The topic of returning to work (RTW) after a cancer diagnosis and the impact of working conditions on the process of RTW has attracted significant attention from occupational health researchers in recent years. This topic is increasingly important for several reasons. First, over the past decades, we have witnessed steady growth in new cancer cases [1]. In Norway, there has been an increase in the number of new cancer cases, with 36,998 new cases being recorded in 2021, representing an increase of over 6,000 cases since 2011 [2]. Second, in Norway, like elsewhere, there has been an increasing trend in long-term cancer survivorship, even for some previously more lethal cancers [3], and in the future, the survival rate for cancer patients is expected to increase further due to early screening and advancements in cancer treatment [4]. Third, the fact that a growing number of long-term cancer survivors are of working age makes the issue of RTW even more pertinent for researchers, as well as policy makers. Specifically, the working conditions that cancer survivors experience may impact their likelihood of resuming or exiting work. Cancer survivors who work under physically and psychosocially demanding conditions may face higher risks of poor health and reduced labor market participation [5-8].
Resumed employment among cancer survivors, as well as other groups who have experienced similar health shocks, are thus high on policymakers’ agenda [9]. In a social democratic welfare state, which relies on a large tax base for its sustainability, high employment rates are an essential prerequisite. For individual workers, employment not only provides earnings and economic wellbeing but also meets psychosocial needs, such as having a time structure, a personal identity, respect, dignity, valued social roles, participation, and a sense of belonging [7, 10]. Given that it is of a certain quality, work may even promote health, in particular mental health, and contribute to recovery from health challenges [11].
Research has highlighted determinants of RTW at several levels, such as the individual, the workplace, and the design of welfare and health systems [9]. These factors also consistently include social class, occupation, and education [12, 13]. Studies often show that RTW generally occurs more often among privileged social groups (e.g., the more highly educated [13]). Such socially stratified processes are therefore likely to reinforce social inequalities, as well as health inequalities. However, researchers have rarely investigated the role played by the work environment in RTW processes [14]. This is surprising in light of research knowledge about the relationship between working conditions and health, which may be health promoting or health deteriorating, as well as the well-known association between socioeconomic position, ill health, and exit from work [12, 13, 15]. Because cancer survivors often experience varied long-term side-effects caused by cancer itself or cancer treatment, it is likely that a poor or demanding work environment is a barrier to RTW. People in lower socioeconomic positions (e.g., those in a low social class and those with little education) are particularly vulnerable, partly because they are more often exposed to hazardous working conditions and partly because their opportunities for alternative jobs are limited. Additionally, research shows that less privileged workers more often suffer from co-morbidities [16]. Thus, under such circumstances, a poor work environment may represent an even larger obstacle, and these workers may be facing a situation of “triple jeopardy,” which is likely to significantly reduce the probability of RTW.
In this study, we scrutinize how working conditions are associated with RTW among cancer survivors in Norway. To do so, we analyze longitudinal register data on the entire Norwegian population. The novel contribution of this study is the use of two job exposure matrices (JEMs) that reflect occupation-based mechanical (or physical) and psychosocial job exposure, respectively [17, 18]. As indicated above, this approach allows us to explore whether hazardous working conditions play a role in RTW after cancer diagnosis while also taking into account sociodemographic and socioeconomic factors.
Research questions
Two questions are addressed in our study:
RQ1: Do cancer survivors have an elevated long-term relative risk of reduced employment after being diagnosed with cancer?
RQ2: Do mechanical and psychosocial working conditions impact the long-term relative risk of reduced employment among cancer survivors?
Conceptual framework
Stergiou-Kita et al. (2014) [19] conducted a meta-synthesis of cancer survivors’ experiences related to obstacles to and opportunities for re-entering work. They reviewed 39 papers on the topic and developed a conceptual framework that is useful for our purpose.
First, the RTW process and the factors framing it are indeed multiple, complex, and found on multiple levels. The factors that are associated with successful RTW can be categorized into three domains: the personal level, involving symptoms, work abilities, coping, and motivation; the environmental level, relating to the workplace, the social/family, and professionals; and the occupational level, including the type of work performed, work demands, and job flexibility.
These three conceptual constructs are helpful in identifying crucial factors and establishing links between the various factors and levels. In this way, this conceptual framework will guide our analysis. As important as it is for this review to pinpoint important framing factors, the time dimension itself is missing, even though it is a crucial factor. Young et al. (2005) [20] have proposed that a RTW process includes four phases: 1) Off work, 2) Re-entry, 3) Maintenance, and 4) Advancement. It follows from the long-time perspective of this study (14 years) that the focus is on long-term consequences (i.e., Phase 3, Maintenance, and Phase 4, Advancement).
