Having an occupation can positively impact cancer survivors not only economically, but also physically and mentally, contributing to an improvement in their Quality of Life (QOL) [1]. Employment can also foster a sense of normalcy and invigorate their zest for life [2]. Furthermore, when survivors Return to Work (RTW), it can help reduce societal costs by promoting labor participation and decreasing the amount of sick leave related to the disease [3].

The physical symptoms of cancer often persist even after treatment has concluded. Furthermore, cancer survivors face numerous challenges during treatment and may experience cognitive impairment and physical fatigue post-treatment. These issues can jeopardize their continued employment and result in additional stress [4, 5]. Survivors may also experience RTW hesitancy due to anxiety about potential recurrence, or they may struggle to continue working even after they have returned [1]. Such stresses can diminish their capacity to manage workplace issues and maintain mental stability, resulting in decreased job satisfaction and QOL [6]. Cancer survivors often endure stress related to mental, physical, and economic hardships, social role confusion, and an elevated risk of mortality [7]. These factors, along with the possibility of recurrence and an unpredictable prognosis post-treatment, can significantly impact their return to social life [1]. Furthermore, the ordeals of having cancer, experiencing disease progression, and receiving a diagnosis at a young age can trigger Post-Traumatic Stress Disorder (PTSD) in many cancer survivors. In fact, more than 50% of breast cancer patients report having this condition [8, 9].

Office workers often face numerous stress-related factors, such as heavy workloads, unclear role definitions, and social issues within the workplace [10]. Those who are also cancer survivors must contend with additional challenges stemming from their treatment, including cognitive impairment, restrictions on physical activity, anxiety, depression, and difficulty maintaining eye contact [4]. Furthermore, they grapple with disease progression-associated distress, a term encompassing a range of emotions including anxiety, stress, worry, panic, and fear. This distress has been identified as a factor impacting their work [11].

The stress experienced by cancer survivors is an important issue that affects daily life and symptom management. However, existing research has been limited to the survivors of certain specific cancers, such as breast and colorectal cancer [7, 12]. Previous studies of breast cancer survivors have demonstrated that current health status, including self-rated health, activity limitations, and physical discomfort, influences stress levels [13, 14, 15]. Furthermore, past research has indicated that health behaviors, such as perceived body image, smoking and alcohol consumption, and physical activity, can also contribute to stress. These findings were observed in studies involving breast cancer and head and neck cancer [13, 14, 16, 17]. Additionally, prior research exploring the relationship between mental health and stress in cancer survivors has found a correlation between stress and mental health issues, such as depression and suicidal ideation [18, 19, 20]. Moreover, while studies have been published on PTSD, psychological stress, and physical stress in cancer survivors, little research has focused on the comprehensive identification of stress-related factors [2, 4, 8].

While some studies have explored stress-related issues in cancer survivors overall, this research has certain limitations. These include small sample sizes and a lack of generalizability to various types of cancer and to survivors of single-organ cancers [8, 9]. Additionally, these studies utilized only 1 year of national data, had limited numbers of participants, and focused solely on specific types of cancer. None of these studies aimed to identify stress factors using comprehensive indicators such as sociodemographic factors, current health status, health behaviors, and mental health characteristics [21]. In certain countries, research has been conducted on the reintegration into the workforce of cancer survivors, with a focus on job type [3, 5]. However, similar research is scarce in Korea. Notably, policies and support projects are currently being implemented in Korea to benefit cancer survivors as a whole [22, 23]. Employment has been shown to positively impact the QOL of cancer survivors [1]. However, cancer survivors face many challenges in maintaining their employment due to additional stressors such as physical fatigue. Research has indicated that a higher percentage of cancer survivors (18.4%) experience job-related stress than the general population (11.3%) [4, 5, 24]. Therefore, a need exists for information that can assist cancer survivors in maintaining their employment by comprehensively identifying and addressing their stress factors. The objectives of the present study were to identify factors associated with the stress experienced by working Korean cancer survivors using 5 years of national data (including cancer types and age groups), as well as to provide foundational data for the development of stress management intervention programs for this patient population.

Multivariate logistic regression analysis revealed that age, gender, self-rated health status, and suicide planning in the previous year were associated with stress among employed Korean cancer survivors. Regarding age, the average age of the stress group was lower than that of the non-stress group. This finding aligns with a study reporting high stress levels in young cancer patients and a separate study in which younger cancer patients were found to be more susceptible to PTSD than older patients [8, 9]. Similarly, a study of women with breast cancer revealed that the younger the patient, the higher the stress level [12]. Young cancer survivors, in particular, have been reported to experience work-related stress and serious financial difficulties due to physical and cognitive impairments [26]. Therefore, it is crucial to implement stress management strategies for young cancer survivors, who typically have relatively promising social and RTW opportunities.

Gender was also identified as a factor influencing stress levels, with a higher proportion of women than men in the stress group. A study focusing on typical office workers revealed that women were more susceptible to stress and anxiety disorders than men due to job-related demands [27]. Another study suggested that female cancer survivors experience greater depression when undergoing cancer treatment while also managing household tasks, which can negatively impact QOL [28]. This may be attributed to the fact that male cancer survivors are more likely to be employed than their female counterparts, while women often face work-family conflicts due to the dual burden of work and family responsibilities [29]. Therefore, when designing a stress intervention program for working cancer survivors, it is crucial to consider the lifestyle of women who, in addition to their jobs, often devote more time to housework and childcare than men.

