Workplace health and safety considerations for young adult cancer survivors
Methods
Search strategy
Eligibility criteria
Review strategy
Quality assessment
First author, year; evidence level and quality ratinga
| Population and eligibility | Study design and purpose, aims, or objectives | Participant characteristics | Relevant measures | Outcomes related to work |
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Aksnes, 2007 Level II—A | Scandinavian sarcoma group
N = 75 eligible 58 responses (77%) 31 male and 27 female Extremity bone tumor survivors Mean age at diagnosis: Males 20; females 16 Age at survey: Males 34 (9.4) Females 27 (4.8) Years since diagnosis: Males 14 (4.5); Females 11 (4.8) 5 years or more after treatment | Cross-sectional, comparative Purpose: To compare quality of life, fatigue, and mental distress in extremity bone tumor survivors with Hodgkin’s disease survivors, testicular cancer survivors, and gender and age-matched individuals from the general population | Cancer sites: Extremity bone tumors (EBT); Hodgkin’s disease (HD); testicular cancer (TC) Working status: Employed 45 Not employed 12 | Fatigue questionnaire Hospital anxiety and depression scale Short form-36 to measure quality of life Short form-36 physical component summary scale and mental component summary scale | Extremity bone tumor survivors did not differ from the other survivor groups as to education and employment status. Extremity bone tumor survivors had lower scores on all physical dimensions of the short form-36 compared to other survivors and normative samples (p < 0.5) In multivariate analyses of the combined survivor and normative data, a low level of education and not being employed were associated with mental distress (OR 2.28; CI 1.26–4.14; p = 0.01). Extremity bone tumor survivors had higher mean fatigue scores than the normative samples (p < 0.5) but about the same levels as other survivor groups. Clinical implications: eventually prepare for reduced physical functioning |
Bellizzi, 2012 Level III—B | National Cancer Institute Surveillance, Epidemiology, and End Results Program Adolescent and Young Adult Health Outcomes and Patient Experience Study
N = 523 Mean age 29 ± 6.7 years 1/3 of AYAs in all 3 age groups: 15–20 years 33.8% 21–29 years 39.9% 30–39 years 38.2% <14 months after diagnosis | Cross-sectional Objectives: To identify the negative and positive impact of cancer on developmental aspects of adolescence and young adulthood and to examine these impacts according to stage of development (age at diagnosis) | Cancer sites: Germ cell, non-Hodgkin lymphoma, Hodgkin lymphoma, acute lymphocytic leukemia, or sarcoma | Life domains: Future Body appearance Control over life | The most prevalent negative life domains reported were specific to a plan: financial situation, plans for having children, plans for working, as well as body appearance and sense of control over life. With regard to a plan, all 3 age groups reported that cancer had a similar level (∼46% of the sample) of positive impact on plans and goal setting. These findings demonstrate the coexistence (in the aggregate) of negative and positive psychosocial aspects of cancer in adolescents/young adults. |
Bieri, 2008 Level III—B | University Hospital of Geneva
N = 124 patients in remission after allogeneic hematopoietic stem cell transplant (HSCT). Comparison with health controls. Median age 34 years (range 14–65) Median time from hematopoietic stem cell transplant was 7.3 years. Median age at time of answering questionnaire: 42 years. >5 years after diagnosis Free of disease at the time of evaluation | Cross-sectional Aim: To assess health-related quality of life in comparison with healthy controls | Cancer sites: AML ALL CML CLL Myelodysplasic syndrome Myeloma Myeloproliferative syndrome Aplastic anemia | Functional assessment of cancer therapy scale with specific modules for bone marrow transplant and the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) Questionnaires | In total, 119 (96%) had an occupation or were in school or training before hematopoietic stem cell transplant. After hematopoietic stem cell transplant, 60% of these patients returned to their activities, 29% returned to full-time employment, 21% part time, and 10% returned to training or school. In total, 40% of the patients did not return to work and depend on disability insurance (39%) or are retired (1%). Among patients fully employed, 73% reported good quality of life as opposed to 22% of those on disability insurance and 28% of those on part-time work (p < 0.0001). |
Davidoff, 2015 Level I—A | US national household survey
