Factors associated with work sustainability in patients with bone metastasis

Abstract

Background

Working while receiving cancer treatment is challenging for patients, with considerable impact on their quality of life (QOL). However, there have been no reports on the factors that prevent employment in patients with bone metastases. This study aimed to investigate the employment status and factors impacting the continued employment of patients with bone metastases.

Methods

We analyzed clinical data from new patients consulting The University of Tokyo Hospital team for bone metastasis treatment between June 2015 and September 2017. Patients who were working at the time of cancer diagnosis (n = 124) completed four QOL questionnaires. Factors associated with work sustainability were identified via univariate analysis and a chi-squared test. Multivariate logistic regression analysis was used for significant variables. Relationships between employment and QOL scales were investigated using the Wilcoxon rank-sum test, with P < .05 considered as statistically significant.

Results

Among the 124 patients, only 45 (36.3%) were still working when the questionnaire was administered. Multivariate analysis revealed temporary employment, lytic or mixed bone metastases, and lower limb or acetabular metastasis, as significant factors hindering work sustainability. The QOL scores were high in the continued employment group. However, the relationship between employment status and pain remains unclear.

Conclusions

Lytic or mixed bone metastases and the lower limb and acetabular metastasis were significantly associated with employment resignation. Mobility difficulties may prevent patients with bone metastases from sustaining employment. Collaboration between rehabilitation professionals, oncologists, and workplaces is imperative to address this problem.

Introduction

The number of cancer patients is increasing among both older adults and those under 65 years of age [1]. According to a survey by the Ministry of Health, Labour and Welfare of Japan, 325 000 cancer patients continue to work while receiving treatment [2]. The 2016 revision of the Cancer Control Act clarified that business owners are responsible for considering the continued employment of cancer patients [3]. Balancing treatment and work is currently a crucial issue in Japan, with 21%–35% of cancer patients resigning after diagnosis, according to previous studies [4–6].

Remaining employed while receiving cancer treatment is challenging and has a significant impact on patients’ quality of life (QOL) [7–9]. Such challenges include treatment- and symptom-related issues, as well as workplace challenges such as difficulty in taking sick leave [10,11]. Previous studies in Japan have highlighted being a woman, temporary employee, older, or having an advanced stage of cancer as factors influencing job resignation [6,12,13]. Patients with bone metastases face additional challenges, including deterioration of motor function due to locomotive syndrome [14]; however, there are no reports on the employment status of these patients.

The aim of this study was to investigate the employment status of patients with bone metastases and assess the relationship between work sustainability, clinical data, and QOL.

Patients and methods

This retrospective cross-sectional study was carried out at the University of Tokyo Hospital. This institution has a multidisciplinary team with expertise in orthopedic surgery, rehabilitation medicine, radiology, and a palliative care for treating cancer patients with bone metastases. Of the 368 new patients consulting this team between June 2015 and September 2017, 193 completed a self-reported questionnaire during their first consultation. Of them, 124 patients who answered being employed at the time of cancer diagnosis were included in the study. The patients answered a self-reported questionnaire including 15 questions regarding their background and employment-related issues, and four questionnaires: the EuroQOL-5 Dimension (EQ-5D) [15]; the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL, hereinafter C15-PAL [16]; the QOL Questionnaire Bone Metastases module (EORTC QLQ-BM22), hereinafter BM22 [17]; and the Kessler Psychological Distress Scale 6 (K6 scale) [18] at the same time. The C15-PAL and BM22 were selected because for their suitability in assessing the QOL of patients with advanced cancer [19].

Clinical data extracted at the first consultation included age, sex, body mass index (BMI), primary cancer lesion, other distant metastases, history of chemotherapy, laboratory results [hemoglobin (Hb), Albumin (Alb), corrected serum calcium by Alb, and C-reactive protein (CRP)], Eastern Cooperative Oncology Group Performance Status, and pain using a numerical rating scale (NRS) of 0–10. Abnormal levels were defined as Hb <12 g/dl, Alb <3.7 g/dl, corrected serum calcium ≥10.3 mg/dl, and CRP ≥0.4 mg/dl. Primary lesions were categorized into rapid, moderate, or slow growth based on Katagiri’s scoring system [20].

Patients who continued working at the time of cancer diagnosis were classified into two groups depending on their continued employment status at the time of the questionnaire, regardless of any changes in employment type (e.g. full-time or part-time). The endpoint was participants’ employment status at the first consultation with the team. We analyzed the relationships between employment status and patient background, clinical data, and QOL.

For data analysis, we used the JMP® software, version 14 (SAS Institute Inc., Cary, NC). Factors associated with work sustainability were identified through univariate analysis and a chi-squared test. Multivariate logistic regression analysis was used for significant variables. Relationships between employment and QOL scales were investigated using the Wilcoxon rank-sum test, with a P value <.05 considered as statistically significant.

This study was approved by the institutional review board of our institute (approval no. 2373) and conducted according to the ethical guidelines for epidemiological research laid out by the Japanese Ministry of Education, Culture, Sports, Science and Technology, and the Ministry of Health, Labour and Welfare.

Results

Of the 193 patients who completed the questionnaire, 124 (64.2%) were working at the time of cancer diagnosis. Table 1 presents the patients’ background characteristics. The mean age of all the patients was 63.0 years (standard deviation, 11.8 years), and 74 (59.7%) were male. Eighty-three (69.7%) patients were full-time workers or self-employed at diagnosis. Radiotherapy was performed in 54 cases (including 40 spinal metastases, 9 pelvic metastases, 2 femoral metastases) and surgery in 5 cases (including 2 spinal metastases, 2 femoral metastases).

