Introduction
In 2022, more than 124,000 cancer diagnoses were reported in the Netherlands (IKNL 2023). For invasive breast cancer, a type of cancer that is common in the working-age population, the average 2-year survival is relatively high compared to other cancer types, specifically 95% in the Netherlands in 2021 (IKNL 2023). However, not all workers that have returned to work are cured and some may be confronted with local or locoregional recurrence at a later time or with distant metastases, for example in the lungs, bones, or the brain.
When cancer cannot be treated curatively anymore, the treatment is palliative and aimed at controlling the disease and reducing symptoms, probably for many years. For instance, women with metastatic breast cancer may continue to live beyond a decade (Kanker.nl 2023). Living with metastatic cancer may cause specific needs, among others as a result of being faced with uncertainty in the length of survival (Tometich et al. Reference Tometich, Hyland and Soliman2020). Return to work with metastasized cancer is associated with younger age, early development of the metastases, and limited comorbidities during the year before diagnosis (Müller et al. Reference Müller, Weigl and Heiden2013). Paid employment is positively associated with quality of life in patients with advanced cancer (Beerda et al. Reference Beerda, Zegers and van Andel2022). However, treatments or symptom management are ongoing. Nevertheless, although increased symptoms and cancer progression may be the reason to stop working (Sesto et al. Reference Sesto, Carroll and Zhang2022; Tevaarwerk et al. Reference Tevaarwerk, Lee and Terhaar2016), work may be a part of the lives of people who are living with cancer for a long period of time.
Figures on the prevalence of workers with recurrent and metastatic cancer are not available. However, given the large number of breast cancer diagnoses at working age and the relatively high survival rates, the assumption can be made that cancer recurrences and metastases may still be detected among a substantial group of workers past the primary cancer diagnosis. Workers with recurrent disease or metastases are often not included in the data collected during research on cancer and work. However, these workers seek contact to find guidance on work-related issues, are present at symposia, and make their voices heard. Although the group of workers living with cancer after returning to work may be relatively small, it is important to learn more about how these workers report their work functioning compared to the group of workers who believe to be cured. Furthermore, it is important to detect targets for interventions at the individual level to enhance the work functioning of workers with recurrent and metastatic cancer.
Work functioning will be investigated by using 3 concepts that are commonly used by Dutch researchers; work ability (Ilmarinen and Tuomi Reference Ilmarinen and Tuomi2004; Ilmarinen et al. Reference Ilmarinen, Tuomi and Seitsamo2005), burnout complaints (Bakker et al. Reference Bakker, Demerouti and Sanz-Vergel2023; Demerouti et al. Reference Demerouti, Bakker and Nachreiner2001), and work engagement (Bakker and Demerouti Reference Bakker and Demerouti2008; Bakker and Leiter Reference Bakker and Leiter2010). First, the concept of work ability was constructed more than 40 years ago (Ilmarinen et al. Reference Ilmarinen, Tuomi and Seitsamo2005). Work ability refers to the extent to which someone regards performing work activities as possible (now and in the future), taking the demands of the job, and health and mental resources into account (Ilmarinen et al. Reference Ilmarinen, Tuomi and Seitsamo2005). The Work Ability Index (WAI) questionnaire (Ilmarinen Reference Ilmarinen2007) is the corresponding assessment tool to measure the level of work ability, although in many studies only the first item is used as it is reported to have a very strong association with the complete WAI (Ahlstrom et al. Reference Ahlstrom, Grimby-Ekman and Hagberg2010). In several studies, work ability is reported to be at the highest level among the younger population and to decrease with growing age. However, among those employed, the decrease is less than among the entire population, as those with better work ability continue to work (Gould et al. Reference Gould, Ilmarinen and Järvisalo2008). Furthermore, a higher work ability with growing age is reported for instance in an Australian study among mature-age women (Austen et al. Reference Austen, Jefferson and Lewin2016). Second, burnout complaints will be investigated as an indicator of work functioning. The concept of burnout was initially introduced in the U.S.A. by Maslach with an assessment tool, the Maslach Burnout Inventory (MBI) (Maslach and Jackson Reference Maslach and Jackson1981). In the Netherlands and Sweden in the last 2 decades, many studies were done using the MBI and later on, other assessment tools were developed, like the Utrecht Burnout Scale (UBOS) (Schaufeli and Van Dierendonck Reference Schaufeli and Van Dierendonck2000) and recently the Burnout Assessment Tool (Schaufeli et al. Reference Schaufeli, Desart and De Witte2020). According to the UBOS, burnout complaints are regarded as a prolonged stress response to chronic stressors at work, characterized by exhaustion, cynicism, and inefficacy (Maslach et al. Reference Maslach, Schaufeli and Leiter2001). Third, work engagement will be used to investigate work functioning in the present study. Work engagement is a positive state of well-being at work. According to the Utrecht Work Engagement Scale (UWES) (Schaufeli et al. Reference Schaufeli, Bakker and Salanova2006), work engagement is characterized by vigor, dedication, and absorption at work (Bakker and Leiter Reference Bakker and Leiter2010).
