Katherine Hobson

As a cardiologist, David Martin is accustomed to reading scientific studies. So when he received a prostate cancer diagnosis in October 2012, he pored over the medical literature to learn as much as possible about his treatment options. Martin, from Medford, Ore., was 50, and with a wife and three sons, he wanted to maximize his chances of having the tumor permanently eliminated, while minimizing his chances of complications. These complications, such as erectile dysfunction and urinary incontinence, occur at rates Martin found to be “disturbingly” high.

As a result of his research, Martin ruled out radiation therapy because the complications can tend to show up later on. Instead, he opted to face the issue upfront. “I wanted to get it treated and move on with my life,” he says. That meant he would have to undergo a radical prostatectomy, either by regular open surgery or by minimally invasive surgery, using a laparoscope (a thin tube with a light and lens at the end) or a robotic surgical system.

Many prostate cancer surgeries are now performed using robotic systems, and they’re increasingly being used in other cancers, too, including gynecologic, head and neck, and thoracic. When performing an open operation, the surgeon makes an incision large enough to see into the body. In a laparoscopic procedure, the surgeon directly manipulates special instruments through small incisions. With robot-assisted surgery, the incisions are still tiny, but the surgeon sits at a console to perform the procedure by directing the robotic arms. This process enables finer movements yet prevents the surgeon from feeling the tissue in the same way as in open surgery.

When performed correctly by well-trained surgeons in appropriate patients, robot-assisted procedures have the potential to prevent short-term complications, such as blood loss, and to reduce the length of hospital stays, compared with open surgery.

Even with all the potential benefits, there exists little research proving that robot-assisted surgery can improve long-term outcomes compared with open or laparoscopic surgery. There is also a lack of trials comparing this surgery with laparoscopic procedures. Moreover, robotic systems are expensive. According to a recent observational study, robotic surgery systems add about $2,200 to the cost of a hysterectomy for a benign condition. (These extra costs are generally absorbed by the hospital, with insurers and patients paying the same amount for the procedure regardless of whether the surgeon uses a robot.)

We think there are some areas where there’s currently a benefit, some areas where there’s probably a future benefit, and many areas where there’s no clinical benefit.

Still, the few studies concerning this surgical technique are promising. A 2012 review of robot-assisted oncologic surgery reported that observational and population-based studies demonstrated fewer surgical complications for some robot-assisted procedures that have been in use for more than five years, including prostatectomy and bladder removal. For robot-assisted radical prostatectomy, the review found that oncologic outcomes were “at least equivalent” to open approaches, with improved rates of decreased surgical complications compared with both laparoscopic and open surgeries. But comparisons of long-term oncologic and functional outcomes—such as incontinence&mdash;are “sparse,” according to the study’s authors.

“We think there are some areas where there’s currently a benefit, some areas where there’s probably a future benefit, and many areas where there’s no clinical benefit,” says Martin Makary, a surgeon at the Johns Hopkins Hospital in Baltimore, who has researched robot-assisted surgery. The challenge is determining which technique will benefit a particular patient.

Surgeons using robotic systems say they can perform minimally invasive operations that would be very difficult or impossible using a traditional laparoscopic procedure. “When you do laparoscopic surgery, you have a hole in the patient and use long instruments, using part of the body as a fulcrum,” says John Meehan, a surgeon at Seattle Children’s Hospital in Seattle. "With the robot, you get 3-D vision and instruments"that bend or hinge like a real arm, he explains. Somesurgeons also point out that it's more comfortable to sitat an ergonomically designed console versus standingat a patient's side maneuvering awkwardly withlaparoscopic instruments. These ergonomic benefitsare believed to reduce surgeon fatigue and potentialtechnical errors, particularly during long operations.

"In gynecologic cancer surgery, the robot has madea big impact because we've converted a lot of ouropen cases into [minimally invasive] cases," says ChadMichener, a gynecologic oncologist at the ClevelandClinic in Cleveland.

Even surgeons who aren’t extensively trained in conventional laparoscopic techniques can learn to use robotic systems because of their easier-to-use instruments and shorter learning curve. Myriam Curet, a surgeon and chief medical adviser at Intuitive Surgical, manufacturer of the widely used da Vinci system, says the technology is not intended to substitute for proven laparoscopic procedures, but to extend the benefits of minimally invasive surgery.

