Factors influencing job loss and early retirement in working men with prostate cancer – findings from the population based Life After Prostate Cancer Diagnosis (LAPCD) study.

Abstract

Purpose:
To investigate factors associated with job loss and early retirement in men diagnosed with prostate cancer (PCa) 18-42 months previously.

Methods:
Men ≤ 60 years at diagnosis who completed the Life After Prostate Cancer Diagnosis (LAPCD) survey were identified. Men who moved from employment at diagnosis to unemployment (EtoU) or retirement (EtoR) at survey (18-42 months post-diagnosis) were compared to men remaining in employment (EtoE). Sociodemographic, clinical and patient-reported factors were analysed in univariable and multivariable analysis.

Results:
There were 3218 men (81.4%) in the EtoE, 245 (6.2%) in EtoU and 450 (11.4%) in the EtoR groups. Men with stage IV disease (OR = 4.7 95% CI 3.1-7.0, relative to stage I/II) and reporting moderate/big bowel (OR = 2.5, 95% CI 1.6-3.9) or urinary problems (OR = 2.0, 95% CI 1.4-3.0) had greater odds of becoming unemployed. Other clinical (≥ 1 comorbidities, symptomatic at diagnosis) and sociodemographic (higher deprivation, divorced/separated), living in Scotland or Northern Ireland (NI)) factors were predictors of becoming unemployed. Men who were older, from NI, with stage IV disease and with caring responsibilities had greater odds of retiring early. Self-employed and non-white men had lesser odds of retiring early.

Conclusion:
PCa survivors who retire early following diagnosis do not report worse urinary or bowel problems compared to men remaining in employment. However, we identified clinical and sociodemographic factors which increased unemployment risk in PCa survivors.

Implications for cancer survivors:
Targeted support and engagement with PCa survivors at risk of unemployment, including their families and employers, is needed.

Full text

Factors influencing job loss and early retirement in working men
with prostate cancer—findings from the population-based Life After
Prostate Cancer Diagnosis (LAPCD) study
Damien Bennett
1
&Therese Kearney
1
&David W. Donnelly
1
&Amy Downing
2,3
&Penny Wright
2
&Sarah Wilding
2,3
&
Richard Wagland
4
&Eila Watson
5
&Adam Glaser
2,3
&Anna Gavin
1
Received: 6 June 2018 /Accepted: 13 July 2018 /Published online: 30 July 2018
#The Author(s) 2018
Abstract
Purpose To investigate factors associated with job loss and early retirement in men diagnosed with prostate cancer (PCa) 18–
42 months previously.
Methods Men ≤60 years at diagnosis who completed the Life After Prostate Cancer Diagnosis (LAPCD) survey were identified.
Men who moved from employment at diagnosis to unemployment (EtoU) or retirement (EtoR) at survey (18–42 months post-
diagnosis) were compared to men remaining in employment (EtoE). Sociodemographic, clinical and patient-reported factors
were analysed in univariable and multivariable analysis.
Results There were 3218 men (81.4%) in the EtoE, 245 (6.2%) in EtoU and 450 (11.4%) in the EtoR groups. Men with stage IV
disease (OR = 4.7 95% CI 3.1–7.0, relative to stage I/II) and reporting moderate/big bowel (OR = 2.5, 95% CI 1.6–3.9) or urinary
problems (OR = 2.0, 95% CI 1.4–3.0) had greater odds of becoming unemployed. Other clinical (≥1 comorbidities, symptomatic
at diagnosis) and sociodemographic (higher deprivation, divorced/separated), living in Scotland or Northern Ireland (NI)) factors
were predictors of becoming unemployed. Men who were older, from NI, with stage IV disease and with caring responsibilities
had greater odds of retiring early. Self-employed and non-white men had lesser odds of retiring early.
Conclusion PCa survivors who retire early following diagnosis do not report worse urinary or bowel problems compared to men
remaining in employment. However, we identified clinical and sociodemographic factors which increased unemployment risk in
PCa survivors.
Implications for Cancer Survivors Targeted support and engagement with PCa survivors at risk of unemployment, including their
families and employers, is needed.
Keywords Prostate cancer .Unemployment .Retirement .LAPCD
Adam Glaser and Anna Gavin are joint senior authors
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11764-018-0704-x) contains supplementary
material, which is available to authorized users.
