Tools to assess employment readiness for colorectal cancer survivors: A scoping review

Abstract Background The ability to return to work and remain at work is an important recovery milestone after a cancer diagnosis. With the projected number of colorectal cancer patients of working age likely to increase, it is important to identify when a person is ready to resume work. There are many employment‐related tools available to help people return to work after injury or illness; however, it is unknown which may be suitable for a person with colorectal cancer. Aim To identify tools related to employment readiness in colorectal cancer survivors and to chart the relevant factors of employment assessed by these tools. Method Literature searches were performed in PubMed, CINAHL, Embase and Medline, the Cochrane library and PsycINFO using search terms around cancer, survivorship and employment to identify all peer‐reviewed articles published in English up to June 2022. Results Thirty‐five studies used a total of 77 tools focused on assessing employment issues experienced by people with cancer in general. Four tools were used with colorectal cancer survivors. None considered all relevant employment‐related factors for colorectal cancer survivors. Conclusion Tools used to identify return‐to‐work and remain‐at‐work were not specific to colorectal cancer. There are a range of existing tools that collate some, but not all, of the domains and outcome criteria required to meet the employment needs of colorectal cancer survivors. To optimize work outcomes for the working colorectal cancer population, a specified tool is warranted.

][5] For many cancer survivors, work is a vital aspect of re-establishing normality.In wider society, work serves a range of functions beyond that of material well-being.In studies of people with cancer, work is perceived as a means of reducing or avoiding social isolation, boredom, loss of self-esteem, financial hardship, and a way of enabling people to regain a sense of normality, and a positive concept of self and identity. 6,7][10] Cancer survivors have reported significant psychological and physical stressors in instances where they have returned to their previous roles before being ready. 11,12The decision of determining if, and when, a person with cancer is ready to return to work can be challenging due to the ongoing nature of treatment, such as extensive follow-up and screening, as well as treatment-related side effects.For example, cancer-related fatigue is the most frequently reported issue preventing cancer survivors from returning to work. 11,13n addition, medical interventions for the treatment of cancer (surgery or chemotherapy) can have persisting and unexpected impact on an individual's physical and cognitive function, negatively influencing productivity at work.Those that do return with a higher degree of comorbidity have been shown to have greater difficulty re-integrating into the work environment. 14Thus, there are many factors that influence the return-to-work process which need to be considered and addressed to inform employment readiness after a cancer diagnosis.
One common cancer with improving prognosis is colorectal cancer. 1,15,16It is the third most commonly diagnosed cancer worldwide, with the highest incidence among developed countries. 17,18However, the introduction of the biennial faecal occult blood test screening programme has seen the prognosis of colorectal cancer steadily improving via early detection, with 5-year survival rates reaching 70% in Australia. 1 The median age for diagnosis for colorectal cancer is 70 years in Australia, indicating that approximately 50% of colorectal cancer patients are still of working age.With the age-related pension threshold set at 65.5 years and set to increase, it is expected that the number of colorectal cancer patients of working age will significantly increase in the future.Survivors of colorectal cancer have reported unique and challenging experiences after their treatment and when returning to work. 19This is in part due to their post-treatment bowel function and the psychological effects and stigma associated with having a stoma. 19,20These procedures are definitive in up to 22% of cases. 21Little is known about the process of returning to work after colorectal cancer and specifically how to support clinicians and individuals in identifying readiness to return to work.
Assessing the return-to-work process is difficult as it is highly individualized and involves numerous stakeholders such as employers and healthcare professionals. 224][25][26] At present, there are no known tools specific to colorectal cancer and return-to-work described in clinical guidelines in Australia or globally. 27Recent systematic reviews have not identified tools specific for colorectal cancer and work although this was not their primary aim. 28Hence, a scoping review of the literature was conducted to explore the tools available for assessing readiness for work after cancer with particular emphasis on colorectal cancer.The aims of this scoping review are as follows: to identify tools related to employment readiness in colorectal cancer survivors and chart the relevant factors of employment assessed by these tools.This information will be useful for the development of new tools or modification of an existing tool.

