Background
Approximately 33% of cancer survivors are in their prime working age range, between 20 and 64 years.1 A cancer diagnosis can alter employment trajectories and cause long-term productivity losses.2 Previous research showed that even years after diagnosis, cancer survivors may reduce working hours to receive medical care, become limited in the type of work they are able to do, or experience employment disability for health reasons.3–5 Moreover, many working cancer survivors may have scheduling challenges in balancing between routine work schedules and treatment plans.5–7 Previous studies have shown that working-age cancer survivors experience greater financial hardships than individuals without a cancer history, even after controlling for socioeconomic status, such as educational attainment and income.8,9 Workplace policies and benefits may explain some of this difference, because cancer survivors may struggle to fulfill job responsibilities while dealing with long-term health effects of cancer and its treatments. In addition to offering health insurance, other accommodations from employers, such as flexible work hours and improvements in working conditions, can facilitate cancer survivors’ return to work and ability to maintain productivity.6,10,11 Access to paid sick leave is also an important benefit from employers because working cancer survivors often need extended leave from their workplaces to receive medical care.12
Paid sick leave provides economic protections to workers in case they become sick and face unintended loss of income because of illness. Unlike most other developed countries, there is no federal requirement for paid sick leave in the United States.13,14 The Family and Medical Leave Act, enacted in 1993 by Congress, only required certain employers to provide 12 weeks of unpaid leave per year to select employees.15 Meanwhile, lack of paid sick leave is associated with lower receipt of recommended preventive services, such as influenza vaccine and cancer screenings in the general population.16–18 However, little is known about the prevalence of lack of paid sick leave and its impact on the use of preventive services among working cancer survivors. Without paid sick leave, cancer survivors may have to compromise medical care to avoid lost earnings, potential job loss, and loss of employer-sponsored health insurance coverage.
Lack of paid sick leave is common in the general population and varies by type of occupation.19 This is probably because different types of employers have various standards or norms with respect to providing paid sick leave to workers.20 To better understand the scope and depth of lack of paid sick leave among working cancer survivors, we used nationally representative data to evaluate access to paid sick leave by various sociodemographic/socioeconomic and employment characteristics, which can help identify subgroups of working cancer survivors who are most affected. We also examined whether lack of paid sick leave was associated with lower use of preventive services or more hospital emergency department (ED) visits among working cancer survivors.
A recent survey showed that the average age of workers changing jobs was 39 years, and people were less likely to change careers in their 50s and 60s.21 Cancer survivors often face long-term health effects related to cancer and its treatments, and thus paid sick leave at the workplace along with other healthcare benefits may play an important role in any decision to switch jobs or change careers. Moreover, existing literature showed that younger cancer survivors were more likely than older cancer survivors to experience financial hardship.8,9,22,23 This may be due to less wealth accumulation and higher household debt, such as first home mortgages and student loans, among younger cancer survivors.24 Lack of paid sick leave may increase the likelihood of income loss among working cancer survivors and consequently worsen their financial hardship. Therefore, we also stratified our analyses by age group (18–39, 40–49, and 50–64 years).
Methods
The 2001–2018 National Health Interview Survey (NHIS) was used to identify working cancer survivors (ages 18–64 years) in the United States.25 The NHIS is an annual cross-sectional household survey with response rates between 64.2% and 88.9% during the study period.25 All NHIS adult respondents were asked about their working status as of 1 week before the interview date. Individuals who reported “working for pay at a job or business” and “with a job or business but not at work” were categorized as working individuals (supplemental eTable 1, available with this article at JNCCN.org),26,27 and were asked the following question: “Do you have paid sick leave on this main job or business?” We defined cancer survivors as individuals who reported ever being diagnosed with any cancer or malignancy by a doctor or other health professional (excluding nonmelanoma skin cancer or skin cancer of unknown type). The sample was stratified into 3 age groups (18–39 years, n=1,584; 40–49 years, n=1,929; 50–64 years, n=4,482).
Individual-Level Characteristics
Individual-level characteristics included age at the time of the survey, sex, race/ethnicity, educational attainment, marital status, family income as a percentage of the federal poverty level (FPL), health insurance coverage (any private/public only/uninsured), number of chronic conditions, NHIS survey year, and US geographic region (Table 1). The number of cancers diagnosed was categorized into either 1 only, or 2 or 3. Time since the most recent cancer diagnosis was calculated by subtracting patient age at survey from age at most recent diagnosis and was categorized as recently diagnosed (<2 years) and previously diagnosed (≥2 years).
