Disparities in employment outcomes in breast cancer survivors

Victoria Blinder, MD, MScAssistant Attending

Disparities in breast cancer outcomes

• Stage at diagnosis• Survival• Morbidity• Quality of life• Employment

Quality of life after treatment for breast cancer

• Most breast cancer survivors’ quality of life recovers once treatment has been completed

– Those treated with chemotherapy and/or endocrine therapy are at higher risk of having a lower quality of life in the long term

Ganz et al, JNCI 2002

Employment after breast cancer• 70-80% return to work within one year of diagnosis

– Primarily Caucasian study populations• 20% African American

– Intermediate to high income

• Correlates of employment status– Demographic: age, race– Economic: income – Health related: cancer stage, general health

status, upper body limitations– Relationship with employer: cancer

discrimination, accommodation

Bouknight, J Clin Oncol 2006. Maunsell, J Natl Cancer Inst 2004. Satariano, Public Health Rep 1996.

Employment disparities in the general population• Ethnic disparities exist in job type, income earned, and unemployment

• African Americans more likely to be outside of or marginally attached to the labor force

• Minorities are disproportionately affected by periods of economic downturn

US Dept. of Labor

Disparities in employment after breast cancer

• Latina survivors more likely to lose jobs than non-Latina whites1

• Less acculturated Latinas more likely to miss >1 month or stop work2

– Also more likely to say work schedule not flexible and paid sick leave not available

• 60% of minority women reported accommodation compared to 90% of non-Latina whites

1. Mujahid, J Cancer Surviv 20112. Mujahid, Br Ca Res Treat 2012

Limitations of current data• A comparison arm matched for ethnicity and

its correlates is needed• Correlates of and barriers to return to work

remain undefined– Ability to obtain accommodation at work

• Eligibility for legal protection at work• Cultural constructs about authority figures• Language barriers with employer

– Access to rehabilitation services

• Little is known about other ethnic and immigrant groups

Employment and quality of life• Relationship between quality of life, income, and employment is multidirectional

Short PF et al, Med Care 2006

How might these outcomes differ by ethnic group?

Ethnic differences in employment, income, and quality of life

Income

Employment

Quality of Life

Adapted from Short et al, Med Care 2006

ETHNICITY

Breast cancer and the workforce: An exploratory qualitative study of an ethnically diverse sample

Study sample

• Focus groups of 23 breast cancer survivors who were working at time of diagnosis

• Ethnic background– African-American, African-Caribbean, Chinese,

Filipina, Latina, or non-Latina white– 61% born outside US

• Median age at diagnosis: 49 (range 27-60)• Job types

– Teacher (most common), janitor, probation officer, actress, medical technician, physician, attorney

Blinder et al. J Comm Health 2011

Results: employment outcomes

• 30% worked throughout treatment period

• 22% took ≤3 months off from work– 35% took 6-12 months off (none took

between 3 and 6 months)

• 9% retired early• 4% stopped working and eventually

started a part-time home business

Blinder et al. J Comm Health 2011

Results: focus group themes

• Normalcy– Being in control– Wellness

• Privacy– Fear of gossip, pity

• Appearance– Lack of privacy

• Stress– Schedules and

deadlines• Lack of schedule flexibility for medical appointments

• Support– Employers– Coworkers– Other BCS at work– Family

Blinder et al. J Comm Health 2011

Normalcy: getting back to normal

I didn’t want my life to be different, and all of a sudden it was. And I wanted my world to be the way it always was. I was in control. I was working. I was the main breadwinner . . . I wanted to know that I was still in charge of my office . . . And so I wanted my life to continue exactly as it was before.

(Administrative assistant)

Blinder et al. J Comm Health 2011

Privacy and normalcy

• Privacy common concern in all focus groups.

• Relationship between appearance, privacy, and normalcy

. . . under no circumstances did I want to be bombarded every day with someone saying, “How are you doing?” or “How are things going?” or “How are you feeling?” . . . so when I came to work it was just business as usual. . . They allowed me to maintain an environment when I came to work, I was able to escape a little bit from the fact that I was dealing with breast cancer and everything else . . .

(Corporate manager)

Blinder et al. J Comm Health 2011

Demands and lack of flexibility at work

It’s either you work full time or you don’t work full time . . . And I felt it would be totally unfair to try and come in and do certain things and not be able to finish it and have somebody pick it up because that’s even worse. So I just decided I just wasn’t going to work, period.

(Parole officer)Blinder et al. J Comm Health 2011

Conclusions

• Several themes emerged from study not previously identified in literature

– Normalcy, appearance, and privacy• Impact on ability to reap emotional

benefits of return to work– Role of employer in maintaining a

“normal” work environment• Accommodation previously cited as

correlate of return to work• Developed questionnaire that is now being used in a large quantitative study

Blinder et al. J Comm Health 2011

Return to work in low-income Latina and non-Latina white breast cancer survivors

Study sample

• Cohort of 290 women with new diagnosis of stage 0-III breast cancer

– Low-income (<200% poverty level)– Uninsured or underinsured (Medicaid)– Employed before diagnosis– Spoke English or Spanish

• 179 Latina; 111 non-Latina white• Telephone interviews 6, 18, and 36 months after diagnosis

Blinder et al. Cancer 2012

Employment trajectories of low-income Latina and non-Latina White breast cancer survivors who were employed prior to diagnosis

*80% rate of return to work seen in wealthier, primarily non-Latina white populations

Blinder et al. Cancer 2012

Factors associated with employment status at 18 months

• Non-Latina whites– Emotional quality of life

• Latinas– Physical and emotional quality of life

– Job type (operator/fabricator)• <5% non-Latina whites vs. 24% Latinas worked as

operators/fabricators

– Axillary lymph node dissection• Similar rates of dissection in two groups

– Different impact of procedure due to differences in lymphedema education or in access to and utilization of lymphedema services?

