The Connections Between Work,Prostate Cancer Screening,Diagnosis,and the Decision to Undergo Radical Prostatectomy

Abstract

Prostate cancer diagnosis can occur at a time when men’s work and careers are central to their masculine identity, sense of purpose, and family life. In Canada, an aging male population, along with medical advances, has resulted in increasing numbers of working men being diagnosed with, and treated for, prostate cancer. Little is known about the linkages between men’s work and their experiences of prostate cancer. In this qualitative study, 24 Western Canadian men were interviewed to distil the connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy. Data were analyzed using constant comparison in the context of masculinities theory. The findings demonstrated that work was central to men’s masculine identities and afforded financial security, social status, and a sense of personal growth. However, work-related strain and demands were also found to affect participants’ health and distance them from their families. A diagnosis of prostate cancer tended to diminish the importance of work, wherein participants focused on optimizing their health and strengthening family relations. In deciding on radical prostatectomy as a treatment to eradicate prostate cancer, few men considered the implications for returning to work. The current study findings indicate that clinicians and patients should explicitly explore and discuss how surgery side effects may affect work and career plans during treatment decision-making.

In Canada, approximately 19% of prostate cancer diagnoses occur in men under the age of 59 years (Canadian Cancer Society’s Steering Committee on Cancer Statistics [CCSACCS], 2012). Thus, prostate cancer diagnosis can occur at a time when men’s work and careers are central to their masculine identity, purpose, and family life. Related, Grunfeld, Drudge-Coates, Rixon, Eaton, and Cooper (2013) demonstrated that prostate cancer treatment side effects can challenge men’s return to work efforts, potentially affecting their career and/or retirement plans. However, to the best of our knowledge, the linkages between men’s work and their experiences of prostate cancer have not been explored in the Canadian context, where more than one in six workers are 55 years or older—with rising employment rates for men 55+ years (Carriere & Galarneau, 2011). While advances in diagnosis and treatment have resulted in 5-year and 10-year relative survival ratios of 96% and 95%, respectively (CCSCCS, 2012), new cases of prostate cancer are also expected to increase due to Canada’s aging population (Quon, Loblaw, & Nam, 2011). These factors suggest that a substantial number of men experience prostate cancer as a chronic illness, and more men are expected to live with the impact of prostate cancer during their work lives.

Research in Western countries has identified the concept of masculinities as being central to men’s work practices (Nixon, 2009; Thurnell-Read & Parker, 2008) and experiences of prostate cancer (Kelly, 2009; Oliffe, 2009). Connell (2005) argued that the concept of masculinities can help advance understandings about how men present and locate themselves in society. Key to masculinities are socially constructed ideals and cultural norms around men’s behaviors—including their work performativities (Connell, 2005; Connell & Messerschmidt, 2005). In this regard, men often engage and align to varying degrees with idealized masculinities that are characterized by stoicism, self-reliance, competitiveness, sexual prowess, physical control, and strength (i.e., hegemonic masculinity) to favorably position themselves in their relationships with women and other men (Connell & Messerschmidt, 2005; de Visser & McDonnell, 2013). As a result, it has been recognized that multiple masculinities can emerge from men’s social practices and interactions with others (Connell, 2005).

Idealized masculinities also include professional achievement and financial independence (Kelan, 2008). Indeed, men are often judged on their occupations and ability to provide for their family (Dyke & Murphy, 2006; Williams, 2008), and on their successful pursuit of career and financial gain—often to the detriment of self-care practices and health (Verdonk, Seesing, & de Rijk, 2010). In this respect, Evans, Carney, and Wilkinson (2013) argued that men’s efforts at achieving work–life balance and improving life quality are often countered by strong social expectations that men should focus on earning income.

With regard to the connections between masculine ideals and men’s experiences of prostate cancer, studies have consistently reported that treatment side effects (e.g., erectile dysfunction, urinary incontinence) significantly challenge men’s sense of sexual prowess (Klaeson, Sandell, & Berterö, 2012) and physical control (Higa, Moraes Lopes, & D’Ancona, 2013). However, masculine practices are diverse and can be reconfigured to safeguard one’s health by adopting health-conscious behaviors after prostate cancer diagnosis and treatment (Satia, Walsh, & Pruthi, 2009). Kelly (2009) argued that reconfiguring masculine practices are often justified by men as a need to remain healthy for the benefit of others. In this regard, Grunfeld et al. (2013) reported that some men frame self-preservation and health-conscious practices after prostate cancer diagnosis as essential in enabling them to continue to work and protect their families.

