Factors associated with return to work of breast cancer patients following axillary lymph node dissection

Abstract

BACKGROUND:

The identification of factors that are related to return to work after surgery for breast cancer could help healthcare professionals accurately identify patients at risk of return to work-related difficulties in order to provide them with appropriate support during breast cancer management.

OBJECTIVE:

The aim of this study was to identify factors related to return to work in breast cancer patients three months after axillary lymph node dissection.

METHODS:

Seventy-three women who were working before the surgery were evaluated. Age, body mass index, level of lymph node dissection, marital status, children, co-resident household members, preoperative chemotherapy, postoperative chemotherapy, postoperative hormonal therapy, postoperative radiotherapy, shoulder range of motion, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and work were evaluated. Patients who had returned to work constituted the return to work group, and those who had not returned to work constituted the no return to work group.

RESULTS:

Of the patients, 36 returned to work at three months. Logistic regression analysis including the five variables showed that shoulder flexion range of motion and DASH were significantly associated with return to work (p < 0.05).

CONCLUSIONS:

The observation that the symptoms and limitations of upper limb function and shoulder flexion range of motion affect return to work may indicate the importance of postoperative rehabilitation in breast cancer patients following axillary lymph node dissection.

Keywords

Rehabilitation upper limb survivors surgery

1 Introduction

Breast cancer is one of the most common malignancies among women of working age [1]. Advances in early diagnosis and treatment are increasing the survival rate of breast cancer patients [1]. For cancer survivors, return to work affects personal satisfaction [2], quality of life [3, 4], and financial security [5, 6]. Increasing survival rates in breast cancer patients are drawing more attention to their return to work [7, 8].

Cancer patients are at increased risk for unemployment and are less likely to be re-employed than cancer-free individuals [9]. In patients with breast cancer, employment decreased after treatment, and significantly fewer patients worked after treatment compared to the general population [10]. Furthermore, after breast cancer occurs, patients need to take sick leave, with the consequent decrease in earnings [11]. Return to work after treatment is important for patients with breast cancer.

With respect to factors affecting return to work, breast cancer patients who were younger, single, divorced, and widowed were more likely to return to work [7 , 13]. With respect to the relationship between treatment and returning to work, surgical lymph node dissection, chemotherapy, and radiotherapy have been reported to be important barriers to returning to work [7 , 15]. Surgery for breast cancer leads to decreased upper limb strength, range of motion (ROM), and function, pain, lymphedema, axillary web syndrome (AWS), and decreased physical activity [16 –20]. Symptoms and decreased upper limb function affected return to work of postoperative breast cancer patients who underwent axillary lymph node dissection and sentinel node examination [21]. After lymph node dissection, decreased ROM and upper limb dysfunction are likely to occur. However, factors affecting return to work remain unclear in patients who underwent lymph node dissection. The identification of factors that are related to return to work after surgery for breast cancer could help healthcare professionals accurately identify patients at risk of return to work-related difficulties in order to provide them with appropriate support during breast cancer management [22].

The aim of this study was to identify factors related to return to work in breast cancer patients three months after axillary lymph node dissection.

2 Methods

2.1 Study design

This was a retrospective, observational study of return to work following breast cancer treatment.

2.2 Patients and methods

Of the patients with breast cancer who underwent mastectomy with lymph node dissection at our hospital from November 2013 to December 2016, the 237 patients who were referred to the Department of Rehabilitation Medicine and whose factors were evaluated for three months and were available were eligible. Of these patients, the 73 who were working before the surgery were evaluated. The patients’ demographic data are shown in Table 1. Patients who did not work before surgery were excluded. All subjects were female.

