Charles Hovis had won.
A year ago, the 27-year-old Mount Washington man defeated cancer. His Hodgkin's disease, a cancer of the lymph system, had been in total remission for four years, and Hovis was ready to enter the working world.
His reception was far from benign.
When Hovis applied for a job as a driver at a Glendale medical transport company, he was handed a four-page medical history to complete. Wary, but wanting the job, he filled the form out truthfully, answering "yes" to the question of whether he had ever had cancer.
Afterward, when a personnel officer interviewed him, she looked over the form, glanced up and asked, "Cancer--how did you catch that?"
The interviewer called Hovis at home a few days later to say the company had decided against hiring him because of his medical record. The firm's operations manager, she said, "wanted someone perfect" for the job.
"It's an attack on your self-image," said Hovis, still angry 12 months after the rebuff. "To work is something that's very important to a person. I feel I have a lot to offer. And I resent my health history being held against me."
Hovis ultimately got a job as a research assistant at County-USC Medical Center, where his medical record was better understood. But the barrier he confronted in Glendale is one faced by many cancer survivors--a growing cadre in the labor force as medical advances extend lives and often completely cure a wide range of cancers, especially those that attack in childhood.
Estimates of the extent of job discrimination against cancer survivors vary widely, but some studies say more than half--not counting workers who have minor scrapes with skin cancer--encounter bias in the workplace. Like Hovis, some are screened out of jobs by intrusive application processes. Others--victims of ignorance or the abiding stigma of a long-dreaded disease--are denied promotions, ostracized by co-workers uneasy about their own mortality or fired by employers who fear that they will be unproductive or will drive up health insurance premiums. Moreover, healthy, recovered cancer patients may face a subtler obstacle: Many find themselves locked into unsatisfying jobs that offer health insurance because they can't risk quitting and taking a better job where their health history may deny them coverage.
The hindrances are insidious. Cancer survivors can complain to government agencies, but resources for combatting job bias are limited and discrimination is not easy to prove. Physicians and counselors say some patients are sucked into a downward spiral; repeated rejections deepen a discouragement that can drive survivors out of the work force, diminish career expectations or rob patients of self-esteem.
"It's difficult enough being diagnosed as having the disease and going through treatment," said JoAnne Frankfurt, an attorney with the Employment Law Center in San Francisco who directs a statewide employment rights program sponsored by the American Cancer Society. "Then, when you see the light at the end of the tunnel, you face the social death of job discrimination."
The Cancer Society first drew attention to the problem a decade ago, backing research by USC social worker Frances Feldman that found that, among adult cancer survivors, 58% of blue-collar workers and 25% of white-collar workers experienced discrimination upon returning to the job market. About 20% of the survivors of cancers that strike in childhood--primarily Hodgkin's disease, non-Hodgkin's lymphoma, leukemia, testicular cancer and kidney, muscle and bone cancers--encountered bias when they sought jobs.
Subsequent research has turned up varying findings. In a Mayo Clinic study, only 3% of cancer survivors reported job bias, while researchers at Stanford University Hospital recently found 42% of the survivors they studied had experienced job-related problems.
Los Angeles oncologist Robert J. McKenna, a former Cancer Society president who helped focus attention on the survivors' plight, said growing awareness that many cancers can be treated and increased advocacy by survivors has made discrimination less common today than 10 years ago. The rise of AIDS, he adds, has deflected society's paranoia away from the cancer patient.
"AIDS clearly has some discrimination of its own, mostly through fear," McKenna said. "And therefore (employers) have shifted away from the cancer issue."
But the number of cancer patients and cured survivors is growing dramatically. Not counting those with mild forms of skin cancer, there are 5 million patients and former patients now, and 850,000 more each year, according to the Cancer Society, as 40% of cancer patients defeat a disease that not long ago was considered a death sentence. And the patients, as well as the doctors and counselors who advise them, say entering or returning to the work force remains among the biggest obstacles to living normal lives.
Sandra Smith, 37, is feisty, with wavy hair and thin, arching eyebrows. The lymphoma she has had for eight years is in remission, evident only in the barely visible biopsy scars on both sides of her neck.