*Damien Bennett
damien.bennett@hscni.net
1
Northern Ireland Cancer Registry, Mulhouse Building, Queen’s
University Belfast, Mulhouse Rd., Belfast BT12 6DP, Northern
Ireland
2
Leeds Institute of Cancer and Pathology, University of Leeds,
Leeds LS2 9JT, UK
3
Leeds Institute of Data Analytics, University of Leeds, Leeds LS2
9JT, UK
4
Faculty of Health Sciences, University of Southampton,
Southampton, UK
5
Faculty Health and Life Sciences, Oxford Brookes University,
Oxford OX3 0BP, UK
Journal of Cancer Survivorship (2018) 12:669–678
https://doi.org/10.1007/s11764-018-0704-x
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Background
As the diagnosis, treatment and survival of most cancers have
improved, the number of cancer survivors has increased, with
this trend set to continue [1]. Prostate cancer (PCa) survivors
account for a large proportion of these, with 30% of UK can-
cer survivors living with the disease [2]. Although PCa inci-
dence is more common in older men, approximately 30% of
UK survivors are of working age and the effect of cancer and
its treatment can adversely impact working life and employ-
ment status [3,4]. Indeed, a UK study found the greatest
increase in PCa incidence rates between 2000 and 2010 was
in men under 60 years of age [5].
Recently, there has been increased focus on workers diag-
nosed with cancer to ensure that appropriate assistance and
information is given to support decisions about work and per-
sonal finances [6]. Work can be important for men recovering
from cancer as it allows them support themselves and their
families, socialise with colleagues and regain a sense of nor-
mality which can help them to ‘move on’[7,8]. Studies of risk
factors for job loss in PCa survivors have involved small
numbers of PCa survivors and usually been part of larger
cancer cohorts from Nordic countries, the USA or Australia
[9]. Although previous studies describe demographic, clinical
and work-related characteristics associated with work ability,
employment status and return to work for cancer survivors
across a range of tumour sites, variable findings have been
reported and few focus specifically on PCa survivors [9]. A
study which reported on 100 PCa survivors in Ireland 6–
24 months post-diagnosis found those who were self-
employed had lower household income and did not have sur-
gery were more likely to continue working following diagno-
sis, while those with lower educational level, medical card
entitlement (providing free access to public health services)
and not receiving sick pay were more likely not to resume
work following diagnosis [10]. However, the effect of recent
diagnosis of PCa on subsequent employment, and particularly
unemployment and early retirement, have not been previously
reported in a large-scale study. This study aimed to identify
factors associated with movement from employment to unem-
ployment or early retirement in working age men diagnosed
with PCa in the UK.
Methods
Data were collected as part of the UK-wide Life After Prostate
Cancer Diagnosis (LAPCD) study. The study design has been
reported elsewhere [11]. PCa survivors between 18 and
42 months following first diagnosis were identified from
population-based cancer registries in England, Wales and
Northern Ireland (NI) and from hospital activity data in
Scotland. A postal questionnaire was sent to 58,930 men.
Respondents answered questions on functional outcomes
and personal and sociodemographic characteristics and other
measures including health-related quality of life (HRQL), so-
cial difficulties, decision regret and emotional well-being.
Men aged 60 years and younger at time of diagnosis who
completed a questionnaire were included in this study. The
UK state pension age for men at the time of survey (October
2015 to November 2016) was 65 years [12] and the average
age of men withdrawing from the labour market was just
below 65 years (64.6 years) [13]. Consequently, we used a
practical threshold of 60 years and below at diagnosis for
inclusion. Although it is difficult to define early retirement,
men aged 60 years and below at diagnosis would have been
aged up to 63.5 years when they participated in LAPCD (18–
42 months later), below the UK male state pension age. In the
UK, currently only 22% of men aged 60 and below have
retired suggesting this as a reasonable cutoff [13].
Responses to questions about employment status at time of
cancer diagnosis and time of survey were used to categorise
men as moving from employment to unemployment (EtoU),
from employment to retirement (EtoR) or remaining in em-
ployment (EtoE) (Survey in Supplementary File 1). Those
who chose ‘full time employment’(FTE), ‘part time employ-
ment’(PTE) or ‘self-employed’(SE) were categorised as
‘employed’while those who chose ‘unemployed, seeking
work’or ‘unemployed, unable to work for health reasons’
were categorised as ‘unemployed’and those who chose ‘re-
tired’were classified as such. Those who recorded ‘looking
after family/home’and ‘other’were excludedfrom analysis as
focus was on movement between employed and unemployed
and retired states and it would bedifficult to clearly delineate a
change in status between these states and the unemployed or
retired state.
Clinical characteristics, sociodemographic factors
and patient-reported symptoms
Stage and age at diagnosis and UK nation of residence were
determined from cancer registration data. Deprivation levels
were determined from UK Indices of Multiple Deprivation
(IMD) derived from patients’home postcode at diagnosis
[14–17]. Respondents’self-reported employment status; relation-
ship status; ethnicity; height and weight (from which BMI was
derived [18]); whether they had carer responsibilities; whether
they had ever seen a healthcare professional for problems with
emotions; nerves or use of alcohol or drugs; treatment type;
comorbidities (total number of long-term conditions (LTCs),
e.g. stroke, diabetes) and overall urinary and bowel function
(from the Expanded Prostate Cancer Index Composite short form
(EPIC-26) questions ‘How big a problem has your urinary/bowel
function been for you during the last 4 weeks?’[19] were taken
from the survey data (Supplementary File 1).
