White Paper: The Impact of Breast Cancer

on the Workplace

HealthAdvocate2 |

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Breast cancer is an issue that will likely affect every workplace at some point. About 1 in 8 women in the U.S. will develop breast cancer during their lifetime and it’s typically diagnosed in the prime working years. As of 2012, there are more than two million survivors of breast cancer in the U.S. and many more survivors are returning to work after short absences than ever before. As more effective interventions emerge and diagnoses increase among an aging workforce, more employers will face the dual challenges of accommodating their valued workers and cancer’s rising costs.1

Breast cancer is an expensive disease and ranks the highest in costs of all cancers. The National Cancer Institute predicts that by 2020, the direct medical costs of breast cancer will reach $20 billion a year, up from the $16 billion in 2010. The costs of lost productivity from intermittent time off for treatments and recovery boosts the costs even higher.2

As a related trend impacting costs, more employed family members are taking care of loved ones with cancer. Most caregivers work and the majority report having to make changes to their work including taking time off.3

“As a chronic disease that often requires ongoing management, the employer’s role in helping workers affected by cancer reach their highest potential cannot be underestimated,” says Marisa Weiss, M.D., radiation oncologist and President and Founder of Breastcancer.org.4

This White Paper reviews the research on the financial and emotional impact of breast cancer in the workplace. The emphasis is on creating carefully designed policies, procedures and support services that can help increase productivity, lower costs and most importantly, help employers retain their most valuable asset—their employees.

Breast Cancer The Impact on the Workplace

What Employers Need to Know

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There is no “average” breast cancer patient. The disease, symptoms, treatments received and reasons to return to work differ from individual to individual. Breast cancer survivors want and need to work for the income and health insurance as well as for the self-esteem and social support that contribute to their quality of life.4

The stage of the cancer at diagnosis, the type of treatment received, and the individual’s response can largely determine how soon a woman is able to return to work and function at an optimal level.

In general, research shows that the majority of breast cancer survivors who go back to work are able to return to their pre-diagnosis job routine with little or no loss in productivity.

In a 2008 survey, researchers found that, overall, productivity for breast cancer survivors is only three percent lower than for healthier workers. This adds up to 2.48 hours of lost work productivity over two weeks of full-time employment.6

Similarly, a more recent Swedish study, reported in 2012, involving more than 500 employed breast cancer patients, showed that three-fourths of the women returned to their normal job routine and 72 percent returned without having to change their schedules.5

Earlier research conducted by the National Cancer Institute using data from the Health and Retirement study found that among survivors who remained working, breast cancer had no negative effect on the hours they worked.7

Characteristics of Working Survivors

Employees Returning to Work After a Cancer Diagnosis

[Source: Unum. Cancer, pregnancy lead causes of Unum’s disability claims: related education and outreach offer support for individuals and employers. Unum. News Release, April 28, 2011.]

Type of Cancer 2001 2008Breast Cancer 47% 52%Prostate Cancer 28% 30%Colon Cancer 23% 30%

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Most women treated for breast cancer return to their prediagnosis job routine.

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Cancer is one of the three most costly conditions and breast cancer has the highest medical costs, especially in the initial phase of care. The cost to American companies exceeds $264 billion per year in health-care costs and lost productivity.2

As far as the specific costs related to breast cancer survivors, researchers at the Cleveland Clinic found that absenteeism, for example, costs $1,900 per breast cancer patient per year and breast cancer patients took 51 days of short-term disability versus 5 days taken by those without cancer.10

Bearing the Costs

Despite these findings, research indicates that the length of leave and days missed, as well as productivity, can depend on whether or not a breast cancer survivor receives chemotherapy.

