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April 14, 2016

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Cancer survivors: the C Word

“Have you heard that Susie’s got cancer?”

Whispered conversations like this probably take place daily around water-coolers, in toilets and canteens across the UK. What happens next is usually fairly predictable — an email goes around about a collection to send some flowers (or something more potent) and a ‘get well’ card. After a variable period of time, the recipient of the gift(s) may return to work, and receive an effusive welcome from fellow employees. However, as things return to normal, and performance is mentally assessed then the mutterings of “Susie’s never been the same since…” might begin.
Why an article about cancer in a health and safety magazine?
  1. Because of the 311,000 new cases diagnosed in the UK in 2011, about 110,000 of them occurred in people of working age.1;
  2. Diagnosis is generally followed by treatment, which produces a group of survivors. In 2008, this population had grown to about 577,000 in the 45-64-year-old age group.2;
  3. Cancer survival is improving, with nearly 60 per cent of adults now still alive five years after diagnosis;3 and
  4. For a variety of reasons, more employees will be working on beyond what used to be regarded as the default retirement ages of 60 and 65.4
More safety advisors will find they’re being asked for guidance about how to reintegrate an increasing number of cancer survivors who are seeking to resume their jobs, their expectations being raised by the fact that the disability provisions of the Equality Act 2010 will almost certainly apply to them, and the start date being backdated to the date of diagnosis.5 This means that the employer is required to make reasonable adjustments to enable the employee to carry out the core duties of their jobs.
The disease is common — about one third of the population will suffer from cancer at some point in their lives6, and it will feature on the death certificates of over 25 per cent.7 In other words, one in three of SHP’s readers, contributors and staff will be afflicted by it, and not less than one in four will die from it.
Also, there seems to be a tendency to regard cancer as a single disease. It’s not. The 10th edition of the International Classification of Diseases lists 97 different types of cancer. These tumours affect different ages, genders, have differing causes (insofar as they are known), treatments and outlooks. Thus Wilms’ tumours (of the kidney) and neuroblastomas commonly affect pre-school children, older children may suffer from acute leukaemia, and young men testicular cancer. Prostate cancer attacks only men, while cervical cancer, only women.
Treatments differ — some tumours can be cut out, others are subjected to chemotherapy and still others to various forms of radiation. Any two, or even all three of these therapeutic modes may be combined.
Finally, the prognosis may vary. At one extreme, over 95 per cent of men with testicular cancer and 85 per cent of women with breast cancer are still alive five years after diagnosis, while at the other, five-year survival rates for lung and pancreatic cancers are still measured in single figures (eight and five per cent respectively).8
Once initial treatment has finished, survivors will follow one of a number of paths. Some will be completely cured of their disease, and it will not return for the rest of their life. Others will be completely cured, but at some expense — they may suffer deformity as a result of amputation, or a skin defect that requires a graft to cover it; or problems with continence as a result of bladder or bowel surgery, for example. Others will have to live with the active disease because the cancer recurs after a period of remission, or the tumour is diagnosed at a late stage. Finally, in some cases, patients will be diagnosed with an indolent tumour which causes few problems during life, so that they die with a cancer, but from another cause.9
However, while cancer can affect anyone of any age, the incidence — particularly of common tumours such as breast, prostate, lung and colon, responsible for about half the new cases each year — rises steeply with age (see figure 1).
Despite legislation such as the Equality Act 2010, and its predecessor, the Disability Discrimination Act 1995, cancer sufferers may seem to face a rather raw deal.  At the moment, there is plenty of scope for improvement. For example, cancer survivors are almost one and a half times more likely to be unemployed than those who are healthy.10  Even where employers were perceived to be supportive (and the large majority, 75 per cent, were felt to be so inclined) a survey conducted in the UK showed that full-time employment fell from 53 per cent to 33 per cent before and after diagnosis, with average hours per week reduced from 38 to 32.11
