Navigating job and cancer demands during treatment: A qualitative study of ovarian cancer patients

Abstract

Objective.

Our objective was to obtain perspectives from ovarian cancer patients on job demands, cancer demands, and workplace or cancer resources and strategies to manage the cancer-work interface using the cancer-work management conceptual framework.

Methods.

We recruited ovarian cancer patients receiving systemic therapy who screened positive for financial distress using Comprehensive Score for Financial Toxicity <26. Interviews were conducted with participants about their costs of care, including employment concerns. Interviews were recorded, transcribed verbatim, and analyzed by three researchers using an inductive thematic analysis.

Results.

Of 22 participants, the average age was 57 years old, 36% were Black, 68% had income <$40,000, 41% had public insurance, and 68% were being treated for recurrent disease. Job demands included decreased productivity, inability to return to work, and worry about losing a job or employer-based health insurance coverage. Cancer demands included physical and cognitive limitations due to cancer treatment and reliance on caregivers, especially for transportation. Workplace resources/strategies including having a supportive employer, modifying job responsibilities, and utilizing family medical leave. Cancer care resources/strategies included planning appointments ahead of time and utilizing resources, such as disability.

Conclusions.

Cancer care teams should consider screening patients for employment concerns; streamline care to minimize the side effects, time, and transportation demands of treatment on patients and caregivers; maximize utilization of available resources; and proactively communicate with employers to accommodate patients and caregivers who want or need to work.

1. Introduction

The impact of a cancer diagnosis and treatment on the employment of patients and their caregivers is often under-recognized. Approximately 45% of newly diagnosed cancer patients in the United States are of traditional working age (ages 20 to 64 years) [1]. Cancer patients are at risk for financial hardship due to accumulation of out-of-pocket costs and reduced income-earning ability [2]. For many, working provides psychological as well as financial benefits, including a source of income and health care benefits [3,4]. However, work limitations and reduced work hours due to symptoms of cancer or ongoing therapies are common and may even extend into survivorship [3,5,6]. Further exacerbating the impact of cancer care on employment, caregivers often need to take time off work to help patients attend their scheduled appointments or for symptom management, which can be unpredictable [7].

The cancer-work management conceptual framework describes how cancer patients balance their cancer and work demands during treatment [8]. Cancer demands are the structural, psychological, cognitive, and/or physical requirements that are expected in the role of cancer patients [8]. Job demands are the physical, psychosocial, or organizational aspects of employment that employed cancer patients must navigate [8]. We previously reported that a third of gynecologic cancer patients on active treatment had lost wages or salary or benefits due to their cancer diagnosis, with patients that screened positive for financial distress experiencing these issues at a much higher frequency than those who screened negative for financial distress (46% vs. 18%) [9]. Due to high risk of recurrences, multiple lines of systemic therapy, and the increasing use of maintenance therapy, ovarian cancer patients and their caregivers may have more prolonged cancer demands that interfere with job demands during and after treatment. However, little is known about these domains in this patient population. To address this knowledge gap, our objective was to obtain perspectives from ovarian cancer patients who were on active therapy and screened positive for financial distress about their experience on the interface of cancer demands and job demands for patients and their caregivers. We also sought to identify resources or strategies available within the cancer care and workplace system environments to mitigate these demands.

2. Methods

2.1. Study design

The current study was approved by our Institutional Review Board. We conducted semi-structured open-ended interviews with ovarian cancer patients who were receiving systemic therapy and screened positive for financial distress to assess their experience dealing with the economic consequences of their cancer diagnosis and treatment. Among one of the topics that we explored was the impact of cancer treatment on patients’ and their caregivers’ employment.

2.2. Participant eligibility

Inclusion criteria were newly diagnosed or recurrent ovarian cancer patients who were receiving systemic treatment at our single institution within the last 3 months. Participants were 18 years or older, English-speaking, and physically and mentally able to participate in a 45-min interview. After informed consent was obtained, patients were further screened for eligibility using the Comprehensive Score for Financial Toxicity (COST), an 11-item validated instrument that measures financial distress, using the threshold COST <26 [10,11]. This criterion was selected to oversample patients who were actively experiencing financial burden as evidenced by screening positive for a broad range of mild (COST 14–25), moderate (1–143, and severe financial distress (COST 0) [11]. Two of the questions in the COST instrument focus on employment concerns, including “I am frustrated that I cannot work or contribute as much as I usually do” and “I am concerned about keeping my job and income, including work at home.”

