all studies and according to cancer type. A Bayesian meta-regression analysis was performed to assess associations of unemployment with cancer type, country of origin, average age at diagnosis, and background unemployment rate. RESULTS Twenty-six articles describing 36 studies met the inclusion criteria. The analyses included 20,366 cancer survivors and 157,603 healthy control participants. Studies included 16 from the United States, 15 from Europe, and 5 from other countries. Overall, cancer survivors were more likely to be unemployed than healthy control participants (33.8% vs 15.2%; pooled relative risk [RR], 1.37; 95% confidence interval [CI], 1.21-1.55). Unemployment was higher in breast cancer survivors compared with control participants (35.6% vs 31.7%; pooled RR, 1.28; 95% CI, 1.11-1.49), as well as in survivors of gastrointestinal cancers (48.8% vs 33.4%; pooled RR, 1.44; 95% CI, 1.02-2.05), and cancers of the female reproductive organs (49.1% vs 38.3%; pooled RR, 1.28; 95% CI, 1.17-1.40). Unemployment rates were not higher for survivors of blood cancers compared with controls (30.6% vs 23.7%; pooled RR, 1.41; 95% CI, 0.95-2.09), prostate cancers (39.4% vs 27.1%; pooled RR, 1.11; 95% CI, 1.00-1.25), or testicular cancer (18.5% vs 18.1%; pooled RR, 0.94; 95% CI, 0.74-1.20). For survivors in the United States, the unemployment risk was 1.5 times higher compared with survivors in Europe (meta-RR, 1.48; 95% credibility interval, 1.15-1.95). After adjustment for diagnosis, age, and background unemployment rate, this risk disappeared (meta-RR, 1.24; 95% CI, 0.85-1.83). CONCLUSION Cancer survivorship is associated with unemployment.

Predictors of health care utilization in the chronically ill: a review of the literature

The objective of this paper is to identify predictors of health care utilization in the chronically ill. This paper reviews 53 studies on hospitalizations and physician visits, published between 1966 and 1997 and identified by MEDLINE and ClinPSYCH databases. Studies with both univariate and multivariate analyses were included. On the basis of the Andersen-Newman model of health care utilization, the effects of predisposing, enabling and need variables are examined. Most studies reviewed indicate that predisposing factors such as age, sex, and marital status are not predictors of hospital utilization in the chronically ill. The enabling factors income, insurance and social support have not been shown to affect health care utilization, but characteristics of the hospitals could have an effect. Need factors such as disease severity, symptom severity and complications adversely affected health care utilization in the chronically ill, while disease duration and comorbidity do not have such an effect. Quality of life and perceived health might affect hospital utilization and physician use. Finally, depression and psychological distress proved to be among the strongest predictors of hospitalizations and physician visits. In conclusion, both disease severity and psychological well-being are most important in health care utilization. Intervention programs to support depressed or psychologically distressed patients should be considered. These could both help the patient and reduce health care utilization costs.

Employment Challenges for Cancer Survivors

There is a considerable body of evidence about the adverse effects of cancer and cancer treatments on employment, work ability, work performance, and work satisfaction among cancer survivors. There is also a growing consensus that cancer survivorship research needs to address the large variety of short‐term and long‐term work‐related problems and that programs to support return to work and employment should be developed and integrated into the follow‐up survivorship care of cancer patients. Cancer survivorship and employment can be considered from the perspective of the cancer survivor, the caregiver and the family, the employer and coworkers, the health care providers, and the community or society—elements that comprise many similarities but also differences between Europe and the Unites States and that may affect employment and return to work among cancer survivors in different ways. Previous research has specifically addressed the likelihood and timeliness of work return, including factors that promote and hinder return to work and work performance, and intervention studies and programs that focus on psychological, physical, pharmacologic, or multidisciplinary approaches to work. The area of work disability has emerged as an international field with research from areas throughout the globe. In this article, the authors provide an overview of the current state of scientific research in these areas and further provide a cancer survivorship and work model that integrates significant individual cancer‐related, treatment‐related, and work‐related factors and outcomes. The report concludes with a discussion of European and American contributions and possible future directions for the enhancement of current efforts. Cancer 2013;119(11 suppl):2151‐59.

