Return to work in European Cancer survivors: a systematic review Sara Paltrinieri, Stefania Fugazzaro, Lucia Bertozzi, Maria Chiara Bassi, Martina Pellegrini, Massimo Vicentini, Elisa Mazzini, et al. Supportive Care in Cancer ISSN 0941-4355 Volume 26 Number 9 Support Care Cancer (2018) 26:2983-2994 DOI 10.1007/s00520-018-4270-6 1 23 Your article is protected by copyright and all rights are held exclusively by SpringerVerlag GmbH Germany, part of Springer Nature. This e-offprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Supportive Care in Cancer (2018) 26:2983–2994 https://doi.org/10.1007/s00520-018-4270-6 REVIEW ARTICLE Return to work in European Cancer survivors: a systematic review Sara Paltrinieri 1 & Stefania Fugazzaro 1 & Lucia Bertozzi 2 & Maria Chiara Bassi 3 & Martina Pellegrini 1 & Massimo Vicentini 4 & Elisa Mazzini 5 & Stefania Costi 1,6 Received: 30 January 2018 / Accepted: 14 May 2018 / Published online: 29 May 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Purpose Return to work (RTW) of cancer survivors (CSs) fluctuates in different contexts. This systematic review searched for recent data on the RTW rate of CSs in Europe, investigating associated factors. Methods Bibliographic search covered the period from January 2010 to February 2018, with no language restrictions. European population-based studies assessing RTW rate after cancer diagnosis were included. We excluded studies focusing on a specific cancer diagnosis. Results Twelve observational studies were selected. The cohorts investigated included 280 to 46,720 individuals from Northwestern and Central Europe diagnosed with cancer from 1987 to 2010. The median interval between diagnosis and documented RTW was 2 years (0.2–23.4 years). RTW rates of CSs ranged from 39 to 77%. RTW of individuals employed at the time of diagnosis ranged from 60 to 92%, the latter registered in a sample with good prognosis. Personal factors, work-related factors, and cancer-related factors were all associated with RTW. Healthcare team interventions facilitated reintegration to work. Conclusions Data from Mediterranean and Central European countries are urgently needed to understand whether RTW is an issue for CSs there as well and whether socio-rehabilitative interventions are required to mitigate the potential negative impact of cancer on individuals and society. Keywords Neoplasms . Return to work . Europe . Survivors . Systematic review literature . Sick leave Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00520-018-4270-6) contains supplementary material, which is available to authorized users. * Stefania Costi stefania.costi@unimore.it Sara Paltrinieri sara.paltrinieri@ausl.re.it 1 Physical Medicine and Rehabilitation Unit, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy 2 School of Physical Therapy, Alma Mater Studiorum, University of Bologna, Via S. Lorenzino 23, 47521 Cesena, Forlì-Cesena, Italy 3 Medical Library, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, Viale Murri 9, 42123 Reggio Emilia, Italy 4 Epidemiology Unit, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, Via Amendola 2, 42122 Reggio Emilia, Italy 5 Medical Directorate, Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, Viale Umberto I 50, 42123 Reggio Emilia, Italy 6 Department of Surgery, Medicine, Dentistry and Morphological Sciences, University of Modena and Reggio Emilia, Reggio Emilia, Italy Stefania Fugazzaro stefania.fugazzaro@ausl.re.it Lucia Bertozzi lucia.bertozzi@unibo.it Maria Chiara Bassi mariachiara.bassi@ausl.re.it Martina Pellegrini martina.pellegrini@ausl.re.it Massimo Vicentini massimo.vicentini@ausl.re.it Elisa Mazzini elisa.mazzini@ausl.re.it Author's personal copy 2984 Purpose In countries with high economic growth index, life expectancy and working age are increasing, which will result in growing numbers of people in the workforce with chronic diseases, including cancer, in the near future. In fact, cancer incidence in the European Union (EU-28) is estimated to be over 500 new cases/year/100.000, excluding non-melanoma skin cancer [1], with an increasing trend projected until at least 2020 [2]. However, the long-term survival of cancer patients is steadily growing in all Western countries, thanks to early diagnostic methods and effective therapeutic strategies [3]. The average 5-year survival of malignant tumors has reached 54.2% [3]; moreover, nearly 50% of new diagnoses and more than 1/3 of cancer survivors (CSs) are people in their working age [4]. Cancer survivorship can be defined as the broad experience