Contemporary vocational rehabilitation strategies for people with advanced cancer: A literature review and conceptual framework

Abstract

BACKGROUND:

People with advanced cancer constitute an emerging vocational rehabilitation (VR) consumer population.

OBJECTIVE:

Following an overview of the nature and needs of Americans who have advanced forms of cancer, the authors present strategies to meet the service and support needs of these individuals across the phases of the VR process.

METHODS:

The authors present the sequential stages of the VR process, including implications for working with advanced cancer survivors during each stage.

RESULTS:

The importance of individualized case planning, employer consultation, workplace accommodations, interface with medical and mental health professionals, and adherence to self-care and symptom management regimens is emphasized throughout the article.

CONCLUSION:

Growing numbers of people worldwide are surviving advanced cancers for longer periods of time than ever before, which makes them an emerging disability population and rehabilitation clientele.

1 Introduction

People with advanced cancer face existential, physical, cognitive, emotional, and financial challenges due to the disease itself and the side effects of its treatment. These new realities can significantly impact one’s ability to work and, more fundamentally, one’s desire to work given the saliency of one’s mortality (Andrew & Andrew, 2017). Therefore, the purpose of this article is three-fold: (a) to describe the characteristics and needs of people with advanced cancer, (b) to examine the detrimental effects that this disease and its treatment have on employment and career development, and (c) to provide practical strategies that rehabilitation professionals can implement to support the vocational rehabilitation (VR) needs of this growing population as we look forward to the end of the COVID-19 pandemic.

2 Methods

2.1 Cancer

Cancer is a collection of diseases that are characterized by uncontrolled, abnormal cell growth (National Cancer Institute (NCI), 2021; World Health Organization, 2023). This growth can originate in any organ or tissue in the body and can spread to other organs, known as metastasizing. Cancer is categorized either by the type of malignant cells causing cancer (e.g., squamous cells) or by the site of origin (e.g., lung cancer, breast cancer). Further categorization is based on the prognosis or stage of one’s cancer (NCI, 2022a). Researchers and clinicians use several systems of staging, typically depending on the type of cancer being staged. Generally, Stage 0 indicates the presence of abnormal cells but is not considered cancerous at the time of evaluation, though it may eventuate in a cancer diagnosis. Stages I and II are early stages, whereas III and IV are late stages. Prognoses are dependent on the type of cancer, which informs how aggressive it is and has certain forms of proven treatments. Advanced cancer, also known as end-stage cancer or terminal cancer, is determined when there is no possibility to cure or control the progression of the disease through medical treatments or procedures (NCI, n.d.).

In terms of the etiology of cancer, causes are often unknown (NCI, 2015). However, there is consensus in the extant literature on risk factors linking certain genetic, environmental, and lifestyle conditions to certain cancers. Based on such risk factors, there are recommended prevention measures people can engage in to reduce their risk for cancer, including avoiding known carcinogens (e.g., cigarette smoking, ultraviolet rays in sunlight) and changing one’s lifestyle and diet (e.g., increasing exercise, decreasing alcohol consumption; NCI, 2023).

Treatment also varies by type and stage of cancer (NCI, 2022b). Common cancer treatments include chemotherapy, hormone therapy, immunotherapy, and radiation therapy, among others. These are considered “traditional” or Western treatments. Some complementary and alternative medicines have also been found to be safe and efficacious, including mind-body therapies (e.g., tai chi) and body-based techniques (e.g., massage therapy, chiropractic therapy; NCI, 2022c).

Worldwide, cancer is the second leading cause of death (World Health Organization, 2023). In the United States alone, 1,958,310 people are projected to be diagnosed with cancer in 2023 (Siegel et al., 2022). It should be noted that screening, early detection, and treatments have each received significant attention from researchers and clinicians and have seen improvements in recent years (Mewes et al., 2012). Encouragingly, the cancer death rate has declined in recent decades (Siegel et al., 2022). These findings suggest that more people are surviving and living longer with cancer than ever before (Stubblefield et al., 2013). Thus, cancer is often considered a chronic illness, one that sometimes can be managed. However, how one lives with cancer differs depending on the type, the accepted treatment, and the individual (ACS, 2019). For example, some people may have a stable or controlled cancer that does not spread; in this case, the cancer is typically controlled by ongoing treatment and is monitored regularly to ensure that it remains stable (ACS, 2019). Other types of cancer may go into remission, either complete or partial, and one must continue to monitor the disease for recurrence and go on treatment to manage symptoms (ACS, 2019).

