Part of patient-centered care includes being aware of who the patient is and considering that what a patient does for a living is crucial information in devising a treatment plan.
—Alan Astrow, MD
The most recent figures from the National Cancer Institute put the number of cancer survivors in the United States at nearly 14 million—by 2022, that number is expected to top 18 million. And for the vast majority of those survivors—more than 80%—returning to work after treatment is a top priority and aids in their recovery, according to the results of a survey conducted by Cancer and Careers, an organization serving the needs of working cancer survivors. In addition, fully 60% of survey respondents said they did not take any time off or took only a few days off from their job after receiving a cancer diagnosis.1
With so many cancer survivors remaining in the workforce or returning to the workforce soon after a diagnosis, part of patient-centered oncology care has to address patients’ employment concerns, which may include adjusting treatment plans whenever possible to reduce side effects, that might inhibit job performance, said Alan Astrow, MD, Director of Hematology and Medical Oncology at Maimonides Medical Center in Brooklyn, New York.
Recently, Dr. Astrow addressed the issues of work and cancer during Cancer and Careers’ National Conference in New York. The ASCO Post talked with Dr. Astrow about the impact a cancer diagnosis may have on patients’ professional lives and what oncologists can do to help patients in their decision-making process about when to return to work after cancer treatment.
What is important for patients to know about their treatment side effects and their potential impact on work?
Every patient’s response to treatment is different. Also, the type of treatment often determines how soon a patient can return to work. Patients needing surgery may require time to recover from the acute effects of surgery before returning to work. Radiation and/or chemotherapy cycles, on the other hand, may last for months and may cause acute or gradually cumulative side effects.
Some patients prefer to continue working or may feel that they need to because of limited sick leave, whereas others will find that treatment toxicities hinder their job performance and they are unable to work. For the minority of patients who receive highly intensive chemotherapy, there may be some work environments that need to be avoided until blood counts recover because of the risk of developing an infection.
The patient’s type of cancer, treatment options, general health, and type of job are all factors in determining whether a patient should continue working while undergoing treatment and how soon after treatment she or he can return to work.
Impact on Treatment
How might a patient’s work concerns alter an oncologist’s treatment plan for that patient?
Part of being a good doctor is understanding what is important to the patient. Family, career, and friendships are all key parts of a person’s life. We have a fellowship program at Maimonides Medical Center where we train our fellows to be aware of those aspects of the person’s life. Part of patient-centered care includes being aware of who the patient is and considering that what a patient does for a living is crucial information in devising a treatment plan.
For example, a patient might be a dancer, a pianist, or a construction worker for whom balance or fine motor coordination is crucial. If that patient needed chemotherapy, you might want to take side effects such as peripheral neuropathy into account, to the extent that you have flexibility in designing the treatment plan.
Although you have to prescribe the most effective treatment for a specific cancer, often there are choices, and when there are choices, you try to consider the patient’s needs. The only way to learn the patient’s needs is by asking.
Encouraging Patient Participation
You encourage patients to speak up about their career concerns with their medical team. Patients might be reluctant to do that for a variety of reasons. How can oncologists broach the subject with their patients?
In New York—Brooklyn especially—patients tend not to be shy, which is a good thing. Wellness requires partnership, and I tell patients that there is no such thing as a bad or stupid question.
It is part of the job of the doctor and nurse to elicit the patient’s fears and concerns. For example, they can simply ask the patient, “How are things going at work?” The patient is free to answer or to let it go.
Paying attention to changes in a patient’s demeanor is part of the physician’s relationship with the patient. While the oncologist’s first responsibility is to treat the cancer, cancer is always happening within a person. If the patient seems out of sorts but doesn’t volunteer information, you might say, “You look worried today” and wait for a response. Or you could ask, “What’s on your mind today? Tell me what you are thinking.”
Please talk about your own prostate cancer diagnosis and your concerns about telling colleagues about the diagnosis.
Three years ago, when I found out that I had prostate cancer, I knew I was going to have to be away from the hospital for a number of weeks after surgery, and I wasn’t sure what to do. Should I tell my colleagues or keep that information private? I had to speak to some of the leadership in the hospital about taking a temporary medical leave, and they were very supportive. They left it up to me about how much I wanted to tell colleagues, or whether I wanted to say anything at all about the cancer.
I thought about it for a while and reasoned that if I were away for a few weeks without saying why, it might lead to wild speculation. Since prostate cancer is very common and a number of prominent individuals have been public about their cancer, I decided that the simplest thing would be to be straightforward and tell the doctors in my group. All my colleagues were understanding and encouraging, and I was glad I told them.
Has having cancer changed the way you relate to your patients?
I’ve always had an empathic style. Naturally, I wish I didn’t have to personally experience a cancer diagnosis to add to my appreciation of what patients go through. Still, conveying a healing presence to patients requires that you give something of yourself. You can use your life experiences as a resource to help others—it is the gift of being, or becoming, a physician. Patients with cancer can be anxious—I certainly have been—and I may have a better sense of how that feels and what it means to patients as a result.
How else has having had cancer changed your life?
You are more aware of the passage of time. We don’t live forever, and anything can happen at any moment. A cancer diagnosis can cut through one’s denial in a useful way, and having had cancer has been a reminder to me that if there are things that I’d like to do, enjoy, or accomplish, I should do them.
I don’t know if having cancer had anything to do with it, but since I had prostate surgery 3 years ago, I’ve been unusually productive. I gave one of the keynote talks at the Conference on Religion and Medicine,2 I am involved in several interesting research projects, and I have had papers published in The New England Journal of Medicine3 and the Journal of the American Medical Association.4 I take my time with my children more seriously than ever and I started playing golf again.
I certainly wouldn’t recommend prostate cancer as a form of life therapy, but having the experience has been strangely liberating. It was a reminder that there is no better time to get moving than now. ■
1. Cancer and Careers: Newly released survey reveals the majority of cancer patients and survivors want to continue working. Available at http://www.cancerandcareers.org/en/2012-survey/2012-survey-press-release. Accessed July 25, 2013.
3. Astrow AB, Popp B: The Palliative Care Information Act in real life. N Engl J Med 364:1885-1887, 2011.
4. Astrow AB: Cancer survivorship and beyond. JAMA 30:1639-1640, 2012.