Functionality and factors associated with work behaviour among Brazilian breast cancer survivors: A cross-sectional study

Abstract

BACKGROUND:

Breast cancer treatments lead to several comorbidities in the upper limbs, such as pain and stiffness, hindering physical functions and the return to work.

OBJECTIVE:

To explore the functionality and factors associated with work behaviour among manual and non-manual Brazilian workers who have recovered from breast cancer.

METHODS:

This is an observational cross-sectional study involving Brazilian breast cancer survivors. The sociodemographic, work, and clinical aspects were assessed through clinical records, upper limb disability, and human functionality obtained from 62 women. Multiple and univariate logistic regressions were used to identify the association of variables on return to work, p < 0.05.

RESULTS:

56.5% of women did not return to work, the mean time for returning to work was 16 months (±15.21), absenteeism from work lasted 41 months (±34.58). Modified radical mastectomy (OR = 5.13, 95% CI = 1.35 to 18.66) and moderate-to-severe disability levels in the upper limbs (OR = 6.77, 95% CI = 1.86 to 24.92) were associated with not returning to work. The loss of productivity was higher among non-manual workers (21.5%) (p = 0.040).

CONCLUSIONS:

The rates of not returning to work after breast cancer treatment are high. Women who did not return to work presented higher levels of disability.

Keywords

Work capacity evaluation breast neoplasms return to work ergonomics

1 Introduction

Keeping breast cancer survivors in the work-force can be challenging following their breast cancer treatment [1, 2]. Considering that returning to work provides a sense of healing, recovery, and a return to routine in the lives of breast cancer survivors, together with socioeconomic benefits, studying rates of return to work among this population is of great interest [2 –6].

High-income countries such as the USA, Canada, and countries in the EU have studied return to work among breast cancer survivors, and a previous systematic review of the phenomenon has identified return to work rates ranging from 43% (Netherlands) to 93% (USA); however, there is a lack of studies in low and middle-income countries, like Brazil [2]. This represents a worldwide drawback in the study of return to work behaviour after breast cancer, and is an obstacle to providing informed public policies that can enhance the re-integration of breast cancer survivors into the workforce [2, 7]. Indeed, the creation of public policies regarding work and disability are major challenges for labour and social markets [8].

The challenges of work reintegration after breast cancer are multidimensional and involve complex interactions with sociodemographic, clinical, labour/ergonomic, and functional factors such as higher age, more work experience, presence of physical complaints in the upper limbs such as pain after surgery, stiffness/weakness, altered sensitivity, and lymphoedema [9]. In addition, difficulty in concentrating on activities which require high cognitive efforts, and breast cancer treatments are associated with failure to return to work [10 –12]. A full exploration of ergonomic and functional factors is important if we are to understand the interactions of the environment, individual, and society, and the effects on return to work after breast cancer.

Considering the breast cancer burden worldwide, it is expected that there will be 2 million new cases of breast cancer by 2020 and that 67% of them will occur in women up to 65 years of age. Data from Brazil indicate the same trend, with behaviour similar to global statistics [13]. Moreover, the increasing survival rates and earlier diagnoses of breast cancer treatments can negatively influence clinical-functional factors, which might lead to some levels of human and physical disability; added to which, labour/ergonomic factors may hinder the rate of return to work, and consequently contribute to an increase in unemployment rates among this population [1, 3].

Regarding ergonomic factors, variables such as the work categories where these women are introduced might influence return to work rates and work capacity, since manual workers are exposed to higher physical strain in comparison with non-manual workers, whose efforts are more cognitive [14].

In accordance with the aforementioned factors, we believe that manual workers and breast cancer survivors with higher physical complaints or higher disability levels might have more find returning to work more difficult. Thus, investigating the factors associated with failure to return to work may contribute to the creation of socioeconomic policies and rehabilitation programs focused on functionality. As such, the aim of this study is to explore the functionality and factors associated with work behaviour among manual and non-manual Brazilian workers who have survived breast cancer.

2 Methods

2.1 Design

This was an observational cross-sectional study involving Brazilian breast cancer survivors who had been surgically treated in a referral public health service in Florianópolis, Santa Catarina. The study was approved by an ethics committee under protocol number 50685414.4.0000.0118 of Universidade Federal de Santa Catarina.All participants gave their informed consent to participate in this research.

