Exploration of interventions to enhance return-to-work for cancer patients: A scoping review

Survivorship concerns among individuals diagnosed with metastatic cancer: Findings from the Cancer Experience Registry

INTRODUCTION

Individuals with metastatic cancer experience many medical, physical, and emotional challenges due to changing medical regimens, oscillating disease states, and side effects. The purpose of this study was to describe the type and prevalence of survivorship concerns reported by individuals with metastatic cancer, and their associations with cancer diagnosis, treatment, and socio-demographic variables.

METHODS

This study utilized data from the Cancer Support Community's Cancer Experience Registry. Individuals were included if they self-reported a solid tumor metastatic cancer and completed CancerSupportSource, which evaluates five domains of concerns (emotional well-being, symptom burden, body image/healthy lifestyle, healthcare team communication, and relationships/intimacy). Multivariable linear regression examined associations between independent predictors of each survivorship concern domain.

RESULTS

Of the 403 included participants, individuals reported a metastatic diagnosis of breast (43%), colorectal (20%), prostate (7%), lung (7%), gynecologic cancer (6%) and other. Nearly all (96%) reported at least one survivorship concern, with the most prevalent concern about cancer progression or recurrence. Survivorship concerns were higher across multiple domains for individuals unemployed due to disability. Individuals who were less than five years since diagnosis reported higher concerns related to emotional well-being, symptom burden, and healthcare communication compared to those more than five years since diagnosis.

CONCLUSION

Individuals with metastatic cancer experience a variety of moderate-to-severe survivorship concerns that warrant additional investigation.

IMPLICATIONS FOR CANCER SURVIVORS

As the population of individuals with metastatic cancer lives longer, future research must investigate solutions to address modifiable factors associated with survivorship concerns, such as unemployment due to disability.

Non-medical interventions to enhance return to work for people with cancer

BACKGROUND

People with cancer are 1.4 times more likely to be unemployed than people without a cancer diagnosis. Therefore, it is important to investigate whether programmes to enhance the return-to-work (RTW) process for people who have been diagnosed with cancer are effective. This is an update of a Cochrane review first published in 2011 and updated in 2015.

OBJECTIVES

To evaluate the effectiveness of non-medical interventions aimed at enhancing return to work (RTW) in people with cancer compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO and three trial registers up to 18 August 2021. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs on the effectiveness of psycho-educational, vocational, physical or multidisciplinary interventions enhancing RTW in people with cancer. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed RCTs for inclusion, extracted data and rated certainty of the evidence using GRADE. We pooled study results judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs) for RTW and mean differences (MD) or standardised mean differences (SMD) with 95% CIs for QoL.

MAIN RESULTS

We included 15 RCTs involving 1477 people with cancer with 19 evaluations because of multiple treatment groups. In this update, we added eight new RCTs and excluded seven RCTs from the previous versions of this review that were aimed at medical interventions. All included RCTs were conducted in high-income countries, and most were aimed at people with breast cancer (nine RCTs) or prostate cancer (two RCTs). Risk of bias We judged nine RCTs at low risk of bias and six at high risk of bias. The most common type of bias was a lack of blinding (9/15 RCTs). Psycho-educational interventions We found four RCTs comparing psycho-educational interventions including patient education and patient counselling versus care as usual. Psycho-educational interventions probably result in little to no difference in RTW compared to care as usual (RR 1.09, 95% CI 0.96 to 1.24; 4 RCTs, 512 participants; moderate-certainty evidence). This means that in the intervention and control groups, approximately 625 per 1000 participants may have returned to work. The psycho-educational interventions may result in little to no difference in QoL compared to care as usual (MD 1.47, 95% CI -2.38 to 5.32; 1 RCT, 124 participants; low-certainty evidence). Vocational interventions We found one RCT comparing vocational intervention versus care as usual. The evidence was very uncertain about the effect of a vocational intervention on RTW compared to care as usual (RR 0.94, 95% CI 0.78 to 1.13; 1 RCT, 34 participants; very low-certainty evidence). The study did not report QoL. Physical interventions Four RCTs compared a physical intervention programme versus care as usual. These physical intervention programmes included walking, yoga or physical exercise. Physical interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.08 to 1.39; 4 RCTs, 434 participants; moderate-certainty evidence). This means that in the intervention group probably 677 to 871 per 1000 participants RTW compared to 627 per 1000 in the control group (thus, 50 to 244 participants more RTW). Physical interventions may result in little to no difference in QoL compared to care as usual (SMD -0.01, 95% CI -0.33 to 0.32; 1 RCT, 173 participants; low-certainty evidence). The SMD translates back to a 1.8-point difference (95% CI -7.54 to 3.97) on the European Organisation for Research and Treatment of Cancer Quality of life Questionnaire Core 30 (EORTC QLQ-C30). Multidisciplinary interventions Six RCTs compared multidisciplinary interventions (vocational counselling, patient education, patient counselling, physical exercises) to care as usual. Multidisciplinary interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.09 to 1.33; 6 RCTs, 497 participants; moderate-certainty evidence). This means that in the intervention group probably 694 to 844 per 1000 participants RTW compared to 625 per 1000 in the control group (thus, 69 to 217 participants more RTW). Multidisciplinary interventions may result in little to no difference in QoL compared to care as usual (SMD 0.07, 95% CI -0.14 to 0.28; 3 RCTs, 378 participants; low-certainty evidence). The SMD translates back to a 1.4-point difference (95% CI -2.58 to 5.36) on the EORTC QLQ-C30.