We purposefully recruited ovarian cancer patients with different characteristics, including age, race, and treatment type, to achieve maximal variation. We initially estimated the need to recruit 20–30 eligible participants to reach thematic saturation [12]. To achieve a diverse sample of interviewed patients, non-mutually exclusive goals were initially set to recruit approximately 33% of participants who were < 65 years old and 33% participants who were Black. In addition, we classified patients into three groups based on treatment type: chemotherapy alone, anti-angiogenesis targeted therapy +/− chemotherapy, and oral poly(ADP)-ribose polymerase (PARP) inhibitor. We initially set a goal to have balanced representation among these three treatment groups as we expected that patients on different treatment types may experience distinctive patterns of financial strain given differences in intensity of treatment, common side effects, and route of therapy. Goals were reviewed and adjusted as recruitment progressed based on feasibility (i.e., the proportion of potential participants ≥65 years old was lower than anticipated), emerging themes (i.e., treatment type was found to be less important than primary vs. recurrent disease), and as thematic saturation was attained based upon informational redundancy for the overall objective of assessing ovarian cancer patients’ experience dealing with the economic consequences of their cancer diagnosis and treatment [13].

2.3. Recruitment

Research assistants reviewed upcoming patient appointments in the gynecologic oncology outpatient schedule from the electronic health record to create a pre-screening log, which was then reviewed by the principal investigator. Subsequently, each patient’s gynecologic oncology provider was asked to approve contact from our research team. Research assistants approached potential participants to review and sign study consent forms with patients who were interested. Participants received a $50 gift card after completion of the interview.

2.4. Conduct of interviews

Interviewers contacted consented and eligible participants by telephone to schedule the in-person interview. Due to the COVID-19 pandemic, the format of the interviews was later changed to telephone interviews after mid-March 2020. In-person interviews were in a non-clinical setting on the UAB campus. Two trained interviewers from the UAB Recruitment and Retention Shared Facility (RRSF) conducted all the interviews. The interview guide was developed based upon findings from our prior survey on financial hardship in gynecologic cancer patients [9]. The interview guide broadly evaluated how patients experience and navigate the financial burden of their cancer care. The current study focuses upon responses to the research exploring cancer treatment impact on employment of patients and caregivers (Table 1).

Table 1.

Sample interview guide questions and probes exploring cancer treatment impact on employment of patients and caregivers.

This next question may or may not apply to you. If it does not apply to you, we will skip it.

How did your most recent ovarian cancer treatment affect your ability to work?

How did your most recent ovarian cancer treatment affect anyone in your household's ability to work?

Probe: How was your ability to work affected?

Probe: How was their (i.e., family member or loved one) ability to work affected?

Probe: Can you describe any experience you had applying for FMLA (Family & Medical Leave Act)? FMLA entitles certain employees to take unpaid, job-protected leave for family or medical reasons.

Probe: How did you (or your family member) talk to your workplace about taking time off for your cancer care?

Probe: What were challenges you (or your family member) faced when talking to your workplace about your needs related to your cancer diagnosis and medical care?

Probe: What made it easier for you (or your family member) to talk to your workplace about your needs related to your cancer diagnosis and medical care?

Can you describe any experience you had applying for disability benefits?

Probe: How did this assistance come about?

Probe: Who helped you find assistance programs?

Probe: How did this assistance program help you?

2.5. Data collection and analysis

Interviews were recorded and subsequently transcribed verbatim by an independent commercial transcription company. Transcripts were analyzed using inductive thematic analysis with NVivo 12 Plus Software (QSR International). Using a constant comparative method, three trained investigators (M.L., J.S., I.H.) independently coded original transcripts to ensure inter-coder agreement and consistency in coding. The coders met regularly to discuss the codes and emerging themes and to create a code book that was used to guide each subsequent step in analysis. Two investigators (M.L., J.S.) explored the data set with a targeted search approach for constructs of interest using the cancer-work management conceptual framework [8].

We abstracted patient characteristics from the electronic health record, including age, race (black vs. white race), insurance type (private vs. public insurance), treatment type as previously described, disease status (primary vs. recurrent disease), and time since diagnosis. Participants were surveyed for household income range at the start of the interview as this was not available from the electronic health record. COST score was calculated as part of the previously described eligibility process. Descriptive statistics, including frequency, percentage, average, median, and range were calculated for the population interviewed.

