1. Coronel Institute Cancer and work Dr Angela de Boer Coronel Institute of Occupational Health, Academic Medical Center University of Amsterdam Chair EU Cancer and Work Network CANWON 11-6-2016

2. Coronel Institute Disclosure No conflicts of interest

3. Coronel Institute Overview Cancer patients of working age and return to work What influences sick leave duration and return to work in cancer survivors? Interventions to help cancer survivors To improve interventions to help cancer survivors Conclusion

4. Coronel Institute Cancer and work: cancer patients of working age and return to work

5. Coronel Institute Incidence of cancer is rising

6. Coronel Institute Cancer patients of working age In Europe: –Number of cancer patients and cancer survivors of working age is increasing –Better treatment and higher survival rates –Higher pension age –Ageing labour population –In Europe each year 3.4 million new cases of cancer –Of which 1.4 million people of working age each year IARC, Eurocare, EUROSTAT

7. Coronel Institute Working age cancer survivors in NL NL: Population 17 million Number of cancer survivors in the working age Cancer Statistics Holland, EUROSTAT, 2015

8. Coronel Institute Return to work after a cancer diagnosis Return to work and staying at work regarded as a rewarding experience by cancer patients themselves –Higher quality of life –Income and Insurance –Back to normal –Structure and social contacts Zaman 2016, Paalman 2016, Dewa 2016

9. Coronel Institute Experiences of patients –“I insisted on returning to work. That was very important for me because when you work you are part of normal life” –“Doing nothing is not good for anyone. One should not overdo it, but yes I have the feeling want to try to go back to work “ –“I 'm the breadwinner so I had to just go back. I also returned to the same job which was also necessary for financial reasons”

10. Coronel Institute Employment after a cancer diagnosis Return to work is also difficult for many cancer patients –Of all chronic medical conditions, cancer has by far the highest prevalence of work loss and work cutback 1 –Average return to work rate: 64 % after 18 months 2 –Cancer survivors: 37% higher chance of unemployment 3 –Especially for survivors with a diagnosis of colorectal, gynaecological, blood, or brain cancer –Survivors of childhood cancer are 85% more likely to be unemployed 4 1 Kessler JOEM 2001; 2 Mehnert 2013; 3 De Boer et al. JAMA 2009; 4 De Boer et al Cancer, 2006

11. Coronel Institute Work disability after a cancer diagnosis Cancer survivors have a 3 times higher chance of disability pension 1 Insurance physicians in the Netherlands 2 : –Around 4.500 applications for a disability pension per year regarding workers with a diagnosis of cancer –Around 3.000 granted –9% of total number of granted disability pensions 1 De Boer et al. JAMA 2009; 2 UWV Netherlands

12. Coronel Institute Summary –Increasing number of cancer survivors of working age in Europe –Employment is important for cancer survivors –However, cancer survivors more likely to be unemployed or receive a disability pension

13. Coronel Institute What influences sick leave duration and return to work in cancer survivors?

14. Coronel Institute Prognostic factors Diagnosis and treatment Age Gender Physical complaints Heavy work Anxiety and depression Perceived work ability De Boer 2016; van Muijen 2013; Harrington 2010.

15. Coronel Institute Fatigue Most prevalent problem in cancer survivorship Different from other forms of fatigue Long-term > 5-years Strong predictor of prolonged sick leave duration Strong predictor of unemployment and disability pensions Hampers work retention De Boer 2016; Islam 2014; van Muijen 2013.

16. Coronel Institute Cognitive impairments Cancer treatment, especially chemotherapy Problems with: –Attention –Speed of information processing –Verbal and visual memory Relation between cognitive impairments and return to work and work output Duijts 2014; Calvio 2010; Reid-Arndt 2010; Nieuwenhuijsen 2009.

17. Coronel Institute Doctors: knowledge and communication Treating doctors feel ill-equipped to address occupational issues of their patients 1 However, they have contact early in the treatment process and their patients raise work issues 1 Occupational and insurance physicians sometimes feel inadequately trained to give advice on work ability of cancer patients 2, 3 Lack of communication between treating doctors, occupational physicians and insurance physicians on work issues of the patient 4 1 Morrison 2015; 2 Amir et al. 2009 ; 3 Klarenbeek 2008; 4 de Boer 2016

18. Coronel Institute Workplace and Employers Employees: –Fear of discrimination and redundancy –Stigma: lack of communication –Given “easy tasks” Employers / supervisors: –Uncertainty –Lack of knowledge –Misperceptions around work ability –Impossibility of workplace accommodations –Sandwiched between employee and company Stergiou 2016; Tiedtke 2014

19. Coronel Institute Summary –Several factors influence return to work and length of sick leave in cancer survivors –Fatigue and cognitive impairments –The role of doctors –Role of work place and employers

20. Coronel Institute Cancer and work: interventions to help cancer survivors

21. Coronel Institute Interventions: review Important to provide employed cancer patients with programs to support their return-to-work Cochrane review Aim: to assess if interventions are effective in enhancing return-to-work in workers with cancer

22. Coronel Institute Conclusions Multidisciplinary interventions led to higher return-to-work rates than care as usual: RR 1.11 Multidisciplinary interventions: a combination of psychological, vocational, and /or physical interventions –Psychological - counselling, education –Vocational - focused on employment –Physical - physical training or exercises Multidisciplinary interventions were offered from the hospital setting Early in treatment process De Boer 2015.

