Return to Work Interventions for Cancer Survivors: A Systematic Review and a Methodological Critique

Cancer patients are more at risk of being unemployed or having difficulties to return to work (RTW) compared to individuals without health concerns, and is thus a major public health issue. The aim of this systematic review is to identify and describe the interventions developed specifically to help cancer patients to RTW after treatment. Two researchers independently screened the articles for inclusion and Critical Appraisal Skills Program (CASP) checklists were used to assess the methodology of the included studies. Ten manuscripts met the inclusion criteria. The type of studies were three quasi-experimental studies, three longitudinal studies, three randomized controlled trials (RCTs) and a qualitative study. RTW interventions were conducted in or outside the hospital (n = 6 and 3 respectively), or both (n = 1). Improvements in RTW were only observed in quasi-experimental studies. No improvement in RTW was noted in RCTs, nor in other measures (e.g., quality of life, fatigue). Lack of statistically significant improvement does not necessarily reflect reality, but may be attributed to non-adapted research methods. This systematic review underscores the need for researches in the RTW field to reach a consensus on RTW criteria and their assessment. Recommendations to this effect are suggested.

PubMed (31.03.2018) (cancer) AND (return-to-work OR return to work/organization and administration [MeSH] OR return to work/statistics and numerical data [MeSH] OR re-integrating OR back to work OR employment [MeSH] OR employment sector OR sick leave [MeSH] OR absenteeism [MeSH] OR occupational medicine [MeSH] OR occupational health [MeSH] OR occupational health services [MeSH] OR "disability management" OR "disability prevention" OR employer*) AND (rehabilitation [MeSH] OR rehabilitation program OR training program* OR training tool* OR training OR occupational rehabilitation OR occupational intervention OR workplace intervention OR occupational therapy OR stress management OR work ability) AND ( randomized controlled trial [MeSH] OR randomized controlled trial OR controlled clinical trial OR controlled clinical trial [Publication Type] OR evaluation study OR evaluate* OR effects OR effectiveness OR efficiency OR process OR outcome) Embase (01.04.2018) (cancer.mp. or exp malignant neoplasm/) and (return to work.mp. or exp return to work/ or reintegrating.mp. or back to work.mp. or exp employment/ or employment.mp. or employment sector.mp. or sick leave.mp. or exp medical leave/ or occupational medicine.mp. or exp occupational medicine/ or occupational health.mp. or exp occupational health/ or occupational health services.mp. or exp occupational health service/ or disability management.mp. or disability prevention.mp. or employer*.mp.) and (rehabilitation.mp. or exp rehabilitation/ or rehabilitation program.mp. or rehabilitation program*.mp. or exp training/ or training program*.mp. or training tool*.mp. or occupational rehabilitation.mp. or exp vocational rehabilitation/ or occupational intervention.mp. or workplace intervention.mp. or occupational therapy.mp. or exp occupational therapy/ or stress management.mp. or exp stress management/ or work ability.mp.) and (randomized controlled trial/ or controlled clinical trial.mp. or exp controlled clinical trial/ or evaluation study.mp. or exp evaluation study/ or evaluate*.mp. or effects.mp. or effectiveness.mp. or efficiency.mp. or process.mp. or outcome.mp.) PsycInfo (02.04.2018) IF,TI,AB(cancer) AND (IF,TI,AB(return to work OR reintegrating OR back to work OR employment OR employment sector OR sick leave OR absenteeism OR occupational medicine OR occupational health OR occupational health services OR "disability management" OR "disability prevention" OR employer*) AND peer(yes)) AND IF,TI,AB(return to work or re-integrating or back to work or employment or employment sector or sick leave or absenteeism or occupational medicine or occupational health or occupational health services or "disability management" or "disability prevention" or employer*) AND IF,TI,AB(rehabilitation OR rehabilitation program OR training program* OR training OR training tool* OR occupational rehabilitation OR occupational intervention OR workplace intervention OR occupational therapy OR stress management OR work ability) AND IF,TI,AB(randomized controlled trial OR controlled clinical trial OR evaluation study OR evaluate* OR effects OR effectiveness OR efficiency OR process OR outcome File S2. Complete details of the quality assessment of the studies included.

Comments
Participants were recruited from a larger sample of a previous study. Twenty participants were interviewed, allowing data saturation for qualitative studies. 5. Was the data collected in a way that addressed the research issue? yes

Comments
Themes explored during the interview were relevant to address the research issue, discussed with a research team of health professionals and based on literature review findings. Interview schedule was also pre-tested. 6. Has the relationship between researcher and participants been adequately considered?
can't tell

Comments
The authors do not provide information on their own role in and influence on the data collection and data analysis. However, it is difficult in a scientific journal to determine their theoretical background and their influence. Generally, in qualitative research, the relationship between a researcher and the participants is considered, but not necessarily presented in the publication.
Section B: What are the results?