N = 2527 cancer survivors age 18–64 years 24.4% of the sample was in the young adult age category 18–44 Variable length of time since treatment | Descriptive Baseline prior to Affordable Care Act (ACA) for future comparison post implementation ACA Purpose: To characterize coverage options for nonelderly adult cancer survivors and the subset with financial hardship | Cancer sites: Breast Prostate Colorectal Other male genitourinary Hematologic malignancy Bone, muscle, soft tissue | Medical Expenditure Panel Survey Household Component (MEPS-HC) data from 2008 to 2010 as a population base for estimates | Overall, 18% of cancer survivors reported financial hardship and 37% of the uninsured reported financial hardship. Of those, 39% (95% CI = 34–45%) would be Medicaid eligible under the Affordable Care Act. It will be important to monitor the effects of the Affordable Care Act on insurance coverage, access to care and out-of-pocket burdens for cancer survivors as the Affordable Care Act continues to be implemented. |
Dieluweit, 2011 Level III—B | German Childhood Cancer Registry (GCCR) University Ulm Age at diagnosis 15–18 years Mean age 15.8 (0.9) Age at study: 20–46 years Mean years since diagnosis 13.7 (6.0) | Cross-sectional Aim: To investigate the educational and professional achievements of German long-term survivors of adolescent cancer | Cancer sites: Leukemia Lymphoma CNS tumors Neuroblastoma Retinoblastoma Renal tumors Hepatic tumors Malignant bone tumors Soft tissue and other extraosseous sarcomas Germ cell tumors | The German Socio-Economic Panel (G-SOEP) study provided comparison data to the general population (age-matched controls) The German Childhood Cancer Registry was used to access medical records. | Survivors were significantly older at the commencement of their first employment (M = 21.8, SD = 3.6) than the G-SOEP participants (M = 19.9, SD = 2.4; t[1,167]=10.9, p < 0.001). A Cox proportional hazard model analysis also demonstrated significant differences between the survivors and the German Socio-Economic Panel sample for age at first employment; even after statistical control for high school graduations and achievement of college/university degrees, survivors were significantly older at their first employment compared to the age-matched sample [survivors vs. German Socio-Economic Panel] OR 1.90, 95% CI 1.67–2.17, p < 0.001). |
Ekwueme, 2014 Level I—A | US national survey
N = 1202 Age at interview 18–39 years 4.5% (3.3–6.0) Age range 18–80+ years Cancer survivors who were employed at any time since diagnosis. | Cross-sectional Purpose: To estimate lost productivity by assessing employment disability, health-related missed work days, and days spent in bed because of ill-health | Cancer site: Not given | The Medical Expenditure Panel Experiences with Cancer Survivorship Survey Did cancer interfere with: Daily activities outside work Ability to perform mental tasks Ability to perform physical tasks required by job Ability to perform mental tasks required by job Employment Change in work Ever felt less productive at work. | Results presented in aggregate: Many cancer survivors (n = 676; 58.3%) return to work and remain productive. However, for cancer survivors who were employed at any time since diagnosis, cancer and its treatment interfered with physical tasks (n = 168; 25.1%) and mental tasks (n = 103; 14.4%) required by the job, with 24.7% (169) of cancer survivors feeling less productive at work. |
Guy, 2014 Level III—A | US national survey
N = 1464 adolescent/young adult cancer survivors 86,864 adults without cancer Young adult cancer survivor age at last interview: 18–29: 11% 30–39: 21% Years since diagnosis: 0–9: 30.5% 10–19: 27.7% 20+: 41.9% | Cross-sectional Descriptive Objective: To use nationally representative data to estimate direct medical costs and indirect morbidity costs among adolescent and young adult cancer survivors, compared to people without a history of cancer. | Cancer sites: Not given | 2008–2011 Medical Expenditure Panel Survey Data | Young adult cancer survivors had higher annual per person medical expenditures ($7417) than adults without a history of cancer ($4247). Annual excess lost productivity was estimated to be $2250 per young adult cancer survivor. Identifying ways to reduce disruptions in education and at work as young adult survivors transition out of treatment is important for reducing the excess burden of cancer. |
Hamilton, 2013 Level III—B | Mount Sinai Medical Center New York & Hackensack University Medical Center New Jersey
N = 181 men and women who had undergone hematopoietic stem cell transplantation (HSCT) 9–36 months prior to assessment Participants were at least aged 18 years (and older than 16 years) at the time of HSCT. 640 days post-transplant | Cross-sectional Objective: To examine whether the portion of survivors’ transplant paid by health insurance, which varies across individuals, and affects how much of the treatment costs they bear, would moderate the association between economic survivorship stress and health-related quality of life. | Cancer sites: Hematologic malignancies | Researchers created own 12 Question tool “Employment Stressors in Hematopoietic Stem Cell Transplantation (HSCT) Questionnaire” Persistent financial, employment, and insurance stressors. | Financial and employment difficulties need to be viewed as sources of chronic stress with implications for survivors’ health long after treatment has ended |
