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Overall and diagnosis-specific sickness absence and disability pension in colorectal cancer survivors and references in Sweden

Overall and diagnosis-specific sickness absence and disability pension in colorectal cancer... Purpose To longitudinally investigate overall and diagnosis-specific sickness absence (SA) and disability pension (DP) in colorectal cancer (CRC) survivors and references and to identify potential risk factors. Methods This longitudinal register-based cohort study included all patients living in Sweden, diagnosed with a first primary CRC in 2008–2011 when aged 18–62 (n=6679), and their matched references (n=26 716). Net days of SA (in SA spells >14 days) and DP were analyzed from 2 years before through 5 years after diagnosis, overall and by specific diagnoses. Among survivors, risk factors for future SADP were explored using logistic regression. Results In survivors, SA peaked in year 1 postdiagnosis, with 62.5% having at least some SA, and then gradually decreased to 20.1% in year 5. In the 2 years after diagnosis, CRC was the most common SA diagnosis in survivors, while SA due to mental diagnoses remained similar to the references. Notable risk factors for postdiagnostic SA or DP were rectal cancer diagnosis, advanced cancer stage at diagnosis, lower educational level, born outside of Sweden, and pre-diagnostic SA, mental morbidity, and comorbidities. Conclusion During 5 years after a CRC diagnosis, CRC survivors had higher levels of postdiagnostic SA and DP than the references, which was mostly due to CRC diagnoses. Although their SA lowered gradually, it did not return to pre-diagnostic levels. Implications for Cancer Survivors Our results provide valuable information for patients with CRC diagnosis, especially that most have none or low levels of SA/DP after a few years. . . . . Keywords Sick leave Disability pension Work loss Cancer survivorship Colorectal cancer Background regain control and normalcy in their lives [6–10]. However, CRC, especially colon cancer survivors, is reported to have Colorectal cancer (CRC) is one of the most common reduced capacity for paid work after diagnosis [11–14]. Risk cancer types, ranking third in cancer incidence and sec- factors for future sickness absence (SA) and disability pension ond in cancer mortality worldwide [1]. Recently, the (DP) include comorbidities, previous SA, advanced cancer incidence of CRC is increasing in high-income countries stage, chemotherapy, radiotherapy, extensive surgery, and among people below 50 years [2, 3], while mortality postoperative complications, with inconsistent findings for declines [4, 5]. Hence, for growing numbers of the influence of educational level [11, 12, 15]. working-age CRC survivors, future work-related out- Most previous studies on CRC survivors’ work capacity comes are of rising importance. have focused on the binary outcome return-to-work (measured Pursuing paid work after cancer diagnosis and treatment is as yes/no) [13, 14]. Furthermore, these studies only have a a significant part of recovery, as it helps cancer survivors to short follow-up, not accounting for long-term effects that CRC diagnosis and treatment may have on survivors’ work capacity. The few previous studies that used SA and DP as an * Lingjing Chen outcome used data from patients diagnosed 1992–2005 and lingjing.chen@ki.se aged 45–54 at diagnosis [11], or measured SA as a binary outcome (yes/no) and not using a reference group [12], or only Division of Insurance Medicine, Department of Clinical including rectal cancer survivors [15, 16]. Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden Moreover, CRC survivors’ specific SA and DP diagnoses Department of Molecular Medicine and Surgery, Karolinska have not yet been investigated. Such knowledge, in Institutet, SE-171 77 Stockholm, Sweden 270 J Cancer Surviv (2022) 16:269–278 comparison to the general population, will enable clinicians to diagnosis date + 365 days). Individuals were censored from better understand occurrences of behind future long-term SA the year following their death, emigration, or turning 65 (old- and even DP in survivors. Hence, there is a need of longitu- age pension age), whichever came first. dinal studies using recent data and a reference group to pro- The reason for this is that they were no longer at risk for the vide comprehensive information on CRC survivors’ long- outcome (SA/DP) afterwards. A detailed flow chart was pre- term SA and DP. sented (Online Resource 1). Therefore, we aimed to (1) longitudinally investigate over- all and diagnosis-specific SA and DP in CRC survivors and in The Swedish public sickness absence and disability their matched references and (2) identify possible risk factors pension benefit scheme for overall SA and DP. In Sweden, SA can be granted to residents ≥16 years with an income from work or unemployment benefit, if their work Methods capacity is reduced due to disease or injury. A physician med- ical certificate is needed from day 8. For employees, the first 2 A longitudinal cohort study of first primary CRC patients and weeks of SA benefits are paid by employers, afterwards by the matched references was conducted. Social Insurance Agency. For the unemployed, the Social Data from the following six nationwide Swedish registers Insurance Agency pays from day 2. Therefore, we only used were linked on an individual level through the personal iden- information on SA spells >14 days registered by the Social tity numbers assigned to all residents in Sweden [17]. Insurance Agency. In most of the studied years, there was no maximum duration of a SA spell. In some of the years, there -National Board of Health and Welfare: Swedish Cancer was a limit of 914 days (2.5 years), followed by a waiting Register [18] for the identification of cancer diagnosis, period of 3 months before SA benefits could be claimed again. diagnosis date, and cancer stage; National Patient Temporary or permanent DP can be granted to people aged Register [19] for inpatient and specialized outpatient 19–64 years with long-term or permanent work incapacity due visits; Cause of Death Register [20] for death date; and to disease or injury [25]. Prescribed Drug Register [21] for dispensed prescribed SA and DP benefits cover 80% and 64% of lost income, psychiatric medication respectively, up to a certain level. SA and DP can be granted -Statistics Sweden: Longitudinal Integrated Databases for for full- or part-time (100%, 75%, 50%, or 25%) of ordinary Health Insurance and Labour Market Studies [22](LISA) work hours [25]; thus, people can have both partial SA and DP for socio-demographic information including sex, birth at thesametime. year, educational level, birth country, and emigration -Swedish Social Insurance Agency: Microdata for Outcome Analyses of Social Insurance [23] (MiDAS) for all DP and all SA spells >14 days regarding start/end date, grade The main outcomes were SA and DP following the CRC (full- or part-time), and main diagnosis (according to diagnosis date. The SA and DP net days/year during the International Classification of Diseases, the tenth follow-up were calculated for survivors and their matched revision, ICD-10) [24] references. Net days were calculated by multiplying the de- gree of compensation with the number of compensated days: e.g., two gross days of 50% SA or DP equaled one net day (net Inclusion and exclusion criteria days are from here on called as only days). SA days were further categorized into 0, >0–30, >30–90, We included all people diagnosed with a first primary CRC in >90–180, and >180 days/year. DP was dichotomized in 0 and Sweden in 2008–2011 (not diagnosed at autopsy) when aged >0 days/year. As the majority of SA and DP days in Sweden 18–62 (N=6679). We used ICD-10 codes C18 and C19–20 to are due to mental and musculoskeletal diagnoses [25, 26], we identify colon and rectal cancer, respectively. From LISA, categorized medical diagnoses for SA and DP days as CRC, 26,716 population references were matched to the patients mental, musculoskeletal, or other diagnoses. regarding sex, age, birth country, and educational level (four references per patient). References were selected randomly Characteristics and were alive and without previous record of CRC before the diagnosis date of the index person and registered as living Sociodemographic variables included sex, age at diagnosis, in Sweden the year before the diagnosis year of the index birth country, and educational level (detailed in Table 1). person and alive at inclusion. Survivors and references were Stage was classified into stage 0, I, II, III, IV, and missing, followed from diagnosis date through 5 years later (e.g., Y = based on the information of T (tumor size), N (lymph nodes), +1 J Cancer Surviv (2022) 16:269–278 271 Table 1 Sociodemographic and Characteristics Colorectal cancer survivors no. (%) References no. (%) clinical characteristics of colorectal cancer survivors All 6679 (100) 26,716 (100) diagnosed in 2008–2011 when aged 18–62 years and of their Sex matched references Men 3598 (53.9) 14,392 (53.9) Women 3081 (46.1) 12,324 (46.1) Age, years 18–50 1783 (26.7) 7132 (26.7) 51–55 1319 (19.8) 5276 (19.8) 56–60 2271 (34.0) 9084 (34.0) 61–62 1306 (19.6) 5224 (19.6) Country of birth Sweden 5624 (84.2) 22,496 (84.2) other 1055 (15.8) 4220 (15.8) Educational level (years) Elementary school (<10) 1467 (22.0) 5868 (22.0) High school (10-12) 3120 (46.7) 12,480 (46.7) University/college (>12) 2092 (31.3) 8368 (31.3) Cancer type Coloncancer 4044(60.6) - Rectal cancer 2635 (39.5) - Cancer stage Stage 0 + I 2109 (31.6) - Stage II 1270 (19.0) - Stage III 1464 (21.9) - Stage IV 1203 (18.0) - Missing 633 (9.5) - Charlson Comorbidity Index in the 3 years prior to diagnosis date (Y – Y ) -3 -1 0+1 5505 (82.4) 25,588 (95.8) ≥2 1174 (17.6) 1128 (4.2) Mental morbidity in the 3 years prior to diagnosis date (Y – Y ) -3 -1 None 5424 (81.2) 22,317 (83.5) Any 1255 (18.8) 4399 (16.5) Charlson Comorbidity Index was calculated based on all diagnoses from specialized healthcare within the 3 years before diagnosis date and M (metastases) [27] from the Swedish Cancer Register. If Statistical analysis T and/or N and M were missing or classified as X (assessment not possible), stage was classified as missing. If more than one The numbers and percentages of people with different levels entry of the same type of cancer diagnosis was found in the of annual SA and DP days were computed from the second register within 30 days, the most advanced stage was used. year before (Y ) through the fifth year after (Y )diagnosis -2 +5 The Charlson Comorbidity Index (CCI) [28]atdiagnosis date for both cohorts. The mean SA and DP days/year overall was calculated for survivors and their references based on the and by specific SA/DP diagnoses were calculated. National Patient Register regarding inpatient and specialized For CRC survivors, univariable and multivariable logistic outpatient visits during all the 3 years before diagnosis date. regression were used to examine the associations between Based on the same register, pre-diagnostic mental morbidity covariates and future SA and DP, respectively. In all logistic was defined as having any healthcare during the 3-year period regression models, pre-diagnostic SA was assessed by using before diagnosis date with ICD-10 codes of “F00-F99” or SA in Y . Therefore, survivors not living in Sweden in Y -2 -2 “Z73” or having any prescribed psychiatric medication for were excluded in those analyses. depression, anxiety, tension, or psychotics, according to the In the analyses of SA risk, the odds ratios (OR) with 95% prescribed drug register. confidence intervals (CI) of having >30 days of SA in Y and +3 272 J Cancer Surviv (2022) 16:269–278 Y , respectively, were estimated. For specific years, survivors In contrast, the mean SA days in references remained were excluded from the analyses if they died or emigrated before stable during the postdiagnostic period (9.1–11.9 or had full-time DP during all of the respective years. For Y , days/year). survivors aged 61–62 at diagnosis were also excluded because of Opposed to mean SA days, mean DP days after diagnosis possible transition into old-age pension. In the analyses of DP were more comparable in both groups and decreased slightly risk during the follow-up period, survivors on any DP in Y and with time during follow-up (from 53.2 to 46.6 days/year in -1 those who died or emigrated during follow-up without having survivors vs. from 48.8 to 36.8 days/year in references). In Y been granted DP were excluded. , the survivors still had higher DP rates, and the difference All statistical analyses were performed with STATA version between survivors and references in overall mean SA was 15 14. For all tests, the level of significance was set at p<0.05. days and in mean DP: 9 days. The project was approved by the Regional Ethical Review Regarding the specific SA and DP diagnoses, among CRC Board in Stockholm. survivors, 68% of all mean SA days in Y were due to CRC (81 mean days) and 27% in Y (7.5 mean days). Meanwhile, the proportion of mean DP days due to CRC increased from 1.1% Results in Y (0.6 mean days) to 6.1% in Y (2.9 mean days). +1 +5 Comparing survivors and references, mean SA and DP days/ In both CRC survivors (n=6679) and references (n=26,716), year due to mental or musculoskeletal diagnoses were similar the majority were men (53.94%) and born in Sweden (84.2%), in both groups during the postdiagnostic follow-up. Mean SA and 34.0% were diagnosed when aged 56–60 (Table 1). days due to mental diagnoses amounted to 2.5 in survivors and Survivors and their references differed regarding the distribu- 2.8 in references in Y and increased in both cohorts during -2 tion of pre-diagnostic CCI (17.6% of survivors vs. 4.2% of follow-up to 3.9 and 3.6 mean SA days in Y , respectively. references with CCI score ≥2). Among survivors, 60.6% had a Mean DP days with mental diagnoses ranged between 12.0 colon cancer diagnosis, and the most common cancer stage and 15.0 days in survivors and 11.2 and 12.7 days in references. was stage 0+I (31.6%). The corresponding baseline character- Regarding musculoskeletal diagnoses, survivors had 3.4 and ref- istics stratified by colon and rectal cancer survivors are pre- erences 3.5 mean SA days in Y whichstayedconstantduring -2 sented in Online Resource 2. follow-up, while mean DP days ranged between 11.5–18.0 among survivors and 11.2–16.7 among references. (The figure Distribution of annual SA and DP did not change if excluding references for which the patient had died or emigrated during follow-up.) SA and DP days/year in survivors and in their matched refer- However, the number of mean SA and DP days for the ences are presented by the different categories (Table 2). Among diagnostic group “other” was slightly higher in survivors than the references, on average 10.6% had some SA during the ob- in their references. While mean SA days/year varied between servation period. The proportion of CRC survivors with SA was 4.2 and 4.9 days in references, survivors had 33.5 mean SA 12.8% during Y and increased to 30.2% in Y .InY , 62.5% days due to other diagnoses in Y , which decreased to 12.9 in -2 -1 +1 +1 of survivors had some SA, half of them for >180 days. This Y . Concerning DP, mean days with other diagnoses in Y +5 -2 proportion decreased to 37.5% in Y and further to 20.1% in were 22.3 in survivors and 18.3 in references and decreased to Y but did not reach the pre-diagnostic levels. The proportion of 18.8 and 14.2 mean days in Y , respectively. Diagnosis- +5 +5 survivors with any SA in Y was 8.8% higher than in the ref- specific mean SA and DP days/year are also presented by erence group. Among survivors, 18.6% had some DP in Y colon and rectal cancer survivors (Online Resource 2). The -2 compared to 16.0% among the references. These proportions percentages were similar, although somewhat higher among decreased to 17.3% and 13.4%, respectively, in Y , with a dif- rectal cancer survivors in the postdiagnostic years. ference of 3.8%. (If excluding references for which the patient had died or emigrated during follow-up, figures were nearly Risk for future sickness absence among CRC survivors exactly the same.) In Y and Y , 23.0% and 17.6% of CRC survivors, not on +3 +5 Diagnosis-specific SA and DP full-time DP, had >30 SA days, respectively (Table 3). After adjustments, in Y , the strongest association with future SA Before diagnosis, overall mean combined SA and DP days/year >30 days could be seen for cancer stage II–IV, with stage IV were slightly higher among CRC survivors compared to among having an OR of 10.3 (95% CI 8.1–13.2) compared to stage references (67.0 days/year in survivors vs. 57.9 days/year in ref- 0+1. Those with SA >30 days in Y also had higher ORs. -2 erences in Y )(Fig. 1). After diagnosis, mean SA days in survi- Having pre-diagnostic SA >180 days compared to 0 such days -2 vors peaked in Y (119.8 days/year) and then drastically rendered an OR of 2.8 (95% CI 1.8–4.3). Other factors with a dropped to 56.0 days in Y and further to 27.7 days in Y . substantially higher likelihood for SA >30 days in Y were +2 +5 +3 J Cancer Surviv (2022) 16:269–278 273 rectal cancer diagnosis and pre-diagnostic CCI ≥2. A lower likelihood on the other hand was found among survivors aged 61–62 at diagnosis compared to 56–60. In Y , similar patterns of risk indicators for having SA >30 days were observed. Diagnosed with stage IV rendered an ad- justed OR of 5.5 (95% CI 3.9–7.9) and pre-diagnostic SA >180 days an OR of 1.8 (95% CI 1.1–3.1). Additionally, pre- diagnostic mental morbidity or being diagnosed at a younger age (18–55 vs. 56–60 years) implied a higher risk of SA >30 days in Y . Risk for future disability pension among CRC survivors Among those at risk for DP (i.e., excluding those already on DP before diagnosis date and those who during the follow-up died or emigrated before being