670 J Cancer Surviv (2018) 12:669–678
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Statistical analysis
Univariable analyses were undertaken to assess differences in
sociodemographic and clinical characteristics between both
the EtoU and EtoR groups and the EtoE group. Differences
in categorical variables were assessed using Chi-squared tests
and continuous variables using ttests. Bonferroni correction
was used to compensate for multiple comparisons. Variables
were entered as predictors in regression analysis using a
univariable analysis cutoff of p< 0.2 or if they were of a priori
importance (e.g., age, patient-reported symptoms). Treatment
type (surgery, radiotherapy, etc.) was not included in regres-
sion analysis. Certain treatments are more likely to lead to
specific function problems (e.g., surgery is associated with
worse urinary function) and it is the effect of resulting symp-
toms that is of interest. Multivariable logistic regression (back-
wards stepwise) analyses was performed with outcome vari-
ables being change in employment status from EtoU and from
EtoR with the reference category being no change in employ-
ment status (i.e. EtoE). Data were analysed with SPSS Version
22.0 (IBM Corp, Armonk, NY).
Results
Of the 58,930 men invited to participate, 35,823 returned com-
pleted questionnaires (60.8% response rate);14.1% (N= 5037/
35,823) of respondents were ≤60 years at PCa diagnosis. Non-
response on employment status was low: 1.5% (75/5037) did
not respond on employment status at diagnosis, 2.2% (N=109)
did not respond on employment status at time of survey and
3.1% (N= 155) did not respond on both. Non-responders were
more likely to be divorced, living in areas of greater depriva-
tion, of non-white ethnicity and report overall urinary problems.
Supplementary Table 1details the characteristics of employ-
ment status respondents and non-respondents.
Employment status and change in employment status be-
tween time of diagnosis and time of survey are shown in Table
1. Of those aged ≤60 years at diagnosis, 4014 were employed
at diagnosis and 3913 of these were employed, unemployed or
retired at survey. Of these 3913 men, there were 3218 (81.4%)
in the EtoE group, 245 (6.2%) in the EtoU group and 450
(11.4%) in the EtoR group (Fig. 1). Table 2details the char-
acteristics, treatment and patient-reported symptoms variables
in the three groups.
Men becoming unemployed
There was no difference in the proportion of EtoU men aged
56–60 years (60.0%) compared to EtoE men (55.9%) (p=
0.29) (Table 2). Univariable analysis demonstrated there were
greater proportions of men who became unemployed who
were divorced, from deprived areas, from Scotland or NI, with
late stage disease at diagnosis, symptomatic at diagnosis, with
more comorbidities and reporting moderate or big problems
with urinary and bowel function (Table 2). There was no dif-
ference in ethnicity between EtoE and EtoU groups (Table 2).
A lower proportion of EtoU men had surgery and experienced
active surveillance, but a greater proportion had external beam
radiotherapy (EBRT) and androgen deprivation therapy
(ADT).
Multivariable logistic regression demonstrated a range of
sociodemographic, clinical and patient-reported factors were
predictive of movement from employment at diagnosis to
Table 1 Employment status at time of diagnosis and survey, and change in status, for men aged 60 years old and less at time of diagnosis
Employed Retired Unemployed Home Other Total Missing
At diagnosis 80.9% 10.4% 7.1% 0.8% 0.8% 100%
(4014) (516) (351) (42) (39) (4962) 75
At survey 66.7% 19.8% 11.3% 0.8% 1.3% 100%
(3289) (977) (559) (40) (63) (4928) 109
Employed to
employed (EtoE)
Employed to
retired (EtoR)
Employed to
unemployed (EtoU)
Employed to
home (EtoH)
Employed to
other (EtoO)
Total Missing
Change in employment status between diagnosis and survey
% (number) 81.4% 11.4% 6.2% 0.3% 0.8% 100%
(3218) (450) (245) (10) (32) (3955) 59
Employed at diagnosis
n = 3913
Employed at survey
n = 3218
n = 450
Unemployed at survey
n = 245
Fig. 1 Schematic of men who were employed at diagnosis and employed,
unemployed or retired at time of survey
J Cancer Surviv (2018) 12:669–678 671
