Abstract
This case series illustrates how three patients with brain cancer returned to work after participating in a tailored three-phase occupational therapy intervention.
Advances in medical interventions have improved the survival rates of people with cancer, and in the next 10 yr, the number of survivors is expected to exceed 21.7 million in the United States (Siegel et al., 2024). Because people are living longer, they are also living with physical, cognitive, social, and emotional cancer-related impairments that affect their ability to perform important activities, including paid work (Hunter et al., 2017). Employment is a common concern for people with cancer and their families (Baxter et al., 2017). The inability to work and the cost of cancer care are the leading causes of financial stress or financial toxicity after a cancer diagnosis (Mols et al., 2020). People who continue to work, or who take paid leave, experience less financial stress and have a greater sense of identity compared with those who do not work or take unpaid leave (Mols et al., 2020).
The ability to return to work is not the same for all people with cancer. Of people with breast, prostate, or colorectal cancer, 50% to 90% return to work (Blinder & Gany, 2020) compared with 47% of those who have brain cancer (Haider et al., 2020). People with brain cancer who do not return to work are more likely to have functional impairments (e.g., related to bathing, dressing, and walking); depression and anxiety; hemiparesis (Leeper et al., 2023); and impaired neuropsychological function, including reduced attention, flexibility, memory, and learning (Nugent et al. 2014). These impairments are similar to those of people who are unemployed and have an acquired brain injury (Wong et al., 2019).
We suggest using the Person–Environment–Occupation–Performance (PEOP) model to guide return to work after a cancer diagnosis because it includes components that have been found to be associated with return to work for people with an acquired brain injury (Murray et al., 2022). Occupational therapy practitioners possess the skills to provide these components by targeting cancer-related impairments, teaching return-to-work advocacy skills, and helping people remediate or adapt their work performance (Hunter et al., 2017). At present, occupational therapy practitioners apply interventions on the basis of their evaluation findings; however, literature that describes occupational therapy assessments and interventions used to support return-to-work for people with brain cancer is scarce (Désiron et al., 2011; Nastasi & Harris, 2021). There is a need to describe occupational therapy return-to-work interventions within a theoretical model, such as the PEOP model, to inform future research.
PEOP Model
One goal of occupational therapy is to support people with cancer who are experiencing disruptions in daily occupations, such as work (Bass et al., 2015). However, occupational disruption is usually not identified in the diagnostic and initial treatment phases of cancer; instead, symptoms and side effects are the primary focus, leading to problem-based care rather than occupation-based care (Dougherty et al., 2017). To bridge this chasm between the medical model and an occupation-based approach, occupational therapy practitioners can use the PEOP model when developing care plans for clients with cancer. The PEOP model considers person factors (e.g., cancer diagnosis, treatment impairments, and other comorbidities), environmental factors (e.g., physical, social, cultural, policy, and technological influences, disability timeline) and occupations (e.g., activities, tasks, and roles) to address both medical considerations and occupational disruptions (Bass et al., 2015). In this case series study, we sought to answer the following question: What components of the PEOP model are present in occupational therapy interventions provided over three phases of care for people with brain cancer who returned to work?
Method
This study’s retrospective case series design was selected to describe occupational therapy evaluations and interventions used to support return to work for people with brain cancer. Evaluation, treatment, and meeting notes were extracted from occupational therapy visit encounter notes. Colton Sayers, who is a certified neurological specialist, was the treating therapist for each case described.
Patients
From June to September 2022, seven individuals with brain cancer were referred to occupational therapy with the goal of returning to work. Four of the seven patients did not complete their occupational therapy plans of care because of travel time, increased medical needs, and a desire to not return to work. Thus, these individuals were excluded from this case series. The remaining three patients described in this case series study completed their occupational therapy plans of care and returned to work.
Patient 1 was a middle-aged woman who underwent medical interventions for a left parietal glioblastoma. Patient 1’s goal for returning to work was linked to her desire to regain her identity as a teacher. She began outpatient therapy services 5 mo after completing her medical interventions to improve the cognitive functions she needed to return to work.