Table 1
Characteristics of all patients

Variable

Age, y^a) 52.5±9.1

Body mass index, kg/m^2a) 22.8±3.9

Shoulder flexion ROM-T, degrees^a) 156.3±12.2

Shoulder abduction ROM-T, degrees^a) 157.3±15.0

DASH, scores^a) 15.4±13.0

Treatment^b)

Surgery 73

Neoadjuvant chemotherapy 20

Postoperativechemotherapy 42

Postoperative hormonal therapy 14

Postoperative radiotherapy 26

Variable
Age, y^a)	52.5±9.1
Body mass index, kg/m^2a)	22.8±3.9
Shoulder flexion ROM-T, degrees^a)	156.3±12.2
Shoulder abduction ROM-T, degrees^a)	157.3±15.0
DASH, scores^a)	15.4±13.0
Treatment^b)
Surgery	73
Neoadjuvant chemotherapy	20
Postoperativechemotherapy	42
Postoperative hormonal therapy	14
Postoperative radiotherapy	26

^a)mean±standard deviation. ^b)proportion ROM-T, range of motion test; DASH, Disabilities of the Arm, Shoulder and Hand.

Age, body mass index, level of lymph node dissection (Level 1 or Level 2 and higher), marital status (married: yes or no), children (yes or no), co-resident household members (yes or no), preoperative chemotherapy (yes or no), postoperative chemotherapy (yes or no), postoperative hormonal therapy (yes or no), postoperative radiotherapy (yes or no), shoulder ROM, upper limb function (Disabilities of the Arm, Shoulder and Hand; DASH), and work were evaluated.

2.3 Ethical approval statement

The National Hospital Organization Shikoku Cancer Center Ethics Committee approved the study, and written, informed consent was obtained from each participant (Approval No. 2018-45).

2.4 Shoulder range of motion test

The shoulder flexion and abduction active shoulder ROM test (ROM-T) was measured by an occupational therapist and a physical therapist using a goniometer. In the present study, shoulder ROM measurements taken three months after surgery were used for the evaluation.

2.5 Disabilities of the arm, shoulder, and hand

The DASH is a self-report questionnaire developed to evaluate symptoms and physical function of the whole upper limb in people with musculoskeletal disorders of the upper extremity [23]. The main part of the DASH is a 30-item disability/symptom scale concerning the patient’s health status during the preceding week [24]. Evidence has been provided of the validity, test-retest reliability, and responsiveness of the DASH [25]. The DASH results at three months after surgery were used for the evaluation.

2.6 Work

With respect to return to work, patients were grouped into two categories. Patients who had returned to work constituted the return to work group, and those who had not returned to work constituted the no return to work group. Return to work was defined as any work resumption, irrespective of the number of hours a participant worked before diagnosis. Participants were asked whether they had returned to work at one-, two-, and three-month follow-ups.

2.7 Statistical analysis

Data distributions were tested for normality using the Shapiro-Wilk test. Univariate analysis was performed using the independent t-test, the Chi-squared test, and the Mann-Whitney U test to identify the factors associated with return to work three months after surgery. Next, including items with p < 0.1 on univariate analysis, logistic regression analysis was performed to identify the best independent predictors of return to work three months after surgery. All statistical analyses were carried out using SPSS software version 22.0 (IBM, Tokyo, Japan). A value of p < 0.05 was considered significant, and all tests were two-sided.

3 Results

Of the patients, 29 returned to work at one month, 31 at two months, and 36 at three months. The occupations of the patients before and three months after surgery are shown in Table 2. Two of the patients returned to work one month after the surgery but retired two months after the surgery. One of the patients returned to work one month after the surgery and continued to work at two months after the surgery, but retired three months after the surgery. Of the 36 patients who returned to work at three months, all returned to the same workplace as before surgery.

Table 2
Patients’ occupations beforeand three months after surgery

Occupation Before Three months

Office work 31 16

Customer service 12 7

Care work 11 4

Esthetician 2 2

Cook/ Chef 2 2

Teacher 6 1

Agriculture 2 1

Information technology-related 2 1

Package sorting 2 2

Cleaning 1

Food delivery 1

Clinical Laboratory staff 1

Occupation	Before	Three months
Office work	31	16
Customer service	12	7
Care work	11	4
Esthetician	2	2
Cook/ Chef	2	2
Teacher	6	1
Agriculture	2	1
Information technology-related	2	1
Package sorting	2	2
Cleaning	1
Food delivery	1
Clinical Laboratory staff	1

The results of the univariate analysis are shown in Table 3. Shoulder flexion ROM, shoulder abduction ROM, level of lymph node dissection, postoperative radiotherapy, and DASH were different between the two groups (p < 0.1). Logistic regression analysis including these five variables showed that shoulder flexion ROM and DASH were significantly associated with return to work (p < 0.05) (Table 4).