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Table 2 Sociodemographic, clinician and patient-reported urinary and bowel symptoms for EtoE, EtoU and EtoR groups for men aged 60 years and
below
Variable Employed to
employed
(EtoE)
Employed to
unemployed
(EtoU)
pvalue (comparing
EtoE and EtoU)
Total Employed to
retired (EtoR)
pvalue (comparing
EtoE and EtoR)
Tot al
Mean age (years) [SD] 55.4 [3.8] 55.9 [3.5] 0.03 (ttest) 57.7 [2.5] < 0.001* (ttest)
Age bands 0.290 < 0.001*
≤50 years 11.0% (353) 8.2% (20) 10.8% (373) 1.6% (7) 9.8% (360)
51–55 33.2% (1067) 31.8% (78) 33.1% (1145) 15.3% (69) 31.0% (1136)
56–60 55.9% (1798) 60.0% (147) 56.2% (1945) 83.1% (374) 59.2% (2172)
Total 100% (3218) 100% (245) 100% (3463) 100% (450) 100% (3668)
Marital status < 0.001* 0.036
Married/civil partnership 80.9% (2598) 68.3% (166) 80.0% (2764) 81.1% (365) 80.9% (2963)
Divorced/separated 10.1% (324) 19.8% (48) 10.8% (372) 8.0% (36) 9.8% (360)
Widowed 1.5% (47) 1.6% (4) 1.5% (51) 2.7% (12) 1.6% (59)
Single 4.7% (152) 7.0% (17) 4.9% (169) 6.7% (30) 5.0% (182)
Other 2.8% (90) 3.3% (8) 2.8% (98) 1.6% (7) 2.6% (97)
Total 100% (3211) 100% (243) 100% (3454) 100% (450) 100% (3661)
Deprivation < 0.001* 0.009
Q1 (Area of least
deprivation)
27.9% (876) 16.3% (39) 27.0% (915) 33.9% (151) 28.6% (1027)
Q2 26.2% (825) 19.2% (46) 25.7% (871) 26.5% (118) 26.3% (943)
Q3 18.7% (587) 18.8% (45) 18.7% (632) 19.1% (85) 18.7% (672)
Q4 16.0 (503) 21.3% (51) 16.4% (554) 13.9% (62) 15.7% (565)
Q5 (area of greatest
deprivation)
11.3% (354) 24.6% (59) 12.2% (413) 6.7% (30) 10.7% (384)
Total 100% (3145) 100% (240) 100% (3385) 100% (446) 100% (3591)
UK country of residence < 0.001* 0.003
England 85.3% (2744) 75.9% (186) 84.6% (2930) 81.6% (367) 84.8% (3111)
Wales 7.0% (225) 6.5% (16) 7.0% (241) 8.9% (40) 7.2% (265)
Scotland 4.5% (146) 9.8% (24) 4.9% (170) 3.3% (15) 4.4% (161)
Northern Ireland 3.2% (103) 7.8% (19) 3.5% (122) 6.2% (28) 3.6% (131)
Total 100% (3218) 100% (245) 100% (3463) 100% (450) 100% (3668)
Ethnicity 0.794 < 0.001*
White 92.6% (2938) 93.3% (223) 92.7% (3161) 97.5% (434) 93.2% (3372)
Non-white 7.4% (234) 6.7% (16) 7.3% (250) 2.5% (11) 6.8% (245)
Total 100% (3172) 100% (239) 100% (3411) 100% (445) 100% (3617)
Stage at diagnosis < 0.001* 0.053
I/II 72.2% (2020) 50.5% (105) 70.7% (2125) 69.5% (267) 72.2% (2020)
III 20.9% (584) 23.6% (49) 21.1% (633) 20.1% (77) 20.8% (661)
IV 7.0% (195) 26.0% (54) 8.3% (249) 10.4% (40) 7.4% (235)
Total 100% (2799) 100% (208) 100% (3007) 100% (384) 100% (3183)
Treatment type < 0.001* 0.071
Active surveillance and
watchful waiting
16.1% (517) 4.5% (11) 15.3% (528) 15.8% (71) 16.0% (588)
Surgery 41.5% (1336) 25.7% (63) 40.4% (1399) 35.3% (159) 40.8% (1495)
ERBT 2.5% (81) 4.1% (10) 2.6% (91) 2.2% (10) 2.5% (91)
Brachytherapy 6.9% (221) 4.9% (12) 6.7% (233) 7.6% (34) 7.0% (255)
ADT 1.3% (42) 3.7% (9) 1.5% (51) 2.9% (13) 1.5% (55)
EBRT + ADT 9.9% (318) 16.3% (40) 10.3% (358) 12.4% (56) 10.2% (374)
Surgery + EBRT/ADT 8.2% (265) 9.4% (23) 8.3% (288) 8.9% (40) 8.3% (305)
ADT + systemic
treatment
1.0% (32) 4.1% (10) 1.2% (42) 1.8% (8) 1.1% (40)
EBRT + systemic
treatment
1.4% (45) 6.1% (15) 1.7% (60) 1.6% (7) 1.4% (52)
Other 11.2% (360) 21.2% (52) 11.9% (412) 11.6% (52) 11.2% (412)
Total 100% (3217) 100% (245) 100% (3462) 100% (450) 100% (3667)
Comorbidities < 0.001* 0.003*
None 47.7% (1536) 27.3% (67) 46.3% (1603) 40.4% (182) 46.8% (1718)
1 33.3% (1070) 33.9% (83) 33.3% (1153) 36.4% (164) 33.6% (1234)
2 12.1% (389) 20.4% (50) 12.7% (439) 12.2% (55) 12.1% (444)
3 3.6% (115) 9.0% (22) 4.0% (137) 6.7% (30) 4.0% (145)
4 or more 3.4% (108) 9.4% (23) 3.8% (131) 4.2% (19) 3.5% (127)
Total 100% (3218) 100% (245) 100% (3463) 100% (450) 100% (3668)
Symptomatic at
diagnosis
<0.001* 0.713
No 48.9% (1555) 31.8% (76) 47.7% (1631) 47.9% (214) 48.8% (1769)
672 J Cancer Surviv (2018) 12:669–678
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unemployment at follow-up (i.e. comparing EtoU to EtoE
groups) (Table 3). Late stage at diagnosis (OR = 4.7 (95% CI
3.1–7.0), stage IV relative to stage I/II) and greater comorbid-
ity (OR ranging from OR 1.6 (95% CI 1.1–2.3) for 1 LTC to
3.5 (95% CI 1.8–6.8) for ≥4 LTCs compared to none) were
the strongest predictors of movement to unemployment.
