Breast cancer detection and care management have undergone dramatic changes in the past three decades. Survival of breast cancer has become more frequent because women are increasingly diagnosed with early-stage disease and screening. Treatment is focused on curing the disease and preventing relapse due to metastatic disease. The overall five-year survival rate is now above 85% in The Netherlands [1] and USA [2].

These major advances in detecting and managing breast cancer have led to the treatment of women who are more likely to be of working age. For some women, breast cancer may impose an economic hardship because it causes them to leave their jobs [3]. Compared with women of similar age without a history of cancer, a slightly higher proportion of cancer survivors experience reduced work ability, temporarily as well as permanently, due to retirement or disability [4–6]. Being unable to return to work after cancer treatment, frequent or prolonged work absenteeism, or problems with work performance may have a substantial economic impact on the survivor and her family [7]. Job absenteeism is an important economic outcome because days missed from work are costly to both the employer and the employee. Moreover, it is stated that the longer people are absent from their jobs, the lower the likelihood is that they will ever return to work [8]. Return to work after breast cancer is important, not only from a societal point of view, but also for the rehabilitation of the cancer survivor [9, 10]. Moreover, returning to or maintaining employment after cancer is important for survivors' quality of life, including physical and mental health [11].

In recent years, rehabilitation therapies have been developed for breast cancer survivors that focus on quality of life including physical and mental health. For example, interventions reported in observational studies that aim to improve quality of life for breast cancer survivors range from inpatient (spa) rehabilitation to telephone counselling [12–16]. The role of exercise for breast cancer patients has been examined for breast cancer-related side effects which may be especially important in patients who receive adjuvant treatment [17–19], though the number of studies is low and different types of exercise are used.

Most of these interventions show some improvement on quality of life or on other physical and psychological outcomes, such as cancer related fatigue, but do not pay attention to the aspect of work which is considered to be an important contributor to quality of life. For this reason we conducted a systematic review with the objective to study the effects and characteristics of intervention studies on breast cancer survivors in which the outcome was return to work.

Our search strategy revealed 5219 studies. Among these studies, 100 potentially relevant abstracts were identified. Following review of the full text articles, four full-length articles remained, each of which was eligible for inclusion [20–23]. The remaining 96 articles were excluded, mainly because these studies did not include work-related outcomes.

The objective of this review was to study the effects and characteristics of intervention studies on breast cancer survivors in which the outcome was return to work. After an extensive literature review we identified only four intervention studies that measured return to work, three of which published more than 25 years ago. Although return-to-work rates around 75%–85% after up to 18 months follow up seem favourable, the lack of recently published high quality trials limits the strength of the evidence observed in these four studies.

It is not clear whether return to work would have been lower without rehabilitation consisting of counseling or exercise, or no intervention, as three out of four studies did not include a comparison group. A recent surveillance study by Bouknight et al (2006) in the US, found 82% of breast cancer survivors returned to work after 12 months [24]. These results are in contrast with a return to work rate of 56% reported in a Spanish breast cancer questionnaire study [25]. There is a wide range in disability outcomes among breast cancer survivors, even when they have had the same disease with equal severity [26]. Sick leave is on average about a year, but nevertheless varies from a couple of days to a couple of years. Though in the similar range, any comparisons between return to work rates observed in our review and recent survey studies are difficult to make as breast cancer survivor populations, medical procedures, rehabilitation strategies, and social security and health insurance provisions are not likely to be comparable.

On the other hand, return-to-work rates from more than two decades ago would likely be lower compared to today, as cancer related morbidity is lower and survival has significantly improved due to medical advances. Despite better medical treatment and physical and psychosocial rehabilitation, a five year follow up update of the Fismen et al study (2000) on the same study population reported that 23% of patients had died of cancer, depression and anxiety were similar to the situation directly post-rehabilitation, and almost half (44%) of the remaining patients had lost their job compared to 22% three months after surgery [27].

Of interest, the included studies [20, 23] indicated that longer time needed to return to work was related to more extensive surgical procedures. In any case, time needed to return to work may be a more important outcome if absolute return-to-work rates continue to improve as some of these high return to work rates suggest.

Given the limitations of the three older studies and the somewhat sobering results of the recent Fisman study, we believe that return to work rates outcomes can be further improved. In addition to design issues and the quality of medical care, it is important to understand that return to work in this review was not the primary aim for any of the four studies included, but rather improvement of "physical and social recovery" in the context of a more 'traditional' rehabilitation context. In all four studies this included instructions or advice on specific exercises, for example to mobilise the shoulder or more general training of physical capacity, both of varying frequency and given in groups, individually or solely as a home assignment. In conjunction, counselling was part of a pre- and post operative care program and provided by a specialized nurse or social worker who provided support, encouragement, advice and openness to discuss feelings. Tailoring the exercise and counselling content specifically towards vocational outcomes (like return to work) was not apparent in any of the descriptions of these four studies and was, as explained earlier, not a specific long term goal.