granted DP), 5.8% of the survivors were granted DP during the 5-year follow-up (Table 3). After adjust- ments, the OR for DP was significantly higher among survivors with stage III (OR 1.9; 95% CI 1.3–2.8) and stage IV cancer (OR 9.6; 95% CI 6.0–15.3) compared to those with stage 0+I. Those with any pre-diagnostic SA compared to none in Y also had -2 higher risk of being granted DP postdiagnosis, especially among those with pre-diagnostic SA >180 days (OR 9.6; 95% CI 5.4– 16.8). Other risk factors for DP were pre-diagnostic mental mor- bidity, pre-diagnostic CCI ≥2, lower educational level, and being born outside of Sweden, while those diagnosed when aged 61– 61 had lower risk compared to those diagnosed when 56–60. Discussion In this large Swedish longitudinal cohort study of 6679 CRC survivors, the proportion of survivors on SA and DP after their diagnosis was significantly higher than among their matched references from the general population. Nevertheless, following the expected peak during the first year postdiagnosis, a clear decline was seen over the 5-year follow-up period. Most survi- vors (65%) did not have any SA or DP benefits in the fifth year postdiagnosis. However, SA in survivors did not decrease to pre-diagnostic levels and remained higher than in references. The risk for having SA and DP during follow-up was highest among survivors with advanced cancer stage and prior SA. Our main finding of higher levels of SA and DP in CRC survivors than in references, with a peak of SA in Y ,are in line with results from two previous studies [11, 15], implying that treatment-related factors may have the strongest impact on SA in the first year postdiagnosis. Uniquely, we also explored the SA and DP diagnoses and showed that CRC was the most common diagnosis for SA days in survivors postdiagnostically until Y , accounting for 68% of all mean SA days in Y and 27% in Y . +1 +5 Table 2 Annual distribution of sickness absence and disability pension, respectively, among colorectal cancer survivors and their matched references Colorectal cancer survivors Matched references Before diagnosis date After diagnosis date Before diagnosis date After diagnosis date No. of days Year -2, no. (%) Year -1, no. (%) Year +1, no. (%) Year +2, no. (%) Year +3, no. (%) Year +4, no. (%) Year +5, no. (%) Year -2, no. (%) Year -1, no. (%) Year +1, no. (%) Year +2, no. (%) Year +3, no. (%) Year +4, no. (%) Year +5, no. (%) All included 6661 (100) 6 679 (100) 6679 (100) 6025 (100) 5553 (100) 4713 (100) 4005 (100) 26,613 (100) 26,716 (100) 26,716 (100) 26,493 (100) 26,331 (100) 23,574 (100) 20,953 (100) Sickness absence 0 5806 (87.2) 4663 (69.8) 2506 (37.5) 3764 (62.5) 4134 (74.5) 3666 (77.8) 3200 (79.9) 23,606 (88.7) 23,869 (89.3) 23,983 (89.8) 23,801 (89.8) 23,720 (90.1) 21,096 (89.5) 18,579 (88.7) >0–30 293 (4.4) 1280 (19.2) 295 (4.4) 409 (6.8) 258 (4.7) 173 (3.7) 164 (4.1) 995 (3.7) 981 (3.7) 937 (3.5) 904 (3.4) 858 (3.3) 736 (3.1) 685 (3.3) >30–90 268 (4.0) 420 (6.3) 1004 (15.0) 568 (9.4) 362 (6.5) 293 (6.2) 217 (5.4) 950 (3.6) 953 (3.6) 910 (3.4) 898 (3.4) 849 (3.2) 795 (3.4) 757 (3.6) >90–180 142 (2.1) 165 (2.5) 720 (10.8) 472 (7.8) 293 (5.3) 222 (4.7) 165 (4.1) 494 (1.9) 455 (1.7) 449 (1.7) 457 (1.7) 422 (1.6) 451 (1.9) 417 (2.0) >180 152 (2.3) 151 (2.3) 2154 (32.3) 812 (13.5) 506 (9.1) 359 (7.6) 259 (6.5) 568 (2.1) 458 (1.7) 437 (1.6) 433 (1.6) 482 (1.8) 496 (2.1) 515 (2.5) Disability pension 0 5421 (81.4) 5413 (81.1) 5393 (80.8) 4901 (81.3) 4574 (82.4) 3906 (82.9) 3313 (82.7) 22,351 (84.0) 22,365 (83.7) 22,332 (83.6) 22,144 (83.6) 22,406 (85.1) 20,268 (86.0) 18,136 (86.6) >0 1240 (18.6) 1266 (19.0) 1286 (19.3) 1124 (18.7) 979 (17.6) 807 (17.1) 692 (17.3) 4262 (16.0) 4351 (16.3) 4384 (16.4) 4349 (16.4) 3925 (14.9) 3306 (14.0) 2817, (13.4) Not included 18 - - 654 1126 1966 2674 103 - - 223 385 3142 5763 Number and percentages of colorectal cancer survivors and references having different numbers of sickness absence or disability pension net days per year during the 2 years before through the 5 years after the date of colorectal cancer diagnosis (for references, diagnosis date of matched patient was used) Individuals were included up to and including the year they turned 65 years of age, died, or emigrated 274 J Cancer Surviv (2022) 16:269–278 SA other DP other SA musculoskeletal DP musculoskeletal SA mental DP mental SA colorectal cancer DP colorectal cancer Y Y Y Y Y Y Y Y Y Y Y Y Y Y -2 -1 +1 +2 +3 +4 +5 -2 -1 +1 +2 +3 +4 +5 Years before and after diagnosis date Colorectal cancer cohort Matched reference cohort Fig. 1 Mean number of sickness absence (SA) and disability pension (DP) references were not included anymore after turning 65 years of age, death, or net days per year and by diagnosis for colorectal cancer survivors and for their emigration. In Y , people not yet living in Sweden at that time were not -2 matched references. Mean number of sickness absence (SA) and disability included. In the colorectal cancer cohort, the total number of people included pension (DP) net days per yearly interval from the second year before (Y ) in the analyses from Y to Y were 6661, 6679, 6679, 6025, 5553, 4713, -2 -2 +5 until the fifth year after (Y ) the date of colorectal cancer diagnosis (for and 4005, respectively. For the matched reference cohort, the corresponding references, diagnosis date of matched patient was used). The survivors and numbers were 26613, 26716, 26716, 26493, 26331, 23574, and 20953 Meanwhile, the proportion of mean DP days due to CRC of future SA and DP than those with stage 0+I, probably due to gradually increased to 6% in Y from 1% in Y . more severe disease and more aggressive and/or longer treatment. +5 +1 No major differences were observed between the survivors This potential association is supported by studies showing lower and references regarding SA and DP days due to mental or work capacity or return-to-work in CRC patients treated with che- musculoskeletal diagnoses in any of the studied years. motherapy, radiotherapy, and extensive surgery [12–15, 31]. Concerning mental morbidity following CRC diagnoses, lit- As also found in two previous studies [11, 12], rectal cancer erature presents mixed results: reduced mental health after survivors had higher odds for SA in Y compared to colon cancer diagnosis compared to in the general population was found survivors. Reasons could be more aggressive treatment strategies in some studies, while no difference was reported in others like neoadjuvant chemo- and radiotherapy, abdominoperineal re- [29]. Here we had no information on mental disorders follow- section with the necessity of a stoma [14, 15], and higher rates of ing diagnoses; however, SA/DP due to mental diagnoses did postoperative complications in these patients [32]. not increase, possibly indicating that mental disorders due to We found that high comorbidity score (CCI ≥2), prior men- the CRC diagnoses were not severe enough to lead to severe tal morbidity, and having more pre-diagnostic SA days all ren- work incapacity. More knowledge is needed about this. dered a higher risk of SA and DP postdiagnosis. These findings The SA/DP diagnostic category “other diagnoses” caused imply that morbidity prior to diagnosis plays an important role most of the remaining difference between survivors and refer- infutureSA andDP,somethingalsosupportedbyprevious ences in mean SA and DP days/year. Part of this difference could studies [11, 12, 15]. Furthermore, mental morbidity is associat- be explained by the diagnosis of secondary cancers, since 18% of ed with higher somatic morbidity [33–35] and may therefore included survivors already had stage IV at diagnosis, and in imply higher risk of future SA and DP not only through mental general, one-third of CRC survivors experience cancer relapse but also somatic disorders. (most within 3 years of diagnosis) [30]. Our results indicate that those with no university/college edu- In line with three other studies [11, 12, 15], we found that those cation have higher risk of SA and DP. Possible reasons for this with advanced cancer stage, especially stage IV, had a higher risk could be an association between lower educational level and later Mean number of net days 0 20 40 60 80 100 120 140 160 180 J Cancer Surviv (2022) 16:269–278 275 Table 3 Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for having sickness absence >30 net days during year 3 (Y )and5(Y ) postdiagnosis, respectively, and for being +3 +5 granted disability pension during the 5-year postdiagnosis period, among colorectal cancer survivors Sickness absence year 3 (Y )(n = 5044) Sickness absence year 5 (Y )(n = 3641) Disability pension during 5-year follow-up +3 +5 Variable and categories On sickness Crude OR Adjusted On sickness Crude Adjusted Granted disability Crude Adjusted absence/all (95% CI) OR (95% CI) absence/all OR (95% CI) OR (95% CI) pension/all included OR (95% CI) OR (95% CI) included included survivors survivors survivors at risk (%) at risk (%) at risk (%) Total 