Search Strategy

The literature review used the following computerised databases: Medline Ovid, PubMed, Cochrane Library, PsychINFO, the University of Alberta library database and the University of Northern British Columbia (UNBC) library database citing peer-reviewed articles between 1994 and 2010. The following search terms were used with combinations thereof breast cancer survivor, RTW, barriers, psychological, risk factors, intervention, treatment, chemotherapy, surgery, radiation therapy, accommodations, cognitive behavioural therapy, exercise, and rural or remote. The reference lists of all articles were checked for other relevant research. The purpose of the search strategy was to identify sources of information evaluating breast cancer survivors and how disease/treatment, person and work related factors can impact the RTW process.

From the initial search strategy using the keywords or search terms aforementioned, we identified 70 records. Of these, 51 articles were excluded as they were not directly relevant to the purpose of this article. Sources of information that did not focus on RTW or social determinants of health for breast cancer survivors were not included (exclusion criteria).

This left 19 articles that have been included herein for the review based on sources of information evaluating breast cancer survivors and how disease/treatment, person and work related factors can impact the RTW process (inclusion criteria). The information source was limited to the English language with a specific focus on North American and European perspectives.

Factors Associated With Return to Work

General research of cancer patients suggests returning to work is related to the severity of the cancer at the time of diagnosis (stage) and treatment, sociodemographic factors and job/workplace characteristics (Satariano & DeLorenze, Reference Satariano and DeLorenze1996). The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is an essential tool that uses functional profiling and intervention targeting to identify and measure the effectiveness of rehabilitation services (Ustun, Chatterji, Bickenback, Kostanjsek, & Schneider, Reference Ustun, Chatterji, Bickenback, Kostanjsek and Schneider2003). Advances in breast cancer detection and treatment have led to the need to address the impact of long term outcomes, such as employment, for breast cancer survivors (Munir, Burrows, Yarker, Kalawsky, & Bains, Reference Munir, Burrows, Yarker, Kalawsky and Bains2010). The ICF can be used as an international tool to understand human functioning and disability by assessing disease/treatment related, work related and person related factors that affect RTW for breast cancer survivors (Ustun et al., Reference Ustun, Chatterji, Bickenback, Kostanjsek and Schneider2003).

Factors Promoting an Earlier Return to work

Many breast cancer survivors of working age perceive the return to paid employment as an important milestone for recovery and return to ordinary routine (Munir et al., Reference Munir, Burrows, Yarker, Kalawsky and Bains2010). The increasing number of breast cancer survivors who are able to resume work and life activities has important implications for not only the survivors and their families but for employers as well (Kennedy, Haslam, Munir, & Pryce, Reference Kennedy, Haslam, Munir and Pryce2007). Many variables are associated with earlier RTW for breast cancer survivors including the characteristics of the profession, treatment symptoms and sequelae, and sociodemographic factors (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010).

Although not all countries have implemented legislation to protect individuals diagnosed with (breast) cancer, those that have, mandate that employers make reasonable adjustments in the work environment to support the RTW process. Direct work related factors such as flexibility in work hours, pace, and work load were found to be associated with earlier RTW for breast cancer survivors (Hoving, Broekhuizen, & Frings-Dresen, Reference Hoving, Broekhuizen and Frings-Dresen2009). These accommodations likely allow for symptom management, continued treatment, and the ability to relearn aspects of the position that may be more difficult to manage due to cognitive difficulties resulting from treatment. A supportive work environment and the perception that employers make appropriate accommodations for work and treatment were associated with earlier RTW (Tiedtke et al., Reference Tiedtke, de Rijk, Dierckx de Casterle, Christiaens and Donceel2010). Colleagues who assisted with some responsibilities, especially during the first months back at work, were found to help support breast cancer survivors with a timely RTW (Tiedtke et al., Reference Tiedtke, de Rijk, Dierckx de Casterle, Christiaens and Donceel2010).

