Looking beyond return to work: a longitudinal study on health-related work functioning in cancer survivors.

Due to earlier diagnosis and better treatment, survival rates are improving
across cancer types (Grunfeld et al., 2008). Consequently, an increasing number
of individuals are living with cancer as a chronic disease. At the time of
diagnosis, approximately half of all cancer patients are employed or available
for employment (Verdonck-de et al., 2010). In the Netherlands, about 400.000
individuals are living with cancer and its consequences. Each year 70.000 new
cancer cases are diagnosed, of which 30.000 cases are of working age. It is
expected that this number will increase until 2015 (Kuijpens, 2008)

Rasmussen and Elverdam (2008) examined the meaning of work and working life
after cancer and observed that cancer survivors try to get back to work after
treatment and try to re-establish their former structure of everyday-life as a
normal and healthy existence. Resuming and maintaining employment after cancer
is important for survivors* quality of life (Groenvold, 2010; Kennedy et al.,
2007). Work contributes to the individual as a social being and plays a role in
establishing the individual*s identity. In contrast, not being able to work
after cancer treatment disrupts everyday life, leading to financial problems,
reduced quality of life, and social isolation.

Numerous studies have addressed the employment consequences of cancer
survivorship, mainly focusing on return to work (RTW) outcomes and work changes
(Amir et al., 2007; Roelen et al., 2009; Gudbergsson et al., 2006, 2008;
Spelten et al., 2002, 2003; Lindbohm et al., 2011). The literature suggests
that between 30 and 90% of those diagnosed with cancer return to work following
treatment (Spelten et al., 2003). When returning to work, it is often assumed
that the capacities of the cancer survivors have been restored and that they
can resume their full duties. However, this assumption might not be correct and
does not address the important issues of a sustainable RTW, functioning well at
work and a good quality of working life - as observed in other diseases
(Bultmann et al., 2007).

The few studies that addressed cancer survivorship and health-related work
functioning were performed outside the Netherlands and were cross-sectional. A
US study showed that brain tumor survivors reported higher levels of work
limitations than a non-cancer comparison group (Feuerstein et al., 2007). From
other US studies it is known that breast cancer survivors report higher levels
of age-adjusted work limitations compared to a non-cancer group (Hansen et al.,
2008). Lavigne et al. (2008) showed that breast cancer survivors reported lower
work productivity when compared to the healthy worker norm. Although these
studies provide much relevant information about cancer survivorship and
health-related work functioning, they cannot be directly translated into the
Dutch context. Moreover the studies were not able to describe the course of
health-related work functioning over time due to their cross-sectional design.

The overall aim of the proposed longitudinal cohort study is to expand our
understanding of health-related work functioning among cancer survivors, who
returned to work after first cancer diagnosis and treatment with curative
intent during 18 months of follow-up.

The specific research objectives are:

1. To describe health-related work functioning among cancer survivors who
returned to work by:
a. examining the course of health-related work functioning in cancer survivors
who returned to work over time at a group level (mean level approach).
b. to identify distinct trajectories of health-related work functioning over
time in cancer survivors who returned to work (trajectories approach; i.e., to
identify subgroups of cancer survivors who show a similar course of work
functioning over time, e.g., stable, improved, deteriorated).
c. to investigate whether the course of health-related work functioning at a
group level and the distinct trajectories differ by cancer site and cancer
treatment.

2. To develop a predictive model including key variables (health status,
socio-demographic, clinical, psychological, work and/or social environmental
factors) that predict the course of health-related work functioning at a group
level and the distinct trajectories of health-related work functioning over
time.

1. Focus group interviews.
Two focus group interviews, each with N=12 participants.
- Cancer survivors who had returned to work in the last three years
- Professionals from the (occupational) health care system (e.g., OP, GP,
specialista, company/indusrial welfare worker).

All participants will sign an informed consent. An interiew schedule will be
developed, tailored to each group. The focus group interviews will be conducted
at the UMCG and led by an external, trained moderator.


2. Main study.
Longitudinal observational cohort study in cancer survivors with an 18 month
follow-up from the time of return to work. At baseline, 6, 12 and 18 months,
they will receive the comprehensive questionnaire and at 3, 9 and 15 months
they fill out a short, online questionnaire.

When an employee resumes work:
1. An employee of an Occupational Health Service invites the potential
participant for the study. If the potential participant agrees to participate,
his/her NAW information will be forwarded to H.F. Dorland-Pel (researcher) or
J.G. Smink (research assistent).
2. The researcher will provide the employee with further written information
about the study. Together with the written information, the researcher will
send a written informed consent form and the study questionnaire to the
employee. In this informed consent, the employee is asked for permission to
obtain administrative data on absenteeism through record linkage with the
Occupational Health Service (absenteeism data and diagnosis code) and also for
cancer-related factors (cancer site and location, stage, month and year of
diagnosis, (type, dose and duration of) treatment) through record linkage with
the NCR of the Dutch CCC.
3. When an employee stops working, for whatever reason, he/she will monitored
(if possible) throughout the study.
4. Employees can end their participation in the study without stating reasons
at any time.

1. Focus group interviews.
Participants undergo a group interview, conducted at the UMCG and led by an
external, trained moderator. The interview lasts 90-120 minutes and they will
give more insight into work functioning problems. There are no expected risks
for this investigation.

2. Main study.
The study consists of completing seven questionnaires. The time spent for the
comprehensive questionnaire (baseline, 6, 12, 18 months) is estimated to be 30
minutes. The time spent for the short questionnaire (3,9,15 months) is
estimated to be 10 minutes. The time spent for the overall study is therefore
150 minutes. There are no expected risks for this investigation.