1161/5044 (23.0) 640/3641 (17.6) 229/3981 (5.8) Sex Men 607/2704 (22.5) 1 1 304/1902 (16.0) 1 1 125/2164 (5.8) 1 1 Women 554/2340 (23.7) 1.07 (0.94–1.22) 1.04 (0.90–1.20) 336/1739 (19.3) 1.26 (1.06–1.50) 1.20 (1.00–1.43) 104/1817 (5.7) 0.99 (0.76–1.30) 0.87 (0.65–1.17) Age (years) 18–50 372/1390 (26.8) 1.11 (0.94–1.30) 1.15 (0.96–1.37) 229/1216 (18.8) 1.37 (1.12–1.68) 1.44 (1.17–1.77) 72/1148 (6.3) 0.91 (0.66–1.26) 1.02 (0.72–1.45) 51–55 269/1001 (26.9) 1.11 (0.93–1.33) 1.17 (0.97–1.42) 188/884 (21.3) 1.60 (1.29–1.98) 1.69 (1.35–2.10) 55/807 (6.8) 1.00 (0.70–1.42) 1.12 (0.77–1.63) 56–60 399/1607 (24.8) 1 1 223/1541 (14.5) 1 1 87/1274 (6.8) 1 1 61–62 121/1046 (11.6) 0.40 (0.32–0.49) 0.36 (0.29–0.46) - - - 15/752 (2.0) 0.28 (0.16–0.48) 0.25 (0.14–0.44) Country of birth Sweden 975/4283 (22.8) 1 1 541/3078 (17.6) 1 1 173/3387 (5.1) 1 1 Other 186/761 (24.4) 1.10 (0.92–1.31) 1.12 (0.92–1.36) 99/563 (17.6) 1.00 (0.79–1.27) 1.06 (0.83–1.35) 56/594 (9.4) 1.93 (1.41–2.65) 1.85 (1.31–2.61) Educational level (years) Elementary school (<10) 224/998 (22.4) 1.05 (0.88–1.28) 1.14 (0.93–1.40) 109/640 (17.0) 1.08 (0.84–1.39) 1.11 (0.85–1.44) 52/729 (7.1) 1.69 (1.16–2.47) 1.58 (1.05–2.39) High school (10–12) 566/2320 (24.4) 1.18 (1.02–1.37) 1.21 (1.03–1.42) 323/1697 (19.0) 1.24 (1.02–1.50) 1.24 (1.02–1.52) 115/1824 (6.3) 1.48 (1.08–2.04) 1.42 (1.01–1.98) University/college (>12) 371/1726 (21.5) 1 1 208/1304 (16.0) 1 1 62/1428 (4.3) 1 1 Cancer type Colon cancer 627/2984 (21.0) 1 1 369/2180 (16.9) 1 1 132/2355 (5.6) 1 1 Rectal cancer 534/2060 (25.9) 1.32 (1.15–1.50) 1.48 (1.28–1.70) 271/1461 (18.6) 1.12 (0.94–1.33) 1.16 (0.97–1.39) 97/1626 (6.0) 1.07 (0.82–1.40) 1.20 (0.90–1.60) Cancer stage Stage 0 + I 249/1835 (13.6) 1 1 197/1416 (13.9) 1 1 64/1568 (4.1) 1 1 Stage II 227/1081 (21.0) 1.69 (1.39–2.06) 1.80 (1.47–2.21) 130/831 (15.6) 1.15 (0.90–1.46) 1.22 (0.95–1.55) 47/909 (5.2) 1.28 (0.87–1.88) 1.43 (0.94–2.15) Stage III 323/1203 (26.9) 2.34 (1.94–2.81) 2.50 (2.06–3.02) 175/849 (20.6) 1.61 (1.28–2.01) 1.71 (1.36–2.15) 57/920 (6.2) 1.55 (1.08–2.24) 1.88 (1.28–2.78) Stage IV 269/453 (59.4) 9.31 (7.40–11.72) 10.34 (8.10–13.18) 75/164 (45.7) 5.21 (3.70–7.34) 5.54 (3.90–7.87) 44/188 (23.4) 7.18 (4.72–10.93) 9.57 (6.00–15.26) Missing 93/472 (19.7) 1.56 (1.20–2.03) 1.53 (1.17–2.00) 63/381 (16.5) 1.23 (0.90–1.67) 1.23 (0.90–1.68) 17/396 (4.3) 1.05 (0.61–1.82) 1.12 (0.63–1.98) Charlson Comorbidity Index in the 3 years prior to diagnosis date (Y – Y ) -3 -1 0+1 941/4394 (21.4) 1 1 559/3283 (17.0) 1 1 174/3572 (4.9) 1 1 ≥2 220/650 (33.9) 1.88 (1.57–2.24) 1.52 (1.24–1.85) 81/358 (22.6) 1.43 (1.10–1.86) 1.25 (0.95–1.65) 55/409 (13.5) 3.03 (2.20–4.19) 2.65 (1.86–3.78) Mental morbidity in the 3 years prior to diagnosis date (Y – Y ) -3 -1 None 949/4273 (22.1) 1 1 508/3090 (16.4) 1 1 159/3465 (4.6) 1 1 Any 212/771 (27.5) 1.33 (1.12–1.58) 1.34 (1.10–1.63) 132/551 (24.0) 1.60 (1.29–2.00) 1.55 (1.23–1.97) 70/516 (13.6) 3.26 (2.42–4.40) 2.46 (1.74–3.49) No. of sickness absence days in the second year before diagnosis date (Y ) -2 0 948/4386 (21.6) 1 1 523/3.167 (16.5) 1 1 161/3.488 (4.6) 1 1 >0–30 63/235 (26.8) 1.33 (0.99–1.79) 1.26 (0.91–1.74) 41/183 (22.4) 1.46 (1.02–2.09) 1.41 (0.97–2.05) 9/179 (5.0) 1.09 (0.55–2.18) 0.89 (0.43–1.83) >30–90 68/218 (31.2) 1.64 (1.22–2.21) 1.84 (1.34–2.54) 42/155 (27.1) 1.88 (1.30–2.71) 1.76 (1.20–2.58) 17/166 (10.2) 2.36 (1.39–3.99) 1.83 (1.04–3.25) >90–180 41/103 (39.8) 2.40 (1.61–3.58) 2.63 (1.69–4.08) 13/62 (21.0) 1.34 (0.72–2.41) 1.16 (0.61–2.21) 14/75 (18.7) 4.74 (2.60–8.66) 4.25 (2.22–8.14) >180 41/102 (40.2) 2.44 (1.63–3.65) 2.75 (1.78–4.27) 21/74 (28.4) 2.00 (1.20–3.35) 1.81 (1.05–3.10) 28/73 (38.4) 12.86 (7.82–21.15) 9.55 (5.43–16.79) Bold text indicates a statistically significant association with both sided p<0.05. In adjusted models, all covariates (sex, age, country of birth, educational level, cancer type, cancer stage, Charlson Comorbidity Index, mental morbidity, pre-diagnostic sickness absence) were included CI confidence interval, OR odds ratio, DP disability pension 276 J Cancer Surviv (2022) 16:269–278 physically demanding jobs in less flexible workplaces [36, 37]. diagnostic levels. The likelihood for long-term SA and DP was Previous findings about associations with educational level have highest among survivors with more pre-diagnostic SA days and been inconclusive [31]. Further research could investigate how advanced cancer stage. These results emphasize the importance occupation-related factors are associated with future SA and DP. to support CRC survivors in improving work-related capacity, The risk for SA and DP was lower in higher ages, as people especially among those at high risk for long-term SA and DP, transitioned into retirement age and some might also have taken and indicate the relevance of early cancer diagnosis to prevent early old-age pension. Notably, the CRC cohort had higher levels long-term work incapacity. of SA/DP days already 2 years before diagnosis and a higher comorbidity score during the 3 years before diagnosis. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s11764-021-01017-7. Strengths and limitations Author contribution Lingjing Chen had the initial idea of the study con- cept and supervised the study. Kristina Alexanderson obtained the funding Strengths of this study include the population-based, longitudinal and the data. Luisa C. Beermann performed the data management and the design using nationwide registers of high quality and complete- analyses, along with drafting the manuscript. Anna Martling gave clinical ness [18, 19, 25], avoiding selection bias and loss to follow-up, advice. All four authors interpreted the results and revised the manuscript. that all, not only employed, were included and that data on SA and DP diagnoses could be included. The large study population Funding Open access funding provided by Karolinska Institute. The study was financially supported by the Swedish Research Council for allowed for sub-group analyses. Another strength is that all were Health, Working Life and Welfare. followed from actual diagnosis date, instead of calendar year. In the analyses, we excluded people not anymore at risk for the Declarations outcome, i.e., after they died, emigrated, or turned 65. It is a strength that we had information on this; if keeping people not Ethical approval The project was approved by the Regional Ethical at risk, the SA/DP rates would falsely have seemed to be lower. Review Board in Stockholm. However, if some of those who died due to, e.g., late diagnosis, might have survived longer if diagnosed earlier, it might have Informed consent The observational study was based on nationwide administrative register data. In Sweden, informed consent is not needed been so that SA rates might have been higher. The results are for such data collection nor for studies based on them. representative of the population in Sweden and can be general- ized to other countries with similar welfare systems. Conflict of interest The authors declare no conflict of interest. Several limitations were noted also. SA spells ≤14 days were not included, possibly leading to an underestimation of annual SA Open Access This article is licensed under a Creative Commons days. However, by using a comparison group, we limited the Attribution 4.0 International License, which permits use, sharing, adap- influence of this. Furthermore, by including only SA spells >14 tation, distribution and reproduction in any medium or format, as long as days, our outcome reflects long-term, more severe SA spells. you give appropriate credit to the original author(s) and the source, pro- Another limitation was that treatment data was not available. vide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included Still, the information about cancer stage may partially compensate in the article's Creative Commons licence, unless indicated otherwise in a for this. Information about cancer relapse was also not included, credit line to the material. If material is not included in the article's possibly causing an overestimation of other factors’ influence on Creative Commons licence and your intended use is not permitted by the risk for SA and DP. Information about cancer stage was miss- statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this ing in 9.5% of cases, but comparable results in the analyses were licence, visit http://creativecommons.org/licenses/by/4.0/. found when excluding all missing data. Conclusion References 1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. This register-based longitudinal cohort study showed that CRC Global cancer statistics 2018: GLOBOCAN estimates of incidence survivors were more likely to have SA and DP than their and mortality worldwide for 36 cancers in 185 countries. 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Overall and diagnosis-specific sickness absence and disability pension in colorectal cancer survivors and references in Sweden

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Springer Journals
