Qualitative study on occupational anxiety among young thyroid cancer survivors before returning to work
Hong Gao and Ping Zhu should be considered joint first authors.
Abstract
The purpose of this qualitative study was to understand the manifestations of occupational anxiety in young thyroid cancer survivors prior to their return to work and to explore coping strategies and essential support upon their return to work. Using purposive sampling, 13 young thyroid cancer survivors were selected for in-depth interviews from July to October 2023. Colaizzi's seven-step analysis method and NVivo software were used to analyze and organize the interview data. Three themes and 12 subthemes were summarized from the interview data: occupational anxiety caused by disease (fear of cancer recurrence, medication behavior anxiety, stigma of illness); manifestations of occupational anxiety (physical disruption, concerns about work intensity, dissatisfaction with the working environment, career disruption, career and job security disruption); and coping strategies (self-regulation, self-improvement, family support, peer support). Medical professionals should recognize the impact of occupational anxiety on young thyroid cancer survivors before returning to work. They should accurately identify and understand the causes, manifestations, and coping methods to alleviate survivors' occupational anxiety prior to their return to work. By establishing vocational guidance, they can improve survivors' cognition regarding the benefits of returning to work and reduce their occupational anxiety.
1 INTRODUCTION
Thyroid cancer is the most common malignancy among tumors of the endocrine system and head and neck region. Its incidence is significantly increasing worldwide.1, 2 Thyroid cancer is being detected increasingly earlier as the level of ultrasound screening and health awareness improves.3, 4 Most thyroid cancers have a favorable prognosis, with a 10-year postoperative survival rate of more than 84%.5 In 2022, approximately 1.3 million newly diagnosed cancer patients aged 15–39 were reported globally, and the number of new cancer cases among young people remains high.6 The incidence of anxiety among young survivors of thyroid cancer in China is 36.25%.7 Sources of anxiety include many factors such as disease treatment, career development, family responsibilities, reproductive fertility, work pressure, and economic pressure.8 It has been found that cancer survivors usually show a high willingness to return to work, however, due to factors such as disease treatment, psychological stress, and work pressure, they face a risk of unemployment that is three times higher than that of the normal population.9, 10
Anxiety is a complex emotional response comprising intertwined feelings of nervousness, worry, and fear, and typically occurs when a person faces a difficult situation.11 Occupational anxiety simply refers to an employee's anxiety due to their occupation and concerns about job performance and completion.12 Roberts's study found a relatively higher level of occupational anxiety among younger and less experienced employees.13 A survey in China indicated that enterprises often overlook career anxiety of young employees. Although psychological counseling positions are established within enterprises, professional counselors are not employed to provide relevant guidance, and such support is far from adequate for survivors.14 Cancer patients also face severe employment discrimination, with a survey of 20 366 cancer survivors revealed an unemployment rate 2.2 times higher than that of the healthy population.15 However, the occupational anxiety of this population is compounded by the Chinese culture of cancerphobia. Under the influence of traditional and modern concepts, Chinese people's fear of cancer and career anxiety interact with each other, seriously affecting the quality of life among survivors. Qualitative research offers the advantage of describing and analyzing social phenomena in greater depth and detail from a microscopic perspective, and can facilitate an in-depth understanding of the occupational anxiety of young Chinese thyroid cancer survivors before they return to work.
This study aims to elucidate and clarify the manifestations of occupational anxiety among young postoperative thyroid cancer survivors before returning to work and to explore coping strategies after returning to work, thereby improving their quality of life and providing targeted assistance for better social reintegration.
2 METHODOLOGY
2.1 Design
This study used purposive sampling to select young thyroid cancer survivors from a tertiary specialized oncology hospital in Jiangsu Province from July to October 2023. A phenomenological research methodology was adopted, which enables researchers to better understand human experiences and perceptions, thereby assisting in addressing relevant issues. The phenomenological method aims to describe the common experiences of a group. In order to include diverse participants and reduce bias, we selected survivors from various age groups and occupational backgrounds to conduct face-to-face interviews.
