Ssion may have accentuated any relationship between chemotherapy and subsequent unemployment

Ssion may have accentuated any relationship between chemotherapy and subsequent unemployment, the findings of this study should not be generalized to settings in which theAuthor Manuscript Author Manuscript Author Manuscript Author ManuscriptCancer. Author manuscript; available in PMC 2015 June 15.Jagsi et al.Pageeconomic environment differs substantially from that experienced by the survivors we studied. As in any observational study, challenges exist in interpreting causation. However, it seems unlikely that women with higher risk of job loss for other reasons would have been more likely to receive chemotherapy. Indeed, we explored other potential explanatory or confounding factors for differential job loss by chemotherapy groups and did not observe an association with chemotherapy receipt, including insurance status, reasons for stopping work (e.g. retirement) or less motivation to continue work (e.g. less importance of work or jobseeking) into the survivorship period. It is, of course, possible that an unmeasured factor might play a confounding role. However, the most plausible candidates for unmeasured factors associated with both chemotherapy receipt and with work loss act in a direction to strengthen rather than weaken the association observed. For example, one unmeasured factor might be the geographic microenvironment. Individuals who live in less populated areas would be expected to have less access to chemotherapy and also less access to jobs. In sum, this study suggests that loss of paid employment after breast cancer diagnosis may be common, often undesired, not restricted to the treatment period, and potentially related to treatment administered. Many clinicians believe that although patients may miss work during treatment, they will “bounce back” in the longer term. Our study suggests otherwise and highlights a possible adverse consequence of adjuvant chemotherapy. Our findings support current efforts to reduce the morbidity and burden of treatments for breast cancer (38). Indeed, initiatives to reduce the morbidity and burden of treatments for breast cancer are actively being evaluated, including better strategies to identify patients who might omit adjuvant chemotherapy because the marginal benefit is small (39?1). Our study reinforces the need to advance these evaluative strategies to help physicians “first, do no harm.”Author Manuscript Author Manuscript Author Manuscript Author ManuscriptSupplementary MaterialRefer to Web version on PubMed Central for supplementary material.AcknowledgmentsFunding: Grants R01 CA109696 and R01 CA088370 from the National Cancer Institute (NCI) to the University of Michigan. Dr. Jagsi was supported by a Mentored Research Scholar Grant from the American Cancer Society (MRSG-09-145-01). Dr. Katz was supported by an Established Investigator Award from the NCI (K05CA111340). The collection of LA County cancer R848 biological activity incidence data used was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the NCI’s Surveillance, Epidemiology and End Results (SEER) Program under contract purchase S28463 N01-PC-35139 awarded to the University of Southern California, contract N01-PC-54404 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement 1U58DP00807-01 awarded to the Public Health Institute. The collection of metropolitan.Ssion may have accentuated any relationship between chemotherapy and subsequent unemployment, the findings of this study should not be generalized to settings in which theAuthor Manuscript Author Manuscript Author Manuscript Author ManuscriptCancer. Author manuscript; available in PMC 2015 June 15.Jagsi et al.Pageeconomic environment differs substantially from that experienced by the survivors we studied. As in any observational study, challenges exist in interpreting causation. However, it seems unlikely that women with higher risk of job loss for other reasons would have been more likely to receive chemotherapy. Indeed, we explored other potential explanatory or confounding factors for differential job loss by chemotherapy groups and did not observe an association with chemotherapy receipt, including insurance status, reasons for stopping work (e.g. retirement) or less motivation to continue work (e.g. less importance of work or jobseeking) into the survivorship period. It is, of course, possible that an unmeasured factor might play a confounding role. However, the most plausible candidates for unmeasured factors associated with both chemotherapy receipt and with work loss act in a direction to strengthen rather than weaken the association observed. For example, one unmeasured factor might be the geographic microenvironment. Individuals who live in less populated areas would be expected to have less access to chemotherapy and also less access to jobs. In sum, this study suggests that loss of paid employment after breast cancer diagnosis may be common, often undesired, not restricted to the treatment period, and potentially related to treatment administered. Many clinicians believe that although patients may miss work during treatment, they will “bounce back” in the longer term. Our study suggests otherwise and highlights a possible adverse consequence of adjuvant chemotherapy. Our findings support current efforts to reduce the morbidity and burden of treatments for breast cancer (38). Indeed, initiatives to reduce the morbidity and burden of treatments for breast cancer are actively being evaluated, including better strategies to identify patients who might omit adjuvant chemotherapy because the marginal benefit is small (39?1). Our study reinforces the need to advance these evaluative strategies to help physicians “first, do no harm.”Author Manuscript Author Manuscript Author Manuscript Author ManuscriptSupplementary MaterialRefer to Web version on PubMed Central for supplementary material.AcknowledgmentsFunding: Grants R01 CA109696 and R01 CA088370 from the National Cancer Institute (NCI) to the University of Michigan. Dr. Jagsi was supported by a Mentored Research Scholar Grant from the American Cancer Society (MRSG-09-145-01). Dr. Katz was supported by an Established Investigator Award from the NCI (K05CA111340). The collection of LA County cancer incidence data used was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the NCI’s Surveillance, Epidemiology and End Results (SEER) Program under contract N01-PC-35139 awarded to the University of Southern California, contract N01-PC-54404 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement 1U58DP00807-01 awarded to the Public Health Institute. The collection of metropolitan.