On February 16, 2010, a Risk Evaluation and Mitigation Strategies (REMS) program to ensure safe use of erythropoiesis-stimulating agents (ESAs) was approved by the US Food and Drug Administration (FDA). The medications included in the REMS program are marketed by Amgen under the trade names Aranesp (darbepoetin alfa) and Epogen (epoetin alfa) and by Centocor Ortho Biotech Products under the name Procrit (epoetin alfa).

The Food and Drug Administration Amendments Act of 2007 (FDAAA), which went into effect on March 25, 2008, reserves the right of the FDA to order REMS for drugs or biologics that have significant toxicity levels and/or demonstrable risk factors. The purpose of these strategies is to ensure that the benefits of specific drugs continue to outweigh risks that they pose for patients. REMS are now being mandated to assess adverse risks associated with specific oncologic drugs, biologics, and supportive care therapies.

Amgen, the manufacturer of Aranesp and Procrit, is required by the FDA to develop the REMS based on studies demonstrating that use of ESAs can increase the risk of tumor growth and shorten survival in patients with cancer. In studies of patients with cancer and patients with renal failure, use of ESAs was shown to increase the risk of myocardial infarction, congestive heart failure, stroke, and thrombotic events.

REMS program have three components, including a medication guide or a patient package insert; a communication plan for healthcare providers; and elements to assure safe use, or ETASU. The specific components used by a REMS program vary based on factors including but not limited to the severity of the risks and the population likely to be exposed. The most common REMS require only the provision of a medication guide.

The REMS program for ESAs requires that all patients receiving ESAs must be provided with a Medication Guide explaining the risks and benefits of ESAs. In addition, Amgen, in collaboration with Centocor Ortho Biotech Products, was required by the FDA to develop the ESA APPRISE (Assisting Providers and Cancer Patients with Risk Information for the Safe use of ESAs) Oncology program for healthcare professionals who prescribe ESAs to patients with cancer. The ESA APPRISE Oncology program was launched on March 24, 2010.

Under the ESA APPRISE Oncology program, Amgen will ensure that only hospitals and healthcare professionals who have enrolled in the program and completed special training will be able to prescribe and dispense ESAs to patients with cancer. Amgen is also required to monitor the program to ensure that hospitals and healthcare professionals are in full compliance with all aspects of the program.

The ESA APPRISE Oncology program requires that all healthcare professionals who prescribe ESAs in patients with cancer meet the following requirements:

• Complete a training module instructing healthcare professionals about the use of ESAs for patients with cancer. The training module must be completed prior to enrollment of the healthcare professional in the ESA APPRISE Oncology program.

• Obtain a signed patient/healthcare professional acknowledgement form prior to initiating a new course of ESA therapy. The acknowledgement form attests that the healthcare professional and patient have discussed the risks associated with using an ESA.

• Re-enroll in the ESA APPRISE Oncology program every 3 years.

• Healthcare professionals not enrolled in the ESA APPRISE Oncology program will not be able to prescribe ESAs for use in patients with cancer.

As part of the enrollment in the ESA APPRISE Oncology program, healthcare professionals must attest to understanding the following:

• ESAs shortened overall survival and/or increased the risk of tumor progression or recurrence in clinical studies in patients with breast, non–small-cell lung, head and neck, lymphoid, and cervical cancer.

• To decrease the risks of ESAs, the lowest dose of ESAs should be used to avoid red blood cell transfusion.

• Aranesp is indicated for treatment of anemia due to the effect of concomitantly administered chemotherapy based on studies that have shown a reduction in the need for red blood cell transfusions in patients with metastatic, nonmyeloid malignancies receiving chemotherapy.

• Epogen/Procrit is indicated for the treatment of anemia due to the effect of concomitantly administered chemotherapy based on studies that have shown a reduction in the need for red blood cell transfusions in patients with metastatic, nonmyeloid malignancies receiving chemotherapy for a minimum of 2 months.

• ESAs are not indicated for use in patients receiving hormonal agents, therapeutic biologic products, or radiotherapy unless these patients are receiving comitant myelosuppressive chemotherapy.

• ESAs are not indicated for patients receiving myelosuppressive therapy when the anticipated outcome is cure.

• ESA use has not been demonstrated in controlled clinical trials to improve symptoms of anemia, quality of life, fatigue, or patient well-being.

• ESAs should be discontinued following completion of a chemotherapy course of treatment.

Additional information on the ESAs, this REMS, and the ESA APPRISE Oncology Program is available on the FDA website, 

. (Search for “Drug Safety Communication: Erythropoiesis-Stimulating Agents [ESAs]: Procrit, Epogen, and Aranesp.”)

Full prescribing information, including clinical trial information, safety, dosing, drug-drug interactions and contraindications, is available at 

www.accessdata.fda.gov/drugsatfda_docs/label/2010/103951s5197lbl.pdf2

www.accessdata.fda.gov/drugsatfda_docs/label/2010/103234s5199lbl.pdf3

A list of FDA-approved REMS is available at 

. (Search for “Approved Risk Evaluation and Mitigation Strategies [REMS].”)

Healthcare professionals should report all serious adverse events suspected to be associated with the use of any medicine and device to FDA’s MedWatch Reporting Program. To do this, an online form can be accessed at at 

, reports can be faxed to (1-800-FDA-0178), one can mail the postage-paid Form 3500 available at 

, or reports can be made by telephone (1-800-FDA-1088).

NCCN.com, the patient/consumer website of the National Comprehensive Cancer Network, provides background information about REMS to patients on their “Living With Cancer” page. Patients who want to learn more about REMS can be referred to “Risk Evaluation and Mitigation Strategies: What Do REMS Mean for You?” available at 

US Food and Drug Administration Approves Risk Evaluation and Mitigation Strategies (REMS) Program to Ensure Safe Use of Erythropoiesis-Stimulating Agents (ESAs)

Articles

On February 16, 2010, a Risk Evaluation and Mitigation Strategies (REMS) program to ensure safe use of erythropoiesis-stimulating agents (ESAs) was approved by the US Food and Drug Administration (FDA).

Oncology Drug Updates

The May 2010 theme of Oncology Nursing Month is “Oncology Nurses: There When You Need Us.” We are certainly there for our patients throughout all phases of the cancer experience, by providing clinical care, support, education, and practical guidance not only during the difficult periods of treatment but also throughout the survivorship phase.