Beyond treatment - Psychosocial and behavioural issues in cancer survivorship research and practice.

The population of cancer survivors has grown steadily over the past several decades. Surviving cancer, however, is not synonymous with a life free of problems related to the disease and its treatment. In this paper we provide a brief overview of selected physical and psychosocial health problems prevalent among cancer survivors, namely pain, fatigue, psychological distress and work participation. We also address issues surrounding self-management and e-Health interventions for cancer survivors, and programmes to encourage survivors to adopt healthier lifestyles. Finally, we discuss approaches to assessing health-related quality of life in cancer survivors, and the use of cancer registries in conducting psychosocial survivorship research. We highlight research and practice priorities in each of these areas. While the priorities vary per topic, common themes that emerged included: (1) Symptoms should not be viewed in isolation, but rather as part of a cluster of interrelated symptoms. This has implications for both understanding the aetiology of symptoms and for their treatment; (2) Psychosocial interventions need to be evidence-based, and where possible should be tailored to the needs of the individual cancer survivor. Relatively low cost interventions with self-management and e-Health elements may be appropriate for the majority of survivors, with resource intensive interventions being reserved for those most in need; (3) More effort should be devoted to disseminating and implementing interventions in practice, and to evaluating their cost-effectiveness; and (4) Greater attention should be paid to the needs of vulnerable and high-risk populations of survivors, including the socioeconomically disadvantaged and the elderly.

Cerebral impairment in chronic solvent-induced encephalopathy

Worldwide, many workers experience occupational exposure to organic solvents, which may induce chronic solvent‐induced encephalopathy (CSE). Disturbances within the frontostriatothalamic (FST) circuitry might explain the symptomatology of CSE. We tested the hypothesis of FST circuitry abnormalities in CSE, as well as associations with performance of psychomotor speed, attention, and solvent exposure. To detect preclinical, solvent‐related effects, we also studied the FST circuitry in solvent‐exposed, but asymptomatic workers.

Effect of job maintenance training program for employees with chronic disease - a randomized controlled trial on self-efficacy, job satisfaction, and fatigue.

OBJECTIVE Employees with a chronic physical condition may be hampered in job performance due to physical or cognitive limitations, pain, fatigue, psychosocial barriers, or because medical treatment interferes with work. This study investigates the effect of a group-training program aimed at job maintenance. Essential elements of the program are exploration of work-related problems, communication at the workplace, and the development and implementation of solutions. METHODS Participants with chronic physical diseases were randomly assigned to the intervention (N=64) or the control group (N=58). Participants were eligible for the study if they had a chronic physical disease, paid employment, experienced work-related problems, and were not on long-term 100% sick leave. Primary outcome measures were self-efficacy in solving work- and disease-related problems (14-70), job dissatisfaction (0-100), fatigue (20-140) and job maintenance measured at 4-, 8-, 12- and 24-month follow-up. We used GLM repeated measures for the analysis. RESULTS After 24 months, loss to follow-up was 5.7% (7/122). Self-efficacy increased and fatigue decreased significantly more in the experimental than the control group [10 versus 4 points (P=0.000) and 19 versus 8 points (P=0.032), respectively]. Job satisfaction increased more in the experimental group but not significantly [6 versus 0 points (P=0.698)]. Job maintenance was 87% in the experimental and 91% in the control group, which was not a significant difference. Many participants in the control group also undertook actions to solve work-related problems. CONCLUSIONS Empowerment training increases self-efficacy and helps to reduce fatigue complaints, which in the long term could lead to more job maintenance. Better understanding of ways to deal with work-related problems is needed to develop more efficient support for employees with a chronic disease.