Many studies have been conducted on the area of work ability, burnout complaints, and work engagement for different populations of workers, however, almost not among workers who are confronted with cancer recurrence or metastases. A recent review on the associations between late effects of cancer treatment and work ability that included 36 studies (Boelhouwer et al. Reference Boelhouwer, Vermeer and Van Vuuren2021) reported about 3 studies also including cases with metastatic cancer (Bielik et al. Reference Bielik, Bystricky and Hoffmannova2020; Couwenberg et al. Reference Couwenberg, Intven and Gregorowitsch2020; Torp et al. Reference Torp, Nielsen and Gudbergsson2012) and 3 including cases with recurrent disease (Ho et al. Reference Ho, Hartman and Gernaat2018; Lindbohm et al. Reference Lindbohm, Taskila and Kuosma2012; Moskowitz et al. Reference Moskowitz, Todd and Chen2014). As far as the authors have been able to find, among cancer survivors only 1 publication is known about burnout complaints (Boelhouwer et al. Reference Boelhouwer, Vermeer and Van Vuuren2022) and only 3 about work engagement (Berg Gudbergsson et al. Reference Berg Gudbergsson, Fosså and Dahl2008; Hakanen and Lindbohm Reference Hakanen and Lindbohm2008; Von Ah and Crouch Reference Von Ah and Crouch2021). No research is known regarding work ability, burnout complaints and work engagement focusing exclusively on the group that is confronted with recurrence or metastases after return to work. Therefore, hypotheses cannot be based on previous studies among this working population.
However, treatments probably are still ongoing, treatment side effects may occur, and the disease itself may also cause symptoms. Despite the incomparability of other chronic conditions with having cancer recurrence or metastases and given the fact that those who think to have been cured of cancer can still suffer from late effects of the cancer treatments, it is important to realize that research among workers with certain chronic disorders has shown that these populations tend to experience lower work ability (Koolhaas et al. Reference Koolhaas, Van der Klink and De Boer2014; Leijten et al. Reference Leijten, Van den Heuvel and Ybema2014; Van den Berg et al. Reference Van den Berg, Burdorf and Robroek2017) and higher burnout complaints (Hallman et al. Reference Hallman, Thomsson and Burell2003; Honkonen et al. Reference Honkonen, Ahola and Pertovaara2006). Work engagement has been studied among various populations, but mixed results have been reported. However, 1 study has been conducted in which workers who have had cancer were compared with healthy references. Work engagement, while high, was found to be slightly lower in workers who have had cancer in the past than in the group with healthy references (Hakanen and Lindbohm Reference Hakanen and Lindbohm2008). Furthermore, low work engagement is reported to be related to low work ability (Rongen et al. Reference Rongen, Robroek and Schaufeli2014). Moreover, work ability also concerns future functioning, which will be a complicated factor for workers with recurrence or metastases. Therefore, the hypotheses regarding work functioning are as follows:
H1: Workers beyond return to work with cancer recurrence or metastases report a lower level of work ability as workers without cancer recurrence or metastases.
H2: Workers beyond return to work with cancer recurrence or metastases report a higher level of burnout complaints as workers without cancer recurrence or metastases.
H3: Workers beyond return to work with cancer recurrence or metastases report a lower level of work engagement as workers without cancer recurrence or metastases.