Characteristics of Working Cancer Survivorsa
Employment Characteristics
Measures for employment characteristics included (1) job sector (private, government [federal/state/local], or self-employed), (2) working hours (full-time, ≥35 hours; part-time, ≤34 hours), (3) employer size (1–49, 50–99, 100–499, or ≥500 employees), and (4) major classifications of occupations/industries (supplemental eTable 1). There were major changes in the coding for occupation/industry classifications in 2005; therefore, lack of paid sick leave by occupation/industry excluded data from 2001 to 2004. Wages of all working populations were obtained from the US Bureau of Labor Statistics website (https://www.bls.gov/) for 2018 and were used as proxies for income differences by occupations/industries (supplemental eTable 2).
Healthcare Utilization Measures
Measures for use of preventive services in the past 12 months included influenza vaccine, blood pressure screening, and cholesterol testing. The measure for ED visits was based on whether a respondent reported any hospital ED visits in the past 12 months (supplemental eTable 1).
Statistical Methods
The distributions of individual-level characteristics among working cancer survivors were compared by age groups. Both unadjusted and adjusted logistic regressions were conducted to examine the trend of lack of paid sick leave by survey years. Bivariate analyses of lack of paid sick leave by occupation/industry were conducted. Generalized logistic regressions were conducted to generate adjusted percentages of working cancer survivors reporting lack of paid sick leave by sociodemographic/socioeconomic characteristics, cancer-related characteristics, and employment characteristics (job sector, working hours, and employer size, further stratified by age groups). All adjusted analyses controlled for sex, race/ethnicity, educational attainment, marital status, number of comorbid conditions, family income level as a percentage of FPL, health insurance coverage, time since diagnosis, number of cancer diagnoses, geographic region, and survey year. Separate adjusted logistic regressions examined associations between lack of paid sick leave and use of preventive services and any ED visits.
The sample weights were used to account for the complex survey design of NHIS for descriptive statistics, predicted margins, and variance estimates (Stata, version 16.1; StataCorp LLC). Statistical comparisons were 2-sided, and significance was defined as P<.05.
Results
Individual-Level Characteristics
By pooling multiple years of NHIS data, a total of 7,995 (weighted n=3.43 million) working cancer survivors aged 18 to 64 years were included in the study. Compared with the age group of 50 to 64 years, younger working cancer survivors (ages 18–39 and 40–49 years) were more likely to be female, racial/ethnic minorities, and not married or living with a domestic partner (ages 18–39 years only) and to have educational attainment lower than high school (ages 18–39 years only), fewer comorbid conditions, lower family income, and public or no health insurance coverage (Table 1). Most working cancer survivors were employed in the private sector and worked full-time (≥35 hours last week), and approximately half of them worked for small employers (1–49 employees).
Lack of Paid Sick Leave by Sociodemographic/Socioeconomic and Cancer-Related Characteristics
Of all working cancer survivors, approximately 36.4% (n=2,925; weighted n=1.25 million) reported lack of paid sick leave (Table 1). In adjusted analyses, working cancer survivors who were uninsured (70.6%) or covered by public insurance only (57.3%) were more likely to report lack of paid sick leave than those with any private insurance (30.9%; P<.001) (Table 2). Moreover, lack of paid sick leave was more common among male versus female cancer survivors, as well as survivors with lower family income or lower educational attainment. Compared with non-Hispanic White survivors, non-Hispanic Black and Hispanic survivors were less likely to report lack of paid sick leave. Married cancer survivors were more likely to report lack of paid sick leave than others. There were no differences in adjusted analyses by cancer-related variables.
Percentages of Lack of Paid Sick Leave by Characteristics of Working Cancer Survivorsa
Lack of Paid Sick Leave by Employment Characteristics
There were large variations in lack of paid sick leave by occupation/industry (Figures 1 and 2). Occupations with the greatest prevalence of lack of paid sick leave were personal care and service (73.4%), construction/extraction (68.9%), food preparation/serving–related (67.6%), and building/grounds cleaning/maintenance (54.9%). Industries with the greatest lack of paid sick leave were agriculture/forestry/fishing/hunting (88.5%), accommodation/food services (73.3%), administrative/support/waste management (66.8%), and construction (61.9%). Moreover, using 2018 wages of all working populations from the US Bureau of Labor Statistics,28 occupations/industries that had lower level of paid sick leave among working cancer survivors generally paid lower wages to workers (supplemental eTable 2).
