Owing to improved treatment and early detection, cancer is increasingly becoming a chronic rather than terminal condition, which means that many cancer survivors are able and willing to return to work. Employment is associated with a higher quality of life, and encouraging survivors to return to work also benefits ageing societies economically, according to Dr Tyna Taskila.
Research suggests that cancer diagnosis has an impact on work; unemployment and early retirement are a reality for many survivors. A systematic review and meta-analysis of nearly 21,000 people with cancer and more than 160,000 healthy people in a control group showed that cancer survivors were 1.4 times more likely to be unemployed compared with people without cancer (de Boer et al, 2009).
Evidence suggests that a majority of cancer survivors are in fact able to return to work after their treatment, but they struggle to remain in work life. Research has shown that itis less likely for those who are absent from work for a long period of time to be successful in their return to work (Mehnert et al, 2013).
Cancer often requires complex treatment models and as a result, sickness absence of up to 12 months is not uncommon. In addition, cancer survivors often have other health problems, which can include chronic symptoms such as fatigue, pain and cognitive dysfunction. It has been estimated, for example, that as many as 40% of all cancer survivors experience chronic fatigue, even several years after the initial diagnosis – which can be as debilitating as the illness itself (Bower et al, 2006).
It can therefore be said that cancer causes partially reduced work capacity rather than disability. In addition to cancer, partially reduced work capacity is common in other chronic illnesses, such as mental health conditions and musculoskeletal disorders (MSDs).
Ideally, people with a partially reduced work capacity should not leave the labour force and should be supported to find, or remain in, an appropriate job. This has not often been the case in the past, but policymakers are increasingly focusing on what people can do rather than what they cannot do.
Recent positive changes in sickness and disability policies in several OECD countries reflect this rethinking of employment and rehabilitation policies. As a result, the importance of early intervention in facilitating the return-to-work process in people with partially reduced work capacity has been increasingly recognised by stakeholders and policymakers. Some initiatives of early intervention have been developed in the UK and elsewhere.
Types of interventions
Return to work is a complex phenomenon influenced by several factors and various stakeholders with different motives. Evidence suggests that multidisciplinary interventions involving various stakeholders that take into account the individual needs of each cancer patient are the most effective way of supporting people with cancer back to work.
Available interventions can be divided into illness-related and work-related versions. Illness-related interventions focus on reducing long-term side effects of cancer treatment and/or comorbidity such as fatigue or concentration problems. Some interventions also aim to improve physical fitness supporting recovery from the treatment. In addition, helping cancer survivors to better self-manage their condition can often be part of illness-related interventions.
Work-related interventions aim to facilitate gradual return to work, making the return to work process as efficient as possible. This can further be facilitated by workplace adjustments. The most effective workplace adjustments for people with cancer are reduced work hours, flexible working and changed work tasks or responsibilities (Taskila et al, 2011).
Macmillan’s rehabilitation model
Macmillan Cancer Support, together with the Department of Health, commissioned he National Cancer Survivorship Initiative (NCSI) Vocational Rehabilitation project to develop and test avocational rehabilitation programmes and work support for cancer patients. The project developed the “Three level model of work support for people with cancer” (Eva G et al, 2012).
Level 1 involves everyone with a cancer diagnosis who is in work or who has the potential to work. Research suggests that patients do not raise work problems with their doctors and nurses because they do not think it is relevant or interesting to them. Level 1 requires healthcare professionals to make sure that patients know that work is on the agenda and that it is legitimate to talk about it.
Many people at this level will not identify any difficulties and might not think that they have problems, but it is important to ensure that work remains on the agenda in a positive way. Actions needed at this level are signposting and providing information on the impact of a cancer diagnosis on work, providing information on self-management support programmes or other support available and, finally, giving advice on how to get in touch with professionals if problems arise in the future.
Level 2 involves people with cancer who have identifiable work problems and who, with some support, would broadly be able to self-manage these issues. In this group, the key is to catch problems early to prevent them from escalating. Actions taken at this level involve the provision of specialised advice or support that people with cancer are able to take forward and implement themselves, but also in some cases signposting to other specialist services and organisations. If support was required, it would typically be of a short duration and could be delivered either face to face, or by phone or email.
Even with the best support available at levels 1 and 2, there are always going to be people with complex problems, and these are the people categorised at level 3 – which means specialist vocational rehabilitation. This is needed when the illness or treatment has affected someone’s physical or cognitive capabilities to the extent that they are having significant difficulties managing their job and are therefore at risk of early retirement or unemployment. Support at this level could involve, but is not necessarily limited to:
- detailed assessment of individual capacity and workplace requirements;
- rehabilitation interventions to build work skills;
- education on managing specific symptoms;
- liaison with employers, negotiating a phased return to work;
- psychological interventions;
- information and advice on rights and responsibilities;
- supported withdrawal from work where appropriate;
- referral to other support services; and
- careers advice and guidance.
Supporting quicker return to work in Finland
Research evidence shows that gradual return to work or working part time is effective for those whose condition, such as cancer, does not allow returning to work on a full-time basis. To reduce the risk of prolonged sick-leave by keeping an employee active and connected with the work community, part-time sick leave is used in some countries.
In Finland, the law of partial sickness allowance was introduced in 2007. It is intended for persons who are employed or self-employed on a full-time basis and who are between 16 and 67 years of age. Employees on long-term sick leave can make an agreement with their employer to return to work on a part-time basis, of between 40% and 60% reduced work hours. While employed part time, employees are paid an earnings-related partial sickness allowance from a private pension insurer and/or the national insurance institution, KELA.