Table 3

Comparison of variables between the return to work group and the no return to work group

Variable	Return to work group	No return to work group	p-value
	(N = 36)	(N = 37)
Age, y^a)	52.7±9.4	52.2±8.9	0.823^c)
Body mass index, kg/m²^a)	23.5±3.9	22.1±3.9	0.088^d)
Married (yes/no)^b)	28/8	28/9	1.000^e)
Children (yes/no)^b)	27/9	27/10	1.000^e)
Co-resident household members (yes/no)^b)	32/4	32/5	1.000^e)
Level of lymph node dissection (I/II/III)^b)	31/4/1	28/4/5	0.212^d)
Shoulder flexion ROM-T, degrees^a)	158.6±13.7	154.0±10.2	0.027^d)
Shoulder abduction ROM-T, degrees^a)	158.9±16.4	155.7±13.4	0.101^d)
DASH, scores^a)	11.8±9.3	18.9±15.1	0.050^d)
Neoadjuvant chemotherapy (yes/no)^b)	8/28	12/25	0.433^e)
Postoperativechemotherapy (yes/no)^b)	20/16	22/15	0.815^e)
Postoperative hormonal therapy (yes/no)^b)	7/29	7/30	1.000^e)
Postoperative radiotherapy (yes/no)^b)	14/22	12/25	0.630^e)

^a)mean±standard deviation, ^b)proportion, ^c)independent t-test, ^d)Mann-Whitney U test, ^e)Chi-squared test. ROM-T, range of motion test; DASH, Disabilities of the Arm, Shoulder and Hand.

Table 4

Predictors of return to workon logistic regression analysis

Variable	Odds ratio (95%CI)	p-value
Body mass index	1.101 (0.951–1.274)	0.197
Level of lymph node dissection	0.182 (0.016–2.086)	0.171
Shoulder flexion ROM-T	1.106(1.011–1.209)	0.028^*
Shoulder abduction ROM-T	0.942(0.876–1.014)	0.110
DASH	0.951(0.909–0.995)	0.030^*

^*significant. CI, confidence interval; ROM-T, range of motion test; DASH, Disabilities of the Arm, Shoulder and Hand.

4 Discussion

The aim of this study was to identify factors related to return to work in breast cancer patients after axillary lymph node dissection. DASH and shoulder flexion ROM were found to have a strong effect on returning to work three months after surgery.

One year after the first surgery, a female breast cancer patient has almost three times as much risk of no longer working compared to a woman in the general population [26]. Fifty-six percent of breast cancer patients were reported to be on sick leave four to six weeks after surgery [27]. Johnsson et al. found that 59%of the women had returned to work, whereas 41%were sick-listed part-time or full-time at 10 months after surgery [28]. In the present study, return to work was examined up to three months after surgery. There was a tendency for the number of patients who returned to work to increase gradually up to three months after surgery, and 49%of patients had returned to work at three months after surgery in the present study.

