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People with cancer experience a range of difficulties with regard to employment. This review highlights these problems and examines the evidence for interventions that could support people living with cancer to remain in or return to work.
In general terms, it’s well-known that work makes a positive contribution to health. It enables a sense of value in society and of significance to others – as such, it’s important for a person’s sense of self and self-esteem.
It provides structure and order in everyday life. It contributes to financial independence and material comfort. Additionally, people with cancer emphasise the significance of work in regaining a sense of normality and control over their lives after, and sometimes during diagnosis and treatment.[3,4]
There are many factors that impact on cancer survivor’s ability to return to work. In health terms, cancer site, stage and prognosis, treatment and the presence of co-morbidities are significant. Socio-demographic and psychological factors such as age, education level, mood and motivation to work are thought to contribute,[4,6] although there are some discrepancies in this evidence.[7,8]
In addition to personal factors, work-related considerations are important. For example, physically demanding work decreases the likelihood of returning to work, while an employer’s willingness to be flexible about working terms and conditions during the recovery period enhances it.
Although there is a growing body of work specific to cancer and employment, it’s a relatively new field of research, and the evidence base is limited. However, there is a great deal to draw on in the larger and more established literature on employment support in other conditions, such as musculoskeletal and long-term neurological disorders.[9,10,11]
In an excellent and detailed meta-analysis of qualitative studies on return-to-work after musculoskeletal injury, MacEachen and her colleagues emphasise the scope and complexity of work support processes, finding that, ‘return-to-work involves more players and dimensions than were identified in any one study.’
Crucially, it’s the interaction between workers, co-workers, employers and health professionals, as well as the organisational environments in both employment and healthcare that supports or undermines successful employment. They argue that, ‘return-to-work extends well beyond local concerns about managing [...] physical function, to broader complexities related to work organisation and the beliefs and roles of a myriad of players’.
An essential ingredient in a successful return-to-work is effective liaison between patients, health professionals and employers. Line managers and rehabilitation or occupational health professionals are described as having key coordinating roles in facilitating return-to-work communication.[9,12]
The patient’s direct healthcare team – clinical nurse specialists, GPs and oncologists – also have a vitally important role to play. However, the research that has been carried out on employment support provided by cancer care professionals shows that this is an area in need of attention. People living with cancer report that they receive little advice from health professionals about work issues.[6,13]
Health professionals, in turn, do not feel equipped to deal with their patients’ employment concerns.
There is a need for health professionals to develop the skills required to respond to patients’ straightforward problems, and to find out about the availability of more specialist services, to which they can signpost people with more complex difficulties.
People who encounter significant problems with employment following a diagnosis of cancer may require specialist help from professionals with specific skills in employment support. The most striking feature of the research on specialist return-to-work interventions for people living with cancer is the lack of methodologically-sound studies.[15,16]
The need for well-designed, prospective, experimental studies is emphasised. In their Cochrane Review of interventions to enhance return-to-work for people with cancer, de Boer and colleagues identified four categories of interventions that have been studied:
1. Psychological interventions (for example, education and/or counselling).
2. Interventions aimed at physical functioning (exercise).
3. Medical interventions (for example, chemotherapy and hormone therapy).
4. Multidisciplinary interventions that incorporated physical, psychological, and vocational components. No trials of specific vocational interventions were found.
If we consider the factors mentioned earlier that are associated with cancer survivors’ successful return-to-work, we can see that effective interventions would need to incorporate a range of supportive, therapeutic and educational activities, including attention to the consequences of specific symptoms in the workplace, especially fatigue, physical fitness and conditioning, enhancing self-confidence, liaison between health services and employers, specific modifications to the work environment and support with managing relationships with colleagues and managers.
This multidisciplinary approach is supported by the Cochrane Review, which found that support incorporating physical, psychological and vocational components was associated with more a successful return-to-work than usual care.
There is growing interest in undertaking research to develop the evidence base on VR/work support interventions, and a number of important studies are currently underway. The protocols of two such studies have been published in the last 12 months.
Kyle and colleagues, based at the University of Stirling, are carrying out a feasibility study of a randomised trial to investigate a VR intervention for women with breast cancer. The intervention comprises a combination of physiotherapy, occupational therapy, occupational health services, counselling and complementary therapy.
Tamminga and colleagues, based at the University of Amsterdam, have developed an intervention that addresses the two factors that can be altered by a return-to-work intervention, ie self perceived work ability and physical workload.
The intervention consists of four meetings with a nurse to start early VR; a meeting with the patient, occupational physician and supervisor to make a return-to-work plan; and letters from the treating physician to the occupational physician to enhance communication.
Work is important to people living with cancer, and the research available shows that we need to improve our efforts to provide effective support both at the basic level of advice and guidance, and at the more specialist level of specific VR interventions.
Please see the references| section.
Dr Gail Eva is Research Fellow at University College London Institute of Neurology. She is an occupational therapist specialising in cancer and palliative care rehabilitation. Her research work centres on the social, psychological and occupational consequences of disability for people with cancer, with a particular focus on fatigue, goal-setting and employment. Email Dr Gail Eva|.
Return to part one - Vocational rehabilitation: building work into a care plan|
Part three - Policy|
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