Impact of Pain on Employment and Financial Outcomes Among Cancer Survivors

PURPOSE

Although pain is a frequently reported symptom among individuals with cancer, there is limited information on the impact of pain on employment or financial outcomes. This study used nationally representative data to examine the role of pain levels on employment and financial outcomes.

METHODS

We used data from the 2016-2017 Medical Expenditure Panel Survey Experiences with Cancer Survivorship Supplement to identify 1,213 adults diagnosed with cancer. Multivariable logistic regression analyses were used to examine association of pain levels and self-reported employment and financial outcomes.

RESULTS

Approximately 43% of adults with a cancer history reported no pain, 29% mild pain, 18% moderate pain, and 10% severe pain over the past 7 days. Compared with those reporting no pain, individuals reporting any pain had significantly increased likelihood of adverse employment outcomes including early retirement, feeling less productive, and staying at a job because of concerns about losing insurance. Individuals with any pain (compared with no pain) also had significantly increased likelihood of adverse financial outcomes including borrowing money or going into debt, inability to cover medical costs, and worrying about paying medical bills. For both employment and financial outcomes, there were dose-response relationships, with worse outcomes generally associated with greater pain levels.

CONCLUSION

Pain is frequently associated with adverse employment and financial outcomes among cancer survivors, and greater pain is associated with worse outcomes. Better assessment of pain severity among survivors and implementation of strategies to assist with employment and financial objectives may be important steps to enhance patient-centered care.

INTRODUCTION

Pain is a frequently reported symptom among individuals with cancer. Approximately 55% of individuals receiving cancer treatment reported pain; among those with advanced, metastatic, or terminal disease, 66% reported pain.¹ Among individuals diagnosed with cancer, pain was associated with adverse outcomes including decreased quality of life, daily activities, and social interactions.^2–4 More than two thirds of patients described cancer pain as distressing and more than one-third as intolerable.² However, approximately one third of patients did not receive appropriate pain management.⁵

CONTEXT

• Key Objective

• Using nationally representative data, is the level of pain experienced by cancer survivors associated with adverse employment and financial outcomes?

• Knowledge Generated

• Among individuals with a history of cancer, those reporting any pain had increased likelihood of adverse employment and financial outcomes. Individuals with moderate to severe pain were significantly more likely to report adverse outcomes than were those with mild pain.

• Relevance

• Better pain assessment and support for pain management may improve employment and financial outcomes among cancer survivors. Development of strategies to assist with employment and address financial hardship is important for enhancing patient-centered care.

Multiple recent studies have documented substantial effects of cancer and its treatment on patients' employment status and financial well-being.^6–11 Despite the high prevalence of cancer pain and the economic effects of cancer for patients and their families, there is limited literature examining the association of cancer pain with financial and employment status among individuals diagnosed with cancer. A number of studies have reported that individuals with cancer pain were less likely to be employed or more likely to work reduced hours than were those without pain,^12–15 although not all studies found this association among all cancer survivors.^16–18 Even less information is available on the relationship between cancer pain and financial well-being. For example, Lathan et al¹⁹ reported significant associations between increased pain and limited financial reserves among patients with lung and colorectal cancer, whereas Malhotra et al²⁰ found that among individuals with stage IV malignancies, greater total pain was associated with greater financial difficulties. In general, these studies were limited to individuals with one type of cancer, from a single geographic region, or who were treated at one health care system. In addition, these studies have generally not differentiated employment or financial impacts by severity of cancer pain or examined detailed employment or financial outcomes.

To provide a more detailed assessment, we used national data to examine associations of pain severity with cancer survivors' employment outcomes and financial hardship concerns.

METHODS

Data Sources and Study Population

This study used data from the 2016 and 2017 Medical Expenditure Panel Survey (MEPS) Experiences with Cancer Survivorship Supplement (ECSS) and the MEPS Household Component Full Year Consolidated Data sets. MEPS is a nationally representative population-based survey collecting data on clinical and sociodemographic characteristics, health conditions, use of medical services, health insurance, income, and employment.²¹ Individuals completing the MEPS household component who had ever been told by a health professional that they had cancer or malignancy of any kind at age ≥ 18 years were asked to complete the ECSS.²² The sample design of the MEPS includes stratification, clustering, multiple stages of selection, and disproportionate sampling. Furthermore, the MEPS sampling weights reflect adjustments for survey nonresponse and adjustments to population control totals. Information about computing standard errors for MEPS estimates on the basis of the complex sample design is available at Agency for Healthcare Research and Quality.²³ Additional information on the MEPS ECSS, including links to survey instruments and sites for downloads of data and analysis weights, is available from the National Cancer Institute's Healthcare Delivery Research Program.²⁴

ECSS respondents with nonmelanoma or unknown-type skin cancer were excluded. As time since last treatment for cancer is an important variable potentially associated with both employment or financial outcomes and cancer symptoms, ECSS respondents who had missing values for this variable or who indicated that they were never treated for cancer (and thus may have been incorrectly categorized as having cancer) were excluded from the study.