Table 2 shows the rate of work sustainability based on background characteristics. Forty-five (36.3%) patients were still working at the time of completing the questionnaire. BMI, employment type at cancer diagnosis, Hb level, radiological findings of bone metastasis, and lesions of bone metastasis were significantly associated with work sustainability in the univariate analysis.

Table 3 shows the results of multivariate logistic regression analysis. There were three significant factors in the multivariate analysis: temporary worker [odds ratio (OR), 0.11 (95% confidence interval (CI), 0.03–0.40)], lytic or mixed bone metastasis (OR, 0.23; 95% CI, 0.07–0.72), and lower limb or acetabular metastasis (OR, 0.30; 95% CI, 0.08–0.90).

Table 4 shows the relationship between work sustainability and QOL scores. Patients who continued working had a higher median EQ-5D score (0.69) than those who did not (0.58). The results of the K6 scale were also related to work sustainability. According to the C15-PAL responses, physical functioning and appetite loss were related to work sustainability. BM22 results showed a relationship between psychosocial aspects and work sustainability. For all QOL scores, the scale related to pain was not significant.

Discussion

In the present study, temporary employment, lytic or mixed bone metastases, and lower limb and acetabular metastases were significantly associated with job resignation.

Numerous studies have reported that cancer patients in temporary employment face a higher risk of job loss compared to those in permanent employment [6,12,13]. In our study, temporary employment was significantly associated with job loss in patients with bone metastases. In general, temporary workers often do not benefit from flexible working arrangements or company health schemes and have more limited access to occupational physicians even in large-scale companies. If temporary workers were given the same support, the risk of job loss would be reduced [6].

Additionally, lytic or mixed bone metastases, particularly in the lower limb and acetabular regions, emerged as independent risk factors for job resignation. These findings are unique to patients with bone metastases. Osteolytic-dominant and weight-bearing bone metastases are both associated with mobility restrictions owing to the risk of pathological fractures. This suggests that mobility problems (e.g. non-weight bearing) may prevent patients with bone metastases from continuing working. In this study, surgery and radiation therapy were not associated with employment. Surgery and radiotherapy may improve pain and ADL, but patients who underwent these interventions may have been in more severe situations. This may be the reason why surgery and radiotherapy were not associated with employment.

In the present study, fractures or paralysis did not consistently correlate with continued employment. Although some patients with spinal fractures were able to continue working, those with metastases to the lower limbs or pelvis often faced work discontinuation. Mobility appeared to be a key determinant of continued employment. For instance, individuals with paralysis due to L5 or S nerve root involvement who retained the ability to walk were more likely to remain employed than those who did not.

We previously reported that the average EQ-5D score of patients with bone metastases was 0.58 [21]. In this study, the QOL for individuals taking sick leave or resigning was significantly lower, with the group continuing to work scoring 0.63 and the sick leave or resignation group scoring 0.54. Physical functioning, as assessed by C15-PAL responses, was associated with work sustainability. Reduced physical function poses challenges to continuing employment because of mobility limitations. In addition, patients facing difficulties in job retention often reported psychosocial and mental conditions such as depression or anxiety disorders. This findings suggest that multifaceted employment support is imperative.

In our study, we found no association between the NRS and pain-related QOL scales with work sustainability. Given the necessity of commuting or moving around workplaces, it appears that mobility difficulties have a stronger impact on work sustainability than pain levels. We suspect that pain was not an independent factor because analgesics, radiation, or other treatments improved the pain in a relatively short period of time, but mobility restrictions had to be continued on a monthly basis even when the pain was controllable. This may have influenced the job resignation. For employment support of patients with bone metastases, ensuring barrier-free access to workplaces and offering flexible options to work from home are more important than pain management alone. Effective communication among the workplace, occupational physicians, and oncologists is essential. Although systems to support cancer patients balancing work and treatment are being promoted in Japan [22], challenges persist due to different positions and poor communication between workplaces, occupational physicians, and oncologists. Oncologists’ awareness of the importance of balancing work and treatment is lacking [23], highlighting the need for strengthening cooperation with cancer consultation and support centers or multidisciplinary teams. Rehabilitation therapists possess the skills to address the unique needs of patients requiring workplace accommodations that benefit their mobility and autonomy, making their involvement crucial in employment support. Therefore, rehabilitation medicine is expected to play a significant role in managing locomotive health risks in employed patients with bone metastases [24,25].

The present study has some limitations. First, it only included patients who were able to complete the self-report questionnaire at their first consultation, potentially excluding those in poorer health condition. For instance, patients on bed rest due to paraplegia caused by spinal cord compression were excluded. Second, we did not investigate whether patients returned to work after taking sick leave, representing a future research challenge.

In conclusion, we identified various important factors associated with work sustainability after diagnosis of bone metastasis in cancer patients. Among patients with bone metastases, lytic or mixed bone metastases, and lower limb and acetabular metastases were significantly associated with employment resignation. Mobility difficulties may prevent patients with bone metastases from sustaining employment.

Acknowledgements

We would like to thank Editage (www.editage.jp) for the English language editing.

Author contributions

Study design: all authors; Data analysis and interpretation: Ryoko Sawada; Manuscript writing—original draft: Ryoko Sawada; Manuscript writing review and editing: all authors; Data acquirement: Ryoko Sawada, Yusuke Shinoda, Takahiro Ohki, and Yuki Ishibashi; Approval of the final version: all authors.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Funding

This work was supported by no funding agency.

Data availability

The datasets generated during and/or analyzed during the current study available from the corresponding author on reasonable request.

References