Return to work after cancer treatment of gynecologic cancer in Japan

Gynecologic cancer is one of the most common malignant diseases in working-age women. This study investigated whether several characteristics influence return to work after treatment of gynecologic cancer. We investigated the correlations between return to work and several other characteristics in 199 gynecologic cancer survivors. Questionnaires were distributed to patients with cancer (≥1 year after treatment and age of <65 years) who visited Okayama University. Logistic regression analysis and receiver operating characteristic curves were used to determine whether each characteristic influenced return to work (no return to work or job change) in these gynecologic cancer survivors. For all patients, the mean age at the time of diagnosis was 47.0 years, and the average number of years after treatment was 4.5. Forty-four patients (53.7 %) who were non-regular employees continued to be employed at the same workplace. Non-regular employment had a significantly higher area under the curve (AUC) (0.726) than other characteristics in terms of negatively affecting return to work. Additionally, non-regular employment tended to have a higher AUC (0.618) than other characteristics in terms of job changes. Non-regular employment was the variable most likely to negatively affect return to work and job changes in employed patients who underwent treatment for gynecologic cancer.


Background
The incidence of gynecologic malignancy has increased in recent years in Japan, with an estimated 30,964 newly diagnosed patients in 2009 [1]. The Japan Society of Obstetrics and Gynecology reported that about 70 % of all patients diagnosed with cancer in Japan were of working age (20-64 years old) [2]. Gynecologic cancer is one of the most common malignant diseases in working-age women, and improvements in the management of gynecologic cancer have increased the survival rate in patients with this disease. Several studies have reported that an average of 60 to 67 % of patients who had worked before their cancer diagnosis returned to work after the initial treatments [3][4][5][6][7]. However, the patients with cancer for whom return to work was investigated and validated included few patients with gynecologic cancer; thus, the applicability of such an investigation of these patients has not been established. This study aimed to clarify the status of return to work among gynecologic cancer survivors.

Study population
Questionnaires were distributed to gynecologic cancer survivors (≥1 year after treatment and age of <65 years) who visited Okayama University for consultation from 28 May 2015 to 28 December 2015. All patients were informed about the survey by their consultant doctors and provided written informed consent to participate in this study. All answers were voluntary. Completed questionnaires were collected using in-hospital collection boxes. This study protocol was approved by the Institutional Review Board of Okayama University Hospital (No. 1504-001). The dataset comprised responses from 199 gynecologic cancer survivors who were employed and working at the time of their cancer diagnosis. Table 1 shows the distribution of the questionnaires with gynecologic cancer survivors (type of employments, work days per week, work time per day, number of people at workplace, personal income, household income, return to work, the work day per week after treatment, the working hours after treatment, person income after treatment, physical and psychological uneasiness after treatment).

Study variables
The type of employment at diagnosis was categorized according to the patients' responses as follows: selfemployed, publicly employed (teacher, dietician, care person), regularly employed (permanently employed), or non-regularly employed (part-time workers, temporary workers, contract-based workers, and dispatched workers). The patients also provided information on the following characteristics: age, marital status, children or no children, cancer site, cancer stage, treatment duration, employment pattern, work days per week, work time per day, number of people at workplace, personal income, household income, physical uneasiness, psychological uneasiness, and return to work (no return to work or change in job). Finally, we examined the correlations between job changes and reinstatement time and between work time and personal income.

Statistical analysis
Statistical analyses were performed using the Mann-Whitney U-test. A receiver operating characteristic (ROC) curve was generated, and the area under the curve (AUC) was calculated to evaluate the discriminatory ability of each scoring system. We also examined the data in crosstabulated form to explore return to work (no return to work or change in job). Analyses were performed using SPSS software, version 20.0 (IBM Corp., Armonk, NY USA). A P value of <0.05 was considered statistically significant.
In this study, 32 patients (16.1 %) did not return to work and 25 patients (12.6 %) changed their job. These patients were investigated in terms of their relationship with each employment pattern. Patients who did not return to work (including because their business closed) were distributed as follows: self-employed (n = 3, 9.7 %), regularly employed (n = 4, 5.9 %), and non-regularly employed (n = 25, 30.5 %). Patients who changed their jobs were distributed as follows: publicly employed (n = 2, 11.1 %), regularly employed (n = 10, 14.7 %), and nonregularly employed (n = 13, 15.9 %). Interestingly, of the  (Fig. 1). We investigated correlations among each characteristic; i.e., age, marital status, children, cancer site, cancer stage, treatment duration, employment pattern, work days per week, work time per day, number of people at workplace, personal income, household income, physical uneasiness, psychological uneasiness, and no return to work or job change. We used ROC curve analyses to predict no return to work or job change. Non-regularly employed patients had a significantly higher AUC (0.726) than did other characteristics in terms of negatively affecting return to work. Additionally, non-regular employment tended to have a higher AUC (0.618) than did other characteristics in terms of job change. Moreover, personal income had a significantly high AUC (0.648) in terms of negatively affecting return to work ( Fig. 2 and Table 3).
To examine the correlations of employed workplace (same workplace/job change) and employment (non-regular employment/self-, public, and regular employment) with the reinstatement time, work time, and personal income, we divided return to work (including a job change) after treatment into four groups: Group 1, same workplace plus self-, public, or regular employment (n = 94); Group 2, job change plus self-, public, or regular employment (n = 11); Group 3, same workplace plus non-regular employment (n = 38); and Group 4, job change plus non-regular employment (n = 14). The percentage of patients with a >6-month reinstatement was significantly higher in Group 2 than Group 1 (p < 0.001) and was significantly higher in Group 4 than in Group 3 (p < 0.001). The percentage of reduced work time was significantly higher in Group 2 than in Group 1 (p < 0.05) and was significantly higher in Group 4 than in Group 3 (p < 0.05). There was a significant difference in the percentage of reduced personal income between Groups 2 and 1 (p < 0.001) and between Group 4 and Group 3 (p < 0.05, respectively) (Fig. 3).