Still, no surgery is without risks. While studies show that robot-assisted procedures are generally safe, Makary says, complications can occur. For example, procedures could take longer to perform, meaning patients would spend more time under anesthesia. Also, the robotic controls make it more difficult for a surgeon to feel other tissues and organs in the body. This makes it easier to nick an artery or other crucial area. The Food and Drug Administration issued a warning to Intuitive Surgical for failing to report such adverse events, and the company was sued over injuries allegedly caused by its robotic system. Curet says that, overall, complication rates from robot-assisted procedures are comparable with those seen in open surgery, based on current data.

Physicians say it’s essential to determine which cases might better benefit from the robot-assisted approach. “Who are those patients? What are the characteristics of the surgery or the cancer?” asks Jason Wright, an assistant professor of obstetrics and gynecology at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York. It’s hard to recruit patients for randomized trials that might answer those questions because so many patients want robot-assisted surgery, regardless of whether it’s appropriate for their situation. “Some people do come in requesting it,” says Kirsten Greene, associate professor of urology at the University of California, San Francisco.

As medical facilities compete for every healthcare dollar by marketing their technology, patients not only expect but also demand access to the latest devices, regardless of evidencebased outcomes. Wright was an author of a 2012 study examining the marketing of robot-assisted gynecologic surgery on 432 hospital websites. While most sites reported improved short-term outcomes with a robotic system, very few cited limitations of the devices, such as complications, operative time or cost. And a study co-authored by Makary and published in the 

 in 2011 reported that of the 41 percent of 400 hospital websites mentioning robotic surgery, 89 percent made statements of clinical superiority, and 32 percent specifically cited improved cancer outcomes. None mentioned any specific robotic-surgery risks.

Like acquiring any expertise, surgeons have a prolonged learning curve as they get up to speed using a robotic system. Intuitive Surgical provides training, including practice procedures through simulators and models, but training needs vary according to the surgeon’s baseline skills and other factors, Curet says. Requirements for how many supervised cases surgeons perform before operating independently and how many cases they must regularly perform to maintain their skills are determined by hospitals, so there’s no universal standard. In the department of obstetrics and gynecology at the Cleveland Clinic, for example, surgeons must perform 20 to 25 supervised surgeries before they can perform the procedures on their own, and must perform 20 robot-assisted procedures per year to maintain their privileges, Michener says.

It’s important when people who are confronted with this to look at the surgeon’s experience and outcomes and feel like they’re cared for.

Jim Hu, director of urologic robotic and minimally invasive surgery at the University of California, Los Angeles, who performs both open and robot-assisted procedures, says patients should focus their search on the surgeon, not the technique. “A robot in the hands of someone who isn’t very good isn’t going to help cure cancer more than someone who is good performing an open surgery,” he says.

“It’s just another tool that a surgeon uses,” Greene says. And it’s not appropriate for everyone. Certain problems, such as severe lung or heart disease, or extensive scarring from previous surgeries, actually make laparoscopic and robotic procedures more dangerous, she adds.

Martin opted to have Hu use a robotic system to operate on him in January. He says his physical recovery was swift and his function rapidly returned. He urges other patients to do their homework before deciding on a treatment. “It’s important when people are confronted with this to look at the surgeon’s experience and outcomes and feel like they’re cared for,” he says.

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Patients should research both the surgeon and the technique when deciding on treatment.

Is Robot-Assisted Surgery the Best Treatment for Your Cancer?

Experts emphasize that patients should search for the best surgeon, not just the one who uses a robot. Patients should begin by asking their primary care physician or oncologist for recommendations based on expertise, experience and track record. And if they know of other patients with the same disease, ask them about their experiences.

Martin Makary, a surgeon at the Johns Hopkins Hospital in Baltimore, suggests patients get thorough information on all of their surgical options—open, laparoscopic and robotic. To that end, it helps if a surgeon has been trained in and uses all three techniques, depending on the disease and the patient, says Jim Hu, director of urologic robotic and minimally invasive surgery at the University of California, Los Angeles. They should ask about if any research supports its use in particular cases.

As with all operations, the surgeon’s training and experience matter. Hu says indicators of an expert include fellowship training in robot-assisted surgery, publication articles, invited presentations on the topic and hosting fellowships. He also says having performed surgeries live online is an indicator of confidence and experience.

Furthermore, a good surgeon will answer questions, and patients shouldn’t hesitate to ask them, says Kirsten Greene, associate professor of urology at the University of California, San Francisco. Both the benefits and the risks should be reviewed for the specific situation. Patients should ask about the surgeon’s own outcomes with the procedure, including recurrence rates, the incidence of side effects and how many of a particular procedure the surgeon has performed successfully. There’s no agreed-upon number, but within reason, the more, the better, she says.