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1932-2259
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10.1007/s11764-021-01017-7
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Abstract

Purpose To longitudinally investigate overall and diagnosis-specific sickness absence (SA) and disability pension (DP) in colorectal cancer (CRC) survivors and references and to identify potential risk factors. Methods This longitudinal register-based cohort study included all patients living in Sweden, diagnosed with a first primary CRC in 2008–2011 when aged 18–62 (n=6679), and their matched references (n=26 716). Net days of SA (in SA spells >14 days) and DP were analyzed from 2 years before through 5 years after diagnosis, overall and by specific diagnoses. Among survivors, risk factors for future SADP were explored using logistic regression. Results In survivors, SA peaked in year 1 postdiagnosis, with 62.5% having at least some SA, and then gradually decreased to 20.1% in year 5. In the 2 years after diagnosis, CRC was the most common SA diagnosis in survivors, while SA due to mental diagnoses remained similar to the references. Notable risk factors for postdiagnostic SA or DP were rectal cancer diagnosis, advanced cancer stage at diagnosis, lower educational level, born outside of Sweden, and pre-diagnostic SA, mental morbidity, and comorbidities. Conclusion During 5 years after a CRC diagnosis, CRC survivors had higher levels of postdiagnostic SA and DP than the references, which was mostly due to CRC diagnoses. Although their SA lowered gradually, it did not return to pre-diagnostic levels. Implications for Cancer Survivors Our results provide valuable information for patients with CRC diagnosis, especially that most have none or low levels of SA/DP after a few years. . . . . Keywords Sick leave Disability pension Work loss Cancer survivorship Colorectal cancer Background regain control and normalcy in their lives [6–10]. However, CRC, especially colon cancer survivors, is reported to have Colorectal cancer (CRC) is one of the most common reduced capacity for paid work after diagnosis [11–14]. Risk cancer types, ranking third in cancer incidence and sec- factors for future sickness absence (SA) and disability pension ond in cancer mortality worldwide [1]. Recently, the (DP) include comorbidities, previous SA, advanced cancer incidence of CRC is increasing in high-income countries stage, chemotherapy, radiotherapy, extensive surgery, and among people below 50 years [2, 3], while mortality postoperative complications, with inconsistent findings for declines [4, 5]. Hence, for growing numbers of the influence of educational level [11, 12, 15]. working-age CRC survivors, future work-related out- Most previous studies on CRC survivors’ work capacity comes are of rising importance. have focused on the binary outcome return-to-work (measured Pursuing paid work after cancer diagnosis and treatment is as yes/no) [13, 14]. Furthermore, these studies only have a a significant part of recovery, as it helps cancer survivors to short follow-up, not accounting for long-term effects that CRC diagnosis and treatment may have on survivors’ work capacity. The few previous studies that used SA and DP as an * Lingjing Chen outcome used data from patients diagnosed 1992–2005 and lingjing.chen@ki.se aged 45–54 at diagnosis [11], or measured SA as a binary outcome (yes/no) and not using a reference group [12], or only Division of Insurance Medicine, Department of Clinical including rectal cancer survivors [15, 16]. Neuroscience, Karolinska Institutet, SE-171 77 Stockholm, Sweden Moreover, CRC survivors’ specific SA and DP diagnoses Department of Molecular Medicine and Surgery, Karolinska have not yet been investigated. Such knowledge, in Institutet, SE-171 77 Stockholm, Sweden 270 J Cancer Surviv (2022) 16:269–278 comparison to the general population, will enable clinicians to diagnosis date + 365 days). Individuals were censored from better understand occurrences of behind future long-term SA the year following their death, emigration, or turning 65 (old- and even DP in survivors. Hence, there is a need of longitu- age pension age), whichever came first. dinal studies using recent data and a reference group to pro- The reason for this is that they were no longer at risk for the vide comprehensive information on CRC survivors’ long- outcome (SA/DP) afterwards. A detailed flow chart was pre- term SA and DP. sented (Online Resource 1). Therefore, we aimed to (1) longitudinally investigate over- all and diagnosis-specific SA and DP in CRC survivors and in The Swedish public sickness absence and disability their matched references and (2) identify possible risk factors pension benefit scheme for overall SA and DP. In Sweden, SA can be granted to residents ≥16 years with an income from work or unemployment benefit, if their work Methods capacity is reduced due to disease or injury. A physician med- ical certificate is needed from day 8. For employees, the first 2 A longitudinal cohort study of first primary CRC patients and weeks of SA benefits are paid by employers, afterwards by the matched references was conducted. Social Insurance Agency. For the unemployed, the Social Data from the following six nationwide Swedish registers Insurance Agency pays from day 2. Therefore, we only used were linked on an individual level through the personal iden- information on SA spells >14 days registered by the Social tity numbers assigned to all residents in Sweden [17]. Insurance Agency. In most of the studied years, there was no maximum duration of a SA spell. In some of the years, there -National Board of Health and Welfare: Swedish Cancer was a limit of 914 days (2.5 years), followed by a waiting Register [18] for the identification of cancer diagnosis, period of 3 months before SA benefits could be claimed again. diagnosis date, and cancer stage; National Patient Temporary or permanent DP can be granted to people aged Register [19] for inpatient and specialized outpatient 19–64 years with long-term or permanent work incapacity due visits; Cause of Death Register [20] for death date; and to disease or injury [25]. Prescribed Drug Register [21] for dispensed prescribed SA and DP benefits cover 80% and 64% of lost income, psychiatric medication respectively, up to a certain level. SA and DP can be granted -Statistics Sweden: Longitudinal Integrated Databases for for full- or part-time (100%, 75%, 50%, or 25%) of ordinary Health Insurance and Labour Market Studies [22](LISA) work hours [25]; thus, people can have both partial SA and DP for socio-demographic information including sex, birth at thesametime. year, educational level, birth country, and emigration -Swedish Social Insurance Agency: Microdata for Outcome Analyses of Social Insurance [23] (MiDAS) for all DP and all SA spells >14 days regarding start/end date, grade The main outcomes were SA and DP following the CRC (full- or part-time), and main diagnosis (according to diagnosis date. The SA and DP net days/year during the International Classification of Diseases, the tenth follow-up were calculated for survivors and their matched revision, ICD-10) [24] references. Net days were calculated by multiplying the de- gree of compensation with the number of compensated days: e.g., two gross days of 50% SA or DP equaled one net day (net Inclusion and exclusion criteria days are from here on called as only days). SA days were further categorized into 0, >0–30, >30–90, We included all people diagnosed with a first primary CRC in >90–180, and >180 days/year. DP was dichotomized in 0 and Sweden in 2008–2011 (not diagnosed at autopsy) when aged >0 days/year. As the majority of SA and DP days in Sweden 18–62 (N=6679). We used ICD-10 codes C18 and C19–20 to are due to mental and musculoskeletal diagnoses [25, 26], we identify colon and rectal cancer, respectively. From LISA, categorized medical diagnoses for SA and DP days as CRC, 26,716 population references were matched to the patients mental, musculoskeletal, or other diagnoses. regarding sex, age, birth country, and educational level (four references per patient). References were selected randomly Characteristics and were alive and without previous record of CRC before the diagnosis date of the index person and registered as living Sociodemographic variables included sex, age at diagnosis, in Sweden the year before the diagnosis year of the index birth country, and educational level (detailed in Table 1). person and alive at inclusion. Survivors and references were Stage was classified into stage 0, I, II, III, IV, and missing, followed from diagnosis date through 5 years later (e.g., Y = based on the information of T (tumor size), N (lymph nodes), +1 J Cancer Surviv (2022) 16:269–278 271 Table 1 Sociodemographic and Characteristics Colorectal cancer survivors no. (%) References no. (%) clinical characteristics of colorectal cancer survivors All 6679 (100) 26,716 (100) diagnosed in 2008–2011 when