2.2 Sample

The inclusion criteria were: (1) women diagnosed with breast cancer (ICD-50.0), (2) aged between 30 and 65 years, (3) who had finished chemotherapy and/or radiation therapy treatment at least 3 months prior to our interview, and (4) had been employed prior to surgery. The exclusion criteria were: (1) work absences for reasons other than breast cancer (ICD-50.0), (2) psychiatry or cognitive diseases reported in medical files, (3) being in palliative treatment, and (4) cancer recurrence.

2.3 Recruitment

Brazilian breast cancer survivors were recruited from a reference University Hospital –Polydoro Ernani de São Thiago of Universidade Federal de Santa Catarina. The research was conducted from August 2016 to April 2017, and all eligible women during the data collection period were included. The first 4 months were dedicated to the pilot study which demonstrated no need for adjustment of the original study design; the assessment was performed by two different physical therapists with previous training.

2.4 RTW and work category

The dependent variable of return to work was established as breast cancer survivors who resumed their paid jobs, full or part-time, after sick-leave for breast cancer treatments, related with the time an individual was absent from labour activities due to functional limitations [15].

Regarding work classification, the dichotomization of manual or non-manual jobs followed Inter-national Labour Office guidelines (ILO). Manual jobs commonly use the hands as the main instrument and require the use of force or physical resistance, and educational levels such as primary or high school might be mandatory. The activities described in levels 1 and 2 of the International Standard Classification of Occupations (ISCO-08) were considered manual jobs, including gardening services, drivers, secretaries, police officers, and machine operators. Consequently, non-manual jobs involve tasks with some level of technical complexity, such as problem solving, decision making, and creativity, which are based on deeper and more specific knowledge, requiring higher levels of education.The activities classified in levels 3 and 4 of the ISCO-08 were considered non-manual jobs and included managers, laboratory technicians, law assistants, engineers, professors, physicians, broadcasting, and musicians [14].

2.5 Sociodemographic, labour/ergonomic, and clinical factors

Sociodemographic factors of Brazilian breast can-cer survivors were age, BMI (body mass index), marital status, educational level, ethnicity, main family provider, and total family income. Labour/ergonomic factors were number of jobs pre- and post-breast cancer, job tenure (years), work status after breast cancer (retuned to work or not), length of sick leave and time to return to work, and category of work pre- and post-breast cancer (manual or non-manual). The clinical factors were side of breast cancer, type of surgery, axillary surgery, chemotherapy, radiation therapy, endocrine therapy, date of surgery, and specific symptoms or physical complaints (e.g., lymphoedema; scar pain in the arm or breast after surgery; weakness sensation in the upper limb homolateral to breast cancer; post-surgery stiffness in the shoulder). All information was checked in medical files, with the exception of specific symptoms, physical complaints and work status that were self-reported in the moment of the interview.

2.6 Functional factors assessment

The World Health Organization Disability Assessment Schedule (WHODAS 2.0), transculturally adapted for the Brazilian population, assessing general human functionality [16], was chosen as this is a construct that evaluates functionality according to the International Classification of Functioning, Disability and Health (ICF) of body functions and structure, activities, and participation. The WHODAS questionnaire comprises six domains: cognition, mobility, self-care, getting along, life activities, and participation, which is consistent with the ergonomic triad; impaired worker, workplace, and task. This 36-item questionnaire was interview-administered. Scores range from 0 to 100 whereas higher scores represent greater disability [16].

The disability level of the upper limbs was assessed by the Disability of Arm, Shoulder and Hand (DASH) questionnaire, which was interview-administered, using the validated and translated version for Brazil [17, 18]. This 30-item construct evaluates the physical disability and symptoms in the upper limbs. The construct is a 5-point Likert-type questionnaire with the score ranging from 0 to 100. Scores represent disabilities as mild (0–25), moderate (25–50), and severe (>50).

2.7 Statistical analysis

A post-hoc power analysis was performed on significant predictors using G^*powersoftware, version 3.1. The alfa was set at 0.05, two-tailed test, R = 0.04, for logistic regression results. For the post-hoc power analysis of DASH differences between groups, the alfa was set at 0.05, two-tailed, and the effect size d, calculated by mean and standard deviations, was set at 0.82. For non-parametric data, post-hoc power analysis was calculated using the following equation $r = \frac{z}{\sqrt{N}}$ which is in accordance with the literature [19], and all 62 participants were considered.