But, as she talked with 15 other cancer survivors earlier this month at Vital Options, a survivor support group in Studio City, Smith was perplexed. She had been offered a job by the phone company and had an intake interview the next day, but wasn't sure what she should say if she was asked about her medical history.
"I don't know how the hell honest to be," Smith said at the time. "I think I was fired from my last job for cancer. I was a few weeks away from being eligible for their insurance plan. Only one person in the place knew I had cancer. And then--boom! I was out."
Smith got the new job, even after telling the company about her cancer without being asked. "I took a chance and was honest with them," she said a few days later.
Smith did not know it, but state law protected her. California is one of just two states--Vermont is the other--that have sought to lift the stigma of cancer survivors' medical past by specifically prohibiting job discrimination against them.
Under the state's Fair Employment and Housing Act, employers of five or more workers cannot fire, demote or refuse to hire people who have been cured of cancer or recovered to the point that they can resume working. Companies also must reasonably accommodate any disability that survivors bear. Legally, the only medical question employers are allowed to ask job applicants is if they have any condition rendering them incapable of performing the job that they are seeking.
But the law, survivors say, is frequently breached. Complaints of violations are up 35% over the last three years, with 76 filed in the year that ended June 30, according to the California Department of Fair Employment and Housing. Yet advocates say the department--which settled just seven cases last year and has filed only one cancer discrimination case with the Fair Employment and Housing Commission in the last six years--has been reluctant to enforce laws guaranteeing cancer survivors' rights.
"I have heard from some clients that they have not necessarily had the door slammed in their face, but it certainly hasn't been opened very easily," said Helen Crothers, associate director for service and rehabilitation at the Cancer Society's Oakland-based California division.
Talmadge R. Jones, director of the state agency, said the department does not ignore complaints from cancer survivors. "I like to think our staff is a very open, caring staff to people with disabilities," he said. "I can't believe the person with either a diagnosis of cancer or who has recouped from cancer would be rebuffed" by the agency.
But Jones acknowledges that the department's staff is less familiar with the bias issues associated with cancer--which make up less than 1% of the complaints handled by the agency--than with those involving race, sex or age. To heighten their understanding, he has asked the Cancer Society to conduct training sessions this spring for the agency's investigators.
Cancer patients and survivors, however, say the law is inherently ineffective. Many employers and job applicants alike are unaware of its provisions. Applicants who invoke the law's protection during an interview do so only at considerable peril to their job hunt.
"The reality of the job market is such that you don't sit in an interview and say, 'You can't ask me that question,' " said Miranda Craig, a Hollywood writer who survived breast cancer five years ago and is active in Vital Options. "That is not the moment in time when you feel it's the time to take a stand. It's the time to get a job."
Discrimination of any kind, moreover, is difficult to establish. Executives tend to deny it happens in their organizations, and interviewers can offer any number of alternate explanations for turning down an applicant, noted Dr. Daniel M. Hays, a USC pediatric surgeon who is conducting federally sponsored research on the economic problems of childhood cancer survivors at Children's Hospital of Los Angeles.
"It's easy to be discriminated against and very hard to prove that," Hays said.
Despite the limitations of anti-discrimination laws, cancer organizations are campaigning for more federal and state legislation to protect survivors. So far, the efforts aren't bearing much fruit.
New York Gov. Mario M. Cuomo vetoed such a bill last summer, saying he did not want to single out the victims of a single disease for special treatment. In Congress, a resolution protesting job bias against cancer survivors passed the House in 1986, but Rep. Mario Biaggi (D-N.Y.) has failed for the last three years to win passage of a bill making cancer discrimination unlawful.
Some of the bias faced by cancer survivors is based on ignorance, activists say--the wrongly held notion that cancer is contagious or the persistent belief that it is uncompromisingly deadly. "Cancer brings home the reality of our own mortality," Frankfurt explained. "People are afraid of death, and they associate cancer with death."
Insurance Critical Issue
Medical advances--the dramatically improved survival rates for childhood leukemia, Hodgkin's disease, testicular cancer, ovarian cancer and other forms of the disease--eventually will erase the lay public's perception that cancer means certain death, survivors expect. But the economic bases for discrimination may be tougher to dislodge.
Some employers, researchers say, are unwilling to invest in hiring and training a worker who they expect--wrongfully, according to long-term studies by Metropolitan Life Insurance Co. and the Bell System--will miss work frequently, be a short-term employee or alienate co-workers.