, Barbara Hoffman discusses an important practical concern that causes many cancer patients and survivors considerable worry: the fear of employment and workplace discrimination. She addresses in her comprehensive article the ways that legal protections for cancer survivors in the workplace have evolved since the Americans with Disabilities Act (ADA) was passed by Congress in 1990, and highlights benefits and potential implications of the ADA Amendments Act of 2008 (ADAAA), which went into effect in January 2009.  As Hoffman notes, and as Victoria Thomas and Arnold Potosky underscore in their excellent commentary, healthcare providers seeking to support and protect their cancer patients in the workplace have until recently been faced with a dilemma: Following a 1999 US Supreme Court decision, Sutton v United Airlines, Inc., the definition of a disability was considerably narrowed and the ruling stated that a court must consider whether an individual used mitigating measures, such as taking medication, in determining whether he or she had a disability.

The result was that a court could find a patient whose cancer was in remission because of successful treatment not to be disabled despite the existence of long-term side effects such as fatigue and cognitive dysfunction.

Before the ADA Amendments Act of 2008, Thomas and Potosky explain, “medical experts who testified regarding whether a person's cancer qualified as a disability under the law were often placed in the difficult position of establishing two possibly conflicting facts: first, that a cancer survivor was sick enough to meet a very demanding standard of disability, and second, that the person was not too sick to do his or her job.”

The ADA Amendments Act, which eliminates the mitigating measures requirement, provides a specific definition of “major life activity” and expands the list of major life activities to include bodily functions that are commonly affected by cancer treatment, such as digestive, neurologic, and respiratory functions.

Since oncology nurses are the cornerstone of cancer patient education and support, it is an important responsibility that we educate ourselves about employment rights so that we can educate, counsel, and assist our patients regarding return to work and workplace accommondation issues. To help us, Thomas and Potosky outline strategies that we as healthcare providers can use to help our patients with cancer receive fair treatment in the workplace.

As Brad Zebrack notes in this issue, “job lock,” or staying in a job only for the insurance benefits, has always been common among cancer survivors but is even more prevalent today. “Attending to the employment rights of cancer survivors,” he writes, “is an important step toward protecting their current and future health and well-being.” This is perhaps more true than ever. We can help and there are 12 million cancer survivors depending on us.

The May 2010 theme of Oncology Nursing Month is “Oncology Nurses: There When You Need Us.”

Supporting Cancer Survivors at Work: We're There When You Need Us

When she learned that she had breast cancer, Patricia Garrett did what many people with cancer do: she continued working. Just a few weeks after her initial surgeries, she returned full-time to her position as the Director of Nursing at a University of Alabama hospital. At various points during her radiation treatment and chemotherapy, she took leave from her job. She always returned to work within a short period of time post-treatment, until one day her supervisor told her she was being demoted. Ms. Garrett brought a discrimination lawsuit because she felt that she was unfairly demoted due to her cancer. The federal court that heard her case, and the federal court of appeals that reviewed the lower court's decision, ruled against her. Following Supreme Court precedent that limited who was protected by the Americans with Disabilities Act, the courts held that regardless of whether Ms. Garrett was treated unfairly, her cancer did not sufficiently limit her abilities, and so she did not have a disability-making it perfectly legal for her employer to demote her for having cancer.[1]

The Americans with Disabilities Act Amendments Act of 2008 (ADAAA), which became effective on January 1, 2009, amends the Americans with Disabilities Act (ADA) to restore the original intent of Congress to protect people with chronic conditions such as cancer, diabetes, epilepsy, and mental illness from discrimination at work, school, public places, and elsewhere.[2] The ADAAA provides hope that in the future, cases like Patricia Garrett's will be decided differently. This hope can only be realized with the help of healthcare professionals.

 by Barbara Hoffman, JD, provides an excellent, comprehensive analysis of the new law. Here we expand on this analysis by offering additional advice to healthcare professionals regarding how to help a cancer survivor establish that he or she is entitled to the ADA's protections. These protections include establishing qualification for an employment opportunity and requiring changes in the workplace (“reasonable accommodations”) that allow survivors to continue working while protecting their health.

HELPING YOUR PATIENT ESTABLISH “DISABILITY” UNDER THE ADA

As noted by Ms. Hoffman, a cancer diagnosis has a negative impact on many surviviors' employment opportunities. Cancer survivors may seek the help of their healthcare providers when facing discrimination at work related to their cancer. Many of them may have no idea that such discrimination is illegal until a knowledgeable healthcare professional points this out.

Once a survivor is aware of the protections of the ADA, he or she will still need the assistance of a healthcare professional to document the diagnosis and to establish that cancer is a disability. To establish employment protections under the amended ADA, a cancer survivor must still prove that he or she meets the law's definition of “a person with a disability.”[3] While the ADAAA made it much easier for healthcare professionals to document that a patient with cancer has a disability, as Hoffman explains, it did not remove the requirement of a basic showing that cancer substantially limits a “major life activity.”[3]

The article by Hoffman does not directly address a great challenge that the ADA once posed to healthcare professionals. Before the ADA Amendments Act of 2008, medical experts who testified regarding whether a person's cancer qualified as a disability under the law were often placed in the difficult position of establishing two possibly conflicting facts: first, that a cancer survivor was sick enough to meet a very demanding standard of disability, and second, that the person was not too sick to do his or her job. Because of Supreme Court rulings narrowing the definition of a disability, that is, a substantial limitation in a major life activity, medical experts had to focus on the ways that cancer substantially limited a person's ability to undertake basic activities such as walking.

Some medical experts fell into the trap this created. They successfully convinced an employer or a court that the cancer survivor did indeed meet the legal definition of disability, but as a result armed the employer to claim that the survivor was too sick to do the job. On the other hand, some medical testimony established that having cancer did not prevent the survivor from doing the job, but armed the employer to claim that the survivor was too healthy to be protected by the ADA, as in Patricia Garrett's case.

As a result of the ADAAA, the healthcare professional's role is now straightforward. As Hoffman notes, a nonexhaustive list of major life activities, including the major bodily function of normal cell growth, has been added to the ADA.[3] A healthcare professional can now focus on the diagnosis and its biological meaning for the person affected, rather than listing how a person may be limited in specific activities of daily living that even very ill people can often perform, such as walking and hearing. The healthcare professional can do this by providing a letter to an employer or testifying in court that a patient is substantially limited in the major life activity of normal cell growth. For example, a treating physician can explain that a patient has been diagnosed with breast cancer caused by abnormal cell growth in breast tissue.

Whereas in the pre-ADAAA days, a physician might have to provide many personal details about the treatment impact on the life of the cancer survivor, now he or she can focus on the clinical or biological meaning of the diagnosis of cancer rather than on how ill the person may feel as a result of his or her cancer and its treatment. As a result, the healthcare professional avoids raising unfounded fears that the survivor will become too sick to work or will be a danger in the workplace, because an employer may legally terminate a worker with cancer based on a reasonable belief that the cancer prevents the worker from doing the job, or makes the worker unsafe.

