1 INTRODUCTION

An ageing population, improved cancer detection, and enhanced treatments are contributing to a growing number of cancer survivors.¹ The 5-year relative survival for all cancers combined was 69.7% in Australia between 2013 and 2017, an increase from 51.3% 25 years earlier.² A substantial number of cancer survivors in Australia are of working age; specifically, 54,382 Australians of working age (aged between 25 and 64 years) were diagnosed with cancer in 2017, representing 39% of all cancers in that year.² In the 2013 to 2017 period, the 5-year relative survival for all cancers combined for Australians aged 25–64 years ranged between 76% and 91%.²

The burden of cancer can cause widespread disruption to daily routine and detrimentally impact autonomy.^{3, 4} Side effects can cause physical and psychological challenges to work participation, with survivors having a significantly higher risk of unemployment, reduced work hours or early retirement.^{3, 5} Disruption to work during cancer treatment is known to adversely affect the financial wellbeing of patients and their families.^6-9 Furthermore, work disruption negatively affects quality of life and is linked to higher rates of anxiety and depression.¹⁰ Despite Australia having universal health care and social welfare benefits, the financial consequences to the individual, their families, and society from lack of reintegration into the workforce remain a significant problem.^{8, 11} An analysis of a 2015 cross-sectional survey conducted by the Australian Bureau of Statistics indicated that 46% of working-aged cancer survivors were not in active work, resulting in $1.7B of lost productivity, and those without tertiary qualifications were almost four times more likely not to be employed.¹¹

For many survivors, reestablishing normalcy to their lives is a key goal.¹² A recurring theme throughout the survivorship literature is that large numbers of working-age cancer survivors are both willing and able to return to work (RTW) with very little impact to their performance. Internationally, around 60%–70% of cancer survivors will eventually RTW, most within 12 months of initial diagnosis.^{3, 13-16} Continuing or returning to work after primary cancer diagnosis promotes a sense of control as well as maintaining professional identity, professional social support structures, and a sense of purpose.^{10, 17-21} The physical, psychological, and financial benefits employment provides are evident.^{11, 22, 23}

There are a range of factors that may impact on a cancer survivor's RTW. Cancer type is associated with RTW, with leukemia and cancers of the lung, central nervous system, and head and neck reported to be associated with greater disability and lower employment.^{24, 25} It is understood that there are a myriad of challenges involved in RTW and numerous international studies have attempted to describe factors impacting on RTW for cancer survivors.^{3, 5, 12, 15, 19-23, 26-34} Factors, including workplace relationships, educational level, sociodemographic factors, social supports, personal finances, and presence of comorbidities, have been identified; however, evidence regarding the impacts of these social determinants in either facilitating or hindering RTW is mixed.^{3, 5, 12, 15, 19, 20, 26, 28-33} Understanding the RTW experience of cancer survivors, and particularly factors that impede RTW, is needed to enable identification of survivors who may be vulnerable to poorer employment outcomes and also to inform design and development of interventions or supportive resources to support people to RTW.

Internationally, numerous systematic reviews investigating RTW have been conducted involving various cancer types^{3, 5, 21, 27, 29, 30, 34}; however, to our knowledge, no systematic review has been conducted investigating social determinants and nontreatment, non-cancer-related variables, and the impact on RTW in Australia has been conducted.

The review focuses on the Australian setting only as we recognize that the RTW experience varies greatly across different countries due to differences in health care systems, availability of welfare, health insurance coverage, and workplace discrimination laws—differences which would render a synthesis of international findings of limited practical use in informing meaningful change. The review excluded cancer-related variables (such as cancer type) and treatment-related variables (e.g., types of treatment, duration of therapies), as we were particularly interested in understanding potential disparities and inequities by virtue of social determinants (which could flag people at risk) to support RTW.

The aim of this systematic review was to identify any nontreatment, non-cancer-related variables that impact on RTW in Australian cancer survivors.

2 METHODS

This systematic literature search was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.³⁵ The review protocol was registered with the International Prospective Register of Systematic Reviews—PROSPERO (registration number CRD42020190766).

3 RESULTS

3.1 Study selection

In total, 1338 records were identified through database searching and a further 57 studies identified through manual checking of reference lists (Figure 1). Three hundred and 22 duplicates were removed, leaving 1073 studies to be reviewed. After title and abstract review, 33 studies proceeded to full-text review. Application of study inclusion criteria identified 27 studies not suitable for inclusion. Six studies were found to be eligible and included in final analyses.

4 DISCUSSION

This systematic review aimed to identify the non-cancer, non-therapy-related variables that are associated with RTW in Australian cancer survivors. We identified factors that were associated with RTW in this population, though found little consistency in findings between studies.

