Interventions to enhance return‐to‐work for cancer patients

Angela GEM de Boer; Tyna K Taskila; Sietske J Tamminga; Michael Feuerstein; Monique HW Frings‐Dresen; Jos H Verbeek

doi:10.1002/14651858.CD007569.pub3

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Figure 1

PRISMA flow diagram of reference selection and study inclusion.

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Figure 2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.

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Figure 3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.

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Figure 4

Funnel plot of comparison: 4 Medical function conserving versus Medical more radical‐RCTs, outcome: 4.1 RTW.

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Analysis 1.1

Comparison 1 Psycho‐educational versus Care as usual, Outcome 1 RTW.

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Analysis 1.2

Comparison 1 Psycho‐educational versus Care as usual, Outcome 2 QoL.

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Analysis 2.1

Comparison 2 Physical versus Care as usual, Outcome 1 RTW.

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Analysis 2.2

Comparison 2 Physical versus Care as usual, Outcome 2 QoL.

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Analysis 3.1

Comparison 3 Medical function conserving versus Medical more radical, Outcome 1 RTW.

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Analysis 3.2

Comparison 3 Medical function conserving versus Medical more radical, Outcome 2 QoL.

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Analysis 4.1

Comparison 4 Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual, Outcome 1 RTW.

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Analysis 4.2

Comparison 4 Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual, Outcome 2 QoL.

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Summary of findings for the main comparison. Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual for cancer

Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual for cancer
Patient or population: Patients with cancer Settings: Hospital Intervention: Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Control	Multidisciplinary physical, psycho‐educationaland/or vocational interventions versus Care as usual
RTW Follow‐up: median 12 months	786 per 1000¹	872 per 1000 (810 to 912)	RR 1.11 (1.03 to 1.16)	450 (5 studies)	⊕⊕⊕⊝ moderate²
QoL Follow‐up: mean 12 months	‐	The mean QoL in the intervention groups was 0.03 standard deviations higher (0.20 lower to 0.25 higher)	‐	316 (2 studies)	⊕⊕⊝⊝ low^3,4
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio;RTW: return‐to‐work; QoL: quality of life.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Median RTW rate in control groups. ²Three out of five trials with high risk of bias, downgraded one level. ³Wide CIs, downgraded one level. ⁴One study with high and one with low risk of bias, downgraded one level.

Summary of findings for the main comparison. Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual for cancer

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Summary of findings 2. Psycho‐educational care versus Care as usual for return to work in cancer patients

Psycho‐educational care versus Care as usual for return to work in cancer patients
Patient or population: Patients with cancer Settings: Hospital Intervention: Psycho‐educational care Comparison: Care as usual
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Care as usual	Psycho‐educationalcare
Return to work (RTW) Follow‐up: 1.5 to 12 months	491 per 1000¹	535 per 1000 (432 to 663)	RR 1.09 (0.88 to 1.35)	260 (2 studies)	⊕⊕⊝⊝ low^2,3
Quality of life (QoL) Various scales Follow‐up: 1.5 to 12 months	‐	The mean QoL in the intervention groups was 0.05 standard deviations higher (0.2 lower to 0.3 higher)	‐	260 (2 studies)	⊕⊕⊝⊝ low^2,4
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; RTW: return‐to‐work; QoL: quality of life.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Average of control groups' RTW rates. ²One study with high and one with low risk of bias, downgraded one level. ³Wide CIs overlapping with 1, downgraded one level. ⁴Wide CI including 0 and small effect size, downgraded one level.

Summary of findings 2. Psycho‐educational care versus Care as usual for return to work in cancer patients

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Summary of findings 3. Physical exercise versus Care as usual for RTW in cancer

Physical exercise versus Care as usual for return to work in cancer
Patient or population: Patients with cancer Settings: Community Intervention: Physical exercise Comparison: Care as usual
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Care as usual	Physical exercise
RTW	357 per 1000¹	429 per 1000 (114 to 1000)	RR 1.2 (0.32 to 4.54)	28 (1 study)	⊕⊕⊝⊝ low²
QoL Various scales Follow‐up: 12 months	‐	The mean QoL in the intervention groups was 0.37 standard deviations lower (0.99 lower to 0.25 higher)	‐	41 (1 study)	⊕⊕⊝⊝ low²
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; RTW: return‐to‐work; QoL: quality of life.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹RTW rate in the control group. ²Wide CIs, only one included study, downgraded with two levels.