| Study design
Scoping reviews are useful for a number of academic needs particularly in identifying the types of available evidence in a given field; to clarify key concepts/definitions in the literature; to examine how research is conducted on a certain topic or field; to identify key characteristics or factors related to a concept; as a precursor to a systematic review and to identify and analyse knowledge. 29As a result, a scoping review was selected to achieve the aims of this study due to the limited literature in the field.The framework by Arksey and O'Malley 29 was adopted utilizing the first five of six stages (Stage 6, consultation exercise, is optional): Stage I, identifying the research question; Stage 2, identifying relevant studies; Stage 3, study selection; Stage 4, charting the data; Stage 5, collating, summarizing and reporting the results.This scoping review was prepared according to the PRISMA-ScR reporting guidelines. 30

| Stage 1: identifying the research questions
The research questions for this review were as follows (1)  What tools are available to inform decision-making about returning to work or remaining at work in colorectal cancer survivors?and (2) What employment-related factors are assessed by these tools?

| Stage 2: identifying relevant studies
The second stage of the scoping review process identified the criteria for inclusion of studies in the review.Although a scoping review is designed to cover a broad spectrum of literature, inclusion and exclusion criteria guided the search and helped to filter the literature.Thus, the scoping review included published peer-reviewed articles that were retrieved from the following electronic databases: PubMed, CINAHL, Embase, Medline, the Cochrane library and PsycINFO.To capture all relevant published material, no limit was set for the publication date to June 2022.Reference chaining (a review of links found through the electronic search) was undertaken to ensure that all possibly relevant articles could be included in the scoping review.Keywords (including Medical Subject headings [MeSH] and 'All field' search terms) used to execute the literature search covered the concepts "cancer," "survivorship," "employment," "sick" and "measurement tool," joined by the Boolean operator "AND" to produce the search results (Table 1).
During an initial search, it was discovered that there was a limited body of evidence specific to colorectal cancer, restricting the exploration of potential publications and tools.Therefore, the scope of the review was widened to all cancers.For the purposes of this review, 'return-towork' is defined as the process whereby a person with a diagnosis of cancer plans to return to their pre-diagnosis paid employment or seek a new job after a period of nonemployment in which medical treatment was received. 31n academic librarian was consulted and advised on the most appropriate MeSH terms for the search and how to modify MeSH terms for the different databases used.Based on this extensive exploratory scoping phase, the search strings for each database were finalized.

| Stage 3: study selection
The results of the searches from different databases were consolidated and duplicates excluded.Three authors (MD, HW and FA) then independently screened the titles and abstracts of the articles against the eligibility criteria.Based on the aims of this review, the following inclusion criteria were applied to search results: peer-reviewed literature of any design, only full text, no date restriction, included cohorts of people with a cancer diagnosis, and studies that had tools related to employment readiness in colorectal cancer survivors.Only studies in English were included.Data, such as conference abstracts, commentaries, books and book reviews, editorial articles and non-peer reviewed grey literature, including health service policy and procedure documents were excluded.Also, studies on children and including only non-working populations were excluded.Disagreements about study eligibility were resolved among the three screening authors (MD, HW and FA) by consensus discussion.Studies that included tools with a few items about employment or reported on incidence/prevalence or measures of employment status or financial burden of cancer on work were excluded as readiness for work is a multifactorial construct. 32Hence, only those tools that considered several medical factors, mediator variables and outcome criteria related to employment readiness were included in this review.The quality of each study was rated using the Mixed Methods Appraisal Tool (MMAT). 33

| Stage 4: charting the data
Based on the preliminary scoping phase, a data extraction framework was developed.The framework was pilot tested by two authors (MD and HW) on a sample of the included studies (10% of the complete list of retrieved studies) to ensure that the coding framework was consistently applied.
Two authors (MD and HW) independently extracted the data from each included study.Each included study was assessed to determine the type of cancer that was being examined, and the tools used to determine employment readiness.Discrepancies in extracted data were discussed between the research team until consensus was reached.