Statistical analysis was carried out using IBM SPSS version 20.0. The normality of data was tested according to the Shapiro-Wilk normality test and analysis of distribution [20]. Continuous variables are reported as mean, standard deviation, or median and interquartile range, according to data distribution; meanwhile qualitative variables are characterized by frequencies. The Mann-Whitney U test was used to identify the differences between the return to work and failure to return to work group regarding WHODAS and the independent T test to compare differences related to DASH. All tests were one-sided, α= 0.05 for all data.

With the purpose of analysing the return to work outcome with clinical aspects (type of surgery, side of breast cancer, symptoms and post-surgery complaints), a logistic regression was used with the backward-Wald method. To compose the multiple logistic regression analysis, variables in the univariate and comparison analysis with p < 0.150 [21] were submitted for multicollinearity diagnosis by linear regression; variables with VIF > 5 were excluded [22]. Finally, to assess the factors associated with return to work (0 = yes; 1 = no) for post-breast cancer, the following variables were used in a binary form similarly to return to work dichotomization (0 = yes; 1 = no): modified radical mastectomy; axillary surgery; post-operatory pain in the scar, breast, or arm; weakness sensation in upper limbs; post-surgery stiffness in shoulder; and upper limb disability by DASH score (0 = mild, 1 = moderate/severe). The confidence interval adopted was 95% .

3 Results

Sixty-two women were included with an average age of 51.40 years (±8.18) and an average BMI of 27.66 kg/m² (±6.35). Regarding breast cancer survivors characteristics, 60.0% were married, 56.0% had completed high school or elementary school, and 74.0% were Caucasian. Regarding social status, the main provider was a husband or relative (48.0%), and the total family income ranged from US$ 286.00 to 857.00 in 42.0% of breast cancer survivors. In terms of the participants’ working conditions before breast cancer, 18% of them had two jobs; in post-breast cancer, none of the women maintained both jobs; the return to work group presented a mean of 16.37 years (±12.47) of work at pre-surgery, while women in the not-return to work group worked 4 years less at pre-surgery, totalling 12.29 years (±11.35). Women in the return to work (n = 27) group took an average of 16 months (±15.21) to resume their jobs, while women in the not-return to work group (n = 35) were still absent from work for approximately 41 months (±34.58).

Prior to breast cancer, 47.0% breast cancer survivors were manual workers, 52.0% were non-manual workers, and 1.6% had two jobs, one manual and the other non-manual work, to complement their income. After breast cancer treatments, manual workers made up 18.0% of those returning to work, while non-manual workers made up 26.0% and 56.5% did not resume their jobs as they were not employed, were retired because of breast cancer, or were on medical leave due to breast cancer treatments or physical/cognitive complications. Among return to work group, 14.5% changed their work from a manual to non-manual job.

According to the univariate analysis, breast cancer survivors who underwent a modified radical mastectomy (OR 3.20, 95% CI 1.04 to 9.84); reported a weakness sensation in their upper limbs (OR 3.53, 95% CI 1.03 to 12.04); or post-surgery stiffness in the shoulder (OR 4.31, 95% CI 1.41 to 13.21) were associated with a failure to return to work, as seen in Table 1.

Table 1
Univariate analysis of sociodemographic, clinical, and labour/ergonomics factors associated with RTW and NRTW groups (n = 62)

Characteristics All survivors (n = 62) Groups Association between groups

n (%) RTW NRTW OR P

(n = 27) (n = 35) (95% CI)

n (%) n (%)

Age group

< 50 years 27 (43.5) 13 (48.10) 14 (40.00) 1.39 (0.51–3.83) 0.522

BC dominant side 31 (50.0) 10 (32.30) 21 (67.70) 0.39 (0.14–1.10) 0.076

Modified radical mastectomy 43 (69.4) 15 (55.60) 28 (80.00) 3.20 (1.04–9.84) 0.042^*

Received axillary surgery 21 (39.00) 12 (57.1) 9 (42.9) 2.31 (0.79–6.76) 0.126

Received chemotherapy 14 (22.60) 4 (14.80) 10 (28.60) 0.44 (0.12–1.28) 0.206

Received radiation therapy 19 (30.60) 5 (18.50) 14 (40.00) 0.34 (0.10–1.11) 0.075

Received endocrine therapy 13 (21.00) 7 (25.9) 6 (17.10) 1.69 (0.49–5.79) 0.402

Upper limbs

Lymphoedema 34 (54.80) 15 (55.60) 19 (54.30) 1.05 (0.38–2.88) 0.921

Post-surgery pain in scar, arm or breast 17 (27.40) 10 (37.00) 7 (20.00) 2.35 (0.75–7.35) 0.141

