Hu D, Li Y, Zhang H, Wang LL, Liu WW, Yang X, Xiao MZ, Zhang HL, Li J. Return to work in young and middle-aged colorectal cancer survivors: Factors influencing self-efficacy, fear, resilience, and financial toxicity. World J Gastroenterol 2025; 31(1): 100357 [DOI: 10.3748/wjg.v31.i1.100357]
Corresponding Author of This Article
Juan Li, MM, Chief Nurse, Academic Affairs Office, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China. 1005945635@qq.com
Research Domain of This Article
Nursing
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Dan Hu, Yue Li, Xin Yang, Ming-Zhao Xiao, Department of Nursing, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Dan Hu, Department of Nursing, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing 400014, China
Hua Zhang, Lian-Lian Wang, Wen-Wen Liu, Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Hao-Ling Zhang, Department of Biomedical Science, Advanced Medical and Dental Institute, University Sains Malaysia, Penang 13200, Malaysia
Juan Li, Academic Affairs Office, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Co-corresponding authors: Hao-Ling Zhang and Juan Li.
Author contributions: Hu D, Li Y, Zhang H, Wang LL, and Liu WW conceived the concept; Hu D and Li Y designed the questionnaire and wrote the original draft; Zhang H, Wang LL, and Liu WW collected the questionnaire data; Hu D and Yang X analyzed the data; Zhang HL and Xiao MZ reviewed and edited the manuscript; Zhang HL and Li J contributed to the supervision of this manuscript and should be considered as co-corresponding authors; and all the authors have read and approved the final manuscript.
Supported by the Chongqing Medical University Program for Youth Innovation in Future Medicine, No. W0019; and Chongqing Municipal Education Commission’s 14th Five-Year Key Discipline Support Project, No. 20240101 and No. 20240102.
Institutional review board statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of the First Affiliated Hospital of Chongqing Medical University, approval No. 2022-K393.
Informed consent statement: The informed consent was waived by the Institutional Review Board.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Juan Li, MM, Chief Nurse, Academic Affairs Office, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400016, China. 1005945635@qq.com
Received: August 14, 2024 Revised: October 29, 2024 Accepted: November 18, 2024 Published online: January 7, 2025 Processing time: 117 Days and 4.3 Hours
Abstract
BACKGROUND
Return to work (RTW) serves as an indication for young and middle-aged colorectal cancer (CRC) survivors to resume their normal social lives. However, these survivors encounter significant challenges during their RTW process. Hence, scientific research is necessary to explore the barriers and facilitating factors of returning to work for young and middle-aged CRC survivors.
AIM
To examine the current RTW status among young and middle-aged CRC survivors and to analyze the impact of RTW self-efficacy (RTW-SE), fear of progression (FoP), eHealth literacy (eHL), family resilience (FR), and financial toxicity (FT) on their RTW outcomes.
METHODS
A cross-sectional investigation was adopted in this study. From September 2022 to February 2023, a total of 209 participants were recruited through a convenience sampling method from the gastrointestinal surgery department of a class A tertiary hospital in Chongqing. The investigation utilized a general information questionnaire alongside scales assessing RTW-SE, FoP, eHL, FR, and FT. To analyze the factors that influence RTW outcomes among young and middle-aged CRC survivors, Cox regression modeling and Kaplan-Meier survival analysis were used.
RESULTS
A total of 43.54% of the participants successfully returned to work, with an average RTW time of 100 days. Cox regression univariate analysis revealed that RTW-SE, FoP, eHL, FR, and FT were significantly different between the non-RTW and RTW groups (P < 0.05). Furthermore, Cox regression multivariate analysis identified per capita family monthly income, job type, RTW-SE, and FR as independent influencing factors for RTW (P < 0.05).
CONCLUSION
The RTW rate requires further improvement. Elevated levels of RTW-SE and FR were found to significantly increase RTW among young and middle-aged CRC survivors. Health professionals should focus on modifiable factors, such as RTW-SE and FR, to design targeted RTW support programs, thereby facilitating their timely reintegration into mainstream society.
Core Tip: This study explored the status of returning to work among young and middle-aged colorectal cancer survivors, as well as the barriers and facilitators of it. Cox regression and Kaplan-Meier survival analyses were employed to analyze the questionnaires of 209 participants. Finally, this study identified several facilitators that promote the return to work among young and middle-aged colorectal cancer survivors. These include a higher family monthly income per capita, employment in white-collar occupations, elevated return-to-work self-efficacy, and family resilience.
Citation: Hu D, Li Y, Zhang H, Wang LL, Liu WW, Yang X, Xiao MZ, Zhang HL, Li J. Return to work in young and middle-aged colorectal cancer survivors: Factors influencing self-efficacy, fear, resilience, and financial toxicity. World J Gastroenterol 2025; 31(1): 100357
In 2020, the International Agency for Research on Cancer disseminated global epidemiological data on cancer, revealing that there were 1.93 million newly diagnosed cases of colorectal cancer (CRC) internationally, thus positioning it as the third most prevalent malignancy worldwide[1]. Concurrently, data from the National Cancer Center indicated that 560000 new CRC cases were recorded in China in 2020, ranking second, with an incidence rate of 12.2%[1]. Furthermore, the 2019 Chongqing Residents’ Health Status Report identified colorectal and anal cancer as the second most prevalent tumors in the region. In recent years, a relatively favorable overall prognosis for CRC has emerged, which is largely attributable to the implementation of comprehensive treatment protocols that integrate surgical intervention and chemotherapy, which have markedly improved survival rates among CRC patients[2]. However, this progress also presents heightened challenges in the realm of survivorship care. Return to work (RTW) constitutes a critical issue within the survival care framework for young and middle-aged CRC survivors, as this demographic is pivotal to household income and social productivity[3].