Indirect work related factors that may impact RTW rates for breast cancer survivors include the level of income of the individual prior to diagnosis. A Canadian study found women whose annual income is greater than $50,000 were more likely to RTW than those with an income of $20,000 or less (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). Also, survivors who did not belong to a union or who were self-employed prior to their breast cancer diagnosis returned to work more quickly than those belonging to a union (Drolet et al., Reference Drolet, Maunsell, Mondor, Brisson, Brisson, Masse and Deschenes2005). Work satisfaction may be a source of motivation for breast cancer survivors to RTW as those who work in positions that require extensive physical effort, including repetitive work, may feel underappreciated, which delays the RTW process (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). This may also be true for those with demanding psychological workloads causing a reluctance or stressful return to employment as the perception of organisational or psychological constraints were characteristics of a work environment that increase time away from work (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). The correlation among psychological and/or organisational constraints of the position held at the time of diagnosis and at the time of work resumption, is an issue that needs to be considered during the rehabilitation process in order to prevent RTW delays for reasons associated with the job rather than symptoms associated with breast cancer or its treatment (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010).

Disease related factors, primarily the type of treatment received have the potential to impact work resumption in varying degrees. The type of surgical procedure affects recovery time, adjustment, and RTW (Hoving et al., Reference Hoving, Broekhuizen and Frings-Dresen2009). Breast cancer survivors who underwent less extensive surgery were able to RTW in an average of three weeks (Hoving et al., Reference Hoving, Broekhuizen and Frings-Dresen2009). However, breast cancer survivors who experienced a radical mastectomy, which can include removal of the breast, axillary lymph nodes, pectoralis muscle, the medial segment of the chest and internal mammary nodes required an average of 10 weeks off work (Hoving et al., Reference Hoving, Broekhuizen and Frings-Dresen2009). The symptoms associated with chemotherapy can significantly delay or limit RTW. Compared to other treatments, chemotherapy was found to be associated with longer absences from work, on average 10 months, compared to other therapies where RTW generally occurred after approximately six months (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010).

There is evidence that suggests person related factors may influence the RTW process more than disease and work related factors (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). The age of an individual at the time of diagnosis can not only impact treatment selection but RTW factors as well, as younger breast cancer survivors were shown to RTW earlier, compared with older breast cancer survivors (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). While studies have found no statistical relationship between the stage of disease and age, an association was found between the type of therapy and age (Satariano & Ragland, Reference Satariano and Ragland1994).

The rate of women returning to work who are older than 55 years, is substantially lower than that of women in other age groups (Satariano & Ragland, Reference Satariano and Ragland1994). This may be due to consideration of retirement or changes in priorities following diagnosis. However, the declining work force over the next two decades reinforces the need for employers to rely on the skills of older workers, including breast cancer survivors, which causes concerns as to why older women are less likely to RTW (Harder & Scott, Reference Harder and Scott2005).

Research has found that breast cancer survivors with a higher education level RTW sooner than those with a lower education level (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). Breast cancer survivors with 12 or more years of schooling were on medical leave less frequently compared to breast cancer survivors with less than 12 years of schooling (Satariano & DeLorenze, Reference Satariano and DeLorenze1966). It has been suggested that a lower educational level is correlated with employment that is more physically demanding and associated with lower salaries (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). This is consistent with the role of physical limitations perceived by some breast cancer survivors regarding their employment (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). Due to the reduced physical capacity experienced by many breast cancer survivors, it is anticipated that those with a lower education level may be more likely to cease their employment in comparison with those with more education (Taskila & Lindbohm, Reference Taskila and Lindbohm2007). Education level may also provide information regarding the socioeconomic background of breast cancer survivors including household income and for married women, their partner's employment status which may affect the RTW rate for breast cancer survivors (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010). Regardless of whether it is a disease/treatment, work or person related factor that is impeding the RTW process, the identification of work barriers and risk factors will help in the recognition and implementation methods that reduce the exclusion of breast cancer survivors from the labour market (Johnsson et al., Reference Johnsson, Fornader, Olsson, Nystedt, Johansson and Rutqvist2007).