Weakness sensation 15 (24.20) 10 (37.00) 5 (14.30) 3.53 (1.03–12.04) 0.044^*

Post-surgery stiffness in shoulder 21 (33.90) 14 (48.10) 7 (20.00) 4.31 (1.41–13.21) 0.011^*

Altered sensibility 7 (11.30) 5 (18.50) 2 (5.70) 3.75 (0.67–21.07) 0.133

Moderate to severe disability (DASH) 43 (69.40) 14 (51.90) 29 (82.90) 4.48 (1.41–14.30) 0.011^*

Survival time

< 5 years post-surgery 43 (69.40) 18 (66.70) 25 (71.40) 1.25 (0.42–3.70) 0.687

Work category after BC

Manual work 27 (46.80) 16 (25.80) 11 (31.40) 1.54 (0.56–4.25) 0.404

Characteristics	All survivors (n = 62)	Groups	Association between groups
Age group
< 50 years	27 (43.5)	13 (48.10)	14 (40.00)	1.39 (0.51–3.83)	0.522
BC dominant side	31 (50.0)	10 (32.30)	21 (67.70)	0.39 (0.14–1.10)	0.076
Modified radical mastectomy	43 (69.4)	15 (55.60)	28 (80.00)	3.20 (1.04–9.84)	0.042^*
Received axillary surgery	21 (39.00)	12 (57.1)	9 (42.9)	2.31 (0.79–6.76)	0.126
Received chemotherapy	14 (22.60)	4 (14.80)	10 (28.60)	0.44 (0.12–1.28)	0.206
Received radiation therapy	19 (30.60)	5 (18.50)	14 (40.00)	0.34 (0.10–1.11)	0.075
Received endocrine therapy	13 (21.00)	7 (25.9)	6 (17.10)	1.69 (0.49–5.79)	0.402
Upper limbs
Lymphoedema	34 (54.80)	15 (55.60)	19 (54.30)	1.05 (0.38–2.88)	0.921
Post-surgery pain in scar, arm or breast	17 (27.40)	10 (37.00)	7 (20.00)	2.35 (0.75–7.35)	0.141
Weakness sensation	15 (24.20)	10 (37.00)	5 (14.30)	3.53 (1.03–12.04)	0.044^*
Post-surgery stiffness in shoulder	21 (33.90)	14 (48.10)	7 (20.00)	4.31 (1.41–13.21)	0.011^*
Altered sensibility	7 (11.30)	5 (18.50)	2 (5.70)	3.75 (0.67–21.07)	0.133
Moderate to severe disability (DASH)	43 (69.40)	14 (51.90)	29 (82.90)	4.48 (1.41–14.30)	0.011^*
Survival time
< 5 years post-surgery	43 (69.40)	18 (66.70)	25 (71.40)	1.25 (0.42–3.70)	0.687
Work category after BC
Manual work	27 (46.80)	16 (25.80)	11 (31.40)	1.54 (0.56–4.25)	0.404

RTW = return to work; NRTW = non-return to work; DASH = Disability of Arm, Hand and Shoulder; OR = odds ratio; UL = upper limbs, ^*p < 0.05.

The multiple analysis of associated factors among the return to work and failure to return to work groups demonstrated that breast cancer survivors with moderate-to-severe upper limb disability levels in the DASH were 6.77 more likely to not return to work (95% CI = 1.86 to 24.92, power = 0.90). Those who had modified radical surgery (95% CI = 1.35 to 18.66, power = 0.84) were 5.13 more likely to not return to work; further information is available in Table 2.

Table 2

Multiple logistic regression analysis with factors associated to NRTW on Brazilian BCS (n = 62)

Variables	OR	95% CI	P
Modified radical mastectomy
No	1	1.35–18.66	0.012^*
Yes	5.13
DASH
Mild disability	1	1.86–24.62	0.004^**
Moderate/severe disability	6.77

NRTW = non-return to work; OR = odds ratio; CI = confidence interval; ^*p < 0.05; ^**p < 0.01.

Regarding the human functionality levels between the failure to return to work and return to work groups, breast cancer survivors who could not resume their jobs demonstrated higher disability levels for the following tasks: self-care (p = 0.009; power = 0.3), getting-along (p = 0.011, power = 0.29), life activities (p < 0.001, power = 0.7), and a total WHODAS score (p = 0.001, power = 0.4), as shown in Table 3.

