SAN FRANCISCO—Within 5 years after completing treatment for non-metastatic colorectal cancer treatment, most patients who were working before their diagnosis are back in the workplace, researchers reported at the 2016 ASCO Cancer Survivorship Symposium. “We found that about 75 percent of the people return to their jobs, and about 25 percent do not,” said Crystal Denlinger, MD, Assistant Professor of Medicine-Oncology at the Fox Chase Cancer Center, Philadelphia (Abstract 126).
Overall, survivors not currently working at the time of the survey had lower physical and mental functioning. For workers and non-workers, younger age, multiple comorbidities, and the presence of symptoms increased the risk for poor physical and mental functioning, Denlinger told OT.
“We as clinicians need to pay attention to modifiable risk factors,” she said. “Doctors should be thinking of fatigue as an intervenable factor after therapy, such as encouraging physical activity. I think addressing neuropathy is something that is going to be very important, especially in respect to physical function. There is a study looking at reductions in the length of treatment with oxaliplatin to reduce the impact of neuropathy on these patients.
“There may be ways we can intervene...to identify people who might be at risk for not returning to work after cancer therapy and try to re-integrate them back into the work force,” she said. “Further work is necessary to improve interventions for modifiable risk factors, especially in survivors currently not working.”
Five year survival of colorectal cancer is 65 percent, Denlinger noted, and survival is greater—about 90 percent in patients who have local disease, and 71 percent for those with regional disease, which results in a lot of people who have productive years ahead of them.
“Our population was not old,” she said. “The median age for the people who were working was 56 years; the median was 60 years for the non-workers. Even 60-year-olds can work.”
But, she added, colorectal cancer survivors face physical and mental late and long-term effects after completing treatment.
“This was a population-based mailed survey of colorectal cancer survivors identified by the Pennsylvania Cancer Registry,” Denlinger explained. “We were looking for people who had been working at the time of their cancer diagnosis and now were 3-5 years after their curative attempt therapy. We were looking to see if they were still working and then looking at what factors might impact work and what workers versus non-workers function.”
Of the 300 patients in the study, 132 or 44 percent had been diagnosed with colon cancer; 168 patients were diagnosed with rectal cancer. About 74 percent of the colon cancer patients were back to work compared with 77 percent of the patients with rectal cancer (P=0.510). About 75 percent of the patients were men and 87 percent were white.
When treatment began, 109 of the patients stopped working; 91 patients stopped working during the treatment, and one-third of the patients—100 individuals—stayed on the job throughout the treatment.
When researchers examined why some of the people failed to return to work, they found that, in the non-working group, younger patients had a fairly low physical functioning score and also had a low mental functioning score, using the Short Form (SF-12) questionnaire.
“If you look at the people who are working, their scores are about at the same level of the general population; but the non-workers are below the median,” Denlinger said. “We can't correlate if lower physical and mental functioning is because they are not working, or they aren't working and, therefore, have lower physician and mental functioning.”
Survivors reporting fatigue (P=0.012), sleep issues (P=0.024), neuropathy (P<0.001), and cognitive issues (P=0.004) were less likely to be working. Urinary or bowel symptoms, ostomy, or distress was not associated with work status.
“It turns out treatment really wasn't the big problem with the exception of ostomy, which is a treatment and a late effect of treatment,” Denlinger said. “What we found was that, except for comorbid conditions, there really wasn't a demographic that was related to lower scores, but if you were someone with three or more comorbidities, you had a lower physical and lower mental functioning scores. We also found non-whites tended to have lower scores compared to whites in the non-working population. Unmarried survivors tended to have lower physical functioning.”
Denlinger said she found the survey matched her own patient population to some degree. “In my practice, I think younger people do seem to have a harder time,” she said. “I don't know if it is because they experience symptoms differently or whether they have more going on in trying to balance work and family versus an older person for whom the burden of having to go back to work is not as great.
“Younger people seem to have a more challenging time going through therapy than with older people,” she said. “That is sort of born out here because younger people really did have lower functioning scores. The things that were related to mental function are related to fatigue, cognitive functioning, distress, and comorbidities. Comorbidities affect both physical and mental functioning.”
Working After Treatment
The survey is a start to understanding the problems patients face after completing therapy, Denlinger said. “We don't have all the answers in this study. We didn't ask why they didn't go back to work. We also didn't ask what kinds of modifications people made when they went back to work to handle residual symptoms.
In commenting on the study, Yousef Khelfa, MD, a fellow in oncology at the Joan C. Edwards Comprehensive Cancer Center at Marshall University, Huntington, W.V., who also studies survivorship issues, suggested the extent of the surgery may have a lot to do with whether a patients remains on the job.
“A lot of the determination of whether a person would return to work would likely be the type of surgery that they had,” he told OT. “A colostomy might be a factor in whether a person returns to work. It might make them tend to withdraw from society and maybe from work as well.
“There are multiple factors that could be reasons for people not returning to work. It could be related to the cancer, it could be related to their surgery, it could be related to something else,” Khelfa said. “Social support is also a major factor in whether patients will return to work. Having family or friends as part of a support network can be helpful in decision to return to work. Physicians should be proactive in discussing these work-related activities with their patients following cancer surgery.”
“I think that as a medical community we need to pay attention to comorbidity in this population as well as stress—an unaddressed symptom in a lot of our survivors,” Denlinger said. “Most of our patients after colon cancer treatment say their life is pretty good, but there is a subset of patients that is not doing as well.”
Ed Susman is a contributing writer.