Abstract
Objectives:
To investigate the association between clinical/sociodemographic factors and labor market attachment, and to estimate employment probability 2 years after colorectal cancer (CRC) surgery.
Background:
A rising prevalence of younger CRC survivors commands a stronger focus on labor market attachment. The association between clinical factors like type of surgery and CRC survivors’ labor market attachment remains poorly investigated.
Methods:
National registries provided information on employment status and clinical/sociodemographic variables for all 20- to 60-year-old CRC patients without previous cancer diagnosed in Denmark from 2001 to 2014, undergoing surgery and being attached to the labor market. Associations between clinical/sociodemographic factors and labor market attachment were investigated in multiple logistic regression analyses.
Results:
A total of 5755 CRC patients were included. Two years after surgery, 59.7% were working. Factors significantly associated with a higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower Union for International Cancer Control stage, and undergoing surgery in the most recent of four time-periods. Two years after undergoing surgery, the probability of working was significantly higher for left-sided than for right-sided colon resections, higher for low anterior resection (LAR)/high tumor than for LAR/low tumor, and higher for abdominoperineal resection than for Hartmann’s procedure. Of the 4798 (86.8%) patients alive 2 years after surgery, 68.8% were working, 7.8% had retired, whereas 23.4% were on temporary benefits, sick leave, or disability pension.
Conclusions:
Clinical/sociodemographic factors were associated with the probability of working 2 years after surgery. This knowledge can be used to inform patients and target interventions towards patients with low post-CRC probability of working.
Mini-abstract: This population-based study included 5755 Danish patients with CRC. Two years after surgery, 59.7% were working. Factors associated with higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at time of diagnosis, low cancer stage, and undergoing a left-sided colon resection or a LAR for a tumor located >10cm.
INTRODUCTION
With an estimated incidence of 1.8 million in 2018, colorectal cancer (CRC) is the third most common cancer worldwide.1 Because close to 1 of 3 CRC patients is diagnosed before the age of 65, the disease ranks second in the working population.2–4 In developed countries, the population of working age CRC survivors is expected to increase further for several reasons: (a) the retirement age is rising in many countries,5 (b) screening for CRC lowers the mean age at diagnosis and improves survival,6 (d) the incidence of CRC among young adults is increasing,7,8 and (d) improvements in the treatment of CRC lead to increased survival rates – particularly in the younger part of the population.9
Although it is positive that improvements in treatment strategies for CRC have significantly increased survival rates during the past decades, the use of extensive surgery and chemo-/radiotherapy comes at a cost. Because CRC is a life-threatening disease that commands intrusive treatment, a large proportion of CRC survivors suffer from a wide spectrum of late sequelae in the years after treatment. The most commonly reported sequelae are bowel, urinary, and sexual dysfunction, stoma-related problems, fatigue, pain, depression, anxiety, and fear of cancer recurrence, all of which have a negative effect on patients’ quality of life (QoL).10–12 The type and severity of late sequelae depend on a number of factors, most importantly the type of surgery and the use of neoadjuvant radiotherapy. It is well documented that late sequelae severely impact health-related QoL,13–15 and we may therefore reasonably assume that such problems may also interfere with labor market attachment and work ability after ending cancer treatment.
Maintaining or regaining the ability to work is considered a sign of successful rehabilitation by patients and professionals alike.16 From a patient’s perspective, being able to work after a CRC diagnosis is important, not just for the patient’s financial situation, but also because working has a positive impact on self-concept, self-esteem, life roles, satisfaction,17 and health-related QoL.18 Furthermore, it is of major societal interest that a high proportion of patients return to work.
Thus, it is crucial to obtain more knowledge about factors associated with labor market attachment after finalized CRC treatment.
Based on previous studies of labor market attachment and late sequelae after CRC surgery, we hypothesized that the probability of working 2 years after CRC surgery is positively associated with male gender, young age, high educational level, low tumor stage, no comorbidity, and undergoing left-sided colon resection.
Aim
The aim of this study was to investigate the association between clinical/sociodemographic factors and working 2 years after surgery and to estimate the employment probability 2 years after CRC surgery.
METHODS
Study Design and Population
The inclusion criteria in this population-based register study were first-time CRC, no previous cancer diagnosis, 20 to 60 years of age at the time of diagnosis, diagnosed with CRC according to the ICD-10 classification system19 between May 1, 2001 and December 31, 2014, and registered in the Danish Cancer Registry (CAR). In CAR, all incident cancer patients diagnosed in Denmark have been registered systematically since 1943.20
Clinical data were linked using the national clinical database of the Danish Colorectal Cancer Group (DCCG), which includes >95% of patients in Denmark with a first-time CRC.21 The database was recently validated, and the authors found very high data completeness and quality of the variables included in this study.22
Moreover, data from Statistics Denmark (STD), the Danish National Patient Register (DNPR),23 and The Danish Register for Evaluation of Marginalization (DREAM)24 were linked to the cohort.
