Trends in Cancer and Work in Japan

The size of the labor force in Japan was 81.73 million in 2010, but it is expected to fall by almost 50% in the next 50 years [1].Consequently, Japan is expected to become a society where women, seniors, and foreigners must all work [1].

As it is common in developed countries, the number of cancer survivors within the working-age population has increased, and the probability of having employees with cancer is increasing [2-4].

There are four possible reasons for this. Firstly, the number of employees who are more than 60 years old has been increasing [1]. In particular, there are concerns about cancer morbidity among employees in their 60s, who are working as non-regular employees following their retirement at the age of 60. Secondly, more women are working in Japan [1]. According to national statistics, the percentage of women in the labor force has increased since the 1990s, and the number of dual-income households now greatly exceeds the number of single-income households [1]. Thirdly, in Japan the prevalence of some cancers has risen, and the age at onset of some cancers has changed. Specifically, there has been a significant increase in the prevalence of breast cancer, and the age at onset of cervical cancer has become younger [5, 6]. Fourthly, thanks to advances in medical treatment, such as the reduced burden placed on the body by endoscopic treatment and the increased efficacy of chemotherapy and radiotherapy, the prognosis of cancer patients has improved, and more are able to return to work (RTW). Furthermore, it is expected that the number of cancer patients who are able to RTW will continue to rise [7].

Guidelines aimed at improving the balance between treatment and occupational requirements in workplaces were issued by the Japanese government in February 2016 [8]. In addition, the Cancer Control Act was amended in December 2016 to require companies to provide support for the RTW of cancer survivors.

Work with Cancer

Cancer patients exhibit various symptoms and side effects caused by cancer treatment, but medical professionals should pay particular attention to “invisible symptoms”, such as cancerrelated fatigue (CrF), cancer pain, mental disorders, and cognitive impairment [9]. The symptom that represents the biggest obstacle to cancer survivors returning to work is CrF [10]. In particular, bone marrow transplants, high-dose anticancer drugs, and anticancer drug treatments that are administered at least once a week are likely to cause CrF [10]. Chemotherapy reduces the quality of life of cancer survivors and produces various symptoms, such as general malaise, psychological distress, and mental disorders [10]. Patients with early stage cancer who are treated using endoscopic methods alone might only suffer minor CrF and might be able to retain sufficient physical strength to allow them to work. However, marked CrF is often seen in patients that undergo laparotomy or high-dose anticancer drug therapy [10]. The restoration and maintenance of sufficient physical strength for employment is the key to allowing cancer survivors to RTW in a sustainable manner.

Cancer patients often suffer from mental disorders and psychological distress for a long time. About 30 to 50% of cancer patients have reported experiencing sleep disorders (especially midsleep awakening), and the maintenance of mental health is also extremely important [9].

Practice of RTW for Cancer Survivors

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As shown in the above figure, being able to live your daily life (component 1, level 1: There are no symptoms that cause serious problems in daily life) is only one of the necessary conditions for a successful RTW. In order for a cancer survivor to successfully RTW, it is necessary that components 2 (motivation to RTW) and 3 (employment abilities; i.e., whether employees who are trying to RTW can work sustainably. For example, do the following statements apply? “I can start work on time 5 days a week", "I can do all the work that is needed", and "I can work with others in the workplace") are also addressed. Finally, it is necessary to include component 4 (RTW support in the workplace). Each of these components must be present for a successful RTW. If components 1 and 2 are satisfied, a doctor can submit a document to the employer stating that “this employee can work”. However, satisfying components 1 and 2 does not necessarily mean that the employee has the ability to withstand work. In Japan, misunderstandings and suffering often result from differences between the perspectives of occupational physicians (OP) and clinical physicians (CP). In addition, a CP's decision to support RTW can be complicated by the gap between levels 1 and 2 in the figure.

When an employee with cancer tells their company that "It is likely I will return to work from my current sick leave," it is important to encourage the employee to submit a document from a CP that states “this employee can work”. If an accident occurs during their RTW and the employee did not submit such a document, the company could be charged with breaching Japanese law, which requires companies to protect the health and safety of their workers. To the greatest extent possible, it is desirable for companies to carry out RTW interviews (by interviewing the RTW employee, the OP, the employee’s superior, and a personnel officer) and to have the OP submit a letter concerning their RTW.

Workplaces are not hospitals or rehabilitation facilities. Companies are organizations with complex interests, and their primary commitment is to contribute to society by increasing productivity and making profits. From the company’s perspective, it is necessary to distinguish "things that can be considered" from "difficulties to consider" in order to support the RTW of cancer survivors. If the conditions surrounding an employee’s RTW are clear, a company can more easily reach a decision on whether the employee can RTW. Therefore, it is desirable to clarify specific details, such as whether the employee will return full-time or if the employee can no longer perform their old duties can they perform other duties.

It is difficult to strike a balance between the employee’s needs due to their illness and the requirements of the workplace. To do this, it is necessary to separate “obstacles to employment” from sickness. “Obstacles to employment” are objective events that are a hindrance to business activity, such as leaving the workplace to go to the toilet more than 10 times each day, or requiring unexpected leave of 3 days or more every month. In a typical company, some form of documentation or correspondence from a medical professional is necessary for such events. On the other hand, “sickness” refers to diseases or symptoms, such as diarrhea, poor appetite, or a pale complexion. As a company, the management must consider and respond to medical issues on a case-by-case basis, ask for opinions about sickness from CP and OP (i.e., “throw the ball" to doctors), and receive opinions from medical professionals (CP or OP)in the form of certificates (have the “ball” returned). It is essential to distinguish between "obstacles to employment" and sickness. While medical certificates from hospitals often only contain information concerning sickness, it is very important for OP to “translate” such information so that employers have clear information about the "obstacles to employment” caused by the patient’s condition. For example, in a case in which the medical certificate states that "Dx: rectal cancer; diarrhea, malaise, etc. are recognized, but it is possible to work under certain consideration", the company might be confused as to what should be taken into consideration when making decisions regarding the employee’s RTW. Therefore, the OP should "translate" the certificate into concrete information, such as, "may leave for the toilet 5 to 10 times a day, might need to work in a sitting position or perform sub-tasks".

In addition, it is possible to prevent confusion and ensure that cancer survivors are given more reasonable consideration by encouraging collaboration among three types of company staff, the employee’s managers; the general office personnel affairs officer; and medical professionals, such as CP and OP. It is important for these three parties (managerial staff, general affairs personnel, and medical professionals) to cooperate closely, e.g., to engage in information sharing, etc.

The two pillars that are most effective at preventing cancer survivors leaving work are an adequate duration of sickness absence and a gradual RTW system (e.g., a system that lasts for 1 year after the employee’s RTW). On average, in Japan the maximum duration of sickness absence in small and medium sized enterprises is about 3 to 12 months; therefore, it would be beneficial if the duration of such sickness absence was prolonged to at least 12 months.

In order to prevent cancer survivors from resigning due to their disease, it is important for companies and medical professionals to continuously support their employment.