To some extent, this could be attributed to the effects of the tumour, since cancer sufferers are often reported as enjoying less ‘good health’ than their contemporaries.12 On the other hand, there is the distinct possibility that, following a brush with a life-threatening disease, some might choose to review their work/life balance.
This is because, at some point, the biopsychosocial factors come into play. Some of these characteristics are very difficult to quantify, but include age, educational level of employee, interpersonal relationships, whether the work is strenuous, and extent of adaptations available.9
Interestingly, one factor that seemed to be important was the extent to which treating physicians, surgeons and GPs were involved in discussions about returning to work. These usually had to be instigated by the employee/patient, but whenever they occurred, and irrespective of who raised the matter, the result was that the employee was able to resume a greater number of hours per week than those who were more passive (36.7 vs 29.4). Furthermore, these discussions were reported as being “very satisfying” by 55 per cent, compared to only four per cent who were “dissatisfied”.11
The main difficulties that cancer survivors will confront on returning to work include fatigue, possible immunosuppression, and psychological effects. These may arise from the effects of the tumour — in fact, they may form part of the prodromal symptoms that lead to the initial diagnosis of the cancer — or its treatment.
Cancer-related fatigue is defined by the National Comprehensive Cancer Network as “a distressing, persistent, subjective sense of physical, emotional and/or cognitive tiredness related to cancer or cancer treatment that is not proportionate to recent activity, and interferes with usual functioning.”
Fatigue is surprisingly common, and will affect at least three quarters of survivors at some point.12 It can last for several months, and although improvement usually occurs in due course, it is not guaranteed. Causes of fatigue include the wasting that can accompany some cancers, associated loss of appetite, nausea and vomiting, which may also be associated with cyclical medication such as chemotherapy, poor sleep — which may of itself have multiple causes — and co-existing disease and its treatment.9
Determining the exact cause is best left to occupational health staff who may be able to liaise with the treating team, but there is no reason why a safety advisor should not tactfully enquire about the presence of persistent fatigue, and suggest ways in which this burden could be lessened. This could include:
  • reducing hours worked, or amending start and/or finishing times so that the employee does not have to cope with the pressures of rush-hour travelling;
  • reallocation of work so that the most strenuous tasks are done by others, the survivor’s self-esteem being salvaged by taking over some of the others duties particularly if the situation seems to be set for the medium or distant future; and
  • participation in appropriate levels of graded exercise may also help to reduce fatigue.
Immunosuppression occurs when the body’s immune system is compromised, and the worker becomes more susceptible to infections — they may get infections more easily, and/or they may be affected more seriously.  It often occurs in association with chemotherapy, but its severity may vary. The immune system is a complex combination of infection-fighting cells which engulf ‘foreign’ germs, and chemicals such as antibodies and inflammatory markers that assist in the location and destruction of invading micro-organisms. A few components can be easily measured, but most cannot.
The problems posed by immunosuppression arise most commonly with workers who may be exposed to infection in the course of their work, e.g. healthcare workers who, incidentally, may represent a hazard to patients under their care since the immunocompromised employee can disseminate infection more readily.
Another group of workers for whom this is relevant are those who travel, particularly to more exotic locations. If vaccination is required, then the administration of live or attenuated vaccines such as yellow fever or MMR should normally be avoided during periods when the immune system is suppressed, since the body may not mount the normal response to the vaccine, and may even develop some symptoms of the disease that the vaccination was supposed to prevent.
However, inactivated vaccines (flu, typhoid, cholera) can usually be administered in accordance with relevant immunisation schedules. If immunosuppression is severe, it is possible that the employee will not be well enough to be at work, which will reduce problems associated with mixing with crowds, particularly if there is an epidemic in the community.
A diagnosis of any major life-threatening illness can give rise to a great deal of distress. When this occurs, it is important to avoid ‘medicalising’ matters while remaining alert to the possibility that the employee may have developed symptoms which are consistent with a diagnosis of a significant mental health disorder, such as anxiety or depression.
