Journal of Cancer Therapy, 2013, 4, 1224-1227
http://dx.doi.org/10.4236/jct.2013.47142 Published Online September 2013 (http://www.scirp.org/journal/jct)
Work Productivity and Activity Impairment in Breast
Cancer Patients Treated with Capecitabine
Marco Vacante1, Giulia Malaguarnera2*, Manuela Pennisi3, Giuseppe Grosso2, Salvatore Salomone2,
Filippo Drago2, Erdogan Ozyalcin1, Vito Catania4, Alfredo Consoli4, Mariano Malaguarnera1
1Research Center “The Great Senescence”, Cannizzaro Hospital, University of Catania, Catania, Italy; 2International PhD Programme
in Neuropharmacology, University of Catania, Catania, Italy; 3Department of Neurosciences, University of Catania, Catania, Italy;
4Department of General Surgery, University of Catania, Catania, Italy.
Received June 11th, 2013; revised July 10th, 2013; accepted July 17th, 2013
Copyright © 2013 Marco Vacante et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Although the majority of breast cancer patients are able to work, lower work ability and reduced job
retention have been reported. The aim of the present study was to evaluate the effect of chemotherapy with capecitabine
in patients with breast cancer on work productivity and daily activity. Methods: 34 patients with metastatic breast
cancer were enrolled for our study. Capecitabine was given twice daily at a cumulative dose of 2500 mg/m2 on days 1 -
14 and repeated on day 22. Work productivity was determined using the WPAI questionnaire. Results: We observed an
increase in absenteeism, presenteeism, work productivity loss and daily activity impairment after 1 cycle and 6 cycles of
therapy, but we could not find statistically different significances. Conclusions: This study provides some data indicat-
ing an association between problems in breast cancer and work. Our results confirm that capecitabine may improve
quality of life of patients with metastatic breast cancer.
Keywords: Breast Cancer; Capecitabine; Work Productivity; Absenteeism; Presenteeism
1. Introduction
Breast cancer is one of the most frequently diagnosed
cancer as well as a leading cause of cancer mortality in
women. A growing proportion of women diagnosed with
breast cancer, present with earlier disease stages. Appro-
ximately 50% of all women diagnosed with breast cancer
develop metastatic disease, and for these patients the av-
erage survival time from the time of diagnosis of metas-
tatic disease ranges from 20 to 36 months. After surgery,
the next question always is the need for adjuvant treat-
ment and also the choice of chemoterapeutic agent. The
goal of systemic therapy in early breast cancer is to era-
dicate micrometastases and reduce the risk of recurrence
and death.
Capecitabine is an innovative fluoropyrimidine carba-
mate, developed as an orally administered precursor of
5’-deoxy-5 fluorouridine [1]. Capecitabine is an effective,
well tolerated, and convenient treatment for patients with
breast cancer. Along a pathway with three enzymatic
steps, capecitabine is finally converted into the active
compound 5-FU at the site of tumor tissue, by the tumor-
associated angiogenic factor thymidine phosphorilase,
which is overexpressed in tumor cells [2]. The oral for-
mulation and the rarity of alopecia make capecitabine a
very acceptable and suitable drug, particularly for metas-
tatic disease, because it is associated with a better quality
of life than intravenous therapies [3]. Although the ma-
jority of breast cancer patients are able to work, lower
work ability and reduced job retention have been re-
ported [4,5]. The aim of the present study was to evaluate
the effect of chemotherapy with capecitabine in patients
with breast cancer on work productivity and daily activ-
ity.
2. Methods
Between January 2011 and February 2013, female pa-
tients with metastatic breast cancer that desired to con-
tinue their job were recruited for postoperative adjuvant
oral chemotherapy with capecitabine. The study protocol
was approved by the Institutional Review Board. Written
informed consents were obtained from all partecipants.
*Corresponding author.

Work Productivity and Activity Impairment in Breast Cancer Patients Treated with Capecitabine 1225
Further eligibility criteria included the following: 1) Age
30 to 50 years; 2) Eastern Cooperative Oncology Group
performance status of 0 or 1; 3) Adequate hematological
function (absolute leukocyte count 4000 to 12,000 leu-
kocytes/mm3; neutrophil count 2000 neutophils/mm3 or
more, and platelets 100,000/mm3 or more) hepatic func-
tion (transaminases 2.5 times or less the upper limit of
normal and serum bilirubin 2.0 mg/dl or less) and renal
function (serum creatinine below the upper limit of nor-
mal); 4) Ability to take oral medication. Patients were
excluded if they had any of following: history of severe
drug allergies, interstitial pneumonitis or pulmonary fi-
brosis, several pleural effusion or ascites, active infection,
diarrhea or serious uncontrolled comorbilities or medical
conditions. Patients were also excluded if they were par-
ticipating in another trial, unwilling to use effective con-
traception or had a medical condition or concomitant ill-
ness that might impair protocol compliance. Patients had
received no prior chemotherapy. Capecitabine was given
twice daily at a cumulative dose of 2500 mg/m2 on days
1 - 14 and repeated on day 22. The total daily dose was
divided into two equal amounts and given roughly 12 h
apart and within 30 min after a meal, usually breakfast
and dinner. Baseline assessment were medical history,
clinical examination, complete haematology with differ-
ential leucocyte count, clinical chemistry including co-
agulation parameters, tumour markers CA 125 and CA
19-9, chest radiography and computed tomographic scans
of the abdomen, pelvis and chest before starting treat-
ment at baseline.
