Changes in importance of work and vocational

J Cancer Surviv DOI 10.1007/s11764-015-0502-7

Changes in importance of work and vocational satisfaction during the 2 years after breast cancer surgery and factors associated with this Marie I. Nilsson 1,2,3 & Fredrik Saboonchi 1,4 & Kristina Alexanderson 1 & Mariann Olsson 2 & Agneta Wennman-Larsen 1,5 & Lena-Marie Petersson 1,6

Received: 8 May 2015 / Accepted: 23 November 2015 # Springer Science+Business Media New York 2015

Abstract Purpose The purpose of this study is to investigate how women, during the 2 years following breast cancer surgery, rate importance of work and vocational satisfaction, and baseline factors associated with rating over time. Methods A prospective cohort study of 692 women aged 20–63 included about 4 weeks after a first breast cancer surgery. Register data on treatment and data from six repeated questionnaires during a 2-year follow-up (at baseline, 4, 8, 12, 18, 24 months) were used in twoway mixed repeated analysis of variance and mixed repeated measures analysis of covariance. Results The women rated importance of work (m=3.74; sd 0.88) (maximum 5) and vocational satisfaction (m=4.30; sd 1.38) (maximum 6) high during the 2 years. Women with planned chemotherapy rated lower vocational satisfaction and especially so at 4 months after inclusion (F 1, 498= 8.20; p=0.004). Higher age, better physical, and mental/ social work ability at baseline influenced rating of vocational satisfaction. Supportive colleagues was an important covariate * Marie I. Nilsson [email protected] 1

Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden

2

Division of Social Work, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden

3

Department of Social Work, Karolinska University Hospital, Stockholm, Sweden

4

Red Cross University College, Stockholm, Sweden

5

Sophiahemmet University, Stockholm, Sweden

6

Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden

that significantly affected ratings of importance of work as well as vocational satisfaction, i.e., women with better support rated on average higher on these outcomes. The effect of chemotherapy disappeared after including the abovementioned baseline covariates. Conclusions Women diagnosed with breast cancer in the following 2 years rate importance of work and vocational satisfaction high, which are associated to lower work ability and social support. Implications for cancer survivors Work is a very important aspect in life also after a cancer diagnosis, which has to be acknowledged when discussing treatment and rehabilitation plans with women with breast cancer. Furthermore, workplace support needs to be assessed as this is an influential factor. Keywords Breast cancer . Work importance . Vocational satisfaction . Trajectory/change

Background In previous qualitative studies, it has been reported that, among individuals diagnosed with cancer, work may lose its importance and that for some persons, this change may remain over time [1–3]; however, this has not been studied in larger cohorts. Lower ratings of importance of work or vocational satisfaction is associated with job discontinuation, decreased working time after cancer, and sickness absence [4–6] as well as with poor mental and physical health [4, 7–10]. Since experienced importance of work and vocational satisfaction are also related to sickness absence, and being sickness absent in turn can also lead to negative effects [11–13], it is relevant to study changes in ratings of satisfaction and importance of work after a cancer diagnosis [14].

J Cancer Surviv

To the best of our knowledge, there are only two studies of changes in vocational satisfaction in cancer survivors. One is a conference abstract briefly outlining the results of a study from the USA, stating that late survivors rate significantly greater job satisfaction than previously during the cancer trajectory [15]. The other is a study by Mehnert et al. [16] who found no significant changes between patients’ total vocational satisfaction score (12 items, i.e., working conditions, payment, work climate) at baseline (when enrolled in cancer rehabilitation) and 1 year later, although levels of satisfaction decreased regarding three items: overall work satisfaction, satisfaction with work tasks and job-related activities, and professional acknowledgement. To the best of our knowledge, there are no studies of factors associated with ratings of importance of work or vocational satisfaction after cancer diagnoses. Such knowledge can be used when designing interventions in order to lessen the impact of a cancer diagnosis on future work life.