The facilitation of RTW for these individuals is of paramount importance. RTW not only serves as a crucial indicator of successful reintegration into normal social life[4] but also promotes daily interpersonal interactions and social connections[5], while contributing to the reconstruction of self-image and self-esteem[6]. Additionally, RTW plays an essential role in bolstering confidence and enhancing the ability to navigate economic challenges[7]. Consequently, promoting postoperative recovery through the facilitation of RTW is imperative. Indeed, RTW represents a vital initiative aimed at advancing the postoperative rehabilitation of cancer patients, with the ultimate goal of reintegrating them into normal life being a key focus of rehabilitation efforts[8]. Healthcare professionals should prioritize and actively engage in research concerning the RTW of CRC survivors, to foster their prompt reintegration into the fabric of social life.
Young and middle-aged CRC survivors face considerable challenges when attempting to reintegrate into the workforce. After treatment, these survivors often grapple with both physical and psychosocial hurdles that hinder their ability to RTW. Physically, CRC survivors frequently contend with complications arising from surgery, chemoradiotherapy, and ostomy procedures, each of which can variably affect their RTW prospects[9]. Psychosocially, many survivors lack a clear understanding and guidance regarding the process of re-entering the workforce, coupled with diminished confidence in their capacity to successfully reintegrate. This situation is exacerbated by economic pressures and insufficient familial support, which can precipitate negative emotions, such as anxiety and fear of disease recurrence, that ultimately obstruct RTW efforts and adversely affect the quality of life[5,6,10,11]. Research has shown that, compared with the general population, CRC survivors experience 3.8-fold greater difficulty in returning to work[12].
The RTW process is influenced by a multitude of factors, including demographic variables, such as age and family income, disease-related factors, such as tumor stage and the presence of colostomy, and occupational considerations, such as job type and work nature. Prior investigations have highlighted that RTW self-efficacy (RTW-SE) is closely linked to the success of the RTW process[13,14], and RTW initiatives can mitigate cancer patients’ fear of progression (FoP)[10]. Furthermore, health literacy has emerged as a modifiable factor that can enhance RTW outcomes[15]. Insufficient family support has been identified as a significant barrier for CRC survivors seeking RTW[16]. Economic factors also play a pivotal role in predicting RTW outcomes among CRC survivors[17]. Therefore, identifying the key determinants that influence the RTW experiences of CRC survivors is essential for improving their physical and psychological well-being, facilitating postoperative rehabilitation, alleviating the economic burden on families, and ultimately generating social value.
Although numerous studies have examined the reintegration of CRC survivors into the workforce internationally, the majority of these investigations are predominantly situated within developed nations such as the Netherlands and the United States[18-20]. Given the disparities among nations, the findings from these international studies may not provide adequate guidance for analogous research within our own country. Therefore, investigations that are focused on the national context of China, with a specific focus on the RTW experiences of CRC survivors, are imperative. Furthermore, the data utilized in foreign research are typically derived from established databases, such as the National Cancer Registry and the National Occupational Health Service Registry. This method allows for the extraction of only certain relevant factors and often omits direct patient engagement, which may result in the absence of critical data. At present, domestic research concerning young and middle-aged CRC survivors’ reintegration into the workforce remains nascent. Several scholars have explored the determinants influencing the RTW of this demographic; however, these studies face specific limitations. Previous investigations have focused primarily on the influence of gastrointestinal symptoms, psychosocial adaptation to illness, and work capability on RTW[9,21], but there is a pressing need to enhance the discourse by incorporating perspectives such as RTW-SE, FoP, eHealth literacy (eHL), family resilience (FR), and financial toxicity (FT) to better understand their roles in the RTW experiences of young and middle-aged CRC survivors.
In summary, the principal objectives of this study were to: (1) Assess the RTW ratio and timeline among young and middle-aged CRC survivors; (2) Examine the distinctions between RTW and non-RTW groups through the lens of demographic data, disease-related factors, occupation-related factors, RTW-SE, FoP, eHL, FR, and FT; and (3) Identify the enabling factors and obstacles affecting the RTW of CRC survivors, based on the factors preliminarily delineated in the research objectives.
MATERIALS AND METHODS
Design and participants
From September 2022 to February 2023, convenience sampling was employed to select young and middle-aged CRC survivors who were 3 months to 12 months postdischarge from the Department of Gastrointestinal Surgery of a class A tertiary hospital in Chongqing. The inclusion criteria for participants were as follows: (1) A confirmed initial diagnosis of CRC; (2) An age range of 18-59 years[22]; (3) Prior employment before the diagnosis of CRC; (4) Completion of surgical treatment; (5) Discharge within 3-12 months; and (6) Provision of informed consent and willingness to participate in the study. The exclusion criteria were as follows: (1) Other malignant tumors or serious physical ailments, such as disabilities; and (2) Mental illnesses or severe cognitive impairments that hindered their ability to cooperate with the research. Approval from the Hospital Ethics Committee, No. 2022-K393 and informed consent from participants were obtained prior to data collection. With the use of Kendall’s method for rough sample size estimation, the required sample size was determined to be 5-10 times the number of variables, and accounting for a potential attrition rate of 20%, it was projected that 150-300 subjects would be necessary[23]. During the data collection phase, a total of 228 questionnaires were distributed. Following the investigation, 11 questionnaires were deemed lost to follow-up, resulting in 217 successfully retrieved questionnaires. In the secondary verification process, after 8 invalid responses outside the stipulated age range were excluded, a total of 209 valid questionnaires were included in the analysis.