3. Results

Out of 157 patients who were screen eligible, 51 patients were approached and 46 were consented. There were 30 patients who the oncology provider requested that the study team did not contact about the current study, although we did not collect the reason for this request. Of these, 24 were eligible to enroll with COST <26 and 22 were not eligible to enroll due to COST ≥26. One participant withdrew from the study and another enrolled in hospice prior to completing their interviews. Interviews were conducted between June 2019 and April 2020, with the last five interviews conducted by phone due to the COVID-19 pandemic. Participant characteristics are summarized in Table 2. The average age was 57 years old (range 31–77). Of 22 participants, 36% were Black, 68% had an income <$40,000, 41% had public insurance, 68% were being treated for recurrent disease, and 50% were receiving chemotherapy alone. The median time since diagnosis at the time of the interview was 727 days (range 41–4062). The median COST score was 10.5 (range 0–23).

Table 2.

Characteristics of interviewed ovarian cancer participants (N=22)

Participant characteristics	Median (range) N (%)
Age (years)	57 (31–77)
Age <65 years	19 (86)
Age ≥65 years	3 (14)
White race	14 (64)
Black race	8 (36)
Annual household income
<$20K	8 (36)
$20–40K	7 (32)
$40–60K	4 (18)
$60–80K	1 (5)
$80–100K	2 (9)
Public insurance	9 (41)
Private insurance	13 (59)
Curative intent treatment	6 (27)
Palliative intent treatment	16 (73)
Treatment type
Chemotherapy	11 (50)
Targeted therapy bevacizumab +/− chemotherapy	6 (27)
Oral PARP inhibitor	5 (23)
COST* score (scale 0–44, all participants COST <26)	10.5 (0–23)

^*Comprehensive Score for Financial Toxicity

Within the constructs of job demands, cancer demands, workplace resources and strategies, and cancer care resources and strategies, we describe two emerging themes within each construct and provide illustrative quotes, which are further summarized in Table 3. Briefly, the cancer-work management framework describes job demands within the employment system and cancer demands within the cancer care system that cancer patients face [8]. Resources and strategies are available through the workplace or through cancer care, which constitute cancer-work fit, and represent how cancer patients manage the cancer-work interface [8].

Table 3.

Quotes illustrating job demands and cancer demands as well as workplace and cancer care resources or strategies to manage these demands among ovarian cancer patients experiencing financial distress during treatment