Intervention Strategies

For most breast cancer survivors, time away from work during the first year after diagnosis is necessary with an average of approximately six months (Drolet et al., Reference Drolet, Maunsell, Mondor, Brisson, Brisson, Masse and Deschenes2005). Research has shown a significant decrease in an excess of absence from work for breast cancer survivors who remain disease-free after two years and by the third year of no recurrence, absence from work was no more frequent or longer than those never diagnosed with breast cancer (Drolet et al., Reference Drolet, Maunsell, Mondor, Brisson, Brisson, Masse and Deschenes2005). However, without appropriate interventions, the RTW process can become complicated further contributing to ineffective strategies and increasing unnecessary time away from work. Returning to work continues to be an issue and there do not appear to be RTW methods designed specifically for breast cancer survivors. RTW outcomes may improve with current RTW methods such as workplace accommodations used in conjunction with complementary intervention strategies.

Cognitive–behaviour therapy (CBT) has been proven to be effective in treating a range of symptoms including those associated with breast cancer. Various long-term effects have been identified with current conservative treatment including persistent fatigue which can occur in up to 40% of cancer survivors, severely impacting QoL and ability to work (Gielissen, Verhage, Witjes, & Bleinjenberg, Reference Gielissen, Verhage, Witjes and Bleinjenberg2006). In a study of the effects of fatigue in cancer survivors conducted by Gielissen et al. (Reference Gielissen, Verhage, Witjes and Bleinjenberg2006), a significant clinical improvement was found for the severity of fatigue, functional impairment, and self-reported improvement for those treated with CBT compared with a control group. Self reports of the intervention group included significant decreases in the severity of fatigue, functional limitations and psychological distress (Gielissen et al., Reference Gielissen, Verhage, Witjes and Bleinjenberg2006). These findings are important, as fatigue was found to be associated with difficulties in the workplace including lifting and positional activities, such as sitting, which can impact the implementation of appropriately modified duties for breast cancer survivors returning to work (Mock, Reference Mock1998). The identification of negative cognitions in the areas of breast cancer survivors’ lives that may cause anxiety and uncertainty, such as the workplace, are critical to the success of implementing CBT with breast cancer survivors.

Behavioural interventions are generally concrete in focus and application and also offer a non-pharmacologic intervention method (Redd, Montgomery, & DuHamel, Reference Redd, Montgomery and DuHamel2001). They are commonly offered as psychosocial services and are widely accepted by breast cancer survivors and health care professionals (Redd et al., Reference Redd, Montgomery and DuHamel2001). The ease of behavioural therapy application, the positive buffering impact on stress and the sense of control during vulnerable times are reasons why behavioural methods are gaining recognition (Redd et al., Reference Redd, Montgomery and DuHamel2001). Behavioural therapy for breast cancer survivors primarily focuses on coping skills and training to reduce symptoms including nausea, anxiety, fear, pain and distress (Redd et al., 2011). Behavioural intervention usually involves the breast cancer survivor and the health care professional working as a team with much of the intervention completed by the survivor (Redd et al., Reference Redd, Montgomery and DuHamel2001).

Nausea and vomiting are adverse effects of chemotherapy that at least 50% of all patients experience (Redd et al., Reference Redd, Montgomery and DuHamel2001). However, research suggests that a large number of individuals also experience these same side effects with the anticipation of chemotherapy, further impacting compliance with treatment (Redd et al., Reference Redd, Montgomery and DuHamel2001). Evidence has shown the use of behavioural methods such as relaxation and hypnosis with a focus on controlling anticipatory side effects of chemotherapy is effective as those treated with these behavioural interventions did not have episodes of anticipatory vomiting (Redd et al., Reference Redd, Montgomery and DuHamel2001). Similar positive results have been found with behavioural interventions effectively decreasing distress and anxiety for those receiving radiation therapies (Redd et al., Reference Redd, Montgomery and DuHamel2001). The use of relaxation and hypnosis to manage the symptoms associated with chemotherapy may decrease the length of absence from work. These behavioural strategies could also be used at the work place in times of distress as they do not require any equipment and are fairly simple interventions that can be carried out almost anywhere. Anticipatory behavioural interventions could also be applied prior to beginning the work process as returning to work can cause anxiety among breast cancer survivors.

