The present qualitative study, based on key informant interviews with patients with early-stage BC and a diverse pool of providers, highlights the fact that the health care system may be under-equipped to address the difficulties related to RTW after BC. We found that patients do not feel adequately supported, providers are mostly inattentive to the problem of RTW or feel unaware of possible solutions. There seemed to be fair curiosity towards digital solutions that can help RTW, which is however often accompanied by a sort of “digital prejudice” building on fear of barriers to digital access that may exacerbate disparities and remove human contact from the patient pathway. This may let us think that the health care system is under-equipped or not yet ready to implement a large-scale intervention. A need of a clear pathway and personalized multimodal approach with a digital and in person approach emerged as a possible solution to respond to the weaknesses of existing interventions.
Our results are coherent with the literature and show there is still a need to support BC patients to RTW . The workforce shortage in oncology, the growing number of new cancer diagnoses and of cancer survivors will limit the ability to implement a comprehensive, scalable and multidisciplinary care delivery system allowing patient evaluation and re-evaluation during follow up by a multidisciplinary team. Thus, at a broad and policy level, digital tools can be of great value for healthcare systems. Indeed, they can help to reduce the utilization of healthcare resources by patients, e.g. regarding BC patients’ RTW, it can help to reduce the economic impact of sick leaves or mismanaged RTW, which can lead patients to unemployment, early retirement or disability. Social services are available in each French cancer center/public hospital in order to help with work-related difficulties but most of their work is focused on helping vulnerable patients to access social benefits .
In this analysis, social workers were the providers that reported to be most at ease in addressing RTW-related questions. Nevertheless, social workers are often overwhelmed with deprived patients and have no time to answer the many needs of the totality cancer patients (e.g. regarding how to address RTW with the employers and/or what are the existing work arrangements). There is a need to create resources easily available for “average” patients to help them RTW and that do not create an extra burden to the health system. All over the country, RTW interventions are being led by charities/NGOs or the social security in hospitals or in other settings but only with small groups of patients. A growing number of people around the world has access to a smartphone. Studies showed a great acceptability of mobile phone applications [39-44]. Regarding the cost of developing an intervention using such digital tool, we think it would allow to reach a broad population of patients with limited cost unlike face to face interventions requiring a lot of time from the providers. Indeed, mHealth offer an innovative way to propose health care interventions that are cost-effective. It allows to enhance the delivery of health care for patients by quickly reaching a large amount of patient . Digitals solutions offer many advantages, they are flexible and thus meet the changing needs of patients, and they can be a source of empowerment . According to our results and previous studies about the use of digital solutions in other setting among cancer patients, digital solutions seem to be a good way of helping patients RTW . Indeed, websites, applications and other digital tools allow patients to be more involved in their care and may help them in a number of aspects of their lives such as RTW or social and family life . In addition, digital solutions can avoid frequent cited barriers for RTW interventions in person including distance and need to go back to work. Nevertheless, according to the results of the study, only-digital solutions might not be the most desirable solutions to assist RTW after cancer and digital solutions complemented with in person support may be best suited. This is associated with the fact that both patients and providers feared the loss of human contact with digital only-solutions. Moreover, even if mHealth solutions may reach a substantial number of patients we acknowledge that they may be inequalities since Internet is not accessible everywhere and by everyone and that not all types of patients are interested in or able to use them.
Therefore, the study underlines that hybrid interventions (digital/in person) may be a good solution being able to: reach a larger number of patients, maintain human contact, be adapted to the needs and be scalable and implementable.
Finally, there is a need to develop interventions with the help of medical oncologists, social workers, psychologists, the structures that are currently working in the RTW field and other providers to think about the implementation process. In this setting, developing a personalized multidisciplinary intervention blending in person and digital resources could be a good way to help cancer patients RTW .
Strengths and limitations
The main strength of the study is the fact that we acknowledged the opinions of both patients and providers. Another strength is to have conducted the study in large cancer centers as well as general hospitals and to have included patients with diverse socioeconomic and occupational status.
We acknowledge our study has limitations. First, we had a limited sample size; nevertheless, we reach thematic saturation. Second, the range of preferences, needs and barriers represented in our interviews are preliminary data that should be further investigated. Third, we acknowledge selection bias, on one side, providers may have been inclined to propose the study to well-disposed and talkative patients and, on the other side, providers who accepted to participate to the study may be the one who are more aware of the issue.