Employment and insurance outcomes and factors associated with employment among long-term thyroid cancer survivors: a population-based study from the PROFILES registry
Qual Life Res
Employment and insurance outcomes and factors associated with employment among long-term thyroid cancer survivors: a population-based study from the PROFILES registry
S. J. Tamminga 0 1 2 3 4 5
U. Bu¨ ltmann 0 1 2 3 4 5
O. Husson 0 1 2 3 4 5
J. L. P. Kuijpens 0 1 2 3 4 5
M. H. W. Frings-Dresen 0 1 2 3 4 5
A. G. E. M. de Boer 0 1 2 3 4 5
S. J. Tamminga 0 1 2 3 4 5
0 Coronel Institute of Occupational Health, Academic Medical Centre, University of Amsterdam , Amsterdam , The Netherlands
1 O. Husson-Formally at Center of Research on Psychology in Somatic Diseases, Tilburg University , Tilburg , The Netherlands
2 VGZ Health Insurance Company , Eindhoven , The Netherlands
3 Comprehensive Cancer Center Netherlands South, Eindhoven Cancer Registry , Eindhoven , The Netherlands
4 Department of Medical Psychology, Radboud University Medical Center , Nijmegen , The Netherlands
5 Department of Health Sciences, Community and Occupational Medicine, University Medical Center Groningen, University of Groningen , Groningen , The Netherlands
Purpose To obtain insight into employment and insurance outcomes of thyroid cancer survivors and to examine the association between not having employment and other factors including quality of life. Methods In this cross-sectional population-based study, long-term thyroid cancer survivors from the Netherlands participated. Clinical data were collected from the cancer registry. Information on employment, insurance, sociodemographic characteristics, long-term side effects, and quality of life was collected with questionnaires. Results Of the 223 cancer survivors (response rate 87 %), 71 % were employed. Of the cancer survivors who tried to obtain insurance, 6 % reported problems with obtaining health care insurance, 62 % with life insurance, and 16 % with a mortgage. In a multivariate logistic regression analysis, higher age (OR 1.07, CI 1.02-1.11), higher level of fatigue (OR 1.07, CI 1.01-1.14), and lower educational level (OR 3.22, CI 1.46-7.09) were associated with not having employment. Employment was associated with higher quality of life. Conclusions Many thyroid cancer survivors face problems when obtaining a life insurance, and older, fatigued, and lower educated thyroid cancer survivors may be at risk for not having employment.
Thyroid cancer; Cancer survivorship; Employment; Population-based study
Cancer is no longer considered a death sentence as many of
the patients diagnosed with cancer survive due to improved
screening, diagnosis, and cancer treatment [
particularly applies for differentiated (papillary and follicular)
thyroid cancer survivors, as the 5-year survival rate exceeds
90 % [
] and the 10-year survival rate exceeds 70 %. This
high survival rate implicates that survivorship care becomes
highly relevant and important for this patient group [
For all cancer survivors within the working age, one
aspect of survivorship includes the ability to remain in or
return to work. Unfortunately, it is known from other
cancer types that many cancer survivors experience
unwanted changes in their employment status such as
working part-time due to cancer [
] and financial status [
or experience problems upon their return to work [
These adverse work outcomes arise due to various factors
such as long-term fatigue, unsupportive work environment,
and physically heavy work [
It is unfortunate that cancer survivors experience such
adverse work outcomes because return to work is
considered a key aspect of survivorship. Most cancer survivors
attribute great meaning to work: it contributes to social
], higher self-esteem [
], a better financial
], and it contributes to better quality of life [
For those reasons, it is important to prevent adverse work
outcomes for all cancer survivors.
Besides adverse work outcomes, it is known from other
cancer types that cancer survivors experience
socio-economic consequences such as problems with obtaining life
and health care insurance [
] or an increase in life or
health care insurance premiums [
]. These insurance
problems may have a negative impact on cancer survivors’
financial situation and quality of life [
]. Therefore, it is
important to draw attention not only to the adverse work
outcomes of cancer survivors but also to these other
socioeconomic consequences of a cancer diagnosis.
