Sustained employability and health-related quality of life in cancer survivors up to four years after diagnosis

Figures & data

Figure 1. Flowchart of cancer survivors identified at the Social Security Agency (SSA).

Table 1. Participant characteristics at baseline.

	Continuously not working (N = 50)	Positive change in employment status (N = 14)	Negative change in employment status (N = 37)	Continuously working (N = 151)	p-value
Socio-demographics	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Age (years)	50.6 (8.1)	47.6 (8.8)	52.1 (8.3)	50.7 (6.6)	0.273
	N (%)	N (%)	N (%)	N (%)
Gender (male)	16 (32%)	3 (21%)	14 (38%)	43 (29%)	0.613
Marital status					0.673
Single	3 (6%)	1 (7%)	6 (17%)	16 (11%)
Married	37 (74%)	10 (71%)	23 (62%)	101 (67%)
Living with partner	4 (8%)	1 (7%)	5 (14%)	19 (13%)
Divorced	6 (12%)	2 (14%)	3 (8%)	15 (10%)
Education					0.080
None/primary school/lower vocational	17 (34%)	3 (21%)	10 (27%)	31 (21%)
Secondary school	12 (24%)	0 (0%)	7 (19%)	18 (12%)
Vocational/upper secondary school	9 (18%)	5 (36%)	12 (32%)	49 (33%)
Upper vocational education/university	12 (24%)	6 (43%)	8 (22%)	53 (35%)
Health-related characteristics	N (%)	N (%)	N (%)	N (%)
Tumor type					0.000
Mamma	18 (36%)	4 (29%)	14 (38%)	85 (56%)
Urinary tract	5 (10%)	1 (7%)	3 (8%)	5 (3%)
Urogenital (male)	0 (0%)	0 (0%)	7 (19%)	1 (1%)
Urogenital (female)	1 (2%)	0 (0%)	1 (3%)	7 (5%)
Respiratory tract	5 (10%)	0 (0%)	3 (8%)	5 (3%)
Digestive system	6 (12%)	2 (14%)	5 (14%)	16 (11%)
Head and neck	5 (10%)	0 (0%)	0 (0%)	8 (5%)
Hematological	6 (12%)	5 (36%)	3 (8%)	18 (12%)
Other	4 (8%)	2 (14%)	1 (3%)	6 (6%)
Treatment modalities
Surgery/Yes	38 (76%)	8 (57%)	28 (76%)	115 (76%)	0.471
No	12 (24%)	6 (43%)	9 (24%)	36 (24%)
Radiotherapy/Yes	30 (60%)	7 (50%)	17 (46%)	98 (65%)	0.162
No	20 (40%)	7 (50%)	20 (54%)	53 (35%)
Chemotherapy/Yes	34 (68%)	13 (93%)	28 (76%)	109 (72%)	0.305
No	16 (32%)	1 (7%)	9 (24%)	42 (28%)
Hormonal therapy/Yes	12 (24%)	3 (21%)	7 (19%)	63 (42%)	0.012
No	38 (76%)	11 (79%)	30 (81%)	88 (58%)
Being free of disease					0.596
Yes	21 (43%)	7 (50%)	18 (50%)	82 (55%)
No	13 (27%)	4 (29%)	5 (14%)	29 (19%)
Don’t know	15 (31%)	3 (21%)	13 (36%)	39 (26%)
Comorbidity
Yes	27 (54%)	8 (57%)	18 (49%)	91 (60%)	0.595