Patient 2 was a middle-aged man who underwent medical interventions for a left parietal glioblastoma. He was a mail carrier who financially needed to return to work. He began outpatient therapy services 3 wk after his surgery to improve the community mobility he needed to return to work.
Patient 3 was a middle-aged man who underwent medical interventions for a left frontal oligodendroglioma. He was a physician and the sole financial contributor for his family and financially needed to return to work. He began outpatient therapy 2 mo after completing his first round of radiation to learn how to effectively and efficiently synthesize patients’ medical information.
Evaluation
The occupational therapy practitioner performed a facility-designed semistructured interview to understand each patient's cancer-related impairments; current functional performance, including work; and their environment (home, community, and work). This narrative with the patients led to assessing the (1) person, by using impairment-driven assessments; (2) occupation, through analyzing the tasks, roles, and activities; and (3) environment, by asking follow-up interview questions. Table 1 contains a summary of the assessments used for each patient, organized on the basis of the PEOP model. After the initial evaluation, the occupational therapy practitioner and each patient codeveloped a plan of care and scheduled follow-up outpatient occupational therapy appointments.
Patient Demographic Characteristics, Medical History, and Therapy Course
Note. 5xSTS = five times sit-to-stand test; PHQ-9 = Patient Health Questionnaire-9; SLUMS = Saint Louis University Mental Status Examination; Trails A and B = Trail Making Test, Parts A and B; WCPA = Weekly Calendar Planning Activity.
Stopped working because of declining health.
Currently working.
Assessments
When choosing the assessments to administer, the occupational therapy practitioner considered clinical diagnosis, patient report, and job demands. Table 1 provides an outline of this clinical process. The assessments included the 10-Item Weekly Calendar Planning Activity (WCPA; Jaywant et al., 2022); the five times sit-to-stand test (5xSTS); the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2016); the Saint Louis University Mental Status Examination (SLUMS; Spencer et al., 2022); the Trail Making Test, Parts A and B (hereafter Trails A and Trails B, respectively; Sánchez-Cubillo et al., 2009), a Dynavision D2 Vision Training System assessment (hereinafter Dynavision; et al., 2020), the Bell’s Test (Gauthier et al., 1989), and a peripheral vision screening.
The WCPA is an objective performance-based measure of executive function that requires the examinee to input 10 appointments into a mock weekly calendar while following specific rules and guidelines. Scoring is based on the examinee’s ability to identify appointments as entered or missing, place appointments on the correct day and time, correctly label the appointment, and self-recognize errors while being timed. Examining both time and accuracy together indicates efficiency. The raw score ranges from 0 to 17, with higher scores indicating lower performance (Shirley Ryan AbilityLab, 2020).
The 5xSTS assesses functional lower limb strength, transitional movements, balance, and fall risk in adults. Scoring is based on the time it takes to move five times from a sitting position to standing. The minimal detectable change for the test is between 3.6 to 4.2 s, and the minimal clinically important difference is 2.3 s (Mong et al., 2010).
The PHQ-9 is a multipurpose self-report instrument for diagnosing, monitoring, and measuring depression severity. Scores on the PHQ-9 indicate the following levels of depression: 0 to 4, no or minimal; 4 to 9, mild; 10 to 14, moderate; 15 to 19, moderately severe; and 20 to 27, severe (Sun et al., 2020). A clinically meaningful change is 5 to 6 points (Kroenke et al., 2016).
The SLUMS is a screening tool for detecting mild neurocognitive disorder and dementia. It measures attention, immediate recall, orientation, memory, visuospatial function, cognitive organization and recall, and executive function. SLUMS scores reflect the following levels of cognitive function: 0–20, severe neurocognitive disorder or dementia; 21–26, mild neurocognitive disorder; and 27–30, normal cognitive function (Spencer et al., 2022).