Measures
RTW: Existing studies have not yet established a unified concept of RTW. In this study, the definition refers to the view put forth by Zhang et al[9], that is, RTW is defined as encompassing not only patients’ resumption of employment after the completion of disease treatment but also their ongoing efforts to sustain their original employment during the intertreatment phase.
General information questionnaire: The questionnaire was meticulously crafted by the researchers after a thorough review of pertinent literature, encompassing social demographic data, disease-related data, and occupation-related data. The social demographic data included variables such as age, gender, education, health insurance, and family monthly income per capita. The disease-related data included factors such as the site of cancer, comorbidity, cancer stage, tumor differentiation, postoperative chemotherapy, and the presence of a stoma. Additionally, the occupation-related data encompassed job type, the nature of work, employment contracts, RTW status (yes or no), and the duration of RTW.
RTW-SE questionnaire: The RTW-SE was developed by Dutch scholar Lagerveld et al[24] in 2010. This instrument is designed to evaluate cancer patients’ beliefs regarding their ability to RTW, thereby reflecting the level of self-efficacy associated with their RTW endeavors. The questionnaire comprises a total of 11 items and employs a 6-point Likert scale, with scores ranging from 1 to 6 to indicate levels of agreement: “completely disagree”, “disagree”, “slightly disagree”, “slightly agree”, “agree”, and “completely agree”. A higher score on the RTW-SE signifies greater self-efficacy in returning to work. The Cronbach’s α coefficient for the Chinese version of the RTW-SE was 0.923, indicating robust reliability and validity for assessing RTW-SE among Chinese cancer patients[25]. The Cronbach’s α coefficient in this study was 0.969.
FoP questionnaire-short form: FoP refers to an individual’s anxiety or apprehension regarding disease progression, metastasis, or recurrence. The FoP questionnaire-short form is utilized to evaluate patients’ FoP levels. Compiled by Mehnert et al[26], the questionnaire consists of 12 items that are divided into two dimensions: Social family (6 items) and physical health (6 items). A 5-point Likert scale is employed, with scores ranging from 1 to 5 corresponding to “never”, “rarely”, “sometimes”, “often”, and “always”. The cumulative score ranges from 12 to 60, with higher scores indicating greater FoP. The Cronbach’s α coefficient for the Chinese version of the FoP questionnaire-short form was found to be 0.88, demonstrating strong reliability and validity[27]. The Cronbach’s α coefficient in this study was 0.940.
Simplified Chinese version of the eHL scale: In 2006, Norman and Skinner[28] introduced the eHL scale, which encompasses three dimensions: The ability to apply network health information and services, the capacity for evaluation, and competence in decision-making. This scale comprises 8 items designed to assess the respondent’s eHL levels. A 5-point Likert scoring system is utilized, with scores ranging from 1 to 5 corresponding to “very inconsistent”, “moderately inconsistent”, “indefinable”, “moderately consistent”, and “very consistent”. The overall score is computed as the sum of individual item scores, with a possible range of 8 points to 40 points. A higher total score signifies a greater level of eHL. Xu et al[29] validated the simplified Chinese version of the eHL scale as an effective and reliable instrument for measuring patients’ self-reported eHL in China, reporting a Cronbach’s α coefficient of 0.96. The Cronbach’s α coefficient in this study was 0.977.
The shortened Chinese version of the FR assessment scale: Developed by American scholar Sixbey[30], this instrument serves as a valuable tool for assessing FR levels among research participants while also offering insights into their coping strategies and capacity to navigate challenges. In addition, it provides guidance for potential family interventions. The scale has a Cronbach’s α coefficient of 0.96, underscoring its reliability. It is widely employed to measure FR across various populations[31]. Furthermore, Li et al[32] undertook localization efforts, resulting in a refined version that encompasses three dimensions and consists of thirty-two items, demonstrating high internal consistency with a Cronbach’s α coefficient of 0.95. The scale utilizes a 4-point Likert scoring system, in which 1 point denotes “strongly disagree”, 2 points signify “disagree”, 3 points indicate “agree”, and 4 points represent “strongly agree”. The total score ranges from 32 points to 128 points, with higher scores reflecting greater levels of FR. This scale has been effectively applied to diverse populations, with its efficacy particularly validated among cancer survivors[33]. The Cronbach’s α coefficient in this study was 0.978.
Comprehensive scores for FT based on the patient-reported outcome measures: This scale represents the inaugural assessment tool specifically designed to measure the extent of FT experienced by cancer patients. Developed by de Souza et al[34], it encompasses 11 items across three distinct dimensions. A 5-point Likert scoring system is employed, with scores ranging from 0 to 4 corresponding to “not at all”, “a little”, “some”, “quite”, and “very”. The total score can range from 0 point to 44 points; a lower total score indicates greater FT faced by patients because of their illness. The Cronbach’s α coefficient for the Chinese patient-reported outcome measures scale was reported to be 0.889[35]. The Cronbach’s α coefficient in this study was 0.964.
Statistical analyses
Data analysis was conducted using SPSS 26.0 software. For measurement data conforming to a normal distribution, the results are expressed as the mean ± SD; conversely, data that did not meet this criterion were are represented by the median and interquartile range. Categorical data are presented as frequencies and percentages. Cox univariate analysis was employed to ascertain the influencing factors related to RTW among young and middle-aged CRC survivors. Variables exhibiting a P value of less than 0.05 were subsequently incorporated into the Cox regression model within the survival analysis framework to further elucidate independent factors associated with the RTW of this demographic. Kaplan-Meier survival curves were constructed for the multivariate significant variables identified through Cox regression. All statistical tests were performed using two-tailed methods, with the significance level set at α = 0.05.
