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A Meta-analysis and Meta-regression

Angela G. E. M. de Boer, PhD; Taina Taskila, PhD; Anneli Ojajärvi, PhD; Frank J. H. van Dijk, PhD, MD; Jos H. A. M. Verbeek, PhD, MD

JAMA. 2009;301(7):753-762.

Context  Nearly half of adult cancer survivors are younger than 65 years, but the association of cancer survivorship with employment status is unknown.

Objective  To assess the association of cancer survivorship with unemployment compared with healthy controls.

Data Sources  A systematic search of studies published between 1966 and June 2008 was conducted using MEDLINE, CINAHL, EMBASE, PsycINFO, and OSH-ROM databases.

Study Selection  Eligible studies included adult cancer survivors and a control group, and employment as an outcome.

Data Extraction  Pooled relative risks were calculated over all studies and according to cancer type. A Bayesian meta-regression analysis was performed to assess associations of unemployment with cancer type, country of origin, average age at diagnosis, and background unemployment rate.

Results  Twenty-six articles describing 36 studies met the inclusion criteria. The analyses included 20 366 cancer survivors and 157 603 healthy control participants. Studies included 16 from the United States, 15 from Europe, and 5 from other countries. Overall, cancer survivors were more likely to be unemployed than healthy control participants (33.8% vs 15.2%; pooled relative risk [RR], 1.37; 95% confidence interval [CI], 1.21-1.55). Unemployment was higher in breast cancer survivors compared with control participants (35.6% vs 31.7%; pooled RR, 1.28; 95% CI, 1.11-1.49), as well as in survivors of gastrointestinal cancers (48.8% vs 33.4%; pooled RR, 1.44; 95% CI, 1.02-2.05), and cancers of the female reproductive organs (49.1% vs 38.3%; pooled RR, 1.28; 95% CI, 1.17-1.40). Unemployment rates were not higher for survivors of blood cancers compared with controls (30.6% vs 23.7%; pooled RR, 1.41; 95% CI, 0.95-2.09), prostate cancers (39.4% vs 27.1%; pooled RR, 1.11; 95% CI, 1.00-1.25), or testicular cancer (18.5% vs 18.1%; pooled RR, 0.94; 95% CI, 0.74-1.20). For survivors in the United States, the unemployment risk was 1.5 times higher compared with survivors in Europe (meta-RR, 1.48; 95% credibility interval, 1.15-1.95). After adjustment for diagnosis, age, and background unemployment rate, this risk disappeared (meta-RR, 1.24; 95% CI, 0.85-1.83).

Conclusion  Cancer survivorship is associated with unemployment.

Author Affiliations: Coronel Institute of Occupational Health, Academic Medical Center, Amsterdam, the Netherlands (Drs de Boer, Taskila, van Dijk, and Verbeek); Primary Care Clinical Sciences, School of Health and Population Sciences, The University of Birmingham, Birmingham, England (Dr Taskila); Finnish Institute of Occupational Health, Good Practices and Competence, Statistical Services, Helsinki, Finland (Dr Ojajärvi); and Finnish Institute of Occupational Health, Knowledge Transfer Team, Cochrane Occupational Health Field, Kuopio, Finland (Dr Verbeek).

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