See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/221878199 Distinct work-related, clinical and psychological factors predict return to work following treatment in four different cancer... Article in Psycho-Oncology · March 2013 DOI: 10.1002/pon.3049 · Source: PubMed CITATIONS READS 28 142 5 authors, including: Alethea F Cooper Matthew Hankins 30 PUBLICATIONS 858 CITATIONS 104 PUBLICATIONS 2,684 CITATIONS University of East Anglia SEE PROFILE University of Southampton SEE PROFILE Lorna Rixon Beth Grunfeld 48 PUBLICATIONS 961 CITATIONS 88 PUBLICATIONS 1,905 CITATIONS University of London SEE PROFILE Coventry University SEE PROFILE All content following this page was uploaded by Beth Grunfeld on 17 December 2016. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document and are linked to publications on ResearchGate, letting you access and read them immediately. Distinct work-related, clinical and psychological factors predict return to work following treatment in four different cancer types Alethea F Cooper1, Matthew Hankins2, Lorna Rixon2, Emma Eaton2, Elizabeth A Grunfeld2 NIHR Comprehensive Biomedical Research Centre, Guy’s & St Thomas’ NHS Hospital Trust & Kings College London, KCL Dept. of Public Health Sciences, Division of Health and Social Care Research, 5th Floor Capital House, Guy's Hospital, London SE1 3QD1 Psychology Department, Institute of Psychiatry, King’s College London, 5th Floor Bermondsey Wing, Guy’s Hospital, London SE1 9RT2 Corresponding author: A F Cooper Psychology Department, Institute of Psychiatry, King’s College London, 5th Floor Bermondsey Wing, Guy’s Hospital, London SE1 9RT. Tel: 020 7188 0196 Fax: 020 7188 0184 alethea.cooper@kcl.ac.uk Running title: Predicting return to work across cancer types Disclaimer: the authors state no known conflict of interest This research was funded by a project grant from Cancer Research UK (C8303/A6130). This is the pre-peer reviewed version of the following article: Cooper AF, Hankins M, Rixon L, Eaton E, Grunfeld EA. Distinct work-related, clinical and psychological factors predict return to work following treatment in four different cancer types. Psychooncology. 2013 Mar;22(3):659-67. doi: 10.1002/pon.3049., which has been published in final form at http://onlinelibrary.wiley.com.ezproxye.bham.ac.uk/doi/10.1002/pon.3049/abstract 1 ABSTRACT Objective: Many factors influence return to work (RTW) following cancer treatment. However specific factors affecting RTW across different cancer types are unclear. This study examined the role of clinical, sociodemographic, work and psychological factors in RTW following treatment for breast, gynaecological, head and neck and urological cancer. Methods: A 12-month prospective questionnaire study was conducted with 290 patients. Cox regression analyses were conducted to calculate hazard ratios (HR) for time to RTW. Results: Between 89-94% of cancer survivors returned to work. Breast cancer survivors took longest to return (median 30 weeks) and urology cancer survivors returned soonest (median 5 weeks). Earlier return among breast cancer survivors was predicted by a greater sense of control over their cancer at work (HR 1.2; 95% CI: 1.09-1.37) and working full-time (HR 2.0; CI: 1.213.31). Predictive of a longer return among gynaecological cancer survivors was a belief that cancer treatment may impair ability to work (HR 0.742; CI: 0.60-0.92). Among urological cancer survivors constipation was predictive of longer RTW (HR 0.98; CI: 0.97-0.99) whereas, undertaking flexible working was predictive of returning sooner (HR 1.70; CI: 1.07-2.7). Head and neck cancer survivors who perceived greater negative consequences of their cancer took longer to return (HR 0.17; CI: 0.06-0.49). Those reporting better physical functioning returned sooner (HR1.05; CI: 1.01-1.08). Conclusion: A different profile of predictive factors emerged for the four cancer types. In addition to optimal symptom management and workplace adaptations the findings suggest that eliciting and challenging specific cancer and treatment-related perceptions may facilitate RTW. Keywords: cancer, oncology, return to work, patient perceptions, treatment beliefs; 2 INTRODUCTION Advances in the early detection and treatment of cancers have resulted in improved prognosis and thus an increasing number of people of working age