aged 18–62 years and of their Sex matched references Men 3598 (53.9) 14,392 (53.9) Women 3081 (46.1) 12,324 (46.1) Age, years 18–50 1783 (26.7) 7132 (26.7) 51–55 1319 (19.8) 5276 (19.8) 56–60 2271 (34.0) 9084 (34.0) 61–62 1306 (19.6) 5224 (19.6) Country of birth Sweden 5624 (84.2) 22,496 (84.2) other 1055 (15.8) 4220 (15.8) Educational level (years) Elementary school (<10) 1467 (22.0) 5868 (22.0) High school (10-12) 3120 (46.7) 12,480 (46.7) University/college (>12) 2092 (31.3) 8368 (31.3) Cancer type Coloncancer 4044(60.6) - Rectal cancer 2635 (39.5) - Cancer stage Stage 0 + I 2109 (31.6) - Stage II 1270 (19.0) - Stage III 1464 (21.9) - Stage IV 1203 (18.0) - Missing 633 (9.5) - Charlson Comorbidity Index in the 3 years prior to diagnosis date (Y – Y ) -3 -1 0+1 5505 (82.4) 25,588 (95.8) ≥2 1174 (17.6) 1128 (4.2) Mental morbidity in the 3 years prior to diagnosis date (Y – Y ) -3 -1 None 5424 (81.2) 22,317 (83.5) Any 1255 (18.8) 4399 (16.5) Charlson Comorbidity Index was calculated based on all diagnoses from specialized healthcare within the 3 years before diagnosis date and M (metastases) [27] from the Swedish Cancer Register. If Statistical analysis T and/or N and M were missing or classified as X (assessment not possible), stage was classified as missing. If more than one The numbers and percentages of people with different levels entry of the same type of cancer diagnosis was found in the of annual SA and DP days were computed from the second register within 30 days, the most advanced stage was used. year before (Y ) through the fifth year after (Y )diagnosis -2 +5 The Charlson Comorbidity Index (CCI) [28]atdiagnosis date for both cohorts. The mean SA and DP days/year overall was calculated for survivors and their references based on the and by specific SA/DP diagnoses were calculated. National Patient Register regarding inpatient and specialized For CRC survivors, univariable and multivariable logistic outpatient visits during all the 3 years before diagnosis date. regression were used to examine the associations between Based on the same register, pre-diagnostic mental morbidity covariates and future SA and DP, respectively. In all logistic was defined as having any healthcare during the 3-year period regression models, pre-diagnostic SA was assessed by using before diagnosis date with ICD-10 codes of “F00-F99” or SA in Y . Therefore, survivors not living in Sweden in Y -2 -2 “Z73” or having any prescribed psychiatric medication for were excluded in those analyses. depression, anxiety, tension, or psychotics, according to the In the analyses of SA risk, the odds ratios (OR) with 95% prescribed drug register. confidence intervals (CI) of having >30 days of SA in Y and +3 272 J Cancer Surviv (2022) 16:269–278 Y , respectively, were estimated. For specific years, survivors In contrast, the mean SA days in references remained were excluded from the analyses if they died or emigrated before stable during the postdiagnostic period (9.1–11.9 or had full-time DP during all of the respective years. For Y , days/year). survivors aged 61–62 at diagnosis were also excluded because of Opposed to mean SA days, mean DP days after diagnosis possible transition into old-age pension. In the analyses of DP were more comparable in both groups and decreased slightly risk during the follow-up period, survivors on any DP in Y and with time during follow-up (from 53.2 to 46.6 days/year in -1 those who died or emigrated during follow-up without having survivors vs. from 48.8 to 36.8 days/year in references). In Y been granted DP were excluded. , the survivors still had higher DP rates, and the difference All statistical analyses were performed with STATA version between survivors and references in overall mean SA was 15 14. For all tests, the level of significance was set at p<0.05. days and in mean DP: 9 days. The project was approved by the Regional Ethical Review Regarding the specific SA and DP diagnoses, among CRC Board in Stockholm. survivors, 68% of all mean SA days in Y were due to CRC (81 mean days) and 27% in Y (7.5 mean days). Meanwhile, the proportion of mean DP days due to CRC increased from 1.1% Results in Y (0.6 mean days) to 6.1% in Y (2.9 mean days). +1 +5 Comparing survivors and references, mean SA and DP days/ In both CRC survivors (n=6679) and references (n=26,716), year due to mental or musculoskeletal diagnoses were similar the majority were men (53.94%) and born in Sweden (84.2%), in both groups during the postdiagnostic follow-up. Mean SA and 34.0% were diagnosed when aged 56–60 (Table 1). days due to mental diagnoses amounted to 2.5 in survivors and Survivors and their references differed regarding the distribu- 2.8 in references in Y and increased in both cohorts during -2 tion of pre-diagnostic CCI (17.6% of survivors vs. 4.2% of follow-up to 3.9 and 3.6 mean SA days in Y , respectively. references with CCI score ≥2). Among survivors, 60.6% had a Mean DP days with mental diagnoses ranged between 12.0 colon cancer diagnosis, and the most common cancer stage and 15.0 days in survivors and 11.2 and 12.7 days in references. was stage 0+I (31.6%). The corresponding baseline character- Regarding musculoskeletal diagnoses, survivors had 3.4 and ref- istics stratified by colon and rectal cancer survivors are pre- erences 3.5 mean SA days in Y whichstayedconstantduring -2 sented in Online Resource 2. follow-up, while mean DP days ranged between 11.5–18.0 among survivors and 11.2–16.7 among references. (The figure Distribution of annual SA and DP did not change if excluding references for which the patient had died or emigrated during follow-up.) SA and DP days/year in survivors and in their matched refer- However, the number of mean SA and DP days for the ences are presented by the different categories (Table 2). Among diagnostic group “other” was slightly higher in survivors than the references, on average 10.6% had some SA during the ob- in their references. While mean SA days/year varied between servation period. The proportion of CRC survivors with SA was 4.2 and 4.9 days in references, survivors had 33.5 mean SA 12.8% during Y and increased to 30.2% in Y .InY , 62.5% days due to other diagnoses in Y , which decreased to 12.9 in -2 -1 +1 +1 of survivors had some SA, half of them for >180 days. This Y . Concerning DP, mean days with other diagnoses in Y +5 -2 proportion decreased to 37.5% in Y and further to 20.1% in were 22.3 in survivors and 18.3 in references and decreased to Y but did not reach the pre-diagnostic levels. The proportion of 18.8 and 14.2 mean days in Y , respectively. Diagnosis- +5 +5 survivors with any SA in Y was 8.8% higher than in the ref- specific mean SA and DP days/year are also presented by erence group. Among survivors, 18.6% had some DP in Y colon and rectal cancer survivors (Online Resource 2). The -2 compared to 16.0% among the references. These proportions percentages were similar, although somewhat higher among decreased to 17.3% and 13.4%, respectively, in Y , with a dif- rectal cancer survivors in the postdiagnostic years. ference of 3.8%. (If excluding references for which the patient had died or emigrated during follow-up, figures were nearly Risk for future sickness absence among CRC survivors exactly the same.) In Y and Y , 23.0% and 17.6% of CRC survivors, not on +3 +5 Diagnosis-specific SA and DP full-time DP, had >30 SA days, respectively (Table 3). After adjustments, in Y , the strongest association with future SA Before diagnosis, overall mean combined SA and DP days/year >30 days could be seen for cancer stage II–IV, with stage IV were slightly higher among CRC survivors compared to among having an OR of 10.3 (95% CI 8.1–13.2) compared to stage references (67.0 days/year in survivors vs. 57.9 days/year in ref- 0+1. Those with SA >30 days in Y also had higher ORs. -2 erences in Y )(Fig. 1). After diagnosis, mean SA days in survi- Having pre-diagnostic SA >180 days compared to 0 such days -2 vors peaked in Y (119.8 days/year) and then drastically rendered an OR of 2.8 (95% CI 1.8–4.3). Other factors with a dropped to 56.0 days in Y and further to 27.7 days in Y . substantially higher likelihood for SA >30 days in Y were +2 +5 +3 J Cancer Surviv (2022) 16:269–278 273 rectal cancer diagnosis and pre-diagnostic CCI ≥2. A lower likelihood on the other hand was found among survivors aged 61–62 at diagnosis compared to 56–60. In Y , similar patterns of risk indicators for having SA >30 days were observed. Diagnosed with stage IV rendered an ad- justed OR of 5.5 (95% CI 3.9–7.9) and pre-diagnostic SA >180 days an OR of 1.8 (95% CI 1.1–3.1). Additionally, pre- diagnostic mental morbidity or being diagnosed at a younger age (18–55 vs. 56–60 years) implied a higher risk of SA >30 days in Y . Risk for future disability pension among CRC survivors Among those at risk for DP (i.e., excluding those already on DP before diagnosis date and those who during the follow-up died or emigrated before being granted DP), 5.8% of the survivors were granted