Interventions to enhance return‐to‐work for cancer patients Edited (no change to conclusions), comment added to review

Abstract

Abstract Background

Cancer patients are 1.4 times more likely to be unemployed than healthy people. Therefore it is important to provide cancer patients with programmes to support the return‐to‐work (RTW) process. This is an update of a Cochrane review first published in 2011.

Objectives

To evaluate the effectiveness of interventions aimed at enhancing RTW in cancer patients compared to alternative programmes including usual care or no intervention.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library Issue 3, 2014), MEDLINE (January 1966 to March 2014), EMBASE (January 1947 to March 2014), CINAHL (January 1983 to March, 2014), OSH‐ROM and OSH Update (January 1960 to March, 2014), PsycINFO (January 1806 to 25 March 2014), DARE (January 1995 to March, 2014), ClinicalTrials.gov, Trialregister.nl and Controlled‐trials.com up to 25 March 2014. 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) of the effectiveness of psycho‐educational, vocational, physical, medical or multidisciplinary interventions enhancing RTW in cancer patients. 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.

Data collection and analysis

Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data. We pooled study results we judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the overall quality of the evidence for each comparison using the GRADE approach.

Main results

Fifteen RCTs including 1835 cancer patients met the inclusion criteria and because of multiple arms studies we included 19 evaluations. We judged six studies to have a high risk of bias and nine to have a low risk of bias. All included studies were conducted in high income countries and most studies were aimed at breast cancer patients (seven trials) or prostate cancer patients (two trials).

Two studies involved psycho‐educational interventions including patient education and teaching self‐care behaviours. Results indicated low quality evidence of similar RTW rates for psycho‐educational interventions compared to care as usual (RR 1.09, 95% CI 0.88 to 1.35, n = 260 patients) and low quality evidence that there is no difference in the effect of psycho‐educational interventions compared to care as usual on quality of life (standardised mean difference (SMD) 0.05, 95% CI ‐0.2 to 0.3, n = 260 patients). We did not find any studies on vocational interventions. In one study breast cancer patients were offered a physical training programme. Low quality evidence suggested that physical training was not more effective than care as usual in improving RTW (RR 1.20, 95% CI 0.32 to 4.54, n = 28 patients) or quality of life (SMD ‐0.37, 95% CI ‐0.99 to 0.25, n = 41 patients).

Seven RCTs assessed the effects of a medical intervention on RTW. In all studies a less radical or functioning conserving medical intervention was compared with a more radical treatment. We found low quality evidence that less radical, functioning conserving approaches had similar RTW rates as more radical treatments (RR 1.04, 95% CI 0.96 to 1.09, n = 1097 patients) and moderate quality evidence of no differences in quality of life outcomes (SMD 0.10, 95% CI ‐0.04 to 0.23, n = 1028 patients).

Five RCTs involved multidisciplinary interventions in which vocational counselling, patient education, patient counselling, biofeedback‐assisted behavioral training and/or physical exercises were combined. Moderate quality evidence showed that multidisciplinary interventions involving physical, psycho‐educational and/or vocational components led to higher RTW rates than care as usual (RR 1.11, 95% CI 1.03 to 1.16, n = 450 patients). We found no differences in the effect of multidisciplinary interventions compared to care as usual on quality of life outcomes (SMD 0.03, 95% CI ‐0.20 to 0.25, n = 316 patients).

Authors' conclusions

We found moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer.

Author(s)

Angela GEM de Boer, Tyna K Taskila, Sietske J Tamminga, Michael Feuerstein, Monique HW Frings‐Dresen, Jos H Verbeek

Abstract

Plain language summary

Interventions to enhance return‐to‐work for cancer patients 

Research question

What is the best way to help cancer patients get back to work when compared to care as usual?

Background

Each year more and more people who get cancer manage to get through treatment alive. Many cancer survivors live well, although they can continue to experience long‐lasting problems such as fatigue, pain and depression. These long‐term effects can cause problems with cancer survivors' participation in working life. Therefore, cancer is a significant cause of absence from work, unemployment and early retirement. Cancer patients, their families and society at large all carry part of the burden. In this Cochrane review we evaluated how well cancer patients can be helped to return to work.

Study characteristics

The search date was 25 March 2014. Fifteen randomised controlled trials including 1835 cancer patients met the inclusion criteria. We found four types of interventions. In the first, psycho‐educational interventions, participants learned about physical side effects, stress and coping and they took part in group discussions. In the second type of physical intervention participants took part in exercises such as walking. In the third type of intervention, participants received medical interventions ranging from cancer drugs to surgery. The fourth kind concerned multidisciplinary interventions in which vocational counselling, patient education, patient counselling, biofeedback‐assisted behavioral training and/or physical exercises were combined.We did not find any studies on vocational interventions aimed at work‐related issues.

Key results

Results suggest that multidisciplinary interventions involving physical, psycho‐educational and/or vocational components led to more cancer patients returning to work than when they received care as usual. Quality of life was similar. When studies compared psycho‐educational, physical and medical interventions with care as usual they found that similar numbers of people returned to work in all groups.