The partial sickness allowance is payable for up to 128 working days (for about three months). It is not available for periods shorter than two weeks. All days on the partial sickness allowance during the preceding two years count towards the 128-day maximum. If the employee reaches the maximum, they must be fit for work for at least one year before they can again receive partial sickness allowance for the same illness.
The number of people using this benefit increased when the required duration of sick leave before partial sick leave could be taken was lowered to two weeks in 2010. Despite this increase in uptake, however, only 2% of the sickness allowance periods paid for by KELA are for employees on part-time sick leave (FIOH, 2012).
A randomised controlled trial of employees with MSDs conducted by The Finnish Institute of Occupational Health (FIOH) showed that those who had been on partial sick leave returned to full-time work more quickly, and had 20% less work disability days over the following year, than those who had been on normal sick leave (Viikari-Juntura et al, 2012).
Unfortunately, there is no research evidence on how well the part-time sick leave would work for people with cancer in particular. Nevertheless, taking into account the similarities that people with long-term conditions experience when returning to work regardless of their condition, it is likely that part-time sick leave would be equally beneficial for people with cancer by enabling them to return to work and remain in work life.
Bower JE, Ganz PA, Desmond KA, Bernaards C, Rowland JH, Meyerowitz BE et al (2006). “Fatigue in long-term breast carcinoma survivors: a longitudinal investigation”. Cancer; vol.106, issue 4, pp.751-758.
de Boer AG, Taskila T, Ojajarvi A, van Dijk FJ, Verbeek JH (2009). “Cancer survivors and unemployment: a meta-analysis and meta-regression”. Jama; vol.301, issue 7, pp.753-762.
Eva G, Playford D, Sach T, Barton G, Riserbo H, Radford K et al (2012). “Thinking positively about work – Delivering work support and vocational rehabilitation for people with cancer”. Macmillan Cancer Support, Department of Health and UCL.
The Finnish Institute of Occupational Health (2012). “Gradual return to work after sickness absence”. Finnish Institute of Occupational Health.
Mehnert A, de Boer A, Feuerstein M (2013). “Employment challenges for cancer survivors”. Cancer; vol. 119, supplement S11, pp.2,151-2,159.
OECD (2007). “New ways of addressing partial work capacity – OECD thematic review on sickness, disability and work issues paper and progress report”.
Taskila T, de Boer AG, van Dijk FJ, Verbeek JH (2011). “Fatigue and its correlates in cancer patients who had returned to work – a cohort study”. Psychooncology; vol.20, issue 11; pp.1,236-1,241.
Viikari-Juntura E, Kausto J, Shiri R, Kaila-Kangas L, Takala EP, Karppinen J et al (2011). “Return to work after early part-time sick leave due to musculoskeletal disorders: a randomized controlled trial”. Scandinavian Journal of Work, Environment & Health; vol.38, issue 2, pp.134-143.
- Cancer survivors are often able to return to work, but are at risk of leaving the work life early.
- Early departure from work life is due to chronic symptoms, such as fatigue, pain and cognitive dysfunction.
- Cancer often causes partially reduced work capacity rather than disability.
- A multidisciplinary intervention involving various stakeholders, and taking account of the individual needs of each cancer patient, is the most effective way of enhancing return to work and job retention of cancer survivors.
- Policymakers across Europe are increasingly recognising the need for developing interventions for cancer survivors and people with other conditions that cause reduced work capacity.
- Good examples of effective policies are: the “Three level model” developed by Macmillan Cancer Support; and the law of part-time sick leave in Finland.
A 58-year-old woman was recovering from bowel cancer. After completing chemotherapy, she suffered a lumbar fracture and exacerbated osteoporosis. She also suffered from fatigue, pain and stiffness.
The vocational rehabilitation (VR) intervention
- The VR case manager carried out a workplace assessment and arranged suitable seating, working jointly with her occupational health department.
- The case manager also made recommendations for adjustments and managing fatigue, plus referring her client to physiotherapy for a further treatment programme.
- Following a graded return to work with adjustments, the woman successfully returned to part-time employment and is able to manage her professional role without needing to take early retirement.
Source: Doncaster vocational rehabilitation pilot, Macmillan Cancer Support.
The Finnish Institute of Occupational Health study
The FIOH study involved employees in six enterprises who had sought medical advice due to musculoskeletal pain. To participate in the study, people’s symptoms and related disability had to be severe enough to justify full-time sick leave according to the prevailing practice, but still allow them to work reduced hours without the risk of deterioration of their condition. A further eligibility criterion was that previous sick leave had to be for two weeks or less.
A total of 120 employees were examined as potentially eligible and 63 were included in the study. The study was an individually randomised controlled trial in which participants were randomised into part-time or full-time sick-leave groups. In the part-time sick leave group (intervention group), working time was reduced by about half and the remaining work tasks were modified if necessary (for example, reduced lifting or reduced work with an arm above the head). The full-time sick leave group served as the control group.
- The time taken to return to work was shorter in the intervention group, a median 12 days versus 20 days.
- Total sickness absence during the 12-month follow-up was about 20% lower in the intervention group than in the control group.
- Work hours were reduced in all cases in the intervention group and work practices were modified for 30%.
- Employees on part-time sick leave reported less disability and functional impairment, and had better self-rated health, than those on full-time sick leave.
- Work arrangements made to suit part-time sick leave were mostly successful and the experiences of supervisors and employees were mainly positive.
Source: FIOH (2012). Policy brief: Gradual return to work after sickness absence.