Table 3

Mann-Whitney U test to identify the differences in human functional factors between NRTW and RTW groups of Brazilian BCS (n = 62)

WHODAS domains	Groups		P
	RTW (n = 27)	NRTW (n = 35)
	Md (range)	Md (range)
Cognition	16.67 (4.17–33.33)	20.83 (8.33–37.50)	0.112
Mobility	25.00 (0.00–35.00)	25.00 (10.00–60.00)	0.110
Self-care	0.00 (0.00–12.50)	12.50 (0.00–31.25)	0.009^**
Getting-along	0.00 (0.00–15.00)	15.00 (0.00–20.00)	0.011^*
Life activities	37.50 (0.00–56.25)	71.88 (65.63–84.38)	0.000^**
Participation	21.88 (3.13–40.63)	25.00 (12.50–50.00)	0.132
Total	17.64 (6.42–29.55)	26.35 (18.92–47.57)	0.001^**

RTW = return to work; NRTW = non-return to work; Md = median; ^*p < 0.05; ^**p < 0.01.

A significant difference was found for the DASH total score (p = 0.002) between the return to work and failure to return to work groups. The failure to return to work group showed higher disability levels (mean 42.95, SD = 18.40, power = 0.89) than the return to work group (mean 27.72, SD = 18.19, power = 0.89). Women from the failure to return to work group presented moderate to severe disability, while the return to work group presented disabilities that varied from mild to moderate.

4 Discussion

We aimed to explore the functionality and factors associated with work behaviour among manual and non-manual Brazilian workers who had survived breast cancer. The results partially confirmed our hypothesis, as higher disability levels in the upper limbs and extensive surgery were associated with a failure to return to work; however, contrary to our expectations, the work category showed no association. Regarding the return to work rates, fifty-seven percent of Brazilian breast cancer survivors did not resume their jobs and 15% changed their occupational category from manual jobs to non-manual jobs after breast cancer treatments. The failure to return to work group had more disability in general and in the upper limbs when compared to the return to work group.

Our results showed Brazilian breast cancer survivors take longer than sixteen months to resume their jobs in comparison with previous occupational health studies conducted in Sweden [23], France [21], Denmark [24], and the United Kingdom [15], where the results ranged from 7 to 10 months. This characteristic is probably due to differences in the public health systems and laws in Brazil regarding health insurance and premature retirement due to disability. In addition, it is important to highlight that the Brazilian public health system suffers from insufficient human resources and difficulties in access to treatment centres, considering the country’s immense size.

Extensive surgery, such as a modified radical mastectomy to treat breast cancer, is in line with a higher level of breast and arm symptoms such as pain, oedema, difficulties in movement, weakness, and paraesthesia in the upper limb [25]. In addition, extensive surgery on the breast changes the scapular pattern of homolateral movement for breast cancer [26, 27], especially for internal shoulder rotation [28], leading to an overload on the homolateral upper limb and further pain in this segment [25, 29]. These findings are in line with our results, since Brazilian breast cancer survivors are 5 times more likely to not return to work when compared to women who undergo breast-conserving surgery.

Notwithstanding, moderate to severe disability in the upper limbs increases the odds of not returning to work by almost 7 times. Previous studies showed that higher disability levels are more evident in extensive and invasive treatments [25 , 30–32]. Another factor that might influence these disability levels is the delay to the start of the public rehabilitation program in the Brazilian public health system, hindering the prevention of comorbidities.

Moreover, manual workers present physical difficulties, since a previous study involving manual workers found lower activity levels in the trapezius, supraspinatus, and anterior deltoid muscles, leading to difficulty in supporting the arm in movements requiring high precision [33]. Despite this, the work category was not associated with a failure to return to work in our study, which is different from the literature, since manual workers can be disproportionally affected by surgical procedures that hamper physical activity [23, 34]. Nevertheless, in the present study, 14% of participants changed their work category from manual to non-manual jobs. Thus, these adjustments could represent an extra-official agreement between employers and their employees, in the light of a good working relationship.

