Are lymphoma survivors really at higher risk for unemployment/underemployment?

In this issue of Leukemia and Lymphoma, Chen and colleagues retrospectively investigated the impact on employment and health insurance status of undergoing treatment for Hodgkin lymphoma (HL). The study found that, compared to their siblings, survivors of HL were more likely to report job denial, difficulty obtaining insurance due to medical history, and difficulty changing jobs due to fear of losing insurance coverage. Factors associated with job denial included: male gender, lower income, and presence of physical disfigurement such as scarring of the head and neck. Being male and having an impairment interfering with a job were associated with difficulty obtaining health insurance. Difficulty changing jobs due to fear of losing insurance was associated with >4 physician visits in 2 years (more frequent ongoing medical care), <10 years from time of diagnosis, and permanent hair loss from treatment [1]. Though survivors of HL reported similar rates of employment and health insurance coverage as their siblings, they faced greater challenges in obtaining desired work positions or obtaining and maintaining health insurance coverage. With increasing numbers of survivors of HL and all cancers in general, there is a need to increase our awareness of potential adverse long-term effects that in turn have profound effects on the ability of survivors of cancer to return to being productive members of society.

The Childhood Cancer Survivor Study (CCSS) offered many insights regarding the relationships of employment, insurance and other post-treatment effects among long-term survivors of cancer. Having cancer diagnoses and receiving cancer treatments were associated with significant cognitive or physical disability, and were found to increase unemployment risk [2]. Another study has shown that survivors of all types of childhood cancer diagnoses were at increased risk of unemployment, being highest among those with brain tumors [3]. This was attributed to deficits in perception, cognition or movement, which are critical functions for most jobs. It has also been shown that, compared to siblings, adult survivors of childhood cancer had significantly lower rates of health insurance coverage and more difficulties obtaining coverage [4]. This is particularly concerning, since survivors of cancer are at risk for second primary tumors and need close medical surveillance throughout life [5]. Other factors shown to affect a cancer survivor's ability to return to work include persistent fatigue, physical ability, amount of work to be performed, and perceived workplace support [6–9].

Survivors of lymphoma who received a bone marrow transplant (BMT) may also encounter an additional myriad of medical and psychosocial long-term affects influencing employment and insurance status post-therapy. Among childhood survivors of BMT, 19% rated finding work as their main concern in life, compared to only 2% of their age-matched controls [10]. There are also reports of persistent deficits in work-related functioning [11]. These findings are in line with a report of Barrera and colleagues who found that young adults who underwent BMT during childhood experienced more problems, compared to their peers, with regard to their studies and work possibilities [12]. The three aspects of fatigue (physical, mental and total), as well as chronic fatigue in the transplant group assessed, were significantly more pronounced in all patients compared with the general population [13].

While the findings on employment problems among survivors of cancer appear to be robust, there is very little attention given to its evaluation by the clinician. Interventions to enhance return to work as the main outcome are also practically non-existent. While quality of life measures that assess one's mental and physical well-being are beginning to be routinely evaluated, comprehensive assessments of indices of return to work among survivors are not available. Such tools may allow us to identify target areas for occupational rehabilitation and formulate individualized strategies to enhance the transition back to work. Ideally, a career coach with resources to counsel the patient on barriers specific to survivors of cancer should be available. Training of survivors should not only focus on the medical aspects of surviving cancer, but also include development of social skills after cancer treatment and education about the challenges facing survivors of cancer in the labor market and how these challenges can be lessened.

Potential conflict of interest

Disclosure forms provided by the authors are available with the full text of this article at www.informahealthcare.com/lal.