DNPR contains detailed clinical and administrative data from all Danish non-psychiatric hospitals since 1977 and from psychiatric inpatients, emergency rooms, and outpatient specialty clinics since 1995. For each patient contact, the primary- and possible secondary diagnoses are entered according to the International Classification of Diseases (ICD) system.25 The positive predictive value of ICD-10 coding in DNPR for the 19 Charlson Comorbidity Index conditions has proven to be very high (98%).26
DREAM provides weekly information on all public transfer payments, such as compensation benefits for sick leave, unemployment benefits, and disability pension.24 Data from DREAM have previously been validated against workplace-registered data on sick leave27 and self-reported information on the type of income.24 Both studies found DREAM to provide highly valid data.
The study population comprised patients having undergone resection or local excision of a CRC who were part of the labor market at the time of surgery (either working, on unemployment benefits, in the flexible job, or receiving sick leave benefits or temporary benefits), ie, they did not receive disability pension or public pension.
In Denmark, the age of public retirement pension is 65 years for people born before 1954. The public retirement age for people born the following 13 years is stepwise increasing to 69 years. During the study period, early retirement pay was an option for a subgroup of Danes from the age of 60 for people born before 1954, and stepwise increasing to 65 years for people born during the following 10 years. Disability pension was possible from the age of 18.
To ensure a high validity of the dataset, we excluded patients for whom data from CAR and the DCCG showed major inconsistencies. Thus, patients were excluded from the analyses if the date of diagnosis in CAR and the DCCG differed by more than 90 days, or if the date of surgery registered in the DCCG was more than 90 days before or more than 365 days after the date of diagnosis registered in CAR. Moreover, we excluded patients not registered in the DCCG and patients for whom no information was available about the level of education or Union for International Cancer Control (UICC) stage. Since a UICC stage cannot be generated for local excisions, this group of patients was not excluded due to the missing UICC stage. Still, they were not included in the multivariate logistic regression due to the low number of patients and the lack of UICC stage. The local excision group is interesting due to the less invasive treatment they undergo despite the malignant diagnosis. Therefore, they were not excluded from the study as we wished to explore the hypothesis that this group would have the highest probability of working.
All data were linked via the patient’s unique personal identification number, which is used as a common identifier across all Danish government services.
Exposures
Patients were categorized into 7 groups according to the following surgical procedures: local excision, left-sided colon resection, right-sided colon resection (including resection of the transverse colon), abdominoperineal resection (APR), Hartmann’s procedure (including sigmoid resection with permanent colostomy), low anterior resection (LAR) for a tumor located 0 to 10 cm from the anal verge (low) or a tumor located >10 to 15 cm from the anal verge (high). The two latter groups were generated as proxies for total mesorectal excision (TME) and partial mesorectal excision (PME), respectively, as information on TME/PME was not available in the DCCG database. These two groups will be referred to below as “low LAR” and “high LAR.” The local excision group consists of transanal local excisions and polypectomies with a histopathologically confirmed adenocarcinoma. Only patients with very early tumors are treated by local excision alone, eg, a small focus of adenocarcinoma in a radically resected polyp, with no adverse features.
UICC stage was categorized as stages 1, 2, 3, or 4. Comorbidity was categorized as 0 or ≥1 based on the Charlson Comorbidity Index (CCI)28 for a period of 5 years before the CRC diagnosis using data from the DNPR.26 Highest completed education at the time of diagnosis was divided into 5 categories based on data from the STD.
In Denmark, the employer pays the sick-listed employee’s wages during the first part of the sick leave period, called “the employer period.” This sick leave is not registered in DREAM. The employer period increased several times during the follow-up period; from 15 days in 2001 to 30 days at the end of follow-up in 2017. To align “employer periods” in this study, periods of sick leave of more than 4 weeks were categorized as sick leave, whereas periods of sick leave shorter than 4 weeks were categorized as working.
Employment status 2 weeks before diagnosis was registered and categorized as (a) working, (b) sick leave benefits, and (c) temporary benefits (social benefits that are given temporarily aiming at promoting subsequent employment). Working was defined as receiving no social transfer income. However, people receiving unemployment benefits or flexible job compensation were categorized as working, because they were considered either fit for duty but not currently having a job, or having a reduced ability to work, ie, they were available for the labor market.
Moreover, gender and age were included as covariates. Age was categorized into five groups (20–40,41–45, 46–50, 51–55, 56–60). The youngest age group has a wider range than the others due to the low number of patients diagnosed before the age of 41.
A priori, we defined four equal time periods of surgery. This number of periods was chosen to have enough categories to investigate the impact of time, without taking up too much space in the multiple logistic regression model, as the main focus of this study was not on time trends.
Outcomes
The primary outcome was working (yes/no) 2 years (104 weeks) after surgery based on data from DREAM. Working was defined as described above.
