September 2007: Working During Treatment

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When mentally ready to return to work?

Question from Leah: Hi. Two months ago I had a mastectomy, and am currently taking tamoxifen. We do not anticipate any further treatment (radiation or chemotherapy) at this time. However, I am still off work, and do not feel mentally prepared to return to my high-stress, long hours, position. Physically, I could probably handle it. Is this normal? When should I expect to be able to return?

Answers —Ruth Oratz, M.D., F.A.C.P.: Each woman who is diagnosed with breast cancer meets that need differently and has to learn how to incorporate not only the implications of the diagnosis physically, in this case hormonal therapy, but the emotional impact of how that affects our future. I don't think there is such a thing as a "normal" or "abnormal" response. Each individual will respond differently. But if you are feeling that it's taking longer than you would expect to be able to return to your normal activities, then you should address this in detail with your treating physician, and if necessary, seek additional guidance from other healthcare professionals, perhaps a psychologist or a social worker or a psychiatrist. Your doctor may help you understand what's going on, and cope better with the effects of the diagnosis and treatment. You may in fact have an anxiety or depression response to this news, and that's not abnormal in this situation. It would be helpful to make sure you don't need some additional treatment from other professionals. In addition to healthcare professionals, support from women who are going through the same process can be very helpful. You may find a support group in your local community, and there are a number of online support groups and other support organizations. So I'd encourage you to reach out to your doctors, as well as other members of the breast cancer community, and also turn to the people you're closest to — your family and friends — and hopefully you can work through this in a timely fashion and be able to return to your normal activities.

Barbara Hoffman, J.D.: You should be aware of any deadlines in your personnel policy about when you are able to return to work. Employers are not obligated to provide unlimited leave, so check the amount of leave you're entitled to. That amount is dependent on the terms of your employment.

Editor’s Note: Read online discussions about managing side effects and finding support in the Breastcancer.org discussion boards.

How many days too sick to work?

Question from Elizabeth: I just had a bilateral mastectomy and will start chemo Oct 2: 4 treatments for 4 weeks, followed by radiation and hormonal therapy. Typically, how many days will I feel too sick to work?

Answer —Ruth Oratz, M.D., F.A.C.P.: This question is about the specific side effects of chemotherapy treatments. I don't know which drugs you're going to be receiving, but I assume it's one of the common regimens used to treat breast cancer. Your oncologist and oncology nurse should certainly meet with you before you begin treatment to discuss in detail which side effects you can expect and how best to prevent and manage those side effects. Some of the most common side effects from chemotherapy include fatigue, nausea, and hair loss. Fatigue is usually cumulative, and builds up gradually over the course of treatment. So with each subsequent cycle, you may feel more tired than you did with the previous cycle. But there should still be a rebound period between treatments when you have a little more energy. If there's nausea associated with your chemotherapy drugs, I'm sure your doctors will prescribe anti-nausea medicine in advance to prevent nausea and vomiting. Most often, we also recommend a specific regimen for the first few days following each chemotherapy treatment. Usually our anti-nausea treatments are very effective. Most patients tell us that they feel well for the first day or two following chemotherapy, and that the side effects seem to be most severe 3-4 days after each treatment, then gradually begin to improve over the next several days. You may wish to discuss the timing of your treatment so you can plan your work and your days off around the treatment day, and so you can know when you can expect to have days when you're not feeling so well.

Fired for poor performance during treatment?

Question from SusanK: I finished radiation 4 weeks ago (no chemo, no drugs). I have been exhausted and forgetful at work, not functioning at my usual level. My boss summoned me for a lecture on my poor performance. I have 3 years with the company and stellar reviews. I took about 8 days off in 3 months for surgery and radiation. Can she really dump me for what I agree is poor performance? What should I do?

Answers —Barbara Hoffman, J.D.: State and federal laws prohibit discrimination based on disability. Most cancer survivors would be covered under that definition. In your case, it sounds like you would be covered. Employers, however, can fire you for failure to complete essential job duties. However, under federal laws such as the Americans with Disabilities Act (ADA), which covers employers with at least 15 employees, and many similar state laws, an employer is required to give employees a reasonable accommodation for such issues related to treatment, such as fatigue or difficulty concentrating. So you should propose something at work that could address the issues you're experiencing, and if the accommodation is not unduly expensive or disruptive, an employer covered by one of these laws would be obligated to provide it. If you think you could complete your job function by possibly needing a break in the middle of the day to regain energy, that may be one type of reasonable accommodation.