Although previous research has highlighted the centrality of work in men’s fulfillment of breadwinner roles (Cha & Thébaud, 2009; Zuo, 2004), evidence has suggested that prostate cancer treatment side effects can significantly restrict men’s work capacity (Gannon, Guerrero-Blanco, Patel, & Abel, 2010; Grunfeld et al., 2013). In this respect, radical prostatectomy, as a surgical treatment for prostate cancer, results in a period of postsurgical convalescence with sudden and dramatic consequences on men’s ability to work lasting up to 12 months after surgery (Oberst, Bradley, Gardiner, Schenk, & Given, 2010). While previous research has documented return to work rates (Bradley, Neumark, Luo, Bednarek, & Schenk, 2005; Oberst et al., 2010), little is known about men’s experiences of work within the context of prostate cancer and radical prostatectomy (Grunfeld et al., 2013). The purpose of the current article is to report on an exploration of the connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy as a means to thoughtfully considering what preoperative information and postoperative plans might be usefully made to ease men’s inevitable work transitions.

Methods

The study employed qualitative research methods comprising individual interviews (Charmaz, 2006). Data collected through interviews with various participants helped contrast perspectives and gain in-depth understandings of the connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy.

Recruitment and Data Collection

Recruitment of participants began in April 2014, after research ethics approval was granted by the University of British Columbia Ethics Committee (UBC BREB #: H14-00559). Twenty-four men were recruited from prostate cancer support groups and a urology clinic in a Western Canadian city. Study materials were distributed by prostate cancer support group leaders at meetings and by staff at the urology clinic; potential participants were invited to contact the lead researcher. Inclusion criteria were as follows: (a) employed at the time of prostate cancer diagnosis, regardless of occupation, current work status, or concurrent illnesses; (b) undergone radical prostatectomy as primary treatment for prostate cancer within the past 36 months, regardless of subsequent or current secondary treatment(s); and (c) able to read and speak English.

Data were collected by the first author through individual, in-depth, audio-recorded, semistructured interviews, which lasted between 60 and 90 minutes. Participants provided written consent prior to interview. Interview questions were aimed at eliciting qualitative data about men’s perspectives of work, experiences of prostate cancer screening and diagnosis, and reasons for undergoing radical prostatectomy (see Table 1). The purpose of the questions was to evoke narratives that contained rich descriptions of the processes and contexts in which men made work- and prostate cancer treatment–related decisions. Participant identifiers were removed in the transcribed interviews and replaced with researcher-assigned pseudonyms.

Table 1.

Semistructured Interview Guide.

Sample questions 1. What was work like before prostate cancer? 2. What did work mean to you before prostate cancer? 3. How did prostate cancer get in your life? 4. How did you decide whether or not to tell about your prostate cancer at work? 5. How did work impact your decision to treat prostate cancer?

Participants self-identified as White (58.3%; n = 14), Asian (20.8%; n = 5), South Asian (8.3%; n = 2), Aboriginal (4.2% n = 1), Caribbean (4.2%; n = 1), and Latin American (4.2%; n = 1). The men’s ages ranged from 44 to 75 years (average age = 62.3), most were married (83.3%; n = 20), college and/or university educated (83.3%; n = 20), and worked full- or part-time (91.7%; n = 22) in a wide range of occupations that included architecture, commercial photography, engineering, and factory production line work.

Analysis

Data collection and analysis occurred simultaneously and drew on constant comparative methods as described by Charmaz (2006). The data were electronically tagged with labels using NVivo^TM to help organize the data. This process consisted of assigning codes to data excerpts in the transcribed interviews describing processes and/or actions. Codes facilitated making constant comparisons, which involved (a) comparing participants’ views, perspectives, and/or experiences; (b) comparing incident with incident; (c) comparing data with category; and (d) comparing category with other categories (Charmaz, 2006). Making constant comparisons led to the understanding of processes represented in the data. Memos about these understandings were written to provide a measure of transparency in the analytic process by offering a detailed record of the process. Writing memos also helped define and clarify concepts and/or categories, summarize and/or distil ideas, and were crucial in achieving understandings of the data. The memos were essential in pointing to areas that required further exploration and guiding subsequent data collection. As analyses progressed, comparisons of experiences and/or incidents/events described in the data gradually shifted to making analytical comparisons of the similarities, differences, and relationships among categories. Categories were then linked and arranged into themes to describe the connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy. The analyses were advanced by integrating masculinities frameworks (Connell, 2005) and previous relevant work (e.g., Kelly, 2009; Nixon, 2009; Oliffe, 2009; Thurnell-Read & Parker, 2008).