Studies among thyroid cancer survivorship including
employment and insurance issues are scarce [
most work-related survivorship studies focused primarily
on breast cancer survivors [
]. However, it is very relevant
to study the work and insurance outcomes of thyroid cancer
survivors because they are relatively young compared to
other cancer survivors and are therefore more often of
working age and in a stage of life in which they want to
obtain a life insurance and mortgage. Furthermore, they
have a high chance of survival, but suffer from higher
levels of fatigue compared to the general population [
which might limit employment possibilities and obtaining
the necessary insurances.
Therefore, the aims of the present study are: (1) to
examine the consequences of a thyroid cancer diagnosis on
work and insurance outcomes, (2) to study which factors
are associated with these work outcomes, and 3) to study
thyroid cancer survivors with and without paid
employment on quality of life outcomes.
Setting and participants
This study was a cross-sectional population-based study
from the southern parts of the Netherlands. The methods of
this study have been described in detail elsewhere [
Cancer survivors diagnosed with papillary, follicular, or
medullary thyroid cancer between 1990 and 2008 and
registered in the Eindhoven Cancer Registry (ECR) were
eligible for participation. Patients with anaplastic thyroid
cancer were excluded because of the very poor prognosis
of this type of cancer. Cancer survivors were further
excluded for this current study if they: (1) were too ill to
participate (n = 31), had unverifiable addresses (n = 70),
died prior to the study (n = 6), were not allowed to be
contacted as decided by their hospital (n = 86), or were not
aged 18–65 years (n = 118). This resulted in a final study
population of 257 cancer survivors. The certified Medical
Ethical Committee of the Maxima Medical Centre in
Veldhoven judged that ethical approval was not required
for this study.
Data collection was performed within PROFILES (Patient
Reported Outcomes Following Initial treatment and Long
term Evaluation of Survivorship) [
] and started in
November 2010. Eligible cancer survivors were informed
about the study via a letter from their (former) treating
physician, including an informational leaflet containing a
link to a secured website, a password, and a login. Cancer
survivors who were willing to participate could provide
informed consent and fill in the questionnaire via the
secured website or by a paper version.
Two types of measures were used. Clinical and
socio-demographic characteristics available through the ECR were
linked with self-reported questionnaire data.
Characteristics collected by means of the ECR included age at
diagnosis, gender, type of thyroid cancer (papillary, follicular,
or medullary), stage at diagnosis according to the tumour–
node–metastasis (TNM) clinical classification [
primary cancer treatment. The questionnaire included the
following work-related characteristics: employment status,
reason for not being employed, number and type of work
changes due to cancer, actual number of hours working,
financial difficulties due to cancer, and a question to assess
whether patients were concerned about not being able to
work if they would become ill again. The questionnaire
further included questions on problems with obtaining
health care insurance, life insurance, and mortgage and
questions on comorbidity, marital status, years since
diagnosis, age at time of survey, educational level,
depression, anxiety, thyroid-specific health-related quality
of life, overall quality of life, global health, and fatigue.
Financial difficulties were measured with a single item
from the EORTC health-related quality of life
questionnaire and dichotomised into ‘not at all’ and ‘a little’ and
compared to ‘quite a bit’ and ‘very much’ [
Comorbidity was assessed with the self-administered Comorbidity
Questionnaire, containing a list of 14 comorbidities
(present/not present), and patients were asked whether they
perceived each comorbidity as a hindrance in their daily
activities at the time of the survey (yes/no) [
Anxiety and depression were assessed with the Hospital
Anxiety and Depression Scale (HADS) [
]. The scale
contains 14 items consisting of HADS-A (anxiety, 7
questions) and HADS-D (depression, 7 questions)
]. All items are rated on a four-point scale (0–3)
with higher scores indicating higher levels of depression
and anxiety. Thyroid-specific health-related quality of life
was assessed with the reliable and valid THYCA-QoL [
The THYCA-QoL consists of 24 items (1–4) with lower
scores indicating less symptoms and higher quality of life
and has seven scales: neuromuscular, voice, concentration,
sympathetic, throat/mouth, psychological, and sensory
problems. Fatigue was assessed with the validated and
reliable Fatigue Assessment Scale (FAS) for use among
cancer survivors [
], which contains 10 items which are
scored on a 5-point scale with higher scores indicating
more fatigue. Global health perception was measured with
a single item of the Short Form-12 [
] ranging from ‘poor
health’ to ‘excellent health’. Overall quality of life was
measured on a 7-point Likert scale [
], with higher scores
indicating a better quality of life.