2.2 Participants
Young thyroid cancer survivors were selected from July to October 2023 from a tertiary specialized oncology hospital in Jiangsu Province, China. Participant inclusion criteria were: survivors diagnosed with thyroid cancer and treated surgically; aged 18–39 years; at least 1 month post-surgery; formally employed prior to diagnosis and about to return to work; voluntarily participating in the study and signing an informed consent form. Respondents did not receive compensation for their participation. The exclusion criteria were mental illness and language disorders. The sample size was determined by information saturation, meaning that interviews were suspended when no new information emerged from interviews.16 Thirteen survivors were interviewed.
2.3 Data collection
Between July and October 2023, H.G. and P.Z. conducted face-to-face semi-structured interviews with 13 survivors. Each interview lasted 20–40 min. Interviews were conducted primarily in quiet and comfortable conference rooms at a tertiary specialized oncology hospital in Jiangsu Province, China. The researchers and survivors agreed on the interview time and location 1 day in advance. Survivors were informed of the confidentiality of the interview, and the purpose and content of the study were explained to them beforehand. The names of the interview subjects were replaced with numbers (P1–P13). The informed consent form was in Chinese, and the interviews were conducted in Chinese. Interviews commenced only after obtaining the participants' consent and signed informed consent forms. The entire process was audio-recorded, and non-verbal behaviors of the interviewees, such as expressions, gestures, and emotions, were also documented. The interviews followed a semi-structured outline; the order and manner of questioning could be flexibly adjusted. Interview techniques, such as follow-up questioning, repetition, and clarification, were employed to ensure participants spoke freely without feeling fatigued. After the interviews, M.M.Z. and B.W. translated the recordings into text within 24 h and labeled the transcripts with key points recorded during the interviews. The following day, survivors were re-interviewed for verification, immediately clarifying any discrepancies to ensure the accuracy and authenticity of the data.
This study used semi-structured interviews with open-ended questions to understand young thyroid cancer survivors' occupational anxiety before returning to work. First, a pre-interview outline was initially developed around the basic definition of occupational anxiety and based on the group's previous work. Second, after conducting pre-interviews with three survivors, we held discussions with experts in the field, gathered feedback, and revised the preliminary outline to address content duplication and omissions. Finally, after several rounds of discussion, modification, and improvement, the formal interview outline of this study was formed, which mainly included: (1) What do you think is the impact of thyroid cancer as a disease on your future work? (2) What are your feelings and thoughts before returning to work? (3) What are the causes of occupational anxiety? What are the reasons for your career anxiety and how can you relieve it? (4) What are the similarities and differences between your upcoming re-employment and your first employment?
2.4 Data analysis
Interview data were analyzed using Colaizzi's seven-step method.17 The steps were as follows: (1) thoroughly reading the transcribed data, (2) identifying and extracting meaningful statements, (3) encoding recurring viewpoints, (4) constructing meaningful units, (5) scrutinizing, reflecting upon, and clustering these units to form preliminary themes, (6) repeatedly comparing themes and descriptions, summarizing similar viewpoints, and formulating theme concepts, and (7) returning to participants for verification and incorporating any new insights gained. M.M.Z. and B.W. transcribed and scrutinized the interview transcripts within 24 h after the interviews. The final cumulative interview time was 325 min, resulting in 40 085 words of content. Transcript files were imported into NVivo 11.0 software for analysis by Y.N. and X.X.L. Data verification and management were performed by H.H. and J.L.S. Theme extraction was conducted by M.Y.Z., T.T.H., and L.L.Z. Three themes and 12 sub-themes were finally formed. Throughout this process, all data were anonymized as P1–P13 to avoid influencing the researchers' judgment.
2.5 Ethical considerations
This study was approved by the Ethics Committee of Nanjing Medical University before commencement (2019007). Prior to the interview, participants were provided with a paper copy of the informed consent form, which outlined the purpose of the study, the inclusion criteria for survivors, the rights and obligations of the researcher and participants, and the principles of data use and confidentiality. To ensure data reliability and research rigor, survivors were interviewed voluntarily after providing informed consent, and all interviews were audio-recorded. Before conducting the interviews, researchers obtained general background information on participants and established a trusting relationship through ongoing communication, thereby reducing potential concerns among survivors. Researchers clearly explained the purpose, methods, and content of the study to the participants, and assured them that all information and recordings would be kept strictly confidential and used solely for this study. Participants had the right to withdraw from the study at any time without adverse consequences. All participants gave voluntary written informed consent to participate and to publish.