RESULTS
Participant characteristics
Among the 209 young and middle-aged CRC survivors surveyed 3-12 months after hospital discharge, 118 (56.46%) did not RTW, whereas 91 (43.54%) successfully resumed their employment, with an average RTW duration of 100.79 days. The scores for RTW-SE, FoP, eHL, FR, and FT were recorded as 45.12 ± 10.45, 26.91 ± 7.14, 24.10 ± 9.70, 106.22 ± 12.08, and 19.67 ± 10.02, respectively. The characteristics of the participants are detailed in Table 1.
Table 1 Characteristics of young and middle-aged colorectal cancer survivors, n (%).
Variable
Total (N = 209)
Non-RTW, n = 118 (56.46%)
RTW, n = 91 (43.54%)
Age (years), mean ± SD
50.55 ± 7.67
50.97 ± 7.46
50.01 ± 7.95
Gender
Male
148 (70.81)
78 (66.10)
70 (76.92)
Female
61 (29.19)
40 (33.90)
21 (23.08)
Education
Junior high school or below
102 (48.80)
69 (58.47)
33 (36.26)
High school or above
107 (51.20)
49 (41.53)
58 (63.74)
Health insurance
Employee health insurance
109 (52.15)
50 (42.37)
59 (64.84)
Other
100 (47.85)
68 (57.63)
32 (35.16)
Family monthly income per capita (RMB), n (%)
≤ 2000
99 (47.37)
76 (64.41)
23 (25.27)
> 2000
110 (52.63)
42 (35.59)
68 (74.73)
Job type
Blue-collar
106 (50.72)
82 (69.49)
24 (26.37)
White-collar
103 (49.28)
36 (30.51)
67 (73.63)
Nature of work
Physical labor
93 (44.50)
69 (58.47)
24 (26.37)
Cognitive labor
116 (55.50)
49 (41.53)
67 (73.63)
Employment contracts
Non-long-term contracts
66 (31.58)
54 (45.76)
12 (13.19)
Long-term contracts
143 (68.42)
64 (54.24)
79 (86.81)
Site of cancer
Colon
99 (47.37)
49 (41.53)
50 (54.95)
Rectum
110 (52.63)
69 (58.47)
41 (45.05)
Comorbidity
No
162 (77.51)
97 (82.20)
65 (71.43)
Yes
47 (22.49)
21 (17.80)
26 (28.57)
Cancer stage
I or II
122 (58.37)
59 (50.00)
63 (69.23)
III or IV
87 (41.63)
59 (50.00)
28 (30.77)
Tumor differentiation
Low or high
26 (12.44)
12 (10.17)
14 (15.38)
Medium
183 (87.56)
106 (89.83)
77 (84.62)
Postoperative chemotherapy
No
61 (29.19)
25 (21.19)
36 (39.56)
Yes
148 (70.81)
93 (78.81)
55 (60.44)
Stoma
No
150 (71.77)
75 (63.56)
75 (82.42)
Yes
59 (28.23)
43 (36.44)
16 (17.58)
Total hospitalization cost (ten thousand yuan), mean ± SD
6.79 ± 1.99
6.97 ± 2.16
6.54 ± 1.74
RTW-SE, mean ± SD
45.12 ± 10.45
37.92 ± 7.96
54.45 ± 3.73
The eHL, mean ± SD
24.10 ± 9.70
22.39 ± 9.50
26.32 ± 9.55
FR, mean ± SD
106.22 ± 12.08
98.79 ± 7.92
115.87 ± 9.45
FoP, mean ± SD
26.91 ± 7.14
30.98 ± 5.51
21.64 ± 5.35
FT, mean ± SD
19.67 ± 10.02
15.55 ± 9.21
25.00 ± 8.42
Differences between the RTW and non-RTW groups
The results of the Cox univariate analysis indicate that the RTW and non-RTW groups exhibited significant differences (P < 0.05) across the majority of the evaluated factors. These factors included the nature of work; family monthly income per capita; employment contracts; postoperative chemotherapy; education, health insurance, presence of a stoma, site of cancer, job type, cancer stage, and scores for RTW-SE, FoP, eHL, FR, and FT (Table 2).
Table 2 Cox univariate analysis of return to work in young and middle-aged colorectal cancer survivors.
Variable
β
SE
Z
HR (95%CI)
P value
Age
-0.01
0.01
-1.03
0.99 (0.96-1.01)
0.303
Gender (with male as reference)
Female
-0.32
0.25
-1.30
0.72 (0.44-1.18)
0.194
Education (with junior high school or below as reference)
Facilitating factors and barriers that impact RTW for CRC survivors
To address the potential confounding variables identified as significant in the Cox univariate analysis, we conducted a multivariate analysis utilizing the Cox regression model within the survival analysis framework. The findings indicated that family monthly income per capita, job type, RTW-SE, and FR independently influenced the RTW outcomes of young and middle-aged CRC survivors (P < 0.05). The results of the Cox multivariate analysis are presented in Table 3. Using the receiver operating characteristic curve, RTW-SE was classified into two categories ≤ 48 points and > 48 points, whereas FR was categorized as ≤ 104 points and > 104 points. The outcomes of the receiver operating characteristic curve analysis are presented in Table 4. In the statistical analysis, reference categories were established for family monthly income per capita (≤ 2000 RMB), job type (white collar), RTW-SE score (≤ 48 points), and FR score (≤ 104 points). Among these variables, the regression coefficient for job type was found to be less than 0 (relative risk < 1), indicating that engagement in white-collar employment has a positive effect on the RTW of young and middle-aged CRC survivors. Conversely, family monthly income per capita ≤ 2000 RMB, RTW-SE ≤ 48 points, and FR ≤ 104 points were identified as obstacles to RTW.