Exercise can improve cardiovascular conditioning, pulmonary function, and self-esteem which are generally aspects of health affected by breast cancer and its treatment (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). Evidence has shown that structured exercise which includes aerobic activity and strength training is safe, reasonable, and well managed by breast cancer survivors improving QoL, and fitness while limiting the effects of fatigue and treatment symptoms (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). Breast cancer survivors who undergo radiation therapy frequently experience pain in the shoulder girdle or at the incision site and report muscle spasms in the shoulder region which can occur with muscle guarding (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). Breast cancer survivors who undergo radiation therapy and then complete structured exercises have a greater range of motion in all directions in the affected shoulder and decreased pain levels compared to those that only complete range of motion exercises (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). Furthermore, six-week exercise intervention programs were found to decrease pain levels and other symptoms associated with chemotherapy (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). This is important for employers and health care providers who may be concerned with modified duties that require any lifting or carrying. Graduated lifting/carrying tolerance through work activities may be more beneficial for the breast cancer survivor than having them continue to work at a sedentary level. Exercise through work activities may help increase range and strength and also increase self-esteem when the survivor is able to resume work duties which they performed prior to diagnosis (Musanti, Reference Musanti2012).

Many physicians advise breast cancer survivors to limit their activity levels that could lead to muscular deconditioning resulting in a loss of function and requiring more effort to complete ordinary activities (Hwang et al., Reference Hwang, Chang, Shim, Park, Park, Huh and Yang2008). This may also be true of family members who overestimate the limitations of the breast cancer survivor which may lead to further frustrations or indirectly alter their return to normal home and work life. Further research is required to identify physicians’ reasoning behind limiting more aggressive exercise for breast cancer survivors and also to evaluate if the benefits of structured exercise beyond range of motion can help support the RTW process by increasing function and minimising pain.

Alternative therapies have gained popularity over the years among breast cancer survivors as research indicates that 67% of Canadian breast cancer survivors reported using complementary/alternative medicine (CAM; Boon et al., Reference Boon, Stewart, Kennard, Gray, Sawka, Belle Brown and Haines-Kamka2000). While most breast cancer survivors who use some form of CAM believe conventional treatments are more likely to treat and prevent cancer spread and recurrence, conventional therapies are thought to weaken the natural immune system reserves and have negative side effects (Boon et al., Reference Boon, Stewart, Kennard, Gray, Sawka, Belle Brown and Haines-Kamka2000). Breast cancer survivors who use CAM have reported the most common reasons for the use of these treatments in descending order to be (a) improving their immune system and QoL, (b) preventing cancer recurrence, (c) providing a sense of control, (d) assisting with conventional treatments, (e) stabilising their current condition, and (e) a reaction to failed conventional treatment (Boon et al., Reference Boon, Stewart, Kennard, Gray, Sawka, Belle Brown and Haines-Kamka2000).

Further Research/Consideration From a Disability Management Perspective

The higher breast cancer rates in developed countries and among individuals with a higher socioeconomic status (SES) could be in part the result of earlier diagnosis, particularly the use of mammography screening (Johnsson et al., Reference Johnsson, Fornader, Olsson, Nystedt, Johansson and Rutqvist2007). SES has been found to be related to physicians’ recommendations and use of mammography (O'Malley et al., Reference O'Malley, Earp, Hawley, Schell, Mathews and Mitchell2001). Characteristics that were positively associated with increased recommendations for mammography include having health insurance and a regular physician, visiting the physician more often, and taking one or more medications, all of which require financial resources and time that already burden women of lower SES (O'Malley et al., Reference O'Malley, Earp, Hawley, Schell, Mathews and Mitchell2001). Low SES was found to have adverse outcomes for those diagnosed with breast cancer as these individuals were more likely to have a late stage diagnosis and less likely to be treated with radiation therapy (Bradley, Given, & Roberts, Reference Bradley, Given and Roberts2002). Social determinants of health can have a large impact on the prevention and management of breast cancer as a lack of access to health care is an issue for those that are already at a disadvantage. Programs that alleviate environmental barriers for low income breast cancer survivors can help minimise the socioeconomic disparities in diagnostic and treatment outcomes (Bradley et al., Reference Bradley, Given and Roberts2002). This is important for low income breast cancer survivors who may not be referred for diagnostic testing or who do not have the ability to take time away from work to receive treatment due to the extra financial burden.