Statistical analyses were done using SPSS version 20.0. We
considered a p value of B0.05 statistically significant.
Socio-demographic, clinical, employment, and insurance
outcomes were reported using descriptive statistics.
Univariate logistic regression analyses with age, gender,
educational level (high (reference) versus medium/low),
marital status (married or living with partner (reference)
versus no partner), cancer diagnosis (papillary (reference)
versus follicular), cancer treatment (surgery only
(reference) versus surgery and additional treatment), cancer
stage [1 and 2 (reference) versus 3 and 4], fatigue, anxiety,
depression, and comorbidity (no comorbidity (reference)
versus one or more comorbidities) were conducted to
identify associations with not having employment. We
choose these factors as these were found to be associated
with employment among other groups of cancer survivors
]. Factors that were statistically significant were
entered in a multivariate logistic regression analysis unless
the correlation coefficient between two variables was C0.7
to prevent multicollinearity. The model was built in three
blocks: (1) socio-demographic variables, (2) clinical
variables, (3) long-term side effects variables, and (4)
demographic, clinical, and long-term side effects variables. Odd
ratios (ORs) will be reported with 95 % confidence
Differences between thyroid cancer survivors with and
without paid employment on the thyroid-specific
healthrelated quality of life scales, global health, and quality of
life were analysed using Student’s t test when variables are
normally distributed or the Mann–Whitney U test
otherwise. To test whether variables were normally distributed,
we used Kolmogorov–Smirnov test of normality (cut-off
p value B0.05).
Of the 257 cancer survivors, 223 returned the questionnaire
(response rate 87 %). Table 1 shows the sample
characteristics. The mean age was 49.5 (standard
deviation ± 9.8) years, and 22 % were male. Almost
threequarter (71 %) of the patients were diagnosed with stage 1
disease. Surgery followed by 131I therapy (70 %) was the
most common treatment. The median time since diagnosis
was 9.0 years.
Employment outcomes and work changes
Seventy-one per cent of the thyroid cancer survivors were
employed (Table 2). Reasons for not being employed were
disability (33 %), early retirement (e.g. due to
reconstitution) (14 %), no job (6 %), or other (e.g. voluntary
unemployed) (46 %). One-third (33 %) reported work
changes due to cancer, i.e. working less hours (16 %),
being disabled (9 %), being fired (5 %), stopped working
(4 %), re-educated (3 %), early pension (1 %), or working
more hours (1 %) as work change due to cancer.
Of those thyroid cancer survivors who tried to obtain an
insurance after their cancer diagnosis, 62 % (n = 37)
reported obtaining problems with a life insurance, followed
by problems with obtaining a mortgage (16 %; n = 12) or
health care insurance (6 %; n = 7) (Fig. 1). Of the 62 % of
patients who reported problems with obtaining life
insurance, 37 % got accepted but had to pay an additional fee,
34 % got rejected, 23 % got accepted eventually, and 6 %
got accepted by another company. Of the 16 % of the
patients who reported problems with obtaining mortgage,
54 % got rejected, 23 % got accepted eventually, 15 % got
accepted by another company, and 8 % got accepted but pay
an additional fee. Of the 6 % of the patients who reported
problems with obtaining health care insurance, 56 % got
accepted eventually, 33 % got accepted but pay an additional
fee, and 11 % got accepted by another company.
Factors associated with not having employment
Factors associated with not having employment in the
univariate logistic regression analysis were: higher age at
time of survey [odds ratio (OR) 1.09, (95 % confidence
SD standard deviation. Education: high (pre-university education, high vocational education, university),
intermediate (lower general secondary education or vocational education), low (no or primary school).