2.1. Laboratory Exams
A complete routine chemistry including red cell count,
hemoglobin, white cell count, platelets, prothrombin time,
fasting plasma glucose, insulin, C-reactive protein, blood
urea nitrogen, serum creatinine, bilirubin, ALT, aspartate
aminotransferase, alkaline phosphatase, γ-glutamil trans-
peptidase, and creatin phosphokinase levels was per-
formed at every medical visit. All patients were included
in the safety and efficacy analyses. The severity of the
adverse effects was evaluated according to the National
Cancer Institute Common Toxicity Criteria (NCI-CTC)
version 2.0 [6].
2.2. WPAI (Work Productivity and Activity
Impairment)
Work productivity was determined using the WPAI ques-
tionnaire. Patients reported the number of actual hours
worked, hours missed due to chemotherapy, as well as
the effect on productivity while working and doing re-
gular activities during the past 7 days. The WPAI was
self-administered and consisted of four questions that eli-
cited employment status. Scores for abseteeism, presen-
teeism, overall work productivity loss and impairment in
regular (non work) daily activities, such as work around
the house, shopping, child care, exercising, studying,
were derived as follows: Absenteeism = hours missed/
hours missed + hours worked; Presenteeism = scale
score/10; Work productivity loss = absenteeism + (hours
worked × presenteeism); Daily activity impairment =
scale score/10. Score were transformed into percentage
with higher percentages indicating greater work impair-
ment, lower productivity and daily activity impairment
[7].
2.3. Statistical Analysis
Results are expressed as means +/− standard deviations.
Comparisons of quantitative data were made using the
Student’s t-test or Mann-Whitney test. Qualitative data
were analyzed using the chi-square test. A P value of <
0.05 was considered as indicating a statistically signifi-
cant difference. All data management and statistical cal-
culations were performed using SPSS 15.0 statistical
package (Chicago, IL).
3. Results
Patients’ characteristics at baseline are reported in Table
1. Blue collars (manual labourers) were 64% and white
collars (non manual/office labourers) were 35%. The oe-
strogen receptor status was positive in 25% of patients,
negative in 41%, unknown in 23%. 58% of patients had
one metastatic site, while 41% had two metastatic sites.
With regard to WPAI score, we observed an increase in
absenteeism, presenteeism, work productivity loss and
daily activity impairment after 1 cycle and 6 cycles of
therapy, but we could not find statistically different sig-
nificances (Table 2 ). Adverse events after 24 weeks che-
motherapy included gastrointestinal toxicity: 5 (14%) pa-
tients had nausea, 4 (11%) vomiting, 7 (20%) diarrhoea,
4 (11%) mucositis, 6 (17%) stomatitis, 2 (5%) abdominal
pain and 1 (2%) proctitis and higher rates of hand-foot
skin reactions (12 patients, 35%). 20 (58%) patients
showed fatigue (Table 3).
4. Discussion
Extensive clinical investigation has established that the
standard 3-week cycle of capecitabine prolongs the time
to disease progression, with similar or prolonged overall
survival in patients with metastatic breast cancer. The
possibility of staying at home instead of receiving treat-
ment in hospital represents an important role on decision
for many patients impacting less on quality of life and
offering greater freedom [8]. This preference has influ-
enced the adoption of oral capecitabine into the treatment
of breast cancer [9]. The goal of this study was to evalu-
ate the possible effects of chemotherapy stress on work

Work Productivity and Activity Impairment in Breast Cancer Patients Treated with Capecitabine 1226
Table 1. Patients’ characteristics at baseline.