of living with, through, and beyond a cancer diagnosis [5]. Thus, it has become imperative to understand the long-term implications of cancer survivorship on social outcomes, such as reintegration into the workplace after cancer treatment, as recommended by the European Cancer Patient’s Bill of Rights (art. 3.4) [6]. Return to work (RTW) of individuals who survive cancer is a major goal, as it facilitates the patient’s ability to deal with the disease, recover personal identity and social role, and improve general health [7–9]. Although the majority of employed CSs return to work, a meta-analysis by De Boer [10] indicated that individuals treated for cancer were 1.4 times more likely to be unemployed compared to healthy controls. Certainly, unsuccessful RTW has a significant impact on direct and indirect social costs, which are paid for by healthcare systems or insurances, by patients and their families, by employers, and, lastly, by society. A quite recent inquiry estimated that 5 years after diagnosis, the missed overall income for the failed reintegration into work of CSs is equal to 3.2 billion euros [11]. Further costs, which are not always easily quantifiable, originate from the period of sick leave (SL) or the need to replace the worker when not reintegrated, or may be associated to a reintegration that encounters barriers. In Italy, it has been estimated that the socioeconomic impact linked to cancer-related productivity loss exceeds 8 billion euros annually [12]. Several review articles from both the USA and the European Union have reported an average rate of RTW of approximately 64% with a wide range of 30 to 94%, which reflects the different contexts in which RTW rates were registered [13, 14]. However, it has been highlighted the lack of methodological quality of the studies conducted in this field [13, 15]. Further, the generalizability of results is frequently limited, since reintegration to work may significantly differ depending on the context analyzed [16]. Support Care Cancer (2018) 26:2983–2994 Therefore, the principal aim of this study is to review the latest literature on the rate of RTW of CSs in Europe. Secondly, we want to identify those factors potentially associated with reintegration to work. Lastly, we present data regarding the duration of SL of European CSs. Methods Eligibility criteria Studies were included if they met the following three criteria: (1) included patients with cancer, (2) assessed employment status after cancer diagnosis, (3) were European populationbased studies. To collect current information generalizable to the whole population of CSs in Europe, studies published before 2010 and studies focusing on a specific cancer diagnosis were excluded. Search strategy We searched the following electronic databases: MEDLINE, CINAHL, EMBASE, PsycINFO, and the Cochrane Library (all databases) from January 2010 to February 28, 2018, with no language restrictions. Search terms were (Work OR employment OR occupation OR labor OR labor market OR absenteeism OR sick leave OR sickness absence OR retirement OR pension OR disability pension OR work ability OR work disability OR wages OR job loss OR job performance OR career OR employer accommodation) AND neoplasm. We adapted this search strategy to each database. Additional records were searched through other sources to complement the database findings; manual search of reference lists of relevant literature reviews and indexes of peerreviewed journals were used. Study selection The literature search was conducted by an information specialist (C.B.) assisted by two healthcare professionals in the rehabilitation field (S.C. and S.P.). The abstracts of empirical studies which met the inclusion criteria were selected and evaluated independently by the latter two reviewers, who appraised full reports of potentially relevant articles for content and quality. Disagreements were resolved through consensus with a third investigator (S.F.). Critical appraisal The quality of included studies was scored by two independent reviewers (S.C. and S.P.) using section A of the Critical Author's personal copy Support Care Cancer (2018) 26:2983–2994 2985 Appraisal Skills Programme (CASP) tool for cohort studies [17]. This tool encompasses eight items associated to five major sources of potential bias in observational studies: adequate cohort recruitment, study attrition, accurate detection of exposure and of outcome, and identification of potential confounding factors. The two items on confounding were considered irrelevant because this