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Journal of Clinical Oncology, Vol 24, No 3 (January 20), 2006: pp. 345-353 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.00.4929 Correlates of Return to Work for Breast Cancer SurvivorsFrom the Departments of Medicine and Epidemiology, Michigan State University, East Lansing, MI; and Department of Health Administration and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA Address reprint requests to Reynard R. Bouknight, MD, PhD, Department of Medicine, Michigan State University, B-338 Clinical Center, East Lansing, MI 48824; e-mail: Rey.Bouknight{at}hc.msu.edu
Purpose: To identify correlates of return to work for employed breast cancer survivors. Patients and Methods: Patients included 416 employed women with newly diagnosed breast cancer identified from the Metropolitan Detroit Cancer Surveillance System. Patients were interviewed by telephone 12 and 18 months after diagnosis. Correlates of return to work at 12 and 18 months were identified using multivariate logistic regression. Results: More than 80% of patients returned to work during the study period, and 87% reported that their employer was accommodating to their cancer illness and treatment. After adjusting for demographic characteristics, health status, cancer stage, treatment, and job type, heavy lifting on the job (odds ratio = 0.42; 95% CI, 0.18 to 0.99), perceived employer accommodation for cancer illness and treatment (odds ratio = 2.2; 95% CI, 1.03 to 4.8), and perceived employer discrimination because of a cancer diagnosis (odds ratio = 0.27; 95% CI, 0.10 to 0.71) were independently associated with return to work at 12 months after breast cancer diagnosis, and perceived employer accommodation (odds ratio = 2.3; 95% CI, 1.06 to 5.1) was independently associated with return to work at 18 months after breast cancer diagnosis. Conclusion: A high percentage of employed breast cancer patients returned to work after treatment, and workplace accommodations played an important role in their return. In addition, perceived employer discrimination because of cancer was negatively associated with return to work for breast cancer survivors. Employers seem to have a pivotal role in breast cancer patients' successful return to work.
Employed women with breast cancer face several challenges as they recover from treatment and attempt to return to the workplace.1-5 Despite these challenges, many breast cancer survivors are able to return to work and maintain their prediagnosis level of employment and income.6 The literature suggests that demographic characteristics,2,7-9 health status,3,10-16 treatment,17-20 and physical job tasks21,22 influence return to work for breast cancer patients, but little is known about the employer's role. The employer might have a major influence on return to work because of employment benefits, job type or tasks, and/or workplace accommodation.23-26 Using multivariate analysis, we studied several different factors to identify correlates associated with return to work for breast cancer survivors. The purpose of this research was to examine the impact of demographic, clinical, and employment characteristics on return to work for newly diagnosed breast cancer patients.
Employed, English-speaking women ages 30 to 64 years with a first, primary diagnosis of breast cancer were identified from the Metropolitan Detroit Cancer Surveillance System (Detroit, MI), which is a participant in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. In our sample, the earliest diagnosis month and year was June 2001, and the latest diagnosis month and year was April 2002. We enrolled 443 women who were working 3 months before their breast cancer diagnosis. Women were ineligible for the study if they had a previous cancer or lived outside of Wayne, Macomb, and Oakland counties. Eligible patients were offered a $25 incentive payment to complete all interviews. This study was part of a larger study that had a participation rate of 83% for patients who were screened and determined to be eligible.27 The retention rate was 94% at 12 months and 92% at 18 months. The Institutional Review Board of Michigan State University (East Lansing, MI) approved this study. All patients provided written informed consent. Four hundred sixteen enrollees participated in an interview that collected data referring to 3 months before the breast cancer diagnosis and an interview that occurred 12 months after breast cancer diagnosis (Fig 1). The recruitment and enrollment procedures have been explained by Bradley et al.27 Four hundred seven enrollees also participated in an interview 18 months after the breast cancer diagnosis. All phases of patient ascertainment, including case abstraction, physician notification, participant mailings, and screening, occurred simultaneously. The target sample size was 500 breast cancer patients. Once this was achieved, study enrollment was discontinued. Thus, there were 38 patients who were not screened because accrual was complete and 13 patients who were eligible but excluded because accrual was complete.
