Acta Oncologica, 2014; 53: 744–751
ORIGINAL ARTICLE
Return to work and sick leave after radical prostatectomy: A prospective clinical study
SIGRUN DAHL1,3, EIVIND A. S. STEINSVIK2, ALV A. DAHL1,3, JON HÅVARD LOGE1,3, MILADA CVANCAROVA1,3 & SOPHIE D. FOSSÅ1,3 1National
Resource Center for Late Effects after Cancer, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway, ²Akershus University Hospital, Nordbyhagen, Norway and ³Faculty of Medicine, University of Oslo, Oslo, Norway Abstract Background. To evaluate work status at three months after radical prostatectomy (RP) in patients with prostate cancer (PCa) in relation to socio-demographics, urinary incontinence and bother, medical complications health-related quality of life (HRQOL) and surgical methods. To identify pre-RP available factors that can predict the duration of immediate post-RP sick leave. Material and methods. This prospective questionnaire-based study included 264 men with PCa 65 years, who were active in the work force before RP. Urinary incontinence and bother were assessed using the Expanded Prostate Cancer Index Composite-50 (EPIC-50). HRQOL was measured using SF-12. Medical complications comprised selfreported new morbidities and re-hospitalizations within three months after RP. Patients’ work status was defined as either “stable/improved” or “declined” at three months compared to work status at baseline. Duration of immediate post-RP sick leave was considered as prolonged when lasting 6 weeks. Associations were analyzed using logistic regression analyses. Results. Almost 30% of the patients had declined work status three months after RP. Change of physical HRQOL was the only factor remaining significantly associated with declined work status in the multivariate analysis. Half of the patients had prolonged immediate sick leave. Having physically strenuous work was the strongest predictor for this outcome. Conclusions. Long periods of sick leave and reduced workforce participation after RP should be considered potential adverse effects of this treatment.
As observed in the industrialized countries in general, due to the extensive use of PSA testing, the incidence of prostate cancer (PCa) has increased dramatically in Norway during the last two decades, particularly among younger men 65 years with T1/T2 tumors [1,2]. Radical prostatectomy (RP) or high-dose radiotherapy (RAD) with or without androgen deprivation therapy (ADT) are the standard curative treatment options for these patients [3,4]. Over the last decade, the use of robotic-assisted radical prostatectomy (RALP) has become popular among US and European urologists, surpassing the use of open retropubic radical prostatectomy (RRP) in many countries [5]. Still, possible benefits of RALP as to oncological results, adverse effects (AEs) and costs are yet to be convincingly demonstrated [6].
Typical AEs like urinary incontinence and erectile dysfunction after RP are well described in the literature, and have recently been confirmed among Norwegian patients [7,8]. Moreover, reviews on peri- and postoperative complications and prolonged duration of hospitalization after prostatectomy are available [6]. Employment rates and various work-related factors among PCa patients have been reported in population-based studies in Norway, Denmark, Finland and the USA among others, with reporting of worse outcomes for survivors than their cancer-free controls [9,10–12]. Surprisingly few investigations have dealt with treatment-related sick leave and return to work. With the increasing proportion of younger men being diagnosed with PCa and prostatectomized, elucidation of this subject is of importance both from the patient’s and society’s perspective.
Correspondence: S. Dahl, Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, PO Box 4953, Nydalen, 0424 Oslo, Norway. Tel: 47 22935786/ 47 97002295. Fax: 47 22935345. E-mail: [email protected] (Received 26 June 2013 ; accepted 6 September 2013) ISSN 0284-186X print/ISSN 1651-226X online © 2014 Informa Healthcare DOI: 10.3109/0284186X.2013.844357
Work participation after radical prostatectomy Searching relevant literature bases, we identified reports from only two research groups that specifically addressed duration of sick leave and/or work participation after RP. A US group led by Bradley et al. demonstrated that men treated with RP missed an average of 33 days of work during the six months following diagnosis [13]. The same researchers described that PCa patients treated with RP were less likely to remain employed and more likely to retire six months after treatment compared to a control group [14]. Hohwü et al. [15] reported significantly shorter periods of paid sick leave among Swedish and Danish patients operated with RALP compared to patients treated with RRP (median 11 vs. 49 days, respectively). Results from the Swedish study group emphasized that men with work requiring high physical activity had particularly long periods of sick leave, and among the US patients a considerable proportion of the patients whose work required physical effort were impeded by the PCa and its treatment [14,15]. However, neither of these register-based studies reported on specific medical reasons for absence from work. Norwegian urologists routinely prescribe a 4–6 weeks sick leave after RP with a possibility for an extension, usually prescribed by the patient’s GP. However, the majority of the patients are expected to regain their pre-operative health and work ability within this time span, which is in agreement with the Swedish official guidelines, recommending six weeks sick leave after prostatectomy [16]. With this background we aimed to identify factors associated with declined work status three months after RP, with particular focus on urinary incontinence, health-related quality of life (HRQOL) and medical complications with or without re-hospitalization evolving after the initial post-RP discharge. Furthermore, we assessed the associations between the duration of immediate post-RP sick leave and available pretreatment variables seeking predictors of sick leave beyond six weeks (prolonged sick leave). We anticipated that almost all patients would have regained their preoperative work status three months after RP, declined work status at that time being associated with urinary incontinence. Based on the experience of Hohwü et al. [15] we expected a shorter sick leave period after RALP compared to RRP and that 70% of the men would have returned to work within six weeks after RP, high physical workload being the main predictor of prolonged sick leave. Material and methods Patient selection and study design The Norwegian Urological Cancer Group performed this national prospective questionnaire-based study of socio-demographic variables, typical AEs, fatigue
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and HRQOL after curative treatment of PCa in patients treated between November 2008 and December 2009 (the NUCG VII study). Study participants received a questionnaire at pretreatment and at three, 12 and 24 months after RP [7]. The current report is restricted to patients 65 years who were working full-time or part-time before RP was performed at one of 14 of Norway’s 17 urological units, excluding men who were already on sick leave prior to RP. Patients eligible for the main analysis should have completed the questions regarding work status at pretreatment and three months after RP. At 12 months, all the respondents received an additional questionnaire assessing immediate post-RP sick leave and work-related factors based on their recall (“Work Questionnaire”). This questionnaire also provided several opportunities for the patients to inform about medical complications beyond typical AEs and re-hospitalizations developing within the first three months after post-operative discharge by completion of optional text fields. Content of the questionnaires Information about relationship status and educational level ( 13 years vs. 13 years) were obtained at baseline only. Data regarding work status, HRQOL and fatigue were collected at all time-points, as well as data on urinary, erectile and bowel function and their corresponding bother. Patients reported co morbidities according to The Medical History Checklist at all time-points [17]. Information on work status was obtained at all time-points by confirmation of one of the following alternatives: full-time work, part-time work, sick leave, rehabilitation, job seeking, disability pension and retirement pension. After comparison of the pretreatment status with the three-month work status, we allocated the patients into either a stable/improved or a declined work status group. The stable/improved work status group consisted of patients who had the same work status as at pre-treatment or had increased their work participation from part-time to full-time work. The declined work status group comprised patients moving from full-time to part-time work and all patients whose work status had changed from full or part-time work to sick leave, as well as the patients who had left the workforce after RP. Duration of immediate post-RP sick leave was assessed by the patients’ reports in the “Work Questionnaire” by one of the following alternatives: 1–2 weeks, 3–4, 5–6, 7–8, 9–10 and 10 weeks. Based on this information we performed a sub-analysis on immediate sick leave after separating the patients into two principal groups: those on 1–6 weeks sick
