J Cancer Surviv (2008) 2:159–168 DOI 10.1007/s11764-008-0059-9
Is cancer survivorship associated with reduced work engagement? A NOCWO Study Sævar Berg Gudbergsson & Sophie D. Fosså & Alv A. Dahl
Received: 14 February 2008 / Accepted: 13 June 2008 / Published online: 25 July 2008 # Springer Science + Business Media, LLC 2008
Abstract Introduction This study explores work engagement in employed tumor-free cancer survivors (CSs) compared to matched controls from the general population (NORM). Methods The sample consisted of 446 CSs tumor-free after primary treatment [226 females with breast cancer and 220 males (166 testicular cancer and 54 prostate cancer)] diagnosed 2–6 years prior to the study. All had returned to work and had favourable prognosis. NORM sample consisted of 588 employed controls (319 females, 269 males). All CSs and NORM filled in a mailed questionnaire covering demography, morbidity, and work-related issues including work engagement which was self-rated by the Utrecht Work Engagement Scale (UWES). Results No differences in work engagement were observed between the CSs and NORM measured by the UWES total scale score or by the Dedication and Absorption domain scores. The Vigor domains score was statistically lower among CSs (p=.03), but the effect size was only 0.19. The CSs reported significantly poorer work ability, poorer health status, greater numbers of disease symptoms, more anxiety, and reduced physical quality of life, and scored significantly higher on both neuroticism and extraversion. Conclusions/Implications for CSs In spite of poorer health CSs who had returned to work after their treatment for S. Berg Gudbergsson (*) : S. D. Fosså : A. A. Dahl Department of Clinical Cancer Research, The Norwegian Radium Hospital, Rikshospitalet University Hospital, Montebello, 0310 Oslo, Norway e-mail:
[email protected] S. Berg Gudbergsson : S. D. Fosså : A. A. Dahl Faculty Division, The Norwegian Radium Hospital, University of Oslo, 0316 Oslo, Norway
breast, prostate, and testicular cancer showed similar work engagement as individuals without cancer. In such CSs employers have no reason to expect reduced work engagement. Future research should preferably have a prospective and comparative design. Keywords Cancer . Work ability . Cancer survivors . Work engagement
Introduction Due to improvement in the prognosis of many types of cancer the population of cancer survivors (CSs) is increasing. Many of them are in the working phase of their life when they are diagnosed with cancer. To illustrate, among 24,488 Norwegians with a new diagnosis of cancer in 2006, 38% (4,405 males and 4,945 females) were aged from 25 to 64 years [1]. Since the employment rates in Norway for persons in this phase of the life were approximately 83% for males and 76% for females in 2005 [2], we can conclude that a large proportion of new cancer patients in this age range are holding jobs at the time of their diagnosis and primary treatment. Both the disease and the treatment can lead to short-term as well as long-term side effects that reduce the mental and physical health of CSs, either temporarily or permanently, and thus could influence their work ability of CSs [3–5]. Studies have shown that most CSs are able to return to work after primary treatment, but more research is needed to improve understanding of the return-to-work process [6–11]. Work ability can be defined as an individual’s physical, psychological and social resources for participation in any kind of paid work or self-employment. Work ability is dependent on the individual’s mental and somatic health
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status as well as on his/her social skills. Work ability is also influenced by the level of education, the extent of the social network, socio-economic status, and by the status of the job market and its willingness to employ individuals with eventual reduced work ability [12–14]. Work ability thus depends on a balance between the individual’s resources and the demands of the job market and the workplace Work engagement (WE) is defined as a positive, satisfying, and work-related state of mind, and such engagement is frequently demanded by the employers [15]. WE is the opposite of burnout and is characterized by a compound from three domains namely: vigor, dedication, and absorption [15–17]. Vigor describes the level of energy, mental resilience during work, and willingness and ability to invest efforts in the work. Dedication concerns enthusiasm, inspiration, pride, and challenge in the job. Finally, absorption covers the concentration invested in one’s job so that the work time goes quickly and one is carried away by the work [17, p. 465]. Therefore, WE is of importance for both work ability and for participation in the labor force. When CSs return to work or want to change their working place, their WE will be of relevance. Recently Steiner et al. [18] in a community-based study of CSs showed that more than half of their sample had changed occupational role due to cancer-related physical and psychological symptoms such as lack of energy, nausea/vomiting, or feelings of uselessness or depression. There are good reasons to believe that these factors have an influence on WE in CSs. By reviews of the PubMed and MedLine databases we were unable to identify any studies of WE in CSs. However, the Utrecht Work Engagement Scale (UWES) has been used in several studies and also been included in the questionnaires used by the Nordic Study Group of Cancer and Work Life (NOCWO). In the present study we, therefore, wanted to explore the associations between being CSs, socio-demographic, and work-related variables (physical and mental work ability, number of work hours each week, job stress), health related variables (subjective physical and mental health, comorbidity, number of somatic symptoms), personality traits (neuroticism, extraversion) and WE measured by the UWES. We also compared the findings in CSs with an age-, gender- and municipality matched control group from the general population (NORM). Our hypothesis was that CSs would have lower WE as expected by scores on the UWES than NORM due to the effects of their cancer experience.
