Occupational health can play a key role when an employee is returning to the workplace after cancer treatment. Emily Gilkes and Anne Harriss present a case of a health worker with breast cancer who achieved a successful return to work with adjustments.
Returning to work following a cancer diagnosis can often be an important part of the recovery process. Indeed, Waddell and Burton (2006) stress that (good) work is health enhancing. Staying in employment should be a realistic option, and with appropriate interventions, workers with cancer can be supported to remain in work (Taskila et al, 2013).
This case study examines the impact that breast cancer and its treatment had on Beryl (pseudonym), a healthcare worker on a medical unit, in relation to a successful return to work (RTW). It highlights the effect of the pathophysiology of cancer, the assessment of Beryl’s fitness for work and planning a successful RTW.
Beryl was referred for an OH assessment by her manager following a diagnosis of breast cancer, as she was keen to stay in work as long as possible, but had concerns due to upcoming surgery.
Beryl’s role involved working 12.5-hour shifts, including rotational night shifts. Her job included a significant amount of manual handling due to the speciality of the ward area.
She had recently undergone an excision of a breast lump, with axillary lymph node clearance. Histology confirmed a large carcinoma. Further treatment over the next seven months included chemotherapy and radiotherapy.
Her physically demanding job role, involving manual handling and microbiological hazard exposure, meant she had to refrain from work until treatment had been completed.
She attended an OH review following 18 weeks of chemotherapy and two hospital admissions. She reported severe side effects associated with chemotherapy, including sensory disturbances, affecting her hands, feet and head, and neutropenia that required isolation treatment in hospital.
Beryl was starting five radiotherapy treatments per week over a period of three weeks. An OH assessment at this early stage was useful in planning an effective RTW. An OH review appointment followed completion of treatment. Beryl reported that although her oncologist was happy with her progress, she was still suffering from several side effects related to her treatments. She had been signed off work for a further two months. Beryl was keen to RTW after this time, but had concerns about manual handling of heavier patients.
The pathological process of breast cancer
The DNA within cell nuclei controls the tightly regulated cycle controlling growth, division, maturity and death of breast cells. Neoplasms occur should this mechanism be disrupted. Cells with damaged DNA are normally destroyed by the immune system. Faults within this system result in tumour development (Mandal, 2013). Several studies suggest an increased risk of breast cancer among women consistently working night shifts (Gray, 2010), but further research is required to understand any links between occupation and breast cancer (Breast Cancer Fund, 2016).
In the UK, breast cancer is the most common cancer in women, with about 46,000 diagnosed annually (Grimsey, 2011). There is a good prognosis if caught early.
The classification of breast cancer relates to the tissue involved. Beryl developed the most common form of breast cancer: an invasive ductal carcinoma arising within the breast milk ducts, which may break through the duct wall, spreading to other breast tissue.
Over time it may spread to other body tissues, including the lymph nodes (Breastcancer.org, 2015).
About 80% of breast cancers are invasive and normally present as a palpable lump. Surgery is usually the first treatment (Froyd and Harmer, 2011); patients are given the option of breast-conserving surgery, such as a wide local excision of lump, or a mastectomy. Long-term survival is the same for breast-conserving surgery followed by radiotherapy as for mastectomy (Breast Cancer Care, 2016); Beryl opted for a wide local excision surgery.
Following such surgery, RTW guidance for people undertaking manual work is six weeks (Palmer et al, 2013). Further treatment given six weeks post-operatively included eight full cycles of adjuvant chemotherapy delivered over 18 weeks, delaying Beryl’s RTW.
Furthermore, she experienced neutropenia, resulting in two hospital admissions. Neutropenia, a common, potentially serious, side effect of chemotherapy affects bone marrow, leading to a reduced neutrophil count, which is normally lowest seven to 10 days after chemotherapy and increases the risk of infection (Lymphoma Association, 2015). Beryl was advised to avoid places/situations where risk of infection is heightened, including busy shops, public transport and people with infections, resulting in her being unable to undertake clinical work during her treatment.