Experts emphasize that patients should search for the best surgeon, not just the one who uses a robot.

Searching for an Oncology Surgeon

When the Americans with Disabilities Act (ADA) was passed in 1990, cancer survivors were relieved, believing the legislation would protect them from workplace discrimination, says Barbara Hoffman, a lawyer and instructor at Rutgers School of Law in Newark, N.J.

But that didn’t always happen. Some federal courts balked at applying the ADA to cancer survivors, Hoffman says, adding: “It was a Catch-22.” On one hand, courts sometimes said survivors didn’t have a substantial, activity-limiting impairment because they were able to work. On the other hand, some courts said that if survivors couldn’t perform certain duties of their job, they weren’t qualified to hold the job. Either way, many claimants’ cases were dismissed before making it to trial.

Then, in 2008, Congress passed the ADA Amendments Act (ADAAA), intended to broaden the definition of “disability.” Among its relevant provisions was that employees taking maintenance medication could still be considered disabled, even if the medication helped their impairment. And employees in remission from cancer could also be defined as disabled, so long as the condition, if active, would be limiting.

Although it’s too soon to evaluate the amendment’s effectiveness, “We think it’s working” to expand access to the law’s protections, Hoffman says. Her analysis shows that the number of cancer-based claims under the ADA rose to 951 in 2011 from 707 in 2008. Moreover, “the number of cancer-based employment discrimination claims that have been resolved favorably for the plaintiff has nearly doubled” since the ADAAA passed, she says.

There have been attempts to expand access to the Family Medical Leave Act by lowering the number of employees an employer must have (currently 50), or by permitting people to take leave to care for siblings, grandparents, grandchildren or domestic partners under certain circumstances. (Right now caregivers are eligible for the leave only to help a child, spouse or parent with a serious health condition.) That would also expand the protected caregiver ranks for cancer patients. So far, none has been successful, says Joanna Fawzy Morales, a cancer-rights attorney and CEO of Triage Cancer, a nonprofit organization offering education and resources on cancer survivorship issues.

In addition, some states have tried to pass requirements that certain employers provide paid sick leave. No federal law requires it, and only Connecticut and a handful of localities—including San Francisco, Seattle and, most recently, Portland, Ore.&mdash;have their own laws guaranteeing paid leave.

There are legal protections in place for survivors in the workforce.

Protections in Place

	High school math teacher Mark Nelson never questioned whether he would work after cancer. After receiving a diagnosis of colon cancer in 2011, Nelson had surgery in June and started chemotherapy just two weeks before the school year began in his hometown of Mondovi, Wis. He had a round of chemotherapy on Wednesday afternoons and taught during the rest of the week using a portable infusion pump. Nelson, now 59, says he needed his job for the paycheck and health insurance. But it went beyond that. “Teaching the kids was saving me,” he says.

	Nelson was on a half-day schedule during treatment—the result of a declining student population and budget cuts&mdash;but now teaches six periods a day, sometimes from a chair, because of neuropathy.

	While he’d like to work more hours, he says the shorter day helps him manage treatment-related fatigue. A former basketball coach at his school, Nelson is looking forward to regaining enough energy to attend night games. “I want to slowly build up to that,” he says.

	An estimated 4.8 million people of working age are survivors of cancer. Most successfully return to work after treatment, but some do not. Even those who do go back to work after, or even during treatment, can face a variety of challenges stemming from the physical and psychological effects of their disease and treatment. The good news is that experts say it’s often possible to overcome those challenges, with some planning and employer support.

	The nonprofit Cancer and Careers and the market research firm Harris Interactive recently released the results of a poll of 400 people working before and after cancer treatment on what motivated them to continue working. Nearly half (48 percent) said they continued working because they wanted to keep things as normal as possible, and more than one-third (38 percent) said that they wanted to feel productive.

	“Most people would say that their greatest source of identity is their job,” says Cathy Bradley, professor and chair of Virginia Commonwealth University’s Department of Healthcare Policy and Research in Richmond, Va. “It provides self-esteem, a distraction and a social outlet.”

	Most people would say that their greatest source of identity is their job.