Problems with bowel (OR = 2.5 (95% CI 1.6–3.9) moderate/
big compared to no/very small/small problems) and urinary
function (OR = 2.0 (95% CI 1.4–2.9) moderate/big compared
to no/very small/small problems) and having symptoms at
diagnosis (OR = 1.5 (95% CI 1.0–2.1)) were also predictors
of movement to unemployment (Table 3). Living in areas of
greater deprivation (OR = 2.6 (95% CI 1.6–4.3] most relative
to least deprived), being divorced/separated (OR = 2.5 (95%
CI 1.7–3.8]) and living in Scotland (OR = 2.1 (95% CI 1.2–
3.6]) or NI (OR = 3.1 (95% CI 1.7–5.6] compared to living in
England) were also significant predictors of becoming
unemployed.
Men retiring early
In the univariable analysis, there were no differences in dis-
ease stage at diagnosis or the proportions who were symptom-
atic at diagnosis between men retiring early and those who
remained in employment (Table 2). There were no differences
in treatment type or overall urinary or bowel function between
the EtoR and EtoE group. Men remaining in employment
were significantly younger (mean age = 55.4 years, p<
0.001) than those retiring early (mean age = 57.7 years), with
a difference of over 2 years between the groups. There was a
greater proportion of older men in the EtoR group with 83.1%
aged 56–60 years compared to 55.9% in the EtoE group
(Table 2). There were greater proportions of EtoR relative to
EtoE men of white ethnicity, from less-deprived areas and
with caring responsibility and lower proportions of EtoR com-
pared to EtoE men living in England and reporting no comor-
bidities (Table 2).
Tabl e 2 (continued)
Variable Employed to
employed
(EtoE)
Employed to
unemployed
(EtoU)
pvalue (comparing
EtoE and EtoU)
Total Employed to
retired (EtoR)
pvalue (comparing
EtoE and EtoR)
Tot al
Yes 51.1% (1623) 68.2% (163) 52.3% (1786) 52.1% (233) 51.2% (1856)
Total 100% (3178) 100% (239) 100% (3417) 100% (447) 100% (3625)
Overall urinary
symptoms
<0.001* 0.831
No/very small/small
problem
89.4% (2868) 69.0% (167) 88.0% (3035) 89.9% (400) 89.5% (3268)
Moderate/big problem 10.6% (339) 31.0% (75) 12.0% (414) 10.1% (45) 10.5% (384)
Total 100% (3207) 100% (242) 100% (3449) 100% (445) 100% (3652)
Overall bowel symptoms < 0.001* 0.614
No/very small/small
problem
94.7% (3034) 77.3% (187) 93.4% (3221) 94.0% (420) 94.6% (3454)
Moderate/big problem 5.3% (171) 22.7% (55) 6.6% (226) 6.0% (27) 5.4% (198)
Total 100% (3205) 100% (242) 100% (3447) 100% (447) 100% (3652)
BMI < 0.001* 0.092
< 25 kg/m
2
26.7% (810) 21% (47) 26.3% (857) 30% (131) 27.1% (941)
25–29.9 kg/m
2
48% (1459) 40.2% (90) 47.5% (1549) 49.1% (214) 48.1% (1673)
≥30 kg/m
2
25.3% (770) 38.8% (87) 26.3% (857) 20.9% (91) 24.8% (861)
Total 100% (3039) 100% (224) 100% (3263) 100% (436) 100% (3475)
Employment type 0.029 < 0.001*
Full time 72.3% (2327) 73.1% (179) 72.4% (2506) 77.8% (350) 73% (2677)
Part time 5.4% (174) 9% (22) 5.7% (196) 10.7% (48) 6.1% (222)
Self-employed 22.3% (717) 18% (44) 22% (761) 11.6% (52) 21% (769)
Total 100% (3218) 100% (245) 100% (3463) 100% (450) 100% (3668)
Seen HC professional for
mental health issues
‡
<0.001* 0.183
Yes 22% (700) 33.7% (82) 22.8% (782) 24.8% (111) 22.3% (811)
No 78% (2489) 66.3% (161) 77.2% (2650) 75.2% (337) 77.7% (2826)
Total 100% (3189) 100% (243) 100% (3432) 100% (448) 100% (3637)
Caring responsibilities 0.875 0.003*
Yes 22.3% (707) 22.9% (55) 22.3% (762) 28.7% (127) 23% (834)
No 77.7% (2470) 77.1% (185) 77.7% (2655) 71.3% (316) 77% (2786)
Total 100% (3177) 100% (240) 100% (3417) 100% (443) 100% (3620)
EBRT external beam radiotherapy, ADT androgen deprivation therapy
*Significant at p< 0.05 after Bonferroni adjustment for multiple comparisons
‡
Ever seen a healthcare professional for problems with emotions or nerves or use of alcohol or drugs
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In the multivariable analysis, age, ethnicity, employment sta-
tus, UK country of residence, stage at diagnosis and carer re-
sponsibilities were significantly associated with moving from
employment to retirement (Table 4). Older age was the strongest
