1. Work and cancer Dr Richard Preece Consultant in occupational medicine Fellow, National Institute for Health and Clinical Excellence 18 October 2012

2. Agenda Cancer incidence and prevalence Work consequences of cancer Patient experiences Advising patients Improving support

3. Question 1 Three years after diagnosis of endometrial cancer women are: About 15% more likely to be in employment About as likely as others to be in employment About 15% less likely to be in employment About 30% less likely to be in employment

4. Question 2 Which of the following did not die from a malignant mesothelioma? John MacDougall, MP Malcolm McLaren, Musician Steve McQueen, Actor Bob Marley, Musician

5. Cancer attributable to occupation 5.3% deaths attributable Asbestos4000 Silica800 Diesel exhaust650 Mineral oils600 Shift work550 Registrations:10000 men + 3600 women

6. Incidence (20-64) 97000 cases (37% of cancers in all age groups) 57% female 55% >55 years old 82% >45 years old Commonest <30 years old = testis Commonest at all ages >30 years = breast >1/3 of all cases in 35-55 years old = breast

7. Incidence (20-64) 1.Breast 23000 2.Colon 9000 3.Prostate 8800 4.Lung 8400 5.Melanoma 5800 6.NH Lymphoma4100 7.Mouth/pharynx 3400 8.Endometrium 3000 9.Kidney 2700 10.Ovary 2600 11.Leukaemia 2200 12.Oesophagus 2000 ~1/2 of female is breast ~1/4 of male is prostate ~1/4 of male is colon+lung

8. Prevalence (Maddams et al British Journal of Cancer (2009) 101, 541 – 547)

9. Risk of unemployment 61,626 cancer survivors 356,484 healthy controls increased risk of unemployment (RR: 1.41 95%CI, 1.23- 1.62 ) but… significant heterogeneity (Wells M et al (2011) CSO Report CZG/2/467)

10. Risk of (un)employment Taksila-Brandt et al Eur J Cancer 2004;40(16):2488-93

11. Getting back to work (USA) Most survivors who returned to work did so in the first year Short, Vasey, Tunceli Cancer 2005;103:1292–301

12. Getting back to work (UK) The majority (59%) of those who returned to work managed to do so within 6 months of diagnosis. 17% of those who were working before diagnosis were absent from work for more than 1 year (p<0.001) Amir et al J Cancer Surviv (2007)

13. Risk factors for delayed RTW Older age More extensive treatment Heavy physical work More physical symptoms Depression Fatigue Diagnosis Lower education Social class CNS/head&neck/blood Female Co-morbidity No associations found: Children in the household Marital status Sleep disturbance Race

14. Leaving later Of the survivors who returned to work 9-11% would quit for cancer-related reasons in the next 3 years Short, Vasey, Tunceli Cancer 2005;103: 1292–301

16. Motivation to resume Sick leave … –Boredom –Isolation –Depression I wanted to get back to work as soon as possible.. Work was the normal life I had before and thats why I focused on it (Amir Neary Luker Eur J Oncol Nurs 2008)

17. Pressures to resume With my surgeons approval (but not my husbands), I have returned to work the third week after surgery. I am recovering quickly, and wanted to get back to normal as soon as possible. (Rasmussen & Elverdam Psycho-Oncology 2008;17(12):1232-38) [Den] Since I decided to stop working, my husband pressures me to get a job. I'm scared because if he leaves me I probably won't be able to provide for my children. (Ashing-Giwa et al J Psychosocial Oncology 2006;24(3):19-51) [USA]

18. Financial pressures I did not feel quite ready physically and I still felt a bit wobbly mentally and emotionally but I was coming to the end of my full pay and I just couldnt afford to go onto half pay… (Amir Neary Luker Eur J Oncol Nurs 2008) I didnt feel as though I had any choice not to return to work... I live alone and Ive got a mortgage, and at that time Id got my youngest son still going through university. (Kennedy et al Eur J Cancer Care 2007;16:17-25)