AUTHORS' CONCLUSIONS

Physical interventions (four RCTs) and multidisciplinary interventions (six RCTs) likely increase RTW of people with cancer. Psycho-educational interventions (four RCTs) probably result in little to no difference in RTW, while the evidence from vocational interventions (one RCT) is very uncertain. Psycho-educational, physical or multidisciplinary interventions may result in little to no difference in QoL. Future research on enhancing RTW in people with cancer involving multidisciplinary interventions encompassing a physical, psycho-educational and vocational component is needed, and be preferably tailored to the needs of the patient.

Physical activity in people diagnosed with cancer: a rapid review of recommendations and critical appraisal of international guidelines

PURPOSE

There are numerous guidelines that recommend physical activity (PA) in people diagnosed with cancer, but the quality of these guidelines is unknown. The aim of this study was to identify existing PA guidelines for cancer survivors, describe the recommendations, and assess their methodology quality.

METHODS

A rapid review of the literature was conducted in PubMed and EMBASE, supplemented by a search of the grey literature. The methodological quality of the guidelines was assessed using the AGREE II checklist. A descriptive synthesis of the recommendations from guidelines judged to be of good quality has been performed.

RESULTS

A total of nine guidelines published between 2006 and 2019 were included. Of nine guidelines, five achieved a high enough AGREE II score and were judged to be of good quality for use in clinical practice. We found that the recommendations from the five guidelines converged on the prescription of supervised PA (aerobic and resistance exercise) of at least 75 min per week of high intensity or 150 min per week of moderate intensity, spread over two to five sessions per week, equating to a PA dose between 8.70 and 17.5 MET.h/week. The recommendations were applicable to address the most common side effects of cancer and its treatment, namely fatigue, lymphedema, anxiety, depressive symptoms, health-related quality of life (QoL), survival, and physical function. However, no guideline recommends PA to improve other cancer-related outcomes, such as cognitive impairment, falls, sexual function, and peripheral neuropathy frequently experienced by cancer survivors. No guideline also referred to work outcomes (i.e., work ability, return to work, etc.).

CONCLUSION

Most PA guidelines for cancer survivors are of good quality. However, specific PA guidelines are needed for a given cancer site (e.g., location, stage), at a particular phase of the cancer trajectory, and for specific outcomes including return to work (RTW) in order to tailor PA to each cancer survivor.

