Barriers and opportunities for return-to-work of cancer survivors: time for action—rapid review and expert consultation

We conducted this rapid review, based on the methodology elaborated by The Knowledge to Action Research Programme [7] and by researchers from the University of York [8]. The seven steps followed to complete this study are presented in Fig. 2. This rapid review was not registered with PROSPERO, and no ethical approval or informed consent was required.

To optimize the search, we framed a PICO. The population (P) is working age cancer patients (18–64), the indicators (I) are all those related to the employment of cancer patients, the comparison (C) is done among patients with different cancer sites or affected by other diseases or disease-free adults, and the outcome (O) of interest is RTW or employment. We limited our search to studies published in the period January 2000 until January 2015 We excluded studies involving patients with a poor prognosis (i.e. survival less than 12 months) and focused on studies that primarily investigated the possible effects of cancer on RTW and employment status.

We searched through three databases: MEDLINE, Cochrane Library and Trip Database. The following MeSH and non-MeSH terms were used to perform the search: rehabilitation, employment status, survivorship, survivors, long-term survivors, cancer patients, return-to-work. In total, the primary search delivered 1860 papers as presented in the PRISMA flow chart of Fig. 3.

We first focused on systematic reviews and meta-analyses. The search resulted into 10 systematic reviews, three of which fitted our research questions: de Boer et al. 2009, van Muijen et al. 2013 and Banning et al. 2011 [9‐11]. Out of the 64 original studies included in these three systematic reviews, we picked up 30 of them, after having eliminated the duplications and those that did not meet our specific criteria. Second, we compared the results from the additional search of original studies and added 13 studies, ending with a total of 43 original studies.

Since we included all types of studies, we decided to assess their methodological quality and level of evidence, in order to value their relevance.

To define the criteria for the quality assessment, we decided to merge three validated assessment tools: the checklist of Downs and Black, the MINORS instrument and the CASP checklist for qualitative research [12‐14]. The three tools delivered 49 questions that we grouped into three categories: questions related to internal validity, external validity and other questions. All questions were screened and compared, and those which recurred in all three tools were kept to fit our list of criteria that we used in our quality assessment. As presented in Table 3, 10 criteria have been retained, nine of which counting for a maximum of three points and one for two points. Each study could get a maximum score of 29 points, and we divided the studies into three groups: studies scoring 24 points or over (i.e. meeting most validity criteria), those scoring between 18 and 23 points (i.e. meeting over half of the validity criteria) and studies with a score of 17 points or less, meaning poor validity (Table 1).

The quality assessment gave the following results: 10 studies scored a ‘high relevance’, 19 ‘a moderate relevance’ and 14 ‘a low relevance’ (Table 3).

In order to validate the factors identified through the literature review, we used the Delphi method [15] and presented the results to a group of experts. We invited participants from different fields of expertise: academics, government officials, health professionals, social carers and patients’ representatives (Table 2). The researchers contacted the main Belgian institutions (head of relevant departments) involved in the professional reintegration after sickness, explaining the objectives of the study. Next, the participating experts were appointed by their institution. The objective of this consultation was to ensure the relevance, in the Belgian context, of the risk factors identified in literature and also to assess their relevance related to the ability of cancer survivors to remain occupationally active.

In total, three rounds of discussion took place, and each lasted 3 h on average. The first session aimed at clearly defining the issue(s) to be addressed by the literature review, the target group and the timeframe and at identifying additional experts or stakeholders to be invited. The second session took place 4 months later and focused on the presentation of the first results of the literature review and on the results from unpublished national studies. In this session, experts and stakeholders were asked the following questions: “Do these results fit with your experience and expertise? To which extent do they apply in the Belgian context (what is their strength)? Which features from the healthcare or employment system would you add as impeding or facilitating factors?”

The third session was dedicated to the final validation, combining the results from the literature, balanced and refined according to the Belgian social and economic context, and expert’s input.

After each session, the content of the discussion was reported ad verbatim by the coordinator and sent to all participants who were given time to complete or refine their statements. The final versions of the reports, available in French and Dutch, were used to draft this paper.