Summary of findings 3. Physical exercise versus Care as usual for RTW in cancer

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Summary of findings 4. Medical function conserving treatment versus Medical more radical treatment for cancer

Medical function conserving treatment versus Medical more radical treatment for cancer
Patient or population: Patients with cancer Settings: Hospital Intervention: Medical function conserving treatment Comparison: Medical more radical treatment
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Medical more radical treatment	Medical function conserving treatment
RTW Follow‐up: median 18 months	850 per 1000¹	884 per 1000 (816 to 926)	RR 1.04 (0.96 to 1.09)	1097 (7 studies)	⊕⊕⊝⊝ low^2,3
QoL Various instruments Follow‐up: mean 9 months	‐	The mean QoL in the intervention groups was 0.10 standard deviations higher (0.04 lower to 0.23 higher)	‐	1028 (2 studies)	⊕⊕⊕⊝ moderate³
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio; RTW: return‐to‐work; QoL: quality of life.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Median RTW rate in control groups of this comparison. ² I² statistic = 51%, downgraded one level. ³ CIs overlap with one, downgraded one level.

Summary of findings 4. Medical function conserving treatment versus Medical more radical treatment for cancer

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Table 1. Characteristics of included studies

Study	Country	Diagnosis	Design	Number	Intervention(s)	Control	Type
Ackerstaff 2009	Netherlands	Head, neck	RCT	34 versus 28	Intra‐arterial chemoradiation	Intravenous chemoradiation	Medical
Berglund 1994	Sweden	Breast	RCT	81 versus 73	Physical training, patient education and training of coping skills re RTW	Care as usual	Multidisciplinary
Burgio 2006	USA	Prostate	RCT	28 versus 29	Biofeedback behavioral training	Care as usual	Multidisciplinary
Emmanouilidis 2009	Germany	Thyroid	RCT	7 versus 6	L‐thyroxine after surgery	Later provision of L‐thyroxine	Medical
Friedrichs 2010	Germany	Leukemia	RCT	163 versus 166	Peripheral blood progenitor cell transplantation	Bone marrow transplantation	Medical
Hillman 1998	USA	Laryngeal	RCT	80 versus 63	Chemotherapy	Laryngectomy	Medical
Hubbard 2013	UK	Breast	RCT	7 versus 11	Physical, occupational, psycho‐educational support services, multi‐disciplinary	Booklet work and cancer	Multidisciplinary
Johnsson 2007	Sweden	Breast	RCT	53 versus 17 55 versus 17 64 versus 17	Tamoxifen Goserelin Tamoxifen+Goserelin	No endocrine therapy	Medical
Kornblith 2009	USA	Endometrial	RCT	164 versus 73	Laparoscopy	Laparotomy	Medical
Lee 1992	UK	Breast	RCT	44 versus 47	Breast conservation	Mastectomy	Medical
Lepore 2003	USA	Prostate	RCT	41 versus 20 43 versus 20	Patient education Patient education + group discussion	Care as usual	Psycho‐educational
Maguire 1983	UK	Breast	RCT	42 versus 46	Physical training, individual counselling and encouragement of RTW.	Care as usual	Multidisciplinary
Purcell 2011	Australia	Radiotherapy patients	RCT	43 versus 48 21 versus 24	Post‐radio fatigue education Pre‐ and post‐radio fatigue education	Flyer with generic information about fatigue.	Psycho‐educational
Rogers 2009	USA	Breast	RCT	14 versus 14	Physical activity training	Care as usual	Physical
Tamminga 2013	Netherlands	Breast	RCT	65 versus 68	Vocational support, counselling, education, multi‐disciplinary, RTW advice.	Care as usual	Multidisciplinary

Table 1. Characteristics of included studies

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Table 2. Quality of the evidence (GRADE)

Comparison/outcome	Number of studies	Study limitations	Inconsistency	Indirectness	Imprecision	Publication bias	Overall quality of evidence
Psycho‐educational versus Care as usual/ RTW	2 RCTs	Yes: 1 high 1 low risk 1 level down	No inconsistency	No	Wide CI 1 level down	Only two studies	Low
Physical versus Care as usual/ RTW	1 RCT	No: Low risk	No	No	Wide CI 2 levels down	Only one study	Low
Medical function conserving versus Medical more radical/ RTW	7 RCTs	No: 2/7 high risk studies contribute 25%	High: I² statistic = 51%	No	Wide CI 1 level down	Not observed	Low
Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual/ RTW	5 RCTs	Yes: 3/5 high risk 1 level down	No: I² statistic = 0%	No	Narrow CIs	Not observed	Moderate
Psycho‐educational versus Care as usual/QoL	2 RCTs	Yes: 1 high, 1 low risk 1 level down	No: I² statistic = 0%	No	Wide CI 1 level down	Only two studies	Low
Physical versus Care as usual/ QoL	1 RCT	No: Low risk	Not applicable	No	Wide CI 1 level down	Only one study	Low
Medical function conserving versus Medical more radical/QoL	2 RCTs	No: Low risk studies	No: I² statistic = 0%	No	Wide CI 1 level down	Only two studies	Moderate
Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual/QoL	2 RCTs	Yes: 1 low, 1 high risk studies 1 level down	No: I² statistic = 17%	No	Wide CI 1 level down	Only two studies	Low
Column headings (with explanations in parentheses): Study design (RCT = randomised controlled trial); study limitations (likelihood of reported results not being an accurate estimate of the truth); inconsistency (lack of similarity of estimates of treatment effects); indirectness (not representing PICO well); imprecision (insufficient number of patients or wide CIs) of results; and publication bias (probability of selective publication of trials and outcomes) across all studies that measured that particular outcome.