The outcome was measured 2 years after surgery as the duration of the CRC treatment pathway varies significantly between patient groups, mainly due to differences in preoperative and/or postoperative oncological treatment and the need for a temporary diverting stoma. Therefore, it was considered important to allow enough time for all patient groups to recover and reach a steady state. On the other hand, the time period was kept as short as possible to decrease the impact of other potential risk factors on the results.
Statistical Analyses
Clinical and sociodemographic variables are presented for all patients, including those undergoing local excision, but this group was not included in any comparative analyses mainly because data on UICC stage, in general, were missing and the total number of patients in this group was small. Initially, patients were compared according to the surgical procedure in relation to clinical and sociodemographic variables by means of Chi-square tests. Next, multiple logistic regression analyses were performed to investigate the association between clinical and sociodemographic variables and working 2 years after surgery. Patients diagnosed after surgery (n = 84) were excluded from these analyses since baseline employment status, which was registered 2 weeks before the diagnosis, was likely to be affected by their cancer treatment.
To explore the effect of the long inclusion period, 2 multiple logistic regression models were analyzed; the first without time-period of surgery (“adjusted model 1”), the second with the time-period included as a covariate (“adjusted model 2 incl. time period”). All point estimates are presented with 95% confidence intervals (CIs). A two-sided probability of P < 0.05 was considered statistically significant.
Since the employment probability 2 years after CRC surgery varies greatly depending on the covariates, the interpretation of the odds ratios (ORs) can be difficult to transform into probabilities. Therefore, tables facilitating the calculation of probabilities based on ORs from the logistic regression analysis (adjusted model 2 incl. time period) are presented in two tables in the appendix. Table A1, see http://links.lww.com/AOSO/A99 presents the employment probability 2 years after CRC surgery for a reference person: a 46- to 50-year-old woman with a primary/high school education without comorbidities, at work 2 weeks before diagnosis and surgery in the last period (2011–2015). The probabilities are presented for all combinations of UICC stage and CRC surgery types. Table A2, see http://links.lww.com/AOSO/A99 shows the change in employment probability 2 years after CRC surgery for patients who differ from the reference person in one or more of the variables age, gender, education, comorbidity, and employment status 2 weeks before diagnosis. Time-period is not included in Table A2, see http://links.lww.com/AOSO/A99 since the latest period is considered most valid for the calculation of predicted probabilities for current/future patients.
The 2-year survival and employment status (proportions) were calculated per time-period of surgery and per type of surgery group.
Stata version MP 16.1 was used as statistical software.
Ethics
The study was registered in the Central Denmark Region’s register of research projects (no. 1-16-02-971-17). All personal identifiers were removed from the dataset by STD.
RESULTS
In CAR, we identified 9705 CRC patients in the age group 20 to 60 years diagnosed with CRC between May 1, 2001 and December 31, 2014 (Fig. 1). A total of 2832 of those were not included in the study population as they were either not part of the labor market at the time of surgery or had not undergone surgery for CRC. Among the remaining 6873 eligible patients, 1118 patients were excluded for the reasons listed in Figure 1. Thus, the inclusion rate was 83.7%. The study population consisted of 5755 CRC patients of whom 3302 were colon cancer patients and 2453 rectal cancer patients.
FIGURE 1.
Flowchart of the study population.
The mean (SD) age of the study population was 53.3 (6.37) years, 43.1 % were 56 to 60 years old, and 55.9% were men (Table 1). Close to 1 of 3 of the included patients underwent left-sided colon resection (30%), whereas only 2.5% underwent local excision. The 2 colon resection groups consisted of colon cancer patients and the 2 LAR groups of rectal cancer patients. The APR group consisted of 608 rectal- and 2 colon cancer patients, the Hartmann’s procedure group of 179 rectal- and 237 colon cancer patients, and the local excision group of 67 rectal- and 75 colon cancer patients.
TABLE 1.