After merging the studies found in the three retained systematic reviews [9‐11], and the database search, after eliminating duplications, 43 studies were included in the analysis. Nine risk factors were identified; these are presented according to the international classification by Collins et al. in 2013 [16]. The main results are presented in Table 3, and the Additional file 1 contains a detailed presentation of the included studies.

Each of the nine risk factors identified in the literature review was presented and discussed with the experts. In addition to these nine factors, experts added three main aspects to be considered in facilitating the RTW of cancer survivors: (1) the role of health professionals in the screening of cancer survivors at risk and their early sensitization to consider the existing options for RTW and to consult with their GP, social security physician and occupational physician; (2) a thorough and systematic evaluation of the (remaining) work capacities; and (3) revised employment policies that promote maintaining and hiring cancer survivors with prolonged sickness absence. These results are described hereafter.

Based on the results of the literature review and from national unpublished work, the experts divided the four main categories of factors into two even groups, i.e. non-modifiable factors and factors open to positive change that may enhance RTW of cancer survivors.

Regarding socio-demographic factors, experts acknowledged that cancer survivors aged over 50 years and less than 35 years had the highest risk of facing difficulties in employment. For the younger ones, difficulties mainly are related to their lack of experience combined with the seriousness of their disease. Also, reluctance of employers to keep them on board or to hire them, fearing relapse and lower productivity, may play a part. For the elderly, difficulties are mostly due to comorbidities, the burden of symptoms and side effects of treatment.

Related to education, experts confirmed, as found in the literature, that cancer survivors with a low level of education often have physically demanding jobs and that the level of their income (usually low) does not present an important incentive to resume work, as to preserve a high standard of living.

Regarding cancer site and stage, experts emphasized the importance to assess these together to draw conclusions on their impact on work ability. These two factors assessed together were believed to provide more accurate information related to the physical and emotional burden of the disease.

The group of experts reported that in the Belgian context, it is important to take into account the region the patient lives in, as employment policy is a regional prerogative. The most remarkable and unique example comes from the Province of Limburg, where employers have been sensitized to physical, cognitive and emotional difficulties of cancer survivors and have been invited to sign a charter committing their company to better support the employed cancer survivors and to positively discriminate others by hiring them.

Regarding the work-related factors, the consulted experts reported the need for more effort to adapt the workload (working time, work schedule, business trips, etc.) or the workstation to the capacity of survivors or to their treatment and recovery needs. In parallel, cancer survivors also need to be better prepared, physically and emotionally, offering them more medical and paramedical support.

Experts emphasized that besides the physiological aspects, the workplace (e.g. the direct supervisor and colleagues) also needs to be prepared for the RTW of cancer survivors who can present temporarily limited capacities or emotional distress. Experts reported it is best to avoid a long period of rupture with the social and professional environment. That is, the length of the absence has a negative impact on the quality of the RTW, making it harder for cancer survivors who were alienated from the workplace to RTW.

Small-sized companies and the private sector have been presented in the literature as risk factors for RTW of cancer survivors. However, experts have reported that national investigations and surveys have shown the contrary [27]. Experts stated that a significant number of small- and medium-sized enterprises (SMEs) in Belgium are particularly willing to adapt the workstation or schedule in order to keep cancer survivors with specific experience and knowledge and who, e.g. have a longstanding relationship with clients. Again, this particular insight serves the experienced (often older) cancer survivors but does not present an advantage for the younger ones, unless they are very qualified (i.e. those with a high educational level).

Related to the more personal and subjective factors, though they are difficult to assess and modify, experts reported that in cancer survivors, addressing RTW issues at an early stage may positively influence the evaluation of the meaning of work. To simply address the work issue with cancer survivors just before the end of their (curative) treatment seems to already raise awareness and questions, for which they can be referred to social security advisers. Also, in case of good prognosis, the reassurance about their future abilities to resume their daily activities(albeit into different extents), can facilitate the RTW process.

The choice not to focus on randomized control trial studies made it impossible to quantify the strength of the identified factors. Nor was it possible to prioritize the factors according to their relevance related to the professional reintegration process of cancer survivors. We encourage future cohort studies to quantify, compare and demonstrate the impact of the risk factors.

Unlike systematic reviews, at the moment, no quality insurance checklist exists regarding the rapid review process. The development of a PRISMA checklist for rapid reviews, taking into account expert opinions, could increase the quality and comparability of such studies.