Trails A and Trails B assess working memory, visual processing, visuospatial skills, selective and divided attention, processing speed, and psychomotor coordination. The score is determined by the overall time required to complete the connections accurately. An average score for Trails A is 29 s and a deficient score is >78 s. For Trails B, an average score is 75 s and a deficient score is >273 s. Normative scores are available by age and sex (Sánchez-Cubillo et al., 2009).
Dynavision is a highly effective visuomotor and cognitive assessment and training device for measuring and improving hand–eye coordination, reaction time, and reaction speed. Scores >3 s indicate a slow reaction time (Blackwell et al., 2020).
The Bell’s Test quantitatively and qualitatively assesses visual neglect within the examinee’s extra personal space. The examinee circles 35 bells embedded within 280 distractors on the test sheet. The maximum score is 35. An omission of six or more bells on the right or left half of the page indicates unilateral spatial neglect (Gauthier et al., 1989).
Peripheral vision is measured in each eye separately and has many different testing options to determine a score. We used the Bernell Vision Disk. A normal visual field extends approximately 100° laterally, 60° nasally, 60° superiorly, and 70° inferiorly (Weisser-Pike, 2014).
Interventions
On the basis of each patient’s plan of care, the occupational therapy practitioner targeted self-care, community, and work-related skills. Each patient’s plan of care described in this case series included the three phases of occupational therapy (see Figure 1). The length of these phases was determined by their treatment progress, need to return to work, and last day of short-term disability. Table 1 outlines the frequency of treatment by phase, the length of each session and example interventions, organized by PEOP model, for each patient.
Three-phase occupational therapy intervention.
Phase 1
Phase 1 focused on (1) restoring the individual’s ability to complete self-care skills and manage their home and (2) teaching employment advocacy skills. The primary intervention was establish–restore and targeted physical, cognitive, social, and emotional skills that had been affected by cancer and its treatment. Patients’ goals were directed toward recovering a skill that had been lost or attaining a new skill that was needed to complete self-care and home management skills. Devices and technologies were used as needed to meet their goals (Bass et al., 2015). In addition, the occupational therapy practitioner provided each patient with practical and legal information to empower and educate them as they prepared to return to work (Cancer and Careers, 2023). Practical information focused on understanding their medical insurance and employer policies and learning how to gain more information about their short- and long-term side effects from their health care providers. Legal information included materials on the Family and Medical Leave Act of 1993 (FMLA; Pub. L. 103-3) and the Americans With Disabilities Act of 1990 (2000; ADA; Pub. L. 101-336). The occupational therapy practitioner and nurse practitioner offered to meet with each patient’s employer’s human resources (HR) department.
Example intervention.
Patient 3 was taught problem-solving strategies to improve organization, prioritization, and planning skills to manage his medications. Problem-solving strategies were codeveloped and included organizing daily medication in a pill box and setting alarms on his phone.
Phase 2
Phase 2 began when Phase 1 goals were met, or progress had slowed or stopped. During this phase, the occupational therapy practitioner directed interventions toward prework skills and community reintegration. Intervention approaches included education, modification–compensation, establish–restore, and advocacy. The occupational therapy practitioner used task analysis to help each patient understand the actions and tasks required to complete their job demands. This information was used to create occupation-based or impairment-driven therapy sessions that simulated their job duties. Last, the occupational therapy practitioner taught patients how to advocate for the services and modifications they needed to participate in the community and complete their work activities (Bass et al., 2015).
Example intervention.
The occupational therapy practitioner and nurse practitioner met with Patient 1, her husband, and the patient’s HR team. During this meeting, a work accommodation list was developed. In addition, the ADA and its connection to her work was reviewed with the patient. She was provided written handouts and links to YouTube videos and websites that discuss returning to work after cancer.