Hammond, 2015 Level III—B | Canada
N = 21 young adult: 13 women and 8 men 18–45 years of age Variable length of time since treatment | Qualitative Aim: To investigate the prevalence of three tricksterly themes expressed within young adults’ stories of cancer. | Cancer sites: Not given. | Performance of tricksterdom in cancer survivors’ narratives from a social constructionist perspective: Destabilizing social or cosmic order Challenging dominant expectations for human life Exploring alternate ways of viewing the world. | 3 major themes: Uncertainty, subversion, and possibility. |
Keegan, 2014 Level II—A | National Cancer Institute Surveillance, Epidemiology, and End Results Program Adolescent & Young Adult Health Outcomes and Patient Experience study
N = 464 adolescent/young adults survivors Age at diagnosis: 15–19 years: 62 (13.3%) 20–29 years: 195 (41.9%) 30–39 years: 208 (44.7%) 15–35 months after diagnosis. | Descriptive Aims: To determine young adult cancer survivors and non-cancer-related medical care in a 12-month period, and to examine sociodemographic and cancer-related factors associated with medical care use among survivors 15–35 months after diagnosis. | Cancer sites: Germ cell; acute lymphoblastic leukemia; non-Hodgkin lymphoma; sarcoma | Source of health insurance General Health Date of last treatment Quality of care Financial support Need for information | Employment categories: Unemployed 71—15.3% PT working/studying 92—19.8% FT working/studying 266—57.2% Other/unknown 36—7.7% Adolescent/young adult cancer survivors with current health insurance were nearly five times more likely to receive cancer-related care than those without health insurance (OR = 4.9; 95% CI = 1.7–13.8)/ |
Kim, 2013 Level III—C | Online forum 164 cancer-related blogs from Planet Cancer by 46 young adult cancer survivors. Age of participants at time of diagnosis or research was not given.
N = 34 females—136 blogs; 12 males—28 blogs Length of time since diagnosis not given. | Qualitative Purpose: To explore the experiences and ganin a better understanding of young adult cancer survivors by examining their blogs. | Cancer sites not given | Survivors blogged about career and employment issues | Themes: life being affected by physical burdens, future prospects, and uncertainty, creating a positive attitude, and the paradoxical nature of cancer survivorship. Blogs provide support when survivors are isolated or physically unable to interact. |
Kirchhoff, 2012 Level III—B | Behavioral Risk Factor Surveillance System (BRFSS) dataset USA, the District of Columbia, Puerto Rico, Guam, and Virgin Islands
N = 1198 young adult cancer survivors between ages 20–39 years of age: 218 (age 20–29 years) 980 (age 30–39) Mean time since dx 7.4 years (SD 3.8) | Cross-sectional Aim: To determine how marital status is affected for young cancer survivors diagnosed ages 18–37. | Cancer sites: Not given | The Behavioral Risk Factor Surveillance System is an annual, nationally representative random-digit telephone survey of non-institutionalized adults ages 18 or older in the USA, DC, Puerto Rico, Guam, and Virgin Islands. The CDC-HRQOL-4 “Healthy Days Measure” was also used | Young adult cancer survivors were older than controls [33.0 (SD = 3.8) vs. 30.0 (SD = 4.0); p < 0.001). Survivors were employed less often (61 vs. 67.4%; overall p < 0.001). Survivors reported being 77% more likely to be divorced or separated among those who had every been married (survivors 18% vs. controls 10%; RR 1.77, 95% CI 1.43–2.19, p < 0.001) than controls. |
Lewis, 2012 Level III—B | MD Anderson Cancer Center and Sisters Network
N = 33 African-American breast cancer survivors Mean age at diagnosis: 37.39 Age range 25–45 years of age. Variable duration post-diagnosis Participants were at least 1 year post-diagnosis, off active treatment other than hormonal therapy. | Qualitative Objective: To explore the impact of cancer on women’s living situations, employment, relationships, fertility, and sexuality. | Cancer site: Breast | Semi-structured phone interviews 45–60 min 141 items focusing on impact of cancer on living situations, employment, relationships, fertility, and sexuality. | 26% believed treatment interfered with employment Change in job due to cancer: Lost job 6% Mild/moderate negative impact on job 18% Positive impact/supportive workplace 24% No change 46% Not working outside home 6% |
Love, 2012 Level III—B | Online forum Open to any young adult affected by cancer across the treatment spectrum. (U of Texas, Austin)