are able to return to aspects of usual life, including work[1]. Along with the obvious financial implications, participation in work is recognised as important for overall psychological and physical well-being[2] and for many cancer survivors returning to work represents a sign of return to normality and social reintegration[3]. A recent review reported 41-84% of cancer survivors returned to work following cancer treatment[4]. The high recurrence rate of cancers of the nervous system and reduced life expectancy of lung cancer account for the lower employment rate observed among these cancer types but generally there are no conclusive findings regarding the impact of disease stage and cancer site on the return to work (RTW) of cancer survivors[4]. This is largely because the majority of studies include either a single cancer type or a range of cancer types (analysed as a mixed group), so possible differences between cancer types are not reported. However, it is reported that some factors associated with cancer (i.e. treatment type), as well as socio-demographic and workrelated factors influence employment and work ability[5]. For example being older, having a lower level of education and working in a blue collar job are associated with not working. In contrast, receiving support from occupational health, flexibility within the workplace and a supportive work environment have been shown to be enabling factors[4]. A recent in-depth review suggested four groups of associated factors that could exert influence on the RTW process, namely the impact of cancer site, the impact of treatment, occupational status and the role of others[6]. However, it is evident from literature across a range of conditions that a patient’s beliefs about their illness are of importance in predicting a range of health-related behaviours. The prominent theoretical model underscoring the importance of illness perceptions is Leventhal’s Self-Regulation Model[7][8]. The model proposes that people construct illness representations (or beliefs about their illness) that allow them to make sense of their condition and that these beliefs direct subsequent illness and health-related behaviours. A recent review states the case for the importance of self-regulatory processes (including patients’ illness perceptions) in relation to health outcome, including work behaviour[9]. Using multivariate analysis, one study among patients with a range of chronic diseases suggested more negative beliefs about the consequences of one’s illness were associated with unemployment[10]; a second suggested that holding a belief that one’s illness would continue for a longer period was associated with taking longer to RTW[11]. However, illness representations are important not just because of their predictive value but also because they have been shown to be modifiable through short cognitivebased programmes which attempt to address misconceptions and improve patient understanding of their condition[12][13]. Therefore, psychological factors that influence RTW could similarly be amenable to intervention to optimise a positive outcome. The aims of this study were to examine the particular psychological, work-related, sociodemographic and clinical factors influencing return to work among four groups of cancer survivors (urological cancer, breast, gynaecological or head and neck) and determine if different profiles of predictive factors emerged across cancer types. Urological (specifically prostate), breast and gynaecological cancers are among the most commonly diagnosed cancer types worldwide but associated with a range of treatment modalities and treatment burden for the individual. Breast cancer survivors and prostate cancer survivor samples have independently been included in existing RTW studies[4][5][6] and one recent study investigated employment and return to work in head and neck cancer survivors as a single group[14] but this group and gynaecological cancer survivors have been investigated less frequently. MATERIALS AND METHODS Patients and procedure Local research ethical approval was obtained. Participants were recruited from out-patient departments of hospitals in three UK Healthcare Trusts (see Figure 1). Patients were eligible for 3 inclusion if aged over 18, employed at the time of diagnosis, had completed treatment and were able to