2.6 Quality control
To ensure the quality of this study, one expert in qualitative research was invited to provide guidance on the setting of interview outlines, interview techniques, and data analysis before the study began. All authors participated in an online qualitative research course of Beijing Normal University. During the interviews, the researcher remained neutral and only asked questions as appropriate, avoiding the expression of personal views or opinions. Data were analyzed and discussed by the first and second authors respectively, through coding, categorizing, summarizing, and refining to ensure that the extracted themes comprehensively and accurately reflected the research questions. Areas of disagreement were discussed, and assistance from qualitative research experts was sought to finalize the qualitative findings related to occupational anxiety among young thyroid cancer survivors before their return to work.
3 RESULTS
A total of 13 thyroid cancer survivors participated in this study. Their occupations varied. Their mean age was 32.31 years (SD = 4.16), ranging from 26 to 39 years. The mean postoperative time was 1.27 months (SD = 0.42), ranging from 1 to 2 months. Table 1 presents their demographic details.
| Serial number | Age (years) | Gender | Educational level | Occupation | Marriage status | Postoperative time (months) | TNM staging |
|---|---|---|---|---|---|---|---|
| P1 | 27 | Female | Undergraduate | Nurse | Married | 1 | T2N1aM0 |
| P2 | 38 | Female | Undergraduate | Electric power employee | Married | 1 | T1aN0M0 |
| P3 | 26 | Male | Vocational school | Police | Single | 1 | T1N1aM0 |
| P4 | 39 | Male | Technical secondary school | Chemical worker | Married | 2 | T1N1aM0 |
| P5 | 31 | Male | Technical secondary school | Material staff | Married | 1 | T1N1bM0 |
| P6 | 30 | Female | Undergraduate | Designer | Single | 1 | T1aN0M0 |
| P7 | 38 | Female | Vocational school | Accountant | Married | 2 | T1bN1aM0 |
| P8 | 34 | Female | Junior school | Medical device sales | Married | 2 | T1aN0M0 |
| P9 | 29 | Male | Undergraduate | Construction manager | Married | 1 | T1N1M0 |
| P10 | 28 | Male | Doctor | Bank clerk | Single | 1 | T1N1M0 |
| P11 | 32 | Male | Vocational school | Toll station staff | Married | 1 | T1N1bM0 |
| P12 | 33 | Female | Undergraduate | Receptionist | Married | 1.5 | T1aN0M0 |
| P13 | 35 | Female | Vocational school | Programmer | Married | 1 | T1aN1aM0 |
- Note: TNM staging: “T” is the initial letter of the word “tumor”. “N” is the initials of the word “Node” for lymph node. “M” is the initials of the word “metastasis”. Grouping of the three TNM indicators to delineate a specific stage.
This study identified three themes: (1) Occupational anxiety caused by disease, (2) Manifestations of occupational anxiety; and (3) Coping styles. Each theme included several sub-themes that illustrated the actual experiences of survivors (Table 2).