Table 3 Cox multivariate analysis of influence on return to work in young and middle-aged colorectal cancer survivors.
Variable
β
SE
Z
HR (95%CI)
P value
Education (with junior high school or below as reference)
High school or above
0.02
0.30
0.07
1.02 (0.56-1.86)
0.94
Health insurance (with employee health insurance as reference)
Other
-0.40
0.31
-1.32
0.67 (0.37-1.22)
0.188
Family monthly income per capita (with ≤ 2000 as reference)
Table 4 the receiver operating characteristic curve results of return-to-work self-efficacy and family resilience.
Variable
AUC
Optimum cut-off value
Sensitivity
Specificity
Cut-off
RTW-SE
0.963
0.832
0.934
0.898
48
FR
0.899
0.718
0.879
0.839
104
Influence of family monthly income per capita on RTW in young and middle-aged CRC survivors: Among the 209 young and middle-aged CRC survivors enrolled in this study, 99 (47.4%) reported a family monthly income per capita of less than 2000 RMB, with a median time to RTW of 6.67 months. In contrast, 110 (52.6%) had a family monthly income per capita exceeding 2000 RMB, and their median time to RTW was 4.8 months (P = 0.013), accompanied by a regression coefficient of 1.04, which is greater than 0. Thus, the disparity between the two groups was statistically significant, indicating that a family monthly income per capita ≤ 2000 RMB serves as a detrimental influencing factor for RTW among young and middle-aged CRC survivors. The results of the Kaplan-Meier survival analysis are illustrated in Figure 1A.
Figure 1 Kaplan-Meier survival curve of multivariate significant variables.
A: Influence of family monthly income per capita on return to work (RTW) in young and middle-aged colorectal cancer (CRC) survivors; B: Influence of job type on RTW in young and middle-aged CRC survivors; C: Influence of RTW-self-efficacy on RTW in young and middle-aged CRC survivors; D: Influence of family resilience on RTW in young and middle-aged CRC survivors. RTW-SE: Return to work self-efficacy; FR: Family resilience.
Influence of job type on RTW in young and middle-aged CRC survivors: Among the 209 young and middle-aged CRC survivors participating in this study, 106 (50.7%) were employed in blue-collar occupations, with a median time to RTW of 8.33 months. Conversely, 103 (49.3%) were engaged in white-collar jobs, and their median time to RTW was 5.27 months (P = 0.002). The regression coefficient was -0.82, indicating a value less than 0. Thus, the difference between the two groups was statistically significant, suggesting that employment in blue-collar jobs constitute a barrier to RTW for young and middle-aged CRC survivors. The results of the Kaplan-Meier survival analysis are presented in Figure 1B.
Influence of RTW-SE on RTW in young and middle-aged CRC survivors: Among the 209 young and middle-aged CRC survivors included in this study, 112 (53.59%) presented RTW-SE scores ≤ 48 points, with a median time to RTW of 8.13 months. In contrast, 97 (47.41%) had RTW-SE scores exceeding 48 points, and their median RTW time was 3.07 months (P < 0.001). The regression coefficient was 0.15, which is greater than 0. Thus, the disparity between the two groups was statistically significant, indicating that an RTW-SE score greater than 48 points serves as a facilitating factor for young and middle-aged CRC survivors at RTW. The results of the Kaplan-Meier survival analysis are depicted in Figure 1C.
Influence of FR on RTW in young and middle-aged CRC survivors: Among the 209 young and middle-aged CRC survivors included in this study, 110 (52.63%) had an FR score of ≤ 104 points, with a median time to RTW of 7.62 months. In contrast, 99 (47.37%) had an FR score exceeding 104 points, and their median RTW time was 3.3 months (P < 0.001). The regression coefficient was 0.08, indicating a positive value. Thus, the difference between the two groups was statistically significant, suggesting that an FR score greater than 104 points serves as a facilitating factor for young and middle-aged CRC survivors at RTW. The results of the Kaplan-Meier survival analysis are illustrated in Figure 1D.
DISCUSSION
The objective of this study was to examine the social challenges faced by young and middle-aged CRC survivors in their efforts to RTW, and to analyze the influence of demographic factors, disease-related variables, occupation-related characteristics, RTW-SE, FoP, eHL, FR, and FT on their RTW journey. Our findings revealed that 43.54% of young and middle-aged CRC survivors successfully returned to work within 3-12 months after discharge, with an average RTW duration of 100 days. Furthermore, factors such as family monthly income per capita, job type, RTW-SE, and FR had statistically significant effects on the RTW of CRC survivors. FoP, eHL, and FT were significant in the univariate Cox regression analysis but were not statistically significant after multivariate Cox regression. The reason may be the influence of confounding factors, insufficient sample size, multicollinearity, or effect dilution. Therefore, it will be necessary in future studies to strengthen the control of confounding factors, increase the sample size, and check for multicollinearity among independent variables. These findings enhance our understanding of the factors influencing the RTW process for CRC survivors and provide innovative insights for the development of targeted RTW support programs. By addressing modifiable factors, such as RTW-SE and FR, we can facilitate a more timely reintegration of young and middle-aged CRC survivors into normal social life.
