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Successful Return to Work of Cancer Survivors
What is the Research Telling Us to Do?
By Dr. Christine Maheu and Ms. Maureen Parkinson
Understand Current Abilities
Strategies and Work
Accommodations
Readiness to RTW
Reducing Stress at work
Employment and Vocational
Rehabilitation Programs
Relevance of Cancer Rehabilitation
www.cancerandwork.ca
Vocational Rehabilitation Model For Cancer Survivors
Bio-Psychological Factors Affecting Work Ability
••••
Person Related Factors
System’s Influences
Worksite Considerations
Work hours,
duties, pay
Job demands (physical,
cognitive or psychological)
Accommodations (flexibility)
Support: Employer & co-worker attitudes
Workplace relationship
and dialogue
;
Increased risk of early retirement compared to healthy controls (Rottenberg, 2018)
Potential reasons: experiencing long-lasting problems such as fatigue, pain, cognitive deficits, anxiety and depression.
If left untreated, these can become chronic or persistent (Cooper 2013; Smith 2007).
Longer sick leave, less favorable workplace environments, lower work ability, higher psychological distress, and lower quality of life (Mehnert et.al. 2016)
Inverse risk cancer of early retirement : Being in remission, perceived + work productivity, work satisfaction, mental quality of life (Mehnert et. al. 2016)
Barriers to Employment Following Cancer Effects of cancer (short-, long-, or late term)
Health status/comorbidity, continuity of care, quality of life, functional impairments, symptom burden, emotional and social well-being, change in identity and role functioning, social (Mehnert et al., 2013, p. 2154).
These barriers to employment can dramatically affect an individual’s participation in the work setting.
For example, treatment side effects such as alopecia (hair loss or ‘‘chemo brain’’ (cognitive functioning deficits) may affect interpersonal relationships or workplace functioning.
Barriers to Employment Following Cancer Work Environment traits
Conditions, demands, and overall climate of the work setting to the accommodation and flexibility of the employer (Mehnert et al., 2013). (Mehnert et al., 2013).
Cancer symptoms and treatment can necessitate changes in work conditions.
For example, reducing demands or changing work hours to accommodate treatment
Predictors of Reduced Work Ability at Return to Work Work ability in breast cancer women survivors: A questionnaire-based study. (Italy)Bonfiglioli, R., et al. (2018). Occup.Environ.Med., Conference.
Predictors of reduced work ability at RTW among breast cancer women (18-65 yrs)
Among 503 working women who RTW, work ability was reduce in
43.5% compared to pre-diagnostic period.
Predictors: non-cohabiting than in cohabiting/married women, in labourers than in Office clerks/sales assistants and managers and more frequent after mastectomy than after breast-conserving interventions.
The 43.5% reported more: Adjustments of work activities, occupational physician visits, less support from employer and colleagues and discrimination.