review regards prognosis studies, which are designed to predict a specific outcome based on a combination of several possible prognostic factors. Agreement on the assessment was reached through consensus of the two reviewers, seeking help from a third (L.B.) when needed. The CASP tool does not provide a minimum score for quality but the first two items assess pivotal requirements for observational studies; lack of satisfaction might suggest it is not worth proceeding with the report appraisal. We established a priori that we would consider high quality those research papers with CASP score ≥ 5 Byes^ (≥ 83% of the maximum attainable score), moderate quality those which scored 3 or 4 Byes^ (≥ 50% of the maximum attainable score), and low quality those that scored less than 3 Byes.^ moderate (Cohen’s kappa of 0.479). None of the studies was judged at high risk of bias and all satisfied at least one of the two pivotal requirements; thus, we included all the selected studies in the analyses of the results. One study did not clearly state the issue under investigation [26], whereas two studies did not adequately represent the primary sector (i.e., agriculture, forestry, fishery, and mining) [21, 22], which was underrepresented in the data source investigated. In most of the cases, both the exposure and outcome were judged accurately defined and measured to minimize bias [18–20, 23–25, 27, 29]. In two cases, the measure of the exposure was judged at risk of bias because the investigators collected data on sickness absence, not taking into account individuals that continued working during cancer treatment [21, 22]. In one further case, the outcome measure and the completeness of follow-up were considered at risk of bias because nearly one half of the general practitioners who were asked to engage patients in the research did not take part in the study. Furthermore, the response rate to the questionnaire was 27% [26]. Data extraction Description of studies included The following data were extracted: country of origin, study design, source for exposure verification (diagnosis), data collection period, time between diagnosis and RTW documentation, main outcome measure and measurement strategy, demographic and clinical characteristics of the sample, response rate, RTW rate, and duration of SL. To achieve the secondary aim of this study, the investigators listed a wide range of potential prognostic factors that, on the basis of current literature, might influence RTW. Where available, cancer sites and their representation in the sample were reported. When the studies proved to be heterogeneous, a qualitative analysis was performed to summarize the available evidence. Table 2 summarizes the characteristics of the 12 research studies included in this review, conducted in the UK, France, the Netherlands, Denmark, Norway, Finland, and Iceland. Study designs were mostly cross-sectional surveys or registry studies collecting longitudinal data. The samples included individuals in their working age selected by cancer registries, occupational registries, health insurance plans, or hospital departments. The cohorts investigated were diagnosed with cancer from 1987 to 2010 and data collection occurred from 1987 to 2012. In one study, these data were not reported and attempts to contact the authors to fill the gap were unsuccessful [25]. The median timeframe between diagnosis and RTW documentation was 2 years (range 0.2–23.4 years). Results Population studied One thousand seven hundred fifty-four citations were retrieved from electronic databases and manual search of reference lists. After the screening process, 106 full-text articles were assessed for eligibility, 94 of which were excluded. Thus, this systematic review includes 12 research reports (Fig. 1). Table 3 summarizes the characteristics of the population under study. The size of the included samples varied from 280 to 46,720 working age individuals treated for cancer. Breast cancer was the most represented cancer (n. 7355), followed by genital and prostate (n. 4868), gastrointestinal (n. 1973), upper aerodigestive tract/lung (n. 1512), blood cancer (n. 1436), skin cancer (n. 1197), urological not prostate (n. 659), head and neck including thyroid (n. 245), and unspecified sites (n. 1250). One study did not report the number of individuals diagnosed with each cancer represented in the sample, and the attempts to receive detailed data from the authors were unsuccessful [18]. Critical appraisal of the included studies Table 1 summarizes the critical appraisal