19. Loss of employment I lost my job after 6 months... their excuse was that because I could do limited lifting after my lumpectomy, they didnt have light duties for me to do. That was a load of rubbish and they know it. I had been with my work for 22 years and they dropped me like a stone!! (Bennett et al Supportive Care In Cancer 2009;17:1057-64) [NZ] Im afraid to apply for jobs, Ill be rejected. Cause I would send my resume in, and Im sure Ill get an interview, but I go in there with my crutches or a cane (Parsons et al Social Science & Medicine 2008;67(11):1826-36) [Ca]

20. Sustaining support …Everybody forgets what youve just gone through. Everybody forgets that youve got cancer and youve got to muck in like everybody else does…. (Amir Eur J Oncology Nursing 2008;12:190-97) Theyd soon forget how tired you get and then youd just be part of the fixture and fittings, theyd forget all about that and then youd be exhausted, but theyd be expecting you to perform. (Kennedy et al Eur J Cancer Care 2007;16:17-25)

21. Accepting changed capabilities When I went back to work, I said to myself, Ill show you, I am capable of doing what I did before and Im capable of doing even more. I had a breakdown. (Maunsell et al Psycho-Oncology 1999;8(6):467-73) [Ca]

22. Evidence-free advice 55-yr-old return to manual work following inguinal hernia repair 1 –advice from GPs 2 – 16 weeks –advice from surgeons 2 - 12 weeks carpal tunnel surgery 2 –advice from surgeons 1 – 36 days –the main predictor for time off was the advice given by the surgeon …. does this harm patients? 1. Majeed AW et al. BMJ 1995;311:296. 2. Ratzon N et al.. Occupational Medicine 2006;56(1):46-50

23. Abdominal hysterectomy Some women are fit to work after 3 to 4 weeks and will not be harmed by this if there are no complications from surgery. Many women are able to go back to normal work after 6 to 8 weeks if they have been building up their levels of physical activity at home.

24. Clayton Verow Occup Med (Lond) 2007;57:525-531 Abdominal hysterectomy RCOG

25. Clayton Verow Occup Med (Lond) 2007;57:525-531 Abdominal hysterectomy Consultant advice

26. UK intervention studies Only one up to 2011 (see Wells M et al (2011) CSO Report CZG/2/467) Maguire, Brooke, Tait, Thomas, Sellwood 1983 [Recent feasibility study (n =13) - Bains et al Cancer Nursing 2011; 34(6): E1-12]

27. Cochrane review Multidisciplinary physical, psychological and vocational interventions do enhance return-to- work for cancer patients The vocational component should not be just patient-oriented but should be directed at the work environment (including work adjustments and supervisors) as well. De Boer et al 2011 Cochrane Collaboration

28. Patient strategies for resuming after cancer Communication and negotiation with employer Acknowledging and accepting changed capabilities Managing symptoms and rebuilding confidence Working smarter Wells et al Psycho-oncology 2012

29. Medical: Critical illness Recommendation 1.1.22: Before discharge to home or community care - Give patients information about driving, returning to work, housing and benefits. [and note NICE referral for long term conditions.]

30. Evidence-based occupational rehabilitation Occupational outcomes improved by (increasing) activity, including early return to (some) work. Rehabilitation is more effective if all take responsibility and play their part when appropriate. Communication leads to faster return to work. Temporary provision of modified work reduces increases return to work rates.

31. Many patients work

32. The Christie: Outpatients ~10000 outpatients of working age

33. The Christie: Inpatients ~5000 inpatients of working age

34. Many cancer patients work Illness jeopardises employment Resuming work is a critical outcome of care Evidence-based advice and support for resumption of work is an integral part of care Summary

35. Work and cancer Dr Richard Preece Consultant in occupational medicine Fellow, National Institute for Health and Clinical Excellence