The findings of this study indicate that the RTW rate among young and middle-aged CRC survivors within 3-12 months after discharge was 43.54% (91/209), a figure that is notably lower than the rates reported by Zhang et al[9] and Yuan et al[21] (68.4% and 51.2%, respectively); this suggests a moderate level that necessitates enhancement. The discrepancies in RTW rates among young and middle-aged CRC survivors may be attributed to varying definitions of RTW across different studies involving cancer patients. In this investigation, RTW is defined as patients either maintaining employment during treatment after a diagnosis or reengaging in work after treatment, which is consistent with prior evidence[9]. In contrast, Yuan et al[21] defines RTW as re-engagement in work after a leave of absence for treatment. To facilitate the generalizability of research findings and ensure the efficacy of interventions, there is a pressing need to further clarify and standardize the definition of RTW. This variation may stem from the fact that the participants in this study were CRC survivors within 3-12 months of hospital discharge. Those discharged less than 12 months prior are typically in the early stages of recovery, focusing predominantly on the rehabilitation of their physical health. As the length of time since discharge increases, these survivors often experience a shift in perspective; their physical condition improves, their self-care capabilities strengthen, and they become more capable of contemplating social reintegration and RTW, thereby increasing the RTW rate. The systematic review conducted by Duijts et al[36] further indicates that it takes time for cancer survivors to adapt before they are capable of coping with the requirements of work again. Thus, nursing staff should conduct systematic vocational rehabilitation assessments for young and middle-aged CRC survivors in the early stages of their recovery; this should be accompanied by the development of a comprehensive RTW support program that addresses key influencing factors, thereby bolstering their awareness and confidence in returning to work and ultimately improving the RTW rate.
This study revealed that the average duration for young and middle-aged CRC survivors to RTW was 100 days after discharge, equating to approximately 3-4 months. This timeframe is notably shorter than that reported by Zhang et al[9], who determined that the average RTW duration for this demographic was 6 months. The variation in RTW timing among young and middle-aged CRC survivors may be attributed to differences in per capita monthly family income, which arise from disparities in economic development between Chongqing and Guangdong. Among the participants in Zhang et al’s study[9], only 16.5% of patients reported a family monthly income per capita of less than 2000 RMB, in stark contrast to the 47.37% of subjects in the present study. This disparity suggests that the level of economic development in Guangdong Province has surpassed that in Chongqing. Most of the participants in this study who were from Guangdong enjoy a higher family monthly income per capita, whereas nearly half of the participants experience a lower income level. Family monthly income per capita is a crucial determinant influencing the RTW prospects of young and middle-aged CRC survivors; those with lower family incomes are likely to face greater economic pressures, compelling them to RTW sooner to alleviate financial strain[21]. These findings indicate that when researchers implement intervention strategies to facilitate RTW for young and middle-aged CRC survivors, they must consider economic development levels and average RTW timelines in various regions, tailoring their approaches accordingly to optimize intervention outcomes.
In addition, a Dutch study reported an average RTW time frame of 14 months for CRC survivors[18]. Such variations in RTW durations may also be influenced by differing welfare systems across countries. For example, in the Netherlands[18], employers are mandated to continue paying the salaries of cancer patients for the first two years after diagnosis, and government financial support diminishes the immediate necessity of RTW. As a result, patients may not feel an urgent compulsion to navigate the challenges associated with RTW after surgery, leading to extended RTW periods; this underscores the importance of medical personnel and occupational rehabilitation therapists providing adequate support to young and middle-aged CRC survivors throughout the RTW process; specifically, they should offer tailored work-related advice, such as recommendations regarding suitable job types, working hours, and necessary rest periods based on the patient’s physical condition. Occupational rehabilitation therapists can play a pivotal role in helping survivors develop realistic and achievable RTW plans[16].
This study revealed that a family monthly income per capita of ≤ 2000 RMB constitutes a significant barrier for young and middle-aged CRC survivors in their RTW, corroborating Zhang et al’s findings[9], which indicated that CRC patients with a higher family monthly income per capita are more predisposed to RTW. Research has consistently confirmed that economic factors serve as critical predictors of RTW among CRC survivors[18]. This phenomenon may be attributable to the notion that young and middle-aged CRC survivors with a higher family monthly income per capita tend to enjoy more favorable working conditions, rendering employment relatively less strenuous and thus increasing their likelihood of returning to work. Conversely, Yuan et al[21] reported a negative correlation between higher income and RTW in CRC patients, which stands in stark contrast to the findings of this study. This discrepancy may stem from the observation that cancer patients with elevated family incomes experience a lower economic burden and, as a consequence, may be less inclined to RTW. In contrast, young and middle-aged CRC survivors with lower family incomes face heightened economic pressures, compelling them to seek employment to bolster family income and cover daily living expenses as well as treatment costs. This suggests that the influence of financial factors on the RTW of CRC survivors remains a contentious issue, highlighting the need for further qualitative research, including semi-structured interviews, to deepen the understanding and interpretation of the impact of financial variables on the RTW of young and middle-aged CRC survivors.
This study also revealed that young and middle-aged CRC survivors employed in blue-collar positions are less likely to RTW compared with their white-collar counterparts. This discrepancy may be attributed to the nature of employment in these two categories. White-collar CRC survivors often work in office environments or professional roles, such as administrators, sales representatives, educators, physicians, and attorneys. These positions typically require a higher level of expertise, skills, and professional qualifications that emphasize cognitive and communicative competencies; they also tend to demand relatively advanced educational backgrounds, primarily involve intellectual labor with lower physical demands, offer more flexible working hours, and facilitate a better work-life balance upon reentry into the workforce. Conversely, blue-collar CRC survivors frequently participate in manual labor or technical work, including construction, mechanics, electrical work, and plumbing. Such occupations are characterized by hands-on production on site, which often entails significant physical exertion and strain. In addition, these roles typically require specialized skills and provide limited opportunities for career transitions, thereby diminishing the likelihood of successful RTW. Given this context, it is imperative that health care administrators and medical professionals prioritize the reintegration into the workforce of young and middle-aged CRC survivors in blue-collar occupations, ensuring that they receive specialized support[37]. Furthermore, health care professionals should actively advocate for enhancements in the social system and the formulation and improvement of public policies designed to safeguard the rights of cancer patients, including employment assistance and medical support. Such measures will further facilitate the successful reintegration of CRC survivors into both the workforce and society[38].
