Cancer and work

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Volume 29, Issue 4 • Fall 2019

eISSN: 2368-8076

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FEA TURES /Ch R o niq UES

Editor Note: This paper is based on presentations for the CANO-ACIO/ONS/ISNCC JOINT SYMPOSIUM AT THE CANO-ACIO CONFERENCE IN Ottawa, Ontario, 2017 and the CANO/CAPO conference keynote address.

Cancer and work

by Maureen Parkinson and Christine Maheu

iNtrOductiON

T

his paper summarizes the Cancer and Work keynote given by Maureen Parkinson and Christine Maheu at the 2017 CANO-ACIO/ONS/

ISNCC joint symposium in Gatineau, Quebec, in October, 2017. The keynote focused was on introducing the Cancer and Work website (www.cancerandwork.ca) to the audience. Cancer and Work is a comprehensive Canadian- focused website for cancer patients and survivors, healthcare providers and employers to support remaining, returning and finding work for cancer survivors. The website was launched in October 2016 and since then has received more than 56,000 site visits.

In Canada, the Canadian Partnership Against Cancer conducted a review of programs and resources to facilitate return to work (RTW) for cancer survivors and found a lack of available vocational focused supports across Canada (Nitkin, et al., 2011; CPAC 2012c; CPAC 2012a; Fitch and Nicoll, 2019). To this end, this paper presents the development of the first and only bilingual Canadian-based Cancer and Work website (www.cancerandwork.ca). Until the development of Cancer and Work, other international return-to-work websites that existed were often too general, not from Canadian sources, not sufficiently tailored to Canadians, or collated in an easy-to-access format. In this paper, we present the website developmental

phases, an overview of the website, a vocational rehabilitation model for cancer survivors (Parkinson 2016), and a case study applying the model and the website content towards guiding a cancer survivor’s RTW.

cANcer ANd WOrK- relAted issues FOr cANcer surViVOrs

The number of cancer survivors facing return to work is increasing.

According to Canadian Partnership Against Cancer (CPAC) projections, by 2031 there will be 2.2 million Canadians living with cancer (hereafter, all of those who have been diagnosed with cancer will be referred to as cancer survivors).

The majority of adults diagnosed with cancer are of working age and working at the time of diagnosis (CCS, 2015; de Boer, et al. 2008).

Cancer survivors often regard returning to work as a symbol of complete recovery. They see their RTW as a return to normal life and financial inde- pendence, and feel a sense of productiv- ity (de Boer et al., 2008; Spelten et al., 2002; Amir et al., 2008). A successful RTW provides for a resumption of work to identify and reduces social isolation (Amir et al., 2008). Currently, there is a 63% return-to-work rate by cancer survivors within one year following the end of treatment (Mehnert, 2011). However, cancer survivors have been found to be 1.4 times more likely to be unemployed compared to healthy controls (de Boer et al., 2009). As well, between 26%–53%

of cancer survivors will experience job loss or will quit working during or after treatment (Mehnert, 2011). These statistics may reflect the one in five survivors who report cancer-related disabilities that have long-term effects on employment and their ability to work (Short et al., 2005). Challenges to returning and remaining at work can stem from potential effects of cancer or its

treatments (e.g., physical [Behringer et al. 2016; Horsboel et al. 2014], cognitive [Dorland et al. 2017; Cheng et al. 2018], psychological [Horsboel et al. 2014]), as well as challenges associated with the workplace (e.g., lack of accommodations and support), and discrimination at work (Feuerstein et al. 2007; Stergiou- Kita et al. 2016; Bouknight et al. 2006).

Cancer survivors who are unable to return to work or who lose their jobs face financial loss with negative conse- quences on their well-being to financial distress (Ghasempour et al. 2015;

Luengo-Fernandez et al. 2013).

Given the increased numbers of working-age cancer survivors and the multiple potential challenges they face, more readily available supports and services are needed to assist them with remaining, returning and finding work.