As depicted in Figure 1, we were unable to contact 169 women, and an additional 163 women refused to participate in the study before they were screened for eligibility. To address issues of potential sample bias, we extracted demographic and clinical data from the SEER registry for all potentially eligible cancer patients. Enrolled women were compared in terms of age, race, and stage at diagnosis to women we were unable to contact and women who refused participation after having been determined as eligible for the study. In addition, we extracted demographic and socioeconomic variables that are predictive of individual socioeconomic status and health outcomes from 2000 census block data. Patients we were unable to contact resided in census tracts with a higher percentage of households living in poverty and lived in block groups with a greater percentage of household incomes less than $20,000 (21% to 23%) compared with the residents in census blocks where the enrolled patients resided (13% to 15%). In addition, those patients who refused participation resided in census blocks where the employment rate was low relative to the employment rate in census blocks where participants resided.27 Given these findings, it is possible that women employed in lower paying jobs had a more difficult return to work experience than women in our sample.
Data Collection
Study Variables
We asked patients questions about job tasks including heavy lifting and data analysis. Responses to heavy lifting and data analysis questions were ordinal (all/almost all of the time, most of the time, some of the time, or none/almost none of the time) and from the patient's point of view. The heavy lifting and data analysis questions were extracted from the Health and Retirement Study, which has been widely used.29 We inquired about job involvement using a modification of the job involvement scale developed by Lodahl and Kejner.30 A minimum job involvement score was 5, and a maximum score was 20. In the analysis, the job involvement score was dichotomized to high (  15) and low. We also inquired about the perceived social support environment of the workplace by asking whether the employer was accommodating to the patient's cancer and need for treatment (strongly agree, agree, disagree, or strongly disagree). In addition, we asked whether the employer discriminated against the patient because of the breast cancer diagnosis (strongly agree, agree, disagree, or strongly disagree). In the reported analysis, the responses for the job characteristics were dichotomized to reflect high or low activity and agreement or disagreement.
Statistical Analysis
Table 1 lists the characteristics of the participants. The mean age at the time of diagnosis was 50.8 years, and patients had a mean household income of $46,800. Twenty percent of the women were black, most were married, and more than 70% had some college or a college degree. At baseline, most women reported good to excellent health, but compared with white women, black women were more likely to report fair or poor health (P = .024), and more had advanced, regional disease (P = .016). The most common stage of disease was local followed by regional, in situ, and distant (2.2%). Less than half of patients had a mastectomy, but more than half received radiation and chemotherapy. Most women were employed full time with white collar positions, and few were self-employed. Women were employed in managerial/professional positions (35%) followed by technical/sales/administrative jobs (26%), service positions (24%), operators/fabricators/laborers jobs (4%), precision production/craft/repair jobs (1%), and other jobs (10%). Half of the patients reported data analysis as a job task, and few women reported heavy lifting as a job task (11%). A high percentage of women (87%) perceived that their employer was accommodating to their illness and need for treatment, and few women perceived that they were discriminated against because of their cancer diagnosis (7%). Every woman who returned to work returned to her same position of employment. At 12 months after breast cancer diagnosis, 18% of patients were not working, and at 18 months, 17% were not working. There were 341 women who returned to work at 12 months, and 26 (7.6%) of these women were not working at 18 months (Fig 3).
In the 12-month univariate analysis, factors associated with a lower likelihood of return to work were lower annual household income, less than high school education, fair/poor health status before diagnosis, advanced-stage tumors, blue collar occupation, heavy lifting required by the job, and perceived employer discrimination related to the cancer diagnosis (Table 2). However, college graduation, in situ cancer stage, having sick leave, white collar occupation, and perceived employer accommodation for cancer illness and treatment needs were associated with a greater likelihood of return to work. At 18 months after diagnosis, older age, black race, less than high school education, and fair/poor health status were associated with a lower likelihood of return to work, whereas in situ stage and perceived employer accommodation were associated with a greater likelihood of return to work.