of the 12 included research reports. The overall agreement between the two reviewers in their appraisal of the risk of potential bias was Author's personal copy Citations retrieved through electronic database search, duplications excluded (n=1752) Additional records identified through other sources (reference list of reviews, systematic reviews, and meta-analyses) (n = 2) Excluded after revision of title and abstract because not focused on the research topic of interest (n.1230) or based on qualitative designs (n.418) (n = 1648) Screening Fig. 1 Search flow diagram Support Care Cancer (2018) 26:2983–2994 Identification 2986 Eligibility Full texts reviewed for eligibility (n = 106) Full text not eligible because: -not focused on cancer patients (n.1) -focused on a specific cancer diagnosis (n.31) -not reporting occupational status of CSs (n.28) -not European population-based (n.32) (n = 92) Excluded because its cohort overlapped with another eligible study (n = 2) Included Studies assessed for quality (n = 12) Studies contributing their data to this systematic review (n = 12) Legend: CSs = Cancer survivors Return to work in cancer survivors Table 3 reports data regarding RTW rate, the factors associated to the outcome of interest and SL duration. Return to work rates of CSs in their working age was reported by four studies [18, 19, 26, 28] and ranged from 39% [18] to 77% [26]. Return to work rates in CSs employed at the time of diagnosis was reported by ten studies [19–25, 27–29], ranging from the 60% registered in the Netherlands [21] to the 92% registered in the UK [25]. The quite low RTW rate in the Netherlands referred to full-time work, while a higher, more realistic proportion of 69% would account for individuals who gradually resume their job with a part-time schedule [21]. Regarding the high RTW rate reported in the UK [25], the sample selected for this study included individuals who had completed treatments and excluded patients with metastatic cancer; this optimistic rate of RTW might thus be explained by these selective eligibility criteria. As a matter of fact, the highest proportions of RTW detected with broader inclusion criteria were registered in Norway and slightly exceeded 80% [23, 28]. Regarding two French studies, Marino [27] registered a 90% rate in a subsample of individuals still employed, although not yet returned to work, already included in the broader cohort investigated by Paraponaris [19], where 66.3% of CSs employed at the time of diagnosis did actually return to work. Prognostic factors for return to work in cancer survivors All the studies included in this review except one [21] analyzed factors that might facilitate or hinder RTW (Table 3). Factors analyzed were largely heterogeneous between studies. Protective factors were positively associated to higher rates of RTW, or faster RTW, or higher number of hours worked by CSs per time unit. Risk factors were associated to lower rate of RTW, or slower RTW, or change in employment status. The prognostic factors identified embraced the crucial areas of personal (sociodemographic) factors, workrelated factors, and cancer-related factors, as per the International Classification of Functioning, Disability, and Health [30] (Table 4). The associations of personal factors and cancer-related factors with RTW were verified in the majority of the selected studies, whereas the influence of work-related factors on reintegration at work was explored by five studies only [19, 20, Author's personal copy Low Low Low Moderate Moderate Low Low Low Moderate Low Low Low Yes Cannot tell Yes Yes Yes Cannot tell Cannot tell Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Cannot tell Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Was the follow-up of subjects complete enough? 2987 23, 25, 27]. Support provided by the healthcare team in coping with RTW issues was investigated in two studies and was reported as a protective factor by both [20, 26]. In particular, Luker [26] showed that when employment issues are discussed between patients and the healthcare team, the number of hours worked per time unit by patients increases; we consider this a rehabilitative intervention that facilitates the social reintegration of CSs. Few studies also examined the associations between exposure and RTW in men and in women separately [20, 22, 26–28]. Male gender seems to act as a protective factor for RTW [26, 27]. Living with a partner and children was positively associated to RTW in CSs [27, 29] and in men, specifically [28]. In women, weak support from work supervisors or from healthcare professionals [20] and being affected by blood cancer were negatively associated to RTW [22]. Cooper et al. [25] analyzed factors associated to RTW separately for each cancer diagnosis represented in their sample but found no common elements. However, in breast CSs, working full time and perceiving control over the effect of cancer at work acted as protective factors. Protective factors were also the perceived high level of physical functioning for head and neck CSs and the possibility to adopt a flexible work schedule for urological CSs. Was the cohort recruited in an acceptable way? Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Did the study address a clearly focused issue? Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Sickness absence of cancer survivors [18] Fiva et al. (2010) [19] Paraponaris et al. (2010) [20] Lindbohm et al. (2011) [21] Roelen et al.(2011) [22] Roelen et al.(2011) [23] Torp et al.(2011) [24] Ross et al. (2012) [25] Cooper et al. (2013) [26] Luker et al. (2013) [27] Marino et al. (2013) [28] Torp et al. (2013) [29] Tison et al. (2016) Table 1 Critical appraisal of the included research reports Is it worth continuing? Was the exposure accurately measured to minimize bias? Was the outcome accurately measured to minimize bias? Was the follow-up of subjects long enough? Risk of bias Support Care Cancer (2018) 26:2983–2994 The duration of SL was analyzed by six studies [19, 21, 22, 25–27], with highly heterogeneous reporting of data. The average duration of SL was 6–12 months in two large samples, accounting for 5293 individuals [21, 27]. However, SL lasted less than 6 months for a consistent proportion of the individuals under investigation [25–27]. Long-lasting SL (≥ 2 years) was associated with physically demanding work [19] and with blood, lung, and gastrointestinal cancers for 30% of individuals affected [22] and, to a lesser extent (nearly 20%), with upper aerodigestive tract and breast cancers [19, 22]. Of note, a longer duration of SL was associated with permanent employment, compared to fixed-term employment and selfemployment (p = 0.042) [27]. Finally, the time to full or partial RTW was significantly longer in the year 2008 than in 2002 (p < 0.01) [21]. Discussion This systematic review provides recent knowledge on CSs’ RTW rate in Northwestern Europe, highlighting that very few data are currently available from Central and Mediterranean Europe. Within Europe, dissimilarities in social security and healthcare systems exist; moreover, the impact of cultural, economic, and financial factors on the economy vary across Europe, especially following the recent 2988 Table 2 Characteristics of the included studies Country Study design Source of exposure Data collection Diagnosis period occurrence Follow-up (months) Main outcome [18] Fiva et al. (2010) Norway Cross-sectional registry study Cross-sectional survey Norwegian Cancer Registry From 1987 to 2000 Not specified 60 French Health Insurance Schemes, the French National Institute for Health and Medical Research, and the French National Cancer Institute The files of one large hospital (Finland and Norway), or the cancer registry (Denmark and Iceland) ArboNed Occupational Health Service register Late 2004 Sep./Oct. 2002 24 Survival rate and Statistic Norway registers employment status Employment status Questionnaire administered by telephone 2003 to 2005 1997 to 2002 12 to 96 Work changes† Questionnaire administered by mail 2002 to 2010 2002, 2005, and 2008 24 Sickness absence ArboNed Occupational Health Service register 2006 to 2008 2004, 2005, and 2006 24 Time to full RTW Cancer Registry of Norway Feb./Mar. 2008 2005 and 2006 15 to 39 Work changes All hospital departments treating cancer patients in three Danish counties 2005 to 2006 Hospitals in 3 UK Healthcare Trust Not specified Two cancer registries Apr./Oct. 2011 0.2 to 23.4 years previously Median 33, Employment status mean 48 (range 2 to 281) Not specified 12 Factors influencing time to RTW 2 to 3 years previously 24 to 36 Employment status ArboNed Occupational Health Service register ArboNed Occupational Health Service register Questionnaire administered by mail Questionnaire administered by mail Long Duration Disease File of the National Health Insurance Fund Cancer Registry of Norway Late 2004 Sep./Oct. 2002 24 Time to RTW 1998 to 2004 1999 60 Employment status 2012 2010 24 Work changes [19] Paraponaris et al. (2010) France [20] Lindbohm et al. (2011) Finland, Norway, Cross-sectional Iceland, and