No	23 (46%)	6 (43%)	9 (51%)	60 (40%)
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Physical dimension score (SIP; 0-100)	10.9 (9.2)	11.1 (8.3)	4.8 (4.9)	3.2 (4.9)	0.000
Fatigue (FACIT-F; 0-52)	20.6 (10.1)	23.6 (11.5)	27.6 (9.0)	31.4 (10.8)	0.000
Depressive mood (CES-D; 0-60)	42.4 (12.6)	18.6 (12.0)	15.3 (8.2)	13.6 (10.5)	0.000
Coping (UCL)
Active tackling (7–28)	17.0 (3.9)	17.1 (3.0)	18.3 (4.9)	18.1 (3.6)	0.253
Palliative reacting (8–32)	17.9 (3.2)	18.4 (2.6)	18.7 (3.6)	18.1 (3.7)	0.724
Avoidance (8–32)	16.6 (3.6)	17.6 (2.7)	15.4 (3.9)	15.8 (2.9)	0.059
Seeking social support (6–24)	12.7 (3.7)	13.6 (3.9)	12.9 (3.5)	13.4 (3.3)	0.674
Passive reacting (7–28)	13.5 (4.1)	13.8 (4.9)	11.7 (2.6)	11.3 (3.6)	0.001
Expression of emotions (3–12)	5.9 (2.2)	5.6 (1.4)	5.4 (1.6)	5.2 (1.5)	0.078
Reassuring thoughts (5–20)	12.6 (2.3)	12.1 (2.7)	12.8 (3.4)	12.7 (2.7)	0.902
Work-related characteristics – at time of diagnosis	N (%)	N (%)	N (%)	N (%)
Type of job					0.829
White collar worker	15 (30%)	5 (35%)	11 (36%)	62 (42%)
Blue collar worker	20 (40%)	6 (43%)	13 (35%)	52 (34%)
Health care worker	15 (30%)	3 (21%)	11 (30%)	37 (25%)
Shift work					0.819
Yes	19 (38%)	6 (43%)	13 (35%)	49 (33%)
No	31 (62%)	8 (57%)	24 (65%)	101 (67%)
Managerial tasks					0.319
Yes	8 (17%)	1 (7%)	6 (16%)	36 (24%)
No	40 (83%)	13 (93%)	31 (84%)	114 (76%)
Working hours per week (Mean; SD)	29.3 (10.3)	26.8 (11.6)	30.3 (8.0)	32.1 (8.0)	0.049
Work demands					0.098
Physical	15 (31%)	2 (14%)	7 (19%)	28 (19%)
Psychological	9 (18%)	3 (21%)	9 (24%)	57 (38%)
Physical and psychological	25 (51%)	9 (64%)	21 (57%)	66 (44%)
Work-related characteristics – at baseline	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Work ability (WAI; 0-10)
Current work ability	2.1 (2.5)	2.3 (1.7)	4.5 (1.8)	5.6 (1.8)	0.000
Work ability related to physical work demands	n/a	n/a	3.2 (0.8)	3.3 (0.7)	0.362
Work ability related to psychological work demands	n/a	n/a	3.6 (0.9)	3.5 (0.7)	0.386
Experience and judgement of work (VBBA; 0–100)
Physical workload	n/a	n/a	41.4 (20.0)	42.0 (15.4)	0.845
Need for recovery	n/a	n/a	59.4 (27.6)	50.7 (30.8)	0.120
Job content (JCQ; 4–16)
Supervisor social support	n/a	n/a	11.5 (2.9)	12.8 (2.2)	0.618
Coworker social support	n/a	n/a	11.7 (2.9)	12.8 (1.8)	0.903