| Stage 5: collating, summarizing and reporting the results
Analysis and conceptual synthesis of the data collected using the data extraction framework provided information on previous research undertaken around employment readiness for all cancer survivors.It is well understood that a range of variables can impact the transition back to the workplace, long-term work productivity or job retention among cancer survivors.To evaluate the utility of a tool in assessing readiness for work in someone with cancer, it is valuable to consider which of these contributory factors the tool assesses, as well as its relevance to the outcome of interest.There are several existing models that document the factors that need to be considered for people with cancer wanting to return to work or maintain their employment.The most comprehensive of these include the models developed by Feuerstein et al., 34 Mehnert 35 and Chow et al. 36 While the terms "model" and "framework" may denote different meanings in certain contexts, the terms are used interchangeably in the papers by Chow  et al. and Feuerstein et al., which would suggest that within this context there is no significant practical difference between the two.As such, we have assessed both models and frameworks to develop the analytical framework for our discussion, focusing on the Mehnert model.
In 2010, Feuerstein et al. developed the Cancer & Work model, a framework to aid in conceptualizing cancerinduced employment issues experienced by survivors both in the short and long-term (Figure 1). 36,37The model was designed both as a framework for future research, as well as for clinical and workplace application, such as in guiding the evaluation, prevention and management of survivors who experience problems returning to and/or Chow et al. 37 developed their conceptual framework on return to work among cancer survivors based on a systematic review of 27 studies.This framework serves to assist policy makers in addressing issues pertaining to return to work among cancer survivors by highlighting various modifiable factors which represent potential areas of intervention.Specifically, the framework outlines five different categories of factors which impact the primary outcome of return to work.These include environmental factors, personal factors, work demand-work ability, health status and financial factors.Several sub-groups of variables are listed within each of these categories.Additionally, arrows provide a visual depiction of the direction of relationships between the factors within the framework.
Many similarities exist between the three models discussed above.Most notably, they are all multivariate in nature, considering the potential impacts of a range of factors related to the individual and their disease, as well as the physical and psychosocial aspects of work.However, several key differences also exist between the three studies and their respective models.Firstly, in terms of the methods and results of the systematic reviews themselves, there were considerably fewer studies included in the review by Chow et  The three models themselves also differ in terms of their content, structure and intended application or purpose.Mehnert's model was primarily constructed for research purposes, while the other two models were designed for more practical application.The Cancer & Work model was developed for use in both clinical and workplace settings to support cancer survivors in returning to or remaining at work.The conceptual framework constructed by Chow et al. primarily serves as an aid for policy makers in reviewing the current healthcare delivery system by highlighting potential areas of intervention to address issues pertaining to work among cancer survivors.All three models incorporated similar categories of factors which impact work outcomes, including those relating to the individual's health and socioeconomic status, as well as work-related factors.However, compared to those by Feuerstein et  Upon consideration of the strengths and limitations of each of the models Mehnert's model was chosen to guide this scoping review and aid in the identification of tools for determining work readiness in colorectal cancer survivors for several reasons.This model was based on the most extensive review of the literature, with the greatest number of included articles of the three studies.Mehnert's model is highly comprehensive, with specific examples of mediating factors listed within each category of variables.Mehnert's model is the most holistic of the three, as it considers psychosocial and economic outcomes in addition to the work outcomes included in the other two models.

| Description (included and excluded studies)
The flow of search results through the stages of the review is presented in Figure 1.After removing duplicates, 8918 titles and abstracts were screened to identify 217 cancer-related abstracts.After full-text screening, 181 articles were excluded, leaving 35 articles eligible for this review.
Sixteen studies examined work-related issues using cohorts of mixed cancer types.The remaining 19 studies specifically investigated one type of cancer, for example head and neck, 37,41 breast, 8,14,38,57 prostate, 39,56 haematological, 67 hepatic (liver), 9 thyroid 47 and myoproliferative. 44our studies focused on the employment needs from the perspective of colorectal cancer survivors. 43,59,62,68ll studies used a variety of tools to assess employmentrelated matters for cancer survivors.