RTW services are not widely available within Canada to support RTW for cancer survivors (Nitkin, et al., 2011; CPAC 2012c; CPAC 2012a; Fitch and Nicoll, 2019). Studies show that timely advice from healthcare providers (Amir, et al., 2008) with proper vocational rehabilitation guidance (Chiu et al., 2014; Chan et al., 2008) tend to lead to successful RTW with cancer survivors. However, oncology healthcare providers are not offering vocationally focused support sufficiently (Amir et al. 2008) and may not have adequate training for RTW for cancer survivors (Bains et al. 2012).

reVieW OF rtW iNterVeNtiONs

reseArcH iN cANcer surViVOrs

As part of the website development, a scoping review of RTW interventions for cancer patients and survivors was undertaken. Many of the vocational rehabilitation interventions in oncology fall into the following categories: guidance by physicians, providing educational materials, improving

ABOut tHe AutHOrs

Maureen Parkinson mparkins@bccancer.bc.ca

Christine Maheu

christinemaheu@gmail.com

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communication, and providing physical and vocational rehabilitation support (Thijs et al., 2012; Grunfeld et al., 2019; Tamminga, Verbeek, de Boer, et al., 2013).

Tamminga et al. (2013) combined the involvement of occupational physicians with hospital-based patient education.

This program included having oncology professionals address return to work in regular medical appointments, improving communication with treating and occupational physicians, and having a meeting with an occupational physician, patient and employer.to make a concrete return to work plan. They found return to work rates of 86% and 83% for treatment and control groups. In Britain, Bains et al. (2012) combined a medical consultation (advice on how colorectal cancer would affect work ability) in con- junction with giving cancer survivors leaflets on managing cancer and unemployment. Cancer survivors particularly found the information and advice on the impact of treatment upon work ability to be most valuable. Nieuwenhuijsen and colleagues (2006) combined giving educational leaflets to survivors and occupational health physicians, having notes sent from radiation oncology to occupational health physicians, and having occupational physicians provide education on how cancer survivors could approach return to work. They found that both cancer survivors and occupational physicians used the information in the leaflets and provided for guidance for return to work.

Brown et al. (2013) introduced skills training using a DVD to educate cancer patients on improving communication at the workplace. Schumacher et al. (2017) had cancer patients complete their own workbook, which guided them on the RTW process through pre-RTW preparation and planning. Thijs et al.

(2012) showed that the completion of a high-intensity exercise program resulted in a less reduction in working hours per week compared to a control group.

Chan et al. (2008) investigated types of vocational services and work out- comes for cancer survivor in the U.S.

who received state vocational services.

Counselling, miscellaneous training, rehabilitation technology services, job

placement assistance, maintenance and other services increased the odds of employment with 57% (n=903) achiev- ing successful employment versus 43%

(n=670) who were not employed following receipt of services. The authors also found that those who were successful with return to work spent less time in services, but received more service than those with additional disabilities. Chiu et al. (2014) further clarified that the survivor’s work status (employed versus not employed) influenced types of services needed. That is, the employed group received primarily diagnostic and treatment services, rehabilitation technology and job accommodations while the unemployed group received more vocational training, job search and job placement services. de Boer et al. (2011) conducted a systematic review of return to work interventions (with control groups) and only found evidence in support of multidisciplinary interventions consisting of physical and psychological with vocational components led to a higher return-to-work rates than care as usual.

In summary, return to work interventions typically involved providing education to support better knowledge of the return-to-work process, enhanc- ing communication between all stakeholders, and providing vocational and rehabilitation assessment and treatment. All of the RTW strategies high- lighted above were incorporated into the cancer and work website.

deVelOPMeNt OF cANcer ANd WOrK WeBsite

To obtain a better understanding of what support and resources were available to Canadian cancer survivors and to further identify the challenges and opportunities to assist cancer survivors with return to work, in 2011, three reports were completed by the Canadian Partnership Against Cancer (Gould et al., 2012; CPAC 2012b; CPAC 2012a). These reports examined return to work from the perspectives of cancer survivors, caregivers, employers, insurers, benefits managers and union representatives.

• Return to work concerns faced by

people dealing with cancer and caregivers: Literature review and consultation

• Research Related to Workplace Support for Cancer Survivors:

Perspective of Employers

• Programs and resources to facilitate return to work for people with cancer or other chronic diseases:

Environmental scan.

Returning to Work after Cancer:

Projects Summary (2012) reports on the main highlights of the three CPAC reports and concludes that employers and small and medium organizations require more education and information about workplace accommodations.

Key stakeholders (individuals with cancer, physicians, employers, coworkers, insurers) also must improve their communication. Financial support was identified as an important element for caregivers and cancer survivors.