Findings

The findings comprise two main themes. The first theme details “the centrality of work in men’s lives before prostate cancer.” The second theme addresses “the connections between work, prostate cancer screening, diagnosis, and the decision to undergo radical prostatectomy.”

The Centrality of Work in Men’s Lives Before Prostate Cancer

Regardless of income, family composition, type of work, and/or social status, work was viewed by participants as a means of generating the income needed to satisfy material needs and fulfill provider roles. In this respect, income and purchasing power generated through work was central in determining men’s success as protectors and providers. Oscar, a 56-year-old business owner, explained:

If you wanna have nice things, and be able to educate your kids and put a roof over their heads and food on the table and clothes and stuff, you gotta run a million miles an hour chasing the buck.

However, participants often described engaging in work that was demanding and stressful. José, a 65-year-old auditor, shared how the resentment he drew from the people he audited made it harder for him to do his work:

My work was very demanding, the workload was heavy. The nature of the work was complex and very technical and the individuals that you have to deal with are very adverse to what you are doing, so it makes the overall situation difficult to deal with.

Overall, men recognized that complying with work-related demands and their experience of stress were justified by their need to generate income to support their families. The centrality of work in men’s lives before prostate cancer can be further understood by detailing (a) the benefits of work; (b) health impacting work; and (c) work impacting health.

The Benefits of Work

Although participants viewed work as a cause of stress, the men also felt fulfilled in knowing that their professional expertise and dedication to work contributed to workplace productivity and/or client satisfaction. Furthermore, some men mentioned that the opportunity to learn new things at work provided them with both an incentive to advance their careers and a sense of achievement. As Ricardo, a 56-year-old environmental consultant, suggested, “You look forward to coming to work. We work on probably 15 to 20 different projects at a time, so there’s always something new (to learn).”

It was evident that work provided tangible as well as indirect benefits. Tangible benefits included access to a wide range of work-related resources such as equipment for personal use and/or extended health insurance plans. For example, 66-year-old Félix recalled his experience as a former airline pilot, “I am truly fortunate my job allowed me and my family to see the world. Not many people can say that about their jobs.” Indirect benefits of work were those that facilitated personal and professional growth, and/or opportunities for socializing through work experiences. Diego, a 58-year-old automobile wholesaler, said, “Over the years, my business competitors became friends and there’s a group of us that meet regularly.” In this respect, work colleagues had first-hand experiences of workplace challenges and became confidants for work-related frustrations, anxieties, and fears. In essence, befriended work colleagues or industry peers became a source of social connection for participants who did not want to burden their families with work-related problems.

Health Impacting Work

Most participants shared the view that health was a physical and mental state of being that affects people’s ability to do the things they want. In this regard, men who experienced good health typically described their work as productive and high performing. As Martín explained: “I run long-distance and consider myself fit and healthy. I can pretty much do anything I could 10-20 years ago. That’s why I work.” Men also framed health as a function of age, where increasing age was associated with poorer health and reduced ability to work. Thus, for many men, health and age determined the type, length of time, and degree of effort they could exert at work. In this respect, a few participants with chronic diseases shared that their work capacity was limited by the intensity of specific symptoms. Augusto, a 67-year-old factory worker who suffered from benign prostate hyperplasia before his prostate cancer diagnosis, explained:

I’d been to the bathroom probably 6-7 times by lunch time. My manager thought I was being lazy, and didn’t believe I really had to go. So there were a few times he followed me into the bathroom to make sure I was really urinating and not just killing time. Everybody at work knew I was going to the bathroom frequently because it is a small company. What’s worse, some of my co-workers made fun of me because of this. But what could I do? All I could do was to hold the urge for as long as possible before going to the bathroom.

The excerpt in the preceding text highlights how health problems could decrease some men’s productivity and marginalize them within workplace milieus. In Augusto’s case, the fear of being laid off and/or ostracized at work were deterrents to disclosing his illness as the reason of his frequent washroom breaks. Similar to Augusto, a few participants shared their reluctance to confide in employers or coworkers about illness for fear of being seen as weak or ill-equipped to work.