In Canadian rural and remote (northern) communities the frequent lack of services for many breast cancer survivors often leads to perceptions of being alone during their recovery process (Curran & Church, Reference Curran and Church1998). Many breast cancer survivors participate in support groups to cope with their illness and have reported a considerable decrease in psychological distress and pain and improvement in QoL (Winzelberg, Classen, Aplers, Roberts, & Koopman, Reference Winzelberg, Classen, Alpers, Roberts and Koopman2003). Successful support groups are comprised of survivors who are at different stages of breast cancer treatment (Winzelberg et al., Reference Winzelberg, Classen, Alpers, Roberts and Koopman2003). Teleconferencing for rural Canadian breast cancer survivors was found to be beneficial for facilitating a social support program that addresses the need for social support and provides information on breast cancer (Winzelberg et al., Reference Winzelberg, Classen, Alpers, Roberts and Koopman2003). It may serve an additional important purpose by presenting a method for stakeholder education and involvement which is one of the key elements of DISM. Through teleconferencing, common goals regarding treatment and RTW plans can be developed including all stakeholders to support a graduated RTW process that may otherwise be difficult to initiate in rural and remote locations. Consistent use of teleconferencing in rural areas could be used to identify performance measurements, another key element of DISM, for establishing supportive and effective RTW strategies for rural breast cancer survivors who may not otherwise be able to connect with all necessary stakeholders at the same time.

Breast cancer survivors who continue to work may have to consider the reality of recurrence and prepare to endure the treatment and RTW process more than once. This is an important implication for employers who may need to accommodate the same survivor over many years. A graduated RTW program is an element of DISM that can be used to develop flexible and creative RTW opportunities (Dyck, Reference Dyck2006). Graduated RTW programs can promote workplace accommodations while nurturing the understanding of co-workers and support of the program (Dyck, Reference Dyck2006). This can be facilitated through a coordinated approach involving the employer, employees, and third parties by collaboratively creating an inventory of appropriately modified duties. Developing a ‘buddy system’ would ensure that support is provided when necessary and would help minimise alienation when breast cancer survivors RTW. Support from colleagues was associated with an earlier RTW (Fantoni et al., Reference Fantoni, Peugniez, Duhamel, Skryzpczak, Frimat and Leroyer2010).

Younger breast cancer survivors may still have children at home and tend to be in the middle of their careers; thus, the disruption and interference in their home and work life may be extensive (Green et al., Reference Green, Krupnick, Rowland, Epstein, Stockton, Spertus and Stern2000). Studies of other illnesses have shown RTW outcomes can be predicted by a patient's own assessment of their illness and work ability (Munir et al., Reference Munir, Burrows, Yarker, Kalawsky and Bains2010). Therefore, the perception of breast cancer survivors regarding their health and employability will likely provide invaluable information on the RTW process.

The potential trauma and barriers associated with breast cancer and its treatment suggests that therapies that focus on the specific needs of breast cancer survivors are critical to ensure that the limitations are being identified and appropriate strategies are implemented. Adjuvant psychological therapy (APT) is a form of CBT that is developed specifically to treat cancer patients (Aapro & Cull, Reference Aaprol and Cull1999). Studies have shown APT can reduce depression by 40% in cancer patients after four months of treatment (Aapro & Cull, Reference Aaprol and Cull1999). While the physical limitations associated with breast cancer and related treatments are better understood today, the psychological barriers have not been addressed to the level required to successfully manage ongoing consequences affecting both personal and professional life for breast cancer survivors. Moreover, employers are less aware of how to accommodate psychological needs in the workplace, especially those that may require special or ongoing accommodations. Supportive benefit programs is a key element of DISM that can provide services such as the Employee Assistance Program (EAP) that can help employees connect with service providers for treatments such as APT, and can also include counselling for an employee and her family. Using benefit programs that are specific for the needs of breast cancer survivors can help manage symptoms more effectively causing fewer disruptions at work and home and have the potential to increase QoL.