Baseline Characteristics of Patients According to Surgical Procedure (n = 5755)
| Total | Left-sided Colon Resection | Right-sided Colon Resection | APR | Hartmann | Low LAR | High LAR | P * | Local Excision | |
|---|---|---|---|---|---|---|---|---|---|
| All, n (%) | 5613 | 1726 | 1262 | 610 | 416 | 862 | 737 | 142 | |
| Age | |||||||||
| 20–40 | 313 (5.6) | 76 (4.4) | 99 (7.8) | 35 (5.7) | 23 (5.5) | 46 (5.3) | 34 (4.6) | 0.003 | 18 (12.7) |
| 41–45 | 410 (7.3) | 128 (7.4) | 93 (7.4) | 45 (7.4) | 27 (6.5) | 73 (8.5) | 44 (6.0) | ||
| 46–50 | 887 (15.8) | 278 (16.1) | 196 (15.5) | 96 (15.7) | 59 (14.2) | 127 (14.7) | 131 (17.8) | 15 (10.6) | |
| 51–55 | 1583 (28.2) | 508 (29.4) | 328 (26.0) | 173 (28.4) | 126 (30.3) | 223 (25.9) | 225 (30.5) | 47 (33.1) | |
| 56–60 | 2420 (43.1) | 736 (42.6) | 546 (43.3) | 261 (42.8) | 181 (43.5) | 393 (45.6) | 303 (41.1) | 62 (43.7) | |
| Gender, n (%) | |||||||||
| Female | 2478 (44.2) | 870 (50.4) | 587 (46.5) | 202 (33.1) | 172 (41.4) | 337 (39.1) | 310 (42.1) | <0.001 | 63 (44.4) |
| Male | 3,135 (55.9) | 856 (49.6) | 675 (53.5) | 408 (66.9) | 244 (58.7) | 525 (60.9) | 427 (57.9) | 79 (55.6) | |
| Education, n (%) | |||||||||
| Primary and high school | 1557 (27.7) | 447 (25.9) | 375 (29.7) | 196 (32.1) | 124 (29.8) | 235 (27.3) | 180 (24.4) | 0.007 | 33 (23.2) |
| Vocational education | 2445 (43.6) | 766 (44.4) | 513 (40.7) | 265 (43.4) | 186 (44.7) | 375 (43.5) | 340 (46.1) | 75 (52.8)† | |
| Short further education | 278 (5.0) | 87 (5.0) | 64 (5.1) | 36 (5.9) | 18 (4.3) | 47 (5.5) | 26 (3.5) | ||
| Bachelor education | 937 (16.7) | 283 (16.4) | 219 (17.4) | 76 (12.5) | 63 (15.1) | 155 (18.0) | 141 (19.1) | 34 (23.9)† | |
| Long further education | 396 (7.1) | 143 (8.3) | 91 (7.2) | 37 (6.1) | 25 (6.0) | 50 (5.8) | 50 (6.8) | ||
| Comorbidity, n (%) | |||||||||
| 0 | 5218 (93.0) | 1614 (93.5) | 1151 (91.2) | 564 (92.5) | 380 (91.4) | 815 (94.6) | 698 (94.7) | 0.002 | 132 (93.0) |
| 1+ | 395 (7.0) | 112 (6.5) | 111 (8.8) | 46 (7.5) | 36 (8.7) | 47 (5.5) | 39 (5.3) | 10 (7.0) | |
| Employment status at diagnosis, n (%) | |||||||||
| Working | 420 (77.0) | 1341 (77.7) | 916 (72.6) | 461 (75.6) | 315 (75.7) | 704 (81.7) | 583 (79.1) | <0.001 | 112 (78.9) |
| Sick leave benefits | 975 (17.4) | 301 (17.4) | 266 (21.1) | 100 (16.4) | 69 (16.6) | 122 (14.2) | 117 (15.9) | 30 (21.1) | |
| Temporary benefits | 318 (5.7) | 84 (4.9) | 80 (6.3) | 49 (8.0) | 32 (7.7) | 364 (4.2) | 37 (5.0) | ||
| UICC stadium, n (%) | |||||||||
| 1 | 926 (16.5) | 267 (15.5) | 96 (7.6) | 164 (26.9) | 22 (5.3) | 244 (28.3) | 133 (18.1) | <0.001 | N.A.‡ |
| 2 | 1692 (30.1) | 537 (31.1) | 410 (32.5) | 171 (28.0) | 101 (24.3) | 237 (27.5) | 236 (32.0) | N.A.‡ | |
| 3 | 1910 (34.0) | 595 (34.5) | 426 (33.8) | 201 (33.0) | 125 (30.1) | 286 (33.2) | 277 (37.6) | N.A.‡ | |
| 4 | 1085 (19.3) | 327 (19.0) | 330 (26.2) | 74 (12.1) | 168 (40.4) | 95 (11.0) | 91 (12.4) | N.A.‡ | |
| Operation period, n (%) | |||||||||
| May 3, 2001–November 2, 2004 | 1359 (24.2) | 397 (23.0) | 317 (25.1) | 142 (23.3) | 132 (31.7) | 190 (22.0) | 181 (24.6) | 0.07 | 31 (21.8) |
| November 3, 2004–May 2, 2008 | 1585 (28.2) | 499 (28.9) | 346 (27.4) | 173 (28.4) | 116 (27.9) | 236 (27.4) | 215 (29.2) | 38 (26.8) | |
| May 3, 2008–November 3, 2011 | 1346 (24.0) | 403 (23.4) | 308 (24.4) | 144 (23.6) | 88 (21.2) | 229 (26.6) | 174 (23.6) | 25 (17.6) | |
| November 4, 2011–May 6, 2015 | 1323 (23.6) | 427 (24.7) | 291 (23.1) | 151 (24.8) | 80 (19.2) | 207 (24.0) | 167 (22.7) | 48 (33.8) |
Local excisions are not included in the statistical tests.
*Chi2 test,
†Cells are merged if <10 observations in a single cell,
‡UICC stadium not applicable for local excisions.
Apart time-period of surgery, all of the included variables varied significantly across the surgery groups.