For example, a 2009 National Institutes of Health study showed that while most women (93 percent) continued to work, chemotherapy recipients were more likely to go on long-term disability, stop working or retire than non-recipients. This was especially true for women age 54 and older. (Radiation did not influence employment.)8

The ability to function at an optimal level can be affected by side effects related to the chemotherapy or other treatments, or even the disease itself. The range of effects can include fatigue, nausea, temporary difficulties with memory and concentration, physical changes such as hair loss, depression, coping with a new self-image, money and legal concerns, and fears concerning the impact on families.9

Chemotherapy Influences Absenteeism and Productivity

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Spiraling Out-of-Pocket Costs

As healthcare costs shift to employees, many breast cancer patients are faced with out-of-pocket costs that can sometimes be crippling.

In a study published in the Journal of the American Medical Association in 2010, figures from 2003-2004 showed that while the median out-of-pocket costs for treatment of breast cancer patients was $1,500, ten percent of patients had total out-of-pocket costs that exceeded $18,000.11

For some patients, the exorbitant expenses can interfere with adherence to treatments. A Harvard School of Public Health survey found that 1 in 12 (eight percent) of insured cancer patients report delaying their treatment or deciding not to get care because of the cost.12

Noncompliance can lead to deterioration in health, prompting more doctor and emergency room visits, and hospitalizations. This, in turn, can increase costs.12

The Cost of Caregiving Three out of four families have at least one member who is a cancer survivor.

As the trend moves from hospitalization to more outpatient care, the pool of caregiving employees—and the effects on their work—is likely to increase. In general, seven in ten caregivers report making changes such as cutting back on hours, changing jobs, stopping work entirely, or taking a leave of absence. More than half of women and a third of men experience workday interruptions as a result of caregiving.3,13

In total, employers in the U.S. pay between $17 billion and more than $33 billion in lost productivity for full-time employed caregivers. These costs include replacing employees, absenteeism and workday interruptions. Additional costs relate to stress and anxiety, which has a high incidence among caregivers.14

Furthermore, caregivers also experience costly chronic conditions including heart disease and depression. In fact, compared to non-caregiver employees, working caregivers have 8 percent higher healthcare costs.15

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To retain valuable workers and reduce costs, employers need to create policies and programs that provide resources and help support employees affected by breast cancer. This ensures that employees can return to work successfully and remain productive.

Researchers at Michigan State University studying breast cancer survivors found that more than 80 percent of the study participants returned to work. Eighty-seven percent said their employer was accommodating to their cancer illness and treatment. Conversely, the researchers also found that perceived employer discrimination because of cancer was negatively associated with return to work.16

The Role of the Employer

Review Leave Policies Cancer is a leading cause of long-term disability and the sixth leading cause of short-term disability. As more survivors return to work, creating a flexible intermittent leave policy that addresses cancer can be critical to their return-to-work success.13,17

Returning to work is more likely when employees perceive that their employer is supportive of their illness and treatment.

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Cancer is a sensitive, personal and individualized issue for the employee. Plans should include in-network access to an Employee Assistance Program, staffed with specialized health experts who are experienced in counseling about cancer-related issues. The program should be made available to employees and their dependents as well as for employees caring for loved ones with cancer.17

Providing EAP services can result in a successful return to work and shorter leaves. In a survey conducted by the Hartford Services Financial Group, for the general employee population, those who had access to an EAP while on short-term disability (STD) returned to work twice as often as employees who did not have an EAP available to them. And for employees with cancer who used the EAP, the duration of the STD claim was approximately 64 days, compared to 71 days for those who did not use the EAP.18

The Importance of Employee Assistance Programs

Employees with cancer who use EAP services during STD, have shorter leaves.

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“It’s very important that managers know how to involve employees in decisions about their work,” says Bert Alicea, MA, CEAP, Licensed Psychologist and Vice President of EAP+Work/Life Services at Health Advocate. “This includes whether they want other coworkers to know about their diagnosis. Confidentiality should be respected.”17

Additionally, EAP professionals should be available to help coworkers who may have questions and concerns about their colleagues who have cancer and how to cope with any additional work duties they may be assigned related to their colleague’s illness.17

Appropriate training of managers and supervisors is also crucial. Studies indicate that understanding and acceptance from colleagues is a factor associated with the survivor’s work ability. Research conducted in 2012 involving survivors of breast, prostate and testicular cancer revealed that reduced work ability was associated with chemotherapy, as well as low workplace support, low organizational commitment, and avoidance behavior from colleagues and supervisors.19