Work Impacting Health

Some participants also shared that work-related strain contributed to their perceived decline in physical and/or mental health. For example, Fernando, a 66-year-old tour bus driver, explained that the physical demands of his work (i.e., lifting passengers’ luggage) caused and exacerbated his chronic wrist tendonitis. Even men who worked in desk or office jobs detailed the ways in which work-related strain impacted their mental and social health. In this, José, a 63-year-old auditor, explained that work-related challenges made him feel “constantly drained” and “stressed out,” symptoms that manifested “a short fuse,” which strained his relationships with family and friends.

Despite the negative impact of work strain on their health, many participants shared that they could not work less for fear of being cast as unproductive workers. Again, José detailed the consequences of working while experiencing acute symptoms of kidney stones, “I never used my (health) condition not to work. I worked even harder. But it was vicious cycle because the harder I worked, the worse I felt.” When asked why he exerted himself, José explained, “Because that’s who I am. I’d rather be doing something than sit at home and ask: ‘Why me?’” José’s responses underscored two reasons why some men choose to work through illness. The first reason pointed to upholding masculine ideals around work rate and productivity. In this regard, most participants viewed work contributions and output as key characteristics of their value and identity as a worker. The second reason had to do with the way some men managed illness. As evidenced in José’s narrative, work afforded him avenues to cope with illness while emphasizing his contribution to workplace productivity.

In summary, most men constructed their identities around masculine ideals prescribing commitment to work and contributing to the well-being of others. Indeed, participants worked through various challenges to meet and/or surpass workplace standards of workmanship and productivity. However, as middle-aged and older men, participants conceded that their most productive years were behind them. In this respect, evidenced was the tension many participants experienced due to their declining work capacity and desire to meet work expectations.

The Connections Between Work, Prostate Cancer Screening, Diagnosis, and the Decision to Undergo Radical Prostatectomy

In this section, descriptions of how men managed work within the context of their prostate cancer–related concerns are detailed in (a) prostate cancer screening; (b) receiving a prostate cancer diagnosis; (c) treatment decision-making; (d) disclosing prostate cancer at work; and (e) working until the day before surgery.

Prostate Cancer Screening

Most participants reported knowing little about the implications of prostate cancer screening with the prostate-specific antigen (PSA) test. However, men viewed PSA testing as a prudent and responsible way of monitoring their health at the time of screening. While some men had their first PSA test for medical reasons (e.g., family history of prostate cancer, urinary symptoms), most participants were asymptomatic and underwent prostate cancer screening at their physician’s recommendation. In this, many men implicitly agreed to prostate cancer screening in recognition of their increasing age and vulnerability to illness. For example, Carlos, a 56-year-old clergyman, recalled:

I was at the doctor’s (office) for my annual checkup and by the end of the appointment he said: “You’re 50 now. So, why don’t we check your blood and add PSA?” I figured I was having blood tests done anyway, so I had it (PSA) tested as well.

Similar to Carlos, many men recalled being suggested to have the PSA test as a result of visiting a doctor for an unrelated health issue. In such contexts, few men recalled discussions with their doctors about the pros and cons of prostate cancer screening. Instead, the PSA test was positioned as a value-added item and a convenient way to detect prostatic disease. Thus, the men’s complicity relied on framing prostate cancer screening as efficient, responsible, and necessary to identify prostate cancer in its early stages.

In contrast, some men had PSA testing for life insurance purposes or as part of a mandatory and comprehensive health-screening program for their work. For example, Jorge, a 61-year-old home inspector, explained, “I went to get life insurance, and as a requirement they tested my PSA,” while Félix, a 66-year-old former airline pilot, underwent the PSA test regularly for work:

(Airline company) invests a lot of money on its pilots and it’s a huge loss to the company if a pilot quits for health reasons. So every two years, they send you to the doctor and do a complete medical assessment that includes PSA.

As a result of having a family history of prostate cancer, urinary symptoms, and/or abnormal PSA test results, most participants were routinely tested and, without exception, they noted rising PSA levels over time. Though many men including Javier, a 68-year-old self-employed carpenter, “seriously learned” about the implications of rising PSA values through the Internet, most participants did not expect that their work would be affected as a result. In this respect, many participants, including Alberto, a 64-year-old government worker, considered that prostate cancer was “a distant possibility at the time. So, (he) didn’t think too much about it.” Indeed, most participants maintained their work routines because they did not perceive that rising PSA levels threatened their work capacity. As Martín, a 69-year-old contractor, recalled, “There was nothing holding me back from work. So I kept working as usual.” Furthermore, none of the men reported disclosing his PSA-related concerns to work colleagues. In this sense, Enrique, a 75-year-old university academic, explained, “I didn’t tell my colleagues about it because it is personal information and I didn’t feel like they needed to know.”