Phase 3
Phase 3 began after the patient had returned to work. Intervention approaches included consultation, advocacy, and modification–compensation. The occupational therapy practitioner and patient discussed person and environmental factors that were impeding their ability to complete work functions. After these discussions, the occupational therapy practitioner and patient codeveloped strategies to compensate for these deficits at work and discussed how to advocate for any adaptations needed (Bass et al., 2015). During the follow-up visit, each patient reflected on how they had used these strategies at work. These strategies were modified as needed, or new strategies were developed.
Example intervention.
Because of work time constraints, Patient 2 was unable to take 3- to 5-min breaks to decrease his cognitive load. Instead, he was taught to breathe deeply to calm himself when the “cognitive fog would kick in.” Patient 2 said this was helpful but was not “100% beneficial, like a break [would be].” He indicated that the deep breathing did calm him down so he could complete all his work tasks.
Results
Patients 1 and 2 were seen at each phase, and Patient 3 was seen at Phases 1 and 2. Each patient’s occupational therapy evaluations and interventions included each component of the PEOP. Table 1 provides a summary, including demographics, cancer type, work goals, a summary of occupational therapy, work accommodations, and return-to-work status. Modification–compensation, such as compensatory strategies, environmental modifications, and external aids, was used with each patient to target cognitive impairment.
Pre- and postintervention data are given in Table 2. Postintervention measurements either remained the same or improved compared with baseline measurements. All patients returned to work, and two of them were working at the time of this writing. Patient 1 worked for 8 mo after the occupational therapy intervention before filing for permanent disability because of increased medical needs.
Outcomes by Patient
Note. 5xSTS = five times sit-to-stand test; Dynavision = Dynavision D2 Vision Training assessment; PHQ-9 = Patient Health Questionnaire-9; RT = reaction time; SLUMS = Saint Louis University Mental Status Examination; Trails A and B = Trail Making Test, Parts A and B; WCPA = Weekly Calendar Planning Activity.
Exceeded the minimally clinically important change of 2.3 s (Mong et al., 2010).
Met the clinically significant change of 5–6 points (Kroenke et al., 2016).
Represents a change from severe cognitive impairment to mild impairment (Spencer et al., 2022).
Patient 1’s WCPA, 5xSTS, and PHQ-9 scores improved, indicating better executive functioning, functional mobility, and mood. However, she continued to have impaired processing speed, attention, and flexible thinking.
Patient 2’s SLUMS, Trails A and B, Dynavision, and Bell’s Test scores improved, indicating better memory, comprehension, attention, reaction, and visual scanning, yet he continued to have slower visual processing speed and impaired peripheral vision, memory, comprehension, attention, and visuospatial awareness.
Patient 3’s WCPA, Trails A and B, and SLUMS scores improved, indicating a positive change in his executive functioning, processing attention, visuospatial skills, and memory, although he continued to have impaired attention, visuospatial awareness, and processing.
Cognition was a person factor mentioned by each patient. Reduced strength, impaired vision, and fatigue were person factors experienced by one or two patients but not all of them. Each patient’s job demands and roles (occupation) were different. Two of the three had nonphysical jobs, and one of the three had a primarily physical job. Two patients’ jobs were considered professional employment, and the other had a blue collar job. Each patient experienced physical and work culture environmental barriers, such as inaccessible work stations or decreased support from human resources.
The PEOP model guided the three-phase approach used in this study. During Phase 1, the occupational therapy practitioner applied a modification–compensation approach to target cognitive impairments for each of the patients and taught them how to advocate for workplace modifications. During Phase 2, the patients applied strategies to meet their job demands (occupation) and overcome fatigue and impaired cognition, vision, and strength. During Phase 3, a metacognitive approach (Boone et al., 2024) allowed the patients to self-reflect and collaboratively solve workplace issues with their employer’s human resources department.
Discussion
To our knowledge, this study is the first to describe returning to work as a three-phase occupational therapy approach that applies the PEOP model to be used with people with brain cancer. Previous occupational therapy intervention studies of people with brain cancer have focused specifically not on returning to work but on returning to daily life activities (Campbell et al., 2009; Chan et al., 2015; Hammill et al., 2019). Occupational therapy interventions in this case series study included evidence-based approaches within each of the phases to target impairments, including those related to physical activity, cognitive training/rehabilitation, and mood, to support the patients’ return-to-work goals (Newman et al., 2024).