Ruth Oratz, M.D., F.A.C.P.: You reported that you only had radiation and no chemotherapy or hormonal therapy. Certainly surgery with anesthesia and radiation can cause fatigue. It would be most unusual to have any cognitive changes from radiation treatment to the breast. I would again raise the concern that you may have some emotional issues around your treatment. Most commonly depression can cause difficulty concentrating and significant fatigue.  Discuss this with your doctors to see if some sort of support, therapy, or even medication may help with these issues.

How does the FMLA protect employees?

Question from BigMo: I worked in a competitive field that was constantly downsizing. Coworkers resented my absence through FMLA and made numerous comments about how they "were healthy" and should be retained instead of me because I had used my FMLA. How do laws actually combat this reality in the workplace?

Answers —Barbara Hoffman, J.D.: The FMLA (Family and Medical Leave Act) is a federal law that protects employees in businesses who have at least 50 workers. It requires the employer to provide up to 12 weeks of unpaid medical leave. An employer cannot discriminate against an employee for exercising her rights under the FMLA. However, if an employer is downsizing anyway, an employee is not guaranteed a job just because she did exercise her rights under FMLA. So the problem is that here, without more information, it's unclear why an employer might fire you. The employer would need to justify firing you on a business-related issue totally different from you exercising your leave under the law.

Ruth Oratz, M.D., F.A.C.P.: If I heard the question correctly, you are also concerned about the relationship with your co-workers, not only your employer. It is not at all uncommon for me to hear from my own patients similar stories, how co-workers can at times be resentful of the woman who has taken a medically and legally justified and legitimate leave of absence from work. It may mean that co-workers are doing more work than they were doing before. It's important on returning to work that you build those bridges and reconnect with colleagues in a way that is not confrontational, but allows both you and your co-workers to understand each others' feelings and point of view. So I'd recommend if there is an HR person at your place of work, or your employer or supervisor, you go to that person and ask for help in facilitating a team meeting to openly air these issues and discuss them together in a supportive environment. If you can't identify an obvious facilitator, then perhaps approaching the individual who seems to be disgruntled, again in a friendly and empathic way, understanding that although you are the person who suffered from this diagnosis and treatment, there were people around you who also suffered. Hopefully you can repair those misunderstandings, and move forward in a positive way so your co-workers can treat you in a supportive and helpful way.

What to do with unsympathetic employer?

Question from Ann64: What do you do if your employer is COMPLETELY unsympathetic to your situation and will not make reasonable accommodations, such as taking an extremely autistic boy out of my classroom, or hassling me to make my appointments so they are the least intrusive to the class. Yes, she used the word intrusive. There is more stress placed on me due to my job than the cancer itself.

Answer —Barbara Hoffman, J.D.: Sometimes talking directly with a supervisor isn't sufficient, because the supervisor doesn't understand the law pertaining to accommodations, or is just unsympathetic on a personal level. In that case, it's usually better to go to someone who supervises your supervisor, and in a teaching situation it sounds like that would be a principal or someone above the principal level who could help facilitate some sort of discussion so you can exercise your right to reasonable accommodation. If that doesn't work, the next step is involving an advocate — perhaps a union representative or attorney. When you get to the stage where an attorney is involved, it becomes more adversarial. Teachers are in unique situations because, on the one hand, you're entitled to reasonable accommodation. On the other hand, physical presence in the classroom is an important part of your job. So you may need to negotiate some combination of physical leave from the classroom with the reasonable accommodation, i.e., changing students from your classroom to another classroom. But as long as you're capable of performing the essential functions of your teaching position, you're entitled to keep it with those reasonable accommodations.

Points to consider in job search?

Question from Stephanie: I have metastatic breast cancer. Due to some funding cuts at my current company, I may need to start a job search. What do you think are some of the most important issues for me to consider as I entertain this possibility (i.e. health insurance, illness disclosure, etc.)?