Importantly, given advancements in systemic treatments, more people are living with advanced or metastatic cancer for longer periods of time (Kolsteren et al., 2022; Tometich et al., 2020). Cancer survivorship, or how to live post-treatment, is a challenge for many people due to the myriad of psychosocial implications to one’s life (Tometich et al., 2020). The impact of living with advanced cancer is felt by survivors in all aspects of life: physical, emotional, psychological, familial, spiritual, existential, and vocational. Researchers have investigated its impact on employment and career development. Kolsteren and colleagues’ scoping review (2022) found a common theme of frustration among advanced cancer survivors regarding the loss of work and income. Notably, Kolsteren et al. explained that the loss was felt not only due to the financial constraints cancer placed on survivors but also the interruption in social connections and a diminished sense of purpose and identity from leaving work due to their cancer. In Paltrinieri and colleagues’ systematic review (2018), specific personal, work-related, and cancer-related characteristics were significant factors in the return-to-work (RTW) of people with cancer. Protective factors included being of medium or high income, having higher levels of educational attainment, being employed at diagnosis, having support from colleagues at work, and having a good prognosis. Conversely, having low income, experiencing discrimination at work, having limited social support, and having metastatic cancer were all risk factors for exiting the labor force.

Indeed, people with metastatic or advanced cancer face numerous existential challenges having to do with employment and RTW (Cardoso et al., 2018; Johnsson et al., 2023; Tamminga et al., 2012). Work and all it means to people can be an essential aspect of one’s identity and a source of “normalcy” in a time of little control that advanced cancer often prompts (Peteet, 2000). Furthermore, for many people with cancer, and perhaps especially for those with advanced cancer, work can be a beneficial way to enhance feelings of self-worth through a sense of accomplishment and contributing to one’s community (Saunders & Nedelec, 2014). However, barriers exist for many cancer survivors who attempt to return-to-work (Saunders & Nedelec, 2014). These include barriers due to symptoms (e.g., pain, fatigue, cognitive impairment, medical appointments for treatment and symptom management), psychological adjustment (e.g., fear of losing one’s job, loss of confidence in abilities), and social interactions (e.g., fears of disclosure to employers, difficulty handling coworker reactions to one’s cancer status; Main et al., 2005; Morrison & Thomas, 2015; Saunders & Nedelec, 2014).

Though much of the RTW literature on cancer either focuses on earlier stages of the disease or fails to report participants’ disease stages (Tamminga et al., 2010), there have been some efforts to understand the career development and RTW process for people who live with advanced cancer. Tevaarwerk et al. (2016) analyzed data provided by 668 working-age individuals with advanced cancer and found that 58%reported the need to make changes to work in some way, with the most common way being the need to stop work entirely. In that study, non-Hispanic white ethnicity/race and better overall functioning were found to be significantly associated with better work outcomes, whereas disease-specific factors (e.g., cancer type, time since metastatic diagnosis, treatment status) had no significant impact. Furthermore, Tevaarwerk et al. identified two malleable factors to improve work-related outcomes: receiving hormonal treatment and improving symptom interference. Although there has been some effort devoted to understanding the life domain of work among people with a variety of cancer types (Tevaarwerk et al., 2016), most efforts to date have focused primarily on metastatic breast cancer (Cardoso et al., 2018; Johnsson et al., 2023; Tamminga et al., 2012). There remains a critical need to understand and support the VR and RTW needs of individuals with all kinds of metastatic or advanced cancer.