Discussion
Cancer treatment options are improving, and the number of cancer survivors thus continues to grow. Returning to Fig. 1 A total of 199 patients with gynecologic cancer were working at the time of cancer diagnosis work after treatment is important for the patient's quality of life, financial security, restoration of a stable social environment, and the feeling of normality in both patients and their family. Returning to work can improve the quality of life of cancer survivors, and could be a symbol of recovery and return to a normal life [5,8]. Returning to work may help patients overcome the negative impacts of disease treatments, has a positive financial outcome for patients, and reduces the economic burden of cancer on society [9,10]. Many cancer survivors are able to return to work [11][12][13], but are likely to encounter significant difficulties as a result of reduced working hours, fatigue, and exhaustion [3,[14][15][16][17][18]. In a systematic review, Spelten et al. [5]   cancer diagnosis returned to work after the initial treatments [3][4][5][6][7]. In Japan, Ito et al. [19] reported that 75.8 % of cancer survivors had returned to work. The present study thus aimed to clarify the status of returning to work among gynecologic cancer survivors. A high proportion of patients (71.3 %) in this study returned to work at the same workplace. Furthermore, 83.9 % of gynecologic cancer survivors who had worked before their cancer diagnosis returned to work, included those who experienced a job change after treatment. The findings of this study are consistent with the results obtained for patients with other diseases and confirm that a significant percentage of survivors quit working for cancer-related reasons.
In this study, 16.1 % of patients did not return to work, and 12.6 % patients changed their job. We investigated the employment patterns and status of returning to work in patients with gynecologic cancer. No return to work (including because the business closed) occurred in 9.7 % of self-employed patients, 5.9 % of regularly employed patients, and 30.5 % of non-regularly employed patients. Those who changed their jobs constituted 11.1 %  In patients with breast cancer, returning to work is associated with several risk factors such as sociodemographic factors, disease-related factors, treatment-related factors, psychological factors, and work-related factors [20]. We investigated the correlations between each characteristic and no return to work or job change. Our results showed that non-regular employment was the variable most likely to negatively affect return to work and job change. Interestingly, the findings of this study confirm that a significant percentage of survivors quit working for reasons related to their employment pattern. Among all employment patterns (non-regular, self-, public, and regular employment), significantly more patients experienced job changes than returned to work at the same workplace on the >6 months reinstatement after treatment. Among all employment patterns, significantly fewer patients changed jobs than returned to work at the same workplace on work times and personal income after treatment. The findings of this study confirm that change the job patients were significant high percentage of survivors extended reinstatement or considerably reduced their work hours and income.
We acknowledge that our study has some limitations. The number of patients was relatively small, and the examination was performed at a single facility. Further prospective studies involving more patients and facilities would provide more definitive data with which to clarify the significance of our findings.

Conclusions
Gynecologic cancer is one of the most common malignant diseases in working-age women. This study has revealed the status of returning to work in patients with gynecologic cancer. The present findings suggest that non-regular employment was the variable most likely to negatively affect return to work and job change in gynecologic cancer survivors. A high proportion of patients (71.3 %) in this study returned to work at the same workplace. However, 53.7 % of non-regularly employed patients continued to be employed at the same workplace. Non-regular employment was the variable most likely to negatively affect return to work and job change. Prevention of not returning to work and changing jobs may be one of the most important factors for positive relationships with the patient, employer, and society. Social support should be established to ensure satisfactory return to work.
Abbreviations AUC, area under the curve; ROC, receiver operating characteristic