Answers —Irene Card, : Of course, in a job interview, you just want to answer the questions asked. Don't volunteer any information. A good interviewer will probably elicit your medical history without asking, so be very aware of that. If you ask too many questions about the health insurance early in the interview, you may be putting up a red flag and alerting the interviewer that you may have a health problem. It's best to wait until you have almost been guaranteed a position before you ask for specific information about the health insurance. If this is a very large company, they will have multiple plans from which to choose. Even small employers with less than 50 employees often have a number of plans from which to choose. You definitely want an insurance plan that gives you the most freedom to choose your providers, namely a preferred provider organization (P.P.O.). This allows you to see anyone who is in the network, but you also have the option to see a provider out of network although it will always cost you more money out of your pocket when you are out of network.

Barbara Hoffman, J.D.: You're likely to have many medical appointments in the future, so having flex time at work would be good for both you and your workplace. To maximize the kind of position where you have flex time, it may be best to work for a very large employer that has at least 50 employees and is covered by many federal and state laws that would give you more options regarding medical leave.

Irene Card, : There is no waiting period for pre-existing conditions so long as you have been continuously insured and do not have a gap in coverage. When you have a gap in coverage, you are not insured.  Some states will allow you to have a gap in coverage for a fixed amount of days not there will be no waiting period for preexisting conditions. Not all states do this. Of course, ideally you do not want a gap in coverage, especially if you are dealing with a current diagnosis of cancer. Any new illness or injury that you receive during a gap in coverage will be considered a pre-existing condition and as Barbara said, the larger the employer, the better your chances are of being insured under a plan that simply has no waiting period for pre-existing conditions. It's important to save any correspondence about your health insurance from one job to the next because in all likelihood, you will have to prove that you had health insurance for a given period of time.

Lose job and insurance coverage?

Question from Darcee: What if your employer fires you and you lose your insurance coverage?

Answers —Irene Card, : The answer depends on which state you reside in, and how large a company you work for. The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that applies to employers with 20 or more employees. It allows you to continue your health insurance for 18 months. If you are disabled, you can extend the 18 months to 29 months at which time you should become eligible for Medicare benefits because of disability. If you work for a small company, namely one with fewer than 20 employees, the state in which you reside may or may not have a law in force to protect you. You should call the Department of Insurance in the state in which you reside for this information. For example, New Jersey passed a law entitled New Jersey Continuation of Benefits. This law is for employers with less than 20 employees and it mimics the COBRA law for the most part. It allows you to continue your benefits. Your employer must notify you of your right to continue benefits and you have a given number of days, depending on which law we are dealing with, to respond and let the employer know you wish to continue benefits. You are responsible for 100% of the premiums and the employer has the right to charge an additional 2% for administrative costs. If a person is out of work, it is usually quite difficult to afford the monthly premiums just at a time when you need the coverage the most. There are some options available for those who cannot afford a health insurance premium. My website has a lot of information: www.micinsurance.com.

Ruth Oratz, M.D., F.A.C.P.: Another website I would refer you to is called www.cancerandcareers.org.

Barbara Hoffman, J.D.: State insurance departments would also have information about your state law.

How to delay bills until able to pay?

Question from Nurse: How I can delay payments of bills without credit damage until I can return to my fulltime job (credit cards for covering medical bills not covered by insurance)?

Answers —Irene Card, : It is most important to let your providers know that their bill is one of many. It is important to try to send a little money to each creditor each month, rather than taking one bill and paying it off before working on the next one because there are too many bills. Communication with your providers is most important when dealing with a lot of medical bills. Even though your health insurance may have paid the biggest percentage of the bill, when you have many bills each having a 20% balance, you can be strapped for a long time. Most doctors will work with you if you only let them know you have a problem. We never assume that the patient cannot pay the bill. That is why it is so important for you to discuss your financial situation with the business manager in your physician's office. If this person turns a deaf ear, speak with the doctor.

Ruth Oratz, M.D., F.A.C.P.: I would add, as the doctor, that indeed most physicians are certainly willing to work out accommodations for patients, whether it's a payment plan or other options. In addition, if there is a social worker or financial advisor available through your doctor's office, clinic, or hospital, you may be eligible for assistance from either charitable organizations or support organizations. You should inquire about those resources as well. There are many support services that are available free of charge. Although these will not necessarily pay all your medical bills, you may be able to get a lot of assistance through these programs. If you're having trouble paying for prescriptions and if you meet certain financial criteria, many oncology drug companies have financial assistance programs that will provide cancer medicines, including chemotherapy, oral agents, and hormonal therapies either free of charge or at a significantly reduced rate. So I would agree it is very important to communicate these concerns as early as possible with your healthcare providers and their social work networks.