	Not everyone returns to work after treatment. Some can’t, while others don’t have to, or decide they have other priorities, says Michael Feuerstein, a professor of medical and clinical psychology at the Uniformed Services University of the Health Sciences in Bethesda, Md., and a survivor of brain cancer.

	Residual symptoms can make returning to the workplace, and staying there, a challenge. A study published this year in the 

 found that patients whose cancer was non-metastatic were less likely than those who were less affected to be working at least six months post-diagnosis if their symptoms interfered with work at least moderately. And those who can’t work at all may merely represent just “the tip of the iceberg,” with many others working part-time when they’d rather be working full-time, or who can’t work at their previous level or rate, says Amye Tevaarwerk, an assistant professor of hematology/oncology at the University of Wisconsin-Madison and a lead author of the study.

	Some late effects of treatment are physical and can be long-standing or permanent. Lymphedema, for example, might not occur until years after treatment, yet it can be a challenge for people whose jobs require physical activity, such as heavy lifting. A 2010 study of patients with newly diagnosed breast and prostate cancer, co-authored by Bradley and published in the 

, found that about 36 percent of women and 17 percent of men reported a physical disability 18 months after diagnosis.

	Fatigue is also a problem for many survivors, and sleep often isn’t a solution. The insurance company Unum offers practical applications to employers, such as workstation flexibility, time and space for breaks, and the ability to plan productive work to avoid the cycles of fatigue. Research also suggests physical activity can help, says Patricia Ganz, a medical oncologist and director of the patients and survivors program at the Jonsson Comprehensive Cancer Center at the University of California, Los Angeles. She co-authored a 2012 study that found Iyengar yoga improved fatigue in survivors of breast cancer.

	Chemotherapy and radiation also can cause memory and cognition problems that can make functioning at work tough for some people. In Bradley’s study, even 18 months after diagnosis, 22 percent of the women and 7 percent of the men reported cognitive disability—and they were more likely to leave the workforce as a result. Ganz is now leading a randomized trial examining whether homework assignments and 10 hours of group sessions can improve attention, memory, multitasking and encoding in survivors of breast cancer.

[Infographic: See how cancer survivors are changing the face of the workforce]

	Nelson says being direct and honest with his supervisors has been key. When he found out that he was scheduled to attend an all-day seated in-service meeting not long after treatment, he told his superintendent that it wouldn’t be possible. “As long as I was upfront, they worked with me,” he says. Disclosure of a disability is required of workers who need a reasonable accommodation under the Americans with Disabilities Act (ADA) or disclosure of an illness for those who need to take unpaid, job-protected time off under the Family Medical Leave Act (FMLA).

	We hear that people don’t want to be labeled as “cancer girl” or “cancer boy.” They want work to be a place of respite.

	With co-workers, the question of how much detail to disclose can be trickier. “We hear that people don’t want to be labeled as ‘cancer girl’ or ‘cancer boy,’” says Kate Sweeney, co-founder of Cancer and Careers and executive director of the Cosmetic Executive Women Foundation. “They want work to be a place of respite.” She advises people to be prepared for the inevitable “How are you?” with a quick answer and a transition into another subject.

	“I’ve always been pretty good at gauging when you can have a conversation,” says Mitria Di Giacomo, a survivor of breast cancer who owns her own marketing consultancy in New York. “If I felt it would be a detriment or would be perceived badly, I wouldn’t talk about it.” She used a career coach through Cancer and Careers. Survivors “need guidelines,” she says. “It’s a whole new situation.”

	Some want—or need&mdash;to more fully disclose what’s going on. Nelson says he told his students details about his surgery and his need for a colostomy. “I had to tell them,” he says. “I told them if I passed gas they’d better laugh because I would.”

	Not everyone finds supportive supervisors and colleagues, however. A recent survey of adults living with cancer in the U.K. found that 37 percent of respondents who returned to work after treatment experienced some type of discrimination.

	“We see a number of cases involving outright employment discrimination or suspected discrimination,” says Shawn Kravich, associate director at the Cancer Legal Resource Center, a joint program of the Disability Rights Legal Center and Loyola Law School in Los Angeles. Some employers are blatant in discriminating—Kravich says one of his clients was fired via voicemail specifically due to cancer&mdash;but usually the discrimination is more subtle. “People often say, ‘I had to take time off from work. I’m returning. And even though I’m working hard, my employer keeps writing me up for job performance, even though I feel like I’m doing my job the way I was always doing it,’” he says.