Thereafter, CPAC convened a consultation workshop (2013) of specialists from across Canada in oncology and return to work to determine next steps. Recommendations from the workshop included creating work-focused toolkits, engaging external professionals with expertise in RTW to work together, and providing access to work-focused community information and resources. The group recom- mended that a project be developed that focused on building awareness, educat- ing, and providing web-based interac- tive tools for three separate subgroups:

patient and caregivers; health professionals, and employers and insurers (personal communication, CPAC, 2013).

In the end, CPAC funded the development of a website under the lead- ership of Christine Maheu, Associate Nursing Professor, McGill University, and Maureen Parkinson, Provincial Vocational Rehabilitation Counsellor, BC Cancer. Together they established an interdisciplinary team including cancer survivors, and specialists in oncology, vocational rehabilitation, nursing, rehabilitation, psychosocial oncology and researchers from various hospitals and academic institutions to work in partnership with the de Souza Institute.

The Institute provided the design team

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for the development of the website and hosted the website for the project period between March 2015–2017. Currently, the website is hosted at McGill and remains a joint collaboration between McGill University and BC Cancer.

The initial development of the content started with the adaptation of the manual, Cancer and Returning to Work:

A Practical Guide for Cancer Patients (2nd edition). This 75-page document had previously undergone evaluation with 60 stakeholders (cancer survivors, healthcare providers and workplace representatives) who found the content important and useful (Parkinson, 2014). To identify additional content that would be featured on the website, the cancer and work development team conducted an environmental scan of the existing scientific and grey literature specific to cancer and work. Sixteen topic areas were identified such as, assessing ability to work, how to communicate with employers, coworkers, insurance providers, union and lawyers, and how cancer and its treatment can affect work ability.

In addition to the 16 potential topics identified for the website, community representatives and stakeholders (cancer survivors, employers and healthcare providers) were asked to complete an online survey to rate the importance of each of these topics, provide suggestion for additional content, and to share known available helpful information and resources.

One hundred and fifty stakeholders responded and ranked all 16 topics as very important. They identified the need for additional content such as how to manage a workplace that is not supporting return to work, how to explain men- tal health challenges following cancer on return to work, managing financial stress, how to ask for specific accommodations (e.g., work outfit clothing challenges when you have a urostomy pouch). The content development phase of the website was further informed by identifying grey and existing literature that focused on supporting returning, remaining and finding work for cancer survivors. The resource had to be helpful to stakeholders, freely available to the public and new content beyond the information for the adapted manual.

Based on the gaps identified during the literature review and stakeholder feedback, new content was developed by the Cancer and Work development team and expert writers. The addition of expert writers enriched the quality of information available, high- lighted and acknowledged the expertise across Canada and around the globe. Expert writers also allowed for regional representation and fostered a sense of ownership of the website, which subsequently helped with promotion. Initially, 26 expert writers provided new content from vocational rehabilitation, nursing, occupational therapy, medicine, disability management, psychosocial oncology, legal experts, career counselling, insurance, neuropsychology, kinesiol- ogy, nutrition and cancer survivors.

An advisory group was also developed consisting of stakeholders who brought expertise from the perspectives of survivors, management, occupational therapy, insurance, and legal.

The advisory group and Community Partners (Canadian Cancer Society, BC Cancer, Princess Margaret, National Institute of Disability Management and Research, Canadian Cancer Society, Canadian Cancer Survivors Network, de Souza Institute, University Health Network, BC Cancer Agency, Alberta Cancer Control, Saskatchewan Cancer Agency, Nova Scotia Health Research Foundation) were enlisted for the review of the content and promotion of the website once it was launched.

At the end of the development phase in September 2016, 450 pages of written content, nine online videos, and eight online tools had been created and resulted in one of the most comprehensive websites available globally. Rather than only providing in-house created information on the topic of cancer and work, the website also links to the best freely available information on the topics across the globe. The website also provides for a research platform to test new approaches (e.g., evaluating the facilitators and barriers to using the online RTW planner and job analysis tools) and new and innovative strategies to support the RTW process.

cONteNt OVerVieW OF cANcer ANd WOrK

The content areas of the website were divided among the three main stakeholder groups involved in the RTW process: cancer survivors, healthcare providers, and employers. The topic headers for each stakeholder group are initially almost all the same, but the content is adapted to each audience. Presenting the content in par- allel for each stakeholder group was chosen to enhance communication between parties using similar language and processes. The few extra sections for survivors and healthcare providers include topics such as changing jobs and looking for other work, finance and disability, and links to vocational focused services and resources. Table 1 presents an overview of the website headers and a snapshot description to some of these section topics.