Table 3 lists the logistic regression analysis results for return to work at 12 months. Women who perceived that their employer was accommodating for their illness or cancer treatment were more likely to return to work (odds ratio = 2.2; 95% CI, 1.03 to 4.8). However, women who had fair/poor health status before diagnosis (odds ratio = 0.31; 95% CI, 0.14 to 0.73), advanced tumors (odds ratio = 0.23; 95% CI, 0.08 to 0.65), jobs that involved heavy lifting (odds ratio = 0.42; 95% CI, 0.18 to 0.99), or perceived employer discrimination because of the cancer diagnosis (odds ratio = 0.27; 95% CI, 0.10 to 0.71) were less likely to return to work. Table 3 also shows the same model with return to work at 18 months as the outcome. Patients who perceived that their employer was accommodating were again more likely to return to work (odds ratio = 2.3; 95% CI, 1.06 to 5.1). Patients with older age (odds ratio = 0.95; 95% CI, 0.91 to 0.99), black race (odds ratio = 0.35; 95% CI, 0.18 to 0.68), or fair/poor health status 3 months before diagnosis (odds ratio = 0.33; 95% CI, 0.14 to 0.77) were less likely to return to work.
In this study, a high proportion of patients reported that their employer was accommodating, which suggests that most employers were sensitive to the health needs of their employees with breast cancer. More than 89% of the patients in this study qualified for accommodations according to the Americans with Disabilities Act because they worked for employers with 15 or more employees. The Americans with Disabilities Act and its impact on working cancer survivors has been comprehensively reviewed by Hoffman.31 The perceived willingness of the employer to accommodate their workers' illness and treatment needs was an important factor for return to work. This finding has implications for employers and recovering breast cancer employees, and, to our knowledge, this is the first time this result has been reported. In a review, Spelten et al24 concluded that a supportive work environment seemed to facilitate return to work and that more systematic research was needed. Chirikos et al7 reported that 41% of breast cancer patients expressed a need for special accommodations to keep working but did not link employer accommodation to return to work as an outcome. Greenwald et al32 found that return to work was positively associated with a cancer employee's ability to control the number of hours worked and amount of work, but this study did not include breast cancer patients. Few women (7%) reported problems with discrimination because of cancer, suggesting that this was not a widespread problem for breast cancer patients in our sample. However, women who reported that they had been discriminated against because of their cancer were significantly less likely to return to work at 12 months. Other investigators have reported some or no employment effects of perceived employer discrimination as a result of illness.33,34 The manifestations of perceived job discrimination attributable to illness and need for treatment warrants further investigation. Our study of the impact of demographic and clinical characteristics on breast cancer patients' return to work yielded results similar to other research.1,5,11-15,21,23,35 Compared with younger patients, older patients were less likely to return to work at 18 months. We would expect age to be associated with retirement, although it is not mandatory in the United States. In addition, black race, low health status, and advanced tumor stage negatively affected return to work for breast cancer patients. In some studies, white collar workers were more likely to return to work and receive accommodations when compared with their counterparts.36-38 We controlled for white collar/blue collar job type in our multivariate analysis and found that, although job type was not statistically significant, heavy lifting as a job task was statistically significantly associated with a lower likelihood of return to work. Data analysis as a job task was not statistically significantly associated with return to work. Chemotherapy had no effect on return to work, and this finding is consistent with the research of other investigators who reported no effect of chemotherapy on return to work or long-term quality of life for breast cancer survivors.19,39-41 There was some variation between the 12- and 18-month assessments of return to work, and some of the difference was a result of a core of women moving in and out of the workforce. We found no distinguishing characteristics of these women to explain their movement in and out of the workforce. Some of the variation between the 12- and 18-month assessments may be attributable to reduction in treatment-related symptoms and employer adaptation to the patient's health condition. A strength of this study is its prospective, longitudinal design. Bushunow