1. Guidance from physiciansHospital-based program
(Tamminga et al., 2013)
2. Education information
(Bains et al., 2011; Nieuwenhuijsen et al., 2005; Brown et al., 2012)
3. Providing counselling, rehabilitation support
(Chan et al., 2008; Chui et al., 2014; Thijs, 2011)
4. Case management approach
(Hubbard et al., 2013)
5. Cochrane Reviews: Multidisciplinary / Multifaceted interventions with approach work focused
(de Boer et al., 2011, 2015; Lessen et al., 2017)
Cancer Interventions in RTW
Sustaining Work: Workplace barriers and facilitators to work participation
● 89.7% versus 77.8 who had changes in their workstation layout in 5 years post remained employed (Alleume et al 2019)
● Supervisor support over 18 months was associated with an increase in work functioning (Dorland et al 2018)
● Increase in quantitative work demands was associated with a reduction in work functioning (Dorland et al 2018)
● Lack of monitoring/follow up and wear-off of empathy post return to work contributed to RTW difficulties (Yarker et al 2010)
Employers Perspective: Barriers and Facilitators to work participation (Greidanus et al 2018)
Facilitators:
● Employers offering support throughout the duration of the illness (time off, reduced hours, sharing workload, changing duties)
● Employers showing an open attitude, interest, commitment and encouragement
● Having a good understanding of the employee’s capabilities, medical condition, treatment and side effects (CPAC 2102)
● Insurance providers and physician having a good understanding of the of the work (CPAC 2012)
● Maintaining open communication with the cancer survivor through non-invasive challenges (ie emails and text messages) and discussing ways to communicate with the survivor
● Establish return to work procedures and policies, but being flexible with these policies
● Appointing a conduit or independent third party● Being well staffed and having staffed cross trained
(CPAC 2012)
Barriers:
● Avoiding cancer related discussions● Lack of knowledge about cancer and/or insufficient
medical information● Insufficient specialist support, few opportunities to
discuss return to work with employers or the company● Difficulties getting a grip on the unpredictability of
cancer (illness and absence) and managing the conditions of return to work
● Balancing the needs of the survivors and interests of the business
● Guiding return to work on standard principles● Lacking information about legal policies● Organization without back to work policies (CPAC 2012)● Obtaining timely medical advice healthcare providers
(CPAC 2012)● Organizations with financial challenges (CPAC 2012)
Recommendations to Employers (Greidanus et al 2018)
● Understand implications of having cancer, including physical and psychological effects during and after treatment and impact on work
● Shit to survivors’ limitation in relation to work as opposed to sharing the diagnosis, and opportunities for work participation
● Providing proper support to cancer survivors can be complex, make use of tools to facilitate open communication between cancer survivors and employer
● Be supportive and empathetic. Offer “real” support, practical and emotional (reduce hours, share workloads)
● Show basic human values, be supportive and empathetic, view cancer survivors as normal, not weak, and improve communication (Dewa et al 2016)
● Share what are the legal options and responsibility concerning RTW of a cancer survivor
Recommendations: Employers Perspective (CPAC 2012)
● Develop a disability management program program including policy, tools and corporate culture
● Provide training and resources for managers on RTW● Prepare pre-formatted forms for physicians to complete & draft return to work
plans for the physician to approve● Develop return to work packages for employees which includes return to work
policies● Improve links to internal expertise/Learn more about external resources
available● Create a fund for accommodations, Have tax breaks to provide
accommodations, and prepare for accommodations ● Use a broader range of flexible work arrangements● Improve contingency plans (identify contractors or cross train employees)
Survivors Advice to Employers (Dewa 2015)
● Make the application for disability income easier● Honour privacy, don’t pity● provide accommodation, be flexible and be clear about constraints and
expectations● Be supportive, positive, and show understanding● Have a plan in place on how to deal with cancer in the workplace● Understand invisible disability: “I may look good, but I am still suffering
from cancer-related fatigue”. ● Learn about cancer and its impact on work● Have a mediator such as a doctor or psychologist to help define terms of
return to work (McKay et al 2013)
Recommendations:
● Graduated return to work plans● Flexible schedules● Modifications of work duties● Altered performance expectations● Retraining● Support at the workplace● Changes in physical work environments
(Stergiou-Kita et al 2016)
Cancer and Work advice
Types of accommodations used (CPAC 2012)
● Modified work schedules and flexible arrangements (less hours, work
from home, compressed work week)
● Modified duty job banks and modified duty programs (CPAC, 2012)
Survivors Perspective: Workplace barriers and facilitators to work participation (Greidanus et al 2018)
Facilitators:
● Maintaining connection to the workplace (McKay et al 2013)
● Perceived employers support (practical: adjusting work tasks, hours, place of work, providing temporary assistance, providing time for re-integration and retraining social/emotional: treating the survivor normally, maintaining privacy, showing commitment)