Denmark survey [21] Roelen et al. (2011) The Netherlands [22] Roelen et al. (2011)‡ The Netherlands [23] Torp et al. (2011) Norway [24] Ross et al. (2012) Denmark [25] Cooper et al. (2013) UK [26] Luker et al. (2013) UK § [27] Marino et al. (2013) France [28] Torp et al. (2013) Norway [29] Tison et al. (2016) France Cross-sectional registry study Cross-sectional registry study Cross-sectional survey Cross-sectional survey Longitudinal prospective Cross-sectional survey Cross-sectional survey Cross-sectional registry study Cross-sectional survey French Cancer Survey and the French Labor Force Survey Questionnaire administered by mail Questionnaire administered online or by telephone Questionnaire administered by telephone Statistics Norway’s Events database Questionnaire administered by telephone or mail Defined as mobility in the labor market among three transition states: employment, non-employment (unemployment or inactivity) and retirement, or making important changes in work situation, or change of employer ‡ Roelen et al. (2011, c) study’s cohort includes a subsample of 1522 individuals (sample 2) of the cohort investigated by Roelen et al. (2011, a) § Marino et al. (2013) study presents original data from a subsample of the cohort investigated by Paraponaris et al. 2010 Support Care Cancer (2018) 26:2983–2994 † Measurement of outcome Author's personal copy Author (year) Results of the included studies RTW rate Average m/f‡ age (%) (years) Response RTW§ rate (%) rate of CSs¶ (%) [18] Fiva et al. (2010) 46,720 48 41/59 Breast, lung, skin 100 39 Not measured [19] Paraponaris et al. (2010) 1725 47 33/67 Breast, upper aerodigestive tracts/lung, blood, colon/rectum, prostate, urogenital tumors 61 56 [20] Lindbohm et al. (2011) 2030 NR NR Breast, testicular, lymphoma, prostate 72 [21] Roelen et al. (2011) 4287 48 36/64 Breast, genitals, gastrointestinal, lung, skin, blood [22] Roelen et al. (2011) 5074 48 36/64 [23] Torp et al. (2011) 1115 52 31/69 [24] Ross et al. (2012) 1490 63 36/64 [25] Cooper et al. (2013) 280 55 44/56 [26] Luker et al. (2013) [27] Marino et al. (2013) 382 50 24/76 1006 49 32/68 RTW rate of CSs employed at diagnosis (%) Protective factors Risk factors SL* duration NR 75 NR 100 NR NR Breast, genitals, gastrointestinal, lung, skin, blood 100 NR Full RTW: 80 in 2002, 74 in 2005, 60 in 2008 Partial RTW: 85 in 2002, 80 in 2005, 69 in 2008 73 (full RTW) Metastatic disease at diagnosis Being not married Low income Physically demanding work Upper aerodigestive cancer Lung cancer Discrimination in the workplace Physically demanding work In female gender: weak support from the supervisor or from the healthcare team NR NR 66 Being in the labor market prior to diagnosis High education NR** Breast, female genital organs, prostate, testicular, lymphoma, colon/rectum, lung, melanoma, bladder, central nervous system, thyroid, leukemia Breast, gastrointestinal, lung, gynecological, prostate, urinary, head and neck, lymphoma, leukemia 54 NR 84 68 NR 63 NR Breast, urological, gynecological, head and neck 87 NR 92 Breast, colon/rectum, prostate, Hodgkin’s disease, bladder Breast, upper aerodigestive tract/lung, blood, 27 77 NR 61 NR 90 In breast CSs: working full time, control over the effect of cancer at work In head and neck CSs: high level of physical function In urological CSs: flexible work schedule Discussing employment issues with the HCPs*** Male gender High education Cancer sites in order of prevalence in the sample ≥ 2 years for 15% of CSs and for > 20% of individuals with physically demanding work, upper aerodigestive tract or lung cancer NR Author's personal copy n.† On average, 8.5 months in 2002 and 9.5 months in 2008 ≥ 2 years for nearly Older age associated to 30% of blood, lung, and genital cancer gastrointestinal CSs and for In female gender: blood nearly 18% of breast CSs cancer Low social support at work NR High education Physically Medium income demanding work Support from supervisor Intellectually Support form colleagues demanding work High decision latitude (at work) Self-employment NR Age ≥ 50 years Active treatment or further diagnostic phase Metastatic disease Lung cancer In gynecological and head and neck CSs: impact of cancer/treatment on life/work In urological CSs: constipation Female gender Permanent job Progressive disease NR A median of 7.5 months for breast CSs, 4.5 months for head and neck and gynecology CSs; 5 weeks for urology CSs < 6 months for 50% of CSs 6–12 months for 34% of CSs Median duration 1 year 2989 Author (year) Support Care Cancer (2018) 26:2983–2994 Table 3 2990 Table 3 (continued) RTW rate Author (year) n.