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leave, and those on 7 weeks sick leave (prolonged sick leave), without differentiating between complete and partial sick leave. The patients reported the previous four weeks’ experience of typical AEs by completing the EPIC-50, which is a frequently used instrument for self-rating of urinary, bowel, sexual and hormonal function and problems (bother) by multiple-choice categorization [18]. We did not consider the items on sexual function in the EPIC-50 relevant for work participation, so items related to this AE were not included. Furthermore, none of the patients had received pelvic radiotherapy or hormones alone within the first three months after RP. Hence, AEs related to bowel and hormonal functioning were omitted, thus only the urinary domain was considered relevant and explored in the present report. Frequency of urinary leakage, pad use and bother (problems) were assessed separately. Cronbachs’ coefficient alpha for internal consistency was 0.9 for these items. We dichotomized the answers for analysis as follows: urinary incontinence: 0 leaking 1 time per day versus 1 leaking 1 time per day, pad use: 0 1 pad per day versus 1 1 pad per day, bother due to incontinence: 0 no problem, very small or small problem versus 1 moderate or big problem. Medical complications comprised self-reported new morbidities and re-hospitalizations within three months after RP. Notably, urinary incontinence was not included in this category, but assessed separately. HRQOL was assessed using the Short Form 12 (SF-12), which is based on measures of eight dimensions and expressed as physical (PCS-12) and mental (MCS-12) composite summary scores [19]. Higher average scores imply better HRQOL than the age-matched population sample. Individual changes in PCS scores and MCS scores were calculated as the differences between a patient’s baseline and three-month score. Statistical analyses Continuous variables were analyzed using t-tests (data with normal distribution) and independent samples Mann-Whitney Wilcoxon test (data with skewed distributions). Categorical variables were analyzed using χ2-tests and Fischer’s exact test. Associations between covariates and the main outcomes were tested using two logistic regression models, with declined work status at three months and sick leave 6 weeks being the dependent variables. Covariates with p-values 0.1 from the univariate analyses were included in the multivariate model. The strength of associations was expressed as odds ratios (ORs) with 95% confidence intervals (CIs).
Correlation and multicollinearity were tested using Spearman’s coefficient rho and the variance inflation factor analysis, respectively. All tests were two-sided. Statistical significance was set at p 0.05. All analyses were performed using PASW for Windows version 18.0. Ethics The Regional Ethics Committee of Southern Norway (REK) approved the NUCG VII study. All participants gave written informed consent. Results Patients Of 414 patients aged 65 years at the time of RP, 282 were working full- or part-time at baseline, and were eligible for this study. Eleven of these patients did not return a three-month questionnaire, four withdrew consent and three did not answer the particular question regarding work status at three months, leaving 264 patients for the main analysis of the three- month work status (Table I). For the analysis of immediate sick leave and medical complications after RP, 211 of these 264 men completed the “Work Questionnaire”. Among the 264 participants, 72% were treated with RALP and 28% with RRP. A higher proportion Table I. Baseline characteristics of patients eligible for the main analysis. Eligible patients N 264
Variables Age1 Work status2 Full-time Part-time Marital status2 Living with partner Not living with partner Education2 13 years 13 years Co morbidity2 No co morbidities 1 co morbidity D’Amico Score2 Low Intermediate High Surgical method2 RALP RRP PCS 121 MCS 121 1 mean
(SD). of patients (%).
2 number
59.2 (4.1) 239 (91) 25 (9) 244 (93) 19 (7) 108 (41) 155 (59) 181 (69) 81 (31) 94 (36) 127 (48) 42 (16) 191 73 53.2 52.2
(72) (28) (4.77) (8.6)
Work participation after radical prostatectomy
univariate analysis (p 0.01) (Table III). There was no statistically significant difference in the prevalence of urinary bother between the RRP and RALP groups (p 0.68, data not shown). The mean physical HRQOL (PCS-12) scores decreased significantly during the first three postoperative months in all patients (Figure 1). Compared to patients with stable/improved three-month work status, men with declined work status experienced significantly greater decrease of their physical HRQOL, resulting in a highly significant difference of the average scores at three months. However, statistically significant though, much smaller differences between these two groups already existed before RP (Figure 1). In the multivariate analysis, only the change in PCS-12 was associated with declined work status (Table III). Bother due to urinary incontinence and change in PCS-12 score were only weakly correlated with each other (Spearman’s rho 0.18, p 0.01).
Table II. Distribution of work status at three months related to status at baseline. Baseline
Work status Full-time Part-time Sick leave Left the workforce
Full-time N 239 175 21 38 5
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Part-time N 25 4 13 2 6
Declined work status in bold.
of low-educated men was treated with RRP (p 0.02, data not shown). At baseline, 90% of the participants were working full-time and 10% part-time. The mean PCS-12 and MCS-12 baseline scores were 53.2 and 52.2, respectively. Three-month work status At three months 192 (73%) patients had an improved or unchanged work status, while for 72 (27%) the work status had deteriorated (Table II). A higher proportion of the patients who worked part-time at baseline had left the work force compared to the patients who worked full-time (p 0.01). The patients who experienced moderate or severe bother due to urinary incontinence were more than twice as likely to report declined work status in
Medical complications and re-hospitalizations Of the 211 men who had completed The Work Questionnaire, 32 (15%) reported various major complications within three months after RP, of which 18 (8.5%) led to re-hospitalization (Table IV). There were no statistically significant associations between
Table III. Associations between work status at 3 months and socio- demographic and medical covariates in all patients (n 264). (Dependent variable: Declined work status). Univariate Variables Age at surgery – years1 Level of Education2 13 years (reference) 13 years Surgical Method2 RALP (reference) RRP Daily pad use last 4 weeks2 No or one pad (reference) 1 pad last Dripping or leaking urine last 4 weeks, bother2 No problem, very small or small problem (reference) Moderate or big problem PCS 12 change*,1 MCS 12 change*,1 1Mean
Multivariate
Stable or improved work status (N 192)
Declined work status (N 72)
OR3
95% CI
p-value
OR4
95% CI
59.1 (4.2)
59.7 (4.0)
1.04
0.97–1.12
0.23
1.06
0.98–1.13
0.14
117 (61) 74 (39)
38 (53) 34 (47)
1.00 1.42
0.82–2.44
0.21
145 (76) 47 (24)
46 (64) 26 (36)
1.00 1.74
0.97–3.12
0.06
1.49
0.77–2.86
0.24
125 (64) 69 (36)
35 (46) 39 (54)
1.00 2.11
1.22–3.65
0.01†
1.00 2.15 1.07 1.01
1.23–3.77 1.03–1.11 0.98–1.05
0.01 0.01 0.6
1.66 1.06
0.90–3.08 1.02–1.10
0.11 0.01
131 57 2.9 1.1
(70) (30) (6.5) (8.3)
37 34 6.8 0.5
(52) (48) (10.4) (8.8)
(SD); 2Number of patients (%); 3Crude; 4Adjusted. *Change is defined as baseline score minus 3 month score; †Omitted from the multivariate analysis due to multicollinearity.
