Factors influencing job loss and early retirement in working men with prostate cancer—findings from the population-based Life After Prostate Cancer Diagnosis (LAPCD) study

As the diagnosis, treatment and survival of most cancers have improved, the number of cancer survivors has increased, with this trend set to continue [1]. Prostate cancer (PCa) survivors account for a large proportion of these, with 30% of UK cancer survivors living with the disease [2]. Although PCa incidence is more common in older men, approximately 30% of UK survivors are of working age and the effect of cancer and its treatment can adversely impact working life and employment status [3, 4]. Indeed, a UK study found the greatest increase in PCa incidence rates between 2000 and 2010 was in men under 60 years of age [5].

Recently, there has been increased focus on workers diagnosed with cancer to ensure that appropriate assistance and information is given to support decisions about work and personal finances [6]. Work can be important for men recovering from cancer as it allows them support themselves and their families, socialise with colleagues and regain a sense of normality which can help them to ‘move on’ [7, 8]. Studies of risk factors for job loss in PCa survivors have involved small numbers of PCa survivors and usually been part of larger cancer cohorts from Nordic countries, the USA or Australia [9]. Although previous studies describe demographic, clinical and work-related characteristics associated with work ability, employment status and return to work for cancer survivors across a range of tumour sites, variable findings have been reported and few focus specifically on PCa survivors [9]. A study which reported on 100 PCa survivors in Ireland 6–24 months post-diagnosis found those who were self-employed had lower household income and did not have surgery were more likely to continue working following diagnosis, while those with lower educational level, medical card entitlement (providing free access to public health services) and not receiving sick pay were more likely not to resume work following diagnosis [10]. However, the effect of recent diagnosis of PCa on subsequent employment, and particularly unemployment and early retirement, have not been previously reported in a large-scale study. This study aimed to identify factors associated with movement from employment to unemployment or early retirement in working age men diagnosed with PCa in the UK.

Data were collected as part of the UK-wide Life After Prostate Cancer Diagnosis (LAPCD) study. The study design has been reported elsewhere [11]. PCa survivors between 18 and 42 months following first diagnosis were identified from population-based cancer registries in England, Wales and Northern Ireland (NI) and from hospital activity data in Scotland. A postal questionnaire was sent to 58,930 men. Respondents answered questions on functional outcomes and personal and sociodemographic characteristics and other measures including health-related quality of life (HRQL), social difficulties, decision regret and emotional well-being.

Men aged 60 years and younger at time of diagnosis who completed a questionnaire were included in this study. The UK state pension age for men at the time of survey (October 2015 to November 2016) was 65 years [12] and the average age of men withdrawing from the labour market was just below 65 years (64.6 years) [13]. Consequently, we used a practical threshold of 60 years and below at diagnosis for inclusion. Although it is difficult to define early retirement, men aged 60 years and below at diagnosis would have been aged up to 63.5 years when they participated in LAPCD (18–42 months later), below the UK male state pension age. In the UK, currently only 22% of men aged 60 and below have retired suggesting this as a reasonable cutoff [13].

Responses to questions about employment status at time of cancer diagnosis and time of survey were used to categorise men as moving from employment to unemployment (EtoU), from employment to retirement (EtoR) or remaining in employment (EtoE) (Survey in Supplementary File 1). Those who chose ‘full time employment’ (FTE), ‘part time employment’ (PTE) or ‘self-employed’ (SE) were categorised as ‘employed’ while those who chose ‘unemployed, seeking work’ or ‘unemployed, unable to work for health reasons’ were categorised as ‘unemployed’ and those who chose ‘retired’ were classified as such. Those who recorded ‘looking after family/home’ and ‘other’ were excluded from analysis as focus was on movement between employed and unemployed and retired states and it would be difficult to clearly delineate a change in status between these states and the unemployed or retired state.

Of the 58,930 men invited to participate, 35,823 returned completed questionnaires (60.8% response rate);14.1% (N = 5037/35,823) of respondents were ≤ 60 years at PCa diagnosis. Non-response on employment status was low: 1.5% (75/5037) did not respond on employment status at diagnosis, 2.2% (N = 109) did not respond on employment status at time of survey and 3.1% (N = 155) did not respond on both. Non-responders were more likely to be divorced, living in areas of greater deprivation, of non-white ethnicity and report overall urinary problems. Supplementary Table 1 details the characteristics of employment status respondents and non-respondents.