Parameter
N 34
Age range (years) 32 - 49
Heart rate (beats per minute) 86
SBP (mmHg) 130 ± 14
DBP (mmHg) 84 ± 9
BMI (kg/m2) 26.4 ± 4.1
Histological grade
I
II
III
Unknown
3 (8%)
15 (44%)
10 (29%)
6 (17%)
Blue collars (manual labourers) 22 (64%)
White collars (non manual/office labourers) 12 (35%)
Oestrogen receptor status
Positive
Negative
Unknown
12 (35%)
14 (41%)
8 (23%)
Number of metastatic sites
1
2
20 (58%)
14 (41%)
Table 2. WPAI score in patients with breast cancer (mean ±
SD).
Baseline
After 1 cycle
treatment
After 6 cycles
treatment Follow up
Absenteeism 3.9  3.4 4.2  3.5* 4.4  3.9* 4.1  3.8*
Presenteeism 30.2  10.2 32.4  11.4* 34.1  14.1* 32.1  12.1*
Work productivity
loss 30.4  12.8 32.4  11.2* 34.8  12.5* 31.6  12.7*
Daily activity
impairment 41.8  15.1 43.6  14.5* 44.8  16.3* 42.8  15.9*
Comparison with baseline: P = NS*; P < 0.05**; P < 0.001***.
ability. The diagnosis and treatment of cancer can lead to
side effects, late effects and psychological distress that
reduce the mental and physical health. Capecitabine ad-
ministered as monotherapy is a reasonable choice when
single-agent chemotherapy is entertained as a treatment
option for metastatic breast cancer. Toxicities are gener-
ally manageable, even for more frail patients. Work is
often related to having a purpose in life, a sense of con-
tributing and a distraction [10]. In employees with breast
cancer, psychological and health-related distress is asso-
ciated with poorer outcomes such as higher work limita-
tions, higher presenteeism, and lower workplace support.
In our patients treated with capecitabine we did not ob-
serve statistically different significances in absenteeism,
presenteeism, work productivity loss and daily activity
impairment after 1 cycle and 6 cycles of therapy. Work
plays an important role in the psychological treatment for
many patients; in fact the level of satisfaction at work
was often stated as a strong motivator for social status
Table 3. Toxic effects in treated patients according to NCI-
CTC.
After 3 weeks
chemotherapy After 24 weeks chemotherapy
Grade 1 - 2Grade 3 - 4 Grade 1 - 2Grade 3 - 4
Laboratory
Lowered
haemoglobin
Lowered leucocytes
Lowered platelets
Raised creatinine
Raised bilirubin
1
0
0
0
0
0
0
0
0
0
2
2
1
0
0
1
1
0
0
1
Gastrointestinal
Nausea
Vomiting
Diarrhoea
Mucositis
Stomatitis
Abdominal pain
Proctitis
2
1
2
2
2
0
0
1
1
1
1
1
0
0
3
3
4
2
4
2
1
2
1
3
2
2
0
0
Others
Fatigue
Anorexia
Alopecia
Hand-foot skin
reaction
4
1
0
6
3
1
0
4
10
2
0
10
10
0
0
2
and for social contacts. We think that cancer patients
should be encouraged to resume their activities as soon
as possible, especially when adverse events are few and
tolerable. Symptoms and well-being interact; the im-
provements of treatment adherence and the low toxicity
permitted our patients to resume their work again. If
work stress is becoming too high this may result in nega-
tive consequences for job performance and possibly the
development of diseases. Cancer diagnosis and treatment
are associated with frailty and vulnerability [11,12]. Pro-
ductivity loss due to absenteeism is often taken into ac-
count in economic evaluations that adopt a societal per-
spective and is measured simply by counting the number
of days off work; measuring productivity loss due to pre-
senteeism, on the other hand, is more complex. In fact,
the evaluation of presenteeism requires the estimation of
a normal productive output for a given role, after which
the impairment in productive output may be quantified
[13]. Reduction in symptoms reduces absenteeism, but its
impact on presenteeism is more uncertain [14,15]. De-
pression affects productivity differently depending on the
occupational status, with various aspects of productivity
more tipycally impaired in different professions [16]. The
most prevalent symptoms in breast cancer treated with
chemotherapy include fatigue, cognitive limitations, dis-
tress, sleep disturbance, hand-foot skin reaction. This
symptom was mostly present in blue collars, while fa-
tigue was present in both blue and white collars. The re-
sults of this study confirm that the use of highly active,
oral drugs with good tolerability is vital and may im-

Work Productivity and Activity Impairment in Breast Cancer Patients Treated with Capecitabine 1227
prove quality of life. This study provides some data in-
dicating an association between problems in breast can-
cer and work. It is unclear whether those who left the
workplace would have remained at work if the problems
related to cancer and its treatment were effectively ad-
dressed.
5. Acknowledgements
GM, GG, MiM were supported by the International PhD
programme in Neuropharmacology, University of Cata-
nia. The authors declare that they have no competing int-
erests.
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