predictor of early retirement (OR 8.5 (95% CI 4.0–18.3), age
55–60 years). Men living in NI (OR = 2.3 (95% CI 1.4–3.6)),
with later disease stage disease (OR = 1.8 (95% CI 1.2–2.6),
stage IV) and carer responsibilities (OR = 1.3 (95% CI 1.0–
1.7)) were also significantly more likely to move to early retire-
ment. Men who were self-employed (OR = 0.40 (95% CI 0.28–
0.57)) and of non-white ethnicity (OR = 0.32 (95% CI 0.16–
0.63)) were significantly less likely to move to early retirement.
Discussion
The clinical factors of advanced disease stage, presence of bow-
el and urinary problems, having symptoms at diagnosis and
greater levels of comorbidity increased the odds of job loss in
PCa survivors, alongside the sociodemographic factors of dep-
rivation, divorce/separation and living in Scotland or NI. In
contrast, having bowel or urinary problems or greater comor-
bidity were not significantly associated with early retirement in
PCa survivors. Men who were older, of white ethnicity, in full-
time employment, with most advanced disease (stage IV) or
with caring responsibilities had greater odds of early retirement.
Table 3 Significant independent
predictors of movement between
employment and unemployment
for men aged 60 years and below
using logistic regression
modelling
Odds ratio 95% CI lower 95% CI upper pvalue
Deprivation
Q1 (area of least deprivation) 1.00
Q2 0.87 0.50 1.50 0.618
Q3 1.57 0.93 2.63 0.090
Q4 1.92 1.16 3.19 0.011*
Q5 (area of greatest deprivation) 2.58 1.56 4.26 < 0.001*
Marital status
Married/civil partnership 1.00
Divorced/separated 2.50 1.65 3.80 < 0.001*
Widowed 1.58 0.51 4.93 0.42
Single 1.51 0.80 2.87 0.205
Other 1.29 0.52 3.16 0.580
UK country
England 1.00
Wales 1.08 0.57 2.05 0.811
Scotland 2.08 1.20 3.61 0.009*
Northern Ireland 3.11 1.71 5.64 < 0.001*
Stage
Stage I/II 1.00
Stage III 1.72 1.17 2.53 0.006*
Stage IV 4.68 3.11 7.03 < 0.001*
Symptomatic at diagnosis
No 1.00
Yes 1.47 1.04 2.06 0.028*
Comorbidities
No comorbidities 1.00
1 comorbidity 1.57 1.07 2.32 0.023
2 comorbidities 2.27 1.44 3.57 < 0.001*
3 comorbidities 2.47 1.30 4.68 0.006*
4 or more comorbidities 3.49 1.80 6.79 < 0.001*
Bowel symptoms (overall)
No/very small/small problems 1.00
Moderate/big problems 2.54 1.64 3.94 < 0.001*
Urinary symptoms (overall)
No/very small/small problems 1.00
Moderate/big problems 2.02 1.37 2.97 < 0.001*
Factors contributing significantly to the model (p < 0.05) are reported. Variables included in the model were age,
relationship status, deprivation quintile, UK country of residence, ethnicity, BMI, type of employment at diag-
nosis, stageat diagnosis, whether symptomatic at diagnosis, whether had PSA testing at diagnosis, comorbidities,
overall urinary problems, overall bowel problems, having ever seen a professional for mental health issues and
caring responsibilities
674 J Cancer Surviv (2018) 12:669–678
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Movement to unemployment
In our study, advanced disease stage at diagnosis was the
strongest predictor of becoming unemployed, with the odds
of men with stage IV disease becoming unemployed almost
five times those of men with stage I/II disease. Problems with
bowel and urinary function were also strong predictors of
becoming unemployed. This suggests that more severe dis-
ease and treatment side effects adversely impact on employ-
ment. Previous studies of cancer survivors report associations
between both cancer severity and adverse effects and delayed
returning to work [20]. However, those involving PCa survi-
vors report variable associations between clinical factors and
employment status, productivity and work engagement
[21–24]. However, these studies were not population based,
involved small numbers of PCa survivors (n< 180) and were
non-UK based. More severe bowel symptoms have, for exam-
ple, been associated with greater number of missed workdays
in irritable bowel syndrome (IBS) sufferers [25], who have
been reported to experience significant work impairment with
substantial productivity and cost implications [26,27].