Employment status and change in employment status between time of diagnosis and time of survey are shown in Table 1. Of those aged ≤ 60 years at diagnosis, 4014 were employed at diagnosis and 3913 of these were employed, unemployed or retired at survey. Of these 3913 men, there were 3218 (81.4%) in the EtoE group, 245 (6.2%) in the EtoU group and 450 (11.4%) in the EtoR group (Fig. 1). Table 2 details the characteristics, treatment and patient-reported symptoms variables in the three groups.

There was no difference in the proportion of EtoU men aged 56–60 years (60.0%) compared to EtoE men (55.9%) (p = 0.29) (Table 2). Univariable analysis demonstrated there were greater proportions of men who became unemployed who were divorced, from deprived areas, from Scotland or NI, with late stage disease at diagnosis, symptomatic at diagnosis, with more comorbidities and reporting moderate or big problems with urinary and bowel function (Table 2). There was no difference in ethnicity between EtoE and EtoU groups (Table 2). A lower proportion of EtoU men had surgery and experienced active surveillance, but a greater proportion had external beam radiotherapy (EBRT) and androgen deprivation therapy (ADT).

Multivariable logistic regression demonstrated a range of sociodemographic, clinical and patient-reported factors were predictive of movement from employment at diagnosis to unemployment at follow-up (i.e. comparing EtoU to EtoE groups) (Table 3). Late stage at diagnosis (OR = 4.7 (95% CI 3.1–7.0), stage IV relative to stage I/II) and greater comorbidity (OR ranging from OR 1.6 (95% CI 1.1–2.3) for 1 LTC to 3.5 (95% CI 1.8–6.8) for ≥ 4 LTCs compared to none) were the strongest predictors of movement to unemployment. Problems with bowel (OR = 2.5 (95% CI 1.6–3.9) moderate/big compared to no/very small/small problems) and urinary function (OR = 2.0 (95% CI 1.4–2.9) moderate/big compared to no/very small/small problems) and having symptoms at diagnosis (OR = 1.5 (95% CI 1.0–2.1)) were also predictors of movement to unemployment (Table 3). Living in areas of greater deprivation (OR = 2.6 (95% CI 1.6–4.3] most relative to least deprived), being divorced/separated (OR = 2.5 (95% CI 1.7–3.8]) and living in Scotland (OR = 2.1 (95% CI 1.2–3.6]) or NI (OR = 3.1 (95% CI 1.7–5.6] compared to living in England) were also significant predictors of becoming unemployed.

In the univariable analysis, there were no differences in disease stage at diagnosis or the proportions who were symptomatic at diagnosis between men retiring early and those who remained in employment (Table 2). There were no differences in treatment type or overall urinary or bowel function between the EtoR and EtoE group. Men remaining in employment were significantly younger (mean age = 55.4 years, p < 0.001) than those retiring early (mean age = 57.7 years), with a difference of over 2 years between the groups. There was a greater proportion of older men in the EtoR group with 83.1% aged 56–60 years compared to 55.9% in the EtoE group (Table 2). There were greater proportions of EtoR relative to EtoE men of white ethnicity, from less-deprived areas and with caring responsibility and lower proportions of EtoR compared to EtoE men living in England and reporting no comorbidities (Table 2).

In the multivariable analysis, age, ethnicity, employment status, UK country of residence, stage at diagnosis and carer responsibilities were significantly associated with moving from employment to retirement (Table 4). Older age was the strongest predictor of early retirement (OR 8.5 (95% CI 4.0–18.3), age 55–60 years). Men living in NI (OR = 2.3 (95% CI 1.4–3.6)), with later disease stage disease (OR = 1.8 (95% CI 1.2–2.6), stage IV) and carer responsibilities (OR = 1.3 (95% CI 1.0–1.7)) were also significantly more likely to move to early retirement. Men who were self-employed (OR = 0.40 (95% CI 0.28–0.57)) and of non-white ethnicity (OR = 0.32 (95% CI 0.16–0.63)) were significantly less likely to move to early retirement.

The clinical factors of advanced disease stage, presence of bowel and urinary problems, having symptoms at diagnosis and greater levels of comorbidity increased the odds of job loss in PCa survivors, alongside the sociodemographic factors of deprivation, divorce/separation and living in Scotland or NI. In contrast, having bowel or urinary problems or greater comorbidity were not significantly associated with early retirement in PCa survivors. Men who were older, of white ethnicity, in full-time employment, with most advanced disease (stage IV) or with caring responsibilities had greater odds of early retirement.

Men who retire early following PCa diagnosis do not report worse overall urinary or bowel problems or different socioeconomic characteristics to men remaining in employment. However, this study has identified risk factors for job loss in PCa survivors, which can be used to support men following diagnosis. Targeted support and engagement with these men, their families and their employers is needed.