Blinder et al. Cancer 2012

Conclusions• Low-income women may take longer to return to work and do so at a lower rate than middle and high-income women

– Marginal financial benefit of working may not be worth the personal cost during illness

– “Low-income” may be a proxy for something else that prevents women from returning to work

• Low-income Latinas take longer to return to work than low-income non-Latina whites

– May be due to differences in job type and access to rehabilitation

Blinder et al. Cancer 2012

Early Predictors of Not Returning to Work in Low-Income Breast Cancer Survivors: A 5-Year Longitudinal Study

Study sample• 274 low-income women followed for 5 years

– Any ethnicity but English- or Spanish-speaking– Employed before diagnosis– Stage 0-III breast cancer

• Surveyed at 6, 18, 36, and 60 months• 36% returned to work by 6 months

– Additional 21%, 10%, and 5% returned to work by 18, 36, and 60 months, respectively

• 27% never went back to work

Blinder et al. Breast Cancer Res Treat. 2013

Cumulative workforce reentry

Blinder et al. Breast Cancer Res Treat. 2013

Baseline predictors of not returning to work

• Lowest annual income group (<$10,000)•≥1 comorbid condition•Receipt of chemotherapy

– Of 174 who were not working at 6 months, 43% never returned to work

– Those still undergoing chemo at 6 months were more likely to report not working at 6 months (81% vs. 55%)

• Ethnicity, job type, and education were not associated with not returning to work

Blinder et al. Breast Cancer Res Treat. 2013

Chemotherapy and cumulative workforce reentry

Blinder et al. Breast Cancer Res Treat. 2013

Conclusions• Very poor women who take time off from work during chemotherapy may have a difficult time reentering the workforce

• Low income may be proxy for workplace characteristics, such as working in informal sector

– Associated with decreased accommodation at work, lack of sick leave and disability

– Chemotherapy may have pronounced effect• Women who intend to stop working temporarily

may be at risk of exiting the workforce permanently

Blinder et al. Breast Cancer Res Treat. 2013

Breast Cancer and the Workforce: Ethnic Differences in the Impact of Breast Cancer on Employment, Financial Stability, and Quality of Life

Study summary

• Primary aim is to evaluate the impact of breast cancer on 3 outcomes in breast cancer survivors of different ethnicities

– Employment status– Financial situation– Quality of life

• Matched cohort design– Comparison arm of healthy peers– Will permit separation of the impact of

breast cancer on employment from that of general fluctuations in the economy

Schema

BREAST CANCER ARM750 patients, employed pre-cancer150 of each group: African AmericanChineseKoreanLatina Non-Latina white

COMPARISON ARM750 peers, employed150 of each group: African AmericanChineseKoreanLatina Non-Latina white

Baseline survey during treatment period*

*Or corresponding time point for peers

Follow-up survey 4 months after treatment completion*

Participating institutions• Participants recruited from medical oncology practices at MSKCC (including 5 suburban network sites) and 4 community hospitals/clinics

– The Ralph Lauren Center for Cancer Care and Prevention

– Lincoln Medical and Mental Health Center– New York Hospital Queens– Queens Medical Associates

Participant eligibility• Patients

– Age 18-65– Stage I-III breast cancer– Employed prior to diagnosis– Speak at least one study language

• English, Korean, Mandarin, or Spanish

• Peers– Employed– No history of cancer– ≤5 years older or younger than patient

nominator– Same ethnic/language group as patient

nominator

Survey administration• Survey administered in

– Study language of participant’s choice– Modality of the participant’s choice

• Computer assisted telephone interviews (CATI)• Web-based survey

• Minimize sampling bias based on– Acculturation– Literacy or education level– Amount of leisure time

Analysis• Primary analysis will compare post-treatment

employment in patients vs. peers across ethnic groups

– Will call patients annually to assess employment status for total of 3 years of follow-up

• Secondary analyses will compare post-treatment quality of life and income in patients vs. peers

• Additional analyses will identify correlates of post-treatment employment status in patients

– Employer accommodation• Self-confidence asking an employer for accommodation

– Job tasks at work• Limitations due to cancer diagnosis, lymphedema diagnosis

(or precautions)

Status of study

• 250 patients and 169 peers completed baseline survey

– 83% of patients and 79% of peers completed follow-up survey

– Almost everyone who completed a follow-up survey has been reachable for year 2 calls

• Anticipate recruitment for 3 more years

Implications

• Develop a framework for understanding the relationship between ethnicity, return to work, and quality of life

– May be applied to other malignancies• Develop ethnically sensitive interventions to facilitate return to work

– These will be evaluated in randomized controlled trials

• Possible examples– Lymphedema education– Training in workplace negotiation and self-

advocacy

Thank you

• Advisory committee– Kevin Oeffinger– Clifford Hudis– Francesca Gany– Cathy Bradley– Ethan Basch– Jennifer Griggs

• Research team– Carolyn Eberle– Sophia Chen– Angie Santiago-Zayas– Iris Miao– Julia Ramírez– Thelma McNish

• Ralph Lauren Center for Cancer Care and Prevention

• NY Hospital Queens• Lincoln Hospital and Mental

Health Center

Thank you

Study participants Funding sources• American Cancer

Society• American Society of

Clinical Oncology• National Institutes of

Health• MSKCC Survivorship

Initiative

Thank you!