This study also established that higher levels of RTW-SE among young and middle-aged CRC survivors correspond to an increased likelihood of returning to work, which aligns with the findings of Black[39]. RTW-SE refers to a patient’s belief in their ability to take the necessary actions to achieve the goal of returning to work[40]. However, owing to a lack of adequate knowledge and guidance, CRC survivors often grapple with diminished confidence in their ability to resume work, perform competently, maintain focus, manage work-related stress, and meet the physical demands of their jobs[16]. In the face of significant physical, psychological, and economic challenges arising from symptom distress and ongoing medical evaluations, young and middle-aged CRC survivors with high RTW-SE is more likely to proactively manage their condition, cultivate a positive outlook through self-regulation or seek support from others, and reconstruct their social roles to facilitate their RTW. Thus, it is advisable that during the continuum of care, medical personnel promptly assess and screen middle-aged and young CRC survivors who exhibit low self-efficacy regarding their ability to RTW. Furthermore, they should introduce successful RTW case studies, encourage active participation in disease management, and leverage individual strengths in stress reduction and positive coping strategies to bolster confidence in returning to work. Dutch scholar Leensen et al[41] integrated career counseling into a physical exercise program for cancer patients undergoing chemotherapy. The findings revealed that 86% of participants were able to RTW within 12 months after engaging in this multidisciplinary rehabilitation program, and this combined approach was effective in enhancing cancer patients’ RTW-SE. Therefore, medical professionals should actively pursue multidisciplinary collaboration and incorporate vocational counseling into tailored exercise programs for young and middle-aged CRC survivors to increase their RTW-SE and facilitate prompt reintegration into the workforce.
The concept of FR was first articulated by Mccubbin and Mccubbin[42] in 1988. It emerges from the dynamic interaction between individual attributes and familial characteristics, functioning as a constructive force that empowers the family unit to navigate stress and adversity with efficacy[43]. This investigation revealed a positive association between elevated FR scores and the propensity of young and middle-aged CRC survivors to reenter the workforce. A cancer diagnosis profoundly influences not only the affected individual but also their familial system, engendering a crisis because of complex interrelations and deep emotional bonds. In recent years, cancer treatment research has undergone a paradigm shift, placing greater emphasis on the significance of FR for both individual and family health rather than solely concentrating on the individual patient[44]. Health care professionals should address various dimensions, including young and middle-aged CRC survivors, caregivers, families, and society, to facilitate the adjustment and adaptation of families impacted by a cancer diagnosis, thereby enhancing their FR. Comprehensive assessments and customized nursing interventions should be implemented for these survivors to optimize their self-care capabilities through an expedited rehabilitation approach. Moreover, emphasis must be placed on reinforcing health education initiatives while fostering a positive coping style among patients confronting this condition. Caregivers require support to enhance their caregiving competencies for individuals with CRC, as well as to acknowledge and process their own emotional experiences. Families are encouraged to confront this illness collectively by promoting effective communication, strengthening familial support networks, and participating in targeted intervention programs aimed at enhancing resilience with respect to both disease-related challenges and societal pressures. Furthermore, communities must cultivate robust social networks and advocate for increased governmental investment in medical resources dedicated to addressing CRC.
This study also has several limitations. It was conducted at a class A tertiary hospital in Chongqing, and the findings may not fully represent the broader population of CRC survivors. Future research should consider expanding the sample size to encompass hospitals of varying tiers across the country as well as diverse work environments. Moreover, a longitudinal study is warranted to thoroughly examine the RTW status of young and middle-aged CRC survivors at multiple time intervals (e.g., 6 months, 1 year, and 2 years after discharge) and to analyze the evolving trends of influencing factors. This approach will facilitate the provision of tailored vocational rehabilitation guidance aligned with the distinct stages of postoperative recovery for CRC survivors, thereby addressing their dynamic needs throughout the RTW process. In addition, we will conduct further research focused on the RTW of stoma and non-stoma groups in the future.
CONCLUSION
In this study, a cross-sectional survey was conducted involving 209 young and middle-aged CRC survivors who had been discharged from the Gastrointestinal Surgery Department of a tertiary A hospital in Chongqing within a time frame of 3-12 months. The primary objectives were to explore the current status of RTW and analyze the impacts of RTW-SE, FoP, eHL, FR, and FT on the RTW experiences of these individuals. The results indicated that 91 participants (43.54%) had successfully re-entered the workforce, with an average employment duration of 100 days. Key factors identified as significant facilitators of RTW included a higher per capita family monthly income, employment in white-collar occupations, and elevated scores on both RTW-SE and FR. It is imperative that health care professionals develop targeted RTW support programs that address modifiable factors, such as RTW-SE and FR. This strategic approach will bolster patients’ RTW-SE and enhance their FR, thus facilitating the reintegration of young and middle-aged CRC survivors into normal social life at the earliest possible opportunity.