Furthermore, Beryl was suffering from neuropathy affecting her hands, feet and head following chemotherapy. Sensory disturbances in her fingers affected her ability to perform tasks such as buttoning clothes and picking up small objects. Symptoms are expected to reduce once the treatment ceases (Macmillan Cancer Support, 2013).
She experienced severe fatigue – a common side effect of radiotherapy. Fatigue usually peaks within two weeks of treatment completion but may continue for several months (Cancer Research UK, 2016). She also reported pain in her left arm. As surgery involved axillary lymph node excision, she was at increased risk of developing lymphoedema due to damaged arm lymphatics (The Circulation Foundation, 2016). Although a diagnosis of lymphoedema had not been confirmed, she was advised to rest her arm and avoid significant manual handling, reducing any future risk of lymphoedema. This had implications for her RTW as her job role included manual handling tasks.
For breast cancer survivors, returning to work can be important for recovery. An early, safe and sustainable RTW is therapeutic (Aw et al, 2007). Goss et al (2014) refer to success in returning healthcare workers diagnosed with breast cancer back to work, with 89% of them returning to work within 12 months.
They found that almost all staff required workplace adjustments, including reduced hours, workloads and limiting physical activities, such as manual handling.
Beryl received OH support throughout her sickness absence. Case management of employees with chronic illnesses or disability is a proactive role for occupational health nurses (OHNs), assisting the employee to manage their condition, aiming for a successful RTW.
The OHN can facilitate collaborative, productive links between the employee, their care providers and their employer (Aziz, 2009). Evaluating a person’s ability to carry out a job must be fair and rigorous (Murugiah et al, 2002). Many models are available to assess fitness to work, and clinical assessments can combine several approaches.
The OH assessment used the biopsychosocial flags concept introduced by Kendall et al in 1997 (cited in Watson, 2010).
This model was adapted for use with Beryl, as it holistically assesses factors affecting an individual’s RTW; including biological, psychological and social factors.
The red flags consider the biological element of the model. In Beryl’s assessment, barriers for a RTW (red flags) were her recent history of breast cancer and treatment side effects. Although these caused a delay in her RTW, she was recovering well and her outlook was good.
A lasting side effect was fatigue, although this was gradually improving; Beryl was preparing for a RTW by attempting to increase her energy levels through gentle exercises.
Studies have found that cancer patients who carry out gentle exercise are less tired, less depressed and sleep better (National Comprehensive Cancer Network, 2016).
Sensory disturbances and continued pain were further biological barriers, but were subsiding, facilitating an increase in her activities.
Arm pain led to her avoiding significant manual handling. A functional assessment confirmed a good range of left arm and shoulder joint movement. Recent blood tests showed an increased white cell count, and although no longer at risk of developing neutropenia, Beryl was avoiding contact with people with known infections.
The yellow flag represents psychological elements of the model. Cancer and its treatments can negatively affect the sufferer’s psychological state. Many patients report that their RTW can be isolating, especially after a protracted absence, as many lose confidence and colleague contact (Cuneen, 2013).
Beryl had many concerns regarding her RTW. These included:
- heavy manual handling within her job role;
- whether or not continued pain would affect her RTW; and
- how chemotherapy-associated hair loss would affect how her colleagues and patients would perceive her, as she was unable to tolerate wearing a wig.
The blue flag represents social elements of the model. Beryl was concerned whether or not she could manage her job demands within a very busy work environment as colleague support can reduce when co-workers become very busy and stressed (Cuneen, 2013).
The black flag is the final one of the model, referring to more objective occupational factors affecting all workers. These include financial issues, policies concerning the conditions of employment, including sickness policy and working conditions (Fawkes and Carnes, 2012).
Beryl wished to RTW as her pay was now reduced by 50%. This can often create dilemmas as some employees may resume work too early, precipitating further absences (Baker-McClearn et al, 2010).