| Themes | Subthemes | Quotes |
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| Occupational anxiety caused by disease |
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| Manifestations of occupational anxiety |
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| Coping strategies |
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3.1 Occupational anxiety caused by disease
3.1.1 Fear of cancer recurrence
I searched the internet for thyroid cancer and found people sharing that it came back a year after having surgery. I'm very worried. I've lost 10 pounds since my diagnosis. (P10, 28 years old)
This should not grow again after the operation, right? (P12, 33 years old)
I rarely think about cancer recurrence. Given today's medical technology, I'm confident my condition can be cured. This experience has helped me appreciate my current job more. (P6, 30 years old)
3.1.2 Medication behavior anxiety
It's anxiety-inducing to take a pill every day, and that pill has to be taken on an empty stomach. (P3, 26 years old)
What does this do to my body if I forget to take my medication? (P4, 39 years old)
Besides levothyroxine sodium, I also need calcium tablets daily, but there's a long interval between these medications. So many precautions! Now I have to remember my medication schedule even at work! (P13, 35 years old)
3.1.3 Stigma of illness
I'm a medical equipment salesperson. Now my voice has become very low after the operation, and others can't hear me clearly when I'm talking. I'm a mouth breather. Although my doctor talked to me before surgery about this risk, I didn't think it would actually happen … can I recover? How long will it take for me to recover? (urgent tone) (P8, 34 years old)
At present, there is such a long incision on my neck. I work at the company's front desk, and I also have a predisposition to scarring. How can I go to work in the future? Do you have a good scar cream? (P12, 33 years old)
3.2 Manifestations of occupational anxiety
3.2.1 Physical disruption
Our community hospital has seven or eight night shifts a month, each lasting 24 hours. This type of shift is extremely exhausting, and afterward, I feel unable to move. (P1, 27 years old)
I'm a toll booth clerk, and my work requires frequent overnight shifts. It's very difficult to go to work from eleven o'clock in the evening to seven o'clock the next day, and I'm afraid it's not good for my health. (P11, 32 years old)
Our working hours are twelve hours, 8:00 a.m. to 8:00 p.m. or 8:00 p.m. to 8:00 a.m., and each shift is continuously on for half a month, and although we have weekends off, our boss offers double pay, so I still consider working overtime. (P5, 31 years old)
3.2.2 Concerns about work intensity
Our work pressure is cyclical; whenever a project comes in, it must be completed within a strict time limit. I feel like I don't have enough energy to keep up. (P6, 30 years old)
The current job was so tiring and stressful. (P5, 31 years old)
I mainly do computer system maintenance work in private enterprises. There are few people in the company, and I basically have to work overtime every day. The normal working hours are from 8: 00 am to 5: 00 pm, but we usually work overtime until 8: 00 pm, without overtime pay. The work pressure is great, but overtime can improve performance evaluations. (P13, 35 years old)
I often have to work overtime as well as travel to other cities, and I am away from my family a lot. (P9, 29 years old)
3.2.3 Dissatisfaction with the working environment
There is a lot of noise from the machines inside the factory, and the overall environment feels depressing and exhausting. (P5, 31 years old)
I was the only one at the toll booth at work, and the job description felt boring. (P11, 32 years old)
3.2.4 Career disruption
I'm currently an intermediate, and I'm planning to move up to a senior position later, but it's too hard to publish core articles now, so I'd better wait. (P2, 38 years old)
We are promoted based on regular performance. If I don't work overtime later on, my title won't advance. However, my health is more important, so nothing else matters. (P13, 35 years old)
3.2.5 Career and job security disruption
Before I got sick, I had a plan to change my job and get a job with higher income than I do now, but now I'm sick and I don't want anything (shaking my head). (P2, 38 years old)
I have a two-year contract with my bank, this is my first year on the job, and I am worried that my leadership will not understand the disease, will think it's a serious problem, and will not renew my contract in the future. (P10, 28 years old)
I dislike working night shifts; in the future, I might consider switching to a job without night shifts. (P5, 31 years old)
If my health prevents me from continuing in my current role, I hope my supervisor will approve a transfer to a different position. (P4, 39 years old)
3.3 Coping strategies
3.3.1 Self-regulation
I like to travel. Every time I come back from a trip, I feel energized to go to work again. (P1, 27 years old)
I like reading when I am at rest. Reading inspires me and relieves my anxiety at work to some extent. (P2, 38 years old)
I like playing games, and I like the feeling of winning games, and I feel that I am the king. (P3, 26 years old)
I love raising my children; being with them helps ease my worries. (P7, 38 years old)
I love shopping with my friends. When I buy my favorite things, the whole mood is pleasant. (P12, 33 years old)
3.3.2 Self-improvement
Our industry is very competitive. Therefore, we regularly attend various training sessions to improve our professional skills. (P6, 30 years old)
I am currently actively preparing for a professional skills certificate to make myself irreplaceable. (P9, 29 years old)
3.3.3 Family support