p-value
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S. Dahl et al. Discussion
Figure 1. Changes in physical HRQOL {PCS-12 score [mean (SD)]} according to work status at three months.
the development of medical complications and the patients’ age, surgical method or pretreatment co morbidities (data not shown). There was a close to significant association between declined work status and medical complications (p 0.05) Immediate post-RP sick leave Post-operative work status. Six weeks after RP 108 (51%) of the 211 patients had returned to work and 58 (27%) were still on part or full-time sick leave after 10 weeks (Figure 2). No patient had zero days of sick leave. In univariate analyses, a low level of education, physically demanding work, RRP and decreasing age were associated with prolonged immediate sick leave (Table V). A low educational level was associated with physically demanding work, but not with RRP for this subgroup (p 0.01, data not shown). In the multivariate analysis, decreasing age and physically demanding work remained significantly associated with sick leave beyond six weeks, while being treated with RRP was close to significantly predicting prolonged sick leave (p 0.06).
The present study is the first to investigate post-RP return to work and sick leave within three months in PCa patients, based on patient-reported sociodemographic and medical variables. Three months after prostatectomy about three quarters of 264 men who were working full- or part-time at pretreatment, had regained or improved their pre-operative work status. In sub-analyses, only half of 211 patients had returned to work six weeks after surgery. Fifteen percent of these patients also experienced medical complications leading to re-hospitalization in half of them. The proportion of patients whose work status had declined at three months (27%) was higher than anticipated. Interestingly, only reduction of physical HRQOL, and not bother due to urinary leakage, remained significantly associated with declined threemonth work status in the adjusted regression analysis, notably with low correlation between changes of physical HRQOL and urinary bother. Patients selected to RP usually display a physical functioning above average, and this is also confirmed in our sample, as the mean PCS 12 score is above the mean score in the age matched Norwegian male population [20]. Theoretically, this should allow fast post-RP recovery and return to work. Our findings thus indicate that RP represents a considerable physical burden to the patients’ general health. The negative physical impact is greater than reflected in the oncourological literature, where reports on short operation times and short post-RP hospitalizations may lead to the impression that RP represents at most a medium- and short-lasting threat to the patients’ physical health. Our finding that 15% of the discharged patients experienced medical complications almost significantly associated with declined three-months work status supports the view that RP may lead to
Table IV. Complications (readmissions) within three months after RP related to work status. Work status
Complications Urinary (infections, obstruction) Wound-related (incl. hernia) or bleeding Deep venous thrombosis/pulmonary embolism Heart/lung/stroke GI (ileus, pain, inflammation) Pain/weakness Depression Total
Stable/improved (N 155) 3 (2) 5 5 (4) 2 (1) 3 (2) 1 (1) 19* (10)
*12% (stable/improved) versus 23% (declined) p 0.05.
Declined (N 56) 5 (4) 2 (1) 1 (1) 2 (2) 1 (1) 1 1 13* (9)
Total (N 211) 8 (6) 7 (1) 6 (5) 4 (3) 4 (3) 2 (1) 1 32 (19)
Work participation after radical prostatectomy
Figure 2. Fortnightly cumulative proportion of patients’ return to work.
significantly decreased physical HRQOL. Half of the men were hospitalized due to these complications. Similar percentages of post-discharge hospital readmissions within three months have been reported by Chung et al. from Taiwan (9.4%) [21]. Nelson et al. reported readmissions in 5–7% of the patients in a US sample, but their results may indicate a shorter follow-up period than three months [22]. Clinicians should be aware of serious complications, especially thromboembolic events that can occur several weeks after RP, as also described by van Hemelrijck et al. [16]. Based on the reports from Bradley et al. [13] and Hohwü et al. [15], we expected that at least 70% of the patients would be back at work six weeks after RP. However, this was the case for only half of them. Strenuous physical work and, surprisingly, low age predicted prolonged sick leave. Longer sick leave
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among patients with high physical workload were observed by Hohwü et al. as well [15]. In a study of employment outcomes of men treated for PCa, Bradley et al. reported that 26% of the patients who had to perform work tasks involving physical effort experienced that the malignancy and its treatment interfered with their ability to perform these tasks 12 months after treatment [14]. However, the authors did not discriminate between different treatment modalities. The association between physical activity and the experience of urinary leakage [23] possibly explains the predictive role of physically strenuous work on sick leave beyond six weeks in our study, even though urinary leakage problems at six weeks were not directly addressed in our “Work questionnaire”. In all likelihood, our findings on urinary incontinence and bother at 8–12 weeks from the three-month questionnaire should be applicable for the post-RP period as well. When we analyzed age as a continuous variable decreasing age predicted prolonged sick leave. However, when we compared the median age between the two groups, the difference was small and not considered clinically relevant. Overall, the duration of immediate post-RP sick leave seems longer and the absence from work lasted longer among prostatectomized Norwegian men than among the participants of the Swedish/Danish [15] and US studies [13,14]. These differences require explanations: Investigating work participation and sick leave is complicated due to a complex
Table V. Duration of immediate post-RP sick leave and predictive socio-demographic and medical variables (Dependent variable: prolonged sick leave [ 6 weeks]). Weeks of sick leave
Variables Age at surgery - years1 Working hours2 Full-time work (reference) Part-time work Level of Education2 13 years (reference) 13 years Co-morbidity present at baseline2 None (reference) 1 co-existing morbidity Surgical Method2 RALP (reference) RRP High physical workload2 No (reference) Yes PCS-12 at baseline1 Mean (SD) MCS12 at baseline1 Mean (SD) 1Mean
Univariate
Multivariate
6 weeks (N 108)
6 weeks (N 103)
OR
95 % CI
p
59.7 (4.0)
58.4 (4.3)
0.93
0.87–0.99
0.03
96 (89) 12 (11)
96 (93) 7 (7)
1.00 0.58
0.22–1.55
0.28
75 (69) 33 (31)
50 (49) 52 (51)
1.00 2.36
1.34–4.16
0.01
79 (74) 28 (26)
72 (70) 31 (30)
1.00 1.23
(0.67–2.22)
0.53
85 (79) 23 (21)
68 (66) 35 (34)
1.00 1.9
1.03–3.52
87 (82) 19 (18)
52 (54) 45 (46)
1.00 3.96
54.1 (3.7)
52.9 (5.1)
54.4 (7.4)
49.8 (11.1)
(SD); 2Number of patients (%).