Supporting Return to Work after Breast Cancer: A Mixed Method Study

Breast cancer (BC) is the most common invasive cancer in the world. Most BC survivors (BCSs) continue working while dealing with cancer-related disabilities. BCSs' return-to-work (RTW) after cancer treatment is an important stage of their recovery and is associated with a higher survival rate. In this study, we addressed the RTW of BCSs with the intention of facilitating this process through direct action in the workplace. Thirty-two women who requested assistance from January to December 2022 were enrolled in the study. Semi-structured interviews and medical examinations were conducted by a team of three physicians. Interviews were analyzed using Thematic Analysis. Moreover, a quantitative cross-sectional study was conducted to compare the health status of BCSs with that of a control group of 160 working women, using standardized questionnaires on work ability, fatigue, sleep problems, anxiety, depression, and happiness. BCSs were also asked to rate the level of organizational justice they perceived at work prior to their illness. From the qualitative analysis emerged three facilitating/hindering themes: (1) person-related factors, (2) company-related factors, and (3) society-related factors. In the quantitative analysis, BCSs had significantly higher scores for anxiety, depression, sleep problems and fatigue, and lower levels of happiness than controls. The RTW of BCSs entails adapting working conditions and providing adequate support. The work-related analysis of each case made it possible to highlight the measures that need to be taken in the workplace to promote RTW. The treatment of cancer should be paired with advice on the best way to regain the ability to work.

How Much Does Presenteeism Change in Response to Interventions or Alterations in Health Status? A Systematic Review and Meta-Analysis Using the COSMIN Methodology

Purpose The purpose of this study was to estimate the extent to which measures of presenteeism among workers change in response to alterations in health status induced by treatment or natural history. Methods We searched eight databases in August 2020 for studies published since 2012 measuring presenteeism longitudinally. Two independent reviewers screened the titles, abstracts, and full-text articles and performed data extraction. Studies were stratified into longitudinal studies using presenteeism as an outcome and measurement studies designed to test the responsiveness of presenteeism measures. We appraised the methodological quality of the measurement studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. Standardized response means (SRMs) for interventional studies where participants reported improvement on anchor measures were quantitatively pooled.Results Our searches returned 2882 results. Eleven measurement studies and 126 longitudinal studies were included. Of the measurement studies (n = 2625 participants), 7 had adequate study quality and 4 studies were deemed doubtful. Anchors and responsiveness methods varied considerably. Our estimate of responsiveness from 5 measurement studies and 4 presenteeism measures is an SRM of 0.85 (95% CI 0.77, 0.92) and Cohen's d of 0.54 (95% CI 0.49, 0.58), translating to an average important change of 17/100. For deterioration, the value is - 17/100. Conclusions We found considerable variation regarding how responsiveness data was reported in measurement studies. There is evidence that responsiveness is strong for four presenteeism measures: the Work Productivity Survey, the Work Functioning Impairment Scale, the Work Role Functioning Questionnaire, and the Nurses Work Functioning Questionnaire.

Breast cancer and occupation: Non-parametric and parametric net survival analyses among Swiss women (1990–2014)

Introduction

Occupation can contribute to differences in risk and stage at diagnosis of breast cancer. This study aimed at determining whether occupation, along with skill level and the socio-professional category, affect the breast cancer survival (BCS) up to 10 years after diagnosis.

Materials and methods

We used cancer registry records to identify women diagnosed with primary invasive breast cancer in western Switzerland over the period 1990–2014 and matched them with the Swiss National Cohort. The effect of work-related variables on BCS was assessed using non-parametric and parametric net survival methods.

Results

Study sample included 8,678 women. In the non-parametric analysis, we observed a statistically significant effect of all work-related variables on BCS. Women in elementary occupations, with low skill level, and in paid employment not classified elsewhere, had the lowest BCS, while professionals, those with the highest skill level and belonging to top management and independent profession category had the highest BCS. The parametric analysis confirmed this pattern. Considering elementary occupations as reference, all occupations but Craft and related trades had a hazard ratio (HR) below 1. Among professionals, technicians and associate professionals, and clerks, the protective effect of occupation was statistically significant and remained unchanged after adjustment for age, calendar period, registry, nationality, and histological type. After adjusting for tumor stage, the HRs increased only slightly, though turned non-significant. The same effect was observed in top management and independent professions and supervisors, low level management and skilled laborers, compared to unskilled employees.

Conclusion

These results suggest that work-related factors may affect BCS. Yet, this study was conducted using a limited set of covariates and a relatively small study sample. Therefore, further larger studies are needed for more detailed analyses of at risk occupations and working conditions and assessing the potential interaction between work-related variables and tumor stage.

