Cancer, fatigue and the return of patients to work—a prospective cohort study

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Abstract

Fatigue is a highly prevalent and debilitating symptom in cancer survivors. The aim of this study was to assess the impact of fatigue and other cancer-related symptoms on the return to work of cancer survivors. A prospective inception cohort study with 12 months of follow-up was initiated. At 6 months following the first day of sick leave, levels of fatigue, depression, sleep problems, physical complaints, cognitive dysfunction and psychological distress were assessed, in addition to clinical, sociodemographic and work-related factors. Data were obtained from one academic hospital and two general hospitals in the Netherlands. 235 patients who had a primary diagnosis of cancer and underwent treatment with curative intent were included. The rate of return to work was measured at 6, 12 and18 months. Hazard ratios (HRs) for the duration of sick leave up to 18 months following the first day of sick leave were calculated. The rate of return to work increased from 24% at 6 months to 64% at 18 months following the first day of sick leave. Fatigue, diagnosis, treatment type, age, gender, depression, physical complaints and workload were all related to the time taken to return to work. Fatigue scores were also strongly related to diagnosis, physical complaints, and depression scores. Fatigue at 6 months predicted a longer sick leave with a hazard ratio of 0.71 (95% Confidence Interval (C.I.) 0.59–0.85), adjusted for diagnosis, treatment type, age and gender. In a multivariate Cox regression analysis, diagnosis, treatment, age, physical complaints and workload remained the only significant predictors of duration of the sick leave. 64% of cancer survivors returned to work within 18 months. Fatigue levels predicted the return to work. This was independent of the diagnosis and treatment, but not of other cancer-related symptoms. Better management of cancer-related symptoms is therefore needed to facilitate the return to work of cancer patients.

Introduction

Cancer-related fatigue has been described as “the commonest and most debilitating symptom in patients with cancer” [1]. From an individual's point of view, not being able to return to work following an illness, frequently results in financial losses, social isolation and a reduction in self-esteem 2, 3. Conversely, returning to work can improve the quality of life of many cancer patients. Patients often see returning to work as proof of a complete recovery. Treating clinicians, as well as occupational physicians, may contribute to a successful return to work, and can thus enhance the quality of life of cancer patients [4]. The economic impact is considerable: 75% of patients and 40% of those who care for these patients change their employment status because of cancer-related fatigue [1]. From a societal point of view, it is therefore important to reduce avoidable work incapacity resulting in such economic loss [5].

Cancer is a collective name for a heterogeneous group of diagnoses whose treatment is far from uniform. There is some evidence that the consequences of the illness and its treatment, or cancer-related symptoms that are experienced by the patients, can affect the likelihood of resumption of work by cancer patients. For example, the relatively rapid return to work of patients with testis carcinoma is explained by the relative absence of cancer-related symptoms [6]. Although, concentrating on differences at the level of diagnosis bears the risk of generalisation: e.g. not all patients with testis carcinoma experience few problems following work resumption.

Cancer-related symptoms are in general independent of the cancer site and treatment. Fatigue is one of the best-known and best-researched symptoms. Other equally relevant cancer-related symptoms are depression, sleep problems, physical complaints, cognitive dysfunction and psychological distress 7, 8, 9. Cancer-related fatigue can have psychological and physical causes and is as such associated with other cancer-related symptoms: e.g. sleep problems, depression and physical complaints [1].

Cancer-related symptoms are not only highly prevalent in cancer patients, irrespective of the cancer site, but they are also likely to have an impact in a wide variety of work settings and may thus hinder the resumption of work. In addition to cancer-related symptoms, the impact of clinical, work-related and subject-related variables [6] on the resumption of work needs to be considered, including diagnosis and treatment, physical workload [10], work stress, age, gender and work hours [6].

The aim of the present study was to examine the relationship between fatigue and other cancer-related symptoms and the return to work in cancer patients, taking into account the impact of clinical-, work- and subject-related factors (Fig. 1). The impact of the symptoms will be considered in a cohort of cancer survivors starting from 6 months following their first day of sick leave. The research question is: do the symptom scores at 6 months after the first day of sick leave predict the time taken to return to work and the rate of return to work at 12 months of follow-up?

Section snippets

Subjects

In this prospective-cohort study, patients who had a primary diagnosis of cancer were consecutively included in the study. Recruitment occurred in three hospitals in The Netherlands: the Academic Medical Centre and the Onze Lieve Vrouwe Gasthuis, both in Amsterdam, and in the hospital De Heel in Zaandam. The following departments were also included in the study: Gynaecology, Haematology, Oncology, Surgery, Radiotherapy, and Urology. The attending physician obtained the patient's informed

Sample characteristics

235 of the 264 patients who were eligible and were approached, completed the first questionnaire (response rate of 89%). Of the 29 patients who declined participation in the study; 12 were not interested, 13 were too ill, 2 participated in a concurrent study and 2 declined for other reasons. Hospital directions prohibited us to collect additional information on the patients who did not participate. The follow-up questionnaire at 18 months following the first day of sick leave was completed by

Discussion

In this study, 64% of the cancer patients had returned to work at 18 months following their first day of sick leave. Fatigue levels at 6 months after the start of sick leave predicted the return to work at 18 months following the first day of sick leave. This was independent of the diagnosis and treatment, but not of other cancer-related symptoms. Age and physical workload were also independently related to the return to work. The other potential predictive factors sleep problems, cognitive

Acknowledgments

This study was supported by a grant from the Dutch Cancer Society (AMC 97-1385). We are grateful to all of the patients for their participation in this study. In addition, we would like to thank the medical staff involved at the Academic Medical Center, the Onze Lieve Vrouwe Gasthuis and at hospital De Heel for their indispensable contribution to this study and Dr M.M. Verberk for his constructive comments.

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