3 Results

3.1 People with advanced cancer and the VR process

Because cancer remains a high-incidence disease and survival rates continue to increase for people with most forms of cancer, rehabilitation professionals can expect to see large and growing numbers of cancer survivors on their caseloads. Rehabilitation professionals need to know the medical, psychosocial, and vocational aspects of cancer, especially forms of the disease that are considered advanced. People are living longer and more active lives with advanced cancer than ever before, so we must apply proven RTW and stay-at-work strategies to help advanced cancer survivors continue their careers as they cope with their disease. Because of the multiple ways advanced cancer affects individuals and their families, VR planning must include an interdisciplinary team and a combination of medical and vocational supports to guide these individuals from the moment of diagnosis through their retirement. In the remainder of this article, we provide VR recommendations using examples that can be implemented at each phase of the rehabilitation process to improve services for individuals with advanced cancer.

4 Discussion

4.1 Outreach and eligibility determination

Outreach and education efforts to recruit people with advanced cancer into the state-Federal VR programs should target oncologists, individuals with advanced cancer, other healthcare professionals, large and small employers, and human resource professionals. Someone with cancer may not identify as a person with a disability, especially if they were non-disabled prior to the onset of the disease (Magasi et al., 2022). Thus, outreach efforts should include the use of language such as “people with chronic health conditions” in replacement of, or in addition to, “people with disabilities” in marketing and recruitment materials (Fujiura, 2001).

The presence of stigma in reaction to individuals with disabling conditions has been found to be prevalent in many societies (Fujisawa & Hagiwara, 2015). The stigma associated with cancer can manifest in several ways, such as reactions of others who blame the person for their cancer (e.g., someone with lung cancer who smoked), the condition associated with the onset of cancer (e.g., sexually transmitted infections), changes to physical functioning (e.g., disfigurement or changes in sexual functioning), and/or treatment decisions (e.g., choosing to discontinue treatment; Stergiou-Kita et al., 2016). Given the different ways stigma can manifest, some research has shown more significant stigma for certain cancers in specific areas related to stigma than others. For example, Marlow et al. (2015)found lung cancer to attract the highest levels of stigma for all subscales (awkwardness, severity, avoidance, policy opposition, personal responsibility, and financial discrimination) compared to breast cancer and cervical cancer, while being similar to melanoma (skin cancer) regarding personal responsibility, avoidance, and policy opposition. Death anxiety is another self-stigmatizing factor in the adjustment to advanced cancer (Stergiou-Kita et al., 2016).

Even the most enlightened rehabilitation professionals must acknowledge potential biases they hold that might stigmatize a prospective or current consumer with advanced cancer. These biases must not influence counselors’ decisions regarding program eligibility and subsequent case planning. Particularly when people with advanced cancer experience a lull in symptoms and side effects, rehabilitation professionals may question the individuals’ qualifications for VR services. This doubt may manifest during lapses in treatment. For example, someone receiving chemotherapy who loses their hair may appear “sicker” than someone who is receiving immunotherapy injections and still has their hair. Physical appearance is not the only possible cause of misjudgment by rehabilitation professionals; individuals with advanced cancer may have periods of remission where their cancer is under control. However, even during remission, people with cancer are still protected by the Americans with Disabilities Act (ADA; Smart, 2009) and its amendments. Thus, public VR eligibility determinations must rely on the cumulative functional limitations that applicants experience throughout their illness.

Furthermore, depression and anxiety are two common psychological co-occurring disorders that affect up to 20%and 10%(respectively) of people with cancer (Pitman et al., 2018). However, oncologists, who for many people with cancer are the primary intermediaries between their physical cancer care and their psychosocial needs, have been found to lack awareness and understanding of how to detect these conditions in people with advanced cancer (Gouveia et al., 2015). Mainly, symptoms including failure, self-dislike, and guilt were the most difficult for oncologists to recognize (Gouveia et al., 2015). Gouveia et al. (2015) encouraged training for oncologists to promote understanding and skills around screening for depressive symptoms in people with advanced cancer. Rehabilitation professionals must also screen for depression and anxiety in individuals with advanced cancer to ensure that potential consumers receive optimal care and appropriate diagnosis and treatment recommendations through referrals for psychological evaluation. Ideally, this care takes place with a professional familiar with and skilled in treating depression and anxiety in people with cancer, given the unique risk factors and treatment implications that come with certain types of cancers (e.g., pancreatic and lung cancer release chemicals thought to lead to depression) and certain types of treatment (e.g., antidepressants can exacerbate cancer symptoms and interact with cancer treatment drugs; Pitman et al., 2018). Rehabilitation professionals must have knowledgeable and qualified psychologists to whom they can refer should a referral for a potential consumer with advanced cancer be warranted.