et al19 studied return to work of breast cancer patients at 1, 3, 6, and 12 months, but this study was retrospective and focused only on the effect of chemotherapy. Other studies have been cross sectional and not designed to account for differences over time.21,42 The sample includes a sizeable minority population, which is absent from some other studies. Several limitations are noted. First, the study sample from the Detroit metropolitan area may not be representative of breast cancer survivors from other parts of the country, especially those residing in rural areas. Our study sample was restricted to employed women, thus they were younger and in better health relative to the population of women diagnosed with breast cancer. In addition, our own analyses indicated that women from poorer areas or with less well-paying jobs may have been under-represented in our sample. Second, we lacked extensive clinical information normally found in a medical record audit. Data were either absent or inconsistently reported for axillary node dissections, disease recurrence, and initiation of hormone therapy, all of which might affect return to work. Third, questions regarding job tasks, accommodation, and discrimination were subject to patient interpretation. The interviewers did not provide definitions of the job tasks, and patients may have interpreted their job responsibilities differently. We did not validate attempts or denial of accommodation by visiting the workplace. Emotional readiness and other psychosocial variables may play an important role in a woman's decision to return to work, but we did not assess patients' feelings about work re-entry. It is possible that workers may use lack of accommodation to justify their decision to quit work or workers may legitimately feel disenfranchised by their employers. Further research is warranted to assess patient and employer understanding of workplace accommodation and to assess the accuracy of patient reports regarding accommodation. Likewise, we neither determined whether discrimination actually occurred nor asked women to explain what they meant by accommodation or discrimination or to provide examples. Nevertheless, the employee's perception of discrimination reflects an impression of a negative job environment, which could possibly be a barrier for job return. Recurrent disease, which was not measured by our study, might influence a woman's desire and/or ability to return to work. However, we suspect that this problem had little impact on our results because there were only nine patients with metastatic disease and other investigators have reported low rates of recurrence within 18 months of a breast cancer diagnosis.43-45 This study highlights the importance of the employer's role in the recovery of employed breast cancer patients. In addition to good health and early tumor stage, workplace accommodation as perceived by the employee is a key factor that increases the likelihood of return to work. Our findings suggest that employer sensitivity and response to their employee's cancer illness and treatment needs will facilitate the return of valuable workers to the workplace. Breast cancer patients can be encouraged to know that when they return to work they are likely to find a workplace environment that is willing to help them adapt to the challenges they face from their illness.
The authors indicated no potential conflicts of interest.
We thank Joseph C. Gardiner, PhD, for his academic contributions and Kathleen Oberst, RN, MS, for data management.
Supported by National Cancer Institute Grant No. R01 CA80645-03S1 (Labor Market Outcomes of Long Term Cancer Survivors; C.J.B., Principal Investigator). Presented in part at the 27th Annual Meeting of the Society of General Internal Medicine, Chicago, IL, May 12-15, 2004. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 tests for categoric variables. Variables with a statistically significant difference of P 
.05 in the univariate analysis were included in the multivariate logistic regression analysis, and some demographic and treatment variables were included as control variables. For the multivariate analysis, clinical variables included self-reported health status (dichotomized as poor or fair health v good, very good, or excellent health), mastectomy (yes v no), receipt of radiation therapy, receipt of chemotherapy, and cancer stage. There were only nine patients with metastatic breast cancer, which was too few to allow for separate statistical analysis of distant stage. Thus, regional and distant stages were combined. With return to work as the dependent variable, we used logistic regression to identify independent variables associated with return to work 12 and 18 months after a breast cancer diagnosis. The STATA statistical program version 7.0 (STATA Corp, College Station, TX) was used for all analyses. 