N = 350 randomly sampled posts from 2007 to 2010 Unknown duration post-diagnosis | Qualitative Research question: What are the types of messages related to psychosocial needs being shared within the community? | Cancer sites: Not given | Speech events or types of talk: Exchanging support Coping Describing experiences Enacting identity Communicating membership | After treatment ends, survivors reported struggling with depression, strained relationships, and maladjustment to work, although some described a more meaningful outlook. Promotion of online support by care providers could provide additional support to individuals in need. |
McCorkle, 2006 Level III—A | Southern New England tumor board
N = 208 Median age at dx 39 years (range 29–92 years); Median age at time of survey 54 years (range 29–92 years) The average length of survival post initial diagnosis was 13.9 years (median = 13). | Cross-sectional Population-based survey Purpose: To describe the prevalence and correlates of depressive symptoms among women who have survived cervical cancer for 5–25 years. | Cancer site: Cervical 70% employed full time or functioning as homemakers | The Center for Epidemiological Studies-Depression Scale (CES-D) | Pain and post-radiation diarrhea predispose a sub-group of cervical cancer survivors to lingering problems that interfere with their ability to work. Researchers reported that this finding highlights the importance of adequate and appropriate management of cancer treatment-related symptoms during the extended or permanent survival stage. |
Parsons, 2008 Level III - B | Toronto, Canada
N = 14 bone tumor survivors (8 men; 6 women) Age at diagnosis: 16–35 years 5 years after diagnosis | Qualitative Objectives: To characterize the lived experiences of illness of people with osteosarcoma; To characterize the lived experiences of resuming vocational pursuits in the context of osteosarcoma; To understand and explain the relationship between these experiences. | Cancer site: Bone | In-depth interviews Topic areas: Vocational experiences and plans pre-diagnosis and post-treatment; Daily routines ‘then’ and ‘now’ Arriving at diagnosis Illness experiences | Respondents recounted being engaged in three kinds of work: illness work, identity work, and vocational work. All three types of work were intricately interwoven with illness work occurring during active cancer treatments, which was described as a transformative experience. Participants felt changed from who they were prior to cancer and when they returned to their respective vocations, they reported a changed relationship to work. Transformation of identity repositioned survivors differently socially, psychologically, and physically. |
Parsons, 2012 Level III—A | National Cancer Institute’s Adolescent and Young Adult Health Outcomes and Patient Experience Study
N = 463 Age at diagnosis (years): 15–19: 16 (31%) 20–24: 17 (25%) 25–29: 28 (29%) 30–34: 24 (27%) 35–39 21 (26%) Within 3 years of diagnosis | Observational cohort Purpose: To examine the impact of cancer on work and education in a sample of adolescent and young adult patients with cancer. | Cancer sites: Germ cell Non-Hodgkin’s lymphoma Hodgkin’s lymphoma Acute lymphocytic leukemia Sarcoma | Survey: What is your current school or employment status? Indicate what kind of impact your cancer has had on plans for education and plans for work. | Greater than 50% of survivors who were working or in school full time before diagnosis reported a problem with work/school both at 6–14 and at 15–35 months after diagnosis. In the follow-up survey, 30% of survivors working full time before diagnosis reported problems with “paying attention” at work/school. Further, at 15–35 months after diagnosis, 53% (N = 205) of all survivors reported problems with “forgetting”, while 28% (n = 107) reported troubles “keeping up with work or studies.” |
Rabin, 2013 Level III—B | Hospital-based tumor registry in Rhode Island
N = 20 young adult cancer survivors between 18 and 39 years of age. Mean age 33.5 years. Diagnosed within 10 years | Qualitative Objective: To develop an in-depth understanding of the preferred content and format of psychosocial and behavioral programs for those diagnosed with cancer during young adulthood. | Cancer sites: Breast (10%) Melanoma (10%) Thyroid (45%) 85% employed. | In-depth, semi-structured individual interviews Topic areas: Types of programs that might be helpful Delivery of programs Barriers to participation | >50% of participants advocated for using an online forum, chat room, or social networking site to receive support from other young survivors and behavioral counselors. |
Rozmovits, 2014 Level III—B | UK
N = 20 men and 19 women 28–68 years at diagnosis 33–87 years at the time of interview 5–9 years after diagnosis
[For this review, results from the young adult cancer survivor participants, aged 15–39 at time of diagnosis, were exclusively used.]