Enhancing return-to-work in cancer patients, development of an intervention and design of a randomised controlled trial.

BackgroundCompared to healthy controls, cancer patients have a higher risk of unemployment, which has negative social and economic impacts on the patients and on society at large. Therefore, return-to-work of cancer patients needs to be improved by way of an intervention. The objective is to describe the development and content of a work-directed intervention to enhance return-to-work in cancer patients and to explain the study design used for evaluating the effectiveness of the intervention.Development and content of the interventionThe work-directed intervention has been developed based on a systematic literature review of work-directed interventions for cancer patients, factors reported by cancer survivors as helping or hindering their return-to-work, focus group and interview data for cancer patients, health care professionals, and supervisors, and vocational rehabilitation literature. The work-directed intervention consists of: 1) 4 meetings with a nurse at the treating hospital department to start early vocational rehabilitation, 2) 1 meeting with the participant, occupational physician, and supervisor to make a return-to-work plan, and 3) letters from the treating physician to the occupational physician to enhance communication.Study design to evaluate the interventionThe treating physician or nurse recruits patients before the start of initial treatment. Patients are eligible when they have a primary diagnosis of cancer, will be treated with curative intent, are employed at the time of diagnosis, are on sick leave, and are between 18 and 60 years old. After the patients have given informed consent and have filled out a baseline questionnaire, they are randomised to either the control group or to the intervention group and receive either care as usual or the work-directed intervention, respectively. Primary outcomes are return-to-work and quality of life. The feasibility of the intervention and direct and indirect costs will be determined. Outcomes will be assessed by a questionnaire at baseline and at 6, 12, 18, and 24 months after baseline.DiscussionThis study will provide information about the effectiveness of a work-directed intervention for cancer patients. The intention is to implement the intervention in normal care if it has been shown effective.Trial registrationNTR1658

Predictors of health care use in patients with Parkinson's disease : A longitudinal study

To predict health care use in patients with Parkinsons disease.

Physical exercise and return to work: cancer survivors’ experiences

PurposeIn this qualitative study, we aimed to explore cancer survivors’ experiences with (1) return to work (RtW) and work performance, (2) a physical exercise program after treatment, and (3) the perceived link between physical exercise and work.MethodsSemi-structured individual interviews were held with ten cancer survivors of working age who had been treated with chemotherapy and had afterwards completed a group-based supervised physical exercise program. The interviews were audio-taped and transcribed verbatim. MaxQDA was used for coding and analysis. A second assessor was involved in coding two of the interviews.ResultsEight participants returned to work. Most said that they had suffered cognitive deficits that impaired their work performance. According to half of the participants, the support in RtW from their occupational physician had been insufficient. Overall, the majority of participants enjoyed the exercise program. The main perceived effects were “improved fitness” and “renewed energy.” Most participants thought that physical exercise had likely contributed to their ability to return to work, primarily by increasing energy levels. Some believed that physical exercise had enhanced their work performance by improving their ability to cope with demanding work. Some respondents found that a supportive work environment stimulated their continuation of physical exercise.ConclusionsCancer survivors experienced a positive influence of physical exercise on RtW and work performance and a positive influence of RtW on physical exercise. By stimulating and facilitating physical exercise during and after RtW, the time to lasting RtW may be shortened, work performance may be optimized, and sustained participation in physical exercise may be achieved.Implications for Cancer SurvivorsStimulating and facilitating physical exercise before and during the process of RtW may enhance fitness and energy levels and may lower fatigue and cognitive symptoms during work. An integrated rehabilitation strategy combining physical exercise and adequate support in RtW may shorten the time to lasting RtW, improve work performance, and lead to sustained participation in physical exercise. Ultimately, this strategy may improve cancer survivors’ quality of life.

The role of neuropsychological functioning in cancer survivors' return to work one year after diagnosis.

Objective: The objective of this study was to investigate the relationship between neuropsychological functioning and the ability to work in cancer survivors.