Breast cancer survivors have indicated that upper limb problems make it difficult for them to resume normal activities associated with paid, as well as unpaid, work [29, 30]. Balak et al. showed that patients with shoulder function impairment resumed their work about two months later than those without any complaints [31]. Breast cancer survivors with upper limb ROM limitations and upper limb pain are more than two and half times as likely to lose some productivity compared to counterparts with no upper limb morbidity [32]. Work-related physical workload, such as heavy lifting, has also been found to negatively affect the employment of cancer survivors [33]. In the present study, the logistic regression analysis showed that the factors that affected return to work at three months after surgery were DASH and shoulder flexion ROM. The DASH is a condition-specific, patient-rated outcome measure developed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity [24]. The DASH questionnaire is being increasingly used to evaluate upper extremity disability and function in breast cancer survivors [34 –36]. A higher score on the DASH reflects greater disability. The upper limbs are frequently used not only in activities of daily living (ADL), but also in the workplace, and the appearance of upper limb disability and symptoms may be a factor limiting return to work. Furthermore, shoulder joint flexion ROM was found to affect return to work. Shoulder joint flexion, such as picking overhead, is a necessary movement not only for ADL but also for work. A home-based exercise rehabilitation program has been found to significantly improve shoulder ROM and grip strength in patients with breast cancer after surgery [37]. After breast cancer surgery, patients need to undergo continuous rehabilitation not only during hospitalization, but also after discharge, to improve upper limb function, and improvement of upper limb function leads to promotion of returning to work. Furthermore, without a system for routinely screening and monitoring patients after discharge, functional problems are unidentified and remain unaddressed [38]. Therefore, for patients after breast cancer surgery, a system that can routinely evaluate physical functions including upper limb function and ADL and perform rehabilitation according to each patient’s problems is required.

Workplace accommodation as perceived by the employee is a key factor that increases the likelihood of return to work [12]. A positive attitude of coworkers and discretion over work hours or the amount of work were positively associated with return to work [4]. In the present study, 51%of patients had not returned to work at three months after surgery. Two of the patients returned to work at one month after the surgery, but retired at two months after the surgery. One of the patients returned to work one month after the surgery and continued to work two months after the surgery, but retired three months after the surgery. Active support from employers and colleagues encourages return to work [39]. Therefore, support from the workplace according to the patient’s condition may increase the likelihood of return to work.

A few studies found that patients who received adjuvant therapies other than chemotherapy [40] or patients who did not receive any adjuvant therapy [7] returned to work earlier. Several studies reported that chemotherapy was associated with sick leave [13, 41], due to its side effects such as nausea, vomiting, fatigue, and cognitive dysfunction [14 , 43]. In the present study, chemotherapy and radiotherapy had no significant effects on return to work. However, side effects of chemotherapy and radiotherapy were not investigated. Therefore, the presence or absence of chemotherapy and radiotherapy does not affect returning to the workplace, but side effects may affect return to work.

Breast cancer survivors who are single, divorced, or widowed preferred to return to their work [7, 13]. A study has reported a significant association between unemployment and childlessness [44]. In the results of these studies, financial insecurity may also be the reason behind this. In the present study, the presence or absence of children and a spouse did not have a significant effect on returning to work. In Japan, invalidity benefits, paid vacation, and sick leave are available, so the financial burden on the patients is small. Therefore, the family situation may not have affected return to work.

5 Study limitations

First, the present study was a short-term survey evaluating return to work for up to three months after surgery, but the long-term work status of these patients has not been investigated. Therefore, whether this result reflects long-term return to work is unknown. Second, although work content and the amount of work may be involved in returning to work, it was not possible to investigate them in this study. Third, the subjects were all female; no male patients were included. Fourth, the present study was not able to investigate whether the subjects wanted to return to work. In the future, we will create a system to support returning to work for patients after breast cancer surgery, which will lead to an increase in the number of patients returning to work.

6 Conclusion

Factors affecting return to work at three months after surgery were examined in breast cancer patients after axillary lymph node dissection. The results showed that DASH and shoulder flexion ROM were strongly associated with return to work. Therefore, after breast cancer surgery, patients need to undergo continuous rehabilitation not only during hospitalization, but also after discharge, to improve upper limb function, and improvement of upper limb function leads facilitating a return to work. Furthermore, a system that can routinely evaluate physical functions including upper limb function and perform rehabilitation according to the patient’s problems is required.

Footnotes

Acknowledgments

The authors would like to thank all those who participated in the research.

Conflict of interest

The authors declare that they have no conflict of interests.

Funding

The authors received no funding for this work.

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