Additionally, the ADAAA makes it easier for healthcare professionals to show that a person whose cancer is in remission is nevertheless a person with a disability, and therefore entitled to protection under the ADA. The law provides two main avenues to do this, both of which require the healthcare professional to describe what would happen if the survivor were in certain situations. First, the healthcare professional can document whether the person would be substantially limited without the benefit of treatment, medical devices, or adaptive behaviors (“mitigating measures”).[3]

For example, many patients would not have gone into remission without treatment and lifestyle changes. Therefore, the healthcare professional can write a letter to an employer explaining that the survivor, when viewed without the mitigating measure of treatment and changed behaviors, would experience significant progression of disease. Second, the healthcare professional can describe how the person would be substantially limited in major life activities during periods of disease progression or recurrence, or during active cancer treatment, even if these limitations only occur intermittently or for short periods of time (conditions that are “episodic or in remission” should be evaluated in their “active state”).[3] For example, survivors who experience episodes when they are too ill to care for themselves, walk, eat, or work as a result of either the cancer or its treatment are substantially limited in those life activities. In such cases, the healthcare professional can explain to employers that the survivor was substantially limited in major life activities because of his or her cancer treatment or its sequelae.

HELPING YOUR PATIENT USE HIS OR HER RIGHTS UNDER THE ADA

While the ADAAA does not change the rights that a person has under the ADA, it makes establishing an entitlement to those rights easier. But what rights does the ADA offer a cancer survivor? Workers are protected from discriminatory employment actions based solely on cancer, such as refusal to hire, termination, or, as in Patricia Garrett's case, demotion. Other patients may need assistance from their doctors and nurses in order to access two other rights afforded under the ADA: individualized assessments and reasonable accommodations.

The ADA forbids employers from making employment decisions based on fears and stereotypes about people with disabilities, and so requires employers to individually assess the abilities of the cancer survivor in question to determine whether he or she is able to do the job (ie, is “qualified”) and whether he or she would pose a danger in the workplace (is a “direct threat to self or others”).[3] Healthcare professionals can help employers properly assess a cancer survivor's abilities. For example, an employer might express concerns that a worker will not be able to keep up with her workload due to cancer. A treating healthcare professional can prevent an employer from legally acting upon those concerns by documenting to the employer that, in his or her medical opinion, the patient's diagnosis and/or treatment will not prevent her from continuing to fulfill her job duties.

Some survivors may seek the advice of their healthcare providers about confronting new difficulties at their workplace related to cancer or complications arising from treatment. Healthcare professionals, usually doctors and nurses, can assist survivors by documenting the need for reasonable accommodations, which are changes in the workplace to enable a person with a disability to continue performing his or her job duties. As long as the survivor can perform the main duties (“essential functions”) of the job with changes that do not present a substantial amount of expense or difficulty for the employer (“undue burden”), the employer is required to provide the accommodations.[4]

A healthcare professional can facilitate the reasonable accommodation process by providing a letter documenting the diagnosis and why cancer is a disability, as explained above, and describing the necessary accommodation(s). For example, a healthcare professional can explain that a factory worker undergoing chemotherapy may experience nausea after chemotherapy and needs to be able to go to the bathroom as needed.

Another common problem that survivors may experience is cognitive impairments caused by toxic chemotherapies. These cognitive impairments can make it difficult for the worker to remember assignments and other important work duties. One potential accommodation a healthcare professional can document is that a survivor is requesting that assignments and other detailed information be given in writing, rather than verbally, due to difficulties with memory resulting from cancer treatment.

Now, healthcare professionals can use the ADAAA's major life activity of normal cell growth to document to an employer that a person with cancer is protected from discrimination. As a result, a worker can assert the right to be judged based on ability, not cancer, and the right to modifications at work to enable continued employment. Cancer survivors face many challenges. With the help of healthcare professionals, establishing the right to work free from discrimination should not be one of them.

Garrett v. Univ. of Ala. at Birmingham Bd. of Trs

2. Thomas V, Gostin L: The Americans with Disabilities Act: Shattered aspirations and new hope. 

3. The Americans with Disabilities Act. 42 USC Â§ 12101, et seq. (2009). 

4. Job Accommodation Network. Available at 

When she learned that she had breast cancer, Patricia Garrett did what many people with cancer do: she continued working.

Helping Patients Access Protections of the ADA

More than 2.5 million breast cancer survivors live in the US today.[1] This number will continue to grow thanks to early detection and advances in treatment that are making early stage breast cancer an increasingly curable disease. None of these gains in survival, however, have come without cost, especially as treatment complexity increases. Long-term effects of treatment, which are complications that begin during treatment and continue beyond the end of treatment,[2] occur as a result of breast cancer therapies and are increasingly prevalent in breast cancer survivors.[3]

Younger women with breast cancer often receive very complex breast cancer treatment regimens, and thus are at risk for a host of various adverse effects. Nowadays, one in three women newly diagnosed with breast cancer is younger than 55 years of age. One of the most common side effects in women with breast cancer, including younger women, is cancer treatment–induced bone loss (CTIBL), which often leads to osteopenia and/or osteoporosis.

In the general US population, more than 8 million women have osteoporosis,[4] a condition characterized by decreased bone strength.[5] Vertebral, hip, and other bone fractures are the chief clinical manifestations of this disease.[6] A Caucasian woman's lifetime risk of osteoporotic fracture is as high as 45%,[7] with these fractures causing significant morbidity and substantial economic consequences.[8] Women with a breast cancer diagnosis are at increased risk for developing both osteoporosis and related fracture,[8,9] in large part due to the substantial role that estrogen plays in bone metabolism.

In women, estrogen protects against bone loss and reduces bone turnover[10] by decreasing the formation, activation, and lifespan of osteoclasts, the cells responsible for breaking down bone. As levels of estrogen decrease, whether due to natural or iatrogenic declines in ovarian function or other treatment effects, bone resorption exceeds new bone formation, leading to net bone loss.[11] Through a variety of mechanisms, treatments for breast cancer interfere with the positive effects of estrogen on bone metabolism, thereby inducing accelerated rates of bone loss.

In April 2004, a 45-year-old Caucasian premenopausal woman, “PM,” presented with a palpable right upper outer quadrant breast mass. Mammogram and ultrasound revealed a 1.8-cm hypoechoicc nodule in the right breast. Ultrasound-guided core biopsy revealed invasive ductal carcinoma, with positive estrogen receptors (ER+, 90% staining) and progesterone receptors (PR+, 70% staining). 

oncogene overexpression was negative (1+).