OR
95 % CI
p
0.9
0.83–0.97
0.01
1.78
0.92–3.45
0.09
0.04
2.05
0.99–4.27
0.06
2.10–7.50
0.01
3.34
1.63–6.84
0.01
0.94
0.88–1.00
0.06
0.95
0.88–1.03
0.18
0.98
0.95–1.01
0.23
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interaction between purely medical and sociodemographic variables, like education and financial resources. In contrast to the system of private insurances in the US, Norwegian health and social services, including sick leave compensation, are financed through the government by taxation. During illness all employees in Norway are entitled to sick leave compensation from The Norwegian Labour and Welfare Service (NAV) for up to 52 weeks [24]. Selfemployees are granted a 65% compensation of their income from NAV after 16 days of sick leave. With this favorable system of financial sick leave compensation, Norwegian workers may be less motivated for rapid return to work than men living in societies with less beneficial compensation systems. Methodological differences might explain the deviating findings in our study compared to the US [13,14] and the Swedish/Danish [15] studies. The registry-based study of Hohwü et al. [15] probably lacked information on work inability and absence for patients who were not entitled to short sick leave compensation at all, or whose insurance rights did not start until a few weeks after RP. This could explain that the authors observed zero days of sick pay in 21% of the patients, as the assumption that patients can return to work the day after RP is quite unrealistic [15]. In the US study on absenteeism related to PCa [13], information on days missed from work was obtained by self-report, which is more in agreement with our study design. However, the US authors reported on days missing after diagnosis and not specifically after RP [13]. Furthermore, patients working part-time before RP were excluded from the US study, while work status prior to treatment was not considered in the Swedish one [15]. Furthermore, the patients in the US and Swedish/ Danish studies were slightly younger than the participants in our study. In agreement with Nelson et al.’s study from the US [22], we found no significant difference in complication- and re-hospitalization rates between the patients treated with RALP and the patients treated with RRP. Chung et al. [21] compared the 90-day readmission rates between RRP, laparoscopic RP (LRP) and RALP in a study from Taiwan. They reported a significantly lower risk of readmission after RALP than after the other surgical methods, though physician characteristics and socioeconomic factors could have biased their results [21]. Hohwü et al. [15] found that the median number of days of post-RP sick leave was significantly shorter after RALP than after RRP among Swedish and Danish patients adjusted for age, tumor stage, BMI, physical workload and income. However, the association between RRP and prolonged sick leave in their study can be explained by a selection bias, as more patients
with physical work were treated with RRP. When only the patients with low and medium physical workload were included in their analyses, the significance of the difference in length of sick leave between the RALP and RRP groups disappeared [15]. In our sample, the unadjusted risk of prolonged immediate sick leave was almost doubled for patients operated with RRP though the statistical significance of this difference was not confirmed in the multivariate analysis. In our view, no definite statement can be made at present as to whether the method of RP is associated with the duration of post-RP immediate sick leave. Our study has some limitations. Since the majority of our patients had undergone RALP, which in 2008/2009 was an option available only at major Norwegian hospitals, we cannot exclude some selection bias as to socio-demographic variables, like educational level. Patients who were on sick leave prior to RP were not included in the study, and this might have overestimated the negative impact of RP. However, we did not have information on reasons for being on sick leave prior to RP, which would have complicated the interpretation concerning the impact of RP. The 12-months recall may affect the reliability and validity of data on immediate sick leave. Type II statistical error may explain the lack of significant differences of some comparisons due to the limited sample size. The major strength of our study is the use of clinical data and the inclusion of the patientreported outcome regarding their work status and health after RP. Conclusions Patients, clinicians and employers should be aware that RP might represent a larger burden to the general health than anticipated. Having strenuous physical work is a significant predictor of post-RP sick leave beyond six weeks, independent of the surgical method. Long periods of sick leave and reduced workforce participation after RP should be considered potential adverse effects of this treatment, affecting the individual patient, his family and society. Hence, issues concerning work should be addressed in pre-RP counseling. Finally, any inter-country comparisons of post-RP work participation and post-RP sick leave are challenging due to heterogeneous systems of sick leave compensation. Acknowledgments The Radium Hospital Foundation and the Norwegian Cancer Society funded this study. The authors acknowledge the comments from Victor Berge and Sævar B. Gudbergsson.
Work participation after radical prostatectomy Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References [1] Kvale R, Moller B, Angelsen A, Dahl O, Fossa SD, Halvorsen OJ, et al. Regional trends in prostate cancer incidence, treatment with curative intent and mortality in Norway 1980–2007. Cancer Epidemiol 2010;34:359–67. [2] Kvale R, Auvinen A, Adami HO, Klint A, Hernes E, Moller B, et al. Interpreting trends in prostate cancer incidence and mortality in the five Nordic countries. J Natl Cancer Inst 2007;99:1881–7. [3] Guidelines on prostate cancer. Available from: http://www. uroweb.org/gls/pdf/08%20Prostate%20Cancer_LR%20 March%2013th%202012.pdf [cited 2013 March 8]. [4] Available from: www.annonc.oxfordjournals.org/content/ early/2013/01/08/annonc.mds624/T3.expansion.html [cited 2013 March 8]. [5] Lowrance WT, Eastham JA, Savage C, Maschino AC, Laudone VP, Dechet CB, et al. Contemporary open and robotic radical prostatectomy practice patterns among urologists in the United States. J Urol 2012;187:2087–92. [6] Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: A systematic review and cumulative analysis of comparative studies. Eur Urol 2009;55: 1037–63. [7] Steinsvik EA, Axcrona K, Dahl AA, Eri LM, Stensvold A, Fossa SD. Can sexual bother after radical prostatectomy be predicted preoperatively? Findings from a prospective national study of the relation between sexual function, activity and bother. Br J Urol Int 2012;109:1366–74. [8] Stensvold A, Dahl AA, Brennhovd B, Smastuen MC, Fossa SD, Lilleby W, et al. Bother problems in prostate cancer patients after curative treatment. Urol Oncol Epub 2012 Feb 16. [9] Syse A, Tretli S, Kravdal O. Cancer’s impact on employment and earnings – a population-based study from Norway. J Cancer Surviv 2008;2:149–58. [10] Carlsen K, Dalton SO, Diderichsen F, Johansen C. Risk for unemployment of cancer survivors: A Danish cohort study. Eur J Cancer 2008;44:1866–74. [11] Taskila-Abrandt T, Martikainen R, Virtanen SV, Pukkala E, Hietanen P, Lindbohm ML. The impact of education and occupation on the employment status of cancer survivors. Eur J Cancer 2004;40:2488–93.
