Social inequalities in return-to-work among colorectal cancer survivors in Germany

BACKGROUND: For working-age patients with colorectal cancer, returning to work is a key rehabilitation goal. This study examines the association between socio-economic position (SEP) and return-to-work (RTW), including competing outcomes (pension entry and death), following medical rehabilitation. METHODS: German Pension Insurance data (2013-2022) were analysed, including 32,174 formerly employed patients (ICD-10 C18-C20) of working age undergoing oncological rehabilitation. Patients were categorised by SEP (education, occupational position, income). Logistic regression and restricted mean survival time (RMST) analyses investigated socio-economic differences in RTW, unemployment, sick leave, pension, and death. RESULTS: Following rehabilitation, 31% of patients returned to work in the first month, and by 2 years, 65% had experienced a long-term RTW lasting ≥ 6 months. SEP was significantly associated with both initial and long-term RTW. The strongest associations were observed for income (long-term RTW highest vs. lowest income tertile: adjusted odds ratio [aOR] 3.06; 95% CI 2.84-3.31) and university education (long-term RTW ISCED‑2011 levels 5-8 vs. 1-3: aOR 2.20; 95% CI 1.94-2.50). RMST showed that patients with higher SEP spent more time in employment and less time unemployed or receiving disability pension than those with lower SEP. The employment time lost between the highest and lowest SEP levels was 8 months for education, 8 months for occupational position, and 10 months for income. CONCLUSIONS: Fifty-eight percent of patients with colorectal cancer were stably employed 2 years after medical rehabilitation. However, despite universal access to rehabilitation in Germany, strong social inequalities in RTW were observed. Monthly employment and pension data allowed reliable estimates, preventing selective non-response and recall bias. However, the results might not generalise to those who do not undergo rehabilitation.