complete a questionnaire in English. Patients with metastatic cancer were excluded. Recruitment was continuous and conducted by two researchers using a similar verbal explanation and invitation. Patient information sheets were provided and written consent was obtained prior to questionnaire completion. The majority of patients completed the questionnaire at home and returned it in a pre-paid envelope. Patients were followed-up at six and 12 months to elicit work status. Measures Sociodemographic factors Participants reported age at study entry, educational level, whether they were the main provider of financial support for their family and gender (head and neck cancer patients). Clinical factors Cancer site, treatment received and co-morbidities were obtained from the patient’s medical records. Work-related factors Self-reported job descriptions were categorised into occupational groups according to descriptive labels provided in the International Standard Classification of Occupations (ISCO 88-COM)[15]. Further regrouping created three broad categories: white collar (managerial and professional occupations), pink collar (clerical, sales and service occupations) and blue collar (manufacturing and materials handling). Participants indicated the size of their employing company (small <60 employees, medium 60-100 employees or large >100 employees) and the number of hours worked per week (categorised as part-time (<35 hrs/week) or full-time (=/>35 hrs/week)). Number of years with company, flexible working allowed (total hours worked, start/finish time) (yes/no), number of months full sick pay allowance and health insurance (yes/no) were also recorded. Psychosocial factors Illness Perceptions Questionnaire (IPQ-R)[16]. Adapted for cancer patients; responses are rated on a five-point likert scale. Subscales assess: timeline (5 items, score range 5-25 ; Cronbach's alpha 0.70), consequences (6 items, score range 6-30; Cronbach's alpha 0.61); personal control (5 items, score range 5-25; Cronbach's alpha 0.69); treatment control (7 items, score range 7-35, Cronbach's alpha 0.66); coherence (5 items, score range 5-25 ; Cronbach's alpha 0.67) and emotional impact (6 items, score range 6-30; Cronbach's alpha 0.83). A higher score for timeline indicates a belief that cancer will be long-lasting ; a higher score for the remaining subscales indicates a greater impact (e.g. more consequenes, higher level of personal control). EORTC Quality of Life Questionnaire (QLQ-C30)[17]. Comprises 30 items covering physical (Cronbach's alpha 0.71), role (Cronbach's alpha 0.85), emotional (Cronbach's alpha 0.88), cognitive (Cronbach's alpha 0.67), and social function (Cronbach's alpha 0.81) as well as global health status (Cronbach's alpha 0.88). In addition, there are symptom scales for fatigue (Cronbach's alpha 0.84 ), nausea and vomiting (Cronbach's alpha 0.67), pain (Cronbach's alpha 0.78) and several single item scales (financial difficulties, dyspnoea, insomnia, appetite loss, constipation, diarrhoea). A higher score represents a higher ("better") level of functioning, or a higher ("worse") level of symptoms. All scales range from 0-100. Hospital Anxiety and Depression Scale (HADS)[18]. Comprises 14 items producing separate anxiety (Cronbach’s alpha 0.84) and depression scores (Cronbach’s alpha 0.79). Score range is 021. A higher score indicates greater anxiety/depression. Fear of Recurrence Scale[19]. Five-item measure of fear of cancer recurrence. Responses are rated on a five-point Likert scale (“not at all” to “very much”). Cronbach's alpha is 0.77. Score range is 5-25. A higher score represents a greater fear of recurrence. Illness perceptions in relation to work[20]. This is a modified version of the Brief Illness Perceptions Questionnaire (IPQ)[21]. The Brief IPQ assesses the cognitive and emotional representations of illness. This adapted eight item scale assessed beliefs about the effect of cancer on work (e.g. “How much do you expect your cancer to affect your life at work?” and “How 4 well do you feel your cancer is understood at work?” (see Table 2)). Each item is treated as an individual score with answers provided on 8-point scales (range 0-7). A higher score represents a greater impact of the sub-scale. Work values[22]. This comprises three subscales: extrinsic work aspects (Cronbach's alpha 