After my illness, my husband has been with me, encouraging me not to worry about my family and work. (P12, 33 years old)
My mom has been taking time off from work to take care of me since I got sick, my dad buys my favorite food every day, and our family is very close. (P6, 30 years old)
3.3.4 Peer support
I and the next bed sister added each other on WeChat. She was particularly positive and optimistic, often guiding me, and said that if you don't want to do it later, you can jump ship to work in her company. (P6, 30 years old)
I joined the WeChat patient group established by your department and found that they basically returned to work and adapted well. (P7, 38 years old)
4 DISCUSSION
The main aim of this study was to elucidate and clarify the manifestations of occupational anxiety among young postoperative thyroid cancer survivors before returning to work and to explore strategies and support needed to cope upon their return to work. The results of this study show that young thyroid cancer survivors have the fear of cancer recurrence before returning to work. One reason might be that survivors searched for thyroid cancer information online and encountered many recurrence cases. Survivors struggled between continuing to rest and returning to work, which increased their career anxiety. Fear of cancer recurrence is a specific stress response in cancer patients.18 Studies by Franche et al. and Kurumety et al. proved that fear of cancer recurrence is one of the top issues for cancer survivors, with more than 73% of survivors having fear of cancer recurrence.19, 20 Long-term survivors may experience high levels of fear of cancer recurrence for decades, severely affecting their quality of life.21 Therefore, medical professionals should pay attention to the fear of cancer recurrence in young survivors. First, patients should receive clear and detailed explanations about the disease, including rigorous and scientifically accurate information about thyroid cancer through videos, public websites, and informational brochures. Second, survivors should be encouraged to openly express their true feelings so that fears of recurrence can be identified early. Individualized health guidance and interventions should then be provided to reduce these fears.
During the interviews, some survivors expressed anxiety about medication adherence. Possible reasons include young survivors' anxiety and resistance to taking medication on an empty stomach regularly after returning to work. Additionally, survivors are uncertain about the consequences of missing doses. G.F. Song et al. pointed out that the best time to take levothyroxine sodium is on an empty stomach in the morning, and it is not advisable to eat or drink within 30 min of taking the drug to ensure its good absorption rate.22 Its dosage and individual efficacy vary greatly, and the dosage needs to be adjusted according to blood test results. Therefore, healthcare professionals need to educate patients about proper medication adherence, advise them to regularly visit the hospital for blood tests, dynamically monitor their hormone levels, and adjust medication dosages accordingly. They should motivate survivors to adhere to fasting medication schedules, thus reducing anxiety about medication adherence.
Several interviewed survivors reported stigma related to postoperative neck scars and vocal impairments. Two previous studies indicated that thyroid cancer survivors experienced sadness related to altered appearance after surgery. Even without significant neurological damage, speech difficulties often persist, particularly within 6 months post-surgery, disproportionately impacting female survivors.23, 24 As healthcare professionals, we need to do a better job of preoperative communication and targeted interventions so that we can reduce patient survivors' stigma and prepare them for better integration into the work environment.
Attention should be given to occupational anxiety among young cancer survivors, supporting their return to work. Another important finding is that cancer treatment creates a certain amount of traumatization and prognostic uncertainty for young cancer survivors. Survivors are unable to return to work as they did before the illness. They expressed concerns about their health, work intensity, and environment, and feared that they might not perform adequately in their former jobs. They fear disruption of their careers and job security, which is generally consistent with the findings of Van et al.25 Young cancer survivors are the backbone of their families and the main labor force for social development. Most of them were working when diagnosed, and the prognosis for thyroid cancer is typically favorable. Consequently, many survivors choose to return to work after rehabilitation.23 Individuals' perceived uncertainty plays a key role in shaping their perceptions of returning to work, and lack of clarity about illness recovery and work-related information hinders survivors' transition back to work.26 A survey showed that 34.3% of survivors had to reduce their working hours, although they returned to work and continued to work.27 Consequently, studies recommend that medical personnel should conduct a rational assessment of the survivor's ability to return to work and help the survivor to rationalize her work planning.28 We call on leaders of relevant organizations to demonstrate greater understanding and care for young cancer survivors returning to work. Adjustments to working hours, workloads, and environments should be made according to survivors' physical recovery, helping them gradually adapt to their original or new jobs. Allowing survivors flexible working conditions and creating a warm, comfortable employment environment can ensure they utilize their strengths and contribute positively to society.