† Average m/f‡ (%) age (years) Cancer sites in order of prevalence in the sample Response RTW§ rate (%) rate of CSs¶ (%) RTW rate of CSs employed at diagnosis (%) colon/rectum, prostate, and other urogenital tumors 3278 47 40/60 [29] Tison et al. (2016) 4110 60 42/58 † n., number of patients included in the study ‡ m/f, male female ratio § RTW, return to work ¶ CSs, cancer survivors Breast, skin, prostate, testicular, colon, lymphoma, ovary, cervix, bladder, leukemia, endometrium, rectum, lung Breast, prostate, thyroid, melanoma, colon/rectum, urogenital, upper aerodigestive tracts, non-Hodgkin disease, lung 100 73 80 100 NR 71 Risk factors SL* duration Living with a partner Good prognosis Chemotherapy Side effects treatment related High education Medium/high income Being employed or self-employed at diagnosis In male gender: living with partner and children Living with children Age ≤ 30 or ≥ 50 Regional/distant cancer ≤ 6 months for 36% of men and 25% of women > 2 years for 35% of men and 28% of women NR Older age Poorer prognosis Author's personal copy [28] Torp et al. (2013) Protective factors NR *SL, sick leave **NR, not reported or not measured ***HCPs, health care professionals Support Care Cancer (2018) 26:2983–2994 Author's personal copy Support Care Cancer (2018) 26:2983–2994 Table 4 Protective factors and risk factors associated with return to work (RTW) 2991 Area Protective factors Risk factors Personal Male gender Female gender Medium-high income Low income High education < 30 and > 50 years old Living with partner/children Work-related Employed at diagnosis Support from supervisor Discrimination at work Support from colleagues Low social support at work Decision latitude Self-employment Permanent job Physically demanding work Cancer-related Good prognosis Intellectually demanding work Metastatic disease Upper aerodigestive cancer Lung cancer Further diagnostic phase Chemotherapy, active treatment Adverse effects Rehabilitative Discuss employment issue with HCPs* *HCPs, health care professionals economic crisis [31]. As a result, RTW rates may differ significantly from one country to another [32]. The estimated rates of RTW registered for Northwestern European CSs range from 39% [18] up to 77% [26]. In France, the only Mediterranean European country represented in this review, the rate of RTW was almost 56% [19], registered before the economic crisis of 2008. Comparing these results with the employment rate of working age Europeans in 2014, it seems that employment rate of CSs was lower than that of the general population [33]. Nevertheless, the same results confirm that the majority of CSs are able and willing to work, since employment may be beneficial to the general health of this population [7–9]. When looking at the RTW rate of CSs employed at the time of diagnosis, a realistic estimate is from 69% [21] to slightly more than 80% [23, 28]. Thus, this review highlights the fact that some Northwestern Europeans in treatment for cancer may lose their jobs. This finding is consistent with those of de Boer et al. [10] who, in 2009, conducted an extensive metaanalysis which, once again, could not adequately represent Central and Mediterranean Europe. This review also points out factors that might facilitate or hinder RTW. According to the ICF classification, those predictors can be classified into three categories: personal, workrelated, and cancer-related. Regarding personal factors, being female negatively affected resumption of work [26], consistent with findings of recent reviews focusing on predictors of RTW in CSs [34, 35]. Having children and/or living with a partner seems to act as protective factors [27–29] while, conversely, being single, widowed, or divorced negatively influenced employment status [18]. A possible explanation for this phenomenon is that, in patients with cancer, the support of family members ameliorates emotional well-being, provides practical help in doing everyday chores, and assists with financial constraints [36]. It is well known that education and income levels are strongly linked to different social outcomes, including work [37]. Indeed, this review shows that higher socioeconomic status and education levels facilitated maintaining one’s job [23, 27, 28], confirming previous findings [34, 38]. Moreover, individuals with physically demanding jobs experienced barriers to RTW [19, 20, 23]. On the other hand, intellectual work capability, which requires solid cognitive capacities, can also