DP during the 5-year follow-up (Table 3). After adjust- ments, the OR for DP was significantly higher among survivors with stage III (OR 1.9; 95% CI 1.3–2.8) and stage IV cancer (OR 9.6; 95% CI 6.0–15.3) compared to those with stage 0+I. Those with any pre-diagnostic SA compared to none in Y also had -2 higher risk of being granted DP postdiagnosis, especially among those with pre-diagnostic SA >180 days (OR 9.6; 95% CI 5.4– 16.8). Other risk factors for DP were pre-diagnostic mental mor- bidity, pre-diagnostic CCI ≥2, lower educational level, and being born outside of Sweden, while those diagnosed when aged 61– 61 had lower risk compared to those diagnosed when 56–60. Discussion In this large Swedish longitudinal cohort study of 6679 CRC survivors, the proportion of survivors on SA and DP after their diagnosis was significantly higher than among their matched references from the general population. Nevertheless, following the expected peak during the first year postdiagnosis, a clear decline was seen over the 5-year follow-up period. Most survi- vors (65%) did not have any SA or DP benefits in the fifth year postdiagnosis. However, SA in survivors did not decrease to pre-diagnostic levels and remained higher than in references. The risk for having SA and DP during follow-up was highest among survivors with advanced cancer stage and prior SA. Our main finding of higher levels of SA and DP in CRC survivors than in references, with a peak of SA in Y ,are in line with results from two previous studies [11, 15], implying that treatment-related factors may have the strongest impact on SA in the first year postdiagnosis. Uniquely, we also explored the SA and DP diagnoses and showed that CRC was the most common diagnosis for SA days in survivors postdiagnostically until Y , accounting for 68% of all mean SA days in Y and 27% in Y . +1 +5 Table 2 Annual distribution of sickness absence and disability pension, respectively, among colorectal cancer survivors and their matched references Colorectal cancer survivors Matched references Before diagnosis date After diagnosis date Before diagnosis date After diagnosis date No. of days Year -2, no. (%) Year -1, no. (%) Year +1, no. (%) Year +2, no. (%) Year +3, no. (%) Year +4, no. (%) Year +5, no. (%) Year -2, no. (%) Year -1, no. (%) Year +1, no. (%) Year +2, no. (%) Year +3, no. (%) Year +4, no. (%) Year +5, no. (%) All included 6661 (100) 6 679 (100) 6679 (100) 6025 (100) 5553 (100) 4713 (100) 4005 (100) 26,613 (100) 26,716 (100) 26,716 (100) 26,493 (100) 26,331 (100) 23,574 (100) 20,953 (100) Sickness absence 0 5806 (87.2) 4663 (69.8) 2506 (37.5) 3764 (62.5) 4134 (74.5) 3666 (77.8) 3200 (79.9) 23,606 (88.7) 23,869 (89.3) 23,983 (89.8) 23,801 (89.8) 23,720 (90.1) 21,096 (89.5) 18,579 (88.7) >0–30 293 (4.4) 1280 (19.2) 295 (4.4) 409 (6.8) 258 (4.7) 173 (3.7) 164 (4.1) 995 (3.7) 981 (3.7) 937 (3.5) 904 (3.4) 858 (3.3) 736 (3.1) 685 (3.3) >30–90 268 (4.0) 420 (6.3) 1004 (15.0) 568 (9.4) 362 (6.5) 293 (6.2) 217 (5.4) 950 (3.6) 953 (3.6) 910 (3.4) 898 (3.4) 849 (3.2) 795 (3.4) 757 (3.6) >90–180 142 (2.1) 165 (2.5) 720 (10.8) 472 (7.8) 293 (5.3) 222 (4.7) 165 (4.1) 494 (1.9) 455 (1.7) 449 (1.7) 457 (1.7) 422 (1.6) 451 (1.9) 417 (2.0) >180 152 (2.3) 151 (2.3) 2154 (32.3) 812 (13.5) 506 (9.1) 359 (7.6) 259 (6.5) 568 (2.1) 458 (1.7) 437 (1.6) 433 (1.6) 482 (1.8) 496 (2.1) 515 (2.5) Disability pension 0 5421 (81.4) 5413 (81.1) 5393 (80.8) 4901 (81.3) 4574 (82.4) 3906 (82.9) 3313 (82.7) 22,351 (84.0) 22,365 (83.7) 22,332 (83.6) 22,144 (83.6) 22,406 (85.1) 20,268 (86.0) 18,136 (86.6) >0 1240 (18.6) 1266 (19.0) 1286 (19.3) 1124 (18.7) 979 (17.6) 807 (17.1) 692 (17.3) 4262 (16.0) 4351 (16.3) 4384 (16.4) 4349 (16.4) 3925 (14.9) 3306 (14.0) 2817, (13.4) Not included 18 - - 654 1126 1966 2674 103 - - 223 385 3142 5763 Number and percentages of colorectal cancer survivors and references having different numbers of sickness absence or disability pension net days per year during the 2 years before through the 5 years after the date of colorectal cancer diagnosis (for references, diagnosis date of matched patient was used) Individuals were included up to and including the year they turned 65 years of age, died, or emigrated 274 J Cancer Surviv (2022) 16:269–278 SA other DP other SA musculoskeletal DP musculoskeletal SA mental DP mental SA colorectal cancer DP colorectal cancer Y Y Y Y Y Y Y Y Y Y Y Y Y Y -2 -1 +1 +2 +3 +4 +5 -2 -1 +1 +2 +3 +4 +5 Years before and after diagnosis date Colorectal cancer cohort Matched reference cohort Fig. 1 Mean number of sickness absence (SA) and disability pension (DP) references were not included anymore after turning 65 years of age, death, or net days per year and by diagnosis for colorectal cancer survivors and for their emigration. In Y , people not yet living in Sweden at that time were not -2 matched references. Mean number of sickness absence (SA) and disability included. In the colorectal cancer cohort, the total number of people included pension (DP) net days per yearly interval from the second year before (Y ) in the analyses from Y to Y were 6661, 6679, 6679, 6025, 5553, 4713, -2 -2 +5 until the fifth year after (Y ) the date of colorectal cancer diagnosis (for and 4005, respectively. For the matched reference cohort, the corresponding references, diagnosis date of matched patient was used). The survivors and numbers were 26613, 26716, 26716, 26493, 26331, 23574, and 20953 Meanwhile, the proportion of mean DP days due to CRC of future SA and DP than those with stage 0+I, probably due to gradually increased to 6% in Y from 1% in Y . more severe disease and more aggressive and/or longer treatment. +5 +1 No major differences were observed between the survivors This potential association is supported by studies showing lower and references regarding SA and DP days due to mental or work capacity or return-to-work in CRC patients treated with che- musculoskeletal diagnoses in any of the studied years. motherapy, radiotherapy, and extensive surgery [12–15, 31]. Concerning mental morbidity following CRC diagnoses, lit- As also found in two previous studies [11, 12], rectal cancer erature presents mixed results: reduced mental health after survivors had higher odds for SA in Y compared to colon cancer diagnosis compared to in the general population was found survivors. Reasons could be more aggressive treatment strategies in some studies, while no difference was reported in others like neoadjuvant chemo- and radiotherapy, abdominoperineal re- [29]. Here we had no information on mental disorders follow- section with the necessity of a stoma [14, 15], and higher rates of ing diagnoses; however, SA/DP due to mental diagnoses did postoperative complications in these patients [32]. not increase, possibly indicating that mental disorders due to We found that high comorbidity score (CCI ≥2), prior men- the CRC diagnoses were not severe enough to lead to severe tal morbidity, and having more pre-diagnostic SA days all ren- work incapacity. More knowledge is needed about this. dered a higher risk of SA and DP postdiagnosis. These findings The SA/DP diagnostic category “other diagnoses” caused imply that morbidity prior to diagnosis plays an important role most of the remaining difference between survivors and refer- infutureSA andDP,somethingalsosupportedbyprevious ences in mean SA and DP days/year. Part of this difference could studies [11, 12, 15]. Furthermore, mental morbidity is associat- be explained by the diagnosis of secondary cancers, since 18% of ed with higher somatic morbidity [33–35] and may therefore included survivors already had stage IV at diagnosis, and in imply higher risk of future SA and DP not only through mental general, one-third of CRC survivors experience cancer relapse but also somatic disorders. (most within 3 years of diagnosis) [30]. Our results indicate that those with no university/college edu- In line with three other studies [11, 12, 15], we found that those cation have higher risk of SA and DP. Possible reasons for this with advanced cancer stage, especially stage IV, had a higher risk could be an association between lower educational level and later Mean number of net days 0 20 40 60 80 100 120 140 160 180 J Cancer Surviv (2022) 16:269–278 275 Table 3 Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for having sickness absence >30 net days during year 3 (Y )and5(Y ) postdiagnosis, respectively, and for being +3 +5 granted disability pension during the 5-year postdiagnosis period, among colorectal cancer survivors Sickness absence year 3 (Y )(n = 5044) Sickness absence year 5 (Y )(n = 3641) Disability pension during 5-year follow-up +3 +5 Variable and categories On sickness Crude OR Adjusted On sickness Crude Adjusted Granted disability Crude Adjusted absence/all (95% CI) OR (95% CI) absence/all OR (95% CI) OR (95% CI) pension/all included OR (95% CI) OR (95% CI) included included survivors survivors survivors at risk (%) at risk (%) at risk (%) Total 1161/5044 (23.0) 640/3641 (17.6) 229/3981 (5.8) Sex Men 607/2704 (22.5) 1 1 304/1902 (16.0) 1 1 125/2164 (5.8) 1 1 Women 554/2340 (23.7) 1.07 (0.94–1.22) 1.04 (0.90–1.20) 336/1739 (19.3) 1.26 (1.06–1.50) 1.20 (1.00–1.43) 104/1817 (5.7) 0.99 (0.76–1.30) 0.87 (0.65–1.17) Age (years) 18–50 372/1390 (26.8) 1.11 (0.94–1.30) 1.15 (0.96–1.37) 229/1216 (18.8) 1.37 (1.12–1.68) 1.44 (1.17–1.77) 72/1148 (6.3) 0.91 (0.66–1.26) 1.02 (0.72–1.45) 51–55 269/1001 (26.9) 1.11 (0.93–1.33) 1.17 (0.97–1.42) 188/884 (21.3) 1.60 (1.29–1.98) 1.69 (1.35–2.10) 55/807 (6.8) 1.00 (0.70–1.42) 1.12 (0.77–1.63) 56–60 399/1607 (24.8) 1 1 223/1541 (14.5) 1 1 87/1274 (6.8) 1 1 61–62 121/1046 (11.6) 0.40 (0.32–0.49) 0.36 (0.29–0.46) - - - 15/752 (2.0) 0.28 (0.16–0.48) 0.25 (0.14–0.44) Country of birth Sweden 975/4283 (22.8) 1 1 541/3078 (17.6) 1 1 173/3387 (5.1) 1 1 Other 186/761 (24.4) 1.10 (0.92–1.31) 1.12 (0.92–1.36) 99/563 (17.6) 1.00 (0.79–1.27) 1.06 (0.83–1.35) 56/594 (9.4) 1.93 (1.41–2.65) 1.85 (1.31–2.61) Educational level (years) Elementary school (<10) 224/998 (22.4) 1.05 (0.88–1.28) 1.14 (0.93–1.40) 109/640 (17.0) 1.08 (0.84–1.39) 1.11 (0.85–1.44) 52/729 (7.1) 1.69 (1.16–2.47) 1.58 (1.05–2.39) High school (10–12) 566/2320 (24.4) 1.18 (1.02–1.37) 1.21 (1.03–1.42) 323/1697 (19.0) 1.24 (1.02–1.50) 1.24 (1.02–1.52) 115/1824 (6.3) 1.48 (1.08–2.04) 1.42 (1.01–1.98) University/college (>12) 371/1726 (21.5) 1 1 208/1304 (16.0) 1 1 62/1428 (4.3) 1 1 Cancer type Colon cancer 627/2984 (21.0) 1 1 369/2180 (16.9) 1 1 132/2355 (5.6) 1 1 Rectal cancer 534/2060 (25.9) 1.32 (1.15–1.50) 1.48 (1.28–1.70) 271/1461 (18.6) 1.12 (0.94–1.33) 1.16 (0.97–1.39) 97/1626 (6.0) 1.07 (0.82–1.40) 1.20 (0.90–1.60) Cancer stage Stage 0 + I 249/1835 (13.6) 1 1 197/1416 (13.9) 1 1 64/1568 (4.1) 1 1 Stage II 227/1081 (21.0) 1.69 (1.39–2.06) 1.80 (1.47–2.21) 130/831 (15.6) 1.15 (0.90–1.46) 1.22 (0.95–1.55) 47/909 (5.2) 1.28 (0.87–1.88) 1.43 (0.94–2.15) Stage III 323/1203 (26.9) 2.34 (1.94–2.81) 2.50 (2.06–3.02) 175/849 (20.6) 1.61 (1.28–2.01) 1.71 (1.36–2.15) 57/920 (6.2) 1.55 (1.08–2.24) 1.88 (1.28–2.78) Stage IV 269/453 (59.4) 9.31 (7.40–11.72) 10.34 (8.10–13.18) 75/164 (45.7) 5.21 (3.70–7.34) 5.54 (3.90–7.87) 44/188 (23.4) 7.18 (4.72–10.93) 9.57 (6.00–15.26) Missing 93/472 (19.7) 1.56 (1.20–2.03) 1.53 (1.17–2.00) 63/381 (16.5) 1.23 (0.90–1.67) 1.23 (0.90–1.68) 17/396 (4.3) 1.05 (0.61–1.82) 1.12 (0.63–1.98) Charlson Comorbidity Index in the 3 years prior to diagnosis date (Y – Y ) -3 -1 0+1 941/4394 (21.4) 1 1 559/3283 (17.0) 1 1 174/3572 (4.9) 1 1 ≥2 220/650 (33.9) 1.88 (1.57–2.24) 1.52 (1.24–1.85) 81/358 (22.6) 1.43 (1.10–1.86) 1.25 (0.95–1.65) 55/409 (13.5) 3.03 (2.20–4.19) 2.65 (1.86–3.78) Mental morbidity in the 3 years prior to diagnosis date (Y – Y ) -3 -1 None 949/4273 (22.1) 1 1 508/3090 (16.4) 1 1 159/3465 (4.6) 1 1 Any 212/771 (27.5) 1.33 (1.12–1.58) 1.34 (1.10–1.63) 132/551 (24.0) 1.60 (1.29–2.00) 1.55 (1.23–1.97) 70/516 (13.6) 3.26 (2.42–4.40) 2.46 (1.74–3.49) No. of sickness absence days in the second year before diagnosis date (Y ) -2 0 948/4386 (21.6) 1 1 523/3.167 (16.5) 1 1 161/3.488 (4.6) 1 1 >0–30 63/235 (26.8) 1.33 (0.99–1.79) 1.26 (0.91–1.74) 41/183 (22.4) 1.46 (1.02–2.09) 1.41 (0.97–2.05) 9/179 (5.0) 1.09 (0.55–2.18) 0.89 (0.43–1.83) >30–90 68/218 (31.2) 1.64 (1.22–2.21) 1.84 (1.34–2.54) 42/155 (27.1) 1.88 (1.30–2.71) 1.76 (1.20–2.58) 17/166 (10.2) 2.36 (1.39–3.99) 1.83 (1.04–3.25) >90–180 41/103 (39.8) 2.40 (1.61–3.58) 2.63 (1.69–4.08) 13/62 (21.0) 1.34 (0.72–2.41) 1.16 (0.61–2.21) 14/75 (18.7) 4.74 (2.60–8.66) 4.25 (2.22–8.14) >180 41/102 (40.2) 2.44 (1.63–3.65) 2.75 (1.78–4.27) 21/74 (28.4) 2.00 (1.20–3.35) 1.81 (1.05–3.10) 28/73 (38.4) 12.86 (7.82–21.15) 9.55 (5.43–16.79) Bold text indicates a statistically significant association with both sided p<0.05. In adjusted models, all covariates (sex, age, country of birth, educational level, cancer type, cancer stage, Charlson Comorbidity Index, mental morbidity, pre-diagnostic sickness absence) were included CI confidence interval, OR odds ratio, DP disability pension 276 J Cancer Surviv (2022) 16:269–278 physically demanding jobs in less flexible workplaces [36, 37]. diagnostic levels. The likelihood for long-term SA and DP was Previous findings about associations with educational level have highest among survivors with more pre-diagnostic SA days and been inconclusive [31]. Further research could investigate how advanced cancer stage. These results emphasize the importance occupation-related factors are associated with future SA and DP. to support CRC survivors in improving work-related capacity, The risk for SA and DP was lower in higher ages, as people especially among those at high risk for long-term SA and DP, transitioned into retirement age and some might also have taken and indicate the relevance of early cancer diagnosis to prevent early old-age pension. Notably, the CRC cohort had higher levels long-term work incapacity. of SA/DP days already 2 years before diagnosis and a higher comorbidity score during the 3 years before diagnosis. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s11764-021-01017-7. Strengths and limitations Author contribution Lingjing Chen had the initial idea of the study con- cept and supervised the study. Kristina Alexanderson obtained the funding Strengths of this study include the population-based, longitudinal and the data. Luisa C. Beermann performed the data management and the design using nationwide registers of high quality and complete- analyses, along with drafting the manuscript. Anna Martling gave clinical ness [18, 19, 25], avoiding selection bias and loss to follow-up, advice. All four authors interpreted the results and revised the manuscript. that all, not only employed, were included and that data on SA and DP diagnoses could be included. The large study population Funding Open access funding provided by Karolinska Institute. The study was financially supported by the Swedish Research Council for allowed for sub-group analyses. Another strength is that all were Health, Working Life and Welfare. followed from actual diagnosis date, instead of calendar year. In the analyses, we excluded people not anymore at risk for the Declarations outcome, i.e., after they died, emigrated, or turned 65. It is a strength that we had information on this; if keeping people not Ethical approval The project was approved by the Regional Ethical at risk, the SA/DP rates would falsely have seemed to be lower. Review Board in Stockholm. However, if some of those who died due to, e.g., late diagnosis, might have survived longer if diagnosed earlier, it might have Informed consent The observational study was based on nationwide administrative register data. In Sweden, informed consent is not needed been so that SA rates might have been higher. The results are for such data collection nor for studies based on them. representative of the population in Sweden and can be general- ized to other countries with similar welfare systems. Conflict of interest The authors declare no conflict of interest. Several limitations were noted also. SA spells ≤14 days were not included, possibly leading to an underestimation of annual SA Open Access This article is licensed under a Creative Commons days. However, by using a comparison group, we limited the Attribution 4.0 International License, which permits use, sharing, adap- influence of this. Furthermore, by including only SA spells >14 tation, distribution and reproduction in any medium or format, as long as days, our outcome reflects long-term, more severe SA spells. you give appropriate credit to the original author(s) and the source, pro- Another limitation was that treatment data was not available. vide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included Still, the information about cancer stage may partially compensate in the article's Creative Commons licence, unless indicated otherwise in a for this. Information about cancer relapse was also not included, credit line to the material. If material is not included in the article's possibly causing an overestimation of other factors’ influence on Creative Commons licence and your intended use is not permitted by the risk for SA and DP. Information about cancer stage was miss- statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this ing in 9.5% of cases, but comparable results in the analyses were licence, visit http://creativecommons.org/licenses/by/4.0/. found when excluding all missing data. Conclusion References 1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. This register-based longitudinal cohort study showed that CRC Global cancer statistics 2018: GLOBOCAN estimates of incidence survivors were more likely to have SA and DP than their and mortality worldwide for 36 cancers in 185 countries. 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Journal

Journal of Cancer Survivorship – Springer Journals

Published: Apr 1, 2022

Keywords: Sick leave; Disability pension; Work loss; Cancer survivorship; Colorectal cancer

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