● Having regular communication which is respectful, positive and personal/ inquiring about how the survivor was doing
● Discussing the survivors return to work plan● Discussing limitations and possible work
adjustments, keeping the survivor up to date● Having a good attitude, good and long term
relationship and recognizing work ability
Barriers:
● Lack of social, financial and practical support● Communication which is negative, poor,
frightening, patronizing, pressuring● Feeling discriminated● Rigid, non-supportive, competitive, hard-nosed
work environment● A negative attitude, strained relationship and
over estimating the survivors work ability (such as with invisible changes /fatigue)
● Struggling financially and having to come back to early (CPAC 2012) or lack of sick leave to recover (Grub et al 2019)
● Highly bureaucratic layers of approval (CPAC 2012)
Cancer Survivors Perspective (Dewa et 2016)
Advice from and to cancer survivors:
● Take responsibility for your health and give time to recover● Let the oncologist advise recovery not peers● Be proactive● Seek support and let people help you● Set reasonable expectations and realistic plan for RTW ● Do not depend on employers to lead the discussion on RTW● Consider disclosure: Weigh the pros and cons● Stay in contact with the workplace● Maintain positive interactions with those at the workplace● Discuss return to work early and often with healthcare providers● Disclose the need for accommodations
Disclosure at the Workplace (McKay et al 2013)
● Fear of loss of long term prospects
● Managers concern sharing too much could lead to over burden of colleagues
● Managers fear of not wanting to ask too much and respecting privacy
● Some cancer survivors did not want to disclose to maintain the feeling of normality
● Survivors, psychologists and managers felt the employee should consulted about what
they need to return to work
● Concerns that survivors may withhold information, have unrealistic expectations, by in
denial and push themselves too hard, not knowing what they need or not feeling
comfortable about what they need
● Not disclosing to colleagues some information could lead to uncertainty and resentment
● Those with metastatic cancer despite being less productive, had concerns with asking for
accommodations (Doyle, 2019)
https://www.cancerandwork.ca/survivors/communication-and-teamwork/how-to-exercise-your-power-of-disclosure/
Healthcare Perspective: Workplace barriers and facilitators to work participation
Facilitators:
● Discussing the survivors return to work plan
● Provide for a treatment summaries as more likely to discuss RTW (de Moor et al 2018)
● Good relationships and trust between professionals from different settings “If we know and trust the team, oncology professionals will make lots of referrals” (Bilodeau et al 2018)
Barriers:
● Task divisions for cancer care follow-up● Lack of clarity of each HCP role for the support of RTW
(MacLennan et al 2017)● Addressing RTW is viewed as a lack of priority to treating
cancer for health care providers (Peterson et al 2017; MacLennan et al 2017)
● Lack of informational continuity between hospital and primary care
● Waiting to discuss RTW until treatment completed (Peterson,et al 2017)
● HCP do not feel competent about advising on work-related question (Tiedtke et al 2012)
● Healthcare professionals require support in their work-related support role and need additional training for this role (Zaman et al 2019)
Tools to improve communication amongst stakeholders
● Cognitive Symptom Checklist-Work (CSC-W: 59 or 21
items) (Ottati & Feuerstein 2013)
● Cancer and Work Return to Work Planner (Kita et al,
2016; Maheu, et. al. 2019)
● Cancer and Work Job Analysis (Parkinson, et. al 2012;
Maheu, et al 2019)
● Return to Work Planning Tool RTW-PT (Amin et al
2017)https://www.cancerandwork.ca/survivors/communication-and-teamwork/
1. Guidance from physicians /
Hospital-based program
(Tamminga et al., 2013; Tamminga et al 2019)
2. Education information
(Bains et al., 2011; Nieuwenhuijsen et al., 2005;
Brown et al., 2012)
3. Providing counselling, rehabilitation support
(Chan et al., 2008; Chui et al., 2014; Thijs, 2011; Sheppard
et al 2019); Mewes et al 2015; Fauser et al 2019))
4. Case management approach
(Hubbard et al., 2013)
5. Cochrane Reviews: Multidisciplinary /
Multifaceted interventions with approach work
focused
(de Boer et al., 2011, 2015; Lessen et al., 2017)
Cancer Interventions in RTW
www.cancerandwork.ca
Cochrane Review - Evaluating Effectiveness of Interventions on Outcome RTW and QoL (De Boer et al 2015)
● 15 RCTs, 4 types of interventions, most with breast cancer patients (n=1835 patients)
● 2 psycho-educationational vs UC: RTW rates similar and QoL no diff.● 1 physical training programme vs UC : No more effective ● 7 RCTs assess medical function conserving (lumpectomy) vs medical more radical
(mastectomy): RTW = similar rates, QoL = no diff● 5 RCTs used multidisciplinary approaches including vocational counselling,
physical, psycho-education vs UC: RTW rates higher, QoL no diff. None used vocational rehabilitation focused
Conclusion: moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer
Systematic Review / Occupational therapy and Cancer Rehab/ Physical activity & Symptom Management Interventions / Part 1 (Hunter et al. 2017)
- Strong evidence for exercise to improve cancer-related fatigue (CRF) (problem solving, energy conservation, education), physical function, muscle tone, lung capacity, does not cause lymphedema or make it worse.