The Association Between Clinical/Sociodemographic Factors and Labor Market Attachment
As shown in Table 2, the proportion of patients working varied significantly between the groups for each of the included covariates. Two years after CRC surgery, 57.5% of women and 61.4% of men were working. Among patients with only primary or high school education, 53.4% were working after 2 years, whereas the corresponding proportion was 75.3% for patients with a long further education. Only 23.7% of the patients on temporary benefits before diagnosis were working 2 years later, whereas 65.8% of those who were working before diagnosis, were working 2 years later. Also, the proportion of patients working varied with cancer stage and +/– comorbidity, ranging from 25.0% (stage 4) to 74.2% (stage 1), and from 48.7% (+ comorbidity) to 60.5% (– comorbidity). Moreover, the proportion of patients working after 2 years varied depending on type of surgery, ranging from 38.1% of patients in the Hartmann’s procedure group to 68.0% of patients who had a LAR for a high tumor. Finally, the proportion of patients working increased with time, from 56.9% in the first period (2001–2004) to 66.7% in the last period (2011–2015).
Table 2.
Associations (OR) Between Sociodemographic and Clinical Variables and Working 2 Years After Surgery (n = 5529)
| Working, n (%) | Crude, OR (CI) | Adjusted Model 1, OR (CI) | Adjusted Model 2, OR (CI) | |
|---|---|---|---|---|
| All | 3300 (59.7) | |||
| Age | ||||
| 20–40 | 171 (55.7) | 0.61 (0.46–0.79) | 0.73 (0.54–1.00) | 0.75 (0.55–1.02) |
| 41–45 | 260 (64.7) | 0.88 (0.69–1.13) | 0.92 (0.69–1.22) | 0.94 (0.71–1.26) |
| 46–50 | 586 (67.5) | Ref | Ref | Ref |
| 51–55 | 990 (63.1) | 0.82 (0.69–0.98) | 0.78 (0.64–0.95) | 0.80 (0.65–0.97) |
| 56–60 | 1293 (54.3) | 0.57 (0.48–0.67) | 0.48 (0.40–0.58) | 0.49 (0.41–0.59) |
| Gender | ||||
| Female | 1400 (57.5) | Ref | Ref | Ref |
| Male | 1900 (61.4) | 1.18 (1.06–1.31) | 1.23 (1.09–1.40) | 1.23 (1.09–1.40) |
| Education | ||||
| Primary and high school | 820 (53.4) | Ref | Ref | Ref |
| Vocational education | 1398 (58.1) | 1.21 (1.06–1.38) | 1.18 (1.02–1.37) | 1.18 (1.02–1.36) |
| Short further education | 183 (67.8) | 1.84 (1.40–2.42) | 1.74 (1.28–2.37) | 1.69 (1.24–2.30) |
| Bachelor education | 604 (65.5) | 1.66 (1.40–1.97) | 1.70 (1.41–2.06) | 1.69 (1.39–2.05) |
| Long further education | 295 (75.3) | 2.66 (2.07–3.42) | 2.52 (1.90–3.34) | 2.50 (1.88–3.32) |
| Comorbidity | ||||
| 0 | 3112 (60.5) | Ref | Ref | Ref |
| 1+ | 118 (48.7) | 0.62 (0.50–0.76) | 0.70 (0.56–0.89) | 0.70 (0.55–0.88) |
| Employment status at diagnosis | ||||
| Working | 2,827 (65.8) | Ref | Ref | Ref |
| Sick leave benefits | 399 (43.2) | 0.40 (0.34–0.46) | 0.38 (0.33–0.45) | 0.38 (0.32–0.45) |
| Temporary benefits | 74 (23.7) | 0.16 (0.12–0.21) | 0.14 (0.10–0.18) | 0.13 (0.10–0.18) |
| UICC stadium | ||||
| 1 | 677 (74.2) | Ref | Ref | Ref |
| 2 | 1184 (70.8) | 0.84 (0.70–1.01) | 0.86 (0.71–1.05) | 0.88 (0.72–1.07) |
| 3 | 1174 (62.3) | 0.57 (0.48–0.68) | 0.54 (0.45–0.65) | 0.55 (0.45–0.66) |
| 4 | 265 (25.0) | 0.12 (0.09–0.14) | 0.10 (0.08–0.13) | 0.10 (0.08–0.13) |
| Type of surgery | ||||
| Left-sided colon resection | 1075 (63.6) | Ref | Ref | Ref |
| Right-sided colon resection | 674 (54.6) | 0.69 (0.59–0.80) | 0.81 (0.68–0.96) | 0.81 (0.68–0.96) |
| APR | 349 (57.3) | 0.77 (0.64–0.93) | 0.65 (0.53–0.81) | 0.66 (0.53–0.81) |
| Hartmann’s procedure | 155 (38.1) | 0.35 (0.28–0.44) | 0.47 (0.37–0.61) | 0.48 (0.37–0.62) |
| Low LAR | 549 (64.1) | 1.02 (0.86–1.21) | 0.79 (0.65–0.96) | 0.79 (0.65–0.96) |
| High LAR | 498 (68.0) | 1.22 (1.01–1.46) | 1.06 (0.86–1.30) | 1.08 (0.88–1.32) |
| Period of surgery | ||||
| May 3, 2001–November 2, 2004 | 763 (56.9) | Ref | – | Ref |
| November 3, 2004–May 2, 2008 | 862 (55.3) | 0.94 (0.81–1.09) | – | 1.05 (0.89–1.24) |
| May 3, 2008–November 3, 2011 | 801 (60.8) | 1.18 (1.01–1.37) | – | 1.25 (1.05–1.49) |
| November 4, 2011–May 6, 2015 | 874 (66.7) | 1.52 (1.30–1.78) | – | 1.58 (1.32–1.89) |
| Odds for a reference patient | 5.16 (3.94–6.76) | 4.23 (3.16–5.66) |
OR, odds ratio; Patients with local excision (n = 142) and patients who were diagnosed after surgery (n = 84) not included.
