نبذة مختصرة : Background: The interplay between underlying mechanisms of long-term social consequences after childhood cancer is largely unknown. Using a mediation analysis framework, we assessed the pathways through somatic diseases, psychiatric disorders, and educational attainment on the risk of being unemployed for health reasons among adult long-term survivors of childhood cancer. Methods: In a Nordic register-based cohort, we identified 8825 survivors of childhood cancer diagnosed age < 20 years old in Denmark, Finland, and Sweden since 1971, and compared these with 36,729 matched individuals from the general population, and 9210 siblings. Using a mediation analysis framework allowing for multiple mediators, we estimated interventional direct and indirect effects, using risk differences (RD) with 95 % confidence intervals (CI). Results: By the age of 30, the RD of health-related unemployment between survivors and the general population was 4.61 % (95 %CI 3.98–5.21); of this, 21 % was attributed to the mediating pathway through somatic diseases, a smaller proportion (6 %) was mediated through educational attainment, and only a fraction through psychiatric disorders. The proportion mediated through somatic diseases increased with age at diagnosis, whereas the pathway through educational attainment was important among survivors diagnosed at younger ages. Conclusions: This three-country wide study suggests that somatic disease burden and educational attainment drive some of the increased risk of health-related unemployment among childhood cancer survivors, and the importance of these mediators varies by age at cancer diagnosis. These findings underscore the need for comprehensive survivorship care to prevent or mitigate late effects and barriers that could interfere with later possibilities for employment.
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