"The employer has to maximize his productivity, and he looks for all the reasons for that not happening, and one of those is the physical limitations, real or imagined, in his employee," said Ivan Barofsky, a former National Cancer Institute official who is completing a book on cancer and work. "I don't accuse the employer of being irrational within his philosophy of economics."
For business, health insurance poses the most stubborn dilemma in the employment of cancer survivors. Insurers say small companies--the source of most employment--rightfully fear that their group health insurance may be cancelled if they hire someone with a history of cancer.
At large companies, there are no medical questions asked when a new employee is added to the group health plan and few, if any, limits on coverage. Underwriting rules grow stricter, though, as firms get smaller. Policies written for companies with 25 to 100 workers typically limit coverage of pre-existing health problems, and many insurers refuse to write coverage for companies with fewer than 25 employees if someone on the payroll has a history of cancer, explained Joseph San Filippo, a vice president at Pacific Mutual Life Insurance Co. in Fountain Valley, which writes $550 million in group health coverage annually.
"If the small employer were to move (its) insurance every year or two, trying to find the lowest rate--which is very common right now--and had an employee who had a serious condition that was ongoing, they might be refused coverage," San Filippo said.
Selma R. Schimmel, the founder and executive director of Vital Options, said insurers are lagging behind medical science by making it difficult for cancer survivors to obtain health coverage.
"It's a confusing message for us," said Schimmel, who survived breast cancer five years ago. "If we really do have a treatable disease and we really can become cancer-free, then why can we not get health insurance?"
Legislators in 14 states have acted to close the insurance gap by creating special insurance programs for people with severe health problems who cannot obtain health coverage in the private sector. Gov. George Deukmejian vetoed a high-risk insurance pool passed by the California Legislature last year, saying he objected to a provision that would have financed the program through a small increase in payroll taxes. Legislation designed to overcome the governor's opposition has been introduced by Assemblyman Phillip Isenberg (D-Sacramento) and Sen. Alan Robbins (D-Van Nuys) this session.
Other initiatives aim to dismantle the hurdles erected by discrimination in hiring.
A small but growing number of cancer survivors are suing employers or would-be employers they accuse of bias, in hopes of inflicting enough economic harm to awaken business to the pitfalls of discrimination. The Cancer Society's employment rights project, which tries to help survivors combat bias by informing them of their legal options, is expanding into a national program. The society's California division, meanwhile, has created a task force on the employment problems of young adults with cancer histories to focus on the fastest-growing survivor population.
The survivors, meantime, are organizing to speak for themselves. Employment issues are a major focus of the Washington-based National Coalition for Cancer Survivors. And it was the experience of encountering discrimination in the job market two years ago that inspired Susan Weintraub Nessim of Los Angeles to found Cancervive, a nationwide organization of cancer survivors that runs support groups and campaigns for improved understanding of cancer facts.
Nessim, who has a slight limp as a result of radiation treatment for soft-tissue cancer 12 years ago, was working in marketing for a cosmetics company when she learned that she and another woman were up for a promotion. Her competitor, she said, was interviewed first and told executives that Nessim had a cancer history and probably was not capable of the job. Nessim was never even interviewed.
"I never realized it would be held against me, and I was also very proud of myself--that I had done so well, that I made it," Nessim recalled. "But I learned soon that it was something to keep under your hat."
Rejection comes too often to cancer survivors for them to remain silent any longer, Nessim said.
"I had one girl call me," she said, "and tell me, 'Why was I cured, if I can't get a job and get on with my life?' "
VICTIMS OF BIAS?
Job discrimination complaints filed by California cancer survivors and money recovered on their behalf from employers. Figures are for the fiscal year running July 1-June 30.
Year Complaints Money recovered 1984-85 49 $40,792 1985-86 69 $47,792 1986-87 76* $23,116 1987-88 26 $0 (through Nov. 30)
* Of the 76 complaints filed in 1986-87, 41 alleged that workers were fired because of a cancer history, 9 charged employers with failing to reasonably accomodate a cancer survivor, 7 alleged harrassment on the job, 5 complained of the denial of a promotion and 14 cited other forms of alleged discrimination.
Source: California Department of Fair Employment and Housing