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[12] Yabroff KR, Lawrence WF, Clauser S, Davis WW, Brown ML. Burden of illness in cancer survivors: Findings from a population-based national sample. J Natl Cancer Inst 2004;96:1322–30. [13] Bradley CJ, Oberst K, Schenk M. Absenteeism from work: The experience of employed breast and prostate cancer patients in the months following diagnosis. Psychooncology 2006;15:739–47. [14] Bradley CJ, Neumark D, Luo Z, Bednarek H, Schenk M. Employment outcomes of men treated for prostate cancer. J Natl Cancer Inst 2005;97:958–65. [15] Hohwu L, Akre O, Pedersen KV, Jonsson M, Nielsen CV, Gustafsson O. Open retropubic prostatectomy versus robotassisted laparoscopic prostatectomy: A comparison of length of sick leave. Scand J Urol Nephrol 2009;43:259–64. [16] Available from: www.socialstyrelsen.se/riktlinjer/forsakrings medicinsktbeslutsstod [cited 2013 March 8]. [17] Litwin MS, Hays RD, Fink A, Ganz PA, Leake B, Leach GE, et al. Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 1995;273:129–35. [18] Wei JT, Dunn RL, Litwin MS, Sandler HM, Sanda MG. Development and validation of the expanded prostate cancer index composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology 2000;56:899–905. [19] Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey – Construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220–33. [20] Gandek B, Ware JE, Aaronson NK, Apolone G, Bjorner JB, Brazier JE, et al. Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: Results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol 1998;51:1171–8. [21] Chung SD, Kelle JJ, Huang CY, Chen YH, Lin HC. Comparison of 90-day re-admission rates between open retropubic radical prostatectomy (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic prostatectomy (RALP). Br J Urol Int 2012;110(11 Pt C):E966–71. [22] Nelson B, Kaufman M, Broughton G, Cookson MS, Chang SS, Herrell SD, et al. Comparison of length of hospital stay between radical retropubic prostatectomy and robotic assisted laparoscopic prostatectomy. J Urol 2007;177:929–31. [23] Martin AD, Nakamura LY, Nunez RN, Wolter CE, Humphreys MR, Castle EP. Incontinence after radical prostatectomy: A patient centered analysis and implications for preoperative counseling. J Urol 2011;186:204–8. [24] Available from: www.nav.no/Arbeid/Jobb+og+helse/ Sykmelding+og+sykepenger/Sykepenger+til+arbeidstakere [cited 2013 June 1].
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ORIGINAL ARTICLE
Return to work and sick leave after radical prostatectomy: A prospective clinical study
SIGRUN DAHL1,3, EIVIND A. S. STEINSVIK2, ALV A. DAHL1,3, JON HÅVARD LOGE1,3, MILADA CVANCAROVA1,3 & SOPHIE D. FOSSÅ1,3 1National
Resource Center for Late Effects after Cancer, Oslo University Hospital, The Norwegian Radium Hospital, Oslo, Norway, ²Akershus University Hospital, Nordbyhagen, Norway and ³Faculty of Medicine, University of Oslo, Oslo, Norway Abstract Background. To evaluate work status at three months after radical prostatectomy (RP) in patients with prostate cancer (PCa) in relation to socio-demographics, urinary incontinence and bother, medical complications health-related quality of life (HRQOL) and surgical methods. To identify pre-RP available factors that can predict the duration of immediate post-RP sick leave. Material and methods. This prospective questionnaire-based study included 264 men with PCa 65 years, who were active in the work force before RP. Urinary incontinence and bother were assessed using the Expanded Prostate Cancer Index Composite-50 (EPIC-50). HRQOL was measured using SF-12. Medical complications comprised selfreported new morbidities and re-hospitalizations within three months after RP. Patients’ work status was defined as either “stable/improved” or “declined” at three months compared to work status at baseline. Duration of immediate post-RP sick leave was considered as prolonged when lasting 6 weeks. Associations were analyzed using logistic regression analyses. Results. Almost 30% of the patients had declined work status three months after RP. Change of physical HRQOL was the only factor remaining significantly associated with declined work status in the multivariate analysis. Half of the patients had prolonged immediate sick leave. Having physically strenuous work was the strongest predictor for this outcome. Conclusions. Long periods of sick leave and reduced workforce participation after RP should be considered potential adverse effects of this treatment.
As observed in the industrialized countries in general, due to the extensive use of PSA testing, the incidence of prostate cancer (PCa) has increased dramatically in Norway during the last two decades, particularly among younger men 65 years with T1/T2 tumors [1,2]. Radical prostatectomy (RP) or high-dose radiotherapy (RAD) with or without androgen deprivation therapy (ADT) are the standard curative treatment options for these patients [3,4]. Over the last decade, the use of robotic-assisted radical prostatectomy (RALP) has become popular among US and European urologists, surpassing the use of open retropubic radical prostatectomy (RRP) in many countries [5]. Still, possible benefits of RALP as to oncological results, adverse effects (AEs) and costs are yet to be convincingly demonstrated [6].
Typical AEs like urinary incontinence and erectile dysfunction after RP are well described in the literature, and have recently been confirmed among Norwegian patients [7,8]. Moreover, reviews on peri- and postoperative complications and prolonged duration of hospitalization after prostatectomy are available [6]. Employment rates and various work-related factors among PCa patients have been reported in population-based studies in Norway, Denmark, Finland and the USA among others, with reporting of worse outcomes for survivors than their cancer-free controls [9,10–12]. Surprisingly few investigations have dealt with treatment-related sick leave and return to work. With the increasing proportion of younger men being diagnosed with PCa and prostatectomized, elucidation of this subject is of importance both from the patient’s and society’s perspective.