0.79), intrinsic work aspects (Cronbach's alpha 0.84) and social relations at work scale (Cronbach's alpha 0.80). Responses are rated on a five-point Likert scale (“very unimportant” to “very important”). Score range is 1-5. A higher score represents stronger work values. Return to work Date of cessation of work was obtained at time of consent to the study. Patients were asked to recall the precise date of RTW at six or twelve month follow-up interview; the date of return was validated via the participants own diary record (majority of cases) or via employers’ records if necessary. Return to work was defined as return to paid employment, whether a different job, reduced hours or full-time. A proxy total number of days off work (for those who had not returned to work at the study end) was calculated as the number of days between the date they left work and study recruitment and adding 365 (the maximum length of study follow-up). Statistical Analysis Statistical analysis was undertaken using SPSS version 15.0 (SPSS Inc. Chicago, Il, USA). Variables were entered singly (univariately) into the first Cox regression to identify independent psychological, sociodemographic, work-related and medical variables related to delay in return to work; these variables (excluding treatment type) were then included as covariates in a multivariate Cox regression model using forward stepwise procedure. Significant variables were entered into a final Cox regression model (block 2, forward stepwise procedure) with adjustment for treatment type where this was identified univariately (see Table 1). Treatment type comprised: radiotherapy (yes/no), chemotherapy (yes/no), surgery (yes/no); for urology patients brachytherapy (yes/no) and for breast cancer patients hormonal therapy (yes/no). Hazard Ratios (HR) are reported along with 95% confidence intervals. A hazard ratio of above 1 indicates a faster RTW. RESULTS Participants Of the 332 patients who were eligible and consented to participate in the study 290 (87%) returned the questionnaire. Participants had a mean age of 55 years (SD 10.5 years) and range 28-65 years. Baseline sociodemographic, psychological, clinical characteristics and work-related factors are presented in Table 1 along with return to work data. The median duration from start of treatment to completion of the questionnaire was 119 days and the median number of days off work to the time the questionnaire was completed was 144 days. Six participants had worked through their treatment and four patients were lost to follow-up. Results pertaining to univariate, multivariate and adjusted multivariate prognostic indicators are presented for the remaining 280 in Table 3. Breast cancer survivors took longest to RTW, median 30.0 weeks (interquartile range (IQR) 45.4 weeks) followed by head and neck and gynaecology cancer survivors median 18.3 weeks (IQR 30.7) and 17.9 weeks (IQR 20.3) respectively; urology cancer survivors returned soonest (median 5.0 weeks (IQR 10.6)). After controlling for age and treatment type, with urology as the referent group, the other three cancer types took approximately twice as long to return to work: breast cancer (HR 0.57; 95% CI 0.36-0.91; p = 0.19), gynaecological cancers (HR 0.53; 95% CI 0.360.78; p < 0.001) and head and neck (HR 0.52; 95% CI 0.334-0.81; p <0.01). At 12 month follow-up 23 participants were not working. In general the subscales do not differ greatly between the cancer types; the head and neck cancer survivors experienced greater problems regarding appetite (EORTC QLQ-C30) (a difference in EORTC score of 10-20 may represent a moderate subjective difference)[14]. Mean HADs scores were not clinically significant in any of the groups. 