CES-D: Center for Epidemiologic Studies Depression Scale; FACIT-F: Functional Assessment of Chronic Illness Therapy-Fatigue Scale; JCQ: Job Content Questionnaire; n/a: not applicable; SD: standard deviation; SIP: Sickness Impact Profile; UCL: Utrecht Coping List; VBBA: Dutch questionnaire on Experience and Judgement of Work; WAI: Work Ability Index.

Table 2. Differences in quality of life over time regarding employment status.

	Continuously not working (N = 50)	Positive change in employment status (N = 14)	Negative change in employment status (N = 37)	Continuously working (N = 151)
Quality of life (EORTC QLQ-C30; 0-100)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	p-value^e
Physical functioning
Baseline (T0)	59.1 (17.5)	65.2 (14.8)	71.6 (15.6)^a	79.1 (15.1)^a	0.000
Follow-up (T1)	65.9 (19.5)	78.6 (16.7)	73.2 (20.5)	85.0 (13.9)^a	0.000
Adjusted follow-up model^d	75.1 (SE =  2.0)	82.1 (SE =  3.6)	74.9 (SE =  2.1)^b	81.4 (SE = 1.1)	0.008
Role functioning
Baseline (T0)	30.3 (27.9)	40.5 (25.9)	46.3 (25.5)^a	59.1 (23.8)^a	0.000
Follow-up (T1)	44.1 (28.5)	64.3 (28.4)^a	51.9 (27.9)^b	71.1 (22.9)^a	0.000
Adjusted follow-up model^d	52.5 (SE = 3.5)	68.2 (SE = 6.3)	54.1 (SE = 4.0)^b	67.3 (SE = 2.0)^a	0.001
Emotional functioning
Baseline (T0)	56.2 (28.1)	64.3 (31.4)	69.4 (23.1)	68.5 (26.2)^a	0.032
Follow-up (T1)	66.5 (25.7)	69.6 (28.0)	67.4 (28.1)^b	78.8 (19.9)^a	0.002
Adjusted follow-up model^d	71.4 (SE = 2.7)	70.1 (SE = 5.1)	66.0 (SE = 3.2)^b	77.5 (SE = 1.6)	0.008
Cognitive functioning
Baseline (T0)	50.0 (30.3)	64.3 (25.2)	59.0 (26.2)	66.9 (27.2)^a	0.003
Follow-up (T1)	58.5 (30.6)	77.4 (18.0)	66.7 (28.7)	73.5 (25.3)^a	0.005
Adjusted follow-up model^d	64.6 (SE = 3.2)	74.1 (SE = 5.9)	68.7 (SE = 3.7)	71.3 (SE = 1.8)	0.273
Social functioning
Baseline (T0)	43.3 (30.7)	52.4 (22.5)	62.6 (26.8)^a	67.1 (26.5)^a	0.000
Follow-up (T1)	63.9 (26.0)	77.4 (20.3)	67.6 (24.6)	78.6 (23.0)^a	0.001
Adjusted follow-up model^d	70.7 (SE = 3.1)	79.3 (SE = 5.7)	66.6 (SE = 3.7)	76.5 (SE = 1.8)	0.054
Fatigue
Baseline (T0)	65.1 (23.2)	59.5 (28.1)	55.2 (23.5)	47.7 (25.7)^a	0.000
Follow-up (T1)	55.0 (26.5)	48.4 (28.8)	49.5 (23.5)^b	35.5 (21.1)^a	0.000
Adjusted follow-up model^d	48.4 (SE = 3.0)	43.4 (SE = 5.6)	48.7 (SE = 3.5)^b	38.0 (SE = 1.7)^a	0.007
Pain
Baseline (T0)	46.3 (33.6)	39.3 (30.9)	41.2 (33.2)	27.4 (28.1)^a	0.001
Follow-up (T1)	45.0 (32.0)	22.6 (27.4)^a	35.2 (30.5)^b	20.7 (25.1)^a	0.000