Stage: tumour–node–metastasis clinical classification. FAS Fatigue Assessment Scale. HADS Hospital
Anxiety and Depression Scale. Higher score means higher fatigue, anxiety, and depression. Numbers do not
always add up to 223 due to missing values. Percentages do not always add up due to rounding
interval (CI) 1.05–1.13), p \ 0.01], lower educational level
[OR 4.67, (95 % CI 2.35–9.29), p \ 0.01], unfavourable
cancer stage [OR 2.23, (95 % CI 1.06–4.72), p = 0.04],
higher level of fatigue [OR 1.08, (95 % CI 1.03–1.12),
p = 0.001], higher level of anxiety [OR 1.08, (95 % CI
1.01–1.17), p = 0.04], higher level of depression [OR 1.13,
(95 % CI 1.03–1.240, p = 0.01], and reporting one or more
comorbidities [OR 3.99, (95 % CI 2.15–7.42), p \ 0.01].
Gender, marital status, type of tumour or the treatment
were not related to not having employment.
Multivariate logistic regression analysis of model 1,
consisting of socio-demographic variables, showed that
higher age at time of survey [OR 1.07, (95 % CI
1.03–1.11), p \ 0.001] and lower educational level were
associated with higher chance of not having employment
[OR 3.67 (95 % CI 1.78–7.58), p \ 0.01]. Multivariate
logistic regression analysis of model 2, including clinical
variables showed that reporting one or more comorbidities
was associated with a higher chance of not having
employment [OR 3.58 (95 % 1.90–6.71), p \ 0.01].
Multivariate logistic regression analysis of variables of model
3, including long-term side effect variables, showed that a
higher level of fatigue was associated with a higher chance
of not having employment [OR 1.07, CI (95 % CI
1.01–1.12), p = 0.02] (Table 3).
In the final multivariate logistic regression model
consisting of a combination of model 1, 2 and 3, higher age
[OR 1.07, (95 % CI 1.02–1.11), p \ 0.01], a higher level
of fatigue [OR 1.07, CI (95 % CI 1.01–1.14), p = 0.02],
and a lower educational level [OR 3.22, (95 % CI
1.46–7.09), p B0.01] remained associated with not having
employment (Table 3).
Quality of life and employment
Employed cancer survivors scored overall better on the
thyroid cancer-specific HRQoL scales as well as on global
health and overall quality of life (Table 4). Employed
SD standard deviation. Numbers do not always add up to 223 due to missing values. Percentages do not
always add up due to rounding
a The total number of type of work changes is higher compared to the number of change in employment
status due to cancer since some participants reported more than one type of work change due to cancer
question whether he/she experienced problems with obtaining a
health care insurance, but did fill in the question what kind of problem
thyroid cancer survivors scored significantly better
compared to thyroid cancer survivors without employment on
neuromuscular problems (20.1. ± 19.5 vs 32.1 ± 25.9,
p \ 0.01), voice problems (7.7 ± 15.2 vs 16.1 ± 24.9,
p = 0.02), and on overall quality of life (69.4 ± 16.5 vs
61.7 ± 20.4, p \ 0.01).
Model 1 OR (95 % CI)
Model 2 OR (95 % CI)
Model 3 OR (95 % CI)
Model 1 ? 2 ? 3 OR (95 % CI)
Bold values indicate p \ 0.05
Employed versus not having employment
Educational level: high (reference) versus medium/low. Cancer stage: 1 and 2 (reference) versus 3 and 4. Comorbidity: no comorbidity
(references) versus one or more comorbidities
OR odds ratio, 95 % CI 95 % confidence interval, FAS Fatigue Assessment Scale, HADS Hospital Anxiety and Depression Scale
* p \ 0.05; ** p \ 0.01
Neuromuscular problems (mean ± SD)
Voice problems (mean ± SD)
Concentration problems (mean ± SD)
Sympathetic problems (mean ± SD)
Throat problems (mean ± SD)
Psychological problems (mean ± SD)
Sensory problems (mean ± SD)
Overall quality of life (mean ± SD)
The purpose of our study was: (1) to obtain insight into
employment and insurance outcomes of thyroid cancer
survivors, (2) to examine factors associated with not having
employment, and (3) to study thyroid cancer survivors with
and without paid employment on quality of life outcomes.
Our finding that many thyroid cancer survivors face
problems when obtaining a life insurance and that older, fatigued,
and lower educated thyroid cancer survivors may be at risk
for not being employed, which may both negatively impact
cancer survivors’ financial situation and quality of life.