Multiple logistic regression analyses (Table 2) revealed that factors associated with higher employment probability 2 years after surgery were male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower cancer stage, and undergoing surgery in the most recent time-period. A nonlinear association between age-group and the probability of working 2 years after surgery was found. The probability increased from the youngest group to the 41 to 45 years old patient and increased furthermore to the 46 to 50 years old patients, which had the highest estimated probability. The probability decreased to the 51 to 55 years old patients and decreased furthermore to the oldest group (56–60 years) which had the lowest estimated probability.
Type of surgery was also associated with the probability of working 2 years after surgery. As shown in Table 2, patients undergoing right-sided colon resection had a lower probability of working than patients undergoing left-sided colon resection (OR 0.81 (0.68–0.96)).
Further multiple logistic regression analyses showed that patients in the ”low LAR” group had a lower probability of working 2 years after surgery than those in the “high LAR” group (OR 0.74 (0.58–0.93)). No statistically significant difference was found between the “low LAR” group and the APR group (OR 1.20 (0.95–1.52)), whereas the “low LAR” group had a higher employment probability than patients in the Hartmann’s procedure group (OR 1.65 (1.25–2.17)). Finally, patients in the APR group had a higher probability of working than patients in the Hartmann’s procedure group (OR 1.37 (1.02–1.83)) (data not shown in Table 2). Because the estimates in the adjusted model 1 and adjusted model 2 incl. time period in Table 2 are similar, the Period of Surgery is not considered a confounder in this analysis.
Patients who had a local excision were not included in the multiple logistic regression analysis, Table 2. However, 73.8% of patients in this group were working after 2 years; thus, they had a higher employment probability than patients undergoing any other type of surgery. Compared with left-sided colon resection patients, the local excision group’s crude OR for working 2 years after surgery was 1.64 (1.11–2.41).
As ORs are difficult to interpret and communicate, and most often useless in communication with patients, a translation of OR into probabilities is provided in Table A1/A2, see http://links.lww.com/AOSO/A99. The tables facilitate the calculation of the probability of working 2 years after surgery for a patient with a specific combination of risk factors. Also, a few examples of how to conduct the calculation are provided.
Survivors’ Employment Status
Of the 4.798 (86.8%) patients alive 2 years after surgery, 68.8% were working and 7.8% had retired, whereas the remaining 23.4% were on temporary benefits, sick leave, or disability pension (Table 3). The mortality rate decreased considerably during the 14-year period, as 17.7% of patients undergoing surgery in the first time-period (May 2001–November 2004) had died 2 years after surgery, whereas this proportion was only 8.2% in the most recent period (November 2011–May 2015). Also, the employment status among survivors varied depending on in which time-period the patients underwent surgery (Table 3). Between the first and the last period, the proportion of patients on disability pension dropped from 7.7% to 3.0%, and the proportion of patients on public pension dropped from 9.5% to 4.7%. Inversely, the proportion of patients on temporary benefits increased from 3.3% to 6.7%.
TABLE 3.
Employment Status Among Survivors 2 Years After Surgery Related to Time-period of Surgery
| Total, n = 5.529 | Time-period of Surgery | Complete Period | |||
|---|---|---|---|---|---|
| May 3, 2001–November 2, 2004 | November 3, 2004–May 2, 2008 | May 3, 2008–November 3, 2011 | November 4, 2011–May 6, 2015 | May 3, 2001–May 6, 2015 | |
| All patients | 1342 | 1559 | 1318 | 1310 | 5529 |
| Alive | 1104 (82.3) | 1316 (84.4) | 1175 (89.1) | 1203 (91.8) | 4798 (86.8) |
| Dead | 238 (17.7) | 243 (15.6) | 143 (10.9) | 107 (8.2) | 731 (13.2) |
| Survivors | 1104 | 1316 | 1175 | 1203 | 4798 |
| Working | 763 (69.1) | 862 (65.5) | 801 (68.2) | 874 (72.7) | 3300 (68.8) |
| Public pension* | 105 (9.5) | 124 (9.4) | 89 (7.6) | 57 (4.7) | 375 (7.8) |
| Sick leave | 115 (10.4) | 178 (13.5) | 141 (12.0) | 155 (12.9) | 589 (12.3) |
| Disability pension | 85 (7.7) | 103 (7.8) | 68 (5.8) | 36 (3.0) | 292 (6.1) |
| Temporary benefits | 36 (3.3) | 49 (3.7) | 76 (6.5) | 81 (6.7) | 242 (5.0) |
*Including emigration (n = 4). Patients with local excision (n = 142) and patients who were diagnosed after surgery (n = 84) not included.