be diminished by chemotherapy [23]. Additional work-related factors which are worth considering are the social environment and flexibility at work. The social work environment can be a barrier to participation when the individual perceives discrimination or lack of support from the employer and colleagues [19, 20, 23, 25, 27]; this is particularly true for females [19, 20]. Thus, the support of the employer and/or the colleagues acts as facilitating factors for RTW [23]. Moreover, having flexibility about scheduling and how much work to do makes it easier to reconcile work and treatment and to resume work after cancer [13, 25, 39]. Numerous work-related factors may be addressed by rehabilitation and work reintegration programs. In Europe, innovative organizational experiences, supported by legislation, have already been activated to enable CSs to resume work Author's personal copy 2992 [40]. Recent qualitative data have shown that employers request more knowledge about cancer and RTW processes to support survivors by offering them various types of accommodation, such as adopting graduated RTW plans with flexible scheduling, modifying work duties, providing retraining and support at the workplace, and modifying the physical work environment or providing adaptive aids [41, 42]. To address these needs, rehabilitation interventions aimed at reducing activity limitations and promoting social participation could be implemented [20, 26], with particular attention to individuals who are profoundly in need of help in returning to work, such as those with lower socioeconomic status [38, 43]. However, to be effective, personalized multidisciplinary rehabilitation interventions should start immediately after the end of treatment and should address limitations or symptoms specific to cancer site or therapy regimen [44, 45]; they also should allow for the early detection of people at risk of long-term treatment side effects, in order to shorten SL duration and its associated social costs [44, 45]. This is particularly important as, according to this review, chemotherapy causes fatigue or cognitive problems [27] that, as already discussed, impact work ability [23, 46]. A possible limitation of this study is that the search strategy adopted was temporally limited to the years 2010–2018. However, we chose to consider the most recent years because Europe’s economy underwent major changes in this period due to the financial and economic crisis. To permit interpretation, data regarding employment rates should always be updated and collected in the context of interest. To our knowledge, this is the first systematic review that investigates RTW of European cancer patients in this historical period. However, it is important to emphasize that this review does not provide exhaustive data from across Europe due to the lack of data available from Mediterranean and Central Europe since 2010. This limit is not attributable to any shortcomings in the search strategy, however, since the same lack of data was also demonstrated by a previous, temporally exhaustive meta-analysis [10]. To conclude, this review adds to current knowledge regarding CSs returning to work in Northwestern Europe, highlighting the urgent need for data from the Mediterranean and Central regions of Europe. It also provides an overview of the principal factors that might influence work resumption in this population and suggests conducting appropriate studies designed to thoroughly investigate how work-related factors might modify the RTW rate. This information will help to implement multidisciplinary rehabilitation interventions tailored to the individual, feasible in the context of interest, and effective in addressing unemployment in CSs. Support Care Cancer (2018) 26:2983–2994 Acknowledgements We thank Jacqueline M. Costa for the English language editing. Funding information This work was supported by the Chamber of Commerce of Reggio Emilia, the Foundation GRADE Onlus of Reggio Emilia, and the Azienda Unità Sanitaria Locale-IRCCS of Reggio Emilia, Italy. Compliance with ethical standards Conflict of interest The Chamber of Commerce and the GRADE Onlus of Reggio Emilia, together with the Local Health Authority-Institute of Research, supported one scholarship thanks to which this study was conducted. However, as disclosed, nobody from the Chamber of Commerce nor from the GRADE Onlus participated in the study at any stage nor did they influence any of the authors during the phases of this review. 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