Cancer survivors' experiences with conversations about work‐related issues in the hospital setting

Abstract Objective Early access to work‐related psychosocial cancer care can contribute to return to work of cancer survivors. We aimed to explore: (a) the extent to which hospital healthcare professionals conduct conversations about work‐related issues with cancer survivors, (b) whether cancer survivors experience these conversations as helpful, and (c) the possible financial implications for cancer survivors of (not) discussing their work early on. Methods The Dutch Federation of Cancer Patient Organizations developed and conducted a cross‐sectional online survey, consisting of 27 items, among cancer survivors in the Netherlands. Results In total, 3500 survivors participated in this study (71% female; mean age (SD) 56 (11) years). Thirty‐two percent reported to have had a conversation about work‐related issues with a healthcare professional in the hospital. Fifty‐four percent indicated that this conversation had been helpful to them. Conversations about work‐related issues took place more frequently with male cancer survivors, those aged 55 years or below, those diagnosed with gynecological, prostate, breast, and hematological or lymphatic cancer, those diagnosed ≤2 years ago, or those who received their last treatment ≤2 years ago. There was no statistically significant association between the occurrence of conversations about work‐related issues and experiencing the financial consequences of cancer and/or its treatment as burdensome. Conclusions Although conversations about work‐related issues are generally experienced as helpful by cancer survivors, early access to work‐related psychosocial cancer care in the hospital setting is not yet systematically offered.

substantial proportion of the Dutch population. Work is often part of that reality and an emotional and/or financial necessity for many. 3,4 While about two-thirds of working-age cancer survivors (CSs) 5 are able to return to work (RTW) within 2 years post diagnosis, 4,6 many experience long-term physical, cognitive, and/or psychosocial limitations that hinder sustainable work participation. 7,8 We view cancer survivorship as "a process that begins at the moment of diagnosis and continues through the balance of life." 5(p. 235) While the personal and societal advantages of being able to work after cancer are well-known, access to work-related psychosocial cancer care in the hospital setting is a relatively new topic in the international literature. In a Swedish sample, Söderman et al showed that initiating a conversation about work (ie, providing advice, support, and encouragement regarding RTW) early in the cancer trajectory can increase CSs' ability to RTW. 9 Qualitative studies, such as those by Kennedy et al (UK), 10 Stergiou-Kita et al (Canada), 11 and Maunsell et al (Canada) 12 found that CSs have unmet needs regarding RTW guidance.
Lastly, in a systematic review of studies conducted in European CSs, Paltrinieri et al found that work-related support provided by healthcare professionals was positively associated with CSs' work participation. 13 Conversely, either not addressing work at an early stage or encouraging patients to stay sick-listed can contribute to longer sickness absence duration and increased financial difficulties in CSs. 13 Currently, it is unknown to what extent CSs are met in their needs for work-related guidance from physicians and other professionals in the hospital setting. Prior qualitative research has shown that few CSs reported having received useful advice from their cancer care team regarding RTW. 14 Moreover, Bains et al reported that the limited offering of work-related guidance by healthcare professionals was due to professionals' lack of knowledge of, and available resources on, work-related consequences of cancer treatments. 15 In the Netherlands, as in several other countries, general and occupational healthcare are organized in separate systems. 16,17 Whereas general healthcare professionals perform curative healthcare tasks, occupational healthcare professionals mainly provide sick leave assessments and reintegration guidance. 18 The availability and accessibility of hospital-based work-related psychosocial cancer care varies per hospital and is often not covered by standard healthcare insurance. These shortcomings presumably contribute to a relatively low number of work-related conversations between CSs and healthcare professionals in the Netherlands.
In this study, we aimed to explore: (a) the extent to which hospital healthcare professionals conduct conversations about work-related issues with CSs, (b) whether CSs experience these conversations as helpful, and (c) the possible financial implications for CSs of (not) discussing their work early on.

| Study sample and procedures
This study was conducted by the Dutch Federation of Cancer Patient Organizations (NFK), an entity that unites 19 cancer patient organizations in the Netherlands. Data were collected through a national, cross-sectional survey using "Survey Monkey." 19 (Table S1). The survey started with a question to identify respondents who have (had) cancer. Respondents who did not select "I have (had) cancer" were excluded from further analyses. Thereafter, respondents were asked to report their gender, year of birth, and highest completed level of education. The remaining 23 questions were organized into six themes (Table S1). Data were collected and analyzed anonymously and stored securely. 22

| Statistical analyses
As this study was designed to be explorative, no minimum sample size was estimated a priori. Of 4556 participants who started the questionnaire, 3504 completed it. Four participants were excluded due to indecipherable answers or duplicate survey entries. Thus, 3500 participants were included for the current analyses. 23 Descriptive statistics were obtained, i.e., percentages for nominal variables and mean and SD, as well as median and interquartile range (IQR) for continuous variables. Chi-squared tests were used to answer the research questions.
Answer categories "I don't know" and/or "Not applicable" were excluded from Chi-squared analyses. Respondents who were retired at diagnosis, and were not otherwise employed, were also excluded from Chi-squared analyses. For all analyses, P-values ≤.05 were considered statistically significant. All analyses were performed using IBM SPSS Statistics version 25. 24

| RESULTS
Mean age of respondents was 56 years (SD = 11) and 71% was female (Table 1). Most respondents were diagnosed with breast cancer (38%) or hematological or lymphatic cancer (19%). The majority of respondents was treated in a teaching hospital (39%). Median time since diagnosis was 4 years (IQR = 6), and median time since last treatment was 2 years (IQR = 5). Nearly half of respondents had a fixed employment contract at time of survey completion (46%), and 8% was on (partial) sick leave from their work.