Receiving a Prostate Cancer Diagnosis

Concerns about increasing and/or abnormal PSA levels were reasons for participants to undergo prostate biopsy and gain a definitive diagnosis of prostate cancer. Although the men had to request and/or arrange to take a day off from work for their biopsy, participants detailed that they were not required to disclose the specific reason for their sick leave. Enrique, a 75-year-old university academic, defended this practice to protect his privacy while asserting that his work colleagues “would not be able to help anyway” and, therefore, he did not want to “trouble them with personal problems.” Evidenced in Enrique’s story was his alignment to masculine ideals around invulnerability and autonomy, characteristics that fueled his reticence to share and/or solicit support for his health-related worries.

In the context of a prostate cancer diagnosis, tumor(s) grading and/or stage determined, to a degree, the men’s level of concern. For example, Carlos, a 56-year-old clergyman, explained how learning from his physician that the cancer “was in its early stages” and “curable” fostered hope that the “problem” could be rectified. In contrast, participants who were told that they had an aggressive form of prostate cancer described experiencing significant anxiety. Fernando, a 66-year-old tour bus driver who was diagnosed with aggressive prostate cancer, worried about it spreading, “I got really frustrated and I was scared. So I said: ‘You know what? Let me just have the damn thing taken out!’”

Faced with the diagnosis of prostate cancer, participants were reminded of their own mortality and reevaluated what was most important to them in life, wherein they prioritized strengthening family relations and improving life quality. Oscar, a 56-year-old businessman, explained:

I was running a million miles an hour chasing this all mighty buck and all of a sudden I saw the finish line and thought: “Wait a minute, I kinda wasted my life chasing the buck and I didn’t really slow down to enjoy life with my family?” So, I’m just gonna falter back, I backed off the throttle, switched gears and just enjoy the scenery instead of concentrating on the rally.

As a result of the diagnosis, many men, including Oscar, increasingly viewed work as competing with, and oftentimes winning over, nurturing family relations. Although participants recognized the importance of generating income to provide for their families, the men also acknowledged that fulfilling work obligations did not necessarily optimize their relationships with loved ones. In this regard, most participants shared their desire to reconnect with family members and a few men described how they had reduced hours at work to spend more time with family. In this context, masculine ideals of toughness and self-reliance were disrupted by prostate cancer diagnosis. Indeed, Javier, a 68-year-old carpenter, described how stoicism gave way to sentimentality and the strong desire he had for being with his family, “We say what we feel. Like, I got all teary when my son looked at me and said: ‘Dad, you gotta stick around.’”

Treatment Decision Making

Participants were diagnosed with localized prostate cancer and understood that it could be treated with either radiation therapy or radical prostatectomy. Most men strove for objectiveness by engaging in a thorough evaluation of the pros and cons of each treatment ahead of deciding on surgery. Participants’ stories around treatment decision-making detailed how masculine ideals of independence and self-reliance gave way to cooperation and consultation as they interacted with physicians. Although physicians’ opinions were highly respected, most men emphasized that consultation with specialists did not erode their autonomy in treatment decision-making. As Alejandro, a 67-year-old software engineer, shared:

My urologist explained the benefits of radical prostatectomy and tried to convince me to have surgery. But I knew that I could see a radiation oncologist or ask for a second opinion because, in the end, I was the one deciding which treatment to have.

Most participants described feeling responsible for learning as much as possible about the treatments available to them. Indeed, many men consulted with various physicians to learn about the effectiveness and side effects of different treatments. Related to this, physicians were expected to provide treatment-related information in a clear and detailed manner. For César, a 63-year-old courier whose first language was Chinese, his physicians’ willingness to “explain things at length using simple terms and examples” was essential to making an informed treatment decision.

Many participants learned that radiation therapy (in either external beam delivery or brachytherapy) had comparable 5-year survival rates with radical prostatectomy and clear benefits over surgery in terms of preserving urinary continence and erectile function for a number of years after treatment. In evaluating radiation therapy, a few men considered its potential implications for work. Jorge, a 61-year-old home inspector, explained:

I was inclined to have brachytherapy because the recovery time was shorter and there would be no big wound, so I could crawl, climb the ladder and do some lifting. But with surgery, I was expected to rest for about three months before I could fully get back to work. That’s too long to be without income.