Strengths and limitations
Strengths of our study include the use of a
populationbased sample with a high response rate, which implies
that our findings can be generalised to thyroid cancer
survivors at large. Furthermore, most studies on cancer
and work considered the return to work of employed
cancer survivors at diagnosis only, excluding unemployed
cancer patients, who just might be at a greater risk of
adverse outcomes. Our study also had some limitations.
First, the cross-sectional design does not allow us to
draw conclusions on the causal effect of the association.
However, it might be possible that the identified factors
might lead to a higher risk of not being employed rather
than being a consequence of not being employed. This
assumption is based on the notion that the relationship
between fatigue as a cause of thyroid cancer treatment
has been well established [
] and the nature of the other
factors included in our model (e.g. age). This should
therefore be studied with a longitudinal design in future
Second, we were not able to include work-related factors
such as physical work and type of occupation (e.g. Ref. [
that have been found to be associated with employment in
other cancer types. For that reason, our model might not be
optimal in explaining all factors that are associated with
employment among thyroid cancer survivors. Work-related
factors should therefore be included in future studies. Finally,
we did not collect data on the year in which a thyroid cancer
survivor experienced problems with obtaining a health care or
life insurance, or a mortgage. In recent years, many changes in
the rules and regulations of insurance companies have taken
place. These regulations largely influence the extent to which
problems are experienced. We are therefore not able to draw
conclusions of who are at the highest risk of experiencing
problems with obtaining these insurances and mortgage and
recommend including this aspect in future studies.
Interpretation of findings
In contrast to other cancer types, long-term thyroid cancer
survivors have comparable employment rates to the general
]. An explanation for this finding might be that
most thyroid cancer survivors are relatively young and have
better long-term physical and psychological outcomes due to
less aggressive forms of cancer treatment (no external
radiotherapy or chemotherapy). For instance, long-term thyroid
cancer survivors ([10 years) do not have elevated levels of
fatigue compared to norm values, in contrast to short-term
thyroid cancer survivors (\10 years) [
] and to both
shortterm and long-term survivors of non-Hodgkin’s lymphoma
Thirty-three per cent of the cancer survivors reported
work changes due to cancer, which is higher compared to a
study among colorectal and haematological cancer
survivors (28 % experienced work changes) [
] and lower
compared to a study among prostate, endometrial, and
haematological cancer survivors [
]. This latter finding
could be explained by the fact that we excluded all patients
aged C65 years, excluding the work change of retirement.
Higher age, lower educational level, and a higher level
of fatigue were associated with not having employment
irrespective of clinical factors. This finding is consistent
with the literature of other cancer types (e.g. [
instance, a Danish study among haematological cancer
survivors found that higher age and lower educational level
was associated with not returning to work [
Danish study among breast cancer survivors found that
lower educational level was associated with unemployment
]. In contrast to other cancer types, we did not find that
cancer treatment was associated with employment (e.g.
]). This finding could also be explained by the less
aggressive forms of cancer treatment of thyroid cancer
We found that only a small proportion of the cancer
survivors had problems with obtaining a health care insurance
or mortgage, which is consistent with a study among both
colorectal cancer survivors and haematological cancer
]. This finding can be explained by the Dutch
health insurance system, which forbids by law risk selection
for the basic health insurance scheme based on someone’s
medical history. In contrast to the study among both
colorectal and haematological cancer survivors, we found that
much more cancer survivors had problems with obtaining a
life insurance (62 vs 20 %) [
]. Additionally, especially for
employed thyroid cancer survivors the effect of not being
able to obtain a life insurance might be more prominent as the
security for their income is more depending on this life
insurance compared to unemployed cancer survivors.