The COVID-19 pandemic has complicated the screening and diagnosis of many people (Eskander et al., 2022; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2023). Specifically, there was a decline in screening and diagnosis for several types of cancer (e.g., melanoma, cervical, endocrine, prostate, lung, and hepatobiliary) during the first wave of the pandemic, with almost 13,000 undetected cancer diagnoses estimated by researchers (Eskander et al., 2022). As society continues to recover and move forward in dealing with COVID-19, VR counselors must stay apprised of cancer trends and ensure smooth eligibility determinations for all people with advanced cancer, whether newly diagnosed or in long-term maintenance.

4.2 Assessment and planning

The employment journey for people with advanced cancer is complex. Like the implications of the disease itself, working while coping with advanced cancer brings with it many unknown possibilities. Zamanzadeh et al. (2019, p. 371) proposed the phrase “taking an obscure path” to be a metaphorical interpretation of the career process for people with cancer, one characterized by uncertainty and anxiety due to limited information, hesitation regarding personal abilities, and worry about reactions from people in the workplace. Rehabilitation professionals can help illuminate this path through education and planning. Regarding limited information, VR counselors must be knowledgeable about the impact of cancer and its treatment on employment and job retention. Sick leave should not necessarily be the first response when working with consumers with advanced cancer. For many, work may be financially necessary, for both income and health insurance coverage. Furthermore, it can be a source of identity and meaning (Peteet, 2000) and an endeavor that can be possible during treatment and maintenance with appropriate support and accommodations. Quality of life has been found to differ between cancer survivors who are working compared to those who are not, with workers reporting a higher quality of life than their non-working counterparts at 24 months post-treatment (Isaksson et al., 2016).

In order to best support cancer survivors to be mentally and physically prepared for continued employment, rehabilitation professionals must provide a holistic, flexible, and individualized approach to the VR process (Isaksson et al., 2016). Furthermore, they must be competent in collaborating with healthcare professionals and employers to meet consumers’ needs. This collaboration is critical given that employment is not always acknowledged or considered an essential treatment goal by the medical team (Zamanzadeh et al., 2019). Issues of confidence around one’s capacity to carry out job tasks, either to one’s expectations or those of their employer, have also been found to be a common theme among cancer survivors in the VR planning process (Isaksson et al., 2016; Zamanzadeh et al., 2019).

Although returning to the same employer in the same position is the gold standard in RTW and VR planning (Strauser, 2021), many advanced cancer survivors may not be readily able to return to the same job and maintain the same level of performance as they did before their diagnosis and treatment (Van Egmond et al., 2017). Therefore, the specialized knowledge that VR counselors have of reasonable accommodations and assistive technology, along with relevant legislation to inform consumers’ rights in these areas, is critical for educating consumers. When accommodations and assistive technology fail to mitigate the functional limitations of cancer survivors, there may be a need to look beyond the consumer’s current employment goals. To do so, a transferrable skills analysis may be an appropriate step to determine future career planning based on past work experiences, skills, and interests. Furthermore, transportation must be considered in planning for employment, especially around medical appointments for continued treatment and maintenance of one’s cancer.

Referral is a vital aspect of the VR assessment and planning phase. Community and national resources that provide outlets for patient advocacy, support, and self-help can further illuminate the otherwise “obscure path” (Zamanzadeh et al., 2019). These resources can be educational in the context of learning about one’s diagnosis, symptoms, treatment, and side effects while offering a support network of people with similar diagnoses. This support network may be vital given the physical isolation many with cancer have experienced during the COVID-19 pandemic, considering the recommendation that people who were immunosuppressed isolate themselves from others to prevent exposure and contraction of COVID-19 (Al-Quteimat & Amer, 2020). This isolation has extended to trips to the hospital for medical appointments themselves; visitors were not permitted in many hospitals, leaving cancer patients without a support person during what could be considered emotionally charged appointments. Therefore, the opportunity to connect with and validate others’ experiences can be invaluable for those who have lived through such experiences.