Finally, the EAP staff can also provide bereavement counseling and serve as a key referral source for community resources, transportation, childcare, eldercare, and financial and legal help.17

Support for Survivors, Coworkers and Managers

It’s especially important for employers to provide information about local support groups and online support groups.17 The importance of these groups cannot be underestimated, says Alicea. “Support groups can help people overcome the aloneness and helplessness that often accompanies a cancer diagnosis. Sharing with people in the same situation can help survivors better cope with their disease.”

Provide Information About Support Groups

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Adhere to ADA and FMLA laws

The Americans with Disabilities Act (ADA) and the Family and Medical Leave Act (FMLA) are federal laws that provide cancer survivors with some protection against employment discrimination and job loss due to illness. It’s crucial that employers are fully familiar with these laws.20

Employers should know how cancer qualifies as a disability, when they may ask an applicant or employee questions about their cancer and how to treat voluntary disclosure, what types of reasonable accommodations employees with cancer may need, and how employers can ensure against discriminating against applicants and employees.20

Employers should keep these facts in mind:20

• Under the ADA, an employer cannot refuse to hire or refuse to continue to employ a person with a disability (including cancer), as long as that person is able and qualified to do the job. The law applies to any private employer, including state and local governments, with 15 or more employees.20

• The law applies to job application, hiring, termination, compensation, leave of absence, sick leave and other benefits.20

• Under the ADA, cancer is a disability when it or its side effects substantially limit(s) one or more of a person’s major life activities.20

• Employers cannot discriminate against workers who care for a person with a disability.21

Americans with Disabilities Act (ADA)

The Family and Medical Leave Act (FMLA) requires employers that offer health insurance to their eligible employees up to 12 work weeks of unpaid, job-protected leave per year. The employee’s group health benefits must be maintained during the leave. FMLA may be taken at intervals or taken all together in 12 weeks.22,23

The law covers employees who are unable to work because of a serious health condition. As it relates to breast cancer, this includes employees who may need time to recover from surgery, chemotherapy or other side effects of breast cancer treatment. The law also includes leave for employees who care for an immediate family member (spouse, child or parent) with a serious health condition.22,23

Family and Medical Leave Act (FMLA)

Be Aware of WHCRA The Women’s Health and Cancer Rights Act (WHCRA) is a federal law that requires most group insurance plans that cover mastectomies to also cover breast reconstruction. The law applies to group health plans, health insurance companies and HMOs, as long as the plan covers medical and surgical costs for mastectomy.24

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Make Reasonable Accommodations

The ADA requires employers to make reasonable accommodations that are needed because of limitations caused by both the cancer itself, and the side effects of medication and/or treatment of cancer.25

Accommodations can vary depending on the needs of an individual and may include: restructured work schedules, work at home, reallocation or redistribution of marginal tasks to another employee, reassignment to another job, and making the workplace easier to navigate.25

An employer is only required to accommodate a “known” disability of the applicant or employee. The employee is responsible for notifying the employer of the disability; the employer is not obligated to provide accommodations if the employee does not ask.25

“Appropriate accommodations depend on a woman’s treatment and response,” says Dr. Weiss, President and founder of Breastcancer.org.4

For example, a woman who has undergone a ten-hour surgery may need different accommodations than a woman who has had a four- hour surgery. Similarly, for every hour of anesthesia, one week of recovery is required. If a woman has ten hours of anesthesia, she may need ten weeks of recovery.4

“The employer and employee should create a workable plan together,” says Dr. Weiss.4

Tailor the Accommodations

In a survey conducted by Breastcancer.org involving breast cancer survivors, employees made the following requests of their employers:26

• 73% requested time off for medical appointments or treatments

• 29% requested reduced hours during recovery

• 18% requested non participation in some activities due to treatment side effects (for example, opting out of a work meeting due to nausea or fatigue)