The strategy-based interventions (Giles et al., 2022) and metacognitive approaches (Boone et al., 2024) described in this case series study have also been used to improve cognition, mood, and occupational performance in people with brain injuries. Although the patients in our study experienced similar responses to the interventions, further research is needed to determine whether these interventions are effective with a larger population. Despite the similarities between people with brain injuries and brain cancer, such as mood, cognitive, and physical impairments, recovery from brain cancer is quite different from recovery from a brain injury (Newman et al., 2024; Patil et al., 2017). People with brain cancer often face additional challenges, such as fatigue, long-term effects of cancer treatments (e.g., chemotherapy and radiation), or cancer recurrence. These factors make returning to work distinctly different for those with brain cancer (Baxter et al., 2017; Newman et al., 2024).
Our research is consistent with current return-to-work research, which is primarily descriptive, specific to a cancer type, conducted in Europe, and has not provided compelling evidence for a particular return-to-work program. However, these studies have common themes that connect to components of the PEOP model and the need to address work within the cancer care continuum. These include fatigue (a person factor; Wolvers et al., 2019); job demands and work self-efficacy (an occupation factor; Tamminga et al., 2019); and policy (e.g., employer medical leave, laws such as ADA and FMLA; Leslie et al., 2020, work culture (e.g., the value of work), and perceived stress (environment factors; Özer Güçlüel & Can, 2023).
Our description of teaching people with brain cancer (occupation) to self-advocate for workplace accommodation—including flexible hours, remote work, and physical modifications, which are mandated by the ADA—has been described by others as important for maintaining employment (e.g., Gruß et al., 2019). These findings support the need for occupational therapy practitioners to provide education for and teach self-advocacy skills to people with cancer to help them navigate employment concerns.
The strengths of this case series study include that the patients had similar cancer diagnoses and a variety of job demands, longitudinal data were used, and assessment details were provided. The limitations include a small sample size recruited using convenience sampling; the lack of a comparison group; and a retrospective analysis of successes, which limits generalizability. Further research, using more rigorous research designs, is needed to understand whether current occupational therapy evidence-based interventions are associated with returning to work. Because of the heterogeneity inherent to brain cancer and other cancer diagnoses, rapidly changing treatments, and various job demands, occupational therapy researchers should consider descriptive studies that include homogeneous cancer types and treatments that are based on theoretical models, such as the PEOP model. In addition to targeting cognitive, physical, and mood impairments, future research should investigate the role of work environment factors in the return-to-work process. For instance, although physical accommodations are often addressed, there may be other environmental barriers, such as work culture, employer attitudes toward cancer recovery, and the stigma associated with illness, that influence a person’s ability to return to work. Future studies should explore the effects of these environmental factors and develop strategies to address them.
Implications for Occupational Therapy Practice
Occupational therapy practitioners should advocate for their involvement in helping clients with a cancer diagnosis return to work. Our holistic approach allows us to work with individuals with cancer throughout their survivorship. The results of this case series study have the following implications for occupational therapy practice. Occupational therapy practitioners. ▪ should evaluate clients with brain cancer after the diagnosis to identify those who want or need to return to work; ▪ should remediate cancer-related impairments, teach return-to-work advocacy skills, and modify or compensate for job demands; and ▪ can collaborate with cancer care providers and HR staff to develop a return-to-work plan.
Conclusion
The findings from this case series study underscore the critical role of occupational therapy in supporting people with brain cancer as they navigate the complex process of returning to work. The use of the PEOP model provides a comprehensive framework within a three-phase occupational therapy approach to support people with brain cancer in return to work. This approach considers the work environment, job demands, workplace policies, ADA, and impairments when codeveloping a return-to-work treatment plan.