Changes in industries, roles and responsibilities have led to an increase in the number of women participating in the work force. In 1984, women in North America made up half of the workforce in industries related to education, government, health services and the financial sector (United States (US) Congress Joint Economic Committee, 2010). By 2009, women comprised more than 50% of the workforce in education, health services, financial, leisure and hospitality and government (US Congress Joint Economic Committee, 2010). Industries such as construction witnessed only a 1% increase in the number of women (US Congress Joint Economic Committee, 2010). While a smaller percentage of women work in the construction industry, which can consists of work duties including heavier lifting and repetitive work, more studies specific to Canada and especially across the provinces are required to determine the number of women that work in the natural resource industry sector. Women working in Alberta may make up more of the trade industry compared to women working in other provinces due to the nature of business and resources found in this province. While the incidence rates of breast cancer are fairly consistent throughout Canada, the RTW rates may be affected by the type of industries women are employed in depending on the province in which they reside. Differences in legislation among Canadian provinces regarding the duty to accommodate and the type of modified work offered will also impact RTW rates for breast cancer survivors. Studies comparing the provincial rate of women working in particular industries with the RTW rate for breast cancer survivors by province will provide more relevant information.

Employers play a critical role in the successful RTW of breast cancer survivors after diagnosis and may have an equally important role in promoting healthy proactive lifestyle behaviours. Workplace wellness is an aspect of DISM that can recognise illness, develop positive workplace relationships and culture and also reward wellness (Dyck, Reference Dyck2006). Employers who offer education initiatives regarding risk factors, diagnosis and treatment associated with breast cancer may be able to increase knowledge among their staff and create a supportive corporate culture in the event an employee requires workplace accommodation as a result of symptoms associated with breast cancer and its treatment.

More than two decades ago, breast cancer survivors reported their greatest work barriers included job loss, unwanted changes in work duties, demotion, conflict with their employer and co-workers, changes in attitude towards work, and reduced physical functioning (Maunsell, Brisson, Dubois, Lauzier, & Fraser, Reference Maunsell, Brisson, Dubois, Lauzier and Fraser1999). These previously reported problems continue to limit breast cancer survivors who wish to RTW and the identification of more recent barriers also restrict the RTW process. Current areas of concern reported include negative consequences associated with learning about the diagnosis at their workplace and the lack of discussions related to RTW issues with health care professionals, suggesting the behaviour of health care professionals can influence the work experience from the time of diagnosis (Maunsell et al., Reference Maunsell, Brisson, Dubois, Lauzier and Fraser1999). The identification of these newly reported barriers and confirmation of barriers identified decades ago, underlines the significance of how extensive these barriers are. Breast cancer survivors reported more communication and involvement between their specialist and their occupational therapist in emphasising the need for flexible work practices, which is essential to support those who wish to continue to work or RTW (Kennedy, Munir, & Pryce, Reference Kennedy, Haslam, Munir and Pryce2007). A communication strategy is an important component of DISM that can develop a plan encouraging the free flow of information between stakeholders (Dyck, Reference Dyck2006). Disability management practitioners can act as a liaison between the health care professional, the employers and the breast cancer survivors to coordinate an appropriate RTW process. By using the Work Health Organization's ICF model, health care professionals, employers and DISM professionals have the opportunity to help breast cancer survivors RTW (Roelen, Koopmans, Graaf, Balak & Groothoff, Reference Roelen, Koopmans, de Graaf, Balak and Groothoff2009). The first opportunity is through better management and addressing RTW as part of the management process (Roelen et al., Reference Roelen, Koopmans, de Graaf, Balak and Groothoff2009). Returning to work is more successful when breast cancer survivors are able to learn new skills, including coping skills, or improve current skills necessary for their work as an integral part of their treatment (Roelen et al., Reference Roelen, Koopmans, de Graaf, Balak and Groothoff2009). The second opportunity consists of addressing and adapting the work environment to facilitate the RTW process by addressing specific aspects of the position and work environment (Roelen et al., Reference Roelen, Koopmans, de Graaf, Balak and Groothoff2009). The third opportunity is to address the rehabilitation focus on changing negative thoughts associated with breast cancer and the various treatments, as each individual will interpret breast cancer differently and consequently behave differently (Roelen et al., Reference Roelen, Koopmans, de Graaf, Balak and Groothoff2009). Further education and communication among health care professionals, breast cancer survivors, and employers concerning supportive and effective RTW is required to limit possible changes in attitudes regarding work as vocation is identified to be an important aspect in the life of breast cancer survivors.