Change of employment status, such as job loss, have been reported in cancer survivors even after a long period of diagnosis and treatment, and caused a low rate of RTW (10, 11). Government has paid attention to the RTW in cancer survivors helped them overcome the transition to a normal life after cancer. RTW has been established by cancer survivorship. There are two perspectives that leading to the outcome of cancer survivors. Firstly, from the policies, procedures and economic factors to work environment. Second, from the interventions and rehabilitation programs promoting RTW. However, the employment status are related to individual and interpersonal factors, and tolerable to the short-term, long term and late effects of different cancer treatments (8). There are many reasons that affect change of employment status in cancer survivors. A qualitative meta-synthesis has demonstrated three categories: personal (symptoms, work abilities, coping, and motivation), environmental (workplace, social, family, and professionals) and occupational (type of work, work demands, and job flexibility), which were associated to change of employment status (12).
Almost half of cancers have been diagnosed younger than 65-year-old in the United States. Early diagnosis and multimodal cancer treatments nowadays have benefited many cancer survivors (8). In our result, the most changes of employment status in younger groups throughout 730 days was salary adjustment. Most of them chose to retain at the same jobs as working gave them self-esteem, while not retained the jobs, they will lose their ability to paying bills and getting adequate health insurance (8). However, they had to face some blocks along the way to finding and keeping the job due to the outdated personal policies (8), such as social comparison between other cancer patients, work-capabilities with other colleagues and workplace support and characteristics (13). Therefore, they might let go from the jobs or put themselves into lower position without getting promotions, facing resentment by co-workers (job discrimination) (8). If not, they may extend their coverage (aged 28-45 groups) or change their department or job position (aged 46-55 groups).
Older was a risk factor for job loss, even in healthy person (12). The younger had a better physical performance than the older while compared to the same aged group. Scientists have demonstrated that the younger’s physical performance status were stronger at 6 months than 18 months after diagnosis (12). Other reason was the frequency of advanced disease in the elderly and advanced disease lead to advanced treatment (9). Therefore, heavy treated patients with more cycle of chemotherapy due to long standing treatment effects significantly, have faced the problem of work loss (6). Other than toxicity, the somatic complications, such as infertility and osteoporosis, may also affect work ability (9). Previous study has demonstrated that personal reasons such as the characteristic of patients also affected the RTW in the before (facing stress, adjustment of emotional), within (early effect of chemotherapy, radiotherapy and cancer types) and after (late effect of chemotherapy, radiotherapy and progression of disease) the cancer therapy (14). Therefore, the characteristics of cancer types, such as chemo-brain effect seemed fewer in the patients with solid tumors (9), and the tolerable to cancer treatments were affected the change of employment status in cancer survivors (6, 9).
Our results showed the higher grade of labor insurance salary, the lower the staying percentage in their workplace and the acceptance of change their department or job position (NTD 24000-40100 and NTD 42000-43900). Scientist have demonstrated that the synergistic effect of low socioeconomic status and prolonged unemployment (14). Low socioeconomic status of employees obtained low paid job, therefore most of them will choose to retain at workplace as they were more difficult to seek a job (14). Our results showed the employees with salary of NTD 16500-22800 have the highest of percentage of cancer survivors to stay in workplace by extending their coverage. In contrasts, in average salary aspect, the higher salary, the more the cancer survivors staying in workplace. If they leave their workplace, the change of their employment status was suspension, it is due to their high grade of labor insurance salary and labor pension. The results were same as the high salary in Northern distinct which had high staying rate among other geographical locations.