Beryl was due to attend a sickness absence meeting with management and HR. She raised concerns about how her absence level would be interpreted under the sickness absence policy. She was reassured that the organisation adjusts non-attendance triggers in relation to long-term conditions.
Return-to-work plan and implementation
A RTW plan assists employees to get back to work after an illness/disability and supports staff with chronic conditions to stay in work.
The plan should include a multi-disciplinary approach involving employers, employees, managers and OH working collaboratively to identify solutions supporting those workers to stay in or return to work (Institution of Occupational Safety and Health, 2015).
Beryl’s plan was underpinned by medical advice on her condition, with the involvement of OHNs, physicians and physiotherapists, line management and HR. It incorporated an assessment of risks and a planned phased return, including changes to hours, workload and start and finish times. Once agreed, the plan was kept under review.
Under the Equality Act 2010, staff diagnosed with cancer automatically meet the disability definition. Section 20 of the Act states “employers are required to make reasonable adjustments for a disabled person at a substantial disadvantage”.
Due to the complexity and lasting treatment side effects she had, an OH physician and occupational physiotherapist reviewed Beryl. She was considered fit to RTW on a phased return incorporating the appropriate adjustments.
A well-designed phased RTW should assist a readjustment to the workplace (Fit for Work, 2015). The phased RTW scheme within Beryl’s organisation facilitates employees gradually increasing their hours over a four-week period, while still receiving a full salary.
The recommended RTW plan for Beryl included working 50% of her normal hours over a two-week period, and gradually increasing her working hours for the following two weeks, aimed at improving her stamina and confidence. Beryl and her manager both agreed this plan. Beryl’s job role normally involved working 12.5-hour shifts, including rotational night shifts, therefore an initial allocation of day shifts was recommended.
Beryl had raised concerns regarding heavier manual handling associated with patient care tasks on a medical ward. OH attempted to facilitate an early RTW by recommending temporary redeployment to a less demanding area, where heavy manual handling could be avoided. Management were unable to accommodate this modification as it was not operationally feasible, however other adjustments were possible. She was considered fit to return to her role, but would benefit from additional breaks to overcome her ongoing fatigue and avoiding the manual handling of heavier patients.
Both Beryl and her manager were happy with this recommendation, but Beryl disclosed ongoing anxieties about returning to work. To address this, regular one-to-one support meetings with her manager were arranged, allowing problems to be addressed.
Labriola et al (2006) refers to an association of increased long-term sick leave with poor management quality and lower managerial support. Beryl expressed anxieties relating to hair loss and this affected her confidence. Her manager suggested she wear a headscarf at work until her hair grew back.
Beryl was expected to make a full recovery, although would still require further follow-ups with her treating oncologist. A final recommendation made to management was that Beryl’s long-term condition should be taken into consideration when monitoring future sickness absences, and attendance at relevant follow-up medical appointments should be supported.
Following Beryl’s RTW, she reported reduced arm pain after OH physiotherapy, and that the recommended adjustments had been initiated and she was receiving good support from all parties. Her fatigue was reducing and she felt more confident, allowing her to increase her workload.
No further OH reviews were planned as she felt able to sustain her attendance in the workplace.
Returning to work following a diagnosis of cancer can often be very daunting for an individual, but can also be part of recovery. Using the biopsychosocial flag system as a basis, a holistic assessment was carried out to evaluate Beryl’s fitness to RTW. Although there are many different OH assessment models available, this system addressed many of the barriers that Beryl faced upon her RTW and allowed OH to provide advice and guidance to both Beryl and her manager.
As cancer is recognised as a disability under the Equality Act 2010, the organisation was required to make adjustments. Collaborative working with the employee, employer, manager and OH team resulted in a positive outcome: a successful RTW.