returN tO WOrK/stAY At WOrK

The first section, “Returning to work/staying at work”, has 11 steps for cancer survivors and healthcare providers and six steps for employers. The steps start with preparing to return to work and finish with monitoring the cancer survivors' progress once back to work. When following through on each of the steps, the user is directed to specific sections on the website, which provides for in-depth guidance on the topic.

strAteGies tO Address cANcer’s iMPAct ON WOrK

In this section, strategies to address cancer’s impact on work aims to help identify and address challenges caused by common side effects of cancer and its treatments on work ability. Written by an interdisciplinary team from nursing, occupational therapy, vocational rehabilitation, psychiatry and psychology, the section outlines 23 of the most common side effects of cancer and treatment divided into three categories; physical, emotional and cognitive subsections.

For each of the 23 common side effects, a general description of the issue is first provided followed by its potential

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vocational implications, self-managing strategies, and job accommodations ideas. The job accommodation section, written by an oncology occupational therapist, is particularly catered to the medium and small employer who may not have access to a rehabilitation or disability management specialist to give job accommodation ideas (i.e., how the job, job duties, work environment and work processes can be changed to allow someone to work if they are coping with a disability). While the job accommodation ideas are specific to the side effects, they are general and not work-site specific to the individual. They provide some potentially helpful ideas.

WOrKPlAce Well-BeiNG

Under the survivor section, the workplace well-being section was developed from feedback in our initial survey and clinical insights gleaned from the BC Cancer Return to Work groups offered since 2012. Many cancer survivors have expressed concerns about the negative impact of stress in the workplace. The purpose of this section is to provide a brief conceptual model describing ways to view and address stress (https://www.

cancerandwork.ca/survivors/workplace-wellbeing/), an introduction to stress management techniques, and links to helpful online resources. The section also includes an online tool that guides the survivor on how to change unhelpful thoughts into more helpful

thought processes using a worksheet.

Videos were also created by a psycholo- gist specialized in cognitive behavioural therapy to supplement the tool.

cANcer is teAMWOrK ANd cOMMuNicAtiON

The Cancer is Teamwork and Communication section encourages and guides cancer survivors to communicate effectively with all those involved in the return to work process including the employers, healthcare providers, and insurance providers. As workplace support often plays an important role in successful return to work (Buys et al., 2019), cancer survivors are encouraged to maintain contact with their workplace to foster employer commitment to their return to work. Cancer survivors who are concerned about the pros and cons of disclosing their cancer diagnosis to their work colleagues may want to review a paper on the Cancer and Work website titled Who gets to know:

How to exercise your power of “disclosure”.

The paper gives helpful ideas on how to decide who and what information is shared with work colleagues. Cancer survivors are given ideas on how to communicate with their employer from the moment they are diagnosed to after they return to work. To optimize communication with healthcare providers, cancer survivors are guided to assess and inform about their work ability, and ask for help for their recovery.

For those who have access to third- party insurance (such as long-term disability), this section informs cancer survivors of typical processes and pit- falls that can result in termination of a claim. It also encourages cancer survivors to assess within their insurance for potential availability of assessment and treatment (e.g., occupational therapy) to support their return to work. The sub-section roles of professional describes how specific representatives of disci- plines within healthcare, insurance and at the workplace can aid them with their return to work.

Under the Cancer is Teamwork and Communication section for healthcare providers, healthcare providers are encouraged to take a more active role in discussing work with cancer survivors. In particular, discussing the impact of cancer and its treatment may have on work can be helpful with vocational planning. Such communication may prompt referrals for treatment and resources, such as rehabilitation to improve work ability functions.

Featured under this section is a video, Physician’s guide to navigating insurance forms and the insurance process from a legal perspective by a lawyer. The goal is to inform healthcare providers on how medical notes may be perceived by insurance providers and how to better address issues of work by describing symptoms in terms of function if there is a desire to promote return to work.

