Commentary (Moore): Are Cancer Patients Subject to Employment Discrimination?

Mark Rothstein and colleagues have tackled a difficult and sensitive subject: the existence of, and reasons for, employment discrimination against cancer victims. Employment discrimination in any chronic disease is not uncommon, but may be even more widespread in cancer patients, whose treatment is very lengthy, often physically or mentally debilitating, and usually exceedingly expensive. Because improved therapeutic approaches to the treatment of cancer have led to increased rates of survival, there will be more and more survivors in our society in the future. In pediatric cancer, therapeutic advances continue to increase the survival rate, which now is estimated at about 70% overall [1]. Thus, the potential for increasingly greater numbers of employable cancer survivors is high. And with children, although representing only 1% of all cancers, the actual number of person-years saved will be exceedingly high [1]. Adult cancers are diagnosed at more advanced age and in many cases the patient is near retirement age. Nevertheless, the issue of employability and job discrimination is very important to resolve.

The number of cancer survivors in the United States currently stands at more than 5 million [2]. As the Rothstein article demonstrates, many of these survivors are willing and able to stay in or re-enter the work force with the potential for many years of additional productivity. Almost 1,100 complaints of cancer-based discrimination by employers were reported to federal courts in 1994. Among persons seeking a new job, 12% said they were not hired because of their cancer diagnosis.

A Surprising Finding

Rothstein et al examined the association of age, occupation, gender, and employer size with incidents of alleged discrimination. One might assume that small employers would be less accommodating to cancer patients because of the lack of a sufficient worker pool to draw from to cover the responsibilities of the patient. However, small employers were more likely than employers of over 250 workers to offer special consideration, such as flex-time, to cancer patients.

Regarding occupation, the survey indicated that laborers were more likely to have their duties taken over by others, whereas professionals were least likely. Job-lock, the practice of staying with an employer for insurability reasons, was especially important; up to 88% of those surveyed indicated that health insurance was a primary reason for staying with their employer. Gender effects on employment status of workers with cancer were slight and thought to be more related to occupation.

Who Bears the Costs?

In the managed care environment of our emerging healthcare system, the willingness of insurers to pay for expensive treatments will continue to wane, sometimes being "justified" by saying that certain treatments are only marginally effective. That leaves patients in the predicament of possibly having to pick up more of the cost of treatment themselves, plus other expenses, such as food, lodging, transportation, child care, and so on [3].

Those of lower socioeconomic status are already at a significantly higher risk of cancer mortality [4]. One of several possible explanations for lower survival rates among the poor and undereducated is the lack of access to adequate medical care. Added to their existing financial burdens, the possible loss of wages due to the diagnosis of cancer can be financially catastrophic.

In addition to the financial costs falling directly on the patient, the employer must bear part of the cost of insurance. Therein lies the problem. Because of the financial incentive to remove a cancer patient from their health insurance rolls, employers may not be motivated to bend over backwards to comply with the Americans with Disabilities Act [5].

A Need for Clarification

The Rothstein et al study involved 422 participants who returned questionnaires regarding their "perceived employment discrimination associated with a diagnosis or history of cancer." It was not clear how many questionnaires were originally sent out, thus estimates of return-rate were not available. In addition, the survey took place between the months of May and September when teachers would be on summer break. It would have helped to have the 19 questions published with the article to evaluate whether this might be a problem and also to evaluate the potential for ascertainment bias.

A rather surprising statistic was that there was a 24% unemployment rate before the diagnosis of cancer. This is much higher than the national norm, but the reasons for such a high rate in this survey were not clear. The unemployment rate rose to 44% at the time of the study.

One other aspect of the study was somewhat unclear. That had to do with the actual treatment status of the participants at the time of the study. Both in-treatment and off-treatment patients were included. The reasons for unemployment in those two groups could conceivably be quite different. Some patients might have had to temporarily relocate in order to receive treatment, thus making continued employment impractical. Or, acute treatment with everyday radiotherapy or lengthy hospitalizations might have influenced the work status of participants. It might have been helpful to survey long-term survivors who were off therapy to see what obstructions to employment they faced once their disease was under control.

This study confirmed that cancer patients are at risk for unemployment, sometimes for reasons that are unjustifiable. The most blatant form of job discrimination, being fired because of a cancer diagnosis, was reported in 27% of the participants. Although reasons were not given (in some patients, perhaps the only job available could no longer be performed by them), undoubtedly many reasons were because employers were unwilling to make modifications, job reassignments, or special allowances (eg, flex-time) or because of a desire to decrease their health insurance cost.

It is clear that most persons with cancer experience a radical change in their employment. Some degree of protection will be afforded by the Americans with Disabilities Act in survivors of cancer. But it will also take a change in attitude by all employers so that they can balance their need for productivity and financial health with a moral responsibility, when at all feasible, to not turn their back on loyal employees.

References:

1. Bleyer WA: The impact of childhood cancer on the United States and the world. CA Cancer J Clin 40(6):355-367, 1990.

2. Cancer Facts & Figures. American Cancer Society, Atlanta, GA, 1995.

3. Lansky SB: The high cost of cancer. Am J Pediatr Hematol Oncol 9(1):89-91, 1987.

4. Cella DF, Orav EJ, Kornblith AB, et al: Socioeconomic status and cancer survival. J Clin Oncol 9(8):1500-1509, 1991.

5. West J (ed): The Americans with Disabilities Act-from Policy to Practice. New York, Milbank Memorial Fund, 1991.