Although rates of new cancer diagnoses tend to increase with age (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute, 2023), cancer can emerge at any stage in life. Therefore, VR counselors must consider the developmental stages of their consumers during the assessment and planning phases. Regarding younger consumers, in 2020, almost 14,000 new cancer diagnoses were officiated for children aged 0 to 19 (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute, 2023). In terms of VR options for younger consumers with advanced cancer, it is necessary to consider early career preparation, including job shadowing, informational interviews, volunteer opportunities, and paid part-time work as means of getting one’s career started (Rumrill & Wickert, 2021).

Strauser et al. (2015) proposed a conceptual VR framework to consider the unique needs of cancer survivors. Strauser et al. (2019) then explored the mediating impact of emotional and physical functioning of young adult central nervous system (CNS) cancer survivors on the relationship between self-management and three vocational outcomes: job awareness, job acquisition, and job maintenance. Emotional functioning was found to partially mediate the relationships between self-management and job awareness and job acquisition, and physical functioning partially mediated the relationship between self-management and job maintenance. Ultimately, the authors concluded that young adult CNS cancer survivors could benefit from support in managing their physical and emotional symptoms resulting from the disease and its treatment.

Young adult consumers with advanced cancer may also benefit from VR-sponsored counseling and psychotherapy to explore their feelings about their diagnosis, including fears and anxieties about mortality (see this article’s subsequent section on Counseling and Guidance). Furthermore, exploring the role of work in the individual’s life, including the potential social, psychological, and physical benefits and challenges of continuing to work during or after treatment, is crucial to supporting consumers with advanced cancer. VR counselors can also refer young adult consumers to other health professionals to manage physical symptoms (e.g., seek palliative care for pain management, ask an oncologist about nausea medications, find a complementary or alternative medicine provider to address physical symptoms) as well as emotional symptoms (e.g., find an oncology social worker or health psychologist who specializes in counseling people with cancer, seek out support groups).

Middle-aged adults (51–64) with cancer have been found to have a similar trend compared to their younger counterparts (≤50) regarding extended leave or other employment changes due to cancer, with almost half taking such leave according to the National Medical Expenditure Panel Survey and Experiences with Cancer Supplement data from years 2011, 2016, and 2017 (de Moor et al., 2021). Those of retirement age (65+) appear to have lower rates of extended leave or other employment changes due to cancer, with only about a third experiencing such impacts on work. This difference may be due to retirement. Notably, de Moor et al. (2021) reported that those with more advanced forms of cancer are underrepresented in follow-up surveys, likely leading to underestimates of the impact of cancer and its treatment on employment for these individuals. Lim et al. (2022) revealed the mixed feelings and challenges surrounding employment for people with advanced colorectal cancer. The themes that emerged identified work as a struggle, as one’s identity, as a savior, and as a financial necessity. Stigma presented a challenge to participants’ continued employment even though many expressed the desire and ability to work. However, those who identified receiving workplace supports appeared to have better employment outcomes.

Additionally, Lyons et al. (2019) determined that people with metastatic breast cancer have significantly lower employment rates compared to pre-diagnosis (21%compared to 70%). Indeed, therapy and rehabilitation could address the factors associated with leaving work (e.g., higher symptom burden and lower functional status). As with young adult consumers with advanced cancer, middle-aged adults with advanced forms of the disease may benefit from frank discussions about the role of work in one’s life (e.g., financial, existential, social) and referrals to other health professionals to improve functional status and symptom management.

Older adults with advanced cancer may express anxiety and fears about their careers and retirement, mainly regarding their financial ability to retire. Giri et al. (2020) found that 27%of older adults with new cancer diagnoses reported experiencing financial distress. Work may be an essential component of financial well-being; therefore, VR counselors should consider job retention services to support older adults with advanced cancer if that is their wish. Additionally, such consumers should receive information and individualized guidance regarding social supports including long-term disability insurance, retirement options, and Social Security Disability Insurance, among others.