Construct 1: Job Demands	Construct 2: Cancer Demands
Theme 1: Patients noted the negative impact of cancer treatment on work productivity, promotion opportunities, and ability to return to work.	Theme 1: Patients experience significant physical and cognitive limitations due to cancer symptoms and treatment.
“Being sick at work and having to leave early sometimes, or missing the whole day, missing out on training… I have missed maybe two promotions.” [Age 42, COST score 9]	“A lot changed. I was no longer able to work. Just my whole way of living my lifestyle. Not able to do a lot of the things physically that I was able to do because I just wasn’t physically able, as far as I experienced a lot of fatigueness. So getting around was – was hard. Socialization changed, I didn’t socialize as much with people during that time especially.” [Age 57, COST score 12]
“Prior to [my cancer diagnosis], I was an ER nurse... And then I've been on disability since trying to go back to work. But every time I go back to work or try to go back full time, the cancer returns... my body canť do what it used to… So, no, I donť know if I'll ever get to go back to work. I want to because I love what I do.” [Age 44, COST score 11]	“When the… effects of the chemo had me so down where I couldnť get out of bed, [my husband] had to stay home” [Age 56, COST score 7]
Theme 2: Patients worried about job loss and loss of benefits, including employer-based health insurance coverage.	Theme 2: Patients felt psychological distress from reliance on caregivers, especially for transportation needs.
“After I was diagnosed, I did go back to work, and I worked in a maximum-security prison as a guard and slash supervisor… They would not work with me… So they more or less basically pretty much said, hey, we don’t have anywhere to put you due to your circumstance. You really need to fill out these papers and retire out.” [Age 77, COST score 20]	“I have to have someone drive me because I can’t drive now… my husband will try to take some time… if my mother is feeling well, which she has cancer also. She’ll try to bring me… and my sister, she’s let her business slide trying to bring me at times.” [Age 58, COST score 9]
“The threat, that when you come back, you donť know if you're going to have a job. [I] talked to them. But, like I said, the way they just treat you overall. All they can say is, "We canť guarantee you your job when you come back." [Age 53, COST score 10]	“'Man, I hate having to have somebody come down here and wait nine hours. You know, thaťs a long time to wait for somebody… It took my independence away from me…” [Age 54, COST score 0]
“If you're out of work, you get to keep that insurance, but you have to pay what the hospital would normally pay plus. So it was like six or eight-hundred dollars a month for me to be able to keep that on just myself” [Age 44, COST score 11]	“When you can’t do the things, it’s humiliating. I’ve always been on the other side of the fence working with my children and helping them with those things. But it sure is a lot harder being on this side now.” [Age 58, COST score 9]
Construct 3: Workplace Resources and Strategies	Construct 4: Cancer Care Resources and Strategies
Theme 1: Patients felt supportive employers and the ability to make workplace accommodations were important and that work provided meaning in their lives.	Theme 1: Patients described how they were able to make their appointment weeks in advance around their own schedule.
“Well, knowing that I have a job no matter what. They reassured me at my job that, no matter how time I need to take off, that I still have a job to come back to. And that has been a big weight lifted off my chest. And the same thing with my husband, they reassured him that any time he needs to be with me and our family.” [Age 48, COST score 21]	“If I can schedule my doctor appointments… to fall on a pay week, then that helps cushion that out-of-pocket expense where we’re coving gas, and like you said, lodging, and food, and what not, that we have to pay while we’re out. And that also really keeps us from getting in a bind. We just have to manipulate my appointments to fall on those specific days.” [Age 48, COST score 21]
“They did not really believe me. They just thought I wanted to be off work… They gave me a really hard time. I had to go to a higher office. It was embarrassing. I got mistreated a little bit, also. It was a just a very, very difficult time. I am in a new department now. They are a little bit more understanding, but it is still—I still feel that I had to miss work and I just got promoted.” [Age 42, COST score 6]	“They make my appointment usually a month ahead of time and I drive myself… I try to coordinate as many appointments on one day as possible instead of making two or three trips in a week. Sometimes… my husband also still goes to see his doctors for… We try to coordinate his appointments with mine, but sometimes that doctor’s clinic days are not the same as mine.” [Age 77, COST score 20]
“This time where I work has been more gracious, and just let me take days off… you donť get paid. This time, now I still…. They just gave me a laptop. I'm doing laptop here. I'm still doing stuff today, but not in the office. By me changing jobs, now I'm at a sit-down job. That has helped.” [Age 53, COST score 10]	Theme 2: Patients described how their care team was able to connect them to resources, such as disability.
“My [daughter’s] job allows me independence in terms of… scheduling and my position… if [she] takes off to do something…medically, [she’ll] work the weekend or do something to make up the time or…do my project the week before. [She has] a lot of flexibility to manage [her] own schedule.” [Age 53, COST score 16]	“The social workers in the hospital, and everybody got together … and they got in contact with disability and let them know that I am in the hospital and what I’m going through. And, you know, do a reconsideration of—getting my disability… They really helped. I feel the social workers and whoever else at the hospital who helped in that part, they played a big part in my getting my disability.” [Age 48, COST score 13]
“It gave me a purpose to get up… It was real easy to be pitiful. If you get up and get focused, even if you can only piddle for a little bit, it keeps your mentally. It gets me up. It gets me motivated and going. Iťs not hard to be sorry for yourself.” [Age 58, COST score 9]	“Well, I talked to [my doctor] and she said she thought it would be good for me to go ahead and [apply for disability] because… employees have to be able to lift 50 pounds and I couldnť do that.” [Age 58, COST score 15]
Theme 2: Patients reported family medical leave was a helpful tool, but also noted its limitations.	“They were very good, they would schedule a night at the Hope Lodge so I could come down here and take my treatment, and then just go straight up to the Hope Lodge and spend the night.” [Age 54, COST score 0]
“I had to request time off from work. I had to get on FMLA, and my time has ran out at work, so I do not have any more time. So I am on family medical leave. They said they would hold my job, but I am not getting paid when I am off.” [Age 42, COST score 9]
“When I first was diagnosed, I did apply for family medical leave… then when the FMLA time ran out I had to request for donated time to cover me. And then I can only do donated time up to a certain point after I had ran out of time that I could use.” [Age 57, COST score 12]

3.1. Construct: Job demands

3.1.1. Theme 1: Patients noted the negative impact of cancer treatment on work productivity, promotion opportunities, and ability to return to work

Patients reported decreased work productivity or inability to return to work after their cancer diagnosis, which impacted potential income and promotions. One patient explained, “being sick at work and having to leave early sometimes, or missing the whole day, missing out on training… I have missed maybe two promotions.” One patient recalled trying to return to work but “every time I go back to work or try to go back full time, the cancer returns... So, no, I don’t know if I’ll ever get to go back to work.”