Jorge’s explicit preference for brachytherapy was due to his understanding that it would not affect his work capacity as much as radical prostatectomy. However, despite the benefits of brachytherapy, Jorge became concerned about its effectiveness in controlling cancer because, as he described, “There (is) no way of knowing if the cancer had spread inside the body or if all the cancer tissue was properly irradiated.” Similarly, other participants felt that the uncertainty in not knowing whether all cancer cells had been destroyed rendered radiation therapy an inferior treatment option.

In essence, participants viewed radical prostatectomy as the treatment that offered the best chances of controlling prostate cancer. Oscar, a 53-year-old businessman, explained that in having surgery, “the cancer (would be) taken out and thrown into the garbage. And as long as none of the (cancer) cells escaped the prostate, you’re cured.” Additionally, many participants noted that biopsy of the resected gland was an important benefit of radical prostatectomy in determining prostate cancer aggressiveness. Alejandro, a 67-year-old software engineer, explained:

You can tell if the cancer escaped the prostate. If it did, you would follow-up immediately with further treatment. You wouldn’t be able to know that with radiation therapy.

Like Alejandro, most participants understood that radiation therapy was often used successfully to treat prostate cancer metastases and/or recurrence after radical prostatectomy. This was perceived as a crucial advantage of radical prostatectomy when the men learned from their physicians that surgery would be difficult and often not advised for treating prostate cancer recurrence after radiation therapy.

Even though most participants knew about the side effects of radical prostatectomy, it appeared that many physicians did not explicitly discuss the potential impact of surgery on work. For example, Augusto, a 67-year-old factory worker, recounted his urologist’s assurances that he could “resume work once the (surgical) wound healed” and that urinary incontinence would “decrease over time.” Thus informed, many participants framed the side effects as temporary and/or relatively inconsequential. Manuel, a 44-year-old franchise owner, explained:

I thought, and still think, prostatectomy was the best option I had to keep me alive and working. I was worried about the incontinence and not having sex and all of that. But, I’ve got other things to worry about and my family came first.

As exemplified in Manuel’s narrative, many men explicitly forwent masculine ideals related to control of the body and sexual prowess and decided to undergo radical prostatectomy to increase their chances of survival and, by extension, maintain their ability to provide for their family. While some masculine ideals were forfeited by the participants, most men assumed and relied on fully returning to work and fulfilling provider roles in the aftermath of surgery.

Disclosing Prostate Cancer at Work

Most participants disclosed having prostate cancer to their employers and/or human resources department as they justified sick leave arrangements and/or requested other work-sponsored entitlements ahead of undergoing radical prostatectomy. However, some men were concerned about maintaining privacy and limited who the information was shared with. Omar, a 61-year-old dentist, explained:

(Prostate cancer) is a pretty personal thing and if the staff knew, it could be broadcast very quickly to my patients. . . . And I thought: “Well, what about my privacy?”

Similarly, a few self-employed participants concealed their diagnosis for fear it could hurt their business. Martín, a 69-year-old contractor, recounted, “I didn’t tell any of my clients because they’d think I wouldn’t be able to do the job and I would lose business.” Like Martín, other participants expressed concerns that disclosing prostate cancer and/or surgery would cause others to view them as unproductive workers. Related to this, men who shared their prostate cancer in professional settings attempted to downplay its impact on work. For example, Francisco, a 62-year-old realtor, reassured his work colleagues that he “would be back to work in no time” and that “everything would be fine.” By minimizing the impact of prostate cancer on work, Francisco, and many other participants, attempted to reassure work colleagues that the disease would not affect their return to work and desire to be productive, qualities central to their identities as men. Evidenced in the men’s stories was that prostate cancer diagnosis and treatment challenged men’s relationships with work, often calling for disclosure of a health issue many men considered private. In this sense, participants thoughtfully evaluated the potential benefits and consequences of disclosing their prostate cancer status at the workplace, and detailed concerns about how this might negatively impact their work and income.

Working Until the Day Before Surgery

It is important to note that most participants worked until the day before their surgery and provided four reasons for doing so. First, work provided a much-needed distraction and was a mechanism for waylaying their worry about impending surgery. Alberto, a 64-year-old government worker who experienced anxiety as he awaited surgery, explained, “It was better to keep my mind occupied. I just felt better at work.” Second, by working until the day before surgery, participants demonstrated their commitment to and competitive spirit at work, as Augusto, a 67-year-old factory worker, explained:

I’m older than most of my co-workers and I’m sure some of them would like to see me gone. But I need this job, so I worked harder so they (employers) would notice and welcome me back after surgery.