• 10% requested accommodations for new routines at work

The same survey showed that 69 percent of the survivors reported that their employers developed a work plan, 42 percent offered flex time, 24 percent offered reduced hours, and 20 percent offered the option to work at home.26

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Not all cancer survivors will require accommodations and most of the accommodations a person needs may cost little or nothing.2,25

According to the Job Accommodation Network, a division of the U.S. Department of Labor, two-thirds of accommodations for any disability, not just cancer, cost less than $500; a quarter cost nothing at all. Yet, more than half of the employers surveyed said that each accommodation benefited their organization an average of $5,000.27

Low-cost Accommodations Have High Impact

Small Gestures Count “Major policy changes are not always necessary to help coworkers feel supported and better able to perform their job,” says Kate Sweeney, cofounder and Executive Director at Cancer and Careers.

As an example, supplying a shorter file cabinet makes it easier for a women recovering from surgery to reach. “Simple changes can make a huge difference for the individual, both physically and emotionally,” Sweeney says.

Even expressing that “we will work it out together” is a powerful, compassionate gesture of support.

Two-thirds of accomodations requested for those with any disability—not just cancer—costs less than $500.

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It’s important to make sure that those diagnosed with cancer understand all the applicable employee benefits as well as COBRA (Consolidated Omnibus Budget Reconciliation Act). COBRA helps employees keep their group insurance coverage if they are laid off, their hours are reduced, or their position is eliminated. Social Security Disability Insurance may be an option for those employees who cannot return to work because of their illness.17

“All the way around, employers can be an important resource to help employees feel in control of decisions that affect their health,” says Bert Alicea, Vice President of EAP+Work/Life Services at Health Advocate.17

This includes providing access to information about programs that can assist with the cost of prescription drugs, decision-making tools, nurse lines that offer information about clinical issues, and helping them get in touch with the appropriate personnel at the insurance company.17

Employers should be aware of evidence-based recommendations for breast cancer screenings, encourage compliance, and provide resources to employees and eligible dependents. “Employees should be regularly reminded about the importance and availability of screenings and that mammograms are free,” says Alicea. There is strong evidence that consistent communication and reminders increase screening for breast cancer and other cancers.17,29

Every effort should be made to remove barriers to screenings, such as providing flex time for appointments.

Create a Culture of Prevention

Cancer is a manageable disease that can be addressed through lifestyle changes.4

Only 5–10% of all cancer cases can be attributed to genetic defects, whereas the remaining 90–95% have their roots in the environment and lifestyle. The lifestyle factors include cigarette smoking, diet (fried foods, red meat), alcohol, sun exposure, environmental pollutants, infections, stress, obesity and physical inactivity.30

“All breast cancer is influenced by lifestyle habits,” says Dr. Weiss. “It’s important to create programs that encourage healthy habits.”4

Employers can offer wellness benefits and encourage tobacco cessation, better nutrition, regular exercise and other healthy behaviors.

“These health promotion efforts, along with recommended immunizations, are cost-saving measures that can keep the company healthy as a whole. The benefits extend beyond breast health,” Dr. Weiss says.4

Providing Information is Vital

Provide Wellness Benefits and Health Promotion Programs

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Employees with breast cancer want and need to work for the income, benefits, and also for the normalcy and stability that improves their quality of life. But their work ability depends on the flexibility, acceptance, understanding and compassion of the employer.4,31

“When employers fully support employees who are experiencing special circumstances, the return is great,” says Dr. Weiss, “It makes a huge difference in an individual’s life and sends a powerful message that the employer cares. This motivates employees and improves the morale of the organization’s entire workforce.”4

Conclusion

“More employers recognize that providing excellent benefits for employees affected by cancer is an investment, not just an expense,” says Elizabeth Danielson, Director of the Payer & Employer Initiatives, National Comprehensive Cancer Network. “It enables employees to continue working or minimize time away from work and the payoff is improved productivity, loyalty and satisfaction.”32

In the coming years, it will become more important for employers to make this investment to meet the dual goals of supporting employees with breast cancer—or any chronic condition—while sustaining their business goals.