ACKNOWLEDGEMENTS
The authors would like to express their gratitude to the scholars who participated in this study for their invaluable contributions.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade A, Grade A, Grade B
Novelty: Grade A, Grade B, Grade B
Creativity or Innovation: Grade A, Grade B, Grade B
Scientific Significance: Grade A, Grade A, Grade B
P-Reviewer: Chen Y; Jayapalan T S-Editor: Bai Y L-Editor: A P-Editor: Zheng XM
Zeng H, Chen W, Zheng R, Zhang S, Ji JS, Zou X, Xia C, Sun K, Yang Z, Li H, Wang N, Han R, Liu S, Li H, Mu H, He Y, Xu Y, Fu Z, Zhou Y, Jiang J, Yang Y, Chen J, Wei K, Fan D, Wang J, Fu F, Zhao D, Song G, Chen J, Jiang C, Zhou X, Gu X, Jin F, Li Q, Li Y, Wu T, Yan C, Dong J, Hua Z, Baade P, Bray F, Jemal A, Yu XQ, He J. Changing cancer survival in China during 2003-15: a pooled analysis of 17 population-based cancer registries.Lancet Glob Health. 2018;6:e555-e567.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 795][Cited by in F6Publishing: 847][Article Influence: 141.2][Reference Citation Analysis (0)]
Zaman ACGNM, Tytgat KMAJ, Klinkenbijl JHG, Boer FCD, Brink MA, Brinkhuis JC, Bruinvels DJ, Dol LCM, van Duijvendijk P, Hemmer PHJ, Lamme B, Loosveld OJL, Mok MM, Rejda T, Rutten H, Schoorlemmer A, Sonneveld DJ, Stassen LPS, Veenstra RP, van de Ven A, Velzing ER, Frings-Dresen MHW, de Boer AGEM. Effectiveness of a Tailored Work-Related Support Intervention for Patients Diagnosed with Gastrointestinal Cancer: A Multicenter Randomized Controlled Trial.J Occup Rehabil. 2021;31:323-338.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 5][Cited by in F6Publishing: 9][Article Influence: 3.0][Reference Citation Analysis (0)]
Kuai B, Guo Y. Comment to "The Predictive Value of Return-to-Work Self-efficacy for Return to Work Among Employees with Cancer Undergoing Chemotherapy".J Occup Rehabil. 2022;32:803-804.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Rosbjerg R, Hansen DG, Zachariae R, Stapelfeldt CM, Hoejris I, Rasmussen MT, Drysdale SW, Labriola M. Validation of the Return To Work Self-Efficacy questionnaire in a population of employees undergoing treatment for cancer.Eur J Cancer Care (Engl). 2021;30:e13373.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Föhner K, Seipp H, Becker A, Maulbecker-Armstrong C, Schneider A, Seifart U, van der Wardt V. Factors associated with return-to-work outcomes in inpatient rehabilitation - a systematic scoping review.Psychol Health Med. 2024;29:191-215.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
den Bakker CM, Anema JR, Zaman AGNM, de Vet HCW, Sharp L, Angenete E, Allaix ME, Otten RHJ, Huirne JAF, Bonjer HJ, de Boer AGEM, Schaafsma FG. Prognostic factors for return to work and work disability among colorectal cancer survivors; A systematic review.PLoS One. 2018;13:e0200720.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 24][Cited by in F6Publishing: 33][Article Influence: 5.5][Reference Citation Analysis (0)]
Ren Y, Zhou Y, Zhang L, Yang Y, Xia R, Yang Y, Li H, Tian D, Wang Q, Su X. Readiness for return-to-work model-based analysis of return-to-work perception of young and middle-aged colorectal cancer patients with stoma in the early postoperative period: a descriptive qualitative study.Support Care Cancer. 2023;31:411.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Bujang MA. An elaboration on sample size determination for correlations based on effect sizes and confidence interval width: a guide for researchers.Restor Dent Endod. 2024;49:e21.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Wang T, Jin M, Zhu R, Zheng L, Wang D, Zhao X, Zhao X. Return-to-work self-efficacy questionnaire: Cross-cultural adaptation and validation in China.Nurs Open. 2023;10:6336-6344.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Sixbey MT.
Development of the family resilience assessment scale to identify family resilience constructs. [cited 10 August 2008]. Available from: https://ufdc.ufl.edu/ufe0012882/00001.
[PubMed] [DOI][Cited in This Article: ]
Li YL, Zhao Y, Zhang J, Lou FL, Cao FL. Psychometric Properties of the Shortened Chinese Version of the Family Resilience Assessment Scale.J Child Fam Stud. 2016;25:2710-2717.
[PubMed] [DOI][Cited in This Article: ]
Wu W, Yackel HD, Salner A, Chen MH, Judge MP, Cong X, Xu W. Work-health balance of cancer survivors returning to work: A meta-ethnography.Eur J Oncol Nurs. 2024;68:102482.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
Schwarz B, Banaschak H, Heyme R, von Kardorff E, Reims N, Streibelt M, Bethge M. A Mega-Ethnography of Qualitative Meta-Syntheses on Return to Work in People with Chronic Health Conditions.Rehabilitation (Stuttg). 2024;63:39-50.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 1][Reference Citation Analysis (0)]
Leensen MCJ, Groeneveld IF, van der Heide I, Rejda T, van Veldhoven PLJ, Berkel SV, Snoek A, Harten WV, Frings-Dresen MHW, de Boer AGEM. Return to work of cancer patients after a multidisciplinary intervention including occupational counselling and physical exercise in cancer patients: a prospective study in the Netherlands.BMJ Open. 2017;7:e014746.
[PubMed] [DOI][Cited in This Article: ][Cited by in Crossref: 44][Cited by in F6Publishing: 41][Article Influence: 5.9][Reference Citation Analysis (0)]
Mccubbin HI, Mccubbin MA. Typologies of Resilient Families: Emerging Roles of Social Class and Ethnicity.Fam Relat. 1988;37:247.
[PubMed] [DOI][Cited in This Article: ]
Cui P, Shi J, Li S, Getu MA, Wang R, Chen C. Family resilience and its influencing factors among advanced cancer patients and their family caregivers: a multilevel modeling analysis.BMC Cancer. 2023;23:623.
[PubMed] [DOI][Cited in This Article: ][Reference Citation Analysis (0)]