PM underwent a right breast lumpectomy and sentinel node biopsy. A 1.7-cm focus of invasive ductal cancer was excised, with clean margins, and three of five sentinel lymph nodes were positive. A subsequent axillary dissection removed 10 additional lymph nodes, of which 2 were involved by breast cancer. Thus, PM was diagnosed with stage IIA (T1N1M0) hormone receptor positive breast cancer.

PM's oncologist prescribed adjuvant chemotherapy with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan) (AC) chemotherapy every 2 weeks for a total of four cycles, followed by paclitaxel every 2 weeks for a total of four cycles. This treatment plan was followed by radiotherapy to the right breast and axillary lymph nodes. After two cycles of AC chemotherapy, PM stopped menstruating and developed hot flashes and night sweats. She returned to see her oncologist following radiotherapy, 3 months after chemotherapy ended, to discuss initiation of hormonal therapy. She still was not menstruating and continued to have hot flashes.

Because she was premenopausal at diagnosis, her oncologist prescribed tamoxifen at 20-mg daily, with a plan to switch to an aromatase inhibitor later if she became clearly postmenopausal. When she returned to the office a year later for routine follow-up, she was still not menstruating, and asked what implications this might have for her health. She was especially concerned because her mother had recently had a hip fracture after a long-standing history of osteoporosis, and she had heard that women with breast cancer are at higher risk of osteoporosis.

Given PM's premature menopause and other risk factors for osteoporosis, including family history of fracture and Caucasian race, her nurse practitioner (NP) orders a dual-energy X-ray absorptiometry (DEXA) scan to evaluate her bone mineral density (BMD). Test results from February 2006 show:

• BMD of the AP spine (L1–L4) = 0.977 g/cm

, T-score is −1.7 standard deviations (SD) below the mean for the young adult.

• BMD of the right femoral neck measures 0.942 (g/cm

); T-score is − 0.7 SD from the mean for the young adult.

• The FRAX tool shows PM's 10-year probability of any fracture is 5.7%, and is 0.2% for her 10-year probability of hip fracture (based on weight = 150 lbs, height = 64 inches, nonsmoker, maternal hip fracture).

PM is diagnosed as having osteopenia, and even though she has a family history of hip fracture, her 10-year risk of osteoporotic fracture does not meet the threshold for starting pharmacologic treatment. Following a discussion with her NP, she adds weight-training to her aerobic exercise regimen, and begins taking 600 mg of calcium and 400 IUs of vitamin D3 daily to supplement her daily glasses of milk.

Two years later, in February 2008, she meets with her oncologist to review her plan of treatment. She has never resumed menstrual periods since chemotherapy, is now 49 years old, and her follicle stimulating hormone (FSH) and estradiol levels show her to be in menopause. Her oncologist switches her to the aromatase inhibitor (AI) exemestane (Aromasin), and asks her to have a repeat DEXA scan to re-evaluate her BMD, as well as a test of her vitamin D level.

PM's vitamin D level is normal, and her DEXA scan again shows osteopenia of the lumbar spine, but it is essentially stable compared with the February 2006 study. Thus, she continues her current regimen of exercise and dietary supplementation with calcium and vitamin D.

Two years later, in February 2010, she remains on exemestane. She has a repeat DEXA scan, given the risk for CTIBL with AIs. The DEXA shows:

• BMD of AP spine L2–4 vertebrae measures 0.894 g/cm

, and PM's T-score = −2.5 SD from the mean for the young adult.

• BMD of the right femoral neck = 0.866 g/cm

, and PM's T-score = 
 −1.1 SD, for an interval change of 
 −5.8% from 2008.

• The FRAX tool shows PM's 10-year probability of any fracture is 9.3%, and is 0.3% for her 10-year probability of hip fracture.

PM now has osteoporosis of the spine and has had a significant drop in BMD in the past 2 years, which will likely continue while she is on exemestane. Even though her 10-year risk of osteoporotic fracture does not meet the threshold for pharmacologic therapy, her diagnosis of osteoporosis and her other risk factors are sufficient to require initiation of pharmacologic treatment.

She is given a prescription for alendronate (Fosamax) at a dosage of 70-mg weekly, with instructions on how to take this medication. (It should be taken on an empty stomach with approximately 8 ounces of water, and the patient should remain upright for 30 minutes after taking the pill.) Her nurse also instructs her to call should she require major dental work, given that withholding of alendronate may be recommended owing to the risk for osteonecrosis of the jaw with bisphosphonates.

PM will continue with her calcium and vitamin D supplementation and her exercise program, and she will have her next DEXA scan in 2 years. Her nursing team will continue to play a pivotal role in monitoring her bone health, promoting her adherence to medications and encouraging her to continue preventive strategies (such as exercise and adequate intake of calcium and vitamin D) that will help to improve the effectiveness of her bisphosphonate therapy.

Chemotherapy-Induced Amenorrhea and Bone Loss

In premenopausal women diagnosed with breast cancer, the development of chemotherapy-related amenorrhea is the greatest risk factor for bone loss,[12–16] since it causes a marked and sudden reduction in circulating estradiol.[12] Premenopausal women who stop menstruating because of chemotherapy have reductions in BMD as high as 7.7% during the year following treatment[16,17]; this is more than seven times the annual rate of 1% observed in women with established menopause[6,10] and equivalent to reductions in BMD that occur following surgical oophorectomy.[18]

This bone loss occurs to a more rapid and substantial degree in the lumbar spine as opposed to the femoral neck.[13] The rate of bone loss decreases after the first 2 years, but bone loss still continues at a slower rate.[19]

Hormonal Therapy for Breast Cancer and Bone Loss

In premenopausal women, tamoxifen is associated with mild reductions in BMD of about 1.5% per year, but treatment with this agent does not cause bone loss in postmenopausal women.[13,20,21] In postmenopausal women, circulating estrogen levels are maintained by the activity of the aromatase enzyme, which converts adrenal androgens to estrogen.[22] Aromatase inhibitors interfere with this enzyme and decrease circulating levels of estrogens by 90%, precipitating bone loss.