Short et al (2005) showed that when work issues are addressed as a part of treatment, return to work is more successful after cancer [28]. Although the literature on breast cancer does not provide us with much information regarding interventions which are specifically targeted at vocational outcomes such as return to work, there is research from studies on cancer and other diseases in the occupational health literature which could be applied to improve return to work outcomes for breast cancer survivors. The issue of return to work should be addressed in intervention studies [29]. This includes more attention, information, support, and advice on work issues, not only by health care professionals but also by employers.

Rehabilitation needs of cancer patients focus around fatigue, reinforcing physical working capacity and psychosocial functioning [30]. In addition to prolonged physical or mental fatigue, qualitative research has also identified personal problems such as cognitive limitations, difficulty mobilising support, difficulty managing stress and anxiety, difficulty coping with a new self image, and changed attitude to work [24, 31–34]. As mentioned above, both exercise and counselling seem good alternatives to deal with these problems that patients experience but could be further improved upon by including work resumption as a specific long term goal.

Work factors that could be positively targeted for interventions deal with, for example, good communication with co-workers and employers, early contact with the workplace, or work accommodations such as flexibility regarding work hours [34–36]. In addition, there is evidence that special arrangements made by the employer such as gradual return to work facilitates return to work [37]. Vocational rehabilitation or return-to-work programs target the barriers and facilitators for the return to work issues listed above and have been successfully applied in the area of rheumatoid arthritis [38] and other diseases [37, 39].

Several rehabilitation strategies have proven valuable for patients with cancer or other diseases. For example, graded activity, a theory that promotes a step by step increase in activity, is beneficial for cancer patients to deal with fatigue and functioning [15]. In addition, workplace interventions such as work modifications and case management involving all stakeholders has been successfully applied for the return to work of workers with low back pain [40, 41]. Also, cancer survivors may benefit from advice to structure the return to work process and use goal-setting during rehabilitation [42, 43]. Verbeek and Spelten (2007) introduced a 10-step plan for return to work that was tested among cancer survivors at a radiotherapy department. The plan consists of a fixed scheme with the end-point return to work starting early in the rehabilitation process and in collaboration with the employer [29].

In this review the number of rehabilitation visits in the included studies is quite low. The duration of traditional rehabilitation is often limited to a maximum of about three months after surgery and this period may not be long enough to support patients who are in the process of returning to work. Therefore, if duration of functional capacity is to be really improved [19, 44] it is suggested that rehabilitation programs are also of adequate duration, frequency and intensity. Additionally, changing psychosocial outcomes, behaviour in particular, may require more intensive intervention strategies during the complex return-to-work process over a longer period of time [43].

In conclusion, the most important finding of this review is the lack of intervention studies that are focused on return to work. Using evidence from qualitative and observational studies on cancer and other diseases, and the good results of studies on return to work programs and vocational rehabilitation, return to work interventions for breast cancer survivors should be further developed and evaluated. Ultimately this may lead to a better quality of life and functioning, improve social economic outcomes, and a quicker return to work for breast cancer survivors.

A) Identification of breast cancer studies

1) (("breast neoplasms" [TIAB] NOT Medline [SB]) OR "breast neoplasms" [MeSH Terms] OR breast cancer [Text Word]) AND "humans" [MeSH Terms]

B) Identification of intervention studies

2) text words

effectiveness [tw] OR program [tw] OR intervention [tw] OR reduction [tw] OR effect$ [ti] OR evaluation [tw] OR decrease$ [tw] OR "prevention and control" [sh] OR measures [tw] OR improve$ [tiab] OR educat$ [tw] OR training [tw] OR rehabilitation [tw]

3. type design – use of PT and MESH

randomized controlled trial [pt] OR controlled clinical trial [pt] OR randomized controlled trials [mh] OR random allocation [mh] OR double-blind method [mh] OR single-blind method [mh] OR clinical trial [pt] OR clinical trials [mh] OR "clinical trial" [tw] OR comparative study [pt] OR evaluation studies [MeSH Terms] OR evaluation studies [mh] OR follow-up studies [mh] OR prospective studies [mh] OR cross-over studies [mh] OR treatment outcome [mh] OR "time series" [tw]

4) sensitive search

effect$ [tw] OR control$ [tw] OR evaluat$ [tw] OR compare$ [tw] program$ [tw] outcome$ [tw]

C) Identification of studies with relevant outcomes/or studies that include a work related term

5) work related outcomes:

"return to work" [tw] OR absenteeism OR "sickness absence" [tw] OR sick leave OR retirement OR "disability pension" OR "work disability" [tw] OR unemployment OR employment OR "work status" [tw] OR "work ability" [tw] OR "employment status" [tw]

6) OR "quality of life" [MeSH Terms] OR "quality of life" [tw]

7) OR fatigue [tw]

8) work related terms:

OR occupation$ OR "occupational health services" OR "occupational health" OR unemployed OR employed OR job OR vocational OR (occupational AND therap$) OR (occupational AND intervention$) OR "supported employment" OR "vocational rehabilitation" [tw] OR "work capacity evaluation" [tw] OR "vocational guidance" [tw] OR "work load"