Comorbidity was also a significant predictor of becoming un-
employed with the likelihood of job loss increasing with the
number of comorbidities. Greater comorbidity has been asso-
ciated with reduced work ability in Nordic PCa survivors [28],
but greater disability was not associated with higher job quit-
ting rates in a US study of PCa survivors [29].
We have identified sociodemographic factors that predict
job loss. Men living in the most deprived areas had over twice
the odds of becoming unemployed. A study reporting on 100
PCa survivors in Ireland found more socioeconomically de-
prived men were less likely to resume work following diag-
nosis [10]. A possible reason may have been difficulty main-
taining physically demanding or manual jobs, which are more
common in men in deprived areas [30]. Cancer survivors with
physically demanding jobs, such as heavy lifting, found their
jobs more challenging [31,32], and manual labour was found
to negatively impact on survivors return-to-work [33]. As men
from more deprived areas may have more physically demand-
ing or manual jobs this may have been a possible reason for
their higher odds of unemployment. Divorced or separated
men had 2.5 times greater odds of becoming unemployed
Table 4 Significant independent
predictors of movement between
employment and retirement for
men aged 60 years and below
using logistic regression
modelling
Odds ratio 95% CI lower 95% CI upper pvalue
Age band
< 50 years 1.00
50–54 years 2.57 1.16 5.71 0.021
55–60 years 8.52 3.97 18.28 < 0.001*
Ethnicity (reference)
White 1.00
Non-white 0.32 0.16 0.63 0.001*
Employment type
Full-time employment 1.00
Part-time employment 1.38 0.94 2.03 0.099
Self-employed 0.40 0.28 0.57 < 0.001*
UK country
England 1.00
Wales 1.25 0.83 1.87 0.281
Scotland 0.67 0.36 1.25 0.208
Northern Ireland 2.29 1.44 3.64 < 0.001*
Stage
Stage I/ II 1.00
Stage III 0.99 0.75 1.31 0.934
Stage IV 1.79 1.22 2.62 0.003*
Carer responsibilities
No 1.00
Yes 1.29 1.00 1.66 0.050*
Factors contributing significantly to the model (p< 0.05) are reported. Variables included in the model were age,
relationship status, deprivation quintile, UK country of residence, ethnicity, BMI, type of employment at diag-
nosis, stage at diagnosis, comorbidities, overall urinary problems, overall bowel problems, having ever seen a
professional for mental health issues and caring responsibilities
J Cancer Surviv (2018) 12:669–678 675
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

compared to married men. Men living in NI and Scotland
were over twice as likely to become unemployed as English
men, which broadly reflect unemployment patterns between
2013 and 2016 in which, against a background downward
trend in all UK countries, unemployment rates in NI and
Scotland were slightly higher than the UK average [34].
Early retirement
Our findings for men who moved from employment to early
retirement were very different, and men with more severe
urinary and bowel problems or a greater number of comorbid-
ities were not more likely to retire early. Older age was the
strongest predictor of early retirement with the odds of retiring
early for men aged 55–60 years almost nine times greater than
that of men less than 50 years old, although numbers in the
reference category (< 50 years) were small (N=20). Itisnot
surprising that older men were more likely to retire than youn-
ger men in this study. However, older men were not more
likely to be become unemployed, with no significant relation-
ship between age and movement to unemployment on logistic
regression analysis.
Those of non-white ethnicity were significantly less likely
to retire early, although numbers in this group were small.
Male ethnic minorities in the UK experience higher rates of
unemployment [35] and have, on average, lower income than
the white population [36], with earning differentials at least
10% less than comparable white men [37]. Consequently,
white UK men may be more economically able to support
themselves and their families in retirement at an earlier age.
Employment type (e.g. full-time, part-time, self-employed)
predicted move to early retirement, but not to unemployment.
The odds of self-employed men moving to early retirement
were 60% less than men in full-time employment, which sup-
ports the finding of Sharp et al. that self-employed PCa survi-
vors were more likely to continue working following diagno-
sis [10].
The findings from the present study suggest that men who
became unemployed and those who retired early following
PCa diagnosis represent very different groups. Compared with
men who remain in employment, those who become unem-
ployed had different socioeconomic characteristics, more se-
vere disease and worse clinical symptoms. In contrast, the
sociodemographic profile and symptom characteristics of
men who retire early was similar to men who continue to
work. Men with PCa who retired early had no worse urinary
or bowel symptoms than those who remain in employment.