How to balance work and treatment?

Question from JHolt: I am a public school teacher at the high school level. I want to know how I can let administration know I cannot stay after school, drive back to school for meetings or cut my treatments out for a day or two each week. How do I stand up to them while I am holding on to my job?

Answer —Barbara Hoffman, J.D.: You have a similar issue to the previous teacher. The teaching does require physical presence, and discrimination laws protect cancer survivors only if they can perform their job with reasonable accommodation. Mostly the essential job function of a teacher is to be in the classroom and teach students, so I think you have a good argument that after-school meetings and other functions are not essential, and the school should accommodate you while you need time off for medically necessary treatments. Start by speaking directly to your principal or supervisor. If that doesn't yield a constructive response, try a union rep or even a colleague to try to work something out.

Retire with breast cancer?

Question from MarisaC: Is a person with breast cancer allowed to ask for retirement?

Answers —Ruth Oratz, M.D., F.A.C.P.: From a clinical point of view, it's important to know if you have active disease, whether the disease is metastatic, and if so what the prognosis is. Or are you someone who's newly diagnosed and is undergoing therapy? I don't know the legal implications, but it seems to me that would be important information to know before answering your question.

Barbara Hoffman, J.D.: Additionally, I'd need to know what the personnel policies are where you work to know the rules regarding retirement.

Ruth Oratz, M.D., F.A.C.P.: Other than retirement, other options are a leave of absence. Or perhaps you're eligible for leave under the Family and Medical Leave policy or you're eligible for disability insurance.

Breast cancer history affects getting insurance?

Question from SLP: I have finished treatment and I will be starting a new job next month. Medical benefits are offered. Is the insurance company obligated to take me on as a subscriber even with my past history of breast cancer? It has been over 2 years since diagnosis.

Answer —Irene Card, : Yes, under the Health Insurance Portability and Accountability Act, all insurers must insure a person regardlQ11ess of their health. There may or may not be a waiting period for a pre-existing condition as explained earlier. But they cannot discriminate and refuse to insure you because you have a history of cancer. Back in the 80s that was the case, but fortunately, enough laws have been passed since then that we don't see that happening anymore.

Employer can deny disability?

Question from Bright Side: Last summer I took 7 weeks short-term disability leave due to extended treatment. I have Stage IV cancer metastasized to the bones and am still in treatment. Does my employer have the option of denying disability to me this time? I'm thinking short-term and then possibly having to go into long-term. Thank you.

Answers —Barbara Hoffman, J.D.: State disability laws govern the terms of when you're entitled to disability, how long, and at what compensation level. So the best thing to do would be contact your state Department of Labor or Unemployment Division to find out how the law covers you. They vary significantly from state to state.

Irene Card, : Some employers offer short-term disability or long-term disability insurance policies. These policies vary dramatically from one company to another as to how long you have to be out of work before you are able to collect benefits, and the amount of money you can collect is based on a percentage of your earnings. But each company is different, so you'd have to carefully review that policy.

Help with increasing physical activity?

Question from Feather: I am 64 and work as a receptionist 50 hours a week out of necessity. I had a lumpectomy in my left breast in 2005. Did not have radiation or chemo. Grade 3, Stage 1. Since I sit all day, I am dragging at night and on the weekend. I have gone from a size 8 to a 14 — help?

Answer —Ruth Oratz, M.D., F.A.C.P.: This is not an uncommon scenario. Often when patients are debilitated from cancer and cancer treatments, their level of physical activity decreases significantly. Alterations in appetite and eating patterns, as well as sometimes the effect of the treatment itself, can lead to weight gain and fluid retention. It is very difficult, and I'm very sympathetic to how difficult it is to lose this weight. But it is important, and you're clearly recognizing, that you do get some help in this regard. The first thing is to speak with your doctor about the treatments you're receiving, and whether these treatments might be contributing to your weight gain. It would also be helpful to meet with a nutritionist who would carefully review your diet and how you can alter your eating pattern in a way that's sensible, not making drastic changes, but making gradual appropriate changes so you can have a slow but steady weight loss. It would also be helpful to have a consultation with either a physical therapist or a physical rehabilitation program to identify what type and what level of physical activity you could begin. It is very important to maintain an ideal body weight. There are many complications from obesity, including the risk of developing diabetes, high blood pressure, and other metabolic disorders. Your doctor should also evaluate carefully for other medical conditions that might be contributing to weight gain; for example, checking your thyroid function. Weight gain is usually the result of many factors: dietary, exercise, drugs you may be taking, as well as other medical conditions that are contributing, and psychological and emotion conditions that may cause some of us to eat more or some of us to eat less than usual. So you should be evaluated by your doctor with referrals to other specialists as warranted.

