Behavioral, Psychological, Educational and Vocational Interventions to Facilitate Employment Outcomes for Cancer Survivors: A Systematic Review
In the United States, an estimated 1.5 million people are diagnosed annually with some type of cancer (American Cancer Society, 2011). Work is an important stabilizing factor for cancer survivors (Arnold, 1999). De Boer and colleagues (2009) identified a rate of 33.8% unemployment among cancer survivors beyond the age of 18 compared to 15.2% among a healthy international control population. Greater awareness of the job-related and workplace issues that cancer survivors face can lead to more comprehensive rehabilitation plans and recovery (Centers for Disease Control, 2011; Nathan, Hayes-Lattin, Sisler, & Hudson, 2011). Although various recent interventions have been developed to address unemployment among cancer survivors, these have not yet been systematically evaluated.
The objective of this systematic review is to examine experimental and quasi-experimental studies about interventions that (i) include one or more behavioral, psychological, educational, or vocational components, (ii) involve cancer survivors aged 18 years or older, and (iii) assess intervention outcomes on employment outcomes. The aims are both to describe the variety of interventions that have been studied using rigorous methods and to estimate intervention effects.
We used electronic search techniques of 27 computerized databases to conduct a comprehensive search. Keywords used were relevant terms from four categories: population, treatment, domain, and design. We identified grey literature through electronic searches of popular search engines, unpublished dissertations/theses, and cancer-related organizations and conferences. In addition, we searched reference lists from included individual studies for potential studies to consider. The dates of the last search for electronic databases and grey literature were November 2013 and October 2012, respectively.
We employed a two-stage process to determine inclusion or exclusion of studies: (1) title and abstract stage and (2) full text stage. Participants needed to be cancer survivors 18 years of age or older. Interventions were included if they measured gainful employment, return to work, wages, or hours worked as an outcome. Interventions were behavioral, psychological, educational, or vocational in nature, including workshops, training, or counseling targeted towards employment initiation, return-to-work, or decreasing absenteeism and use of work disability or sick leave. Interventions included an element apart from medical or physical treatment (e.g., exercise, surgery, pharmaceutical treatment). Studies with a research design of randomized controlled trial or quasi-experimental study were included.
DATA COLLECTION AND ANALYSIS
The combined electronic search, hand searches, and examination of the grey literature produced a total of 20,249 citations. Of these studies, a total of 70 citations were advanced for collection of a full text copy of the study when either one of the two independent reviewers agreed it appeared to meet the inclusion criteria. Twelve studies met the inclusion criteria.
The results of the studies were synthesized in a random-effects meta-analysis using odds ratio effect sizes.
We found 12 studies evaluating the effects of psychosocially-related interventions on the employment of cancer survivors (N = 2151). Our results provide promising evidence that the included interventions may improve employment status (OR = 1.71, 95% confidence interval (CI) = 1.26 to 2.32) for cancer survivors. For RCTs (k = 6), the weighted mean effect size for employment status was OR = 1.44 (CI = 0.99 to 2.09), favoring the intervention groups. The mean odds ratio of 1.44 translates to an employment rate of about 68% for intervention participants compared to a baseline 60% for comparison group participants. For QEDs (k = 6), the weighted mean effect size for employment status was OR = 2.18 (CI = 1.32 to 3.60), also favoring the intervention groups. The mean odds ratio of 2.18 for the quasi-experimental studies translates to an employment rate of about 77% for intervention participants, compared to the baseline rate of 60% for the comparison group participants. Although the mean effect size from QEDs was larger than that from the RCTs, there is no significant difference between the two types of experimental designs (p = 0.19).
There was no evidence of an effect on the number of hours worked (OR = 0.89, CI = 0.22 to 1.52) or number of sick leave days (OR = 1.18, CI = 0.81 to 1.71). Overall, the assessment of the risk of bias was high, and conclusions about the effectiveness of the included interventions should be interpreted with caution.
This review highlights the positive effect psychosocial interventions may have on employment outcomes for cancer survivors. However, the methodological shortcomings of the included studies overall makes it likely that there is bias in the results and too few studies to provide sufficiently strong evidence to recommend particular practices. This review brings attention to the need for additional rigorous studies in this area, in particular, randomized controlled trials with more detailed reporting of data and study design and methodology.