Correspondence: S. Dahl, Department of Oncology, Oslo University Hospital, The Norwegian Radium Hospital, PO Box 4953, Nydalen, 0424 Oslo, Norway. Tel: 47 22935786/ 47 97002295. Fax: 47 22935345. E-mail: [email protected] (Received 26 June 2013 ; accepted 6 September 2013) ISSN 0284-186X print/ISSN 1651-226X online © 2014 Informa Healthcare DOI: 10.3109/0284186X.2013.844357
Work participation after radical prostatectomy Searching relevant literature bases, we identified reports from only two research groups that specifically addressed duration of sick leave and/or work participation after RP. A US group led by Bradley et al. demonstrated that men treated with RP missed an average of 33 days of work during the six months following diagnosis [13]. The same researchers described that PCa patients treated with RP were less likely to remain employed and more likely to retire six months after treatment compared to a control group [14]. Hohwü et al. [15] reported significantly shorter periods of paid sick leave among Swedish and Danish patients operated with RALP compared to patients treated with RRP (median 11 vs. 49 days, respectively). Results from the Swedish study group emphasized that men with work requiring high physical activity had particularly long periods of sick leave, and among the US patients a considerable proportion of the patients whose work required physical effort were impeded by the PCa and its treatment [14,15]. However, neither of these register-based studies reported on specific medical reasons for absence from work. Norwegian urologists routinely prescribe a 4–6 weeks sick leave after RP with a possibility for an extension, usually prescribed by the patient’s GP. However, the majority of the patients are expected to regain their pre-operative health and work ability within this time span, which is in agreement with the Swedish official guidelines, recommending six weeks sick leave after prostatectomy [16]. With this background we aimed to identify factors associated with declined work status three months after RP, with particular focus on urinary incontinence, health-related quality of life (HRQOL) and medical complications with or without re-hospitalization evolving after the initial post-RP discharge. Furthermore, we assessed the associations between the duration of immediate post-RP sick leave and available pretreatment variables seeking predictors of sick leave beyond six weeks (prolonged sick leave). We anticipated that almost all patients would have regained their preoperative work status three months after RP, declined work status at that time being associated with urinary incontinence. Based on the experience of Hohwü et al. [15] we expected a shorter sick leave period after RALP compared to RRP and that 70% of the men would have returned to work within six weeks after RP, high physical workload being the main predictor of prolonged sick leave. Material and methods Patient selection and study design The Norwegian Urological Cancer Group performed this national prospective questionnaire-based study of socio-demographic variables, typical AEs, fatigue
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and HRQOL after curative treatment of PCa in patients treated between November 2008 and December 2009 (the NUCG VII study). Study participants received a questionnaire at pretreatment and at three, 12 and 24 months after RP [7]. The current report is restricted to patients 65 years who were working full-time or part-time before RP was performed at one of 14 of Norway’s 17 urological units, excluding men who were already on sick leave prior to RP. Patients eligible for the main analysis should have completed the questions regarding work status at pretreatment and three months after RP. At 12 months, all the respondents received an additional questionnaire assessing immediate post-RP sick leave and work-related factors based on their recall (“Work Questionnaire”). This questionnaire also provided several opportunities for the patients to inform about medical complications beyond typical AEs and re-hospitalizations developing within the first three months after post-operative discharge by completion of optional text fields. Content of the questionnaires Information about relationship status and educational level ( 13 years vs. 13 years) were obtained at baseline only. Data regarding work status, HRQOL and fatigue were collected at all time-points, as well as data on urinary, erectile and bowel function and their corresponding bother. Patients reported co morbidities according to The Medical History Checklist at all time-points [17]. Information on work status was obtained at all time-points by confirmation of one of the following alternatives: full-time work, part-time work, sick leave, rehabilitation, job seeking, disability pension and retirement pension. After comparison of the pretreatment status with the three-month work status, we allocated the patients into either a stable/improved or a declined work status group. The stable/improved work status group consisted of patients who had the same work status as at pre-treatment or had increased their work participation from part-time to full-time work. The declined work status group comprised patients moving from full-time to part-time work and all patients whose work status had changed from full or part-time work to sick leave, as well as the patients who had left the workforce after RP. Duration of immediate post-RP sick leave was assessed by the patients’ reports in the “Work Questionnaire” by one of the following alternatives: 1–2 weeks, 3–4, 5–6, 7–8, 9–10 and 10 weeks. Based on this information we performed a sub-analysis on immediate sick leave after separating the patients into two principal groups: those on 1–6 weeks sick
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leave, and those on 7 weeks sick leave (prolonged sick leave), without differentiating between complete and partial sick leave. The patients reported the previous four weeks’ experience of typical AEs by completing the EPIC-50, which is a frequently used instrument for self-rating of urinary, bowel, sexual and hormonal function and problems (bother) by multiple-choice categorization [18]. We did not consider the items on sexual function in the EPIC-50 relevant for work participation, so items related to this AE were not included. Furthermore, none of the patients had received pelvic radiotherapy or hormones alone within the first three months after RP. Hence, AEs related to bowel and hormonal functioning were omitted, thus only the urinary domain was considered relevant and explored in the present report. Frequency of urinary leakage, pad use and bother (problems) were assessed separately. Cronbachs’ coefficient alpha for internal consistency was 0.9 for these items. We dichotomized the answers for analysis as follows: urinary incontinence: 0 leaking 1 time per day versus 1 leaking 1 time per day, pad use: 0 1 pad per day versus 1 1 pad per day, bother due to incontinence: 0 no problem, very small or small problem versus 1 moderate or big problem. Medical complications comprised self-reported new morbidities and re-hospitalizations within three months after RP. Notably, urinary incontinence was not included in this category, but assessed separately. HRQOL was assessed using the Short Form 12 (SF-12), which is based on measures of eight dimensions and expressed as physical (PCS-12) and mental (MCS-12) composite summary scores [19]. Higher average scores imply better HRQOL than the age-matched population sample. Individual changes in PCS scores and MCS scores were calculated as the differences between a patient’s baseline and three-month score. Statistical analyses Continuous variables were analyzed using t-tests (data with normal distribution) and independent samples Mann-Whitney Wilcoxon test (data with skewed distributions). Categorical variables were analyzed using χ2-tests and Fischer’s exact test. Associations between covariates and the main outcomes were tested using two logistic regression models, with declined work status at three months and sick leave 6 weeks being the dependent variables. Covariates with p-values 0.1 from the univariate analyses were included in the multivariate model. The strength of associations was expressed as odds ratios (ORs) with 95% confidence intervals (CIs).
Correlation and multicollinearity were tested using Spearman’s coefficient rho and the variance inflation factor analysis, respectively. All tests were two-sided. Statistical significance was set at p 0.05. All analyses were performed using PASW for Windows version 18.0. Ethics The Regional Ethics Committee of Southern Norway (REK) approved the NUCG VII study. All participants gave written informed consent. Results Patients Of 414 patients aged 65 years at the time of RP, 282 were working full- or part-time at baseline, and were eligible for this study. Eleven of these patients did not return a three-month questionnaire, four withdrew consent and three did not answer the particular question regarding work status at three months, leaving 264 patients for the main analysis of the three- month work status (Table I). For the analysis of immediate sick leave and medical complications after RP, 211 of these 264 men completed the “Work Questionnaire”. Among the 264 participants, 72% were treated with RALP and 28% with RRP. A higher proportion Table I. Baseline characteristics of patients eligible for the main analysis. Eligible patients N 264
Variables Age1 Work status2 Full-time Part-time Marital status2 Living with partner Not living with partner Education2 13 years 13 years Co morbidity2 No co morbidities 1 co morbidity D’Amico Score2 Low Intermediate High Surgical method2 RALP RRP PCS 121 MCS 121 1 mean
(SD). of patients (%).