Study Outcomes Measures

The study included two outcomes measures from the ECSS. Employment concerns were collected only from individuals who worked for pay any time at or after their cancer diagnosis. Employment concerns included taking paid time off work, changing to part-time or less demanding job, retiring early, and being less productive any time following cancer diagnosis. Financial concerns captured information on effects of cancer and cancer treatment on finances any time following cancer diagnosis; these included having uncovered medical expenses, borrowing money or going into debt because of cancer, being unable to cover medical care costs, and delaying needed medical care (treatment or specialist visits) or prescription medications following cancer diagnosis. All outcomes are based on self-report.

Study Population Characteristics

The main study independent variable was self-reported average level of pain over the past 7 days, rated 0 (no pain) to 10 (worst imaginable pain). Pain was classified as mild (1-3), moderate (4-6), or severe (7+).^25,26 Other respondent characteristics included sex, race and/or ethnicity (Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic others), age group (quartiles of < 56, 56-66, 67-75, and ≥ 76), education (no college education v any college education), cancer site (breast, cervix, colon, melanoma, prostate, uterus, and others, with others including all sites that comprised < 5% of the weighted study population), history of multiple cancer diagnoses (yes or no), health insurance over the past 12 months (any private insurance coverage [including TRICARE], any Medicare coverage, any Medicaid or other non-Medicare public coverage, or uninsured for entire past 12 months), number of health care provider visits over the past 12 months (quartiles of 0-3, 4-7, 8-16, and 17+), and time since last cancer treatment (< 1 year ago [including current treatment], 1 to < 5 years, 5 to < 10 years, or more than 10 years ago. For health insurance, each insurance type variable is coded as zero (no) or one (yes) on the basis of whether the patient had that type of coverage at any point in the past 12 months. Study population characteristics and outcomes were collected from the same individuals using the MEPS ECSS.

Study Analyses

We performed descriptive analyses using Pearson's chi-square tests to compare patient characteristics (Table 1) and study outcomes (Table 2) by pain level and multivariable logistic regression analyses to examine associations of mild, moderate, or severe pain versus no pain (reference category) with the study employment and financial outcomes. Patient characteristics included in regressions were sex, race and/or ethnicity, age quartiles, education, cancer site, history of multiple cancer diagnoses, time since last cancer treatment, insurance during prior 12 months, and physician visits during prior 12 months. All analyses used sample weights provided with the ECSS to provide nationally representative estimates and address survey nonresponse. Analyses were performed using PROC SURVEYFREQ and SURVEYLOGISTIC in SAS 9.4, with adjustment for the complex survey design of the MEPS.

TABLE 1.

Characteristics by Pain Level of MEPS Cancer Survivor Population^a

TABLE 2.

Unadjusted Associations of Pain Level With Employment and Financial Outcomes^a

RESULTS

Study Population Characteristics and Pain Severity

Table 1 presents characteristics of the study population by pain category. The study population included 1,213 individuals who completed the 2016 or 2017 ECSS. Approximately 43.3% of the weighted sample reported no pain, 29.2% mild pain, 17.9% moderate pain, and 9.6% severe pain. Significant difference in pain severity was observed by education, age group, race and/or ethnicity, insurance status, and number of health care provider visits.

Association of Pain Category with Study Outcome

Table 2 presents the unadjusted distribution of study outcomes by pain category. Individuals reporting no pain were less likely to report each of the adverse employment outcomes following cancer diagnosis (except for taking paid time off or staying at a job because of concern about losing health insurance) compared with survivors reporting moderate or severe pain. These differences were particularly stark for early retirement. For example, among those who planned to retire early, almost 21% indicated experiencing severe pain; in those not planning to retire early, fewer than 6% indicated severe pain.

Adverse financial outcomes following cancer diagnosis (also presented in Table 2) showed similar patterns. Individuals with moderate or severe pain were more likely to have each of the adverse financial outcomes except for having uncovered medical expenses. For example, among individuals who delayed getting necessary medical care, the proportion reporting severe pain (27.4%) was almost twice that of those who did not delay seeking care (14.2%).

Multivariable Analyses of Pain Category and Employment Outcomes

Table 3 presents results from multivariable logistic regression analyses of associations of pain category with employment outcomes following cancer diagnosis. Odds ratios statistically significant at P < .05 are in bold. Compared with those reporting no pain, individuals with moderate or severe pain had significantly increased likelihood of indicating that following cancer diagnosis they changed to a part-time job, didn't pursue a promotion, retired earlier than planned, felt less productive at work, or stayed at a job in part because of concerns about losing health insurance. This was particularly noticeable for early retirement, where odds compared with individuals with no pain ranged from approximately 3.7 for individuals with mild pain to more than 15 for individuals with severe pain.

TABLE 3.

Association Between Pain Category and Employment Outcomes (OR and 95% CI)^a

For three of the employment outcomes (changing to a part-time job, retiring early, and feeling less productive), there was an apparent dose-response relationship between pain level and outcome. That is, the odds for adverse employment outcomes were greater among those reporting moderate pain than among those reporting mild pain and were greater among those reporting severe pain than among those reporting moderate pain.