| Tools used to identify employment-related factors in cancer survivors
From the 35 included studies, a total of 77 tools were identified that assessed some aspect related to employment (Tables 2 and 3).Only 15 tools were specific to work outcomes such as the Work Limitations Questionnaire.The majority of tools included were those assessing factors potentially influencing work outcomes such as stress (e.g.Perceived Stress Scale) or fatigue (e.g.multidimensional Fatigue Inventory).Of these, the Hospital Anxiety and Depression Scale (HADS) was the most frequently used tool across all cancer types.Most of these tools were originally designed for populations other than cancer (e.g.HADS).This tool was included in six studies for breast, haematological, mixed, prostate and thyroid cancers. 38,44,46,47,56,67The second most used measure was a quality-of-life scale, The European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC-QLQ-C30).This was included in three studies that focused on breast, colorectal, head and neck, and thyroid cancers. 37,38,56The following measurement tools were used in more than one type of cancer: Multidimensional Fatigue 8,65,67 and Short Form-12. 39,46,47,62Table 4).All tools were self-reported outcome measures, featuring between 12 and 47 items.Only one tool, the WLQ, assessed a work-related outcome.The WLQ has previously been demonstrated to be valid populations with chronic health conditions. 69Similarly, the SF-12 was designed for assessing quality of life for any health condition and the general population.All these tools are standardized and have had some level of psychometric testing undertaken.
The four tools that were relevant to colorectal cancer were then mapped against the Mehnert model (Table 5).As seen in Table 5, none of the identified tools considered all factors/variables or outcomes of Mehnert model.Three of the tools, City of Hope Quality of Life, Short Form-12 and the Memorial Sloan Kettering Cancer Centre Bowel Function Index included a total of three features of Mehnert's model.These tools were not consistent in the features included, with only one category of mediator variable (Impairments and health status of the individual) that was similar across all.Of interest, none of the tools included features about disease specific factors (Table 5, column 1), factors that may motivate the individual to work (e.g.work satisfaction; meaning of work, Table 5, column 6), the influence of work-related interventions (Table 5, column 8) or potential economic outcomes (Table 5, column 11).