Augusto’s story also demonstrated how some men diagnosed with prostate cancer may harbor concerns about job security and actively contested dominant social norms that prescribe older, ill men as less productive workers. Third, many participants shared that their impending sick leave would result in greater workloads for their work colleagues. To address this issue, men worked until the day before surgery to minimize the impact of their absence from work. For example, Alejandro, a 67-year-old software engineer who felt “responsible in contributing to the team effort,” shared, “I worked to the last day” to “help reduce my (co-workers’) load.” Fourth, some participants felt compelled to work until surgery due to financial concerns. In this, Camilo, a 63-year-old freelance photographer, shared, “I don’t have any employee benefits. No sick leave, nothing. So, there is not much of a safety net for me. That’s why I worked.”

Evidenced were benefits and strong reasons for men to work until the day before surgery. However, threaded through the men’s stories were references to masculine ideals and social expectations around their ability to generate income, provide for family, and be seen as productive men.

Discussion

This study’s findings highlighted the complex and significant influences work had on men’s lives before and after prostate cancer diagnosis and in the lead up to radical prostatectomy. Affirmed and built upon are understandings about the significance of work in men’s lives (Emslie & Hunt, 2009; Grunfeld et al., 2013; Halrynjo, 2009) including the centrality of work in men’s identities and linkages to financial security, social status, and a sense of personal growth and purpose. Underpinning these connections were men’s alignments to masculine ideals wherein some participants self-identified as experts in their respective jobs and were remunerated accordingly for their work contributions. In this sense, many participants’ identities as men were tied to successful careers, affluence, and recognition that they had fulfilled protector and provider roles for their families. These findings align with Fideler’s (2014) assertions that men over 60 years often remain in the workforce because they find contentment and meaning in using their professional skills, abilities, and expertise in productive ways. However, the current study also highlighted that the health of some participants was threatened by work strains, confirming previous research linking work to poor health outcomes in some men (Demerouti, Bakker, Geurts, & Taris, 2009; van Hooff, Geurts, Kompier, & Taris, 2007; Oliffe et al., 2013).

Although previous research has reported that men’s masculinities shift in the aftermath of prostate cancer diagnosis and treatment (Gannon et al., 2010; Kelly, 2009; Oliffe, 2005, 2006), the current study is among the first to find that men align, in varying degrees, to ideals of masculinities and work, prior prostate cancer diagnosis. In this regard, for some men, preexisting illnesses had already curtailed their work capacity. In contrast, many participants’ financial needs underpinned their desire to remain in the workforce for as long as possible. These are important differences because they signal the plurality of masculinities in the context of work, prostate cancer diagnosis, and impending surgery.

Nineteen participants from this study underwent PSA testing for prostate cancer screening within the context of a medical appointment for an unrelated health issue and in recognition of their advancing age and increased susceptibility to illness. These results add to Springer and Mouzon’s (2011) findings that older men negotiate between conflicting masculine ideals of physical toughness and taking responsibility for their own health when assessing the need to seek medical assistance. Although most participants in the current study lacked urinary symptoms and knew little about the pros and cons of prostate cancer screening, the men retrospectively justified PSA testing as a wise practice by positioning it as central to detecting prostatic disease in its early stages and as key to optimizing potential prostate cancer treatment outcomes. Clinicians, in this regard, must recognize that men may not be fully aware of the implications of prostate cancer screening and they need to explore patients’ preferences prior to suggesting prostate cancer screening.

Prostate cancer diagnosis prompted the reevaluation of what was most important in participants’ lives. In this respect, the importance of work diminished amid participants’ efforts to optimize health and strengthen family relations. These results support Jonsson, Aus, and Berterö’s (2009) findings that prostate cancer diagnosis is a potent reminder of men’s fragility and limited control over life. For current study participants, prostate cancer diagnosis triggered a process of adaptation focused on a reconfiguration of life goals. Therefore, despite depictions that prostate cancer is a disease that is unlikely to cause death (Canadian Task Force on Preventive Health Care, 2014), its diagnosis was a major event that reshaped men’s life priorities and relationships to work and family.