2 number
59.2 (4.1) 239 (91) 25 (9) 244 (93) 19 (7) 108 (41) 155 (59) 181 (69) 81 (31) 94 (36) 127 (48) 42 (16) 191 73 53.2 52.2
(72) (28) (4.77) (8.6)
Work participation after radical prostatectomy
univariate analysis (p 0.01) (Table III). There was no statistically significant difference in the prevalence of urinary bother between the RRP and RALP groups (p 0.68, data not shown). The mean physical HRQOL (PCS-12) scores decreased significantly during the first three postoperative months in all patients (Figure 1). Compared to patients with stable/improved three-month work status, men with declined work status experienced significantly greater decrease of their physical HRQOL, resulting in a highly significant difference of the average scores at three months. However, statistically significant though, much smaller differences between these two groups already existed before RP (Figure 1). In the multivariate analysis, only the change in PCS-12 was associated with declined work status (Table III). Bother due to urinary incontinence and change in PCS-12 score were only weakly correlated with each other (Spearman’s rho 0.18, p 0.01).
Table II. Distribution of work status at three months related to status at baseline. Baseline
Work status Full-time Part-time Sick leave Left the workforce
Full-time N 239 175 21 38 5
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Part-time N 25 4 13 2 6
Declined work status in bold.
of low-educated men was treated with RRP (p 0.02, data not shown). At baseline, 90% of the participants were working full-time and 10% part-time. The mean PCS-12 and MCS-12 baseline scores were 53.2 and 52.2, respectively. Three-month work status At three months 192 (73%) patients had an improved or unchanged work status, while for 72 (27%) the work status had deteriorated (Table II). A higher proportion of the patients who worked part-time at baseline had left the work force compared to the patients who worked full-time (p 0.01). The patients who experienced moderate or severe bother due to urinary incontinence were more than twice as likely to report declined work status in
Medical complications and re-hospitalizations Of the 211 men who had completed The Work Questionnaire, 32 (15%) reported various major complications within three months after RP, of which 18 (8.5%) led to re-hospitalization (Table IV). There were no statistically significant associations between
Table III. Associations between work status at 3 months and socio- demographic and medical covariates in all patients (n 264). (Dependent variable: Declined work status). Univariate Variables Age at surgery – years1 Level of Education2 13 years (reference) 13 years Surgical Method2 RALP (reference) RRP Daily pad use last 4 weeks2 No or one pad (reference) 1 pad last Dripping or leaking urine last 4 weeks, bother2 No problem, very small or small problem (reference) Moderate or big problem PCS 12 change*,1 MCS 12 change*,1 1Mean
Multivariate
Stable or improved work status (N 192)
Declined work status (N 72)
OR3
95% CI
p-value
OR4
95% CI
59.1 (4.2)
59.7 (4.0)
1.04
0.97–1.12
0.23
1.06
0.98–1.13
0.14
117 (61) 74 (39)
38 (53) 34 (47)
1.00 1.42
0.82–2.44
0.21
145 (76) 47 (24)
46 (64) 26 (36)
1.00 1.74
0.97–3.12
0.06
1.49
0.77–2.86
0.24
125 (64) 69 (36)
35 (46) 39 (54)
1.00 2.11
1.22–3.65
0.01†
1.00 2.15 1.07 1.01
1.23–3.77 1.03–1.11 0.98–1.05
0.01 0.01 0.6
1.66 1.06
0.90–3.08 1.02–1.10
0.11 0.01
131 57 2.9 1.1
(70) (30) (6.5) (8.3)
37 34 6.8 0.5
(52) (48) (10.4) (8.8)
(SD); 2Number of patients (%); 3Crude; 4Adjusted. *Change is defined as baseline score minus 3 month score; †Omitted from the multivariate analysis due to multicollinearity.
p-value
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S. Dahl et al. Discussion
Figure 1. Changes in physical HRQOL {PCS-12 score [mean (SD)]} according to work status at three months.
the development of medical complications and the patients’ age, surgical method or pretreatment co morbidities (data not shown). There was a close to significant association between declined work status and medical complications (p 0.05) Immediate post-RP sick leave Post-operative work status. Six weeks after RP 108 (51%) of the 211 patients had returned to work and 58 (27%) were still on part or full-time sick leave after 10 weeks (Figure 2). No patient had zero days of sick leave. In univariate analyses, a low level of education, physically demanding work, RRP and decreasing age were associated with prolonged immediate sick leave (Table V). A low educational level was associated with physically demanding work, but not with RRP for this subgroup (p 0.01, data not shown). In the multivariate analysis, decreasing age and physically demanding work remained significantly associated with sick leave beyond six weeks, while being treated with RRP was close to significantly predicting prolonged sick leave (p 0.06).
The present study is the first to investigate post-RP return to work and sick leave within three months in PCa patients, based on patient-reported sociodemographic and medical variables. Three months after prostatectomy about three quarters of 264 men who were working full- or part-time at pretreatment, had regained or improved their pre-operative work status. In sub-analyses, only half of 211 patients had returned to work six weeks after surgery. Fifteen percent of these patients also experienced medical complications leading to re-hospitalization in half of them. The proportion of patients whose work status had declined at three months (27%) was higher than anticipated. Interestingly, only reduction of physical HRQOL, and not bother due to urinary leakage, remained significantly associated with declined threemonth work status in the adjusted regression analysis, notably with low correlation between changes of physical HRQOL and urinary bother. Patients selected to RP usually display a physical functioning above average, and this is also confirmed in our sample, as the mean PCS 12 score is above the mean score in the age matched Norwegian male population [20]. Theoretically, this should allow fast post-RP recovery and return to work. Our findings thus indicate that RP represents a considerable physical burden to the patients’ general health. The negative physical impact is greater than reflected in the oncourological literature, where reports on short operation times and short post-RP hospitalizations may lead to the impression that RP represents at most a medium- and short-lasting threat to the patients’ physical health. Our finding that 15% of the discharged patients experienced medical complications almost significantly associated with declined three-months work status supports the view that RP may lead to
Table IV. Complications (readmissions) within three months after RP related to work status. Work status
Complications Urinary (infections, obstruction) Wound-related (incl. hernia) or bleeding Deep venous thrombosis/pulmonary embolism Heart/lung/stroke GI (ileus, pain, inflammation) Pain/weakness Depression Total
Stable/improved (N 155) 3 (2) 5 5 (4) 2 (1) 3 (2) 1 (1) 19* (10)
*12% (stable/improved) versus 23% (declined) p 0.05.