Our study showed that employed thyroid cancer
survivors report better global health and overall quality of life
compared to thyroid cancer survivors without a paid job,
which is consistent with the literature [
]. Our finding that
thyroid cancer survivors without employment experience
more problems on neuromuscular and voice level
compared to employed thyroid cancer survivors indicates that a
certain level of physical functioning is needed to be able to
work. Surprisingly, we did not find differences between
employed thyroid cancer survivors and thyroid cancer
survivors without employment on concentration problems,
while concentration problems have often been reported as a
problem for returning to work in other cancer types [
Recommendations for further research and practice
As the employment rate of thyroid cancer survivors is
comparable to the general population, interventions to
enhance employment for all thyroid cancer survivors seem
not needed. However, as in other cancers it is important to
reach thyroid cancer survivors who are older, have a lower
educational level, and have a higher level of fatigue with an
appropriate intervention that will reduce their risk of not
having employment. For instance, such an intervention
could consist of cognitive behaviour therapy, as it has been
proven effective in reducing fatigue among cancer
]. However, its effect on employment is
unknown. Furthermore, health care professionals should be
aware of the socio-economic implications of a thyroid
cancer diagnosis: in particularly which patients have a
higher risk of not having employment and that survivors
may face problems with obtaining a life insurance. When
health care professionals are aware of these implications,
they will be able to point out problems and refer patients to
appropriate interventions and authorities.
A recommendation for further research is to include
workrelated parameters such as type of work or previous
unemployment spells in the study. In this way, a model that explains
employment would most likely be more complete and could
provide further information on which patients are at the
highest risk and which parameters should be addressed in an
intervention. In addition, on the traditional work outcome,
employment rate, thyroid cancer survivors have comparable
outcomes compared to the general population. However, as
unemployment often is considered the tip of the iceberg of
possible adverse work outcomes, it would be very relevant to
study subtle work outcomes such as quality of working life,
work functioning, and work-home balance in the future.
In addition, a recommendation for further research is to
use a longitudinal design to examine whether the earlier
identified factors also have a causal relation with
employment and to obtain insight in labour market transitions. The
first is important for the development of interventions; the
latter for a better understanding of employment, as being
employed is not a fixed event, but many transitions may
occur in the working life course.
Acknowledgments The data collection of this study was funded by
the Comprehensive Cancer Centre South, Eindhoven, The
Netherlands, and a Medium Investment Grant from the Netherlands
Organisation for Scientific Research (NWO#480-08-009). This work
was supported by the Work Disability Prevention Canadian Institutes
of Health Research (CIHR) Strategic Training Program Grant (FRN:
53909). This work was supported by COST Action IS1211
Compliance with ethical standards
Conflict of interest SJ Tamminga declares that she has no conflict
of interest. U Bu¨ltmann declares that she has no conflict of interest.
O Husson declares that she has no conflict of interest. JLP Kuijpens
declares that he has no conflict of interest. MHW Frings-Dresen
declares that she has no conflict of interest. AGEM de Boer declares
that she has no conflict of interest.
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
Informed consent Informed consent was obtained from all
individual participants included in the study.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
1. Ganz , P. A. , Desmond , K. A. , Leedham , B. , Rowland , J. H. , Meyerowitz , B. E. , & Belin , T. R. ( 2002 ). Quality of life in longterm, disease-free survivors of breast cancer: A follow-up study . Journal of the National Cancer Institute , 94 ( 1 ), 39 - 49 .
2. van der Zwan , J. M. , Mallone , S., van Dijk, B. , Bielska-Lasota , M. , Otter , R. , Foschi , R. , et al. ( 2012 ). Carcinoma of endocrine organs: Results of the RARECARE project . European Journal of Cancer , 48 ( 13 ), 1923 - 1931 . doi: 10 .1016/j.ejca. 2012 . 01 .029.
3. Hewitt , M. , Greenfield , S. , & Stovall , E. ( 2006 ). From cancer patient to cancer survivor: Lost in transition . Washington: National Academies Press.
4. Mols , F. , Thong , M. S. , Vreugdenhil , G. , & van de Poll-Franse , L. V. ( 2009 ). Long-term cancer survivors experience work changes after diagnosis: Results of a population-based study . Psychooncology , 18 ( 12 ), 1252 - 1260 . doi: 10 .1002/pon.1522.
5. Syse , A. , Tretli , S. , & Kravdal , O. ( 2008 ). Cancer's impact on employment and earnings-A population-based study from Norway . Journal of Cancer Survivorship , 2 ( 3 ), 149 - 158 . doi: 10 . 1007/s11764-008-0053-2.