	Earlier this year, Lamar Dobbs was abruptly let go by the nursing home where he had worked for nearly three years. The 56-year-old certified nursing assistant from Wilmington, Del., says he was initially treated well by his supervisors after returning to work last fall from a 12-week medical leave following surgical removal of a cancerous kidney. His bosses switched his duties from the more physical nursing tasks to a desk job, making it easier for him to recover.

	A few months later, Dobbs developed a hernia, which was a complication of the surgery, requiring another operation. After presenting the necessary paperwork to the director of nursing, Dobbs recalls being told not to worry about his employment situation and to instead focus on his health. But when he returned to work following the hernia repair, he says his supervisor told him that he no longer had a job. Though the employer’s official reason for termination was that Dobbs had exhausted his medical leave, Dobbs isn’t satisfied with the explanation.

	Now Dobbs receives unemployment benefits and is working on getting better—he is also being treated for prostate cancer&mdash;before he looks for work again. “It really hurts a lot,” he says of the circumstances surrounding his termination. “I can’t understand it.”

[Learn what legal protections are in place for survivors who work]

	The ADA requires private employers with at least 15 employees to make “reasonable” workplace accommodations for employees. The definition of reasonable is very specific to the individual and his or her job responsibilities, says Joanna Fawzy Morales, a cancer-rights attorney and CEO of Triage Cancer, a nonprofit organization offering education and resources on cancer survivorship issues. Telecommuting may be a perfectly reasonable accommodation for an office worker, for example, but maybe not be for an airline pilot.

	Changes to the work space, technology and company policy, such as working from home or using a chair at a retail checkout counter, can be reasonable accommodations if they’re conducive to the job, Morales says. So is more time off, or a job transfer—such as a teacher with a compromised immune system shifting to an administrative role&mdash;if there’s a vacancy, she says. (Check potential accommodations at 

, the Department of Labor’s Job Accommodation Network, for more information). The protection doesn’t apply, though, if a worker is simply no longer able to perform the essential functions of the job.

	One week after having surgery on his brain tumor, Feuerstein returned to work, where he immediately suspected his employment situation had changed. He says a grant he had received before his diagnosis was returned to the source because no one could figure out to whom the money had been allocated. His employer’s attempt to accommodate his illness and recovery involved someone taking notes for him at conferences, which he didn’t need. So Feuerstein filed a claim under the ADA but later dropped it when his situation improved.

	Feuerstein co-authored a study in 2007 that found that people with cancer-related disputes were more likely than those with impairments, such as cardiovascular or neurological problems, to claim under the ADA that they’d received differential treatment or lost their job. Even with the higher profile of cancer survivors, “people are still scared of cancer,” Feuerstein says. He also acknowledges that businesses have legitimate concerns, such as when long-term or late effects of treatment affect a survivor’s productivity.

	If a worker is temporarily unable to perform a job, the FMLA permits up to 12 workweeks of unpaid leave per 12-month period—so long as the private employer employs 50 or more people. Medical certification must be supplied if an employer requests it.

	Debra Wolf, a senior attorney at LegalHealth, a program of the New York Legal Assistance Group, advises people seeking accommodations to start with the human resources or employee benefits department, not a direct supervisor. She says workers should put everything in writing. They should also include a letter from their physician explaining that they’ve reviewed the request for an accommodation, that it’s medically necessary and that the worker is able to perform the essential functions of their job. She also urges people to understand their state laws, which may go beyond provisions in the ADA.

	Many survivors find that they have a different perspective on work after cancer. Di Giacomo’s 2007 breast cancer diagnosis came in the middle of a career transition: She was trying to figure out whether to go back to a corporate job or start her own business. She didn’t work for a few weeks while she researched the disease and prepared for surgery. But after the surgery, she picked up some freelance public relations work, committing for a four-month stretch at three days a week.

	While still feeling the effects of chemotherapy, Di Giacomo discussed a job with a potential employer. When the potential employer said, “This is a 24/7 commitment,” she knew it probably wasn’t for her. Now she’s thrilled to be working for herself, on her own terms. “I’ve always enjoyed work. Now I think it’s important, but I’m not interested in being at my desk for 15 hours,” she says. “Before, I didn’t realize that life could be fragile.”

After cancer, dealing with employment issues is all in a day's work.

Katherine Hobson

Is Robot-Assisted Surgery the Best Treatment for Your Cancer?

Searching for an Oncology Surgeon

Protections in Place

Task Force: Tackling Work After a Cancer Diagnosis

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