items regarding demographics, and work from all six questionnaires were analyzed. In total, 971 women met the inclusion criteria. Of those, 48 (4.9 %) were not invited due to administrative failures. The questionnaire was completed and returned by 724 of the invited women (74.6 %), who, thereby, agreed to participate and gave their informed consent. No significant age differences were found between participants (m=51.3, sd=8.1), nonparticipants (m=52.4, sd=8.1), and those who were missed due to administrative failures (m=51.9, sd=7.5) (F=1.343, df=2, p=0.262). In this study, women not working at baseline due to disability pension and/or early old-age pension were excluded, leaving 692 women included in the analyses. The attrition rate in the following questionnaires was 49 women at 4 months, 51 women at 8 months, 90 at 12 months, 92 at 18 months, and 133 at 24 months, i.e., the response rate was very good (81–93 %).

Measures Aim The aim of this study is to investigate how women, during the first 2 years after breast cancer surgery, rate the importance of work and vocational satisfaction, and baseline factors associated with ratings over time.

Method and materials A prospective cohort study was conducted, using data from six repeated questionnaires and a clinical-based breast cancer register. Included were women who had a first breast cancer surgery when aged 20–63 years, who, in working ages, lived in Stockholm County, and were literate in Swedish [17–19]. Exclusion criteria were known distant metastasis, pre-surgical chemotherapy, and/or a previous breast cancer diagnosis. Inclusion was performed consecutively in 2007–2009 at the first consultation for planning of further treatment, about 4 weeks after the surgery. The women received oral and written information about the study at inclusion, stressing voluntary participation and possible withdrawal at any time. Two types of data were used: answers from the six repeated comprehensive questionnaires, administrated at inclusion and after 4, 8, 12, 18, and 24 months and data from the Swedish National Breast Cancer Register [20] regarding planned postoperative treatment. The baseline questionnaire and a prepaid return envelope were provided at the medical consultation whereas the follow-up questionnaires were mailed to the participant’s home addresses. In the present study, responses to

Dependent variables Importance of work was measured with a question from QPS Nordic questionnaire [21]; BHow important is your work to you^ with five response alternatives ranging from one of the least important things in my life (=1) to one of the most important things in my life (=5). Satisfaction with vocational situation was measured by one question from the Life Satisfaction checklist-11 (LiSat-11) [22, 23], a well-validated instrument often used in rehabilitation studies [24]. The six response alternatives to the question BMy vocational situation (or lack thereof) is …^ ranged from very dissatisfying (=1) to very satisfying (=6). Covariates Age at baseline was used as a continuous variable. Planned postoperative chemotherapy was classified as yes or no through data from the Swedish National Breast Cancer Register [20]. Work ability at baseline was measured by two questions from Work Ability Index [25] of subjective estimations of work ability in relation to physical and mental/social job demands: “How do you estimate your current work ability in relation to physical demands in your work” and “How do you estimate your current work ability in relation to mental or social demands”, with response options were very poor (=1), moderate (=2), rather good (=3), and very good (=4). Work ability at baseline was included in the analyses to control for early signs of

J Cancer Surviv

worse health, possibly even due to health problems previous to breast cancer surgery. Social support from supervisor and colleagues at baseline was measured by two single items from the National Working Life Cohort study [26]: BAre you able to get support and encouragement from colleagues when you feel that things aren’t going well at work^ and BAre you able to get support and encouragement from your immediate boss/supervisor when you feel that things aren’t going well at work^. The response options were always (=3), usually (=2), seldom (=1), and never (=0).

Statistical analyses The statistical analyses were performed by SPSS 20.0 with a level of significance set at α=0.05. Two-way mixed repeated measurement analysis of variance (ANOVA) was used to test the differences in mean ratings of importance of work and of vocational satisfaction over time with importance of work and vocational satisfaction as dependent variables, and the between-subjects factor group (planned post-operative chemotherapy vs no planned chemotherapy) and within-subjects factor time (baseline, 4, 8, 12, 18, 24 months) as independent variables. This analysis yields estimates of main effects for each independent variable, and an interaction effects of time x group. When a significant interaction is detected, the main effects should not be interpreted directly, i.e., no definite conclusions can be made about the main effect of each independent variable since they depend on each other. Spaghetti plots were performed for the individual women’s values for the repeated outcome measures versus six assessments, and additional spaghetti plots were performed with error term introduced. These figures were included to visualize the variation in the data. Further mixed repeated measures of ANCOVA were used to test the differences in mean ratings of the dependent variables over time and associations with all baseline covariates. Variables which were significantly associated were included in further analysis.