5 Univariate analysis For all cancer groups, sociodemographic, clinical and psychological variables were important in relation to RTW (see Table 3). With regard to treatment type, in gynaecological cancer patients, there was a trend for those who underwent radiotherapy (n=19) to take longer to return to work (median 25.4 weeks; IQR 36.0) than those who did not (n=37) (median 14.1 weeks; IQR 13.6); (HR 0.05; CI 0.27-1.00; (p=0.06)). For urological cancer patients, men undergoing brachytherapy (n=18) returned to work sooner (median 2.9 weeks (IQR 3.1)) than those who did not (n=70) (median 7.7 weeks (IQR 10.6)); (HR 1.85; CI 1.08-3.2; (p<0.05)). Multivariate analysis Adjusted (mutually and for treatment type) multivariate analyses are also shown in Table 3.. Breast cancer patients For women with breast cancer, those who perceived greater control over the effect of their cancer at work were more likely to RTW sooner (HR 1.20; 95% CI 1.09-1.37; p < 0.01). The median rate of return to work for those in the 75th percentile was 9.5 weeks (IQR 38.6) compared to 35.9 weeks (IQR 29.4) for those in the 25th percentile. Furthermore, those who worked full-time were twice as likely to RTW sooner (median 20.4 weeks (IQR 35.9) compared to 40 weeks (IQR 40.9); HR 2.20; 95% CI 1.33-3.70; p<0.001). Gynaecological cancer patients Those who perceived a greater impact of the effect of their cancer treatment at work took longer to RTW than those who did not (median for those in the 75th percentile was 21.9 weeks (IQR 45.6) compared to 12.8 weeks (IQR 13.6) for those in the 25th percentile (HR 0.74; 95% CI 0.60-0.92; p<0.01)). Head and neck cancer patients Among the head and neck cancer patients those who perceived greater consequences as a result of their cancer took longer to RTW (median for those in the 75th percentile 42.3 weeks (IQR 58.1) compared to 16.0 weeks (IQR 17.4) for those in the 25th percentile; HR 0.18; 95% CI 0.07-0.46; p<0.001). Those who reported a greater level of physical functioning returned to work sooner than those who did not (75th percentile median 13.6 weeks (IQR 19.4) compared to 38.4 weeks (IQR 59.9) for 25th percentile; HR 1.03; 95% CI 1.01-1.06; p < 0.01). Urology patients On multivariate adjusted analysis, one symptom was significant, those who reported constipation took longer to return to work (median 13.4 weeks (IQR 29.0) weeks compared to 4.4 weeks (IQR 7.4); HR 0.98; 95% CI 0.97-0.99; p < 0.01). Those who were able to undertake flexible working were likely to return sooner (median 3.6 weeks (IQR 6)) than those who were not (median 9.8 weeks (IQR 12)); (HR 1.70; CI 1.07-2.7 (p=<0.05)) DISCUSSION This study set out to examine predictors of the length of time to RTW within four cancer types and include the role of psychological factors. Results suggest that different predictors of return to work, including psychological factors, may be relevant to individual cancer types, independent of treatment type. Overall, the majority of patients within each cancer type returned to work; just over 10% of patients recovering from head and neck cancer did not RTW, whilst between 6% and 8% of patients with urological cancer, gynaecological cancer and breast cancer had not returned to work by the 12month follow-up. As may be expected, with different disease and treatment burden, the time to 6 return to work varied between the cancer types; those recovering from urological cancer returned soonest, a similar finding to previous reports[19], with the other cancer types taking approximately twice as long. Treatment may have been less onerous, comprising either daycase keyhole surgery, surgery only or brachytherapy in the majority of cases. In line with other literature, treatment type was related to RTW. On univariate analysis there was a trend for those undergoing radiotherapy to take longer to return to work for people recovering from gynaecological cancer. Radiotherapy may specifically be associated with stiff joints and muscles, localised swelling and skin soreness in the affected area which could impact on work-related physical demands. In the prostate cancer patients those men undergoing brachytherapy were more likely to return to work sooner, perhaps reflecting the minimal treatment burden associated with this single dose/single day therapy. In the same patient group experience of constipation was associated with time to RTW on adjusted multivariate analysis. Managing changes in bowel function resulting from treatments such as surgery (decreased mobility may lead to changes in bowel function) and radiotherapy (self-medication for diarrhoea may cause constipation) is clearly of prime importance for these men. Among the breast cancer sample those who worked full-time returned sooner than those who worked part-time. The majority of the breast cancer sample were white collar workers, highly educated and approximately half were single - factors shown to be related to a faster RTW in previous studies[4]. In