| DISCUSSION
In this scoping review, 11,704 journal articles were screened with 35 articles selected to examine the current evidence relating to readiness for return to work or remain at work for people with cancer including colorectal cancer.Most of the published research identified was focussed on cancer in general.It is evident that there are only a limited number of studies specifically focussed on colorectal cancer that utilize tools to identify employment concerns.
The 35 studies included in this review generally demonstrated that there are numerous barriers to returning to work after a diagnosis of, or treatment for cancer.Those that do return with a higher degree of comorbidity were shown to have greater difficulty re-integrating into  2 and 3) were designed for use in patients with health conditions other than cancer.
For example, tools designed to assess pain in those with musculoskeletal problems (Brief Pain Inventory/Index), were used with breast cancer clients. 8Most studies that used a measure of pain also assessed other factors (e.g.quality of life) in recognition that employment readiness is a multifactorial outcome.This suggests that in the absence of a comprehensive tool for the cancer population, pain should not be considered in isolation of other factors.This review identified four tools that have been used to explore return-to-work among colorectal cancer survivors.All are self-report tools, as opposed to clinician-rated tools, of which two were designed to assess global quality of life.The first tool is the Short Form-12 which is a generic assessment of health-related quality of life from the patient's perspective while the City of Hope Quality of Life Colorectal Cancer Tool includes factors specific to colorectal cancer-for example, the presence of a temporary or permanent ostomy.The City of Hope tool consists of two parts.The first part includes 47 items that relate to the patient's sociodemographic characteristics including work-related items, health insurance, sexual activity, psychological support, clothing, diet and daily ostomy care.The second component includes 43 quality of life items that use 10-point Likert scales for recording responses.The quality-of-life component is further divided into four domains or subscales: physical well-being (items 1-11), psychological well-being (items 12-24), social well-being (items 25-36) and spiritual well-being (items 37-43).The psychometric properties of this tool have not been confirmed. 57The one study that used the City of Hope tool identified several demographic (younger age, higher household income, educational attainment), diseaserelated (lower disease stage and age at diagnosis and fewer comorbidity burdens) and workplace (workplace adjustments) factors associated with being employed compared with not being employed. 43This suggests the need to  8) general health perceptions.While quality of life is relevant when considering employment readiness, neither of the above tools individually captures all features important to assessing the colorectal cancer survivor's ability to return to work.The City of Hope tool thoroughly addresses one issue, that is the presence of colostomy bags, which is an issue that presents unique challenges and barriers to work performance.This has indeed been shown to be one of the primary concerns of colorectal cancer survivors due to the changes they cause in bodily and social function. 19owever, this tool lacks a more nuanced examination of overall work function or dysfunction and all questions are specific to the presence of an ostomy, which is not necessarily an outcome for all colorectal cancer survivors.
Conversely, the Short Form-12 provides only a generic assessment of health, which remains applicable to all colorectal cancer survivors; however, it lacks depth in treatment and disease specific effects and outcomes.
The final two tools used to examine work outcomes in colorectal cancer survivors were the Memorial Sloan Kettering Cancer Centre Bowel Function Index and the Work Limitations Questionnaire.The Memorial Sloan Kettering index contains 18 questions designed to assess bowel function after sphincter-preserving surgery for rectal cancer.It details information about a person's diet, urgency and frequency post-surgery, but there are no questions related to employment.On the contrary, the Work Limitations Questionnaire was designed to measure the degree to which health conditions interfere with specific components of job performance and the productivity impact of these work limitations.It is a generic tool used for chronic health conditions.Of the two tools above, one measures post-colorectal cancer surgery related issues, the other measures work-related issues which are both important components to be included in an employment readiness related tool.It is possible that a combination of the two tools could capture a comprehensive understanding of colorectal cancer survivors' work-related issues.Return-to-work is a complex process and each of the four tools discussed above capture various elements of the process.A truly comprehensive tool would require an approach examining each element for a nuanced understanding of an individual colorectal cancer survivor's readiness for work.For this review, the model used to chart the factors relevant for employment in cancer survivors was that by Mehnert. 35A unique feature of this model is that it not only considers factors relevant to work but a range of employment outcomes such as continuity of work; work ability; sick leave, length of absence from work; work changes; work productivity; and burden at work.Of the four tools specific to the assessment of employment in colorectal cancer survivors in this review, none mapped against all the features identified in Mehnert's model.
The WLQ was the tool that included two items addressing work-related factors and outcomes.Identifying work-related outcomes is an important consideration in the selection of any tool.These outcomes consist of a wide range of variables such as continuity of work, employment and return to work process, work ability, absence from work and career changes.This also incorporates dimensions of quality of life, such as social reintegration and psychological well-being as well as-though less frequently-economic variables such as costs of decline in work productivity.The WLQ systematically measures the degree to which health problems interfere with specific aspects of job performance and the productivity impact of these work limitations.However, it lacks inclusion of some of the cancer-specific factors, both disease and treatment related, that are relevant when considering the return-to-work process.These include some health and disease-related factors both pre-and post-diagnosis, such as stage of cancer, cancer site and physical fitness level pre-diagnosis.Also, absent were treatment-related factors including chemotherapy agent, and associated nausea, vomiting and cognitive dysfunction, radiotherapy medium, hormonal therapy, postoperative infection rate, frequency of follow-up appointments and cancer-related fatigue.These omissions may therefore limit the appropriateness of the WLQ for use among colorectal cancer survivors.
This scoping review applied an approach of assessing the outcome criteria examined by tools used in the setting of returning and remaining at work after a cancer diagnosis.Namely, it used the Mehnert framework as a means by which to interrogate the applicability of a number of tools to the return-to-work process for colorectal cancer.
To ensure that tools remain contemporary, an updated assessment tool would recognize a greater number of factors identified in the Mehnert framework.Factors such as sociodemographic factors; health and disease-related factors; treatment-related factors; psychological factors and work-related factors have emerged as important to consider when returning to work. 35s generic tools lack the necessary focus on the worklimiting effects of symptoms specific to colorectal cancer, the development of a new tool will require the input of colorectal cancer survivors.This input will ideally help elucidate which symptoms of their cancer and its treatment affect their ability to return-to-work.This review has found that only a minority of generic tools thoroughly investigated effects on working life.It will therefore be important to have the input of survivors to determine which aspects of their working life changed due to their cancer and its treatment.

