The Wall Street Journal
By ANJALI ATHAVALEY
December 11, 2007; Page B9

Andrew Flaton survived a brain tumor as a child, but he still suffers from the effects of his cancer treatments. One of his most challenging tasks: holding down a job.

Andrew Flaton was first diagnosed with a brain tumor at 18 months old.
He was left almost entirely deaf after undergoing chemotherapy. He can't work more than four hours a day without feeling exhausted, and he often suffers from panic attacks, which he struggles to keep under control. The 25-year-old Oakville, Mo., resident earns less than $700 a month and lives with his grandparents, and the longest period he has spent in one job -- doing part-time filing work for an anesthesiologist -- is two years.

Before landing his current job as a retail clerk, Mr. Flaton was unemployed for a year. He filled out close to two dozen job applications without receiving any calls for an interview. "It was very difficult to find an employer who was accepting of what I could and could not do," he says.

As Mr. Flaton's struggle illustrates, the transition into the workplace can be rocky for many childhood-cancer survivors -- especially those who have been treated with high doses of radiation and chemotherapy. The resulting cognitive and physical impairments can make it hard to keep a job. And while workers who contract cancer or a chronic illness as adults carry similar impairments, childhood survivors face the added obstacle of trying to get and keep that all-important first job -- for many people the first chance to get employer-provided health insurance -- and establish a career.

The problem is becoming more acute as a greater number of childhood-cancer survivors enter the work force, thanks to improvements in treatments over the past few decades. For patients age 14 and younger who were diagnosed between 1975 and 1977, 58% survived at least five years, according to the National Cancer Institute. For those diagnosed between 1996 and 2003, the rate jumped to 80%. Though no one tracks the number of survivors in the work force, doctors and agencies who deal with childhood cancer patients say it is increasing.
Survivors of pediatric cancer "are competing with young, enthusiastic, healthy, hard-working people," says Robert Hayashi, co-founder of the Late Effects Clinic at St. Louis Children's Hospital. "They are often at a disadvantage when they are being considered for entry-level positions."

According to a study published in June in the journal Pediatric Blood and Cancer, 5.6% of cancer survivors have never been employed, compared with 1.2% of their siblings.

"We were surprised at the magnitude of the difference," says Debra Friedman, an author of the study and director of the Survivorship Program at the Fred Hutchinson Cancer Research Center in Seattle. The research was based on self-reported employment history in 9,736 childhood-cancer survivors and 3,065 siblings over age 18 between 1994 and 1999.

Survivors' Risks

The risk of having never been employed was highest among survivors of brain tumors and bone cancers, who typically go through the most severe treatments, which include high doses of radiation and sometimes even amputation. But the risk of chronic health problems resulting in employment problems was spread across various types of cancer, says Dr. Friedman, who is also an associate professor of pediatrics at the University of Washington in Seattle. The risk of unemployment was higher if patients were diagnosed at a younger age, presumably because the consequences of treatment are more severe.

Another factor that could affect employment: the psychological impact of being diagnosed with cancer and undergoing treatment. "We see a fair amount of psychiatric illness in our survivors," Dr. Friedman says, such as post-traumatic stress disorder, anxiety and depression.

In many cases, childhood-cancer survivors are protected from employment discrimination by the federal Americans with Disabilities Act. Employers must make accommodations for people who have a disability where there is some kind of workplace barrier that needs to be removed, such as allowing time off for medical treatments or ensuring that workplace buildings are accessible to employees with physical impairments, says Peggy Mastroianni, associate legal counsel at the U.S. Equal Employment Opportunity Commission. But the ADA applies to employers only with 15 or more employees.

Companies can't legally ask a job applicant's medical history, but they may ask questions related to ability. Federal law prohibits employers that offer group health-insurance plans from denying employees coverage based on health status.
Clinics that specialize in treating adult survivors of childhood cancers encourage their patients to find positions at larger employers, which are more likely than small businesses to offer group health plans. "People who are late adolescents have very sparse benefit packages to begin with," says Dr. Hayashi, who is also associate professor of pediatrics at Washington University School of Medicine in St. Louis.