Adjuvant use of AIs for 2 to 5 years is associated with both higher fracture rates[23–25] and greater bone loss[26–30] compared with tamoxifen or placebo (as high as 7.2% over 5 years on anastrozole). The risk of a major fracture is about 10% with 5 years of AI therapy (see Figure 1).[31] Ovarian ablation, which is presently being evaluated in large clinical trials to determine its role in the treatment of premenopausal women, causes substantial and rapid bone loss.[18,21]

It is also important to consider general risk factors for osteoporosis (see Table 1) when evaluating and treating breast cancer survivors. These include nonmodifiable characteristics such as age and race, as well as external, modifiable factors such as health behaviors and medication exposures.[4] African Americans and Latinos have higher BMD than whites,[6] while low body weight, a personal history of fragility fracture, and a family history of fracture increase osteoporosis risk.[32]

The gold standard test for screening and diagnosis of osteoporosis is the DEXA scan, a highly accurate X-ray technique that can measure BMD at any bony site.[6] BMD measurements of the hip and/or spine are preferred (see Table 2 for clinically important values), and include the absolute BMD, the percent change over time, and the T-score, which compares BMD to that of a healthy young adult (24–45 years) of the same sex. The American Society of Clinical Oncology (ASCO) guidelines for bone health in women with breast cancer recommend DEXA scans every 1 to 2 years in women at risk due to age, premature menopause, or hormonal therapy (see Table 3).[33] Most other national and international organizations recommend a 2-year interval between tests.[4,34] In general, the closer the BMD value is to the threshold at which treatment would be initiated, the sooner BMD testing should be repeated.[6]

The primary goal for both prevention and treatment of osteoporosis is preventing fracture.[4,35] National guidelines recommend lifestyle strategies for all women, including adequate calcium and vitamin D intake (see Table 3), avoidance of smoking or excessive alcohol intake, and either weight-bearing or muscle resistance training exercises.[33,36] Evidence is unclear as to whether supplementing to obtain certain threshold vitamin D levels, specifically 25-hydroxy vitamin D, is useful for promoting bone health,[31] but guidelines universally recommend vitamin D supplementation regardless of such monitoring.[33,37] ASCO guidelines recommend that pharmacologic treatment be initiated when the T-score falls at or below − 2.5 SD.[33]

Other national and international guidelines echo this recommendation[36] but now also integrate use of the FRAX tool, a validated model for predicting probability of fracture based on clinical risk factors in addition to BMD.[38] The FRAX tool is available online at 

 and calculates the 10-year probability of hip fracture and any major osteoporotic fracture. In addition to the threshold T-score of − 2.5 SD or greater, the US-based National Osteoporosis Foundation recommends initiation of pharmacologic therapy when the 10-year probability of hip fracture is 3% and/or when the 10-year probability of any major osteoporotic fracture reaches 20%.[36] Table 4 provides dosage recommendations for vitamin D and calcium from the National Osteoporosis Foundation.[37]

Bone health and fracture prevention are clearly issues of increasing importance among breast cancer survivors. Optimal strategies to address the serious potential complication of osteoporosis in this population continue to evolve.

1. Ries L, et al: SEER Cancer Statistics Review, 1975-2005 [cited May 15, 2008]. Available at: 

2. Hewitt M, Greenfield S, Stovall E: From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC, The National Academies Press, 2006.

3. Partridge AH, Winer EP: Long-term complications of adjuvant chemotherapy       for early stage breast cancer. 

4. World Health Organization: Prevention and Management of Osteoporosis: Report of a WHO Scientific Group. WHO Technical Report Series 2003. April 20, 2006. Available at: 

http://whqlibdoc.who.int/trs/WHO_TRS_921.pdf

5. Boonen S, et al: Effect of osteoporosis treatments on risk of non-vertebral       fractures: Review and meta-analysis of intention-to-treat studies. 

6. Cummings SR, Bates D, Black DM: Clinical use of bone densitometry: Scientific       review. JAMA 288(15):1889â1897, 2002. [See erratum in 

7. Bringhurst FR, et al: Bone and Mineral Metabolism in Health and Disease,       in Kasper DL, et al (eds): 

More than 2.5 million breast cancer survivors live in the US today.[1] This number will continue to grow thanks to early detection and advances in treatment that are making early stage breast cancer an increasingly curable disease.

Osteoporosis in a Young Breast Cancer Survivor

Treatment of patients with advanced renal cell cancer.

Prevents angiogenesis (new blood vessels), and growth of some tumors. It is a multitargeted tyrosine kinase inhibitor of:

•Vascular endothelial growth factor receptor 1,2,3 (VEGFR-1,2,3)

• Platelet derived growth factor receptor (PDGFR)-α and β

• Fibroblast growth factor receptor (FGF)-1,3

• Interleukin-2 (IL-2) receptor inducible T-cell kinase (Itk)

• Leucocyte-specific protein tyrosine kinase (Lck)

Following oral dosing, drug reaches peak plasma concentration in 2–4 hours. If tablet is crushed rather than swallowed whole, bioavailability and area under the curve (AUC) serum level are increased by 46%. Administration with high-fat meal also increases AUC, so a whole tablet should be taken on an empty stomach. Drug is primarily metabolized by CYP3A4 hepatic enzyme system, and to a minor degree by CYP1A2 and CYP2C8. Drug mean half-life is 30.9 hours after administration. Drug is eliminated in the feces, and to a lesser degree in the urine. If patient has moderate hepatic impairment, drug clearance is reduced by 50%, so drug dose should be reduced in these patients.

• Pazopanib 800 mg orally once daily without food (at least 1 hour before or 2 hours after a meal).

• Drug dose in moderate hepatic impairment is 200 mg orally without food.

• Drug is not recommended for patients with severe hepatic impairment, defined as total bilirubin > 3 × upper limit of normal (ULN) with any level of alanine transaminase (ALT).

• Coadministration of strong CYP3A4 inhibitor (eg, ketoconazole, ritonavir, clarithromycin): Reduce dose of pazopanib to 400 mg orally once daily without food, but may need further dose reduction if side effects are severe.

• Patients who require concomitant chronic administration of strong CYP3A4 inducer medication should not take pazopanib.

• Available as 200- and 400-mg tablets.

• Drug may cause changes in liver and bile blood chemistry results so patient’s blood will be monitored closely (liver function tests) before starting therapy, and at least every 4 weeks for the first 4 months of therapy, or more frequently if needed.

• Drug may cause loss of pigment in the hair strands (depigmentation) during treatment, which will return to normal once the drug is stopped.

• It is very important to take the medicine on an empty stomach; if taken with food, this may increase the drug side effects.

• Rarely, severe and possibly fatal liver damage may occur. Patient should call doctor right away if s/he experiences any of the following: yellowing of the skin or whites of the eyes; unusual darkening of the urine; unusual tiredness; pain in the right upper part of abdomen.

• Women of child-bearing potential should use effective birth control measures to prevent pregnancy, as the drug may harm the fetus. Mothers should not nurse while receiving the drug.

• CYP3A4 inhibitors (strong, eg, ketoconazole, ritonavir, clarithromycin, grapefruit or juice): may increase the plasma pazopanib concentration. Avoid coadministration. (For more information, see 

 22(11):33,52–56, February 2009.) If coadministration is necessary, consider a dose reduction of pazopanib.