Emily Gilkes DipHE, RGN is an occupational health nurse at Northampton General Hospital NHS Trust. Anne Harriss MSc, BEd, OHNC, RSCPHN, PFHEA, NTFHEA, CMIOSH is associate professor course director, occupational health programmes, at London South Bank University.
Aw TC, Gardiner K, and Harrington JM (2007). Pocket consultant: occupational health. 5th edition. Oxford: Blackwell Publishing.
Aziz B (2009). “A bigger role for occupational health nurses”. Accessed 6 June 2016.
Baker-McClearn D, Greasley K, Dale J, and Griffith F (2010). “Absence management and presenteeism: the pressures on employees to attend work and the impact of attendance on performance”. Human Resource Management Journal. 20 (3), pp.311-328. DOI: 10.1111/j.1748- 8583.2009.00118.x.
Breast Cancer Care (2016). “Invasive ductal breast cancer”. Accessed 6 June 2016.
Breast Cancer Fund (2016). “Workers and occupation”. Accessed 6 June 2016.
Breastcancer.org (2015). “IDC – invasive ductal carcinoma”. Accessed 6 June 2016.
Cancer Research UK (2016). “Radiotherapy tiredness”. Accessed 6 June 2016.
Cuneen J (2013). “Steps to take to avoid discriminating against cancer”. Accessed 6 June 2016.
Fawkes C and Carnes D (2012). “What is the relevance of coloured flags to osteopathic practice?” Accessed 6 June 2016.
Fit for work (2015). “Phased return to work after sickness absence”. Accessed 6 June 2016.
Froyd H and Harmer V (2011). “The histopathology of breast cancer”, in: Harmer V (ed). Breast cancer nursing: care and management. 2nd edition. Oxford: Blackwell Publishing Ltd.
Goss C, Leverment IMG and De Bono AM (2014). “Breast cancer and work outcomes in healthcare workers”. Occupational Medicine, vol.64, pp.635-637. DOI: 10.1093/occmed/kqu122.
Gray J (2010). “State of the evidence: The connection between breast cancer and the environment”. 6th edition. San Francisco: Breast Cancer Fund. Accessed 6 June 2016.
Grimsey E (2011). “An overview of the breast and breast cancer”, in: Harmer V (ed). Breast cancer nursing: care and management. 2nd edition. Oxford: Blackwell Publishing Ltd.
Institution of Occupational Safety and Health (IoSH) (2015). “A healthy return: good practice guide to rehabilitating people at work”. Accessed 6 June 2016.
Labriola M, Christensen KB, Lund T, Nielsen ML, and Diderichsen F (2006). “Multilevel analysis of workplace and individual risk factors for long term sickness absence”. Journal of Occupational Environmental Medicine, vol.48(9), pp.923-929.
Lymphoma Association (2015). “Neutropenia and risk of infection“. Accessed 6 June 2016.
Macmillan Cancer Support (2013). “Peripheral neuropathy”. Accessed 6 June 2016.
Mandal A (2013). “Breast cancer pathophysiology”. Accessed 6 June 2016.
Murugiah S, Thornbory G, and Harriss A (2002). “Assessment of fitness”. Accessed 6 June 2016.
National Comprehensive Cancer Network (2016). “Fighting cancer fatigue”. Accessed 6 June 2016.
National Institute of Clinical Excellence (2012).“Neutropenic sepsis: prevention and management in people with cancer”. Accessed 6 June 2016.
Palmer KT, Brown I, and Hobson J (2013). “Fitness to work: the medical aspects”. 5th edition. Oxford: Oxford University Press.
Taskila T, Gulliford J, and Bevan S (2013). “Returning to work: cancer survivors and the health and work assessment and advisory service”. Accessed 6 June 2016.
The Circulation Foundation (2016). “Lymphoedema”. Accessed 6 June 2016.
Waddell G and Burton K (2006). “Is work good for your health and well-being?”. London: TSO.
Watson H (2010). “Psychosocial flags system”. Accessed 6 June 2016.