When health is impaired, as is also the case with people with chronic diseases, psychosocial adjustments are observed (Helgeson and Zajdel Reference Helgeson and Zajdel2017). Psychological capital (Avey et al. Reference Avey, Luthans and Smith2010; Luthans et al. Reference Luthans, Youssef and Avolio2007b), which encompasses the elements hope, optimism, resilience, and self-efficacy, is state-like positive psychological construct that recently also receives attention in the field of psycho-oncology. Enhancing these constructs at the individual level is regarded as crucial also for the well-being of cancer patients (Cui et al. Reference Cui, Wang and Zhang2021). Work is also part of the lives of the participants of the present study; however, research regarding associations of psychological capital and work functioning has been done mainly among healthy populations for instance reporting that optimism and self-efficacy show negative associations with burnout complaints (Alarcon et al. Reference Alarcon, Eschleman and Bowling2009) and positive associations with work engagement (Bakker and Leiter Reference Bakker and Leiter2010). There has been a study reporting that optimism is more important for work engagement among cancer survivors than among referents (Hakanen and Lindbohm Reference Hakanen and Lindbohm2008). To the best of our knowledge, there is a lack of studies examining the relationships between hope, resilience, and self-efficacy with work functioning in large samples that specifically compare a population with a history of cancer to a healthy population. Studies specifically among workers with cancer recurrence or metastases to investigate the association of psychological capital with work functioning are not known. Nevertheless, the expectation is that psychological capital will be associated with better work functioning within this population as well. Therefore, the hypotheses regarding the associations of psychological capital with work functioning are as follows:
H4: The level of hope, optimism, resilience, and self-efficacy among workers beyond return to work with cancer recurrence or metastases is positively associated with the level of work ability.
H5: The level of hope, optimism, resilience, and self-efficacy among workers beyond return to work with cancer recurrence or metastases is negatively associated with the level of burnout complaints.
H6: The level of hope, optimism, resilience, and self-efficacy among workers beyond return to work with cancer recurrence or metastases is positively associated with the level of work engagement.
Methods
Procedure and participants
A survey study was carried out (between June 2018 and December 2019) among workers 2–10 years past cancer diagnosis (N = 750), of which 73% (n = 550) reported a diagnosis of breast cancer and 27% (n = 200) a diagnosis of a cancer other than breast cancer. The respondents gave written (online) informed consent. The Research Ethics Committee (cETO) of the Open Universiteit in the Netherlands assessed the ethical acceptability of the study and agreed with the study design and method (reference cETO: U2018/03891/MQF) on June 5, 2018.
Measures
To indicate if a participant’s medical situation involved cancer recurrence or metastases, the answer (“yes” or “no”) on the following question was used: “Do you still have cancer or have you been diagnosed with cancer again?.” “Age” was the calendar age in years reported by the participant, “sex” by the respondent’s choice of “male” or “female,” “number of years since diagnosis” was calculated by using the year of diagnosis and the moment the participant filled in the survey, and the presence of “other chronic or severe illnesses” was questioned with the option to answer “yes” or “no.”
Work ability was measured with the first item of the WAI (Ilmarinen et al. Reference Ilmarinen, Tuomi and Seitsamo2005), which has a strong association with the complete WAI (Ahlstrom et al. Reference Ahlstrom, Grimby-Ekman and Hagberg2010). The item investigates the extent to which someone reports to be able physically and mentally to perform current and future work on a scale of 0–10 (where “0” means “completely unable to work”). Burnout complaints were measured using the Utrecht Burnout Scale (UBOS-A) (Schaufeli and Van Dierendonck Reference Schaufeli and Van Dierendonck2000) by means of 15 items on a 7-point scale. Cronbach’s alpha for the overall UBOS-A scale was .91. Work engagement was measured using the UWES (Bakker et al. Reference Bakker, Schaufeli and Leiter2008), consisting of 9 items on a 7-point scale from 1 (never) to 7 (always). Cronbach’s alpha for the overall UWES scale was .94.
The Psychological Capital Questionnaire (Luthans et al. Reference Luthans, Avolio and Avey2007a, Reference Luthans, Youssef and Avolio2007b) consisting of 23 items (5-point Likert scale) was used. The subscales are hope (6 items), optimism (6 items), resilience (6 items), and self-efficacy (5 items), with Cronbach’s alpha, respectively, of .88, .72, .76, and .80. The items are used for various populations, so for instance “hope” is not related to the situation of having or having had cancer. An example of an item of this subscale is “At work, I am confident that if I can’t figure it out, I would be able to find different solutions.”
Analyses
The data were analyzed using SPSS software, version 28 (IBM Corporation, Armonk NY, USA) for Windows®/Apple Mac®.
Descriptives were analyzed for the complete study sample and the 2 subgroups of participants with and without cancer recurrence or metastases separately. Descriptives were demographics (age, sex, and educational level), type of employment, years since diagnosis, type of cancer, and other chronical diseases. Age was used for controlling the results of the analysis of variance (ANOVA) to analyze possible differences in work functioning between the 2 subgroups. Possible differences in psychological capital were also analyzed between groups using ANOVA, however, without a control variable included.