Table 1: Overview of Cancer and Work headers and subheadings

Survivors Healthcare Providers Employers

Returning to work / staying at work Returning to work / staying at work Returning to work / staying at work Cancer’s impact on work and strategies Cancer’s impact on work and strategies Cancer’s impact on work and strategies Return to work is communication and

teamwork Return to work is communication and teamwork Return to work is communication and teamwork

Assessment of your work ability Assessment of work ability Assessment of work ability Finances and Disability Finance and Disability

Workplace accommodation Workplace accommodations

Changing jobs/looking for work Assisting patient in changing jobs/looking for work

Workplace well-being Workplace well-being

Caregivers Caregivers Caregivers

Law, policy and practice information Law, policy and practice information Law, policy and practice information Links to services and resources Links to services and resources

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In our in-house survey, employers asked for guidance on how to communicate with individuals diagnosed with cancer at the time of diagnosis and thereafter. Under the Cancer is Teamwork and Communication section for the employer, communication tips and directions are provided. Research (Dorland et al., 2017; Buys et al., 2019;

Fitch and Nicoll, 2019) and clinical experience show that good relationships and support at the workplace from employers, supervisors and colleagues are very important in helping employees return to work more quickly and successfully.

Thus, this section guides the employer on how to communicate with cancer survivors to help them transition back to work and stay working. The section also includes addressing privacy and guides colleagues on how to be supportive.

One communication aid is a Return to Work Planner tool developed by an occupational therapist that outlines six steps for the employer and employee to plan the return to work. The Return to Work Planner incorporates restrictions and limitations, as defined by the medical profession, with how to implement job accommodation ideas, a schedule for return to work over a time period, a formalizing schedule for meetings, and who is responsible for evaluating and overseeing the return-to-work plan.

The Return to Work Planner is built with three guiding principles: 1) The plan should be individualized; 2) incor- porate feedback from all those who are impacted by the plan, and 3) be flexible to address the ongoing changes for the employee.

LAW, PRACTICE AND POLICY INFORMATION

This section covers detailed information on human rights and resources.

Lawyers were asked to respond to common legal questions regarding human rights such as disclosure of medical information at the workplace, rights and obligations for accommodations for those returning or looking for work as they apply to Canadian laws, and one section that specifically addresses Quebec laws. Resource links were also

gathered in this section highlighting where cancer survivors can obtain support and information in their own province. This section is one of the most viewed on Cancer and Work. The Law, Practice and Policy Information for employers is specifically designed for small- or medium-sized firms who may not have in-house access to human resources, disability management or legal expertise. Employers may not be aware of the details related to “duty to accommodate” legislation. This section provides a brief overview and provides contacts and resources in each province to learn more.

ONliNe tOOls

Eight online tools were developed to assist in the process of assessment and treatment for the return to work following cancer. Two tools allow cancer survivors to systematically track their energy to help in vocational rehabilitation planning. The Energizer and Drainer Tool, initially developed for the BC Cancer Returning to Work Practical Guide, helps cancer survivors identify and determine which activities drain them (“drainers”) and which activities provide them with energy (“the ener- gizers”). The Cancer and Work Fatigue Tracking tool is meant to assist individuals in assessing their fatigue according to two dimensions: their level of fatigue and the time of fatigue during the day and over the course of four weeks. Both tools allow cancer survivors to condense the information into down- loadable graphs they can take to their healthcare provider to further discuss.

The summary results and the graphs from completing the online tools can help guide a survivor to know when he or she is ready to return to work and, if so, whether job accommodations can be suggested to address their fatigue and capitalize on high-energy time.

The Cancer and Work Job Analysis tool, adapted from BC Cancer Returning to Work: A Practical Guide (Parkinson, 2014), helps assess cancer survivors' abilities with reference to the physical, psychological, and cognitive demands, as well as the environmental

factors of the job. Such an assessment will aid in the determination of work ability and return to work planning. Two tools under job analysis have been created, one for the employer to describe job demands if they have not already created an in-house description of their own. The other job analysis tool for cancer survivors is to complete based on their perceived work ability and the demands of their job. The job analysis tool for cancer survivors helps to summarize challenges in reference to the job demands; a summary form is created that can be presented to their healthcare providers to help them determine work readiness. The summary can also guide restrictions and limitations that need accommodations and explore opportunities for medical and rehabilitation services to increase work ability. As a precursor to completing the job analysis tool, there is also Cancer and Work Task Analysis Worksheet (Cancer and Work et al., 2016) to help cancer survivors or employers identify job duties and tasks that are deemed essential or non-essential.