Comments
Ethical approval was obtained for the study and authors specified in the methodology how the study was presented to the participants. 8. Was the data analysis sufficiently rigorous? yes

Comments
The results were analyzed independently by two reviewers and sufficient verbatims are presented in the results section. However, no information was presented on the researchers' roles. 9. Is there a clear statement of findings? yes

Comments
The results were analyzed independently by two reviewers and were discussed in relation with previous research. The authors expected offering a RTW intervention to cancer patients to lead to an improvement in duration until RTW, compared to the usual care.
2. Was the assignment of patients to treatments randomized? yes yes yes

Comments
Allocation ratio was 1:1 for the intervention and usual care arms. The randomization procedure was partially blind: a statistician provided the allocation sequences to a researcher; another researcher, who was not aware of participant allocation, was responsible for participant recruitment and data collection.
The ALEA computerized randomization program was used to assign participants to one of the groups.
Participants were randomized in 3 strata considering work status and then they were randomly assigned to one group.
3. Were all of the patients who entered the trial properly accounted for at its conclusion? yes yes no

Comments
A flow diagram is presented in the article and provides a clear explanation of patient exclusion before randomization and exclusion from the analysis.
A flow diagram is presented in the article and provides a clear explanation of patient exclusion before randomization and exclusion from the analysis.
The loss of participants between T1 and T3 is not explained. However, the analyses are performed well.

Is it worth continuing? (yes/no) Yes Yes
Yes 4. Were patients, health workers and study personnel 'blind' to treatment? no no no

Comments
Participants were aware of their allocation group (it could not be dissimulated). The randomization procedure was partially blind (i.e. the researcher who performed the participant recruitment and data collection was not aware of the participants' group allocation).
Patients and researchers were aware of the allocation as it was impossible to conceal allocation for this study.
Participants were aware of their allocation group (it was impossible to conceal).

Comments
Statistical analysis is not provided to determine group similarity before the start of the intervention. However, descriptively, some No statistical differences were observed between the two groups in No statistical differences were observed between the two groups in terms of participant characteristics (see Table 1), differences were observed between the groups (e.g. in the intervention group, 85.7% were in full-time employment while they were 45.5% in the usual care group).
terms of participant characteristics (see Table 1).
except for 4 variables (ethnicity, more patients with brain tumors in the control group, patients in the control group received more radiotherapy and had a higher level of fatigue). 6. Aside from the experimental intervention, were the groups treated equally?
yes yes yes

Comments
The study was presented the same way for all the participants, they completed the same questionnaires longitudinally and both groups received an information booklet.
The study was presented the same way for all the participants and they completed the same questionnaires longitudinally.
The study was presented the same way for all the participants and they completed the same questionnaires longitudinally.
Section B: What are the results? (strong/moderate/weak/ca n't tell) 7. How large was the treatment effect? weak weak weak

Comments
No statistical difference was observed in the primary and secondary outcomes (except for 1 sub-score -FACT-B BCS).
No statistical difference was observed in the primary and No statistical difference was observed in the primary and secondary outcomes between the groups.
secondary outcomes between the groups. 8. How precise was the estimate of the treatment effect? weak weak weak

Comments
Confidence limits are in a high range.
Confidence limits and median time provided when applicable are in a high range.
Confidence limits are in a high range. To be able to blend their care with the Cancer@Work intervention, care providers had access to a special section of the e-health intervention with which they are able to see whether patients have used the Cancer@Work intervention, see which functionalities each patient has used, evaluate the content of some of the assignments, answer questions from patients, send messages to patients and receive support from and answers to questions from an oncological occupational physician. The Cancer@Work intervention includes: (1) a library to inform patients and various subjects related to RTW (e.g. work adjustment, legal and insurance issues), (2) action to help patients drawing-up a RTW plan, to take action on the potential financial consequences and toward their obligations to social security. Patients can also learn from other patients' experience through frequently asked and answered questions or advices.Patients can also send private messages to their personal care provider, through the e-health tool. Focus on work, work ability and RTW Patients received conventional medical rehabilitation and work-related medical rehabilitation. Medical rehabilitation included: exercise therapy, physiotherapy, social counseling, occupational therapy, psychological seminars and counseling and 100 hours of therapy maximum Hospital dieting (3 weeks). The work-related medical rehabilitation was composed of 6 modules: additional work related diagnostics, multi professionals team meetings (i.e., individual case conference to discuss patients individual RTW program), introductory session, work-related functional capacity training, workrelated psychological groups and intensified social counseling.
[602] Zaman et al., (2016), Netherlands To help RTW Support provided to the patient was determined by a questionnaire assessing patients' needs. Three individual meetings with a healthcare professional were provided: 1) Inform patients about the importance of work during and after treatment, to identify any workrelated problems, and to make a plan for the RTW 2) inform and evaluate the goals of the first meeting (3 to 6 months after) 3) inform and evaluate the goals of the first and second meetings (6 to 9 months after treatments) 6 to 15 months. Each meeting last around 30 min. Hospital