This will be best dealt with by ensuring that the person is aware of the availability of counselling services, such as Macmillan, whose website has a section offering advice to employees.13 ‘Talking therapies’ are sometimes derided, but appropriate ones have been shown to be at least as effective as medication in the treatment of mild to moderate anxiety and depression. Furthermore, they can also impart useful coping strategies. Do not underestimate the value of tactful support from colleagues and line managers.
Safety advisors should take a particular interest if the employee’s job involves driving. In order to drive safely, the driver needs to be able to co-ordinate input from a variety of senses — particularly vision — with actions to control the vehicle safely. Some cancers, particularly lung cancer, tend to spread to the brain, raising the possibility of sudden incapacitation through seizures or strokes. Furthermore, medicines used to control symptoms have the potential to interfere with cognitive function. A careful risk assessment is essential to decide whether it is appropriate, or not, for driving to continue and it may be helpful to approach the Driver & Vehicle Licensing Agency for advice, after studying the At a glance publication.14 Since the document is written for medical practitioners, it may be helpful to have access to occupational health advice.
This article has tended to assume that the cancer suffered by the employee is incidental to his or her work. In most instances, this is so, but some safety advisors will be employed by organisations that potentially expose workers to known carcinogens, such as asbestos, ionising radiation, solar radiation, nickel and chromium compounds. If so, it is essential to ensure that all steps have been taken to ensure that the risks arising from these compounds or agents are well controlled. Furthermore, although only about five per cent of cancers arise from workplace activities15, the possibility of new carcinogens must always be borne in mind, so vigilance is vital, and discussion with colleagues who work in the same sector may help to get a better understanding of the potential scale of the problem.
The diagnosis of cancer will often represent a life-changing event for an employee. Despite the problems that this may cause, being able to continue working is often essential to that person’s wellbeing, and is often rated second only to the effects that the disease will have on other family members.
Many will mean well, and claim to have the sufferer’s best interests at heart, but the safety advisor who is aware of the hazards, has a good knowledge of the workplace and knows where to go for advice on matters which are outwith their understanding will be best placed to advise the employee and their managers of ways in which the sufferer can continue to work productively.
References
2. Maddams J, Brewster D, Gavin A, et al. Cancer prevalence in the United Kingdom: estimates for 2008. Brit J Cancer 2009;101:541-47.
5. Howard GS, Williams T, Disability and Equality Law. In Fitness for work –  the medical aspects. 5th. Edn 2013 Eds Palmer KT, Brown I, Hobson J Oxford University Press p 42-68
9. Wynn P, D’Sa S. Cancer survivorship and work. In Fitness for work — the medical aspects. Eds Palmer KT, Brown I, Hobson J.  5th Edition 2013, Oxford University Press p621 — 38.
10. de Boer AG, Taskila T, Tamminga SJ et al. Interventions to enhance return to work in cancer patients. Cochrane Database Syst Rev 2011, Feb 16:2CD007569.doi.10.1002/1465
11. Luker, K Campbell M, Amir Z, Davies L A UK survey of the impact of cancer on employment. Occup Med 2013,63;7:494-500.
12. Ahlberg K, Ekman T, Gastom-Johannson F, Mock V. Assessment and management of cancer-related fatigue in adults. Lancet 2003;362(9384):640-650.
15. http://www.hse.gov.uk/research/rrhtm/rr800.htm (Accessed 2 February 2014)
Dr Chris Ide is an occupational physician and regular contributor to SHP. The author would like to thank Mrs AMM Ide for helpful comment.
This article was original published in SHP magazine in March 2014.

What makes us susceptible to burnout?

In this episode  of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.

We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.

stress

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Jan Moore
Jan Moore
10 years ago

An excellent article above. I am a health and safety advisor (a non-smoker)who was diagnosed with lung cancer in 2007. Following diagnosis came 12 weeks of chemotherapy and a month long daily dose of radiotherapy. I took no time from work throughout but was not assessed to see if I could cope. I self assessed and decided when colleagues (open office scenario) were at work with ‘flu symptoms etc., felt it better to work from home. This was “not allowed”. I have since turned this around and hopefully have educated those I work alongside, particularly management. It is the mental… Read more »