Table 1 Ratings of importance of work and vocational satisfaction in numbers, percentage, and mean with standard deviation (SD) at six measure points over 24 months follow up in a cohort of 692 women who had had breast cancer surgery

Importance of work Least important (1–3) Most important (4–5) Mean (SD) Vocational satisfaction Low satisfaction (1–4) High satisfaction (5–6) Mean (SD)

Ethical approval The study was approved by the Regional Ethical Review Board in Stockholm, Sweden.

Results The women were on average 50.8 years old (SD 8.07), the majority (57.4 %) had college/university education, chemotherapy treatment was planned for 51.6 %, and 61 % were sickness absent at baseline. The majority stated work to be one of the most important aspects of life at all six assessments (Table 1). Slightly more than half of the women rated being satisfied with their vocational situation, with the exception of 4 months.

Changes in ratings of importance of work and vocational satisfaction over 2 years Importance of work In the total cohort, the average mean rating of importance of work fluctuated slightly over time (Fig. 1), and variations of ratings were found within the group (Figs. 2 and 3). A significant effect for the independent variable time was found for importance of work in the whole group. This was also found for women with planned postoperative chemotherapy (Table 2). No interaction effect for time and postoperative chemotherapy was found regarding ratings of importance of work. The analysis with all the covariates (Table 3) included was then trimmed by retaining only the significant covariates in a final model. According to this analysis, baseline support from colleagues was the covariate that had a significant main effect on average rating of importance of work (F 1, 472=6.217; p= 0.013) that is women with a higher support from colleagues rated higher importance of work. In this analysis, the effects of planned postoperative chemotherapy were rendered non-significant (p=0.520).

Baseline

4 months

8 months

12 months

18 months

24 months

n=688 241 (35.0) 447 (65.0) 3.76 (0.9) n=673 321 (47.7) 352 (52.3) 4.23 (1.5)

n=645 239 (37.1) 406 (62.9) 3.73 (0.8) n=643 349 (54.3) 294 (45.7) 4.04 (1.5)

n=645 252 (39.1) 393 (60.9) 3.71 (0.9) n=644 317 (49.2) 327 (50.8) 4.29 (1.3)

n=605 227 (37.5) 378 (62.5) 3.73 (0.9) n=609 289 (47.5) 320 (52.5) 4.30 (1.4)

n=606 260 (42.9) 346 (57.1) 3.62 (0.9) n=611 288 (47.1) 323 (52.9) 4.37 (1.3)

n=554 222 (40.1) 332 (59.9) 3.68 (0.9) n=571 256 (44.8) 315 (55.2) 4.39 (1.3)

J Cancer Surviv Fig. 1 Mean rated importance of work in chemotherapy recipients and non-recipients during 24 months post-breast cancer surgery

Vocational satisfaction In the cohort, the mean rating of vocational satisfaction increased, except for the assessment at 4 months (Table 2). Also concerning vocational satisfaction, there were variations of ratings within the group (Figs. 4, 5, and 6). The main effects of the independent variables included a significant withinsubject effect of time on rating of vocational satisfaction during the 2 years in the total group and a significant betweensubjects effect for planned postoperative chemotherapy with regard to average rating of vocational satisfaction (F 1, 498= 8.20; p=0.004). However, multivariate tests of vocational satisfaction showed a significant interaction between group (chemotherapy vs no chemotherapy) and time (questionnaire assessment occasion) (Wilks’ Lambda=0.907, F 10.12 4, 494, p