• CYP3A4 inducers (strong, eg, rifampin): may decrease the plasma concentration of pazopanib. Avoid coadministration.

• Substrates of CYP3A4, CYP2D6, CYP2C8 with a narrow dose range: Do not coadminister, as the drug metabolism may be inhibited resulting in serious side effects from the coadministered drug.

• Consider tumor lysis prevention with allopurinol.

• Increases in BP may occur and are related to steady-state drug plasma concentrations.

• Drug may rarely prolong QTc interval, increasing the risk of ventricular tachycardia (torsades de pointes).

• If patient develops diarrhea, s/he should follow the instructions given by the doctor or nurse. Patient should report diarrhea that is moderate to severe or does not stop within 24 hours.

 

 • Severe and fatal hepatotoxiciy may occur. Monitor liver function tests (LFTs) at baseline, then at least monthly for the first 4 months, and then regularly during therapy. 
 Elevation of the transaminases (ALT, aspartate transaminase [AST]) occurs in the first 18 weeks of therapy.

• If ALT is increased to 3 × ULN – 8 × ULN, pazopanib can be continued with weekly monitoring of LFT until ALT returns to Grade 1 or baseline.

• If ALT is increased > 8 × ULN, pazopanib should be interrupted. If the potential benefit of the drug outweighs the risk, pazopanib can be reintroduced at 400 mg orally once daily, or a lower dose, with weekly monitoring of LFTs for 8 weeks. If after reintroduction, ALT increases to > 3 × ULN again, the drug should be discontinued.

• If ALT is increased > 3 × ULN together with an 
 increased bilirubin > 2 × ULN, pazopanib should be permanently discontinued.

• Use drug cautiously in patients with Gilbert’s syndrome, as drug is a UGT1A1 inhibitor. UGT1A1 is a glucuronidation enzyme that is inefficient in patients with Gilbert’s syndrome, resulting in an elevated level of bilirubin (indirect or unconjugated hyperbilirubinemia).

• Drug can prolong the QT interval (period of ventricular depolarization) 500 msec, which increases the risk of torsades de pointes (type of ventricular tachycardia). Risk is increased in patients taking other drugs that prolong the QT interval (eg, antiarrhythmics), and/or who have pre-existing cardiac disease, hypomagnesemia, hypocalcemia, and hypokalemia. Patients should have a baseline EKG with QTc determination, and it should be repeated during therapy. In addition, baseline electrolytes should be determined, any abnormalities corrected before therapy begins, and electrolytes monitored closely during therapy.

• Antiangiogenic class effects may occur.

• Hemorrhage may occur (16% all grades, 2% grades 3–5), and may be rarely fatal. Patients with a history of hemoptysis, cerebral, or significant GI hemorrhage within the last 6 months should not receive pazopanib.

• Arterial thrombotic events may rarely occur (3% all grades, 2% grades 3–5), manifested as myocardial infarction, angina, ischemic stroke, or transient ischemic attack. Drug should be used cautiously in patients who are at higher risk for these events, and should not be used in patients who have had an event within the previous 
 6 months.

• Rarely, GI perforation or fistula can occur (0.9%) and patients should be monitored closely for signs and symptoms.

• Hypertension occurs in 40% of patients, so it should be well-controlled prior to starting pazopanib therapy; 88% of patients who developed hypertension did so early, within the first 18 weeks of therapy. If hypertension persists despite antihypertensive therapy, the dose of pazopanib may be reduced. The drug should be stopped if severe hypertension persists on antihypertensive therapy and after pazopanib dose reduction.

• Wound healing may be impaired, although no studies have been done. Pazopanib should be stopped at least 
 7 days before scheduled surgery, and resumption of drug should be based on extent of adequate wound healing. Drug should be discontinued if wound dehiscence occurs.

• Hypothyroidism occurs in 4% of patients, so monitoring of thyroid function tests is recommended.

• Proteinuria may occur in 8% of patients. Assess baseline urinalysis and repeat periodically during therapy.

Approved Drugs: Pazopanib (Votrient)  Indications

Pazopanib, a Multitargeted Tyrosine Kinase Inhibitor for Advanced Renal Cell Cancer

ABSTRACT: Abstract Before the passage of laws that protected persons with disabilities from employment discrimination, cancer survivors faced blatant employment discrimination with little legal recourse. From the early 1990s to 2008, cancer-based discrimination significantly diminished as survivors benefited from expansion of their legal rights, advances in medical care, and improvements in public perceptions about living with and beyond a cancer diagnosis. Survivors who sued their employers for discrimination in federal court, however, were seldom awarded a satisfactory remedy. In 2008, Congress revised the Americans with Disabilities Act to make it less burdensome for individuals who have disabilities to seek remedies for employment discrimination. This article will review the work experiences of cancer survivors, describe their rights under the original Americans with Disabilities Act of 1990, and project how the Americans with Disabilities Act Amendments Act of 2008 may improve cancer survivors' employment opportunities.

With about 12 million cancer survivors living in the US,[1] cancer affects millions of working Americans. Improvements in early detection and treatment have resulted in a significant number of newly diagnosed and long-term survivors of working age. Approximately 4,180,000 people-38% of all cancer survivors-are 20 to 64 years old.[2] The majority of these individuals want to and are able to return to work after diagnosis and perform their jobs.

Cancer treatment limits the ability of only a minority of survivors to work as they had prior to diagnosis. Surveys in the 1980s reported that approximately 80% of survivors return to work after diagnosis.[3] A survey of 10 studies that assessed return-to-work rates of a total of 1,904 cancer survivors from 1986 to 1999 found that a mean of 62% returned to work.[4] A study of 1,763 survivors who were first diagnosed between January 1997 and December 1999 found that of the 1,433 who were working at diagnosis, 73% returned to work within 1 year of diagnosis and 84% returned to work within 4 years.[5] Bradley et al. interviewed 253 long-term survivors in 1999 and found that 67% were employed 5 to 7 years later.[6]

Nonetheless, cancer can have a significant negative impact on survivors' employment opportunities. Although the majority of cancer survivors are able to continue working or return to work without limitations resulting from their diagnosis or treatment, some survivors experience significant physical or mental limitations that affect their ability to work.[5–8] An analysis of the 2000 National Health Interview Survey found that cancer survivors have poorer outcomes across all employment-related burden measures relative to matched control subjects.[9] One estimate is that 16.8% of working-age survivors (compared with 5% of matched controls) are unable to work because of a physical, mental, or emotional problem; of those who could work, 7.4% (compared with 3.2% of matched controls) were limited in the kind or amount of work they could do.[6] An analysis of 36 studies of 177,969 participants found that survivors were more likely than healthy control participants to be unemployed. (33.8% vs 15.2%).[10]