Advice on working odd hours, infection risk?

Question from Scotty: I'm 35 and being treated for ductal carcinoma. I have AC every other week for 4 cycles, then Taxol every week for 12 weeks. I work part-time at a department store from 6-11 p.m., sometimes until 1 a.m. I want to keep working, but am worried about germs and wearing myself down. (I also have a 2 1/2 year old son to wear me out.) What are your recommendations on working such crazy hours?

Answer —Ruth Oratz, M.D., F.A.C.P.: There are many components to this question. The first aspect relates to the risk of infection for individuals taking chemotherapy. The chemotherapy regimen you described can be associated with a significant decrease in the white blood cell count. Our white blood cells help to protect and defend us against infection. Your doctor should be checking your white blood cell count prior to administering chemotherapy at each cycle. If your white blood cell count is low, it may be helpful to receive an additional medication called Neupogen (chemical name: filgrastim) or Neulasta (chemical name: pegfilgrastim) which can help to boost or maintain the white blood cell count during chemotherapy. You should discuss whether or not that is indicated for you with your oncologist. Some oncologists use prophylactic oral antibiotics to protect patients during the timeframe when the white blood cell count is at its lowest. Again, you should discuss with your treating physician what his/her protocol is with respect to this issue. In general, you should avoid contact with individuals who are obviously sick — fevers, coughs, runny nose, etc. This does not mean that you can't go outside or be in public places or take public transportation. But it does mean you should exercise some general caution. Young children, especially if they're in school or day care, as we all know are often exposed to infections from other children and bring them home. Wash your hands frequently. If your own child is sick, speak with your doctor and/or your child's pediatrician about whether or not your child has a bacterial or a viral infection and whether or not you need to be tested and/or treated for infection. Most individuals are able to continue working without contracting serious infections during chemotherapy. The second part of your question refers to the advisability of working long hours. I generally advise patients to listen to their own bodies. If you are able to work those hours, if you are productive and enjoy working those hours and you can manage it, by all means work. But if you find that you need to have some accommodation in your work hours because you are fatigued, then you should talk with your employer about reasonable accommodation in your hours.

Work in an environment at high risk for infection?

Question from Michaela: Can I get some advice? Should I continue working before, and for that matter, during and after treatment at my job? I am working in the CL3 environment: avian influenza and other animal diseases.

Answer —Ruth Oratz, M.D., F.A.C.P.: It sounds as if you are in an environment where you might be exposed to some rather serious infections. You did not specify what treatment you're taking, but it sounds like it might be chemotherapy or other treatments that might increase your susceptibility to infection. There are some precautions that could be taken, and some medication that could be used to help maintain the integrity of your immune system during treatment, and you should discuss this with your oncologist. You should also review the general precautions in your workplace that would protect you and other employees from contracting a serious contagious disease. There should be OSHA (Occupational Safety and Health Administration) and other federal workplace regulations about protecting employees who are working with infectious agents.

Advice for self-employers in treatment?

Question from JStephenson: I don't have the luxury of a weekly paycheck. I am a real estate broker working on commission only. How do other self-employed folks keep themselves out there in the market, looking for business and keeping proactive while being treated for breast cancer?

Answers —Barbara Hoffman, J.D.: For the most part, individuals who are self-employed are not covered by job discrimination laws such as the federal Americans with Disabilities Act or FML Act, and are not covered by most state anti-discrimination laws that are similar to the Americans with Disabilities and FML acts. A few state laws cover employees regardless of the size of the company they work for. But if you are an independent contractor and self-employed, then your goal is to try to work as efficiently as possible to maximize your income while balancing your healthcare needs. I don't think there's a single answer to that, because it depends on your diagnosis, physical health, and resources. One thing that we have been talking about is how important it is to work with your healthcare team to try to manage that balance so you don't work so much that you compromise your healthcare.

