Cancer and return to work
Cancer prevalence has increased worldwide in recent years due to improvements in diagnostic procedures and treatment [
1]. Approximately 40 % of new cancers are found in the working population [
2], of whom many are motivated for and expect to return to work (RTW) [
3], as RTW constitutes “normalcy”, has impact on quality of life and economic independence [
4,
5]. However, the cancer disease and the treatment still increases the risk of early withdrawal from the labour market [
6,
7]. Even though work is perceived as an important factor in quality of life [
8,
9], for some cancer survivors work participation may be deprioritised by other ways of active participation in society [
10]. Therefore knowledge on how cancer survivors value their work and how this affects the RTW process is needed. Among cancer survivors who do RTW some may face both health-related and work-related difficulties leading to reduced workability and recurrence of sick leave [
11], which further increases the risk of prematurely exit from the labour market [
12]. Some consistency exists in the literature about which factors are associated with RTW despite adverse side-effects from cancer treatment [
13]. However, often cancer patients are left on their own to deal with these challenges [
11,
14,
15,
10]; partly due to unclear agreements between stakeholders responsible for occupational rehabilitation [
10,
16] and partly due to reluctance and fear of articulating work and RTW to a cancer survivor [
17].
Research on RTW in cancer survivors has in recent years increased, partly because survival rates have increased [
18,
19], and because patients with advanced, incurable disease are able to perform some kind of work, and will often prefer to stay on the labour marked as long as possible. Nevertheless, there still is a need for rigorous studies applying a randomised controlled trial design, with thorough information on intervention components and data reporting [
19]. Due to the inconsistent conclusions drawn from the existing RTW studies in cancer survivors; evidence from research conducted on musculoskeletal and/or mental-related sickness absentees can give insights into effective RTW interventions in general and guide researchers in putting hypotheses forward on which elements cancer-oriented RTW interventions may contain. Thus, the provision of occupational rehabilitation to cancer survivors that consists of a combination of general and cancer specific intervention elements may prove to be an effective approach.
Some evidence supports that RTW interventions targeted musculoskeletal-related [
20] or depressed absentees [
21] are more effective when they address the workplace than interventions not targeting the workplace. Thus, in the planning of the present study it was crucial to incorporate involvement of the workplace as one of the key elements in the intervention. In a cancer setting it has been shown that employer and colleague support as well as work accommodation increases the RTW rate and reduces the likelihood of cancer-related work impairments after RTW [
13].
Problem-solving-therapy interventions towards employees sick-listed due to adjustment disorders enhanced partial RTW compared to a non-guideline based care [
22]. Cancer survivors may also display adjustment disorders due to difficulties in coping with having a cancer diagnosis along with expectations from relatives and friends, workplace and health care professionals in the RTW process. Fear of cancer recurrence may lead to fear avoidance behaviour, which limits participation in life - including work [
23,
24]. Therefore, the identification of cancer survivor-experienced barriers regarding RTW and assistance in barrier modification were important elements that the present intervention should include.
Feuerstein et al. developed the Work and Cancer Model based on an extensive review of the literature [
25]. A variety of factors coexists and may act both as facilitators and inhibitors of RTW among cancer survivors; individual characteristics, health and well-being, symptoms, function, work demands, work environment and finally structural factors [
25]. There seems to be agreement in the literature that RTW-interventions in general should target the multi-dimensional factors that are associated with sickness absence and that seems also to be true in a cancer specific context. This perspective is in part substantiated in the Cochrane review by de Boer et al. on RTW interventions to cancer survivors. Although the studies had low quality it was concluded that one-dimensional interventions, i.e. psychological, physical or medical interventions did not improve RTW compared to care as usual, whereas a moderate quality evidence was found for a multidisciplinary approach (involving physical, psychological and vocational elements) compared to care as usual [
18].
Cancer survivors in low socioeconomic groups may in particular experience the RTW-process difficult and tend to be at risk of recurrent sickness absence, unemployment or permanent withdrawal from the labour market [
7,
26,
27]. It is not clear which role socioeconomic status plays on cancer survivors’ RTW-process, but unfavourable work conditions characteristic for low income and low-level educational jobs may explain some of this inequality [
28]. Therefore work accommodations and supervisor support may be of particular importance in occupational rehabilitation in cancer survivors [
3,
10,
29] to help cancer survivors overcome the imbalance between health and work demands.
Despite improved long-term survival rates for cancer patients, survivorship does not mean living without health complaints, but rather living with a chronic disease [
30]. Cancer survivors do have an increased risk of recurrent cancers along with co-morbidities like cardiovascular disease, diabetes, osteoporoses etc. [
31]. This further increases the risk for reductions in workability and calls for collaboration between the occupational rehabilitation stakeholders to enhance the chance of sustainable RTW.
