This study evaluated factors associated with unemployment among cancer survivors using data from the MEPS and associated CSAQ, a nationally representative US survey. The objective was to identify the factors that increase the risk of unemployment within a nationally representative sample of cancer survivors. Major findings from the analyses reported here suggest that cancer-related psychological job distress, cancer-related interference with mental job tasks, and lack of workplace resources and flexibility were related to long-term unemployment among cancer survivors. These findings highlight key psychosocial and employment factors that contribute to disparities in employment outcomes among cancer survivors. These results also provide support for the need to develop evidence-based interventions to address how these factors contribute to unemployment.
Reviews of the literature on cancer and work have previously indicated that sociodemographic factors influence cancer survivors’ ability to RTW.15 Results reported here suggest that not only do sociodemographic factors influence RTW but also survivors’ success at remaining employed following RTW. Our findings underscore the importance of supporting cancer survivors past the RTW milestone in order to maximize success for remaining employed. Furthermore, it is essential to identify the types of support that are most beneficial for remaining employed after RTW, and which stakeholders (oncology care team, social workers, employers, and family) are best positioned to provide additional supports for survivors’ employment success.
A greater proportion of unemployed survivors reported cancer-related psychological job distress. Specifically, unemployed survivors were more likely to worry about being forced to retire or quit early due to cancer while employed than their employed counterparts. Survivors who acknowledged anxiety about fulfilling home or work responsibilities if their cancer returned or got worse were nearly three times more likely to be unemployed. These data highlight the challenges of managing the impact of cancer on home and work quality of life and the negative effect this type of distress may have on employment among survivors. It is possible that employed cancer survivors those who experience physical or psychological effects of cancer may worry more about being forced to retire and fulfilling work and home responsibilities than cancer survivors with less adverse effects.7 Presence of job-related psychological job distress may be correlated with limitations of activities of daily living, work ability or psychological dysfunction and serve as a proxy measure for the said dysfunctions that result in unemployment.16–18 Additionally, following Mehnert’s model of factors related to employment outcomes among cancer survivors,7 the presence of psychological distress may mediate the relationship between cancer and work, such that those who experience job-related psychological distress may be more prone to unemployment.
Unemployed survivors reported cancer-related interference with both physical and mental aspects of their job tasks. Moskowitz et al19 noted that functional impairment among cancer survivors is a stronger predictor of work ability than health and well-being or residual symptoms. The current findings, however, indicate that only cancer-related interference with mental job tasks was related to unemployment after adjustment for demographic differences between employed and unemployed. This contrasts with previous studies that have shown that physically demanding jobs affect cancer survivors’ ability to work. Alternatively, it may also indicate that for survivors who RTW, challenges related to mental aspects of jobs are more difficult to overcome and manage. Cancer-related interference with mental job tasks may reflect a unique challenge for managing the cancer–work interface. Moskowitz et al noted previously that functional limitation – cognition being among the most important across all job types and categories, perhaps – is a stronger predictor of work ability than actual physical health.19,20 Our findings support the importance of cancer-related functional limitations, especially mental (ie, cognitive aspects) for positive employment outcomes.16
Unemployed cancer survivors were significantly less likely than employed survivors to have taken paid time off due to cancer diagnosis and were less likely to have switched to a flexible job schedule during or following cancer treatment. These findings raise the possibility that cancer survivors without access to paid time off or who have rigid schedules may eventually become unemployed due to the lack of workplace accommodations or available resources to help survivors manage the cancer–work interface during treatment or transition back to work after treatment.
Despite the value of examining factors associated with unemployment in cancer survivors in a large nationally representative sample, this study had several limitations. First, the response rate to the MEPS Experiences with Cancer survey was 49.4%; therefore, the eligible sample might not be fully generalizable to the population of US cancer survivors. Our strategy for maximizing generalizability was to apply sample weights to all analyses, which included an adjustment for nonresponse. Second, the MEPS and CSAQ data are based on self-report and are therefore subject to recall bias. CSAQ items required respondents to recall feelings and decisions made over a 5-year period in the past. Respondents may or may not accurately recall these events and feelings. In an effort to limit recall bias, the current analyses were restricted to respondents who completed the CSAQ, had worked for pay since their cancer diagnosis, and were within 5 years of their diagnosis. This resulted in an analytic sample that was relatively small and may or may not adequately represent the full range of experiences of cancer survivors. Another limitation of the study is the reliance on a dichotomous measure of employment. Such a measure does not allow for a more nuanced understanding of the effects that cancer has on survivors’ employment experiences. For instance, a survivor may be employed but because of consequences associated with cancer may be underemployed or working fewer hours than prior to cancer diagnosis. This was a limitation that could not be addressed as it is a constraint of the original methodology of the MEPS and CSAQ. Finally, as with any secondary analyses, our analyses were limited by the variables available from the primary study, the completeness of these variables, and the content of questions used to derive variables. We were unable to include variables related to cancer stage, physical or psychological functional job limitations, or detailed information about employer accommodations (ie, supervisor support) – factors associated with employment outcomes.7