Social support systems should be strengthened to help survivors effectively manage occupational anxiety and comfortably return to work. The results of this study showed that young cancer survivors self-regulated by shifting their attention to their hobbies and by enjoying time with family and friends, greatly reducing occupational anxiety. This finding is consistent with the findings of Richardson et al.29 Interviews revealed that some young thyroid cancer survivors practiced self-regulation and self-improvement, and received substantial family and peer support. Studies have shown that active family support can help survivors return to work as soon as possible.30 In previous studies, peer support mainly played an important role in the rehabilitation stage.31
This study found that few survivors talked about their workplace, medical staff, and social support, suggesting that these external supports were inadequate. Previous research noted that employing organizations often fail to provide support such as reduced workloads or flexible working hours based on the cancer survivor's physical condition.32 Cancer patients often do not clearly understand the optimal timing for returning to work, and returning too early or too late can lead to negative outcomes for survivors, organizations, and society.33 Another study showed that social support systems are effective in reducing anxiety among cancer survivors.34 To summarize, to promote the smooth return to work of young cancer survivors, self-regulation, family support, and peer support are essential. Equally critical are support and involvement from medical professionals, workplaces, and society, collectively forming a multidimensional and comprehensive support system that allows young cancer survivors to comfortably reintegrate into work and society.
4.1 Strengths of the study
This study differs from previous research by including young survivors from various ages and professions. Furthermore, the study examines occupational anxiety rather than medical aspects of the illness itself. Finally, qualitative methods provided detailed and in-depth insight into the causes, manifestations, and coping strategies related to occupational anxiety among survivors prior to returning to work.
4.2 Limitations of the study
This study was conducted in a tertiary care oncology hospital, and results may differ in other settings. Future research could recruit survivors from general hospitals to enrich findings. The object of investigation included in this study were patients who were about to return to work after surgery, and the results may not be applicable to the experiences of other young thyroid cancer survivors who have already returned to work. It is suggested that future studies investigate occupational anxiety among young thyroid cancer survivors who have resumed working.
5 CONCLUSION
Young thyroid cancer survivors require a period of rest and adjustment before returning to work after surgery. The psychological journey during this time is complex. This is especially true for young survivors, who bear the additional burden of family, work and social responsibilities. They face more occupational anxiety than survivors of other age groups. Our research results not only reflect their psychological experiences before returning to work, but also show the causes of occupational anxiety and methods to alleviate it, which can be further verified by quantitative research in the future. Medical professionals, family members, and peers should actively provide strong support to young thyroid cancer survivors, serving as internal and external drivers to assist with their psychological adjustment. Moreover, government policies should enhance employment protection for cancer survivors, while businesses should establish supportive work environments, thereby reducing occupational anxiety and promoting successful reintegration into the workforce.
AUTHOR CONTRIBUTIONS
Hong Gao: conceptualization, methodology, interview, formal analysis, writing—original draft, writing—review and editing, funding acquisition. Ping Zhu: conceptualization, interview, data curation. Maomao Zhang: methodology, writing-review and editing. Bing Wu: methodology, writing-review and editing. Yun Ning: formal analysis. Xiaoxu Li and Hui Huang: data collection. Jinlan Shao: methodology, data collection. Meiying Zou: supervision, provision of resources. Tingting Hu and Liuliu Zhang: project administration, supervision. All authors commented on all versions of the manuscript. All authors read and approved the final manuscript.
ACKNOWLEDGMENTS
The authors are grateful to the patients who gave their voluntary consent and participated in the study and to all the health care professionals and researchers who helped with this study.
FUNDING INFORMATION
This study was supported by the Nursing Project of Nanjing Medical University Affiliated Cancer Hospital (Grant Numbers: ZH202104, ZH202209, ZJ202310, ZL202313), the National Natural Science Foundation (Grant Number: 82203171), and the Medical Scientific Research Project of Jiangsu Provincial Health of Commission (Grant Number: BJ23023).
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
This study was approved by the Ethics Committee of Nanjing Medical University (Ethics Code: 2019007) and was conducted in accordance with the principles of the Declaration of Helsinki.
Open Research
DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