Self-rated health status was also found to be associated with stress among employed Korean cancer survivors. In a previous study of patients with rectal or anal cancer, depression and anxiety accounted for a large proportion of the causes of stress. Furthermore, depression was linked to negative perceptions of physical health [30]. In a similar study, self-rated health status was revealed to have substantial impacts on QOL, RTW, and job satisfaction among cancer survivors [31]. Interventions involving physical activity can positively influence the subjective self-rated health status of cancer survivors, potentially reducing the risk of several cancer-related symptoms such as pain, depression, and anxiety. These interventions can also aid cancer survivors attempting to RTW [3]. As such, self-rated health status is an important factor in stress management for working cancer survivors. Therefore, it is vital to develop an intervention program targeting self-rated health status, such as a physical activity intervention involving 30 minutes of low-to-moderate-intensity exercise [32].

Participants who had a suicide plan over the previous year were more likely to be in the stress group. This relates to the elevated suicide rate associated with a cancer diagnosis, mirroring the findings of earlier studies that discovered high stress levels among cancer survivors who had suicidal thoughts or plans [18]. Research conducted in the United States revealed that cancer survivors had statistically higher suicide rates than the general population [33]. Furthermore, in Korea, cancer survivors exhibited higher rates of depression and suicide attempts in the previous year compared to the general population [18]. Consequently, suicide planning is an important factor to consider when managing cancer survivors, and stress management interventions such as mindfulness-based techniques and mobile health interventions are needed [34, 35].

In this study, with the goal of increasing RTW success among cancer survivors, the factors associated with stress among employed survivors were identified as comprehensive indicators. These factors included sociodemographic characteristics, current health status, health behaviors, and mental health characteristics. This contrasts with studies on head and neck cancer survivors, which highlighted financial stress as a prominent factor for those unemployed [25, 36]. Employment can positively impact the physical and mental health of cancer survivors, beyond its economic benefits, and can contribute to improved QOL [1]. Furthermore, stress and QOL have been found to be influenced by different factors depending on the employment status of the cancer survivors [37]. Notably, employed survivors exhibit better QOL and lower symptoms of stress and depression compared to their unemployed counterparts [37]. These findings underscore the need for stress-reducing interventions and/or rehabilitation programs, such as mindfulness-based stress management intervention, mobile health intervention, and low-to-moderate-intensity exercise for cancer survivors planning to RTW. These measures could enhance the success rate of RTW and job retention. Consequently, we recommend that future research should focus on developing a nursing stress management intervention program for Korean cancer survivors who are employed or planning to RTW. This could facilitate their post-traumatic growth. We also propose a future study on the stress factors of employed cancer survivors, incorporating data from the eighth KNHANES.

This study had several limitations. First, it was based on an analysis of secondary data; thus, only variables present in the raw data could be utilized, restricting generalizability. Moreover, the application of stress relative to the condition of the cancer patient is challenging due to the absence of detailed information about the cancer survivor, such as the survival period post-diagnosis and the cancer stage. Second, the data item evaluated in the analysis was daily life stress, which may have included stress unrelated to returning to work. Third, the stress evaluation items in the KNHANES were assessed by selecting a fixed response on a 4-point scale for a single item concerning stress perception level. As a result, specific aspects of stress in cancer survivors could not be assessed. Furthermore, participants were divided into a stress group (those who responded "very much" or "much") and a non-stress group (those who responded "little" or "hardly any at all") based on their answers to the stress question. However, dividing the stress group into four subgroups and analyzing data from additional survey years would yield more detailed study results. Additionally, the KNHANES provides national data for Koreans, with potential differences from Western culture and institutions. Finally, this study was conducted using KNHANES data through 2018, so a need exists to better reflect the latest trends. Therefore, we propose a follow-up study using data from the eighth KNHANES. Despite these limitations, this study was meaningful through its use of comprehensive data. By utilizing national data spanning 5 years (2014~2018) that included a full set of cancer types and various age groups, we could comprehensively identify the factors associated with stress among employed Korean cancer survivors.

Cancer survivors often experience considerable stress during and after treatment, which can manifest as cognitive impairment and physical fatigue. Consequently, these individuals may struggle to maintain their employment or RTW. Therefore, it is crucial to provide effective stress interventions to cancer survivors at an early stage. The findings of this study are anticipated to serve as foundational data for developing interventions aimed at reducing stress among working cancer survivors.

This study was conducted to identify the factors influencing stress among employed Korean cancer survivors, using KNHANES data. The overall predictors of these factors were identified in this research. Logistic regression analyses revealed that younger age, being a woman, self-rated health status, and having planned suicide in the past year all impacted stress in working cancer survivors. These findings suggest that these factors should be considered when designing stress intervention programs for survivors. Furthermore, this research can inform the development of a stress intervention program for Korean cancer survivors who are employed, whether in the workplace or the community. Consequently, we recommend that future research should focus on creating a nursing stress management intervention program for Korean cancer survivors who are employed or about to RTW, to facilitate their post-traumatic growth.