Regarding human functionality, day-tp-day activities (e.g. maintaining a household/caring for a family) and labour tasks had lower scores among breast cancer survivors in the failure to return to work group, showing a difficulty in performing those tasks, which is in line with a previous study [35]. Some functional activities demand strenuous and precise movements of upper limbs, such as self-care tasks including dressing, showering, and eating, which have been previously reported as limiting the daily routine [36] and which justify the findings of present study. Difficulties in socialization such as getting along with friends, relatives, and colleagues have already been documented [35]. There is a consensus in the literature that emotionally supporting breast cancer survivors [11, 37] healps decrease the social and physical-functional difficulties and keep them working; however, these factors have not been associated with a return to work [10, 21]. The general disability score was related to higher levels of symptoms and complaints about upper limbs [38]. In this study, women in the failure to return to work group felt weakness and post-surgery stiffness in the shoulder.

Contrary to the literature, lymphoedema in our study was not associated with a return to work [10]. This result is probably due to a lack of control of the limb volume in our study, since it was self-reported and a few women might have reported subclinical lymphoedema, which, according to the International Society of Lymphology, is distinguished by a heavy sensation of the limbs, without changing the volume of the limb [39]. Among clinical aspects, adjuvant treatments such as chemotherapy, radiation therapy, and endocrine therapy showed no association with a failure to return to work; similar results were found in a study involving breast cancer survivors in Denmark [24] and France [21].

Limitations must be considered when interpreting the results: (1) this is a cross-sectional study, which makes the establishment of cause-effect relationships difficult; (2) the data must be generalised with caution due to the moderate sample size of this study, although efforts were made to include eligible breast cancer survivors, it was necessary to maintain homogeneity and respect the eligibility criteria; (3) we did not control which breast cancer survivors received health benefits, desired to resume their jobs, or their satisfaction with work - these factors might have influenced the return to work; (4) we also did not divide the workers from public and private sectors. In private sectors, an occupation change is more complex than in the Brazilian public sector. Another difficulty is the lack of cut-off values of the WHODAS, in which disability is attributed to scores near 100. However, the majority of the population where the study was conducted is composed of workers in the public sector; therefore, these results might not be generalized to the private sector.

To the best of our knowledge, this is the first study to explore return to work rates among breast cancer survivors in Brazil and South America. This subject needs to be widely explored to better understand the return to work, making possible the creation of public policies that support breast cancer survivors to to re-enter the workforce in good health, security, and well-being [40, 41], since our reality is similar to other middle-income countries, where this subject is underexplored. Considering that upper limb disability levels were predictors of a failure to return to work, it is understood that early labour and rehabilitation focused on upper limb symptoms could help minimize disabilities and facilitate the breast cancer survivors to resume their jobs. Future studies with a cohort design should address the upper limb dominance, muscular behaviour via electromyography, and time of establishment of upper limb symptoms among manual and non-manual workers that resumed their jobs at different times; in addition to controlling lymphoedema and comparing functionality and work behaviour between breast cancer survivors with and without lymphoedema. Furthermore, it is important to highlight the need for multidisciplinary care to vary the exposure of limb activities and avoid repetitive movements that hinder a safe return to work [42].

5 Conclusion

In conclusion, more than half of Brazilian breast cancer survivors did not resume their jobs; their time for re-entering the workforce was 18 months after surgery. Among participants in the job market after disease, only 14% changed their work category. The women who did not resume their jobs showed low levels of human functionality and higher disability levels in the upper limbs. The associated risk factors that hinder the resumption of work are related to moderate/severe upper limb disability and modified radical mastectomy. As a minority of participants changed their occupation category, it is of great importance that clinical practitioners should address these questions before the rehabilitation program begins. In addition, it is important to highlight the need to create public politics regarding occupational health in developing countries such as Brazil which is very incipient.

Conflict of interest

None to report.

Funding

This work was supported by the Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina [grant number FAPESC 01/2016].

Footnotes

Acknowledgments

The authors wish to thank the medical doctors of HU Polydoro Ernani de São Thiago/Floria-nópolis/SC, Bráulio Leal Fernandes, MD and Renato Salerno Wilkens, MD. We also thank Rosicléia Pacheco Inácio, for her constant support. We would also like to thank all the breast cancer patients, especially our grandmothers Herminia Rizzi Sperandio and Odete Zomkowski for inspiring this paper.

References

Sun

, Shigaki

, Armer

. Return to work among breast cancer survivors: A literature review. Support Care Cancer. 2017;25(3):709–18.