Unadjusted percentages of working cancer survivors without paid sick leave, by occupations, 2004–2018 NHIS (total n=6,670; weighted n=3,533,856). Data from 2001 to 2004 were also omitted because of major changes in the coding of categorizations of occupation and industry. Several occupations were omitted because of small sample sizes (cutoff n<50): farming, fishing, and forestry occupations (n=22); military-specific occupations (n=7); and unknown (n=48). Supplemental eTable 2 provides 2018 population wages by occupation.
Abbreviation: NHIS, National Health Interview Survey.
Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7058
Unadjusted percentages of working cancer survivors without paid sick leave, by industries, 2004–2018 NHIS (total n=6,670; weighted n=3,533,856). Data from 2001 to 2004 were also omitted because of major changes in the coding of categorizations of occupation and industry. Several industries were omitted because of small sample sizes (cutoff n<50): management of companies and enterprises industries (n=15); mining industries (n=37); utilities industries (n=45); and unknown (n=52). Supplemental eTable 2 provides 2018 population wages by industry.
Abbreviation: NHIS, National Health Interview Survey.
Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7058
Adjusted results showed that survivors who were self-employed, had part-time jobs (≤34 hours), or worked for small businesses (1–49 employees) were least likely to have paid sick leave across all 3 age groups (Table 3). In general, younger working cancer survivors were more likely than older survivors to report lack of paid sick leave (ages 18–39 years, 42.1%; ages 40–49 years, 36.3%; ages 50–64 years, 34.5%). Similar patterns were found by job sector, working hours, and employer size.
Adjusted Percentages of Lack of Paid Sick Leave by Employment Characteristics, Stratified by Age Group, 2001–2018 NHISa
Lack of Paid Sick Leave and Use of Preventive Services
In adjusted analyses, lack of paid sick leave was associated with lower use of influenza vaccine (ages 18–39 years, 21.3% vs 33.3%; ages 40–49 years, 25.8% vs 38.3%; ages 50–64 years, 46.3% vs 52.4%; P<.05 for all), cholesterol screenings (ages 18–39 years, 43.1% vs 62.5%; P<.05), and blood pressure checks (ages 18–39 years, 85.0% vs 91.7%; P<.05) (Figure 3). Lack of paid sick leave was not associated with any ED visits (supplemental eFigure 1).
Adjusted percentages of use of influenza vaccine (2001–2018, stratified by age group: 18–39 years, n=1,584; 40–49 years, n=1,929; and 50–64 years, n=4,482), cholesterol screenings (2003, 2008, 2011–2018, stratified by age group: 18–39 years, n=614; 40–49 years, n=871; and 50–64 years, n=2,397), and blood pressure checks (2001–2018, stratified by age group: 18–39 years, n=1,584; 40–49 years, n=1,929; and 50–64 years, n=4,482) among working cancer survivors with and without paid sick leave in the United States, 2001–2018 NHIS. All analyses were adjusted for age at time of the survey, sex, race/ethnicity, educational attainment, marital status, number of comorbid conditions, health insurance coverage, time since diagnosis, number of cancer diagnoses, survey year, and region. All measures refer to a time period of 12 months before the survey date. Cholesterol screenings were only available in years 2003, 2008, and 2011–2018. Black bars represent 95% confidence intervals.
Abbreviation: NHIS, National Health Interview Survey.
*P<.05.
Citation: Journal of the National Comprehensive Cancer Network 20, 11; 10.6004/jnccn.2022.7058
Evaluation of Trend of Lack of Paid Sick Leave Over Time
Both unadjusted and adjusted results showed that there was no statistically significant linear trend of lack of paid sick leave in the period from 2001 through 2018 (supplemental eFigure 2).
Discussion
This study used nationally representative data and found that approximately 1.25 million (36.4% of total weighted sample) working cancer survivors aged 18 to 64 years lacked paid sick leave in the United States. Lack of paid sick leave varied greatly by occupations/industries. Cancer survivors working in agriculture, services, construction, or food-related industries/occupations were most likely to lack paid sick leave. In adjusted analyses, lack of paid sick leave was more common among younger survivors (ages 18–39 years) and survivors with lower household income or educational attainment. Moreover, cancer survivors with part-time jobs or working for smaller employers were also less likely to have access to paid sick leave. Among working cancer survivors, lack of paid sick leave was associated with lower use of preventives services, including influenza vaccine (all age groups), and blood pressure checks/cholesterol screenings (ages 18–39 years only). Therefore, ensuring that all working cancer survivors have paid sick leave may be an important mechanism for reducing disparities in receipt of recommended preventive services.