All hypotheses were analyzed by 3 separate multivariate regression analyses (for work ability, burnout complaints, and work engagement) controlling for age, within the population with cancer recurrence or metastases. Hope, optimism, resilience, and self-efficacy were centered at their means. The hypotheses were tested in 3 steps; age in the first step, type of cancer (breast cancer) in the second step, and hope, optimism, resilience, and self-efficacy in the third step.
Results
Descriptives
The mean age of the study sample (N = 750) was 48.8 years (SD, 8.78), the educational level was high in 54.1%, and the type of employment was salaried in 82.8% of the cases. No differences between workers with or without cancer recurrence or metastases were observed for these variables. Significant differences were observed for sex (74.5%, respectively, 91.2% female), the mean number of years since diagnosis (5.4, respectively, 4.6), type of cancer (41.8%, respectively, 75.8% breast cancer), and other chronical diseases (60.0%, respectively, 39.9%) (see Table 1).
Characteristics participants study sample (N = 750) and subgroups with and without recurrence or metastases (respectively, n = 55 and n = 695)
# One missing value.
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
*** Correlation is significant at the 0.001 level (2-tailed).
Work functioning (work ability, burnout complaints, and work engagement) and psychological capital (hope, optimism, resilience, and self-efficacy) show moderate or strong bivariate associations in the expected directions. Age showed a significant small, positive bivariate association with work ability (r = .074, p < .05) and with work engagement (r = .072, p < .05) but not with burnout complaints (see Table 2).
Bivariate correlations of age, recurrence or metastases, breast cancer, work ability, burnout complaints, work engagement, hope, optimism, resilience, and self-efficacy (N = 750)
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
Hypotheses testing: H1, H2, and H3
Work ability is significantly lower among workers with cancer recurrence or metastases (controlling for age). The mean work ability of the workers confronted with a breast cancer diagnosis in the past with cancer recurrence or metastases is 6.4 and 7.3 for those without (p < .05). The mean work ability of the workers confronted with other cancer diagnoses than breast cancer in the past with cancer recurrence or metastases is 6.8 and 7.5 for those without (p < .05) (see Table 3). Therefore, H1 is confirmed. Burnout complaints and work engagement are at comparable levels for workers with and without cancer recurrence or metastases (see Table 3). Therefore, H2 and H3 are not confirmed.
Analysis of variance (ANOVA) of work functioning (work ability, burnout complaints, and work engagement) controlled for age and psychological capital (hope, optimism, resilience, and self-efficacy) for participants with and without recurrence or metastases (breast cancer diagnoses and other cancer diagnoses than breast cancer analyzed separately)
* Correlation is significant at the 0.05 level (2-tailed).
Hypotheses testing: H4, H5, and H6
A higher level of hope is positively associated with work ability (β = .402, p < .05). Optimism, resilience, and self-efficacy are not associated with work ability analyzed in combination with hope in the same step of the regression analysis. Therefore, H4 is partly confirmed (see Table 4).
Multivariate regression analyses of the association of hope, optimism, resilience, and self-efficacy, with work ability, controlled by age and breast cancer, among workers 2–10 years past (initial) diagnosis (n = 54)
Hope, optimism, resilience, and self-efficacy are centered around their means.
* Significant at the 0.05 level (2-tailed).
A higher level of hope or of resilience is negatively associated with burnout complaints (respectively β = −.568 and β = −.440, p < .001). Optimism and self-efficacy are not associated with burnout complaints analyzed in combination with hope and resilience. Therefore, H5 is partly confirmed (see Table 5).
Multivariate regression analyses of the association of hope, optimism, resilience, and self-efficacy, with burnout complaints, controlled by age and breast cancer, among workers 2–10 years past (initial) diagnosis (n = 54)
Hope, optimism, resilience, and self-efficacy are centered around their means.
*** Significant at the 0.001 level (2-tailed).
A higher level of hope is positively associated with work engagement (β = .409, p < .05). Optimism, resilience, and self-efficacy are not associated with work engagement analyzed in combination with hope. Therefore, H6 is partly confirmed (see Table 6).
Multivariate regression analyses of the association of hope, optimism, resilience, and self-efficacy, with work engagement, controlled by age and breast cancer, among workers 2–10 years past (initial) diagnosis (n = 54)
Hope, optimism, resilience, and self-efficacy are centered around their means.
* Significant at the 0.05 level (2-tailed).