Islam

, Dahlui

, Majid

, Nahar

, Mohd Taib

, Su

, et al. Factors associated with return to work of breast cancer survivors: a systematic review. BMC Public Health. 2014;14(Suppl 3):S8.

de Boer

AGEM

, Taskila

, Ojajärvi

, van Dijk

FJH

, Verbeek

JHAM

. Cancer Survivors and Unemployment. JAMA. 2009;301(7):753.

Timperi

, Ergas

, Rehkopf

, Roh

, Kwan

, Kushi

. Employment status and quality of life in recently diagnosed breast cancer survivors. Psychooncology. 2013;22(6):1411–20.

Zempleni

M-Z

, Michels

, Mehnert

, Schurch

, Kollias

. Cortical substrate of bladder control in SCI and the effect of peripheral pudendal stimulation. Neuroimage. 2010;49(4):2983–94.

Mehnert

, de Boer

, Feuerstein

. Employment challenges for cancer survivors. Cancer. 2013;119(Suppl 11):2151–9.

MacEachen

, Du

, Bartel

, Ekberg

, Tompa

, Kosny

, et al. Scoping Review of Work Disability Policies and Programs. Int J Disabil Manag. 2017;12:e1.

OECD. Sickness, Disability and Work: Breaking the Barriers [Internet]. OECD Publishing; 2010. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/sickness-disability-and-work-breaking-the-barriers_9789264088856-en

Cocchiara

, Sciarra

, D’Egidio

, Sestili

, Mancino

, Backhaus

, et al. Returning to work after breast cancer: A systematic review of reviews. Work. 2018;61:463–76.

10.

Azarkish

, Mirzaii Najmabadi

, Latifnejad Roudsari

, Homaei Shandiz

. Factors Related to Return to Work in Women After Breast Cancer in Iran. Iran Red Crescent Med J. 2015;17(9):e19978.

11.

Tamminga

, de Boer

AGEM

, Verbeek

JHAM

, Frings-Dresen

MHW

. Breast cancer survivors’ views of factors that influence the return-to-work process–a qualitative study. Scand J Work Environ Health. 2012;38(2):144–54.

12.

Zomkowski

, De Souza

, Da Silva

, Moreira

, De Souza Cunha

, Sperandio

. Physical symptoms and working performance in female breast cancer survivors: A systematic review. Disabil Rehabil. 2017;40(13).

13.

Ferlay

, Soerjomataram

, Dikshit

, Eser

, Mathers

, Rebelo

, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86.

14.

International Labour Office. International Standard Classification of Occupations. Geneva; 2012. Available from: http://www.ilo.org/public/english/bureau/stat/isco/docs/publication08.pdf

15.

Cooper

, Hankins

, Rixon

, Eaton

, Grunfeld

. Distinct work-related, clinical and psychological factors predict return to work following treatment in four different cancer types. Psychooncology. 2013;22(3):659–67.

16.

Organization WH. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule (WHODAS 2.0). World Health Organization; 2010. pp. 144.

17.

Hudak

, Amadio

, Bombardier

, Beaton

, Cole

, Davis

, et al. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder, and head). Am J Ind Med. 1996;29(6):602–8.

18.

Orfale

, Araújo

PMP

, Ferraz

, Natour

. Translation into Brazilian Portuguese, cultural adaptation and evaluation of the reliability of the Disabilities of the Arm, Shoulder and Hand Questionnaire. Brazilian J Med Biol Res. 2005;38(2):293–302.

19.

Rosenthal

. Meta-analytic procedures for social research [Internet]. Sage Publications; 1991. pp. 155.

20.

Ghasemi

, Zahediasl

. Normality tests for statistical analysis: a guide for non-statisticians. Int J Endocrinol Metab. 2012;10(2):486–9.

21.

Fantoni

, Peugniez

, Duhamel

, Skrzypczak

, Frimat

, Leroyer

. Factors related to return to work by women with breast cancer in northern France. J Occup Rehabil. 2010;20(1):49–58.

22.

Field

. Discovering statistics using SPSS [Internet]. SAGE Publications; 2009. pp. 821.

23.

Johnsson

, Fornander

, Rutqvist

L-E

, Vaez

, Alexanderson

, Olsson

. Predictors of return to work ten months after primary breast cancer surgery. Acta Oncol. 2009;48(1):93–8.

24.

Carlsen

, Ewertz

, Dalton

, Badsberg

, Osler

. Unemployment among breast cancer survivors. Scand J Public Health. 2014;42(3):319–28.

25.