Irene Card, : Inasmuch as you are paid by earning a commission, which can vary dramatically from month to month, it is important that you establish a budget and only draw X number of dollars each month to meet your budget, keeping the balance in an interest-bearing account that you may need to draw from for next month's budget. Of utmost importance is paying your health insurance premium on time. Do not be late and risk lapsing your coverage.

Can working during treatment be harmful?

Question from Kona: My wife has breast cancer metastasis. She is currently receiving her second round of radiation therapy and will probably soon receive her third round of chemotherapy. Through all this, she still insists on working full-time, calling in sick on only the worst days. Could she be doing herself harm working during treatment?

Answer —Ruth Oratz, M.D., F.A.C.P.: It's unlikely that working during treatment could be causing her harm if she's not experiencing physical discomfort or other symptoms. If her energy level is adequate and she's able to work, I would encourage her to continue working for many reasons. It's important to remain physically active. Psychologically and mentally, work helps us remain engaged and productive. However, if your wife feels that work is somehow contributing to her feeling worse, again there might be accommodation with respect to type of work, the number of hours she's working, the number of days a week she's working etc. that she could address with her employer. And she should discuss with her doctor the specific side effects she can expect from treatment and how to incorporate her work and treatment schedules together into a productive program for her. I encourage people to work if they're up to it.

Long-term disability during treatment?

Question from Michaela: I am paying long-term disability (LTD) at work, but was told I have to take first vacation, then overtime, and then go on unemployment insurance. Is that right? Can I go on LTD during treatment?

Answers —Barbara Hoffman, J.D.: That is probably governed by the terms of your employment contract and your state's employment law.

Irene Card, : Disability coverage varies by insurer. Some policies will state that you must use all of your sick time and vacation days before the policy will begin to pay benefits. Read your policy carefully.

Employment discrimination common?

Question from PW: Every time I leave for a chemo treatment, my employer docks my pay. Has anyone else been subjected to such horrible treatment by an employer during this stressful time?

Answer —Barbara Hoffman, J.D.: That probably is employment discrimination, because if you work for an employer that's covered by the Americans with Disabilities Act, you may also be covered by state anti-discrimination laws. That's an unfortunate situation, but the good news is that it's becoming increasingly uncommon. Employment discrimination against cancer survivors has decreased. Most survivors are treated fairly at work, according to recent studies. Laws such as the ADA and the FMLA are working. Also, attitudes about cancer exemplified by the use of terms such as cancer survivor and cancer survivorship have also helped to decrease workplace discrimination.

Salary workers better off than hourly?

Question from Betsy: I am a salaried worker. What does that really mean? Do I have more flexibility in my schedule from week to week? What are the legal safeguards for salaried exempt employees when it comes to medical time off?

Answer —Barbara Hoffman, J.D.: The fact that you are paid a set salary instead of hourly should have no effect on your rights under laws such as the ADA and most states' anti-discrimination laws. The most important factor is whether the company has to obey those laws and that's related to how many employees the company has. So for example, the FMLA covers employers who have at least 50 workers. The ADA covers employers who have at least 15 workers. State laws vary significantly.

Laid off due to diagnosis?

Question from AngelA: I received a lay-off notice on Thursday, and had had my first breast cancer surgery the Monday prior. The margins did not come up clear, and a sentinel node tested positive. I live alone and am self-supporting. I was offered a severance package, but can I get additional compensation due to my precarious stage of treatment? I'm 52 years old.

Answer —Barbara Hoffman, J.D.: The timing of being laid off is very suspicious. If you were laid off within just a few days of your employer learning of your cancer diagnosis, that's a red flag that you're being laid off because of your cancer, which would be illegal under most circumstances. So I would recommend that before signing any kind of package with the employer, that you consult with a local employment attorney who can give you advice so you don't sign away what you may be entitled to. Additionally, you may want to consider whether you want to stay and keep your job, which you may be legally entitled to keep, or if this is a sign that this is not a terrific employer to work for, and ending your employment under the best possible terms may be better for you.

How will side effects affect traveling job?