Mortality varied significantly across type-of-surgery groups as shown in Table 4. Among survivors, the proportion of patients working 2 years after surgery ranged from 68.4% to 72.1% in the four groups undergoing colon resection or LAR. However, among patients with a permanent colostomy, the employment probability was only 58.8% after 2 years.
TABLE 4.
Distribution of Dead/Alive, and Working/Not Working Among Survivors 2 Years After Surgery per Type-of-Surgery Group (n = 5.529)
| Left-sided Colon Resection, n (%) | Right-sided Colon Resection, n (%) | APR, n (%) | Hartmann’s Procedure, n (%) | Low LAR, n (%) | High LAR, n (%) | |
|---|---|---|---|---|---|---|
| All patients, N | 1690 | 1235 | 609 | 407 | 856 | 732 |
| Alive, n (%) | 1501 (88.8) | 946 (76.6) | 561 (92.1) | 296 (72.7) | 803 (93.8) | 691 (94.4) |
| Dead, n (%) | 189 (11.2) | 289 (23.4) | 48 (7.9) | 111 (27.3) | 53 (6.2) | 41 (5.6) |
| Survivors, N | 1501 | 946 | 561 | 296 | 803 | 691 |
| Working, n (%) | 1075 (71.6) | 674 (71.3) | 349 (62.2) | 155 (52.4) | 549 (68.4) | 498 (72.1) |
| Not working, n (%) | 426 (28.4) | 272 (28.7) | 212 (37.8) | 141 (47.6) | 254 (31.6) | 193 (27.9) |
Patients with local excision (n = 142) and patients who were diagnosed after surgery (n = 84) not included.
DISCUSSION
In this population-based register study, we investigated attachment to the labor market 2 years after surgery for CRC. Data from 5755 Danish CRC patients were included, and the results showed that among resected patients, 59.7% were working 2 years after surgery. Factors associated with a higher probability of working 2 years after surgery were age group 46 to 50 years, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower cancer stage, undergoing LAR for a high tumor, and undergoing surgery in the most recent time-period. Among survivors, 68.8% were working 2 years after surgery and 7.8% had retired, whereas the remaining 23.4% were on temporary benefits, sick leave, or disability pension.
Overall, our results on the probability of working 2 years after CRC surgery were similar to those reported in previous studies. These studies have reported that 60 to 70% of CRC patients of the working-age are working 12/24 months after surgery.29–33
No previous study has investigated the association between working 2 years after surgery and clinical exposures, such as type of surgery, in a large population-based cohort of both colon and rectal cancer patients, as done in this study.
Other studies have found that labor market participation is affected among cancer patients in general34 and among CRC patients in particular.30,33,35–39 Several prognostic factors have been investigated in cohorts of CRC patients, but the vast majority of individual factors were investigated in only 1 or 2 studies. Previous studies have shown, that (Neo)adjuvant therapy, higher age, low educational level, and comorbidity impact labor market attachment negatively; whereas unemployment, extensive surgical resection, and postoperative complications increase the risk of work disability.38,40 Furthermore, return to work is impaired by the presence of metastases, emotional distress, postoperative complications, part-time employment at baseline, and being employed in a large company.33,41
Although statistically significant associations between working 2 years after surgery and a number of sociodemographic and clinical factors were found in this study, the main reasons why 1 in 3 CRC survivors had not resumed work after 2 years, can only be hypothesized. A possible important barrier may be, that a large proportion of CRC patients suffer from long-term bowel dysfunction severely impacting their QoL13,14,42 and that such problems also may impact the patients’ ability to work.43 This hypothesis fits well with our results, showing that patients in the “high LAR” group had a higher probability of working compared with the “low LAR group” which can be explained by a significantly higher prevalence of severe bowel dysfunction in the latter group.44 Also, we found that patients who had a left-sided colon resection had a higher probability of working compared with patients who had a right-sided colon resection, which may be due to the higher prevalence of chronic diarrhea in the latter group.14 Although “low LAR” vs. APR was not statistically significantly different the adjusted ORs showed that patients with a permanent colostomy had a lower probability of working compared with the other types of surgery. This finding might be explained by physical as well as psychosocial stoma-related problems, which can severely affect patients’ QoL and workability.12,33,45 Although an older Cochrane review found no clear difference in QoL between rectal cancer patients with or without a permanent stoma,46 one should bear in mind, that the present study investigated a rather young CRC population. Younger patients may be more affected by a stoma than older patients in many ways, and having a stoma can be challenging in the process of returning to work, both physically, mentally, and socially.45,47 Among patients with a permanent colostomy, we found that those undergoing a Hartmann’s procedure had a lower employment probability compared with the APR patients. This is probably due to the fact that in Denmark, a Hartmann’s procedure is primarily chosen in more fragile patients with a higher number of comorbidities, which is clearly reflected in the much higher mortality rate in the Hartmann’s group compared with the APR group (27.3% vs. 7.9%, Table 4). Future studies must investigate this hypothesis, and whether stoma patients, in general, need tailored support in the return-to-work process.