Patients and methods This study is a part of a Nordic project carried out by (NOCWO) which aimed to examine the work situation of CSs in Denmark, Finland, Iceland, and Norway. NOCWO
J Cancer Surviv (2008) 2:159–168
collaboratively designed a cross-sectional case-control questionnaire study in which the common Nordic form was combined with a national one. The patient eligibility criteria of the NOCWO study were: (1) First cancer diagnosis made at age between 25 and 57 years. The upper age limit was chosen in order to avoid closeness to the age of natural pensioning; (2) Primary surgery or chemotherapy should have been finished 2 to 6 years prior to the survey (between 1998 and 2002). Ongoing adjuvant systemic hormone treatment was allowed; (3) No evidence of relapse or any new malignancy (except baso-cellular skin cancer). Procedures and response rates In 2004 the Nordic questionnaire covering demography, morbidity, life style, mental distress, fatigue, quality of life, job strain, and work engagement was mailed to 852 eligible CSs who had been treated at The Norwegian Radium Hospital in Oslo. The CSs invited consisted of 427 females with breast cancer and 425 males with either prostate cancer (N=110) or testicular cancer (N=315). In case of non-response, CSs got one reminder. Breast cancer is the most common invasive form of cancer in females and affects both young and older females [1]. Since there is no type of cancer in males with a prevalence and age distribution corresponding to breast cancer, we covered the age spectrum in males by including men with testicular cancer (young men) and with prostate cancer (middle-aged and elderly men) [19]. Based on population data Statistics Norway drew one to two controls per CSs matched by age, gender, and place of dwelling from the general population. Altogether 1,548 controls (777 females and 771 male) were drawn (NORM) [20, 21] (Fig. 1). Due to the regulations of anonymity decided by the Norwegian Data Inspectorate, NORM had no reminder. Any attrition analysis of the non-responders in NORM was thus precluded. Among CSs 513 (response rate 60%) returned valid questionnaires and 700 did the same among NORM (response rate 45%). The working CSs sample consisted of 220 males with testicular (N=166) or prostate (N=54) cancer, and 226 females with breast cancer. The NORM sample included 588 individuals (319 females and 269 males) who reported that they were working at the time of the survey. An attrition analysis of non-responding (N=339) and responding (N=513) CSs did not show any statistically significant difference as to age at survey, gender, type of cancer, stage, and treatment modalities. However, the nonresponders were younger at the time of diagnosis (p=0.02), and had longer intervals from diagnosis to survey (p= 0.002). Since the effect sizes of these statistically signifi-
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FIGURE 1 Subjects and recruitment.
Cancer Survivors Cancer subject identified and contacted 852 Female: 427 Male: 425 (Breast: 427 Prostate: 110 Testes: 315)
Declined 120 (14%) (Breast: 79 Prostate: 13 Testes: 28)
Returned valid questionnaire 513 (60%) (Breast: 269 Prostate: 71 Testes: 173)
In full-time or part-time work with valid UWES 446 (87%)
(Breast: 79
No response 219 (26%) Prostate: 26 Testes: 114)
(Breast: 226 Prostate: 54 Testes: 166)
NORM
Gender and age matched controller subject identified and contacted 1.548 (Female: 777 Male: 771)
Non - or not valid response 848 (55%) (Female: 395 Male: 453)
Valid response 700 (45%) (Female: 382 Male: 318)
In full-time or part-time work with valid UWES 588 (84%) (Female: 319 Male: 269)
cant differences were 0.08 and 0.11, respectively, they were not considered as clinically significant. Treatment issues All survivors with breast cancer had stage I disease and had been treated with local surgery (either mastectomy or lumpectomy without axillary lymph node dissection), which always was followed by radiotherapy in case of lumpectomy; after mastectomy no radiotherapy was applied. Dependent on clinical stage histological grade, and/or hormone receptor status of the tumor tissue, adjuvant chemotherapy, hormone treatment were given. Survivors with prostate cancer had either retropubic radical prostatectomy or high dose pelvic radiotherapy, which in high-risk patients was combined with adjuvant hormone treatment for three years. Depending on the type
of tumor and staging, survivors with testicular cancer entered a surveillance program, had infra-diaphragmatic radiotherapy, or received chemotherapy followed by resection of residual masses. We had no information about preexisting disease or impairment, and the questionnaire did not cover these issues. Measures in the Nordic and Norwegian questionnaires Under the direction of The Finnish Institute of Occupational Health, NOCWO developed a common Nordic questionnaire to be used in all countries. The questionnaire was based on several valid and reliable international and national measures in order to cover relevant issues concerning work in general, somatic and mental health, and work consequences of cancer. The main instruments were The Work Ability Index (WAI), The General
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Questionnaire for Psychological and Social factors at work (QPS-Nordic), The Structural–Functional Social Support Scale (SFSS), The Demand–Control–Support Questionnaire (DCSQ), and The Utrecht Engagement Scale (UWES) [10]. In the present study we mainly used the last one (UWES) to measure engagement at work. In addition, Norwegian participants received a national questionnaire covering other socioeconomic variables, social participation, and additional work-related issues. Background variables The following socio-demographic variables were defined: age at survey, gender (male as reference), two levels of education [≤12 years and ≥13 years (reference)], and civil status categorized as non-paired [single/divorced/widow (er)] versus paired [married/cohabiting (reference)], and having children at home ≤17 years [(yes or no (reference)]. Social class were defined as social class I (reference), II or III according to the profession grouping in the international Erikson Goldthorpe Portocare social class schema [22, 23] using the Occupation Classification 2000 [24]. Social class I consisted of high-grade professionals, administrators and officials who were self-employed high grade professionals or in management positions in public or private organizations. Social class II consisted of lower-grade professionals, administrators, officials, higher-grade technicians, and managers in small industrial establishments, supervisors of non-manual employees and armed forces employees. Social class III contained routine non-manual employees of both higher and lower grade; small proprietors such as artisans, farmers and smallholders; others who are self-employed in primary production such as farmers and fishermen; and fishery workers, lower-grade technicians, supervisors of manual workers and skilled, semi-skilled and unskilled manual workers [19–23]. Annual household income was based on self-reported total income of the household and was dichotomized at the median income of the total sample [