Question from RoseL: I'm a TV producer and travel frequently, often to developing countries. It's a demanding job, long hours. I will start on AC, followed by T. I have no idea what to expect and would like to continue my current project which will involve a lot of travel. Any ideas?

Answers —Ruth Oratz, M.D., F.A.C.P.: This is similar to some of the other questions that we heard earlier this evening about what the anticipated side effects of treatment might be and how they would impact on the ability to work; in this case specifically, travel abroad. The most salient factors will be the risk of infection, the development of fatigue, and perhaps some nausea, particularly related to the AC part of treatment. You should review your treatment schedules in detail with your physician or oncology nurse and coordinate that with your anticipated work and travel plans. It is likely that you will be able to continue working, but it is also likely that you will need to make some accommodation in your work schedule so as to receive your chemotherapy on time and without interruption. Your doctor and nurse should be able to map out for you the dates of treatment and which days you might be able to expect to feel well and which days you might expect to need rest or that you won't function at your highest ability.

Irene Card, : When you are abroad, most health insurance carriers will provide a benefit for medical care that you may require. It is important to get an itemized bill with a diagnosis code and a procedure code. Make sure you write down the exchange rate compared to the dollar. When you get back to the States and submit the claim, be sure to address your claim to the Foreign Claims department. This will expedite payment. I might add that there are some folks that intentionally go to a foreign country to seek treatment that is not available in the United States. Such treatment will not be covered by any health insurance plan in the U.S. because the treatment has not been approved by the FDA. Furthermore, I am assuming that you are under the age of 65. But if that is a mistake, you should know that Medicare is only good in the United States. Hopefully you will have group insurance from your employer to pick up where Medicare leaves off, or if you work for a company with more than 20 employees, your group insurance will be primary and you should not experience any difficulty getting claims paid for medical services rendered outside of the country.

Does disability cover metastatic cancer?

Question from Stephanie: Are you eligible to receive disability (Social Security) if you have metastatic breast cancer or do you have to be physically disabled?

Answer —Irene Card, : Again, this is a question where it goes according to the state. State disability is very difficult to get. Your success in getting state disability will depend totally on your medical history, your diagnosis, and your treatment. This varies from state to state.

Help to find a lawyer for discrimination?

Question from Music Lover: I would like to contact a lawyer regarding what I believe was a discriminating decision on my employer’s side. However, now that I don't have a job, how can I pay for this? I'm already having to cover my health insurance. Are there lawyers who work for low-cost?

Answer —Barbara Hoffman, J.D.: There are some lawyer referral services that may help you find an attorney who will donate his/her time or work for low cost. Look through your local bar association, or through an organization called the National Employment Lawyers Association, the website for which is www.nela.org. It has information about contacting an attorney who specializes in employment discrimination. Additionally, there are some cancer advocacy organizations that can help you find a lawyer specializing in cancer-related discrimination. These include the National Coalition for Cancer Survivorship (www.canceradvocacy.org) and the Patient Advocate Foundation (www.patientadvocate.org).

Help in communication with insurance company?

Question from Marcella: I'm still covered under my ex-husband's insurance, but all communication with the insurance company has to go through him, and he's not being wonderfully cooperative in helping me. Is there anything I can do?

Answer —Irene Card, : First, contact your insurance carrier and ask them to change the address.  When you state that you are still covered under your ex-husband’s insurance policy, I am assuming that you are on COBRA. If you are, then it is your insurance and the carrier must honor your request to use your address. If you don’t succeed in getting the address corrected, speak with your attorney immediately. So often when married couples divorce, the woman gets the short end of the stick with health insurance. Benefits can be continued for 36 months under the COBRA law so long as the employer qualifies for COBRA law benefits. It is so important for a woman who is going through a divorce to research what kind of health insurance she can purchase individually and what it will cost, and make sure her attorney understands this fully so that compensation can be included in the divorce settlement. All too often, the woman finds out after it is too late that her premium may be $500 a month, and she may have a very high deductible and be left with major out-of-pocket expenses. In your case, where all communication must go through your ex-husband, it's most important your attorney work out an arrangement with your ex-husband's attorney. I have often seen where the mail will go to the attorney and he/she forwards the mail to the client. This is especially the case when there are extremely hard feelings and no communication between the two former spouses.