Although the difference was minor, we also found that the probability for working 2 years after surgery was lower for females than for males, which may be explained by variation in work-related factors like job types, tasks, and income level, but possibly also differences in the impact working can have on the individual’s self-concept and self-esteem.17
The long-term sequelae many patients experience after CRC treatment is not common knowledge for all stakeholders involved in supporting cancer patients in returning to work. Because many of the potential functional problems might be perceived as “private” and shameful, they might not be mentioned by the patients themselves. Hence, potential bowel dysfunction, chronic pain, or other possible long-term side effects may not be taken into account by counselors at the employment service offices. This could be another barrier to returning to the workforce for CRC survivors. Moreover, patients often report that information on return to work from healthcare professionals is limited or they receive conflicting advice.40,48 They also underline the importance of communication with the workplace manager and colleagues, and receiving work adjustments.49 A deeper understanding of barriers and facilitators is crucial to fully understand CRC patients’ return to work prognosis and to be able to design effective interventions preventing patients from dropping out of the job market. Therefore, the above-mentioned hypotheses and questions must be investigated in future appropriately designed studies.
The major strengths of this study were its population-based design, a high number of included patients, a high inclusion rate (83.7%), broad inclusion criteria, and use of highly valid data from several Danish registries linked by the unique personal identification number; all decreasing the risk of bias. Among the limitations of our study was the lack of information regarding oncological treatment. Unfortunately, such information was not available in a valid format. Furthermore, we had no information about the possible health-related causes for not working 2 years after having undergone surgery; such reasons could include relapse or new cancer. In addition, a major limitation was that only patients diagnosed up until 2014 were included. We saw a trend towards a higher probability for working over time, but we can only speculate whether this trend will continue. Since 2014, the use of minimally invasive surgery has increased significantly, accounting for >90% of the CRC procedures performed in Denmark in 2020.50 Hypothetically, this may have led to fewer complications, faster recovery, and less long-term sequelae. In addition, reforms aiming at restricting the access to disability pension and sickness benefits came into force in January 2013 and July 2014, respectively.51,52 These factors may in combination increase the probability of returning to work significantly. However, the hypotheses need to be explored in future studies including more recently treated CRC patients.
The international generalizability of this study is challenged by differences in treatment modalities, labor market conditions, public benefits, etc., across nations. Nevertheless, it is reasonable to believe that similar associations between clinical/sociodemographic factors and the ability to work after CRC treatment are present in other Scandinavian countries, and in other countries with labor market conditions similar to the Danish.
In this register-based study, we included variables available in the Danish registries, well aware that patients’ perspectives are not sufficiently covered by this design. Therefore, future studies should include patient-reported outcome measures (PROMs) to obtain detailed, in-depth knowledge regarding which factors impact labor market attachment from a patient’s perspective. Furthermore, qualitative studies have the potential to explore patients’ experiences of barriers and facilitators in the process of returning to work after CRC. Such information can support the identification of CRC patients at high risk of losing labor market attachment, and it may guide the development of focused interventions aimed at those with a need for occupational rehabilitation.
CONCLUSION
In this population-based register study of 5755 Danish CRC patients of working-age, we found that 2 years after surgery 60% of the patients were working. Several sociodemographic and clinical factors, including the type of surgery, are associated with the probability of working 2 years after surgery. Future studies should clarify if interventions are needed for patients at the highest risk of dropping out of the labor market. The efficiency of interventions supporting patients in maintaining attachment to the labor market should also be investigated.
Supplementary Material
Footnotes
Published online 22 February 2022
Disclosures: The authors declare no conflicts of interest.
Funding: The study was funded by Helsefonden (grant number 19-B-0035); Novo Nordisk Foundation (grant number 19OC0022988); Danielsensfonden (grant number 18-10-0572); and Wedellsborgs Fond (grant number 10-19-1).
T.J., S.L., N.T.A., C.V.N., T.M., and P.P. contributed substantially to the conception and design of the work. T.J., K.J.E., and P.P. contributed substantially to the acquisition of data for the work. T.J., S.L., N.T.A., and P.P. contributed substantially to the analyses and interpretation of data of the work. T.J., S.L., N.T.A., and P.P. drafted the work. All authors revised the work critically for important intellectual content. All authors gave their final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com).
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