Wennman-Larsen

, Alexanderson

, Olsson

, Nilsson

, Petersson

L-M

. Sickness absence in relation to breast and arm symptoms shortly after breast cancer surgery. Breast. 2013;22(5):767–72.

26.

Crosbie

, Kilbreath

, Dylke

, Refshauge

, Nicholson

, Beith

, et al. Effects of mastectomy on shoulder and spinal kinematics during bilateral upper-limb movement. Phys Ther. 2010;90(5):679–92.

27.

Shamley

, Srinanaganathan

, Weatherall

, Oskrochi

, Watson

, Ostlere

, et al. Changes in shoulder muscle size and activity following treatment for breast cancer. Breast Cancer Res Treat. 2007;106(1):19–27.

28.

Freitas-Silva

, lio Marques Conde

, de Freitas-Jú nior

, Zangiacomi Martinez

, nior

F-JR

. Comparison of quality of life, satisfaction with surgery and shoulder-arm morbidity in breast cancer survivors submitted to breast-conserving therapy or mastectomy followed by immediate breast reconstruction. Clinics. 2010;65(8):781–7.

29.

Shamley

, Lascurain-Aguirrebeña

, Oskrochi

, Srinaganathan

. Shoulder morbidity after treatment for breast cancer is bilateral and greater after mastectomy. Acta Oncol. 2012;51(8):1045–53.

30.

Ibrahim

, Muanza

, Smirnow

, Sateren

, Fournier

, Kavan

, et al. Time course of upper limb function and return-to-work post-radiotherapy in young adults with breast cancer: a pilot randomized control trial on effects of targeted exercise program. J Cancer Surviv. 2017;11(6):791–9.

31.

Sagen

, Kaaresen

, Sandvik

, Thune

, Risberg

. Upper limb physical function and adverse effects after breast cancer surgery: a prospective 2.5-year follow-up study and preoperative measures. Arch Phys Med Rehabil. 2014;95(5):875–81.

32.

O’Toole

, Ferguson

, Swaroop

, Horick

, Skolny

, Brunelle

, et al. The impact of breast cancer-related lymphedema on the ability to perform upper extremity activities of daily living. Breast Cancer Res Treat. 2015;150(2):381–8.

33.

Milerad

, Eriscson

. Effects of precision and force demands, grip diameter, and arm support during manual work: an electromyographic study. Ergonomics. 1994;37(2):255–64.

34.

Blinder

, Patil

, Thind

, Diamant

, Hudis

, Basch

, et al. Return to work in low-income Latina and non-Latina white breast cancer survivors: a 3-year longitudinal study. Cancer. 2012;118(6):1664–74.

35.

Giardini

, Anna

, Pisoni

, Camilla

, Giorgi

, Ines

, et al. ICF, quality of life, and depression in breast cancer: perceived disability in disease-free women 6 months after mastectomy. Support Care Cancer. 2013;21(9):2453–60.

36.

Sousa

, Nascimento De Carvalho

, Bergmann

, Nogueira Fabro

, De Almeida Dias

, Rosalina , et al. Functionality in Women after Breast Cancer Treatment. Cancerologia. 2013;59(3):409–17.

37.

Tan

, Loh

, Su

, Veloo

, Ng

. Return to work in multi-ethnic breast cancer survivors–a qualitative inquiry. Asian Pac J Cancer Prev. 2012;13(11):5791–7.

38.

Chachaj

, Małyszczak

, Pyszel

, Lukas

, Tarkowski

, Pudełko

, et al. Physical and psychological impairments of women with upper limb lymphedema following breast cancer treatment. Psychooncology.. 2010;19(3):299–305.

39.

Guedes Neto

, Hueb

, Saliture Neto

, Saad

, Fukasaua

, Esteves

, et al. Diagnóstico e tratamento de linfedema periférico -2003: consenso da Sociedade Internacional de Linfologia. J Vasc Bras. 2004;65–71.

40.

Zamanzadeh

, Valizadeh

, Zirak

, Rahmani

. Taking an obscure path, a common concern during returning to work after cancer. J Vocat Rehabil. 2019;1–8.

41.

Morrison

, Thomas

. Cancer survivors’ concealment or disclosure of diagnosis: Implications for return to work. Work. 2015;52:643–55.

42.

Straker

, Mathiassen

. Increased physical work loads in modern work - a necessity for better health and performance? Ergonomics. 2009;52(10):1215–25.