Salary adjustment are the most change in the employment status in cancer survivors but without tremendous difference between day 1 and day 730 (NTD 1,421). The salary fluctuation was small within 2 years in cancer survivors was because of the protection of Ministry of Labor. The employers must maintain their salary as the victims of occupational accidents within 2 years regarding the protection of workers. If the workers have been confirmed by a designated hospital inability to perform the original work without reaching disability requirements after two years, the employees may pay 40 months' average wage if the workers have agreed.17 Although the protection to workers of Ministry of Labor, cancer survivors may suffer inadequate rest due to many factors. Scientists have demonstrated an adequate paid sick leave may reduce the unpaid time off during cancer treatment but only 60% of workers paid sick leave during cancer treatment (11). An inadequate rest may cause long time absenteeism due to psychological pain and stress, ineffective working, disability and even premature death were the indirect cost of cancer, which costs much than direct treatment costs of cancer, which have exacerbated the economic burden (2). Therefore, the balance between economic hardship, insurance coverage and time of sick leave among cancer survivors were important in economic perspective (11), and a comprehensive self-assessed work ability scoring system need to be established in order to predict the retained job in cancer survivors after 2 years of labor’s law protection in Taiwan (3, 15).
A self-assessed work ability scoring system have been constructed to predict the RTW of cancer and their result showed a direct proportional of cancer types and RTW score (3, 15). Scientist have categorized RTW rate into two groups: lung, hepatic, pancreatic, esophageal, blood cancers were in the lower full RTW rate groups, while gastric, intestinal, breast, GU cancers were in higher full RTW rate groups (3). Breast cancer, which was categorized into higher full RTW groups, was the most common cancer in women worldwide, while hepatic cancer and lung cancer were the common cancers in male worldwide, were categorized into lower RTW groups. It was compatible to our results, which showed high staying rate in women in the first 2-3 months after diagnosis of cancer.
In addition, the social support, including cancer supporting group programs, interaction between occupational health professionals and health providers, was another superordinate theme that facilitated in the RTW process (13), such as breast cancer’s survivors have contributed a strong association in Taiwan, which sharing the useful information and social support to paid work to breast cancer’s survivors. Therefore, the percentage of women who remained in their workplace was greater than men within 540 days. However, the declined of staying rate in women in day 730 may cause by the demographic structure of the society. Men trended to be the family finance support while women trends to head the household. In addition, women were more easily influenced by the advice of other cancer survivors and thus effecting their personal subjective work capacity although most of them have higher working capacity than other cancer types of patients (16). Therefore, upward information generated positive effect and impacted their self-esteem and self-evaluations while downward information deteriorated their health status (13).
The impact of RTW after 1 year of cancer diagnosis are more vulnerable in small- and medium-sized companies in Japan (3). Self-employed people that authorized small-sized company have less legal support from public health insurance and lower social support at work in Norway (5). It was difference from our results. Our results had showed the bigger the company, the lesser the staying percentage. Compared to >1000 person companies, which salary adjustment was the most change of employment status (>80%), extending coverage was showed greater in 10-1000 person’s companies (>30%). It may because the company which less than 5 employees, is not a compulsory insurance unit. However, the company should still enroll the employees to participate in employment insurance or labor insurance voluntarily (17). As a result, units of insurance company managing the compulsory insurance paid much for their employees.
The General Accounting Office announced that the median annual salary of employees in 2018 was NTD 490,000 and the average of annual total salary was NTD 629,000 (18). As a result, nearly 70% of the employees’ annual wages were lower than the average, especially in Agriculture, Forestry, Fishing and Animal Husbandry and Water Supply and Remediation Activities are manual labors with more physical works. While Wholesale and Retail Trade, Transportation and Storage had the highest grade of labor insurance salary and had all types of change of employment status.
Our study has few limitations. First, we were not able to know what types of cancer that they have been diagnosed as the epidemiology of gender difference in cancers and the treatment are varied. Second, we were not able to know their exactly job conditions, such as their working hours, either they were able to get help from other work colleagues or work at a slower pace. Third, the option of cancer survivors either continued to work while being treated or their jobs were flexibly adjusted by the employers, was under investigated. Fourth, psychological and social factors either they were financially responsible or not, were limited in this database. However, these limitations can be addressed through actual employment tracking of cancer survivors.