4.3 Counseling and guidance

Cancer can cause considerable distress, uncertainty, and worry in individuals, thereby increasing the risk of mental health problems and diminishing quality of life (Kawashima et al., 2019; Ng et al., 2018). However, only a fraction of those endorsing such problems as depression and anxiety receive psychological help (Holland, 2004; Wang et al., 2020). Several reasons could explain this gap, including a belief that such feelings should be handled privately, independently, and without professional help (Clover et al., 2015); the stigma around receiving counseling (Anuk et al., 2019); and other organizational, cultural, and individual clinician-related barriers (Dilworth et al., 2014). Therefore, when rehabilitation professionals are supporting consumers with advanced cancer, it is vital to know these potential reservations and barriers and be able to normalize their consumers’ psychological symptoms.

First, it is essential to inquire about the mental wellness of consumers with advanced cancer. Even though some consumers may already be receiving psychosocial support, others may benefit from such services through a referral from their VR counselor. If consumers report not needing such services, the VR environment could provide an emotionally safer space to explore such feelings and develop coping strategies while focusing on employment. Thomsen et al. (2010) identified seven important factors in coping with advanced cancer: creating meaning, support systems, minimizing the impact of cancer, bodily and mental functioning, control, uncertainty, and emotions. Emotion-focused coping was determined to be more effective than problem-focused coping.

The nature of VR counseling – working together to find, obtain, and maintain meaningful employment – may lend itself to providing a sense of control over one’s life and potentially reinforcing the meaning one assigns to their life. To that end, VR counselors can facilitate consumers’ psychological adjustment to cancer by harnessing their existing social supports and referring them to new ones, including support groups, psychological services, and other health professionals.

Disclosure of chronic illness and disability is a topic that must be broached by VR counselors to support their consumers with advanced cancer. Fears related to disclosure and the difficulty in deciding whether to disclose to employers are commonly expressed by people with cancer (Stergiou-Kita et al., 2016; Tiedtke et al., 2010). Some people with cancer have reported feeling pressure to leave work to avoid disclosure (Tiedtke et al., 2010). Concealment, or intentionally decreasing the visibility of a condition, whether in the workforce or in one’s personal life, is a commonly expressed theme among people with disabilities, including people with cancer (Allen & Carlson, 2003). This employment-related disclosure combines with considerations that people with cancer experience in their roles as patients; cancer patients often report a loss of privacy and personal dignity that accompanies having to tell healthcare providers about the most personal details of their health status (Morrison & Thomas, 2015).

The disclosure decision is highly individualized, and each person must make the choice that is most comfortable for them. Some people may choose to disclose openly with everyone at work, whereas others may prefer to disclose only to a supervisor and leave the decision to them to determine who else needs to know (Morrison & Thomas, 2015). Morrison and Thomas (2015) offered a decision tree to support cancer survivors in determining whether to disclose or maintain their privacy. De Rijk et al. (2019) reported on the experiences of cancer survivors returning to work, and disclosure was a recurring theme in those experiences.

Suppose a consumer approaches their VR counselor with issues that may indicate workplace discrimination on the basis of the consumer’s cancer. In that case, the VR counselor must be knowledgeable and competent to guide and support them in addressing possible discriminatory conduct on the employer’s part. Cancer has not always been considered a presumptive disability under the Americans with Disabilities Act (ADA, 1990). Since the ADA Amendments Act of 2008 (ADAAA), however, people with cancer are considered people with disabilities under the law because their cancer substantially limits the major life activity of normal cell growth (Roessler et al., 2018).