They were less likely to be self-employed and not more de-
prived. However, they are more likely to have caring respon-
sibilities, suggesting this may be a possible reason for retiring
early. Although it is unsurprising that those from more de-
prived areas had greater odds of becoming unemployed and
those from less-deprived areas had greater odds of retiring
early, there are few studies which consider factors associated
with change in employment status of cancer survivors follow-
ing diagnosis (i.e. moving from employment to either unem-
ployment or early retirement compared to those who stay in
employment) and none involving a population-based study of
prostate cancer survivors.
Practical implications
This study has identified characteristics associated with job
loss and early retirement, which can be used by health and
social care staff, employers and human resources staff to target
information, advice and support for PCa survivors to mitigate
work impairment and support return to work. Local networks
integrated with existing care systems have been suggested as a
model, which can support urological cancer survivors who
wish to stay in employment [38] and workplace counselling
[39], workplace evaluation [40] and workplace rehabilitation
[41] may help sustain cancer survivors in employment.
Ideally, PCa survivors at risk of unemployment would be
empowered to actively seek assistance, which could maintain
employment.
Factors associated with employment outcomes for cancer
survivors include health and well-being, symptom control
and function as well as work demands, work environment
and policies and economic factors [42]. Our study found that
men with worse urinary and bowel symptoms had greater
odds of becoming unemployed. Men with a greater number
of comorbidities, and likely poorer function, also had greater
odds of losing their job. Men who were divorced/separated
or living in deprived areas also had greater odds of losing
their job. Targeted support to maintain employment may be
warranted for PCa survivors who are, for example, divorced
or separated, from more deprived backgrounds and with a
number of comorbidities, especially those experiencing uri-
nary or bowel symptoms following treatment. This study
will also help inform future research into maintaining em-
ployment following PCa diagnosis. Such research could fo-
cus on disease-specific symptoms and general health status
alongside social and demographic factors, ideally in longitu-
dinal studies which would also consider work-related
factors.
Limitations
Although this is the first study to investigate a range of
sociodemographic, clinical and patient-reported factors asso-
ciated with movement from employment at time of PCa diag-
nosis to unemployment or early retirement in a large-scale UK
population-based study, there were a number of limitations.
We did not have details of when men became unemployed, of
income, pension or educational levels or of work-related fac-
tors, such as type of occupation (e.g. service and
676 J Cancer Surviv (2018) 12:669–678
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

manufacturing) and hours worked, which may have been as-
sociated with movement to unemployment or early retirement.
Although we report significant associations with movement to
unemployment or early retirement, we cannot assume causal
relationships. We acknowledge that some of the observed
movement to early retirement may have occurred independent
of PCa diagnosis. We compared both EtoU and EtoR groups
with recently diagnosed PCa survivors who were employed
both at diagnosis and follow-up (EtoE group) and assumed
these men remained in employment during that period. Some
variables had low numbers in sub-categories (e.g. those of
non-white ethnicity who retired early, N=11)which warrant
caution in interpretation. However, these were in the context
of large category numbers (e.g. 261 men of non-white ethnic-
ity in the sample) and overall group numbers (3218 in EtoE,
245 in EtoU and 450 in the EtoR groups) which were much
greater than previous studies of job loss and early retirement
involving PCa survivors.
Conclusion
Men who retire early following PCa diagnosis do not report
worse overall urinary or bowel problems or different socio-
economic characteristics to men remaining in employment.
However, this study has identified risk factors for job loss in
PCasurvivors,whichcanbeusedtosupportmenfollowing
diagnosis. Targeted support and engagement with these men,
their families and their employers is needed.
Acknowledgements The authors thank all the men who completed the
surveys. The authors acknowledge the following people for their contri-
bution to the development, setting up and running of the study: Heather
Kinnear, Victoria Cairnduff, Oonagh McSorley, Conan Donnelly, Linda
Roberts, Rebecca Mottram, Majorie Allen, Adrian Slater, the LAPCD
User Advisory Group and Clinical & Scientific Advisory Group, Picker
Institute Europe and Business Services Organisation (NI). This study is
based in part on information collected and quality assured by the cancer
registries in each nation. This work uses data provided by patents and
collected by health services as part of their care and support.
Funding The Life After Prostate Cancer Diagnosis study was funded by
the Movember Foundation, in partnership with Prostate Cancer UK, as
part of the Prostate Cancer Outcomes programme (grant number BO26/
MO).
Compliance with ethical standards
Conflict of interest The authors declare that they have no competing
interests.
Ethical approval The study received the following ethical approvals:
Newcastle & North Tyneside 1 Research Ethics Committee (15/NE/
0036), Confidentiality Advisory Group (15/CAG/0110), NHS Scotland
Public Benefit and Privacy Panel (0516–0364), Office of Research Ethics
Northern Ireland (16/NI/0073) and NHS R&D approval from Wales,
Scotland, and Northern Ireland. All procedures performed in studies
involving human participants were in accordance with the ethical stan-
dards of the institutional and/or national research committee and with the
1964 Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license, and indicate if changes were made.
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