International literature suggests demographic and social factors that may be associated with a higher likelihood of RTW include younger age,^{3, 15, 29, 43, 44} higher level of education,^{3, 5, 29, 43} male gender,^{3, 44} continuity of care across hospitals,³ and friends and family support.^{3, 5, 15, 19, 20, 26, 28, 30, 34, 45} Factors associated with lower likelihood of RTW include older age,^{5, 28, 32, 43, 44, 46, 47} female gender,^{5, 15, 32, 43, 44} and lower levels of education.^{5, 29, 32, 46} Bates et al., ¹¹ in a paper exploring workforce participation (rather than RTW and so did not meet inclusion criteria for this review), demonstrated that having cancer and not being in the workforce was 3.73 times more likely in those without a tertiary education. The present review found evidence for the association of older age and lower likelihood of RTW among Australian cancer survivors but did not show a consistent association for gender, place of residence, education level, relationship status and employment of partner, and number of people in the home and involvement in caring roles.

Communication between employer and employee is vital to make RTW a success and involves negotiating needs, overcoming barriers, acknowledging and accepting compromise, and rebuilding confidence by providing the right support.²¹ Work-related factors in the literature that may be associated with higher RTW include flexibility in resuming work responsibility,^{3, 28, 45} less stressful work,⁴⁵ work that matches physical and cognitive ability,^{45, 48} cancer disclosure to colleagues/employer,^{3, 45, 19} higher number of work hours,^{5, 43} self-employment,⁴⁵ responsibility/loyalty to workplace,^{26, 45, 19} greater company size,⁵ greater level of communication with employer,^{20, 28, 30} positive work environment,^{20, 28, 30} fear of being fired,¹⁹ and duration of employment.²⁶ Findings from the current review consistent with findings from the above literature are fewer hours of unpaid work, fewer weekly work hours pre-diagnosis and length of employment. Working environment, manual work, physical exertion,^{3, 5, 15, 32, 34, 45, 47, 48} attitude of coworkers, less accommodation and support in workplace,^{3, 15, 20, 28, 29, 44, 45} perceived employer discrimination, psychological or self-perceived constraints,^{3, 28, 30, 32, 34, 44, 45, 49} employed >5 years,⁵ opting instead for retirement,^{3, 19, 43} difficulty with transportation,^{32, 48} and union membership^{3, 32} have been reported to be associated with less likelihood of RTW. In relation to these findings, this study found no evidence that the size of employer, work schedule, work autonomy, contract and workplace type, challenging and physically demanding work, and commute time is associated with RTW in Australia.

Health care costs for cancer are reported to be five times higher than for non-cancer conditions.²⁹ Cancer presents a serious challenge to family finances and may be the dominant reason behind decisions on RTW.^{20, 21, 26, 45, 19, 48, 49} Other frequent reported factors positively associated with RTW include being free from financial concerns,⁴⁵ higher income,^{5, 29} length of sick leave available,³ and health insurance tied to employment.¹⁹ Other literature suggests that low income,^{3, 5, 28, 32, 47} lack of employer benefits (leave of absence),⁵ access to adequate sick leave benefits,⁴⁵ inadequate occupational health care,⁵ and family able to provide financial support¹⁹ may be associated with a lower likelihood of RTW. Our review noted that not having private health insurance and having personal income insurance and financial support from spouse or family members may result in a lower chance of RTW; however, the mechanisms behind these observations are unclear. It may be that not having health insurance (in an Australian setting) is an indication of greater socioeconomic disadvantage, which may indicate less job security, flexibility, or control around working conditions.⁵⁰ Household income, however, was not associated with RTW in the present review, which suggests having private health insurance may be associated with benefits outside of socioeconomic status, such as greater access and usage of cancer rehabilitation and survivorship services, which may assist in RTW.⁵¹ The impact of private health insurance on RTW and other survivorship outcomes warrants further investigation.

Interventions to assist people to RTW following cancer treatment have been developed, including inpatient and outpatient rehabilitation programs, and various supportive care interventions comprised education and counseling (reviewed in Refs. [^{46, 52}]); however, the evidence of benefit of these interventions on RTW is mixed and findings limited by study design (i.e., lack of randomized controlled trials). A consistent feature and criticism of past interventions is focusing interventions on survivors, with little to no involvement of employers in RTW initiatives.⁴⁶ Further work is needed to understand the impacts of the various work, health, demographic, and financial-related factors on RTW described in this review and to design interventions that are appropriately targeted, accessible, and include all the necessary stakeholders, including employers.

There is scope for further Australian-based research looking to identify variables that are associated with RTW. Subsequent research should be carried out in populations where cancer and treatment-related toxicity is relatively homogenous to allow the greatest practical applicability within Australian society. There is also a need for greater understanding of the variables that influence disparities in RTW. A greater understanding of these variables will help to identify vulnerable groups most in need of support and intervention.

5 CONCLUSIONS

This review included six papers that addressed non-cancer, nontreatment factors associated with RTW in Australian cancer survivors. A number of demographic, health, work, and financial factors were identified as impacting on RTW; however, there was little consistency across studies. Generalizability of findings is limited by a lack of representation of survivors from a range of cancer types. This review highlights an important knowledge gap, with further research needed to understand factors that may impact upon RTW for cancer survivors, which may inform development of targeted support to help survivors RTW. Given the unique health, welfare and workplace conditions in Australia, further the exploration of RTW should be undertaken within Australia. Studies should include survivors with a range of cancer diagnoses, cancer types prevalent in people of working age, and should focus on factors that have been identified in the limited Australian, and more extensive international, literature.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.