Employers are Responding

When employers make a commitment to improve health, everyone benefits.

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References 1. American Cancer Society. Available at www.cancer.

org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics

2. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. Projections of the Cost of Cancer Care in the United States: 2010-2020. Jan 19, 2011, JNCI, Vol. 103, No. 2. National Cancer Institute at the National Institutes of Health

3. Caregiving in the U.S. National Alliance for Caregiving in collaboration with AARP. November 2009

4. Weiss, Marisa, M.D. Health Advocate Inc., webinar. October 2012

5. Hoyer M., Nordin K., Ahlgren J., Leif Bergkvist J., Lambe M., Johansson B., Lampic C. Change in Working Time in a Population-Based Cohort of Patients With Breast Cancer. Journal of Clinical Oncology. October 2011

6. Lavigne J.E., Griggs J.J., Tu X.M., Lerner D.J. Hot flashes, fatigue, treatment exposures and work productivity in breast cancer survivors. J Cancer Surviorhood. December 2008 (4).

7. Bradley C.J., Bednarek H.L., Neumark D. Breast cancer and women’s labor supply. Department of Medicine, Michigan State University

8. Hassett, M.J., M.D., M.P.H., O’Malley J.A., Ph.D., Keating N.L., M.D., M.P.H. Factors Influencing Changes in Employment Among Women with Newly Diagnosed Breast Cancer. Cancer. National Institutes of Health. 2009 June 15. 115(12): 2775–2782

9. Hansen J.A., Feuerstein M., Calvio L.C., Olsen C.H. Breast cancer survivors at work. Journal of Occupational and Environmental Medicine. 2008 Jul; 50(7):777-84

10. Sullivan S.D., Fu A. Z., Jhaveri M., N. P. Christiansen. University of Washington, Seattle, WA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH. American Society of Clinical Oncology. Costs of absenteeism and short-term disability associated with breast cancer to U.S. employers. Journal of Clinical Oncology. 28:15s, 2010 (suppl; abstr 6048)

11. Elkin E.B., PhD, Bach P.B., MD, MAPP. Cancer’s Next Frontier: Addressing High and Increasing Costs. The Journal of the American Medical Association. JAMA. 2010; 303(11):1086-1087. doi:10.1001/jama.2010.283

12. The USA Today/Kaiser Family Foundation/Harvard School of Public Health. National Survey of Households Affected by Cancer. November 2006

13. Finch R., Ed.D, Wolff S., MS, MBA. Weathering the Storm: Supporting Employees During Diagnosis and Treatment for Cancer. An Employer’s Guide to Cancer Treatment and Prevention. November 5, 2012

14. Family Caregiver Alliance, National Center on Caregiving. Retrieved from www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=439

15. Albert S.M., Ph.D., Schulz R., Ph.D., University of Pittsburgh Institute on Aging, University Center for Social and Urban Research and Department of Behavioral and Community Health Services, and Colombi, A., M.D. The MetLife Study of Working Caregivers and Employer Health Care Costs: New Insights and Innovations for Reducing Health Care Costs for Employers. February 2010

16. Bouknight R.R., Bradley C.J., Luo Z. Correlates of Return to Work for Breast Cancer Survivors. Journal of Clinical Oncology. 2005. October 26. vol 24 no 3

17. Alicea B., MA, CEAP, Licensed Psychologist, Vice President of EAP+Work/Life Services, Health Advocate Inc., webinar. October 2012

18. The Hartford. Healthier, More Productive Employees: A Report on the Real Potential of Employee Assistance Programs (EAP). Hartford, CT. 2007

19. Lindbohm M.L., Taskila T., Kuosma E., Hietanen P., Carlsen K., Gudbergsson S., Gunnarsdottir H., Work ability of survivors of breast, prostate, and testicular cancer in Nordic countries: a NOCWO study. Journal of Cancer Survivors. 2012 March;6(1):72-81

20. The U.S. Equal Employment Opportunity Commission. Questions and Answers About Cancer in the Workplace and the Americans with Disabilities Act (ADA)