| STUDY LIMITATIONS
The strength of this review lies in the identification of few colorectal cancer-specific studies.This enabled the planning of the search strategy to include all cancer types so that broader lessens could be learned that can inform future tool development for colorectal cancer survivors.This review only searched the abstract, title, subject headings and keywords in several databases, which may not have yielded a complete pool of relevant articles.Articles published in other languages (not in English) were also excluded.The omission of grey literature meant that websites and tools developed by cancer agencies were not included, as while they may yield potentially useful information, they have not been subject to scientific scrutiny.

| CLINICAL IMPLICATIONS/ CONCLUSION
Currently, the reporting of return-to-work issues and employability following colorectal cancer specifically is limited, with no tools available to comprehensively address one of the most common cancers in the world.With improving medical treatment and cancer survivorships, employment and return to work becomes increasingly important for all cancer survivors in their quality of life.A measurement tool for return-to-work in colorectal cancer survivors will help healthcare professionals and policymakers to obtain a more detailed and insightful understanding of people's well-being beyond the medical diagnosis of cancer.Such a tool would likely incorporate al. and Chow et al., Mehnert's model included a far more detailed outline of these mediating factors, with specific examples of such variables listed under each broad category.Both Feuerstein et al. and Chow et al. utilized unidirectional and bidirectional arrows to depict the complex interplay between the various factors and outcomes in their models.This is lacking in Mehnert's model, which instead merely suggests a one-way progression from independent and mediator variables to outcomes as a whole.Finally, the three models include different outcome variables.The conceptual framework by Chow et al.only considered the primary outcome of return to work, while both Feuerstein et al. and Mehnert included several categories of outcome criteria within their models.The Cancer & Work model by Feuerstein et al. focussed solely on various work outcomes, such as return to work, work ability, work performance and sustainability.In comparison, one of the distinguishing features of Mehnert's model is that it considers psychosocial and economic outcomes in addition to work outcomes, and as such is more holistic and comprehensive.Feuerstein et al. addressed long-term employment outcomes, not just return to work immediately following cancer diagnosis or treatment.

4. 2 |
Aim 2: chart the relevant factors of employment against Mehnert's model 4.2.1 | Main findings Keywords used in the literature search of electronic databases.
T A B L E 1 Characteristics of included papers on cancer and employment (N = 35).The Cognitive Symptom Checklist-Work in cancer patients (CSC-W Dutch Version).European Organization for the Research and Treatment Quality of Life Questionnaire (EORTC-QLQ).European Organization for the Research and Treatment of Breast Cancer Quality of Life Questionnaire (EORTC-QLQ-BR23).European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30).European Organization for the Research and Treatment of Head & Neck Cancer Quality of Life Questionnaire (EORTC-QLQ-H&N35).European Quality of Life Scale 5D Version (EuroQol 5D).European Quality of Life Scale 5D Version-5 Level (EuroQol EQ-5D-5L).Functional Assessment of Cancer Therapy (FACT Fatigue Scale).
T A B L E 2Note: a Control, Autonomy, Self-Realization and Pleasure (CASP19).

3.4 | Characteristics of tools assessing employment-related factors in colorectal cancer
Four of the 77 tools were used in the three studies that involved a focus on colorectal cancer: Short Form-12, City of Hope Quality of Life Colorectal Cancer tool, Memorial Sloan Kettering Cancer Centre Bowel Function Index and the Work Limitations Questionnaire (WLQ) Tools identified assessing employment-related factors in cancer survivors in included studies.
Characteristics of tools assessing employment-related factors in colorectal cancer.
T A B L E 4