Whether a survivor continues to work during treatment or returns to work after treatment-and if so, whether that survivor's diagnosis or treatment will result in working limitations-depends on many factors. They include the survivor's age, stage at diagnosis, financial status, education, and access to health insurance and transportation, as well as the physical demands of the job and the presence of any other chronic health conditions.[5,6,11] For example, survivors in physically demanding jobs have higher disability rates than those in more sedentary jobs; survivors with advanced education have higher return to work rates than those with less education.[5,11] Medical treatment decisions that consider quality of life and the shift towards providing cancer treatment in outpatient settings have contributed to the increasing number of survivors who can work during their treatment.[12]

Prior to the passage of laws that prohibited disability-based discrimination, a significant percentage of cancer survivors (25% to 84%) experienced cancer-related employment discrimination.[13–15] In the late 1980s and early 1990s, new federal and state laws prohibited employment discrimination based on disabilities such as cancer. Since then, survivors have reported decreasing incidences of work problems attributable to their cancer.

A 2006 national survey of cancer survivors found that most employers appear to be highly sensitive and accommodating to the needs of employees who have cancer and to employees who are caregivers for cancer survivors.[16] Three out of five survivors reported receiving co-worker support, such as help with work or random acts of kindness.[16] Survivors and caregivers reported very low incidences of negative reactions from their employers and co-workers.[16] The most common negative reaction, reported by one in five survivors, was that an employer gave a survivor less work after diagnosis.[16] Other consequences, such as being fired or laid off (6%), denied a raise or promotion (7%), and denied health insurance benefits (4%), were far less common.[16]

CANCER SURVIVORS' EMPLOYMENT RIGHTS UNDER THE ORIGINAL AMERICANS WITH DISABILITIES ACT OF 1990

Prior to 1990, cancer survivors had few legal protections from cancer-based employment discrimination. The Federal Rehabilitation Act,[17] which governed only federally funded employment, and a patchwork of state laws provided very limited remedies to a small number of cancer survivors. By 1992, however, the employment provisions of the Americans with Disabilities Act of 1990[18] became effective. Additionally, many states amended their employment discrimination laws to cover persons with disabilities, including, in most cases, cancer survivors. Under these laws, an employer cannot treat a survivor who meets the statutory definition of a person with a disability differently from other workers in job-related activities because of his or her cancer history, as long as the survivor is qualified for the job. Individuals are protected by these laws only if 1) they can do the major duties of the job in question; and 2) their employer treated them differently from other workers in job-related activities because of their cancer history.

The Americans with Disabilities Act of 1990 (ADA) prohibits some types of job discrimination by employers, employment agencies, and labor unions against people who have or have had cancer. The ADA covers private employers with 15 or more employees, state and local governments, the legislative branch of the federal government, employment agencies, and labor unions. From July 26, 1992 through September 30, 2008, of all charges brought under the ADA 3.1% were cancer-based discrimination claims.[19,20] The ADA prohibits employment discrimination against individuals who have a disability, have a record of a disability, or are regarded as having a disability. A disability is a major health problem that substantially limits the ability to do everyday activities, such as care for oneself or walk. Because most cancer survivors, even those who do not consider themselves to be limited by their cancer, fit under at least one of these three groups, most cancer survivors are protected by the ADA from the time of diagnosis.

Whether an individual is covered by the ADA is determined on a case-by-case basis. Most federal courts find that cancer survivors who are qualified for their jobs are covered by the ADA.[21] As will be discussed in this article, some federal courts, however, applied the ADA so strictly as to place cancer survivors in a Catch-22 situation by concluding that a cancer survivor who is sufficiently healthy to work is not a person with a disability as defined by the ADA.[21] The ADA prohibits discrimination in almost all job-related activities. (See Table 1 for selected examples of restrictions on employment practices under the ADA.)

In most cases, an employer may not ask prospective employees if they have ever had cancer. An employer has the right to know only if the applicant can perform the duties of the job in question. An employer may not ask a prospective employee about his or her health history, unless the employee has a visible disability and the employer could reasonably believe that it affects the person's ability to perform that job. A job offer may be contingent upon passing a relevant medical exam, provided that all prospective employees are subject to the same exam. An employer may ask detailed health questions only after offering a job.

Employers must keep employee medical histories in a file separate from other personnel records. The only people entitled to see employee medical files are supervisors who need to know whether the employee needs an accommodation, emergency medical personnel, and government officials who enforce the ADA.

If a survivor needs extra time or help to do his or her job, the ADA requires an employer to provide a “reasonable accommodation.” An “accommodation” is a change in working conditions, such as in work hours or duties (see Table 2).

“Undue hardship” and “reasonable accommodation” under the ADA

An employer does not have to make changes that would be an “undue hardship” on the employer or other workers. “Undue hardship” refers to any accommodation that would be unduly costly, extensive, substantial or disruptive, or that would fundamentally alter the nature or operation of the business. For example, an employer may be permitted to replace a cancer survivor who has to miss a substantial amount of work time and whose work cannot be performed by a temporary employee. Studies of employees with disabilities report that most employees can be accommodated with relatively simple and inexpensive solutions.[22] The ADA does not prohibit an employer from firing or refusing to hire a cancer survivor under any circumstance. Because the law requires employers to treat all employees similarly, regardless of disability, an employer may fire a cancer survivor who would have been terminated even if he or she were not a survivor.

The ADA allows employers to establish attendance and leave policies that are uniformly applied to all employees, regardless of disability. Employers must grant leave to cancer survivors if other employees would be granted similar leave. They may be required to change leave policies as a reasonable accommodation. Employers are not obligated to provide additional paid leave, but accommodations may include leave flexibility and unpaid leave.

The ADA does not require employers to provide health insurance, but when they choose to provide health insurance, they must do so fairly. For example, an employer who provides health insurance to all employees with similar jobs may violate the ADA by refusing to provide health insurance to a cancer survivor. The employer must prove that the failure to provide health insurance is based on legitimate actuarial data or that the insurance plan would become insolvent or suffer a drastic increase in premiums, co-payments, or deductibles.

Most employment discrimination laws protect only the employee. The ADA offers protection more responsive to survivors' needs because it prohibits discrimination against family members, too. Employers may not discriminate against workers because of their relationship or association with a “disabled” person. Employers may not assume that an employee's job performance would be affected by the need to care for a family member who has cancer. For example, employers may not treat an employee differently because they assume that the employee would use excessive leave to care for a spouse who has cancer. Additionally, employers that provide health insurance benefits to dependents of employees may not decrease benefits to an employee solely because that employee has a dependent with cancer.