4.4 Job development and placement

Once the consumer with cancer is ready to return-to-work or initiate their career, specific job development and placement interventions become the focus of the VR process. VR counselors should not assume that consumers with advanced cancer understand their legal rights in the workplace. Many of these consumers will need up-to-date and accessible information about the provisions of the ADA, the Family and Medical Leave Act, the Affordable Care Act, and other legal protections available to them. VR counselors must be prepared to provide guidance and technical assistance regarding such processes of ADA implementation as requesting reasonable accommodations, documenting disability status, and making formal complaints of employer discrimination. Accommodation planning is an important part of this phase of the VR process. Federal legislation obligates only employers who employ 15 or more workers to provide reasonable accommodations; however, individual states may have different regulations, with some states requiring as few as one employee for reasonable accommodations to be legally required. VR professionals must be familiar with the laws of the state in which they practice to appropriately guide their consumers.

It is imperative to begin the accommodation planning process by discussing with the consumer the coping strategies and accommodations they use in their daily lives because many of these can easily be translated into on-the-job accommodations (Job Accommodation Network [JAN], 2014). Employers also may need to be educated about the low cost and ease of most accommodations (e.g., flex-time, flex-place, telecommuting, schedule modifications, natural supports) for workers with cancer and other disabilities. In fact, scheduling modifications and flexible leave policies have been found to be the most commonly used workplace accommodations among cancer survivors (Blinder & Gany, 2020).

VR counselors can also provide valuable consultation to employers in ways that facilitate employment opportunities for their consumers with advanced cancer. In discussing the role of the rehabilitation professional as a consultant and technical advisor to employers in the ADA era, Mullins et al. (1996) and Nissen and Rumrill (2014) stressed the importance of helping employers:

Establish an ADA compliance office.

Communicate with other employers and community agencies regarding accommodation techniques and resources.

Determine that all company policies are consistent with ADA guidelines regarding such considerations as job interviewing, medical testing, and promoting employees.

Consult with rehabilitation professionals in the development and implementation of accommodations for employees.

Evaluate accommodation efforts to determine whether they have had the desired effects.

4.5 Job retention, follow-up, and return-to-work services

Job retention, follow-up, and return-to-work services are central culminating components of the VR process. In their systematic review of the literature, Thomas and Morgan (2021) identified four intervention strategies that improve job retention for people with a variety of disabilities: develop and apply self-determination/self-advocacy skills regarding accommodations and workplace challenges, social skills, medication management, and natural on-the-job supports. Each of these interventions is critical for people with advanced cancer who wish to remain in the workforce. There are national resources that rehabilitation professionals and consumers with advanced cancer can utilize to develop their job retention skills. One such resource is Cancer+Careers (2023), an organization dedicated to supporting people with cancer to thrive in their jobs through educational tools, including webinars, publications, checklists, and career coaching. VR counselors can also play an important role in supporting consumers with cancer in managing their treatment schedules, transportation to and from work and the hospital, navigating side effects from cancer treatment and symptoms from the disease itself, and, more broadly, educating individuals on health insurance and leave policies. Triage Cancer (2023) is another national resource that rehabilitation professionals and consumers with advanced cancer can turn to when in need of guidance on health insurance, disability policies and laws, Social Security with a cancer diagnosis, and leave laws.

Finally, it must be understood that the job retention prospects for individuals with advanced cancer are affected by factors such as the availability of workplace accommodations, socioeconomic status, gender, race/ethnicity, employer support, and the person’s specific job demands vis-à-vis cancer symptoms (Blinder & Gany, 2020). Accordingly, VR counselors must be prepared to address these personal and environmental factors in delivering the final phase of support for workers with advanced cancer. How these personal and environmental factors intersect with the consumer’s cancer experience and long-term career goals may be the ultimate determinant of success after VR services have been discontinued.

Conclusion

Due to encouraging trends in survival rates, advanced cancer is an emerging disability that will be increasingly seen in VR counselors’ future caseloads. People with advanced forms of cancer are an underserved VR clientele, and their needs for support and rehabilitation services are not yet well understood. With that in mind, this article has presented considerations for providing responsive VR services to individuals with advanced cancer, in keeping with the changes to the domestic and global labor force that have been brought about by the COVID-19 pandemic. Each of the sequential phases of the VR process requires careful examination of the medical, psychosocial, technological, career development, and community living issues that face people with this increasingly prevalent condition.