| Qualitative Aim: To consider aspects of the distress expressed by colorectal cancer patients in their personal narratives of illness and to produce a more detailed account of the illness’s impact on their identities and self-understanding. | Cancer site: Colorectal | Sample was referred for In-depth narrative interviews by Database of Individual Patients’ Experiences (DIPEx), an Internet resources based on illness narrative interviews | Major theme: loss of adulthood Sub-themes: loss of professional identity; loss of ability to socialize; loss of dignity, privacy, and independence. Management of bowel symptoms interferes with job performance and social expectations about professional behavior. |
Rutskji, 2010 Level II—A | Cancer Registry of Norway: Testicular cancer survivor (TCS) Controls: Gallup Institute of Norway
N = 1326 Mean age at survey 44.7 years (range 23–75 years); Mean age at orchidectomy 33.3 years (range 15–64 years) 11.4 years mean time after diagnosis (range 4.3–21.4 years) | Cross-sectional Objective: To explore approach and avoiding coping strategies in long-term testicular cancer survivors. | Cancer site: Testes Work status = paid work & self-employed vs. unemployed or pensioned | Research Questions: What is the pattern of approach-avoidant coping in testicular cancer survivors, and what are the differences in somatic and mental morbidity between testicular cancer survivors with more avoidance vs. more approach coping? What variables are significantly associated with approach/avoidance coping? Do testicular cancer survivors use more approach coping than a normative sample of men from the general population? | Approach and avoidance are 2 major coping strategies. Approach coping implies facing the stressor and making active efforts to manage it. In contrast, avoidance coping is characterized by passive, suppressive, and disengaged attitudes toward the stress. Paid work, self-employed testicular cancer survivors used more approach coping styles N = 966 (88) |
Wettergren, 2003 Level III—A | Stockholm County Council’s database
N = 121 Hodgkin’s lymphoma survivors Mean age at diagnosis 33 years Mean age at time of study 47 (11.9). Median time from Hodgkin’s lymphoma diagnosis to interview was 14 years (range 6–26 years). | Cross-sectional Descriptive Comparative Aim: To use an individual approach in evaluating quality of life in long-term survivors of Hodgkin’s lymphoma and their view of what impact the disease has had on life. | Cancer site: Hodgkin’s lymphoma | Extended version of the Schedule for the Evaluation of the Individual Quality of Life-Direct Weighting (SEIQoL-DW) | The most important areas in life, nominated by more than 50% of the Hodgkin’s lymphoma survivors as well as the control group, were family, personal health, work and relations to other people. |
Yabroff, 2012 Level I—A | US national survey
N = 884 Age category 18–44 (23.7%) Most cancer survivors were diagnosed 6 or more years prior to survey (52.7% for 18–64 years; 59.7% for 65+ years) | Cross-sectional Aim: To evaluate the association between cancer survivorship and service use frequencies and patient time costs. | Cancer sites: Not specifically given; included all. | The Medical Expenditure Panel Survey with Cancer Survivorship Supplement | Cancer care was typically more aggressive in younger than older cancer patients, potentially resulting in greater medical cost, productivity loss, late and long-term effects. Working young adults experience different types of late effects than survivors diagnosed with cancer at older ages. |
Yanez, 2013 Level III—B | Tuluna, an online Research Panel
N = 335 Mean age = 31.8 Stratified by cohort/time post-active treatment (months): 0–12 (118) 13–24 (98) 25–60 (106) Within 5 years of diagnosis | Cross-sectional Purpose: To explore whether age and cancer-related education/work interruption interacted with distress. | Cancer Sites: Breast Cervical Melanoma Lung Colorectal Thyroid Testicular | Impact of Event Scale (IES) Patient-Reported Outcomes Measurement Information System (PROMIS) CR work interruption was assessed by a single author-constructed item: ‘did you stop working because of your cancer?’ Yes/no | 67.1% of the sample did not stop working because of cancer. Highest level of distress -13–24 months attend to cancer-related distress beyond the completion of treatment; target interventions such as psycho-social services. |
Results
Work ability
Physical functional ability
Cognitive functional ability
Distress
Coping
Support
Changing perspectives
Generating supportive relationships
Discussion
Conclusions
Clinicians | Occupational settings |
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Discuss plans for returning to work | Discuss plans for returning to work |
Discuss alternate careers and employment opportunities if needed | Tailor work to accommodate individual needs |
Refer for mental health counseling if needed | Provide Professional Employee Assistance services |
Refer to secure online support forums, chat rooms, or social networking | Notify survivors of services available in the workplace |