23. Coronel Institute 1. Hospital-based work-support Content 4 appointments with an oncological nurse of ± 15 minutes each –To guide patients to return to work –Occupational training for nurse –To translate clinical knowledge into impact on work, eg fatigue, cognitive complaints, impairments –Early in the treatment process 1 brainstorm session with supervisor, occupational physician, and patient –To make a return-to-work plan –To facilitate communication with work place Tamminga, 2013

24. Coronel Institute 1. Hospital-based work-support To improve the communication between the hospital and the occupational physician Letter from the treating physician to OP with information they would normally not receive; with permission of patient Sent to the occupational physician –Information about diagnosis, treatment, and physical and psychological symptoms –Contact about patient if needed

25. Coronel Institute Main results (RCT) N=133 female patients mainly with breast cancer Primary outcome partial return to work 86% (intervention group) versus 82% (control group) Relative risk: 1.03 (95% BI 0.84-1.2), no significant effect The intervention was easily accepted in usual care Patients, nurses and occupational physicians were highly satisfied Barriers Difficult to reach supervisor with a hospital-based intervention Communication between OP and treating physician hard to improve Not tailored: same intervention for all patients Vulnerable groups not included Tamminga, 2013 1. Hospital-based work-support

26. Coronel Institute Breast cancer patients in Scotland Case management in hospital Case manager conducts telephone assessment of individual’s needs to enable work retention or return to work Referral for a range supportive services –physiotherapy –occupational therapy, occupational health nurse, occupation health doctor –counsellor or psychological therapy 2. Case management vocational rehabilitation Hubbard, 2013

27. Coronel Institute Results RCT Of the 1,114 women assessed, 163 (15%) were eligible Data for 18 women were analysed (intervention: n = 7; control: n = 11) Intervention group: 53 fewer days of sick leave over the first 6 months post-surgery than control group (p = 0.122). More tailoring needed for the exact components of the VR intervention 2. Case management vocational rehabilitation Hubbard, 2013

28. Coronel Institute Summary –Multidisciplinary interventions are effective in enhancing return-to-work in cancer survivors –Several interventions have been developed –Early in treatment process –Interventions need to be tailored to the needs of an individual patient –Vulnerable groups should be included in interventions –Communication between stake holders needs to be enhanced

29. Coronel Institute Cancer and work: to improve interventions to help cancer survivors

30. Coronel Institute 1. Girona GIRONA: Gastro Intestinal cancer patients Receiving Occupational support Near and After diagnosis Development of a tailored work-related intervention to support gastro-intestinal (GI) cancer patients Decision framework Patients are referred, based on the decision framework, to one of three types of support which differentiate in the severity of work-related problems

31. Coronel Institute 1. Girona Support A: Oncological nurse Support B: Oncological occupational physician Support C: Multidisciplinary team: –Treating physician (oncologist, surgeon) –Oncological nurse –Oncological occupational physician Three (individual) meetings in clinical setting RCT ongoing

32. Coronel Institute 2. Cancer@work Tailored website for patients regarding employment issues –Tailored information and library –Tailored information of other cancer patients Face-to-face return-to-work consultations –Oncological nurse –Trained in work-related information and in work-related counselling –Contact via website, protected access Involvement of employer: access to public part of website Occupational physician trained in oncological issues: in case of complex problems Tamminga, 2016

33. Coronel Institute Aim: sustainable return to work for employed cancer patients RCT ongoing 2. Cancer@work

34. Coronel Institute University Rehabilitation Institute of Slovenia, Vocational rehabilitation centre Ljubljana Referral agencies –Health insurance –Pension and disability insurance –Employment service Vocational rehabilitation team –Medical doctor, spec. of occupational medicine –Psychologist and Social worker –Occupational therapist; –Rehabilitation technologist 3. Vocational rehabilitation

35. Coronel Institute Last two years 20 cases of Cancer survivors (8% of all cases) Majority of them with brain tumours: Vulnerable group Assessment of working ability (10 working days in the Centre) Contact with the employer Workplace visit –Presentation of functional abilities –Presentation of legal possibilities for RTW –Workplace adjustments and special equipment Support during on the job training 3. Vocational rehabilitation

36. Coronel Institute 4. Information and support MacMillan (UK), for employees: –Information on impact of cancer on work and working during treatment –Legislation –Self-employment –Communication with employers and colleagues Online information, telephone support, Work it out tool, videos MacMillan (UK) for employers: Information, training, support, consultancy

37. Coronel Institute MacMillan: Cancer and work information for health care professionals E-learning on communication on cancer and work Booklet: occupational impact of cancer 4. Information and support www.macmillan.org.uk

38. Coronel Institute Spanish Association Against Cancer (AECC) Job Placement Program to promote socio-labour integration of unemployed Breast Cancer Survivors Vulnerable group Assessment of motivation, work ability and employability factors Increase social and employability skills Support during the job searching process For employers: information about illness and potential physical consequences for work 5. Job Placement program

39. Coronel Institute Results: Low-skilled workers, 26% immigrants Of the 112 participants, 40 women found employment (36%) and were still employed at 40 months of follow-up Improved well-being, self-concept, and self-esteem of participants 5. Job Placement program Rio Suarez, in preparation

40. Coronel Institute Summary –Ongoing development and evaluation of interventions to support return to work of cancer survivors: –Information –Support –Training –Tailored to the needs of patients –Collaboration between stakeholders –Inclusion of vulnerable groups

41. Coronel Institute Conclusion –The number of cancer survivors of working age in Europe is increasing –Return to work can be difficult –Multidisciplinary interventions to support RTW are effective –Supportive programs have been developed and validated –Different stages of the treatment process –Collaboration of stake holders is needed –Research is on effectiveness is ongoing

42. Coronel Institute Thank you! a.g.deboer@amc.nl