Qualifying for Coverage

Indeed, Mr. Flaton, who currently pays for his own health insurance, has struggled in the past to get coverage through employers. His was let go from his second job -- as a locksmith in St. Louis -- before qualifying for insurance coverage, even though he was able to work a 45-hour week when he was 19. Mr. Flaton suspects it was because his employer, Beishir Lock & Safe Inc., didn't want to give him health benefits. In Missouri, insurance companies are allowed to charge more to smaller employers if someone in the group has a serious health condition. Whenever he inquired about getting the coverage that other full-time workers had, his boss brought up his lack of progress in taking the locksmith exams required of company employees, he says.

Ted Beishir, president of Beishir Lock & Safe, says he doesn't recall the specific reasons Mr. Flaton was terminated but that it wasn't because of health insurance. He says he tells new hires upfront that he doesn't offer health insurance until they have worked at the company for a year.

The range of difficulties that childhood survivors face in adulthood varies, depending on diagnosis and treatment, says Dr. Friedman. Brain-tumor survivors who have gone through cranial radiation and chemotherapy treatments, for instance, may experience developmental and cognitive issues ranging from mild attention-span difficulties to profound learning disabilities.

Survivors of leukemia can be at risk for obesity, diabetes and high blood pressure, which could result in cardiovascular disease, and some chemotherapy drugs used to treat bone cancer may cause heart problems.

Whatever their experience, survivors who have gone through extreme treatments that result in cognitive problems often have difficulty finding a job, and may be afraid "of showing that they have a condition that would limit their work," says Kevin Oeffinger, director of the Program for Adult Survivors of Pediatric Cancer at the Memorial Sloan-Kettering Cancer Center in New York.

Taking Time Off

In some cases, there may be obvious physical characteristics that drive an applicant to voluntarily disclose his medical history, says Dr. Oeffinger.
Jason Cox, a 36-year-old probate-litigation attorney in Houston, has contended four times with recurrence of a cancer diagnosed when he was 14. The rhabdomyosarcoma, a fast-growing malignant tumor, in his right cheek has required at least 15 facial surgeries.

His history of cancer didn't come up four years ago during his job interview at Houston law firm Galligan & Manning, he says. But a year-and-a-half ago, he developed an infection in his cheek. He had to undergo hyperbaric treatment, which is used to promote blood flow in tissue damaged by radiation therapy. He would have to take off half a day for about 30 days, plus extra time for surgery.
"That was when it became something that had the potential to interfere with the amount of work that I could do, so I had to be very clear with them about what was going on," Mr. Cox says. His boss allowed him to take as much time off as he needed.

Mr. Flaton, who is divorced and has joint custody of his daughter, is less fortunate. After losing his locksmith job, he spent time working at his family's business, Flaton Machine Works Inc., where he has had insurance coverage for much of his working life. At 23, he found work at Performance Motors, a local auto-repair shop, while studying for an automotive associate's degree at St. Louis Community College. He "loved cars and was obsessed" with them, he says. The owners of the shop were family friends.

When he was hired, he had hoped to work as a mechanic, but mostly test-drove cars and chauffeured customers. Still, he found the work exhausting and switched to part-time from full. After eight months, in late 2005, his boss told him he wouldn't be needed until the following summer, Mr. Flaton recalls. Last year, he was hired as a part-time store associate at Dallas-based retail chain Tuesday Morning Corp., which sells discounted home accessories. He assists customers, stocks sales merchandise and works the cash register. Recently, he helped unload trucks and was so fatigued afterward that he had to ask the manager if he could go home.

"It's not my dream job," says Mr. Flaton. "I want to wake up and do something I really enjoy doing." Ideally, he says, he would like to work for the Missouri Department of Conservation or be a full-time writer. But right now, "I don't have a whole lot of options," he says.