Many participants explicitly anchored their commitment to treatment on masculine ideals linked with breadwinner roles, wherein their health and longevity were tied to providing family benefits. This finding supports Robertson’s (2006) argument that men frame the making of health-related decisions in terms of their duties and/or responsibilities to others. In this respect, the current study participants dismissed potential treatment side effects as they focused on eradicating prostate cancer to maintain and/or regain the health needed to fulfill protector and provider roles. Related to this, it is important for clinicians to recognize that work and providing for family are important influences on men after prostate cancer diagnosis. Thus, in acknowledging that radical prostatectomy may significantly change men’s work capacity, clinicians and patients must plan for postsurgical interventions that include physiotherapy and/or rehabilitation to help men resume work routines in a safe and sustainable manner.

The current findings about men’s treatment decision-making confirm previous research suggesting that physically removing prostate cancer is an important factor in men’s preference to undergo radical prostatectomy (Anandadas et al., 2010; Sidana et al., 2012). It is concerning that the implications and consequences of radical prostatectomy on work and everyday life were minimized and/or not fully explored with participants at the time of treatment decision-making. While participants understandably prioritized eradicating prostate cancer as early as possible to reduce the chances of metastases, Orom, Biddle, Underwood, Nelson, and Homish (2016) have argued that clinicians must guide patients in the acquisition, interpretation, and integration of prostate cancer treatment–related information as a way to support and better inform men’s treatment decisions. In this regard, clinicians must explain that postsurgical complications (e.g., wound infections) can occur and that some prostatectomy side effects (e.g., urinary incontinence, erectile dysfunction) may last longer than expected or even become permanent. Furthermore, given that health-care providers view positively the role of prostate cancer support groups in disseminating and/or sharing first-hand information about prostate cancer treatments (Oliffe et al., 2015; Yu Ko et al., 2016), patients should be encouraged to attend prostate cancer support groups to enquire from men who have previously been treated for prostate cancer about the potential impacts of treatment on their work lives.

The current study findings highlight important issues men faced when making sick leave arrangements prior to radical prostatectomy. For instance, self-employed men often chose not to tell clients about their prostate cancer diagnosis and/or radical prostatectomy for fear of losing business, while men who were employees were reticent to disclose their diagnoses because of concerns about being cast as lazy or not willing to work hard by their work colleagues. These results align with Stergiou-Kita, Pritlove, and Kircsh’s (2016) findings that working men diagnosed with a range of cancers are perceived by others as being less productive. In this regard, and in response to masculine ideals prescribing dedication to work, most participants in the current study worked until the day before surgery. Indeed, though some men positioned their engagement in work prior to surgery as a way of coping with prostate cancer–related preoccupations, most men worked until the day before radical prostatectomy to demonstrate their desire to contribute at work, lessen their coworkers’ workload, and to earn as much income as possible ahead of a potentially lengthy sick leave. Recognizing the centrality of work in men’s identities as workers and providers for family, future studies should explore how work shapes men’s health practices and treatment decisions in the context of other types of cancer and/or illnesses.

Strengths of the current study include the use of data containing rich descriptions about the experiences of men who worked in diverse occupations. Analysis considered current Canadian work contexts such as increasing concerns around job security (Canadian Labour Congress, 2014), aging workforce (Carriere & Galarneau, 2011), and changing social attitudes wherein workers are expected to work for longer (Sun Life Canadian Unretirement Index, 2015). Limitations include the lack of generalizability of research findings, as all participants lived in Western Canada and their stories about work and access to health-care services are specific to that particular context. Second, despite the diverse occupations represented in the participants’ accounts, most men held office jobs and did not experience financial difficulties. Thus, findings presented here are not representative of the diversity of employed men who are diagnosed with prostate cancer and should be considered as providing preliminary insights to the connections between socioeconomic status and the experience of prostate cancer.

Conclusion

The current study findings demonstrated diversity in men’s alignments to masculine ideals and work-related values wherein some participants acknowledged health- and prostate cancer–related vulnerabilities, while others detailed expectations for returning fully to work. Though men prioritized radical prostatectomy with knowledge of the common potential side effects (i.e., urinary incontinence and erectile dysfunction), the implications of surgery on work were rarely discussed. Drawing from this finding, clinicians should anticipate that work provides many men with activities and practices that allow them to fulfil protector and provider roles, constituting significant masculine capital and identity markers. Recognizing that radical prostatectomy can invoke unexpected work transitions for men leading up to, as well as after, surgery (Grunfeld et al., 2013), clinicians are well positioned to engage men in conversations about the nature of their work as the pathway for adapting to a range of “work” changes, some of which might prevail long after the surgery has been completed.