3.1.2. Theme 2: Patients worried about job loss and loss of benefits, including employer-based health insurance coverage

Several patients were worried about job loss and employer-based insurance. Patients faced job instability and were told by employers, “We don’t have anywhere to put you due to your circumstance. You really need to fill out these papers and retire out” or “We can’t guarantee you your job when you come back.” One patient remembered having to pay “six or eight-hundred dollars a month” to keep their insurance after losing their job. This was important as several patients relied on their own or a family member’s employment to maintain employer-based insurance coverage to pay for treatment. One patient was able to change jobs to obtain insurance.

3.2. Construct: Cancer demands

3.2.1. Theme 1: Patients experienced significant physical and cognitive limitations due to cancer symptoms and treatment

Patients shared the significant impact treatment had on their physical and cognitive abilities. One patient explained “[I] was not able to do a lot of the things physically… I experienced a lot of fatigueness… getting around was hard... socialization changed, I didn’t socialize as much with people.” Another patient explained “when the… effects of the chemo had me so down where I couldn’t get out of bed, [my husband] had to stay home.”

3.2.2. Theme 2: Patients felt psychological distress from reliance on caregivers, especially for transportation needs

In many cases, patients relied heavily on caregivers for transportation and symptom management in addition to financial and emotional support. One patient spoke about the sacrifices that family members made on their own careers because “I have to have someone drive me because I can’t drive now…my husband will try to take some time… and my sister, she’s letting her business slide to bring me at times.” Several other patients felt negative emotions towards being dependent on others. One patient stated that “I hate having to have somebody… wait nine hours… it took my independence away from me.” Another patient stated that she usually is the one helping her family and “it’s humiliating…being on this side now.”

3.3. Construct: Workplace resources and strategies

3.3.1. Theme 1: Patients felt supportive employers and the ability to make workplace accommodations were important and that work provided meaning in their lives

Participants cited having a supportive employer as a helpful workplace resource. One participant was reassured she and her husband had “a job no matter what.” In contrast, another participant shared that she had to talk to higher offices and move to a new department because her former office “did not really believe [her]… and thought [she] wanted to be off work…” Participants also described the positive impact of modifiable workplace accommodations while receiving cancer treatment. One participant describes how her employer now “has been more gracious and lets [her] take days off… [and] gave [her] a laptop [and]… changing jobs… [to] a sit down job.” One participant has a daughter with a position that allows her to “work the weekend or do something to make up the time…” A few participants explained the importance of having a form of control in their lives and achieving goals, including regular work tasks. One participant continues working to give “[her] a purpose to get up… motivated and going… [so she does not] feel sorry for [herself].”

3.3.2. Theme 2: Patients reported family medical leave was a helpful tool, but also noted its limitations

Family medical leave is an important tool but has its limitations in duration of use and the need to find additional financial support as it is often unpaid. The participant stated, “my time has ran out at work… So I am on family medical leave. They said they would hold my job, but I am not getting paid when I am off.” Another participant recalled that she “ran out… [of Family Medical Leave Act (FMLA) time]… and had to request for donated time…” but could only request a certain amount of donated time.

3.4. Construct: Cancer care resources and strategies

3.4.1. Theme 1: Patients described how they were able to make their appointment weeks in advance around their own schedule

Patients shared certain practices that helped them navigate through their cancer care. While some patients did not have a time management system or schedule, several participants described planning their appointments in advance to arrange travel logistics, coordinate with other appointments, and ensure available income. One patient describe how she schedules “doctor’s appointments…to fall on a pay week… [to cover] out-of-pocket expense[s].” Another participant shared that she tries “to coordinate as many appointments on one day as possible [and tries] to coordinate [her husband’s] appointments with [hers].