Adjusted follow-up model^d	40.5 (SE = 3.5)	22.7 (SE = 6.6)	32.7 (SE = 4.2)	22.4 (SE = 2.0)^a	0.000
Nausea and vomiting
Baseline (T0)	11.7 (24.1)	11.9 (20.1)	5.1 (11.1)	7.1 (16.3)	0.243
Follow-up (T1)	12.2 (22.5)	3.6 (9.6)	5.9 (14.7)	4.3 (13.0)^a	0.018
Adjusted follow-up model^d	11.6 (SE = 2.2)	-0.2 (SE = 4.1)	7.9 (SE = 2.6)	4.5 (SE = 1.2)	0.022
Dyspnea
Baseline (T0)	35.4 (32.2)	40.5 (35.0)^b	24.5 (32.1)	17.9 (23.4)^a	0.000
Follow-up (T1)	29.1 (30.0)	31.0 (38.0)	32.4 (34.3)^b	14.5 (22.4)^a	0.000
Adjusted follow-up model^d	23.0 (SE = 3.3)	23.6 (SE = 6.1)	27.3 (SE = 3.9)	18.0 (SE = 1.9)	0.153
Insomnia
Baseline (T0)	58.0 (35.5)	45.2 (36.1)	42.6 (34.4)	39.3 (35.6)^a	0.016
Follow-up (T1)	49.0 (36.1)	35.7 (30.6)	33.3 (28.4)	29.6 (30.5)^a	0.003
Adjusted follow-up model^d	43.1 (SE = 4.0)	34.8 (SE = 7.4)	35.5 (SE = 4.7)	30.4 (SE = 2.3)	0.068
Appetite loss
Baseline (T0)	19.7 (29.6)	14.3 (21.5)	18.5 (28.1)	9.1 (20.0)^a	0.018
Follow-up (T1)	16.7 (30.3)	0.0 (0.0)^a	15.7 (32.0)^b	5.1 (13.8)^a	0.001
Adjusted follow-up model^d	12.0 (SE = 2.7)	-5.5 (SE = 5.0)^a,c	14.6 (SE = 3.2)	7.0 (SE = 1.5)	0.003
Constipation
Baseline (T0)	24.7 (35.5)	25.6 (36.4)	9.3 (17.1)^a	10.7 (22.6)^a	0.002
Follow-up (T1)	21.8 (31.6)	10.3 (16.0)	13.1 (24.9)	7.4 (16.4)^a	0.001
Adjusted follow-up model^d	18.5 (SE = 3.0)	7.5 (SE = 6.0)	15.4 (SE = 3.5)	8.3 (SE = 1.7)^a	0.016
Diarrhea
Baseline (T0)	12.7 (26.8)	28.6 (43.1)^b	12.0 (22.8)	7.9 (19.9)	0.015
Follow-up (T1)	13.3 (26.1)	23.1 (28.5)^b	14.1 (25.0)	5.4 (17.5)	0.004
Adjusted follow-up model^d	10.3 (SE = 2.7)	15.0 (SE = 5.5)	14.4 (SE = 3.3)	6.5 (SE = 1.6)	0.106
Financial impact
Baseline (T0)	42.9 (36.6)	31.0 (35.7)	33.3 (33.8)	26.0 (31.1)^a	0.020
Follow-up (T1)	34.0 (32.3)	23.8 (30.5)	43.8 (36.8)^b	22.0 (28.6)	0.001
Adjusted follow-up model^d	29.4 (SE = 3.8)	27.4 (SE = 7.0)	42.0 (SE = 4.4)^b	22.9 (SE = 2.1)	0.002
Global health/QoL
Baseline (T0)	43.3 (18.9)	54.8 (15.9)	58.8 (15.9)^a	64.6 (19.7)^a	0.000
Follow-up (T1)	51.7 (23.1)	70.2 (15.9)^a	62.0 (19.4)	74.3 (18.0)^a	0.000
Adjusted follow-up model^d	60.2 (SE = 2.5)	72.5 (SE = 4.5)	61.4 (SE = 2.9)^b	71.6 (SE = 1.4)^a	0.000
Summary score
Baseline (T0)	59.9 (17.4)	65.6 (16.7)	69.4 (12.4)^a	75.3 (14.8)^a	0.000
Follow-up (T1)	67.1 (15.0)	77.8 (12.7)	72.7 (12.0)^b	82.0 (12.7)^a	0.000
Adjusted follow-up model^d	72.9 (SE = 1.8)	81.2 (SE = 3.5)	73.9 (SE = 2.1)^b	80.6 (SE = 0.9)^a	0.001

EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; SD: standard deviation; SE: standard error. ^aSignificant difference with group ‘Continuously not working’ at a level of p < 0.05; ^bSignificant difference with group ‘Continuously working’ at a level of p < 0.05; ^cSignificant difference with group ‘Negative change in employment status’ at a level of p < 0.05; ^dAdjusted for baseline outcome measure, age, gender, education, tumor type, hormonal therapy, working hours per week and work demands; ^ep-Value shows significance of change in employment status at a level of p < 0.05.

Table 3. Univariate time lag model for selecting predictors of work continuation at follow-up.

	Work continuation at follow-up
Socio-demographics	Beta (SE)/OR (95% CI)	p-value^a
Age	−0.06 (0.03)/0.94 (0.89–1.00)	0.031
Education
None/primary school/lower vocational	Ref.
Upper vocational education/university	0.75 (0.41)/2.11 (0.94–4.75)	0.072
Health-related characteristics	Beta (SE)/OR (95% CI)	p-Value^a
Tumor type
Mamma	Ref.
Urinary tract	−1.29 (0.72)/0.28 (0.07–1.12)	0.071
Urogenital (male)	−3.68 (1.10)/0.03 (0.00–0.22)	0.001
Respiratory tract	−1.34 (0.72)/0.26 (0.06–1.07)	0.063
Treatment modalities
Radiotherapy/No	Ref.
Yes	0.57 (0.26)/1.77 (1.07–2.93)	0.028
Hormonal therapy/No	Ref.
Yes	1.12 (0.41)/3.06 (1.37–6.81)	0.006
Physical dimension score (SIP)	−0.05 (0.02)/0.96 (0.92–0.99)	0.023
Quality of life (EORTC QLQ-C30)
Global health/QoL	0.01 (0.01)/1.01 (1.00–1.02)	0.065
Physical functioning	0.03 (0.01)/1.03 (1.01–1.04)	0.007
Financial impact	−0.01 (0.01)/0.99 (0.98–1.00)	0.062
Summary score	0.02 (0.01)/1.02 (1.00–1.04)	0.059
Work-related characteristics	Beta (SE)/OR (95% CI)	p-Value^a
Work ability (WAI)
Current work ability	0.23 (0.06)/1.26 (1.12–1.43)	0.000
Work ability related to physical work demands	0.43 (0.20)/1.53 (1.03–2.27)	0.035
Experience and judgement of work (VBBA)
Need for recovery	−0.01 (0.01)/0.99 (0.98–1.00)	0.018

EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; OR: odds ratio; Ref.: reference category; SE: standard error; SIP: Sickness Impact Profile; VBBA: Dutch questionnaire on Experience and Judgement of Work; WAI: Work Ability Index.

^aFor the univariate generalized estimating equations analyses, a cutoff for p-values of 0.10 was used.

Table 4. Multivariate time lag model for selecting predictors of work continuation at follow-up.

	Work continuation at follow-up
Socio-demographics	Beta (SE)/OR (95% CI)	p-value^a
Age	−0.01 (0.04)/0.99 (0.93–1.06)	0.757
Education
None/primary school/lower vocational	Ref.
Upper vocational education/university	0.45 (0.57)/1.56 (0.51–4.75)	0.433
Health-related characteristics	Beta (SE)/OR (95% CI)	p-Value^a
Tumor type
Mamma	Ref.
Urinary tract	−0.40 (0.69)/0.67 (0.18–2.59)	0.565
Urogenital (male)	−2.63 (1.31)/0.08 (0.01–1.10)	0.060
Respiratory tract	−0.51 (1.18)/0.60 (0.06–6.04)	0.663
Treatment modalities Radiotherapy/No	Ref.
Yes	0.57 (0.52)/1.76 (0.64–4.86)	0.274
Hormonal therapy/No	Ref.
Yes	0.84 (0.51)/2.32 (0.85–6.35)	0.102
Physical dimension score (SIP)	−0.02 (0.05)/0.98 (0.89–1.07)	0.628
Quality of life (EORTC QLQ-C30)
Physical functioning	0.01 (0.02)/1.01 (0.98–1.04)	0.491
Financial impact	−0.01 (0.01)/1.00 (0.99–1.01)	0.843
Summary score	0.01 (0.02)/1.01 (0.98–1.04)	0.609
Work-related characteristics	Beta (SE)/OR (95% CI)	p-Value^a
Work ability (WAI)
Current work ability	0.38 (0.14)/1.46 (1.11–1.92)	0.007
Work ability related to physical work demands	−0.25 (0.32)/0.78 (0.41–1.47)	0.442
Experience and judgement of work (VBBA)
Need for recovery	0.00 (0.01)/1.00 (0.99–1.02)	0.753

EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; OR: odds ratio; Ref.: reference category; SE: standard error; SIP: Sickness Impact Profile; VBBA: Dutch questionnaire on Experience and Judgement of Work; WAI: Work Ability Index.

^aFor the multivariate generalized estimating equations analysis, a cutoff for p-values of 0.05 was used.