- Lymphedema: compression bandages worn on daily basis were foundtobe important for volume control
- Moderate evidence for strength, interval and home based exercise to improve QoL and sleep.
- Supervised better than non supervised, and counselling and telephone provided additional benefit.
- Moderate evidence for yoga to benefit mental health, Qol, decrease stress.
- Moderate evidence for CBT in CRF
Systematic Review / Occupational therapy and Cancer Rehab/ Physical activity & Symptom Management Interventions/Part 2 (Hunter et al. 2017)
- Strong evidence for rehab program for many types of cancer to improve function.
- Moderate evidence for rehab program for both before and after treatment.
- Rehab programs in advance, progressive, recurrence are cost-effective and improve QoL.
- Psycho-interventions helpful for symptom management, QoL- *multidisciplinary interventions that include physical and psychological
aspects in addition to vocational support provided return-to-work benefits (de Boer et al., 2011), regardless of cancer type or stage of cancer..
Systematic Review and Meta-Analysis: Psychological interventions to facilitate employment outcomes for cancer survivors (n=12 studies/ 7 countries/ >2000 participants) (Fong et al 2018)
Cancer survivors’ employment outcomes with intervention:
- employment status/RTW rates stronger for the intervention groups:: 1.71 ES (71%)
- 68% to 60 % for the intervention group
- But no effect on work disability /sick leave
Only two interventions directly address RTW plans combined with informational sessions.
Physical Rehabilitation / Exercise Studies● High intensity exercise time to return 11.5 versus 13.2 weeks, less
reduction in hours 5 versus 11 hours; Long-term follow-up: 78% versus 66% RTW to pre-diagnosis working hours in comparison to control (Thijs et al 2012)
● Occupational Physician advice and exercise – no difference with RTW but productivity increased / 5.8 hours more a week for a year (Mewes et al 2015)
Recent Interventions Focused on Work 1/2
● Usual care (exercise, physiotherapy, occupational therapy psychological and
nutritional counselling) versus the addition of work related functional capacity
training: no difference in role functioning but participants reported better physical
functioning and better ability to cope with pain and fatigue (Fauser et al 2019)
● Health coaching and occupational rehabilitation (6-8 coaching sessions on physical,
psychological, social and general/spiritual wellbeing) (Sheppard et at 2019)
● Nurse navigator at the worksite : coaching and referral to a website. Low uptake
and no difference on self-efficacy in comparison to a control group. Appreciated
the non-judgmental approach. (Aubel 2019)
Recent Interventions Focused on Work 2/2
● Hospital Base Support (Nurse/Social Work Intervention, letter from treatment physician to
occupational physician, meeting with occ physician, survivor and employer to develop a
RTW plan- no difference between groups in resumption of full work hours, quality of life
and work ability (Tamminga et al 2019)
● Oncology occupational physician (OOP) integrated into the health care team: Satisfaction
high with OOP because they had knowledge about cancer and work-related problems
(Zaman et al 2015).