3.4.2. Theme 2: Patients described how their care team was able to connect them to resources, such as disability

Participants felt that their care team helped link them to available resources. Several patients describe how social workers encouraged them to apply for disability following diagnosis. Specifically, one participant described how “the social workers…and everybody got together…to [reconsider] getting disability” after being denied initially. One participant shared that her physician “thought it would be good…to go ahead and [apply for disability] because of her inability to complete certain job tasks. Another participant stated that her care team “scheduled a night at the Hope Lodge” so she could complete her treatment.

4. Discussion

We found that ovarian cancer patients and their caregivers faced competing job and cancer demands during treatment. Participants confirmed that employment was an important source of income and was often tied to health insurance coverage. To this end, “job lock” or staying at one’s job to maintain employer-based health insurance impacts approximately 20–30% of cancer survivors [14]. Participants noted a negative impact on their work productivity, promotion opportunities, and ability to return to work. Participants also experienced physical and cognitive limitations due to their cancer diagnosis as well as the side effects of treatment and relied heavily on caregivers for symptom management and transportation, which further inflates the impact of cancer treatment on employment. It is estimated that 20–30% of informal caregivers make extended employment changes [15]. Altogether, these stressors undoubtedly stretch beyond ovarian cancer patients as a prior study estimated that 20% of gynecologic cancer patients changed from full- or part-time employment to long-term disability, retirement, or work cessation following their cancer diagnosis [16].

Participants identified several workplace and cancer care resources and strategies, including negotiating with supportive employers, utilizing family medical leave, coordinating appointments, connecting to available assistance resources. While policies such as Social Security Disability Income and Family Medical Leave Act exist, there are limitations to both including eligibility criteria and the duration that these policies can be utilized [3]. Moreover, studies have shown that low-wage workers have less work schedule flexibility and fewer low-wage workers in the United States have access to sick leave compared to 80% of non-low-wage workers in the United States [17]. To date, the small body of literature on patient-oriented interventions has been primarily in breast and prostate cancer patients, has focused on interventions at the hospital rather than employment setting, and have mostly been conducted outside of the United States. In a Cochrane review, multi-disciplinary interventions that involved physical training, patient counseling, and/or vocational components were associated with higher return-to-work rates compared to usual care [3,18].

This single institution study focuses on ovarian cancer patients, who often have a long trajectory of active cancer therapy, and purposefully sampled patients who were experiencing the most financial distress by including COST <26 as an eligibility criterion. A limitation of our study is that these findings may not extrapolate to other populations, such as patients who are male, have other cancer types, or receive other types of therapy such as radiation. While we focused on patients who were on active therapy, a study of gynecologic cancer patients in Denmark showed that among gynecologic cancer patients, ovarian cancer patients had the highest risk of permanently reduced working ability, which suggests cancer patients in remission continue to experience employment concerns [19]. In this study, patients who were ≥ 65 years old or on oral maintenance therapies were under-represented. While not all cancer patients are employed, our study demonstrates that caregivers also experience employment issues during cancer treatment; however, we did not interview caregivers to gather their perspective directly.

From this study, we propose several interventions to consider in the clinical and research settings. First, training care teams to ask patients directly about their employment or implementing employment screening questions can identify patients with employment needs that would otherwise go unnoticed. Next, while oncologists likely have more experience selecting treatments based on less frequent treatments or fewer symptoms that impact work (i.e., neuropathy), incorporating technology (i.e., telehealth, remote symptom monitoring) and improving coordination of care in the community setting closer to where patients live can minimize cancer demands. In addition, providing personnel trained specifically to assist patients in obtaining disability or utilizing family medical leave would maximize the use of work-related policies. Beyond this, leveraging partnerships with community organizations or payors to create affordable options for transportation assistance could alleviate a major stressor on cancer patients, which could potentially improve adherence to care and decrease distress during cancer treatment. Finally, developing tools for patients and care teams to communicate proactively with employers to find accommodations for patients and caregivers will help to ensure their access to financial stability and health insurance during and after treatment.

HIGHLIGHTS.

• Cancer teams should screen for employment concerns and develop resources for patients and caregivers who need/want to work.

• Job demands include decreased productivity, inability to work, potential for job and employer-based health insurance loss.

• Cancer demands include work limitations due to symptoms, reliance on working caregivers for transportation.

• Workplace resources/strategies include having a supportive employer, modifying job responsibilities, family medical leave.

• Cancer care resources/strategies include streamlining care to minimize work impact and providing information on disability.