Multivariable Analyses of Pain Category and Financial Outcomes

Table 4 presents odds ratios and 95% CIs from regression analysis of associations of pain category with financial outcomes following cancer diagnosis. Odds ratios statistically significant at P < .05 are in bold. Compared with those reporting no pain, individuals with any level of pain had significantly increased odds of indicating that following cancer diagnosis they worried about paying medical bills because of cancer, delayed getting necessary medical care, and delayed getting necessary prescription medications. For two outcomes—borrowing money or going in debt because of cancer, and being unable to cover the cost of medical care for cancer—those reporting mild pain were not significantly different from those with no pain, whereas those with moderate to severe pain had significantly increased odds of both outcomes. For all financial outcomes except having uncovered medical expenses because of cancer and delaying necessary medical care, the odds of reporting each outcome among those with moderate or severe pain were greater than the odds among those with mild pain.

TABLE 4.

Association Between Pain Category and Financial Hardship Outcomes (OR and 95% CI)^a

DISCUSSION

This study used data from a nationally representative population of cancer survivors to examine the association of pain level with employment and financial outcomes following cancer diagnosis. We found that survivors reporting pain were in general more likely to also report adverse employment and financial outcomes. A dose-response effect was noted for several study outcomes, with greater odds of adverse impacts for those with moderate or severe versus mild pain. The mechanisms by which pain is associated with increased odds of adverse employment and financial outcomes in the study population are uncertain but are likely varied. These findings have several implications for improving care for cancer survivors. Multiple studies have reported that pain among individuals with cancer is often undertreated.^1,5,27 The presence of moderate to severe pain among more than a quarter (27.5%) in the current study suggests that pain in this population is also undertreated, indicating the need for better cancer pain assessment, evidence-based pain treatment recommendations, and referrals for individuals for pain management.^28–30 Previous studies have reported that individuals from underserved populations are less likely to receive treatment for cancer pain.^31–33 Additional research is needed to better understand how assessment, reporting, and treatment of pain differ by race and/or ethnicity, socioeconomic status, cancer type, and treatment modality and how pain severity in these populations may affect employment and financial outcomes. As discussed by Poirier,^34(p316) “Aggressive pain and side-effect management has the potential to help keep patients in the workforce.”

Our results are consistent with previous studies indicating associations of cancer pain with employment outcomes.^12,13,17 Building on this previous work, results from the present study suggest that cancer centers and oncology practices should consider providing referrals to employment counselors and other professionals who can assist survivors in planning career activities following cancer treatment. Oncology professional societies and advocacy organizations may also consider outreach to employers regarding strategies to assist cancer survivors maximize their career opportunities. The strong association of cancer pain with early retirement (Table 3) may mean that employers are losing valuable employees who could potentially remain as part of the workforce with appropriate job accommodations.

Our findings of significant associations of pain and adverse financial outcomes have direct clinical implications. For example, among patients reporting pain but not taking analgesic medications, an inability to pay for these medications was cited as a reason by more than three-quarters.³⁵ Furthermore, the association of cancer pain with adverse financial outcomes likely extends beyond cancer survivors; in a study collecting survey data from respondents in households that recently experienced a cancer death, severe pain in the decedent was associated with increased likelihood of major financial strain.³⁶ These findings indicate that additional strategies are needed to address financial burdens among individuals with cancer, particularly among those with moderate to severe pain.

There are several limitations associated with this study. Data are all based on self-report; as MEPS data are de-identified, it is not possible to validate responses. Pain level is based on the past 7 days, whereas responses to questions on employment and financial outcomes and cost conversations were from any time following cancer diagnosis, preventing causal links between pain and study outcomes. Similarly, cancer diagnoses may have occurred years before survey completion; reported pain may not be cancer-related. No information is available on whether individuals in the MEPS sample experienced cancer recurrence; if so, pain reported may be because of recurrence rather than the initial cancer or cancer treatment. The MEPS sample generalizes only to US civilian, noninstitutionalized population; individuals in nursing homes or long-term care institutions are excluded from the sample. The study population may therefore underestimate the proportion of cancer survivors with pain. We were not able to control for cancer stage or treatment history as those variables are not included in the MEPS, although we did control for self-reported cancer type and time since last treatment.

Despite these limitations, this study has important implications for improving the care and outcomes of cancer survivors. Pain among survivors is strongly associated with adverse employment and financial outcomes, with a dose-response effect associating increased levels of pain and worse outcomes. Better assessment and management of pain among survivors and development of strategies to assist survivors with employment and financial objectives are important steps to enhance patient-centered care. For example, survivors who are able to continue working following a cancer diagnosis tended to score significantly better on multiple quality-of-life scales than did survivors whose work was interrupted.³⁷ Future research is needed to develop and test interventions for effective pain management that also address downstream effects on employment and financial outcomes. This work should be informed and complemented by implementation science research to ensure that effective interventions are disseminated and implemented into clinical practice.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Impact of Pain on Employment and Financial Outcomes Among Cancer Survivors

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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