Table 2. Quality of the evidence (GRADE)

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Comparison 1. Psycho‐educational versus Care as usual

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 RTW Show forest plot	2	260	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.88, 1.35]

1.1 Patient education	1	61	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.77, 1.51]
1.2 Patient education, group discussion	1	63	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.99, 1.79]
1.3 Post‐radiotherapy fatigue education	1	91	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.54, 1.76]
1.4 Pre‐ and post‐radiotherapy fatigue education	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.41, 1.67]
2 QoL Show forest plot	2	260	Std. Mean Difference (IV, Fixed, 95% CI)	0.05 [‐0.20, 0.30]

2.1 Patient education‐physical QoL	1	61	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.44, 0.62]
2.2 Patient education and group discussion‐physical QoL	1	63	Std. Mean Difference (IV, Fixed, 95% CI)	0.22 [‐0.32, 0.75]
2.3 Post‐radiotherapy fatigue education	1	91	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.46, 0.36]
2.4 Pre‐ and post‐radiotherapy fatigue education	1	45	Std. Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.56, 0.61]

Comparison 1. Psycho‐educational versus Care as usual

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Comparison 2. Physical versus Care as usual

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 RTW Show forest plot	1		Risk Ratio (Fixed, 95% CI)	Totals not selected

1.1 Physical activity	1		Risk Ratio (Fixed, 95% CI)	0.0 [0.0, 0.0]
2 QoL Show forest plot	1		Std. Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Physical versus Care as usual

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Comparison 3. Medical function conserving versus Medical more radical

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 RTW Show forest plot	7		Odds Ratio (Random, 95% CI)	1.32 [0.78, 2.25]

1.1 Chemoradiation	1		Odds Ratio (Random, 95% CI)	0.73 [0.25, 2.14]
1.2 Early thyroid hormones	1		Odds Ratio (Random, 95% CI)	11.36 [1.17, 110.34]
1.3 Minimal surgery	3		Odds Ratio (Random, 95% CI)	1.52 [0.74, 3.14]
1.4 Adjuvant endocrine	1		Odds Ratio (Random, 95% CI)	1.28 [0.24, 6.77]
1.5 Peripheral blood progenitor cell transplantation	1		Odds Ratio (Random, 95% CI)	0.81 [0.38, 1.73]
2 QoL Show forest plot	2	1028	Std. Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.04, 0.23]

2.1 Chemoradiation	1	126	Std. Mean Difference (IV, Fixed, 95% CI)	0.17 [‐0.18, 0.52]
2.2 Minimal surgery	1	902	Std. Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.06, 0.23]

Comparison 3. Medical function conserving versus Medical more radical

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Comparison 4. Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 RTW Show forest plot	5		Odds Ratio (Random, 95% CI)	1.86 [1.16, 2.99]

1.1 Physical training, patient education and coping with RTW	1		Odds Ratio (Random, 95% CI)	1.84 [0.78, 4.37]
1.2 Physical exercise, counselling, encouragement of RTW	1		Odds Ratio (Random, 95% CI)	2.69 [1.07, 6.74]
1.3 Physical exercise, patient education and biofeedback	1		Odds Ratio (Random, 95% CI)	0.96 [0.27, 3.42]
1.4 Case management vocational rehabilitation	1		Odds Ratio (Random, 95% CI)	2.97 [0.51, 17.33]
1.5 Enhancing RTW, patient education, counselling	1		Odds Ratio (Random, 95% CI)	1.57 [0.57, 4.34]
2 QoL Show forest plot	2	316	Std. Mean Difference (IV, Fixed, 95% CI)	0.03 [‐0.20, 0.25]

2.1 Physical training, patient education and coping with RTW	1	188	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.08 [‐0.36, 0.21]
2.2 Enhancing RTW, patient education, counselling	1	128	Std. Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.17, 0.52]

Comparison 4. Multidisciplinary physical, psycho‐educational and/or vocational interventions versus Care as usual

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