6. Tamminga , S. J., de Boer , A. G. , Verbeek , J. H. , & Frings-Dresen , M. H. W. ( 2011 ). Breast cancer survivors' views of factors that influence the return-to-work process-A qualitative study . Scandinavian Journal of Work , Environment and Health,. doi: 10 . 5271/sjweh.3199.
7. Tiedtke , C. , Dierckx de Casterle , B. , Donceel , P. , & de Rijk , A. ( 2014 ). Workplace support after breast cancer treatment: Recognition of vulnerability . Disability and Rehabilitation ,. doi:10.3109/09638288 . 2014 . 982830 .
8. van Muijen, P. , Weevers , N. L. , Snels , I. A. , Duijts , S. F. , Bruinvels , D. J. , Schellart , A. J. , & Van der Beek , A. J. ( 2013 ). Predictors of return to work and employment in cancer survivors: A systematic review . European Journal of Cancer Care , 22 ( 2 ), 144 - 160 . doi: 10 .1111/ecc.12033.
9. Feuerstein , M. , Todd , B. L. , Moskowitz , M. C. , Bruns , G. L. , Stoler , M. R. , Nassif , T. , & Yu , X. ( 2010 ). Work in cancer survivors: A model for practice and research . Journal of Cancer Survivorship , 4 ( 4 ), 415 - 437 . doi: 10 .1007/s11764-010-0154-6.
10. Tiedtke , C. , de Rijk , A. , Dierckx de Casterle, B. , Christiaens , M. R. , & Donceel , P. ( 2010 ). Experiences and concerns about 'returning to work' for women breast cancer survivors: A literature review . Psychooncology , 19 ( 7 ), 677 - 683 . doi: 10 .1002/pon.1633.
11. Mols , F. , Vingerhoets , A. J. , Coebergh , J. W. , & van de PollFranse, L. V. ( 2005 ). Quality of life among long-term breast cancer survivors: A systematic review . European Journal of Cancer , 41 ( 17 ), 2613 - 2619 . doi: 10 .1016/j.ejca. 2005 . 05 .017.
12. Mols , F. , Thong , M. S. , Vissers , P. , Nijsten , T. , & van de PollFranse, L. V. ( 2012 ). Socio-economic implications of cancer survivorship: Results from the PROFILES registry . European Journal of Cancer , 48 ( 13 ), 2037 - 2042 . doi: 10 .1016/j.ejca. 2011 . 11 .030.
13. Meneses , K. , Azuero , A. , Hassey , L. , McNees , P. , & Pisu , M. ( 2012 ). Does economic burden influence quality of life in breast cancer survivors? Gynecologic Oncology , 124 ( 3 ), 437 - 443 . doi: 10 .1016/j.ygyno. 2011 . 11 .038.
14. Husson , O. ( 2013 ). Information provision and patient reported outcomes in cancer survivors: With a special focus on thyroid cancer . Tilburg: Tilburg University.
15. Husson , O. , Nieuwlaat , W. A. , Oranje , W. A. , Haak , H. R., van de Poll-Franse, L. V. , & Mols , F. ( 2013 ). Fatigue among short- and long-term thyroid cancer survivors: Results from the populationbased PROFILES registry . Thyroid , 23 ( 10 ), 1247 - 1255 . doi: 10 . 1089/thy. 2013 . 0015 .
16. van de Poll-Franse , L. V. , Horevoorts , N., van Eenbergen , M. , Denollet , J. , Roukema , J. A. , Aaronson , N. K. , et al. ( 2011 ). The Patient Reported Outcomes Following Initial treatment and Long term Evaluation of Survivorship registry: Scope, rationale and design of an infrastructure for the study of physical and psychosocial outcomes in cancer survivorship cohorts . European Journal of Cancer , 47 ( 14 ), 2188 - 2194 . doi: 10 .1016/j.ejca. 2011 . 04 .034.
17. Sobin , L. H. , Wittekind , C. ( 2002 ). TNM classification of malignant tumors (6th ed .). New Jersey: Wiley.
18. Aaronson , N. K. , Ahmedzai , S. , Bergman , B. , Bullinger , M. , Cull , A. , Duez , N. J. , et al. ( 1993 ). The European Organization for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology . Journal of the National Cancer Institute , 85 ( 5 ), 365 - 376 .