HOW THE ADA AMENDMENTS ACT OF 2008 IS LIKELY TO IMPROVE CANCER SURVIVORS' EMPLOYMENT RIGHTS

Although the ADA greatly reduced incidents of discrimination based on disability, including cancer, most employees who filed complaints with the Equal Employment Opportunities Commission and who sued their employers in court met with little success. The vast majority of claimants received neither a favorable settlement with their employers nor a remedy from a court.[23–26] The main reason the ADA provided a remedy in only a small number of employment discrimination cases is that judicial interpretation of the ADA imposed a very high threshold for employees to prove they had a disability, as defined by the statute, and in so doing prevail in court.[23–26]

In response, Congress passed the ADA Amendments Act of 2008 (“Amendments Act”) to make it easier for claimants to meet the definition of an “individual with a disability.” The Amendments Act, which took effect on January 1, 2009, retains the three alternative ways to prove disability: 1) an impairment that substantially limits one or more major life activities; 2) a record of such an impairment; or 3) being regarded as having such an impairment. A claimant's ability to prove that he or she satisfies one of these alternatives will be less burdensome, however, because of four key changes provided by the Amendments Act.

Four Key Changes Provided by the ADA Amendments Act of 2008

First, the Amendments Act adds the definition of “major life activities” to the statute itself and expands the list of covered activities.

 The regulations to the ADA had defined major life activities as “functions such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.”[27] The Amendments Act supplements this nonexhaustive list by adding “eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, and communicating.”[28] Moreover, the Amendments Act broadens the definition of major life activity to include “the operation of a major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.”[29] Under the ADA, some cancer survivors could not prove that their cancer had an impact on one of the major life activities identified by the regulations. The far more expansive definition of major life activities in the Amendments Act provides practically all survivors the ability to identify a major life activity affected by their cancer.

Brad J. Zebrack, PhD, MSW, MPH
 Associate Professor
 University of Michigan School of Social Work
 Adjunct Associate Professor
 University of Michigan School of Public Health
 Ann Arbor, Michigan

Much has been written about cancer survivors feeling the need to hold on to their jobs while undergoing cancer treatment, for fear of losing their health insurance benefi ts (“job lock”). Certainly today's tough economic times pressure survivors to stay in their jobs while undergoing or recovering from treatment for cancer, because they worry that these jobs may not still be available to them when they are ready to return to work. Many may shun taking a break from employment at a time when their ill health and need for healing are paramount.

In the US, two-wage-earner households are the norm, and this helps to cushion the fi nancial blow of job loss. Whether caused by illness and disability or the economic downturn, becoming unemployed has serious implications for the long-term health and well-being of jobless people and their families. Research by Andrew J. Oswald, an economist at the University of Warwick, UK, indicates that the stress effect of being involuntarily out of work for 6 months or longer is equivalent to experiencing the death of a spouse, one of the most stressful experiences that a person can or will endure in his or her lifetime. These mental health impacts have little to do with the financial strains associated with the loss of a paycheck.[1] Most of the effect is related to one's sense of self and loss of self-worth. For middle-aged men especially, research has shown job loss and an accompanying loss of a daily routine and sense of purpose in life are often followed by an increase in alcohol and substance use, onset of depressive symptoms, increases in suicidal ideation and suicide, and domestic violence.

Beyond these mental health and social issues, research suggests that physical health problems and unemployment are related, most likely having to do with fewer fi nancial resources and higher stress levels. Of course, cancer increases one's risk of physical health problems and even death, but so does losing one's job. Economist Till Marco von Wachter at Columbia University, New York, concluded in a recent study that there appears to be “a particularly pronounced increase in mortality following job loss and a long-run increase of 10% to 15% in the annual probability of dying persisitng for at least the next 20 years.”[2] Furthermore, in a recent study he found that the lives of workers who lost their jobs at 30 years of age were shorter than those who lost their jobs at age 50 or 55, and shorter than those who never lost their jobs at all. Thus, the younger the worker, the greater the effect of job loss on his/her lifespan. Translated to cancer survivors, losing one's job because of illness may compound the risk of death and have an impact on cancer survivors' future health.

Older adolescent and young adult cancer survivors may be at the greatest risk of all when it comes to unemployment. Research indicates that two-thirds of real lifetime wage growth typically occurs in the first 10 years of one's career or involvement in the job market.[ 3] Missing out on employment opportunities as a result of cancer and its treatment threatens young adult survivors' long-term career opportunities, fi nancial status, and lifetime earnings. Furthermore, work by sociologist Krysia Mossakowski from the University of Miami, Coral Gables, Florida, indicates that people who are unemployed for long periods in their older teen and young adult years are far more likely to develop alcohol problems and depressive symptoms.[4,5]

Summarizing US labor statistics, Deputy Managing Editor Don Peck of 

 reported that in 2009, 44% of US families experienced a job loss, reduction of hours, or pay cut.[6] These losses can be attributed to multiple and varied causes, including the economic downturn, disability, and illness. Attending to the employment rights of cancer survivors is an important step toward protecting their current and future health and well-being.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturer of any products or providers of any service mentioned in this article.


 1. Gardner J, Oswald A: How is mortality affected by money, marriage, and stress? 

 23(6):1181–1207, 2004.
 2. Sullivan D, von Wachter T: Job displacement and mortality: An analysis using administrative data.

 124(3):1265–1306, 2009.
 3. Topel RH, Ward MP: Job mobility and the careers of young men. 

 107(2):439–479, 1992.
 4. Mossakowski KN: Is the duration of poverty and unemployment a risk factor for heavy drinking? 

 67(6):947–955, 2008.
 5. Mossakowski KN: The infl uence of past unemployment duration of symptoms of depression among young women and men in the United States. 

99(10):1826–1832, 2009.
 6. Peck D: How a new jobless era will transform America. 

http://www.theatlantic.com/magazine/archive/2010/03/how-a-new-jobless-era-will-transformamerica/7919/

With about 12 million cancer survivors living in the US,[1] cancer affects millions of working Americans. Improvements in early detection and treatment have resulted in a significant number of newly diagnosed and long-term survivors of working age.

ONCOLOGY Nurse Edition Vol 24 No 4 | Oncology Nurse Edition

Oncology Drug Updates

Supporting Cancer Survivors at Work: We're There When You Need Us

Helping Patients Access Protections of the ADA

Osteoporosis in a Young Breast Cancer Survivor

Pazopanib, a Multitargeted Tyrosine Kinase Inhibitor for Advanced Renal Cell Cancer

Cancer and Work: Protections Under the Americans with Disabilities Act

Curcumin

Trouble Sleeping During Breast Cancer Adjuvant Chemotherapy Treatments

Screening for Emotional Distress in Older Patients With Lung Cancer