title: A Systematic Review of the Effect of Cancer Treatment on Work Productivity of Patients and Caregivers.
abstract: BACKGROUND
  Cancer is a leading cause of death with substantial financial costs. While significant data exist on the economic burden of care, less is known about the indirect costs of treatment and, specifically, the effect on work productivity of patients and their caregivers. To examine the full effect of cancer and the potential value of new therapies, all aspects of care, including indirect costs and patient-reported outcomes, should be evaluated.
  
  
  OBJECTIVE
  To perform a systematic review of the literature examining the effect of cancer treatment on work productivity in patients and their caregivers.
  
  
  METHODS
  Articles, abstracts, and bibliographies were searched in MEDLINE, Cochrane, Scopus, CINAHL, and conference lists from the American Society of Clinical Oncology, International Society for Pharmacoeconomics and Outcomes Research, and Academy of Managed Care Pharmacy up to January 2016. The PRISMA guidelines were used. Controlled search terminology included individual pharmacologic therapies for cancer and terms related to patient and caregiver work productivity. Citations were included if they evaluated the effect of cancer treatment on work productivity, used and described productivity assessments and instruments, and were written in English. Studies that reported only clinical outcomes or assessed only nonpharmacological treatments were excluded. Identified studies were screened and extracted for study inclusion by 2 independent reviewers, with adjudication by 2 secondary reviewers during the final eligibility phase.
  
  
  RESULTS
  Of 978 potential citations, 62 articles or abstracts were included. Forty-six studies (74.2%) evaluated patient-related productivity; 10 studies (16.1%) focused on caregivers, and 6 studies (9.7%) were a combination. Sixteen countries contributed literature, including 26 studies (41.2%) conducted in the United States. The most commonly studied cancer was breast cancer (53.2%). Nearly 22% of the studies were conducted on multiple types of cancer. The significant diversity of study methodologies and measurements rendered a single unifying conclusion difficult. A variety of metrics were used to quantify productivity (hours lost, return to work, change of status, and activity impairment). The Work Productivity and Activity Impairment questionnaire was the most commonly used standardized tool (n = 9; 14.5%). Factors found to be associated with impairment in productivity included disease- and treatment-related effects, such as disease progression and severity, cognitive and neurological impairments, poor physical and psychological status, receipt of chemotherapy, and time and expenses required to receive therapy.
  
  
  CONCLUSIONS
  This review highlights the considerable variety of studies that have assessed work productivity for cancer treatment and the multifaceted reasons affecting patients and caregivers. With increasing emphasis being given to understanding the value that patients assign to various aspects of cancer treatment, more streamlined information on productivity may be important to patients as they play a greater role in selecting treatment goals through shared decision making with their providers.
  
  
  BACKGROUND
  This study was funded by Novartis Pharmaceuticals, which provided the concept, general oversight, and research collaboration on the project. Covvey and Kamal received research funding from Novartis Pharmaceuticals and the College of Psychiatric and Neurologic Pharmacists. Zacker is employed by, and owns stock in, Novartis Pharmaceuticals. A related poster abstract was presented at the Academy of Managed Care Pharmacy April 2016 Annual Meeting and published as Kamal KM, Covvey JR, Dashputre A, Ghosh S, Zacker C. A conceptual framework for valuebased oncology treatment: a societal perspective. J Manag Care Spec Pharm. 2016;22(4 Suppl A):S28. A publication-only abstract was presented at the American Society of Clinical Oncology 2016 Annual Meeting and published as Covvey JR, Kamal KM, Dashputre A, Ghosh S, Zacker C. The impact of cancer treatment on work productivity of patients and caregivers: a systematic review of the evidence. J Clin Oncol. 2016;34(Suppl):e18249. Study concept and design were contributed by Zacker, Kamal, and Covvey. Dashputre and Ghosh took the lead in data collection, along with Kamal and Covvey, and data interpretation was performed primarily by Shah and Bhosle, along with Ghosh, Dashputre, Covvey, and Kamal. The manuscript was written by Kamal, Covvey, Shah, and Bhosle and revised primarily by Zacker, along with Shah, Bhosle, Kamal, and Covvey.
authors.affiliation: 1 Duquesne University Mylan School of Pharmacy, Pittsburgh, Pennsylvania.
authors.forename: Khalid M
authors.initials: KM
authors.lastname: Kamal
authors.affiliation: 1 Duquesne University Mylan School of Pharmacy, Pittsburgh, Pennsylvania.
authors.forename: Jordan R
authors.initials: JR
authors.lastname: Covvey
authors.affiliation: 1 Duquesne University Mylan School of Pharmacy, Pittsburgh, Pennsylvania.
authors.forename: Ankur
authors.initials: A
authors.lastname: Dashputre
authors.affiliation: 1 Duquesne University Mylan School of Pharmacy, Pittsburgh, Pennsylvania.
authors.forename: Somraj
authors.initials: S
authors.lastname: Ghosh
authors.affiliation: 2 University of Georgia College of Pharmacy, Athens, Georgia.
authors.forename: Surbhi
authors.initials: S
authors.lastname: Shah
authors.affiliation: 3 Outcomes, Inc., Ashburn, Virginia, and Community Care of North Carolina, Raleigh.
authors.forename: Monali
authors.initials: M
authors.lastname: Bhosle
authors.affiliation: 4 Novartis Oncology, East Hanover, New Jersey.
authors.forename: Christopher
authors.initials: C
authors.lastname: Zacker
mesh_terms: D017028:Caregivers / Q000191:economics*; D003657:Decision Making; D017850:Economics, Pharmaceutical; D006801:Humans; D008495:Medical Oncology / Q000191:economics; D009369:Neoplasms / Q000188:drug therapy* / Q000191:economics*; D017063:Outcome Assessment, Health Care / Q000191:economics