Our results suggest that certain subgroups of working cancer survivors experience disproportionately high risks of lack of paid sick leave, especially those who are publicly insured or uninsured and have lower family income and educational attainment. This is consistent with previous research showing that cancer survivors with lower socioeconomic status are more likely to experience medical financial hardship and worry about daily financial needs.8,9,22–24,29 Higher intensity of financial hardship has also been linked with worse self-rated health and more ED visits among cancer survivors.30 The gap in access to paid sick leave might further exacerbate health disparities in access to care among working cancer survivors.31 In particular, we found that lack of paid sick leave was also associated with lower use of recommended preventive services. Although the Affordable Care Act eliminated cost-sharing for all preventive services recommended by the US Preventive Services Task Force in most health plans since 2010,32 some may still not avail themselves of preventive services because of worry about not getting paid or losing their jobs if they take time off for health reasons.33 Additional research is also needed to examine the associations between lack of paid sick leave and receipt of guideline-concordant cancer screenings among working cancer survivors.
Our findings are very timely during the ongoing, rapidly evolving COVID-19 pandemic, which has caused major disruptions in almost all economic sectors, including the food supply chain. Our results showed that lack of paid sick leave was especially common among cancer survivors working in industries related to agriculture and food services or preparation. Many COVID-19 outbreaks have occurred in food processing plants, especially in meat and poultry processing facilities,34 probably because workers need to stay in close quarters in the production process and may work while symptomatic. Moreover, cancer survivors may already face higher risks of COVID-19 infection because their immune system can be weakened by cancer and its treatments,35 and they have a high prevalence of conditions associated with COVID-19 infection.36 Therefore, targeted healthcare policies are needed to strengthen safety as well as economic protections (ie, paid sick leave) for working cancer survivors.
To help mitigate the health impact of COVID-19 on the workforce, Congress passed the Families First Coronavirus Response Act: Employer Paid Leave Requirements, effective on April 1, 2020, through the end of that year.37 The act required certain private and public employers to provide their employees with up to 2 weeks of paid sick leave related to COVID-19 symptoms, testing, quarantines, and treatments. Vaccination for COVID-19 was retrospectively added to the act by The White House in April 2021.38 Although the Families First Coronavirus Response Act: Employer Paid Leave Requirements expired at the end of 2020, the American Rescue Plan Act of 2021 extended the paid sick leave mandate until September 30, 2021.39–41 Unfortunately, both acts have expired, and workers who are impacted by the new COVID-19 variants will no longer be protected. Moreover, there are large variations in mandates of paid sick leave at the state and local government levels. For example, a New York City 2014 paid sick leave mandate was associated with improved preventive services use among low-income adults.42 However, 30 states do not have any mandates for paid sick leave,43 and cancer survivors working in these states may have higher risk of lacking paid sick leave.
This study has several limitations. Measures of paid sick leave, employment characteristics, and use of preventive services are self-reported. Because working status was measured as of last week at the time of the survey, and because preventive services were measured as of the past 12 months, this discordance could be a potential source of bias in our study. For example, cancer survivors who worked at some point in the past year but were unemployed in the past week were not included in our analyses. Moreover, working cancer survivors with and without paid sick leave might be inherently different because of the job selection process. Workers may weigh health benefits (eg, paid sick leave) against work schedule or pay scale. Therefore, additional research on employment dynamics is needed to understand differences in healthcare use between working cancer survivors with and without paid sick leave. Moreover, certain types of employers that offer paid sick leave to their employees may also be more likely to offer on-site vaccinations. Some employers may offer paid sick leave for vaccinations but not for other preventive services. Therefore, the observed differences in influenza rates by paid sick leave may also be due to differences in on-site vaccination promotions and employer policies. In addition, future research should also address any differential impact of lack of paid sick leave on healthcare utilization between working cancer survivors and working individuals without a cancer history. More than 80% of our study sample are longer-term cancer survivors surveyed ≥2 years since diagnosis. Future research that focuses on recently diagnosed cancer survivors who are still undergoing cancer treatments is needed.
Conclusions
A healthy workforce is essential for long-term economic development. However, lack of paid sick leave is common among working cancer survivors, and it varies greatly by employment characteristics in the United States. Working cancer survivors with lower household income or educational attainment are most likely to lack paid sick leave. Moreover, lack of paid sick leave among working cancer survivors is associated with lower use of certain types of preventive services, which may translate into health disparities.
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