● Self-guided workbook (included exercises) and goal focused education related to the
workbook Grunfeld (2019) 30% controls versus 43% intervention group returned to work
● Cancer and Work website developed with input from 250 stakeholders in a survey, 60
provided satisfaction evaluations (Maheu et al 2016)
Program Evaluation: State Vocational Services (Chan et. al, 2008; Chui et. al., 2014)
● 58% participants obtained employment (Chan, et. al., 2008)
VR Counselling, misc training, rehab technology, job placement, job search assistance, maintenance services increased the odds of employment. Those who were successful had more services but spent less time in services.
● Services received varied on employment status (Chui et. al., 2014)
Employed group: received diagnostic and treatment services, rehabilitation technology and job accommodations services
Unemployed group: received vocational training, job search instruction and job placement
Results of a meta-analysis of Cancer Survivors’ experience with RTW (Stergiou-Kita et al 2014)
Early in their recovery process to help make decisions about RTW, Cancer survivors need:
● Assistance or knowledge on cancer-related issues affecting their job performance
● On income replacement benefits ● On workplace support or accommodations
Recommendations are:
● Early rehabilitation, soon after diagnosis, is most appropriate in oncological rehabilitation, because the longer the period of sick leave, the more difficult it is to achieve RTW (Koopmans, Roelen, & Groothoff, 2008).
The Seasons of Cancer Survivorship and RTW issues
At Diagnosis
● Maintain or strengthen physical and mental health
During Treatment
● Fatigue● Anxiety ● Depresion● Pain syndromes
After Treatment
● Fear of recurrence● Anxiety● Depression● Cognitive dysfunction● Fatigue● Pain syndromes● Peripheral neuropathy● Sexyal dysfunction● Problems with body image, balance and gait ● Problems with bladder and bowel functioning● Mobility issues● Lymphedema● Speech and communication difficulties● Deconditioning (physical and work)
Back to Work
● Cardiac treatment-induced myopathy
● Continued cognitive challenges, pain, fatigue, anxiety, depression.
The Seasons of Cancer Survivorship and RTW Communication (Duijts et al 2018)
At Diagnosis
● Continue or stop work● Disclosing diagnosis to
employer: pros and cons● Need for time-off for
appointments and treatment
● Potential impact of treatment decision on work and work abilities
● Potential need for accommodations if staying at work
During Treatment
● Healthcare to deploy flexibility to accommodate choice of work status
After Treatment
● Use vocational rehab model and conduct assessments of functions & propose tailored interventions as needed
● Assess readiness to return to work
● Address work deconditioning and how to prepare for an imminent return with a RTW simulation
● Discuss how to overcome main challenges e.g. reduce executive functioning.
Back to Work
Continued monitoring of functions, especially cognitive and the need for accommodations.Assess for side effects of endocrine treatment, signs of recurrence, and physical symptoms.
Healthcare Providers ● Treating physicians do not feel competent about advising on work related
questions (Tiedtke et al 2012)● GP considers specialist cancer nurses to be best to discuss RTW because of their
frequent patient contact while nurses thinks should be reverse (Whitehorn 2019)
● Barriers for GP: Feel they do not know enough about the CS job role to provide advice on RTW (Bains et al 2011). No consensus on whose role it is to initiate and communicate with CS on RTW (Bains et al 2011)
● OT are considered best to provide this support but cost could be prohibitive (Whitehorn 2019)
● Patient appreciate oncology occupational physicians. Seen by patient as more independent than workplace occupational health, providing greater awareness of work and provided consistent advice amongst the team (Zaman et al 2015)
Building RTW Interventions Targeted at Employers(Whitehorn, 2019 JBI Evidence Summary; Greindanus et al 2018)
● Build resources for employers to give support for the entire duration of the illness (either practical or emotional support) (Greidanus et al 2018)
○ Practical could include providing time off for medical appointment, reducing hours, sharing workload, and changing duties
○ Emotional: understand their situation, treat them as normal, maintain privacy● Build interventions that optimize employer support during the RTW of cancer survivors
○ Avoid “1-size-fits-all” intervention approach (for example provide physiotherapy exercises specific to the individual’s workplace)
● Test different means of communication and their effectiveness to facilitate a successful, non-threatening return to work
● Provide for occupational-based interventions specific to the job, and to include activities that go beyond physical function to address activity and work participation
Barriers/Facilitators to Work
Work environment traits that can influence survivors’ work outcomes. T● Traits = conditions, demands, and overall climate of the work setting to the accommodation and flexibility of the employer
(Mehnert et al., 2013). ● Cancer symptoms, treatment and late and long term effects can necessitate changes in work conditions, such as reducing
demands or changing work hours to accommodate treatment.