21. The Council for Disability Rights: Advancing rights and enhancing lives of people with disabilities. Retrieved from www.disabilityrights.org/adafaq.htm

22. United States Department of Labor, Wage and Hour Division. Retrieved from www.dol.gov/whd/fmla/

23. American Cancer Society. Retrieved from cancer.org/treatment findingandpayingfortreatment/understandingfinancialandlegalmatters/family-and-medical-leave-act

24. Women’s Health and Cancer Rights Act. The Federal law. American Cancer Society. 2012

25. U.S. Equal Employment Opportunity Commission, U.S. Department of Justice Civil Rights Division. Americans with Disabilities Act Questions and Answers

26. Breastcancer.org. Survey of Community Members. September 2012

27. United State Department of Labor, Office of Disability Employment Policy. Investing in People: Job Accommodation Situations and Solutions.

28. Sweeney, K. Cancer and Careers. Phone Interview. October 2012

29. Sabatino S.A., Lawrence B., Elder R., Mercer S.L., Wilson K.M., DeVinney B., Melillo S., Carvalho M., Taplin S., Bastani R., Rimer B.K., Vernon S.W., Melvin C.L., Taylor V., Fernandez M., Glanz K. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services. American Journal of Preventive Medicine. 2012 July;43(1):97-118

30. Preetha, A., Kunnumakara B., et al Sundaram, Kuzhuvelil B. Harikumar, Sheeja T. Tharakan, Oiki S. Lai, Bokyung Sung, Bharat B. Aggarwal. Cancer is a Preventable Disease that Requires Major Lifestyle Changes. Pharm Res. 2008 September; 25(9): 2097–2116.

31. Blinder V.S., Murphy M.M., Vahdat L.T., Gold H.T., de Melo-Martin I., Hayes M.K., Scheff R.J., Chuang E., Moore A., Mazumdar M. Employment after a breast cancer diagnosis: a qualitative study of ethnically diverse urban women. Journal of Community Health. 2012 August;37(4):763-72.

32. Elizabeth Danielson. National Comprehensive Cancer Network. Phone Interview. October 2012

A special thank you to Breastcancer.org for their research, feedback and support.

©2013 Health Advocate, Inc. HA-B-1205012-12WP

About Health AdvocateHealth Advocate™, Inc., is the nation’s leading independent healthcare advocacy and assistance company. We help millions of Americans

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White Paper: The Impact of Breast Cancer on the WorkplaceThis is a two-part publication, providing a White Paper and a Checklist of Strategies

Health Advocate™, Inc., the nation’s leading independent healthcare advocacy and assistance company, has published this White Paper to provide research about important issues relating to breast cancer that impacts the workplace, and how employers can meet the challenges. The White Paper offers comprehensive research about the scope, causes and costs of breast cancer, and its role in absences, lost productivity, accidents and illness. The companion “Checklist of Strategies: The Impact of Breast Cancer on the Workplace” provides a range of specific strategies to help employers develop policies to help address breast cancer in their organization.

Independent. Confidential. Convenient.Health Advocate is not affiliated with any insurance or third party provider. Health Advocate does not replace health insurance coverage, provide medical care or recommend treatment.

Additional White PapersThe following previously published Health Advocate White Papers are available for free on our website at: HealthAdvocate.com/webinars_seminars.aspx. There is a companion Checklist that accompanies each White Paper.

Guide to Workplace Wellness: Healthy Employees, Healthy Bottom Line

Obesity in America: Workplace Solutions

Stress in the Workplace: Meeting the Challenge

Sleep Deprivation:A Wake-up Call for Business

Caregiving:The Impact on the Workplace

The Impact of Domestic Violence on the Workplace

Guide to Pandemic Business Planning & CommunicationsLearn how you can protect your employees and keep your business viable.

Find out how a wellness program is a cost-effective solution to rising healthcare costs.

Gain insight about incorporating weight management in a wellness program

See how helping employees better manage stress can help preserve your bottom line.

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Learn how prevention strategies protect your workers and your business.

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