Quality of the evidence

We found low quality evidence of similar return‐to‐work rates for psycho‐educational interventions compared to care as usual. We also found low quality evidence showing that physical training was not more effective than care as usual in improving return‐to‐work. We also found low quality evidence that less radical cancer treatments had similar return‐to‐work rates as more radical treatments. Moderate quality evidence showed multidisciplinary interventions involving physical, psycho‐educational and/or vocational components led to higher return‐to‐work rates than care as usual.

Author(s)

Angela GEM de Boer, Tyna K Taskila, Sietske J Tamminga, Michael Feuerstein, Monique HW Frings‐Dresen, Jos H Verbeek

Reviewer's Conclusions

Authors' conclusions

Implications for practice

There is moderate quality evidence that multidisciplinary interventions combining physical training, psycho‐educational and/or vocational elements improve the RTW of cancer patients. The most apparent setting for this intervention would be the hospital because all multidisciplinary providers are located there and it is the main focal point for the patients. Interventions conducted in a hospital setting are feasible for recently diagnosed cancer patients who are engaged in curative treatment and who are expected to have sufficient recovery to RTW. Other possible settings for RTW interventions for cancer patients would be multidisciplinary rehabilitation outpatient services in community or reintegration teams at large workplaces or multinational corporations. Furthermore, we need to provide effective guidelines to employers needing to deal with a cancer patient returning to work. Thus, it is possible to find ways to improve RTW for people who survive cancer.

There is low quality evidence that psycho‐educational, physical interventions and function‐conserving medical interventions yield similar RTW rates compared to care as usual.

Implications for research

Multidisciplinary interventions enhance RTW for cancer patients. Most research so far has been conducted in breast cancer patients and prostate cancer patients. Research should additionally focus on patients with other prevalent diagnoses of cancer in the working population, such as colorectal cancer and blood or lymph cancers. Other important patient characteristics, such as age, education and ethnicity, should also be measured. Future research on enhancing RTW in cancer patients should involve multidisciplinary interventions with a physical, psycho‐educational and vocational component. The vocational component should not be just patient‐oriented but should also be directed at the work environment (including work adjustments and supervisors). With regard to psycho‐educational interventions it is unclear whether patient education or patient counselling is most effective. Both interventions should be compared against each other and care as usual.

We did not find any studies assessing vocational interventions aimed at enhancing RTW in cancer patients for this review although one would expect the largest impact on RTW from this kind of intervention. Future research should focus on vocational interventions that include any type of intervention focused on employment. Vocational interventions might be person‐directed, that is, aimed at the patient to encourage RTW, meaning vocational rehabilitation or occupational rehabilitation, or they might be work‐directed, that is, aimed at the workplace by means of workplace adjustments such as modified work hours, modified work tasks, or modified workplaces and improved communication with or between managers, colleagues and health professionals.

So far, not all studies comparing the effect of an intervention on RTW with care as usual or an alternative intervention have been conducted using a RCT design. Consequently there is uncertainty about effectiveness and we need more high‐quality RCTs. Therefore, all studies evaluating the effect of an intervention on RTW should employ a RCT design although this might be sometimes difficult in daily practice. These RCTs should perform ITT analysis. In some cases, a cluster‐RCT design might have to be chosen in which the providers of the intervention or the settings are randomised and not the patients. In addition, the studies described in this review were all relatively small and thus we need RCTs with a much greater number of recruited patients.

With regard to outcome measures, many more clinical trials should incorporate RTW measures. For instance, currently many trials are being conducted evaluating the effect of physical exercise on physical fitness, fatigue or QoL, but almost none of these studies will evaluate effects on sick leave duration or RTW although it is reasonable to expect these interventions to be beneficial for employment. With regard to medical interventions, the search is always on for less radical or less invasive treatments that give comparable medical outcomes. When evaluating the effectiveness of these interventions studies should not only measure medical outcomes or QoL but also work‐related outcome measures. In future research, work‐related outcome measures should not only include the rate of patients returning to work because this measure is a valid, but broad and general indication of RTW. Other work‐related outcome measures that are more precise measures of RTW and should be measured include: total number of days of sick leave from first day of sick leave until first day of return, measures of work retention once back at work, and work productivity. Studies also need to define what RTW is: return to full‐time or part‐time work or return to the same job or a lesser job.

RTW is an important outcome measure for cancer patients indicating recovery and return to normalcy. In this Cochrane Review, we found no difference in QoL in the included studies while people had returned to work. This would imply that probably most cancer patients return to work only when it is feasible. After patients have returned to work, it is important that cancer patients are able to remain working. Research beyond RTW, focusing on work retention and factors associated with it, is needed (Moskowitz 2014). Based on these factors associated with remaining at work, researchers should develop new interventions for work retention of cancer patients.

Finally, many treatments for cancer take several months and result in long‐lasting side effects. This might influence the effectiveness of interventions aimed at RTW of cancer patients. Furthermore, work disability can be episodic. Given these fluctuations in work absence we need studies with long term follow‐up. 

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