Declined (N 56) 5 (4) 2 (1) 1 (1) 2 (2) 1 (1) 1 1 13* (9)
Total (N 211) 8 (6) 7 (1) 6 (5) 4 (3) 4 (3) 2 (1) 1 32 (19)
Work participation after radical prostatectomy
Figure 2. Fortnightly cumulative proportion of patients’ return to work.
significantly decreased physical HRQOL. Half of the men were hospitalized due to these complications. Similar percentages of post-discharge hospital readmissions within three months have been reported by Chung et al. from Taiwan (9.4%) [21]. Nelson et al. reported readmissions in 5–7% of the patients in a US sample, but their results may indicate a shorter follow-up period than three months [22]. Clinicians should be aware of serious complications, especially thromboembolic events that can occur several weeks after RP, as also described by van Hemelrijck et al. [16]. Based on the reports from Bradley et al. [13] and Hohwü et al. [15], we expected that at least 70% of the patients would be back at work six weeks after RP. However, this was the case for only half of them. Strenuous physical work and, surprisingly, low age predicted prolonged sick leave. Longer sick leave
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among patients with high physical workload were observed by Hohwü et al. as well [15]. In a study of employment outcomes of men treated for PCa, Bradley et al. reported that 26% of the patients who had to perform work tasks involving physical effort experienced that the malignancy and its treatment interfered with their ability to perform these tasks 12 months after treatment [14]. However, the authors did not discriminate between different treatment modalities. The association between physical activity and the experience of urinary leakage [23] possibly explains the predictive role of physically strenuous work on sick leave beyond six weeks in our study, even though urinary leakage problems at six weeks were not directly addressed in our “Work questionnaire”. In all likelihood, our findings on urinary incontinence and bother at 8–12 weeks from the three-month questionnaire should be applicable for the post-RP period as well. When we analyzed age as a continuous variable decreasing age predicted prolonged sick leave. However, when we compared the median age between the two groups, the difference was small and not considered clinically relevant. Overall, the duration of immediate post-RP sick leave seems longer and the absence from work lasted longer among prostatectomized Norwegian men than among the participants of the Swedish/Danish [15] and US studies [13,14]. These differences require explanations: Investigating work participation and sick leave is complicated due to a complex
Table V. Duration of immediate post-RP sick leave and predictive socio-demographic and medical variables (Dependent variable: prolonged sick leave [ 6 weeks]). Weeks of sick leave
Variables Age at surgery - years1 Working hours2 Full-time work (reference) Part-time work Level of Education2 13 years (reference) 13 years Co-morbidity present at baseline2 None (reference) 1 co-existing morbidity Surgical Method2 RALP (reference) RRP High physical workload2 No (reference) Yes PCS-12 at baseline1 Mean (SD) MCS12 at baseline1 Mean (SD) 1Mean
Univariate
Multivariate
6 weeks (N 108)
6 weeks (N 103)
OR
95 % CI
p
59.7 (4.0)
58.4 (4.3)
0.93
0.87–0.99
0.03
96 (89) 12 (11)
96 (93) 7 (7)
1.00 0.58
0.22–1.55
0.28
75 (69) 33 (31)
50 (49) 52 (51)
1.00 2.36
1.34–4.16
0.01
79 (74) 28 (26)
72 (70) 31 (30)
1.00 1.23
(0.67–2.22)
0.53
85 (79) 23 (21)
68 (66) 35 (34)
1.00 1.9
1.03–3.52
87 (82) 19 (18)
52 (54) 45 (46)
1.00 3.96
54.1 (3.7)
52.9 (5.1)
54.4 (7.4)
49.8 (11.1)
(SD); 2Number of patients (%).
OR
95 % CI
p
0.9
0.83–0.97
0.01
1.78
0.92–3.45
0.09
0.04
2.05
0.99–4.27
0.06
2.10–7.50
0.01
3.34
1.63–6.84
0.01
0.94
0.88–1.00
0.06
0.95
0.88–1.03
0.18
0.98
0.95–1.01
0.23
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interaction between purely medical and sociodemographic variables, like education and financial resources. In contrast to the system of private insurances in the US, Norwegian health and social services, including sick leave compensation, are financed through the government by taxation. During illness all employees in Norway are entitled to sick leave compensation from The Norwegian Labour and Welfare Service (NAV) for up to 52 weeks [24]. Selfemployees are granted a 65% compensation of their income from NAV after 16 days of sick leave. With this favorable system of financial sick leave compensation, Norwegian workers may be less motivated for rapid return to work than men living in societies with less beneficial compensation systems. Methodological differences might explain the deviating findings in our study compared to the US [13,14] and the Swedish/Danish [15] studies. The registry-based study of Hohwü et al. [15] probably lacked information on work inability and absence for patients who were not entitled to short sick leave compensation at all, or whose insurance rights did not start until a few weeks after RP. This could explain that the authors observed zero days of sick pay in 21% of the patients, as the assumption that patients can return to work the day after RP is quite unrealistic [15]. In the US study on absenteeism related to PCa [13], information on days missed from work was obtained by self-report, which is more in agreement with our study design. However, the US authors reported on days missing after diagnosis and not specifically after RP [13]. Furthermore, patients working part-time before RP were excluded from the US study, while work status prior to treatment was not considered in the Swedish one [15]. Furthermore, the patients in the US and Swedish/ Danish studies were slightly younger than the participants in our study. In agreement with Nelson et al.’s study from the US [22], we found no significant difference in complication- and re-hospitalization rates between the patients treated with RALP and the patients treated with RRP. Chung et al. [21] compared the 90-day readmission rates between RRP, laparoscopic RP (LRP) and RALP in a study from Taiwan. They reported a significantly lower risk of readmission after RALP than after the other surgical methods, though physician characteristics and socioeconomic factors could have biased their results [21]. Hohwü et al. [15] found that the median number of days of post-RP sick leave was significantly shorter after RALP than after RRP among Swedish and Danish patients adjusted for age, tumor stage, BMI, physical workload and income. However, the association between RRP and prolonged sick leave in their study can be explained by a selection bias, as more patients
with physical work were treated with RRP. When only the patients with low and medium physical workload were included in their analyses, the significance of the difference in length of sick leave between the RALP and RRP groups disappeared [15]. In our sample, the unadjusted risk of prolonged immediate sick leave was almost doubled for patients operated with RRP though the statistical significance of this difference was not confirmed in the multivariate analysis. In our view, no definite statement can be made at present as to whether the method of RP is associated with the duration of post-RP immediate sick leave. Our study has some limitations. Since the majority of our patients had undergone RALP, which in 2008/2009 was an option available only at major Norwegian hospitals, we cannot exclude some selection bias as to socio-demographic variables, like educational level. Patients who were on sick leave prior to RP were not included in the study, and this might have overestimated the negative impact of RP. However, we did not have information on reasons for being on sick leave prior to RP, which would have complicated the interpretation concerning the impact of RP. The 12-months recall may affect the reliability and validity of data on immediate sick leave. Type II statistical error may explain the lack of significant differences of some comparisons due to the limited sample size. The major strength of our study is the use of clinical data and the inclusion of the patientreported outcome regarding their work status and health after RP. Conclusions Patients, clinicians and employers should be aware that RP might represent a larger burden to the general health than anticipated. Having strenuous physical work is a significant predictor of post-RP sick leave beyond six weeks, independent of the surgical method. Long periods of sick leave and reduced workforce participation after RP should be considered potential adverse effects of this treatment, affecting the individual patient, his family and society. Hence, issues concerning work should be addressed in pre-RP counseling. Finally, any inter-country comparisons of post-RP work participation and post-RP sick leave are challenging due to heterogeneous systems of sick leave compensation. Acknowledgments The Radium Hospital Foundation and the Norwegian Cancer Society funded this study. The authors acknowledge the comments from Victor Berge and Sævar B. Gudbergsson.
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