| Conversations about work-related issues
Nearly one-third of respondents (n = 992, 32%) indicated that a healthcare professional within the hospital had discussed the workrelated consequences of cancer and/or its treatment with them.
Male CSs (35%) had a conversation about work-related issues more often than female CSs (31%) (P ≤ .05). CSs aged 55 years or below (35%) had such a conversation more often than CSs aged above 55 (30%) (P ≤ .01). The occurrence of these conversations did not differ significantly by educational level (P = .25). While CSs diagnosed with gynecological (40%), prostate (36%), breast (34%), and hematological or lymphatic cancer (33%) reported to have had conversations about work-related issues most often, these conversations took place least often in CSs diagnosed with lung cancer (23%). CSs who received their most recent diagnosis ≤2 years ago (37%) had a conversation about work-related issues more frequently than CSs whose most recent diagnosis was >2 years ago (30%) (P ≤ .001). Similarly, CSs who received their last treatment ≤2 years ago (35%) reported these conversations to have taken place more often than CSs who received their last treatment >2 years ago (29%) (P ≤ .001). Occurrence of conversations about work-related issues did not differ by hospital type (P = .95) ( 3.3 | Financial consequences of (not) discussing work early on in the hospital setting Of all CSs, 60% (n = 2082) reported that cancer and/or its treatment has had financial consequences, 90% (n = 1810) of which indicated lowered income, and 68% (n = 1367) of which indicated increased T A B L E 3 Factors associated with needs for a conversation about workrelated issues in the hospital Do you feel the need to discuss work-related consequences of cancer and/or its treatment with a healthcare professional in the hospital?

T A B L E 4 Associations between the occurrence of conversations about workrelated issues and financial consequences
Did a healthcare professional in the hospital discuss work-related consequences of cancer and/or its treatment with you? n (%) Have the financial consequences of cancer and/or its treatment been a problem for you? healthcare costs (multiple answers were possible). Further, 27% stated that the reported financial consequences have never been a problem to them, whereas for 50%, 15%, and 8%, this was sometimes, often, or always a problem, respectively (Table 1). No statistically significant association between the occurrence of work-related conversations and experiencing financial consequences as burdensome was found (P = .15) ( Table 4). We did not further explore these associations for specific subgroups (eg, age groups or diagnosis categories).

| DISCUSSION
Healthcare professionals in the Dutch hospital setting did not systematically discuss work-related consequences of cancer and/or its treat-  25 which might have contributed to these differences.
Furthermore, Dutch and Swedish social security systems are differently organized, for example, in Sweden, reintegration guidance is part of hospital-based care paid by healthcare insurance rather than part of occupational healthcare paid by companies in the Netherlands. 26 Our results showed that male CSs had a conversation about work-related issues more frequently than female CSs. Within the Dutch family composition, the family's income is often largely dependent on the male's salary. Men commonly work full-time and women often part-time (ie, 27% of women vs 72% of men worked full-time in 2019). 27 Part-time work, flexible working hours, and the decision to stop working after cancer diagnosis therefore might be culturally viewed as more acceptable in women than in men. However, female CSs expressed a need to discuss the work-related consequences of cancer and/or its treatment more often than male CSs. Although a large percentage of women in the Netherlands work part-time, a national increase in working women has been observed over the years, which might contribute to higher needs for work-related support in female compared to male CSs. 28 Additionally, female CSs might report the need for such a conversation more often than male CSs simply because they receive such conversations less often.
Our findings showed that conversations about work-related issues take place more often with CSs aged ≤55 years, than with CSs aged >55. One possible explanation for this is that healthcare professionals might view paid employment as more relevant for younger CSs than for older CSs. Older age has been identified as a predictive factor in early retirement for CSs 29 but does not preclude older CSs from wanting to work or having a need for work-related guidance. To illustrate, in our sample, 20% of CSs >55 years indicated a need for a conversation about work-related issues. Considering that retirement ages are rising and that employment can contribute to CSs' healthrelated quality of life, 30 it is pertinent that healthcare professionals pay attention to the work-related needs of CSs of all ages.
Additionally, we found that CSs whose last cancer diagnosis was ≤2 years ago reported conversations about work-related issues more frequently than CSs whose last cancer diagnosis was >2 years ago.
However, 24% of CSs whose most recent cancer diagnosis was Finally, the questionnaire that the NFK used was not validated, which may complicate international comparison and weaken the quality of the presented evidence.

| Clinical implications
Hospital-based work-related guidance can contribute to CSs' ability to RTW. 9,25 Moreover, labor participation can contribute to CSs' quality of life as well as their mental and physical well-being. 30 Thus, hospitalbased healthcare professionals have a unique opportunity to contribute to CSs' rehabilitation and societal participation, by making (return to) work a regular topic of discussion early on. Yet, our results showed that work-related consequences of cancer and/or its treatment are not systematically discussed in the Dutch hospital setting.
We recommend that healthcare professionals, in their conversations about work-related issues, take into account factors such as age, gender, cancer diagnosis, and time since most recent diagnosis and treatment, alongside other predictive factors of sustainable work participation in CSs. Multidisciplinary treatment teams should reach a consensus on who to put forward as first point of contact regarding workrelated issues. Hospital-based healthcare professionals, for example, occupational therapists, 31 can meaningfully prepare CSs for RTW by enhancing CSs' self-efficacy regarding cognitive and physical sideeffects of cancer treatment. Reintegration planning and supporting communication with the workplace (eg, occupational physician) should be outsourced by healthcare professionals to community-based professionals, for example, reintegration consultants, in a collaborative effort to bridge the gap between medical (after)care and societal reintegration.

ACKNOWLEDGMENTS
NFK would like to express her gratitude to all cancer survivors who participated in this study by completing their survey, as well as all professional and patient experts involved in the development of the survey. This study was funded by NFK.