Discussion
Implications for research and practice
Very few previous studies have been conducted among workers experiencing cancer recurrence or metastases. Therefore, the insight presented in this study is important, namely that the work functioning of workers with cancer recurrence or metastases is not lower in all aspects, but that work ability is reported to be lower than among workers past cancer diagnosis without cancer recurrence or metastases. In this study, it is not possible to determine whether the reported work ability might be influenced by the awareness of an uncertain or limited life expectancy. However, the group with breast cancer (which both in this study and in real life, represents a large proportion of workers with cancer) is extra vulnerable given their lower levels of resilience and self-efficacy, in addition to a lower work ability.
All elements of psychological capital showed associations with work functioning, but the element hope was identified as showing the strongest association with work functioning. Therefore, this element within psychological capital may be the most important target for interventions. This points in the direction of interventions aimed at strengthening confidence in finding ways to achieve goals and the feeling that achieving goals will be possible within the work situation, for instance. The behavior and guidance of a manager are important for workers and their work functioning; however, workers with cancer recurrence or metastases may need specific attention which a manager may not be able to provide. An expert with a background in occupational coaching and clinical psycho-oncological practice may be needed to offer additional guidance and advice to the manager. An understanding and insight into the specific situation in which workers with cancer find themselves is essential, especially those with recurrence or metastases. This offers an understanding of the perspectives and motives that may play a role in these workers, the goals they set, and the choices they make regarding work. The clinical psycho-oncological practice, therefore, may benefit from the insights presented in the current study in guiding this vulnerable group of workers.
Limitations
A limitation of the current study mainly relates to the composition of the study sample, as all other cancer types other than breast cancer had to be analyzed together in 1 subgroup because of the low numbers. Another limitation is that the presence of cancer may involve recurrence or metastases, with different prognoses. Furthermore, the group that reported a cancer recurrence or metastases was relatively small, as may be expected within the population workers with a past cancer diagnosis in the Netherlands in general. Furthermore, a bias may be have been present as those with the least medical health problems perform work activities most easily.
As mentioned before, the answers on the first item of the WAI may be affected by the awareness of a limited life expectancy. This is supported by 2 additional analyses (not shown) using the seventh item of the WAI (Ilmarinen et al. Reference Ilmarinen, Tuomi and Seitsamo2005; Lundin et al. Reference Lundin, Leijon and Vaez2017) and an item from a scale to determine sustainable employability (Veld et al. Reference Veld, Semeijn and van Vuuren2016). Given their current state of health, the workers with cancer recurrence or metastases reported their expected ability to still perform their current job 2 years from now as less likely than workers without recurrence or metastasis. Furthermore, a lower expectation to be physically able to work until retirement age is reported by the subgroup with breast cancer recurrence or metastases.
Furthermore, concerning the elements of psychological capital, it is also conceivable that the reported values are related to the extent to which participants think they can still recover or to their view of their life expectancy. However, it is questionable whether this can be asked using a survey. A qualitative follow-up study may be an option to gain more insight into this issue. On the other hand, individual differences in the level of experienced psychological capital are reported among healthy persons (Newman et al. Reference Newman, Ucbasaran and Zhu2014) and may be a general finding regardless of the health situation.
Changes over time in the experienced psychological capital may also occur. This was for instance reported among healthy financial advisory-type employees (Peterson et al. Reference Peterson, Luthans and Avolio2011). However, the data of the current study are cross-sectional, and possible longitudinal changes were not investigated. Nevertheless, it is conceivable that these changes may have occurred. Moreover, it is also conceivable that perspectives given disease progression can influence this. These issues were not addressed in the current study, however may be important topics to be addressed in future studies among this population of workers using a longitudinal design.
To conclude, workers who are confronted with cancer recurrence or metastases represent a vulnerable group requiring additional support in their work functioning, also with a focus on their psychological capital, especially the element hope. Even if the group is relatively small, it is important to realize that workers who are in a situation of cancer recurrence or metastases are also active on the labor market. Much more attention should be paid to this, both from practice and research. It is crucial to listen to these workers, engaging in a meaningful dialogue to explore the specific actions required to support them in their professional lives.
Acknowledgments
We are grateful to all participants for taking part in this study.
Author contributions
IB and TV developed the study design. IB was responsible for the data collection, prepared the data analysis, and wrote the first draft of the manuscript. The later drafts of the manuscript were adjusted by both authors in collaboration. Both authors read and approved the submitted version.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests
The authors declare no conflict of interest.