Long Term● 89.7% versus 77.8 who had changes in their workstation layout, 5 years
post diagnosis remained employed (Alleume et. al. 2019)● Supervisor support over 18 months was associated with an increase in
work functioning (Dorland 2018)● Decrease in meaning of work for the first 12 months and remained stable;
increase in meaning of work improved work functioning (Dorland 2018)● Increase in quantitative work demands was associated with a reduction in
work functioning (Dorland 2018)● Cognitive challenges remained stable over 18 month ● Patients reported with an increase of work functioning there was a
decrease in fatigue and depression over the first 12 months
Cancer & Work Rehabilitation Program: A Multidisciplinary Task!
Rehabilitation Lead (Physician)
Vocational therapyOncology team
Nursing Nutritional counseling Physiotherapy Occupational therapy
Physical therapy
Social work
Creating a Cancer and Work Multidisciplinary Rehabilitation Program in the Health Care Setting
Roles of multidisciplinary members to support cancer survivors with working: including physiatry, oncology nurse navigator, occupational therapists, speech pathologists, vocational counsellor (Silver et al 2012)
Role of Occupational Therapist 5 steps (Desiron et al 2016)
Cancer and Work: Roles of Professionalshttps://www.cancerandwork.ca/survivors/communication-and-teamwork/roles-of-professionals/
https://www.cancerandwork.ca/survivors/communication-and-teamwork/roles-of-professionals/
Cancer & Work Rehabilitation Program: A Multidisciplinary Task!
Rehabilitation Lead (Physician)
Vocational therapyOncology team
Nursing Nutritional counseling Physiotherapy Occupational therapy
Physical therapy
Social work
Overall Recommendations
● Screen: for risk factors early and often and if indicated intervene● Assess: Improve access to information on work function for healthcare
providers, survivors and employers with tools, training , access to experts● Guide: Increase expertise and subsequent advice to healthcare providers,
employers and survivors on how specific cancers and treatments might impact and provide suggestions to improve work ability
● Foster a Supportive Workplace: Encourage continued positive communication between the employer, colleagues and the cancer survivor
● Support sustained employment: Consider accommodations and financial support systems to allow a person to work their capacity over time
● Create multidisciplinary teams: that are work focused that includes experts in occupational therapy and vocational rehabilitation and involves the employer
Seeking Study Participants for Cancer and WorkThe research team at Cancer and Work is conducting a usability, and utility study on the website and new creations of tools to support the return to work process of cancer patients and cancer survivors.
We appreciate all levels of participation. If interested, please contact us at:
Thank you!
Reviews
Feuerstein, M., Todd, B. L., Moskowitz, M. C., Bruns, G. L., Stoler, M. R., Nassif, T., & Yu, X. (2010). Work in cancer survivors: A model for
practice and research. Journal of Cancer Survivorship : Research and Practice, 4(4), 415-437. doi:10.1007/s11764-010-0154-6 [doi]
Kiasuwa Mbengi, R., Otter, R., Mortelmans, K., Arbyn, M., Van Oyen, H., Bouland, C., & de Brouwer, C. (2016). Barriers and opportunities for
return-to-work of cancer survivors: Time for action--rapid review and expert consultation. Systematic Reviews, 5, 35-z.
doi:10.1186/s13643-016-0210-z [doi]
Mehnert, A. (2011). Employment and work-related issues in cancer survivors. Critical Reviews in Oncology/Hematology, 77(2), 109-130.
doi:10.1016/j.critrevonc.2010.01.004 [doi]