19. Sangha , O. , Stucki , G. , Liang , M. H. , Fossel , A. H. , & Katz , J. N. ( 2003 ). The Self-Administered Comorbidity Questionnaire: A new method to assess comorbidity for clinical and health services research . Arthritis and Rheumatism , 49 ( 2 ), 156 - 163 . doi: 10 .1002/ art.10993.
20. Zigmond , A. S. , & Snaith , R. P. ( 1983 ). The hospital anxiety and depression scale . Acta Psychiatrica Scandinavian , 67 ( 6 ), 361 - 370 .
21. Husson , O. , Haak , H. R. , Mols , F. , Nieuwenhuijzen , G. A. , Nieuwlaat , W. A. , Reemst , P. H. , et al. ( 2013 ). Development of a disease-specific health-related quality of life questionnaire (THYCA-QoL) for thyroid cancer survivors . Acta Oncologica , 52 ( 2 ), 447 - 454 . doi: 10 .3109/0284186X. 2012 . 718445 .
22. Michielsen , H. J. , De Vries , J. , & Van Heck, G. L. ( 2003 ). Psychometric qualities of a brief self-rated fatigue measure: The Fatigue Assessment Scale . Journal of Psychosomatic Research , 54 ( 4 ), 345 - 352 .
23. Aaronson , N. K. , Muller , M. , Cohen , P. D. , Essink-Bot , M. L. , Fekkes , M. , Sanderman , R. , et al. ( 1998 ). Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations . Journal of Clinical Epidemiology , 51 ( 11 ), 1055 - 1068 . doi: 10 .1016/S0895- 4356 ( 98 ) 00097 - 3 .
24. Statistics Netherlands. ( 2011 ). In Dutch: Central bureau voor de statistiek CBS. www.cbs.nl
25. Oerlemans , S. , Mols , F. , Issa , D. E. , Pruijt , J. H. , Peters , W. G. , Lybeert , M. , et al. ( 2013 ). A high level of fatigue among longterm survivors of non-Hodgkin's lymphoma: Results from the longitudinal population-based PROFILES registry in the south of the Netherlands . Haematologica, 98 ( 3 ), 479 - 486 . doi: 10 .3324/ haematol. 2012 . 064907 .
26. Mols , F. , Thong , M. S. , Vreugdenhil , G. , & van de Poll-Franse , L. V. ( 2009 ). Long-term cancer survivors experience work changes after diagnosis: Results of a population-based study . Psycho-oncology , 18 ( 12 ), 1252 - 1260 . doi: 10 .1002/pon.1522.
27. Horsboel , T. A. , Nielsen , C. V. , Nielsen , B. , Jensen , C. , Andersen , N. T. , & de Thurah , A. ( 2013 ). Type of hematological malignancy is crucial for the return to work prognosis: A registerbased cohort study . Journal of Cancer Survivorship , 7 ( 4 ), 614 - 623 . doi: 10 .1007/s11764-013-0300-z.
28. Carlsen , K. , Ewertz , M. , Dalton , S. O. , Badsberg , J. H. , & Osler , M. ( 2014 ). Unemployment among breast cancer survivors . Scandinavian Journal of Public Health, doi:10 .1177/ 1403494813520354.
29. Munir , F. , Burrows , J. , Yarker , J. , Kalawsky , K. , & Bains , M. ( 2010 ). Women's perceptions of chemotherapy-induced cognitive side affects on work ability: A focus group study . Journal of Clinical Nursing , 19 ( 9 - 10 ), 1362 - 1370 . doi: 10 .1111/j.1365- 2702 . 2009 . 03006 .x.
30. Gielissen , M. F. , Verhagen , S. , Witjes , F. , & Bleijenberg , G. ( 2006 ). Effects of cognitive behavior therapy in severely fatigued disease-free cancer patients compared with patients waiting for cognitive behavior therapy: A randomized controlled trial . Journal of Clinical Oncology , 24 ( 30 ), 4882 - 4887 . doi: 10 .1200/ JCO. 2006 . 06 .8270.