The Cognitive Symptoms at Work Checklist can be used to assess for cog- nitive challenges at work. Adapted from a tool created by Ottati and Feuerstein (2013), this tool has been validated to be effective in predicting cognitive challenges for those who have returned to work. The online version is now being used as an anticipatory tool to inform the conservation of potential cognitive challenges at work. Cancer survivors complete the online form, which identifies types of challenges in the context of work such as remembering the content of a conversation or meeting, understanding how a task fits into a plan or system and using new information to re-evaluate what is known. Following, they are asked to rate how much of a concern these challenges are with reference to work performance. A summary result is provided that cancer survivors can print and share with their healthcare providers, insurance providers or employers as a way to obtain access to rehabilitation support or job accommodation, as needed.

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usiNG tHe VOcAtiONAl reHABilitAtiON MOdel FOr cANcer surViVOrs tO Guide AssessMeNt ANd iNterVeNtiON

Vocational rehabilitation models can be helpful in guiding healthcare providers to conduct their assessment and make decisions regarding care to support return to work. The Vocational Rehabilitation Model for Cancer Survivors (Parkinson, 2016) describes four factors as biopsychological, person related, system influences, and work-site considerations.

Biopsychological factors include all psychological and biological factors that proceed, emerge, or continue after the cancer diagnosis. This can include pre-existing disability; cancer and treatment-specific factors and how these impact recovery; stability or course of cancer; side effects of treatment; and whether physical, cognitive, and psychological disabilities are temporary, long-lasting, or permanent.

Person-related factors can be the cancer survivors’ perceptions of work including how they view the meaning of work; how they identify the importance of their work role, their expectations around recovery and their motivation to work. Person-related also includes how survivors view the impact of cancer and treatments on their ability to work and whether they perceive work posi- tively or negatively, such as the fear that work stress causes cancer. This section also includes demographic factors such as age, education and gender factors that influence access to work. (See note below.)

System factors can include available financial support (e.g., access wage replacement: for how much and for how long), the cancer survivor’s economic situation, the availability of resources within the medical system such as timely access to healthcare for assessments (e.g., scans) treatments, symptom management, and rehabilitation. In addition, factors such as views and advice of the healthcare team about work and cancer can be influences.

Other factors include supports from insurance such as access to a vocational

focused rehabilitation program and from the community. Pressure from insurance companies (such as from case managers) also can influence return to work. Finally, legal support such as human rights legislation to support working, as well as family and cul- tural factors can influence the demands, pressures, and beliefs with regards to work.

Worksite factors are specific job demands (physical, psychological, and cognitive), work hours (part/full time, evening/day), as well as the availability of accommodations and workplace supports (by employer and colleagues).

Additionally, previous and current relationships with those at the worksite will play a role as well as access to rehabilitation or disability management at the worksite.

*Note: Perceived work stress can fall under biopsychological, person-cen- tred or work demands depending on the influencing factors. For example, when someone has a low threshold for anxiety related to their work, this aspect could fall under biopsychological. High work demand and low control can fall under work demands factors. If a cancer survivor reports that work is stressful with- out evidence of biopsychological or high work demands, this may fall under person-related factors. The challenge is that perceived work stress can be caused by a combination of factors. Part of the nursing assessment is to explore the ori- gin of the stressful feelings.

cAse eXAMPle usiNG VOcAtiONAl reHABilitAtiON tO HelP NAViGAte HelPFul iNFOrMAtiON FrOM cANcer ANd WOrK

(WWW.cANcerANdWOrK.

cA)

Through the use of a case example and the vocational rehabilitation model, the following identifies a few sections on the Cancer and Work website that can be helpful for addressing the issues identified within the four factors and supporting the return to work.

Using the Vocational Rehabilitation Model for Cancer Survivors, we get an

overview of the challenges Sally is facing (See Figure 1). She was diagnosed with breast cancer and stopped working 18 months ago and her treatment (sur- gery, chemotherapy and radiation) was completed six months ago. While her doctor expects her to fully recover from her treatment, she identifies barriers to work as fear of work stress and sleep challenges. In her role as Manager of Accountants, she dislikes the demands of the job and work has less meaning for her, reflecting a change in work priorities. Her job is very specialized and is sedentary, and she sees her work as psychologically and cognitively demand- ing. It also requires overtime. This is a well-paid job and her family relies on her income and she cannot afford to retire. She is receiving long-term disability benefits and the insurance case manager is calling her once a month inquiring about her expected date for returning to work. She is unsure how supportive her employer will be if she returns to work.

Bio-psychological

Given the fear of stress at the workplace, the workplace well-being section may be helpful to Sally, as it gives an overall introduction to stress management. Resources include how to address stress through changing job duties or changing jobs. Using cognitive behavioural techniques can challenge unhelpful stressful thoughts and feelings. The section also introduces ways Sally can change her reactions by learning stress management skills that can help her be more resilient to stress.