In their literature review, Stergiou-Kita et al. (2014) [19] also point out certain research gaps. These include, first, the need to address long-term developments, rather than short term transitions pertaining primarily to the re-entry phase. The authors claim that “the vast majority of studies” (p.667) have directed attention to survivors’ early RTW. Thus, there is a need for studies that have a longer timeframe, such as the present study. Second, based on the documented knowledge gaps, they argue that future research should “investigate the influence of job tasks, occupational demands, and work environment, on survivors’ RTW experiences” (p.667), which is exactly what the present study is aiming to accomplish.
Based on this framework, the present study will focus on factors operating on the personal level and, as is especially called for, the occupational level, primarily in terms of working conditions but also in terms of social class. Furthermore, the time horizon is long term and addresses later phases of the RTW process, such as the maintenance and advancement phases.
Previous research
Current studies on RTW after cancer diagnosis primarily focus on investigating the likelihood of RTW and the associated factors during the early phases of the RTW process. The prevailing trend in many countries indicates that cancer survivors, during the re-entry phase, often manage to resume work but are more likely than those who have never had cancer to experience a decline in labor force participation and earnings in the long term [21-28]. Evidence from both the United States and European countries reveals that about 62% of cancer patients RTW within one year of diagnosis and that this figure reaches 89% at 24 months after diagnosis [24]. Notably, Norway has one of the highest rates of RTW among cancer survivors, with 80–90% of survivors returning to employment post-diagnosis [26, 29]. However, the likelihood of RTW differs depending on gender and the specific type of cancer. One study found that, even with the implementation of supportive programs, such as “Rapid-Return to Work,” female cancer survivors still encounter challenges in RTW [30]. Certain types of cancer, such as lung, brain, bone, colorectal, and head-and-neck cancer, as well as treatment with chemotherapy for cancers like leukemia and lymphomas, are associated with higher risks of reduced employment than others [26].
Current research has identified the factors associated with RTW among cancer survivors at various levels. At the individual level, factors such as gender, age, marital status, level of education, income, type of cancer, type of treatment, and psychosocial and physical health conditions have been reported to be linked to RTW [24, 31-36]. Furthermore, current studies have documented social stratification in RTW, wherein cancer survivors with lower socioeconomic status face higher risks of unemployment, impaired work ability, reduced working hours, and financial burdens [29, 37-40]. In addition to the individual level, factors related to the environmental level, such as workplace accommodation and services received from health or vocational support services, have also been reported to be linked to RTW [41-44]. At the occupational level, discrimination at work, low social support, and high work demands are risk factors for not returning to work [7]. Specifically, heavy physical work demands, strenuous work posture and unsupportive work settings have been found to be negatively associated with resuming work after cancer [5, 6, 8, 45].
Although important findings have emerged in previous studies on employment in cancer survivorship, several knowledge gaps exist. First, most studies investigating the effects of occupational factors on RTW have primarily relied on survey or interview data [6, 8, 29, 46-48]. Register data that include entire populations are seldom used, and if they are, information on working conditions has been absent. Second, most cancer survivorship studies have followed up for only 2 or 3 years after diagnosis [34, 44, 49, 50], with only one study, using Norwegian data, that followed up cancer survivors for 9 years [21]. The lack of studies investigating RTW over a long period of time may lead to a limited understanding of RTW across multiple phases, spanning from the early phase (re-entry) to the later phases (retention and maintenance work) after cancer diagnosis and treatment.
Therefore, the primary aim of our study is to compare a cohort of cancer survivors with a cohort of cancer-free employees (1) with respect to employment prospects over a 15-year period and (2) with respect to the differential impact of working conditions on employment over this time period.
We utilize register data to perform a 15-year longitudinal study, considering data from 2006 to 2020, to provide new evidence on the relationship between working conditions and employment after a cancer diagnosis. The study will utilize two job exposure matrices, which will be described in the Methods section, to assess the role of working conditions in the RTW process. Given the evidence regarding social stratification in RTW [39, 41], our study includes position in the socioeconomic hierarchy (i.e., educational level and occupational class), in addition to sociodemographic variables.
The Norwegian institutional context
An employee with an illness or disease is normally entitled to sickness benefits for 1 year. The first 16 days are paid by the employer, whereas the remaining days are paid by the social security administration (NAV). Sickness benefits are equal to the full salary paid by the employer. There is, however, a cap on the benefit. Salary exceeding six times the base amount of social security (in 2023, 111,477 NOK) is not compensated. After one is certified as sick, work-related activities may be required to receive the benefit. The main rule is that the worker is required to carry out such activities within eight weeks. Within four weeks, the employer and the employee must prepare a follow-up plan[1]. If the employee is not ready for work after one year, (s)he may be eligible for a work assessment allowance (WAA). To qualify for a WAA, the ability to work must be impaired by at least 50%. A WAA is based on the pensionable income earned the year before the capacity to work was reduced. A WAA can be received for up to 3 years, and the person is entitled to 66% of the earned income, with a cap of six times the base amount. To have the right to a WAA benefit, the recipient must comply with “the duty to act.” This involves developing an activity plan describing the steps needed to RTW[2]. If RTW fails after a certain period of time, the person may be eligible for a permanent disability benefit.