American Society for Transplantation and Cellular Therapy Return to Work Guidance Committee Recommendations for Health Care Providers Who Take Care of Hematopoietic Cell Transplantation Patients

Hematopoietic cell transplantation (HCT) health care providers report a desire to improve long-term outcomes and quality of life for their patients. One of the items frequently cited by patients in terms of transitioning from being a patient back to pre-HCT life is return to work (RTW). However, these patients report little support from their health care providers in facilitating this process, and only 50% to 60% achieve RTW, at a median of 3 years post-HCT. Barriers are physical, psychological, and logistical, as well as poor communication between the patient and their employer. We convened a group of experts in survivorship, rehabilitation, social work, and psychology to draft an evidence-based document to assist health care providers in guiding their patients' RTW journey. Guidance is drawn from the existing literature for HCT and general cancer patients and is divided into pre-HCT, peri-HCT, and post-HCT categories. Collaboration among health care providers, patients, and their employers is key to this transition. Suggested referrals and evaluations also are provided. The goal is for this guidance to be continually updated as we advance the field with more HCT-specific literature.

Informing the development of multidisciplinary interventions to help breast cancer patients return to work: a qualitative study

PURPOSE

Return to work (RTW) after breast cancer (BC) can be a major challenge for patients. Multidisciplinary interventions seem to be effective but the role of digital solutions is under-developed and therefore not evaluated. We explored the preferences, needs, and barriers regarding RTW interventions, including opinions about the use of digital approaches to deliver such interventions.

METHODS

We conducted a qualitative study based on interviews with 30 patients with BC and 18 healthcare providers in four French regions. Emergent themes were identified using thematic content analysis.

RESULTS

Most providers declared that they did not proactively address RTW with patients, mainly due to having other priorities and a lack of knowledge. The following themes emerged: several development and deployment barriers regarding RTW interventions exist, multidisciplinary interventions are preferred, and there is a need to maintain contact between the patient and workplace during sick leave, including pathways and interlocutors that can facilitate RTW. Participants had mostly positive representations of using digital tools to facilitate RTW; however, fear of loss of human contact and the exacerbation of inequalities were identified as possible risks associated with the development of digital-only interventions.

CONCLUSIONS

Interventions blending the needs and preferences of patients with BC and the healthcare system are warranted. A personalized multimodal approach with mixed digital and in-person features has surfaced as a possible solution to address the weaknesses of existing interventions.

IMPLICATIONS FOR CANCER SURVIVORS

Since most women work at the time of diagnosis, it is of particular relevance to build interventions promoting RTW.

Variation over time of the factors influencing return to work and work capacities after a diagnosis of breast cancer: a study on the behalf of the Seintinelles research network

PURPOSE

To evaluate the dynamics of the determinants of returning to work (RTW) in a population of patients treated for breast cancer (BC) in a real-world setting.

METHOD

We conducted a retrospective study including 1278 BC patients working or looking for work at the time of diagnosis. We performed a focused principal component analysis to highlight the dimensions of a persistent decline in work capacity. Logistic regression analyses were performed to identify correlates of non-RTW 1 and 2 years after treatment.

RESULTS

One-third (31%, n = 389) of patients continued working during treatment. At study inclusion, 1100 patients had returned to work (89%). Three-quarters (n = 508, 75%) of the women reported a decline in work capacity 1 year after RTW and 22% (n = 148) presented a persistent decline in work capacity 2 years after the diagnosis. The odds ratio for non-RTW at 1 year was significantly higher for patients treated with a combination of chemotherapy and trastuzumab (OR = 1.72, 95% CI [1.07-2.76]), manual workers (OR = 3.99, 95% CI [1.54-10.81]), patients with lower incomes (OR = 2.33, 95% CI [1.29-4.19]), and patients experiencing fatigue (OR = 1.81, 95% CI [1.34-2.48]). The odds ratio for non-RTW at 2 years was higher for various occupational categories (OR = 3.49, 95% CI [1.89-6.74] for clerks, OR = 4.58, 95% CI [1.48-12.82] for self-employed workers, OR = 8.98, 95% CI [2.69-27.89] for manual workers), patients with comorbidities (OR = 2.80, 95% CI [1.61-4.93]), and patients experiencing anxiety symptoms (OR = 2.54, 95% CI [1.18-5.76]), while the impact of the type of treatment was no longer significantly associated with RTW.

CONCLUSION

The determinants of RTW change over time. Patients should be offered supportive interventions tailored to risk factors and time from diagnosis.