addition, a prompt return to work could be the result of financial pressure and it is possible that some women may have returned to work too soon. A long-term follow-up would determine satisfaction with the RTW process and possible subsequent withdrawal from the workplace. A recent qualitative study of the experiences of working among gynaecological cancer survivors indicated a need to address unrealistic expectations regarding ability to work and to help manage long-term residual symptoms[24]. A key finding is that perceptions of the impact of cancer (or its treatment) on work, as well as general illness perceptions, were independently predictive of length of time to return to work in three of the four cancer types. A perception of more severe consequences (and a longer timecourse for the illness) has been shown to predict work behaviour among myocardial infarction patients[25]. Similarly, maladaptive illness perceptions have been observed among work-disabled patients with various chronic diseases[10]. However, this is one of the first studies examining the role of patient illness and treatment perceptions in people recovering from cancer. Furthermore, we have shown that perceptions of cancer specifically in relation to work are relevant to the behaviour of cancer survivors, a similar finding to that reported previously which indicated that self-assessed work ability was an important prognostic factor for RTW among employed cancer patients who underwent treatment with curative intent[26]. Ilness representations are important not just because of their predictive value but also because they are modifiable through short cognitive-based programmes. Such interventions have been successful in addressing maladaptive beliefs and perceptions[12][13]. In addition, a recent review of RTW interventions concluded that successful interventions should include person, environment, and work-directed components[27]. These interventions elicit individual patterns of belief in either individual or group format therefore such interventions would be suitable across cancer types; individualising and tailoring the programmes would make them shorter and more attainable. Our findings suggest that for head and neck cancer patients an important focus for intervention may be coping with practical issues and may help address the concern regarding the perceived consequences of the cancer and physical functioning which were predictive of length of time to RTW. Similarly increasing perceptions of control over the effects of cancer at work and minimising the perceived impact of treatment on ability to work are relevant for breast cancer and gynaecological cancer survivors respectively. The optimal management of symptoms (e.g. constipation) comprising appropriate, timely verbal and written information thus maximising clinical support, appears to be warranted among prostate cancer patients. The importance of the 7 involvement of health professionals, including oncology specialists and allied health professionals, in the delivery of such interventions should not be underestimated. To date the role of such professional in the RTW process has been largely neglected[6] but evidence suggests that even simple advice regarding RTW, when delivered by an oncologist, is effective in improving work outcomes[27]. Furthermore, among patients recovering from myocardial infarction their physician's advice was strongly associated with RTW and remained the only predictor in the multivariate model[28]. Therefore, healthcare professionals working with cancer patients may benefit from an understanding of how cognitive processes influence patient outcomes, such as RTW, and may benefit from a skills-base to elicit individual patient beliefs in order to support patients both during and after treatment. This skill is important as recent research has shown that both health professionals[29] and employers[30] report illness perceptions that are discordant with those reported by cancer survivors. Communication skills training that incorporates cognitive (i.e. examination of clinicians’ beliefs about their role) and behavioural aspects (i.e. practical training in the elicitation of the beliefs of patients) leads to improved confidence in the ability to elicit patients’ beliefs and an increase in this behaviour in clinical practice[31]. The sample