Sally may also benefit from exploring the section on emotional and psycholog- ical cancer’s impact on work and strat- egies, written by two psychiatrists. This section gives her ideas on self-management of stress and anxiety strategies, as well as helpful resource links to learn more on how to self-manage.

Given Sally has mentioned challenges with sleep, the sleep subsec- tion on the physical symptoms section, under Cancer and its Impact, can provide information on sleep strategies such as sleep hygiene and ways to cope at the workplace. Sally’s reported fear of stress may be reflective of anxiety, which may have a negative impact on her overall

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daily quality of life, sleep quality and, possibly, her work ability. She could use some of the assessment tools (such as moodfx) to prompt her to reach out and inform her healthcare provider for the support and care that she needs.

Similarly, as Sally is having difficulty with sleep, she might benefit from systematically tracking her sleep using a validated sleep tool. She can share this with her healthcare provider to inform the conversation and discuss ways to have this addressed.

Person Related

If Sally is unsure about how she feels about her work and the importance of work, and is considering looking for another work situation, she might benefit from reviewing the changing jobs and looking for work section. In this section, she can read about change in work priorities, online

career exploration procedures. If she decides to change jobs, job search techniques are particularly relevant to cancer survivors.

Systems

As Sally is getting calls from a repre- sentative from her long-term disability provider, she might benefit from learning more about how long-term disability plans work. Having a better understanding of the expectations and the process, she can address concerns she has and avoid or prepare for a termination of her claim. For example, since she has been off work for some time, she might be coming up to a change in the defi- nition of her qualifications of benefits.

With many policies, after the two-year mark of being off, benefits representatives will ask the question, “Can she do any job?” If the answer is yes, her benefits could be stopped whether she has

a job to return to or not. Understanding the supports available to her through her insurance, such as rehabilitation and psychological supports, might be helpful to her with the barriers she is experiencing (i.e., sleep and anxiety) with the return to work. The section on communicating with your insurance provider may be helpful to her to help her learn more about how to communicate effectively with her insurance provider, explain her challenges and ask for what she needs. Sally could ask for insurance-funded vocational rehabilitation specialists to help negotiate and obtain the accommodations she needs from with her employer and ease her transition back to work. Hopefully, by reading this section, she will be encouraged to know more about how her insurance works and how she can take a more active role in her vocational rehabilitation.

Figure 1: Application of the Vocational Model to a case study

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The cancer is teamwork and communication section provides guidance on how to maintain optimum communication with her employer. As well, this section can guide her communication with employers in staying in contact with her work, so that she can maintain and foster support for her return to work. She may also benefit from learning how to question her healthcare providers about assisting her to have her concerns addressed before she tries to return to work.

Job Demands and Worksite Support Assuming she is cleared to return to work by her healthcare team, she is now ready to plan her return to work.

She mentioned that she is concerned about how supportive her employer will be with her return to work. Sally may want to review the human rights legal section to understand her legal rights and responsibilities in obtaining the job

accommodations she needs to allow her to return to work. Featured under workplace accommodations, the job accommodations for cancer-specific issues can provide ideas that she can discuss with her employer on how her job tasks and job environment might be changed to help her ease back and be more pro- ductive at work. In combination with guidance from her healthcare providers outlining restrictions and limitations of her work ability, she and her employer could use the return to work planner online tool to create a customized plan that articulates work timelines, incorpo- ration of job accommodations, and plan dates for monitoring and adjustments to the plan as needed.

cONclusiON

There has been a considerable need to support the burgeoning population

of cancer survivors who plan, need, and want to return to work after a cancer diagnosis. Using the information derived from intervention research, position papers by the Canadian Partnership Against Cancer, and survey results from stakeholders, the Cancer and Work website was developed.

Cancer and Work is now an information hub sharing global and national information, resources and tools to support Canadian cancer survivors with working. The website is designed for multiple stakeholders, cancer survivors, healthcare providers and employers, to support cancer survivors with staying, returning or finding work. This comprehensive, free and easily accessible website, available in both French and English, attempts to begin addressing the needs of Canadians coping with cancer and work.

reFereNces

Amir, Z., Neary, D., & Luker, K. (2008).

Cancer survivors’ views of work 3 years post diagnosis: A UK perspective.

European Journal of Oncology Nursing:

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