The Danish healthcare system
Permanent residents in Denmark pay approximately 40-50 % taxes of their income, by which almost all examinations and treatments within the Danish healthcare system are free of charge. The Danish Health and Medicines Authority is responsible for the organizational and clinical standards for the diagnostics and treatment for all cancer types, i.e. integrated cancer pathways [
16]. The objective of the pathways is to reduce referral time, obtain faster diagnosing and early onset of treatment. To accomplish these general goals the pathways are operationalised in several Disease Management Programmes for Cancer of which one defines Rehabilitation and Palliation in Cancer [
16]. The specific aim of cancer rehabilitation is, besides optimizing the patient's physical, psychological and social functioning while countering the limitations imposed by the side effects of cancer treatments and/or co-morbid conditions, also to offer occupational and vocational rehabilitation [
32]. Few studies have been conducted on occupational rehabilitation offered parallel to cancer treatment at the hospital [
33,
34], however more studies are ongoing/in preparation [
35‐
37]. Thus, knowledge is scarce on whether occupational rehabilitation applied early and parallel to cancer treatment facilitates the RTW-process for cancer survivors. To our knowledge, no studies have been conducted in a Danish setting or in other Nordic countries, which has similar tax-financed health care systems as Denmark.
Sickness absence management in Denmark
According to the Danish Sickness Benefit Act [
38], the municipal job centres are responsible for paying sickness benefits and initiating occupational/vocational rehabilitation to help sick-listed persons to RTW.
All employed, self-employed, temporarily employed and unemployed persons fulfilling the criteria of previous employment (minimum 74 h within a period of 8 weeks) are eligible for sickness benefits.
According to law, the employer pays sickness benefits during the first 4 weeks, afterwards the municipality refunds the employer’s wage expenses for a maximum period.
The regulations for sickness benefits have been subject to several changes [
39] and continue to be so. When the study started the maximum period was 52 weeks within a period of 78 weeks. From July 2014 the maximum period in general was reduced to 26 weeks. However, extensions can be granted and for persons suffering from cancer the maximum period may be unlimited.
Medical certificates were not mandatory but could be requested by the municipal social security system and the employer. However, from January 2015 a medical certificate became obligatory after 8 weeks of sickness absence.
After the newest reform in 2014–15 the sickness beneficiaries are assigned into three categories: Category 1 includes persons who are likely to RTW within eight weeks without intervention. Category 2 includes persons who are unlikely to RTW within eight weeks unless activities facilitating RTW are initiated, i.e. coping-sessions and graded RTW. Category 3 includes persons who are unlikely to RTW within eight weeks unless multidisciplinary rehabilitation is implemented. This is planned by a municipal rehabilitation team within 12 weeks.
In accordance with the law sickness benefit officers are obliged to conduct regular follow-up interviews at least every four weeks with beneficiaries in category 2 and 3. Thus, municipal officers have been appointed the role as case managers, whereas employers have little responsibility for sickness absence management after they have had the first obligatory meeting with the employee after four weeks of sick-listing.
Most cancer survivors may be assigned in category 2, but in reality they are often spared the obligatory meetings with the social security officer and activities initiated by the job centre while receiving their treatment. This leads to a short time frame in which the cancer survivors are offered vocational/occupational rehabilitation; i.e. time between the end of treatment and the maximum period of sickness benefit reimbursement. Offering early occupational rehabilitation parallel to cancer treatment focusing on preparations for RTW and making arrangements together with the employer regarding work accommodations, graded RTW etc. should improve the RTW-process and reduce the recurrent sickness absence after RTW.
Readiness for return to work scale
RTW after long-term sickness absence may be seen as a behavioural change or a process in several stages [
40], depending on factors of which the person’s own RTW perceptions are predictive of future work participation [
41‐
43]. The Readiness for RTW (R-RTW) scale [
40] is based on the original stages of change model [
44], which have been applied to various behaviours and across diverse disorders [
45].
The R-RTW model addresses the motivational and social factors contributing to RTW behaviour and maintenance of work participation [
46]. According to this model, the person progresses through stages of behaviour change i.e. RTW after sickness absence, shifting from the intention not to engage in RTW behaviour in the foreseeable future to a stage with initiating behaviour change, to maintain behaviour change and to RTW in a sustainable fashion.
Based on the score of the R-RTW scale it is possible to identify a person’s stage of readiness for change with regard to RTW allowing professionals, e.g. job consultants to tailor effective and individual support.