sizes in our study are relatively small compared to retrospective questionnaire studies utilising large cancer registries for recruitment. Although questionnaire burden was limited as much as possible some patients chose not to participate so soon following treatment. The small head and neck patient sample limits exploration of gender differences. However, the results of this study are still important. In particular, the findings highlight the importance of illness and treatment-related perceptions. The differences between cancer types should also be given consideration by those delivering interventions; who is best placed to do this has received little attention but physicians, cancer nurse specialists and allied health professionals are likely to be trusted by patients. Furthermore, such interventions should contain a cognitive component, addressing possible misconceptions and apprehensions regarding cancer and treatment-related factors which affect the RTW process. ACKNOWLEDGEMENTS Cancer Research UK project grant: (C8303/A6130). The authors thank the patients who took part in this study; Pauline Martin: data collection. AFC: the Department of Health via the NIHR comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust with King’s College London. CONFLICT OF INTEREST No conflict of interest to be declared by any author REFERENCES 1. 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J Clin Oncolo 2002; 20: 765-769. 10 Table 1: Demographic and clinical characteristics of the participants Number (%)/ Mean (SD) Breast Gynaecological N=89 N=56 Time to return to work (in weeks) Median 25th-75th percentile SOCIODEMOGRAPHIC FACTORS Gender Female Male Mean age at study entry (years) Ethnicity White Black Caribbean Black African Asian Other Marital Status Married Not married/Divorced/Widowed Financially responsibility for family Academic Attainment No qualifications GSCE/Equivalent A level/Equivalent Degree or higher CLINICAL FACTORS Treatment type (total) Radiotherapy (r/therapy) Chemotherapy (c/therapy) Surgery Treatment combinations Radiotherapy only Chemotherapy only Surgery only Surgery and c/therapy Surgery and r/therapy Surgery and c/therapy and r/therapy Chemotherapy and radiotherapy Hormonal therapy Brachytherapy One or more co-morbidities WORK RELATED FACTORS Size of company Small (<60 employees) Medium (60-100 employees) Large (>100 employees) Self-employed Number of years with company Hours worked Full-time (>35hrs/wk) Part-time (<35 hrs/wk) Collar Grouping White Urological N=88 Head &Neck N=47 30.0 6.4-51.8 17.9 11.0-31.3 5.0 2.9-13.4 18.3 7.7-38.4 89 (100) 49 (7) 56 (100) 48 (10) 88 (100) 54 (11) 12 (25.5) 35 (74.5) 52 (9) 74 (83.1) 5 (5.6) 4 (4.5) 0 (0) 6 (6.7) 51 (91.1) 0 (0) 1 (1.8) 3 (5.4) 1(1.8) 70 (79.5) 9 (10.2) 2 (2.3) 3 (3.4) 4 (4.6) 42 (89.4) 2 (4.3) 1 (2.1) 0 (0) 2 (4.3) 53 (59.6) 36 (40.4) 38 (45.8) 37 (64.3) 20 (35.7) 16 (29.6) 73 (83) 15 (17) 45 (54.9) 35 (74.5) 12 (25.5) 19 (44.2) 8 (9.0) 21 (23.6) 19 (21.3) 41 (46.1) 8 (14.3) 8 (14.3) 8 (14.3) 32 (57.1) 19 (21.6) 20 (22.7) 15 (17.0) 34 (38.6) 9 (19.1) 14 (29.8) 9 (19.1) 15 (31.9) 78 (87.6) 66 (74.2) 88 (98.9) 19 (33.9) 12 (21.4) 53 (94.6) 5 (5.7) 14 (15.9) 66 (75) 39 (83) 13 (27.7) 33 (70.2) 1(1.1) 0 3(3.4) 8(9.0) 19(21.3) 58(65.2) 2(3.6) 0 31(55.4) 8 (14.3) 10 (17.9) 4(7.1) 4(4.5) 0 51 (58.0) 14 (15.9) 1(1.1) 0 8(17.0) 0 8(17.0) 0 18(38.3) 7(14.9) 69 (77.5) 35 (39.3) 1(1.8) 24 (42.9) 0 18 (20.5) 44 (50.0) 6 (12.8) 21 (44.7) 21 (23.6) 14 (15.7) 39 (43.8) 15 (16.9) 10.1 (8.3) 9 (16.1) 5 (8.9) 35 (62.5) 7 (12.5) 10.3 (10.3) 14 (16.5) 5(5.9) 46 (54.1) 20 (23.5) 15.1 (11.7) 5 (10.6) 5 (10.6) 28 (59.6) 9 (19.1) 13.4 (13.7) 57 (64.8) 31 (35.2) 37 (68.5) 17 (31.5) 71 (87.7) 10 (12.3) 35 (76.1) 11 (23.9) 56 (62.9) 39 (69.6) 43 (49.4) 25 (53.2) 11 Pink Blue Flexible working allowed Number of months full sick pay Health insurance available Number (%)/ Mean (SD) 21 (23.6) 12 (21.4) 12 (13.5) 5 (8.9) 41(46.1) 19 (33.9) 3.6 (3.7) 3.4 (2.9) 18 (20.5) 11 (19.6) 9 (10.3) 35 (40.2) 41(48.8) 2.2 (2.8) 27(31) 6 (12.8) 16 (34.0) 20 (42.6) 3.4 (3.0) 10 (21.3) 12 Table 2: Mean scores on measures Mean (SD) Breast Gynaecological N=89 N=56 Urological N=88 Head &Neck N=47 Illness Perceptions Questionnaire Consequences Emotional Impact Timeline Treatment control Coherence Personal Control 4.1 (0.6) 3.3 (0.7) 3.0 (0.8) 3.8 (0.4) 3.8 (0.7) 3.7 (0.7) 4.0 (0.7) 3.4 (1.1) 2.8 (0.7) 3.9 (0.5) 3.8 (0.7) 3.4 (0.8) 3.9 (0.6) 3.1 (0.9) 3.0 (0.7) 3.8 (0.6) 3.8 (0.7) 3.6 (0.7) 4.1 (0.4) 2.9 (0.7) 3.0 (0.7) 3.9 (0.5) 3.6 (0.8) 3.8 (0.5) Fear of Recurrence 13.6 (3.3) 13.5 (4.6) 12.0 (3.8) 12.3 (3.8) Hospital Anxiety & Depression Scale Anxiety (total score) Depression (total score) 6.3 (3.9) 3.0 (2.5) 6.6 (4.1) 4.9 (3.4) 4.4 (3.4) 3.2 (2.9) 4.8 (3.9) 3.4 (3.8) Quality of life (EORTC) Global health status Physical functioning Role function Emotional functioning Cognitive functioning Social functioning Fatigue Nausea Pain Dyspnoea Insomnia Appetite Constipation Diarrhoea Financial difficulties 70.8 (18.3) 80.2 (16.8) 77.6 (21.4) 73.2 (22.2) 72.1 (25.1) 68.9 (29.5) 39.0 (24.8) 4.5(10.8) 24.9(24.5) 15.2(22.4) 41.0 (33.2) 7.7 (18.4) 10.3 (21.5) 6.1(14.9) 36.6(37.3) 64.2 (21.0) 76.2 (19.9) 65.4 (32.2) 65.1 (27.6) 72.0 (24.9) 62.4 (30.7) 42.2 (21.6) 6.2 (13.5) 25.6 (24.3) 8.0 (17.0) 42.8 (33.5) 13.0 (22.8) 22.2 (31.7) 13.6 (22.9) 28.4(36.9) 67.7 (21.3) 82.0 (16.8) 70.8 (29.5) 78.3 (19.7) 83.7 (19.1) 62.1 (29.3) 34.0 (24.1) 7.5 (14.8) 23.3 (25.3) 15.6 (26.4) 30.0 (31.4) 10.6 (22.1) 13.0 (22.0) 11.8 (24.2) 23.6(33.0) 67.7 (23.6) 85.3 (16.6) 77.6 (27.4) 74.2 (24.1) 84.5 (25.8) 72.0 (28.5) 38.2 (29.8) 13.2 (22.3) 22.4 (27.9) 12.4 (20.6) 30.2 (36.9) 33.3 (35.3) 20.2 (30.9) 4.7 (11.6) 29.5(37.2) 2.7 (1.8) 2.5 (1.8) 3.8 (2.2) 2.3 (1.9) 2.0 (1.8) 2.6 (2.0) 5.0 (1.8) 2.6 (2.0) 2.3 (2.0) 1.9 (1.7) 3.9 (2.2) 1.9 (1.6) 1.5 (1.4) 2.7 (2.2) 4.5 (2.0) 2.8 (1.9) 1.9 (1.7) 1.8 (1.6) 4.6 (1.9) 1.5 (1.5) 1.5 (1.6) 2.1 (1.9) 4.5 (1.9) 1.8 (1.7) 2.1 (1.9) 2.4 (2.0) 4.6 (2.1) 2.0 (2.0) 1.5 (1.5) 2.4 (2.1) 4.8 (2.1) 2.0 (2.1) 4.1 (0.5) 3.9 (0.6) 4.5 (0.6) 4.0 (0.8) 3.7 (0.7) 4.3 (0.7) 4.0 (0.6) 3.7 (0.6) 4.1 (0.6) 3.9 (0.5) 3.6 (0.6) 4.1 (0.5) Illness Perceptions in Relation to work Life at work affected by cancer How long work will be effected Control over effects of cancer at work Treatment impairs ability to work Experience symptoms at work Concern over cancer returning Cancer is understood at work Affected emotionally at work Work values Intrinsic Extrinsic Social 13 Table 3: Univariate, multivariate and adjusted multivariate prognostic indicators for return to work in cancer survivors (only significant variables shown) Independent unadjusted variables HR BREAST CANCER Academic Attainment None vs degree/higher GCSE equivalent vs degree/higher Hours worked Full time vs part time Total hours worked Illness Perceptions Consequences Fear of recurrence EORTC Quality of life Fatigue Illness perceptions in relation to work Control over effects of cancer at work GYNAECOLOGICAL CANCER Hours worked Full time vs part time Illness Perceptions Personal control Illness perceptions in relation to work Treatment impairs ability to work HEAD AND NECK CANCER Illness Perceptions Consequences HADs Depression EORTC Quality of life Global health score Physical function Social function Illness perceptions in relation to work Life at work affected by cancer How long work will be affected UROLOGICAL CANCER Flexible working vs not EORTC Quality of life Role function Emotion function Social function Nausea *0.40 **0.32 Multivariate mutually adjusted 95% CI HR 95% CI Multivariate adjusted for treatment type HR 95% CI N/A N/A N/A N/A 0.17-0.94 0.13-0.79 *1.59 *1.02 0.99-2.53 **2.0 1.00-1.05 *0.64 *0.91 0.40-0.98 0.84-0.98 *0.99 0.98-1.00 **1.16 1.04-1.30 *1.86 0.99-3.46 *1.42 0.99-2.03 **0.77 1.21-3.31 ***1.2 1.09-1.37 0.64-0.94 **0.74 0.61-0.91 ***0.25 0.12-0.58 **0.27 0.11-0.68 N/A *0.89 0.81-1.00 *1.02 **1.03 *1.02 1.00-1.03 1.01-1.06 1.00-1.03 **1.04 1.01-1.08 N/A N/A **0.82 0.72-0.94 *0.81 0.69-0.97 *1.65 1.05-2.7 *1.67 1.02-2.67 *1.70 1.07-2.7 **1.01 *1.02 *1.01 *0.98 1.00-1.02 1.00-1.03 1.00-1.02 0.97-1.00 **0.74 0.60-0.92 N/A 14 Constipation **0.98 Illness perceptions in relation to work Life at work affected by **0.82 cancer Treatment impairs ability *0.86 to work Experience symptoms at *0.85 work Treatment type Brachytherapy vs none *1.86 HR - hazard ratio; CI - confidence interval 0.97-0.99 **0.98 0.97-0.99 *0.99 0.97-1.00 0.72-0.94 0.74-0.99 0.73-0.99 1.08-3.2 * = p < 0.05; ** = p < 0.01; *** = p < 0.001 Reference group for continuous variables: a higher score on that variable is related to a faster (if HR>1) or slower (if HR<1) return to work. 15 View publication stats