Breast cancer affects women worldwide, with a 2020 incidence of 2.26 million cases (1–3). Of these women ~67% were aged <65, with 56% being between 40 and 64 years old, considered the prime working years (4, 5). Increased incidence, improving 5-year survival (~80% in developed countries) (1) and extending retirement ages (6), mean growing numbers of working-age women are diagnosed with breast cancer (BCW) (5, 7). However, cancer patients have 1.6x and 1.3x higher risks for early retirement (8) and unemployment (9), respectively, and a lower incidence of reemployment than do healthy controls (10–12). Consequently, returning to work (RTW) and job retention are crucial unmet needs of this population, and of major concern in the field of cancer survivorship (5). For many, RTW after a cancer diagnosis and treatment is needed for financial stability and regaining normalcy, contributing to patients' wider recovery and quality of life (5, 11, 13–15). Societally, RTW for BCW has extrinsic economic value in terms of reduced direct and indirect medical and welfare costs, and from less disease-related productivity loss, especially in light of increasing female labor force participation (5, 11, 16, 17).

Data reporting global mean RTW rates for cancer patients (63.5%) ranges from 24 to 94%, depending on time since diagnosis (12). In Hong Kong, 6-month and 12-month post-cancer treatment RTW rates were 39 and 63%, respectively (17). A recent systematic review reported RTW rate among BCW within 12 months of diagnosis of between 43–93% (18), with a steadily rising trend observed over the survivorship trajectory (19), suggesting a majority eventually reentered the workforce. Yet, BCW may experience a prolonged delay in RTW compared to individuals with other forms of cancer (20). The average duration of work absence due to BC ranged from 86 to 349 days, with a median of 210 days (e.g. compared to 125 days for gynecological cancer patients) (18, 20). BCW's RTW is associated with work environment, physical and psychosocial functioning, educational level, personal finances, and illness perception, medical/treatment-related factors and social support (7, 11, 12, 15, 18–22). However, evidence is mixed regarding whether these determinants either facilitate or hinder RTW (15). Different regional contexts between studies may account for the reported conflicting evidence and varied RTW rates, reflecting differences in healthcare provision, employment policies, social security, and cultural perspectives on gender across regions (7, 17, 19, 21, 23). For example, in Hong Kong up to 120 paid sick leave days can be accumulated when supported by a valid medical certificate whereas in the United States no federal law guarantees the right to paid sick leave (17). Most existing RTW studies on BCW have studied Caucasian populations in western cultural settings post-treatment or during survivorship (21). Even among the scant evidence on East Asian populations (22, 24, 25), the RTW rates varied across countries; 37%-59% in Korea (22, 26), 41% in Malaysia (25), and 21–33% in China (27, 28). More importantly, there are no prospective studies following BCW from the initial diagnostic stage of the cancer journey to RTW and, thereafter, productivity in work, indicating an important gap in the RTW literature. Understanding BCW's employment experiences in different setting and tracking their RTW status longitudinally from the immediate aftermath of primary surgery more comprehensively illuminates the entire decision-making processes in RTW, clarifying associated long-term facilitators and barriers, enabling efficacious tailored interventions or supportive resources to be developed, and refining relevant laws and regulations to meet specific needs and promote early RTW, ultimately improving rehabilitation outcomes for this population (15, 17, 22). In this regard this study significantly advances the existing literature.

Following successful work resumption, BCW face employment-related challenges, including activity impairment and work productivity loss (absenteeism: time lost from work, and presenteeism: reduced work performance) (12), potentially preceding work cessation (17, 22). Greater activity impairment and work limitation, and poorer work performance, is reported by BCW than by healthy controls (12, 19, 29). However, we lack empirical evidence that disentangles whether BC and its treatments affect activity impairment and longer-term work productivity loss, and predictors thereof.

RTW after cancer is a complex process requiring the consideration of multiple factors (5). Mehnert (12) identified six influences on work-related outcomes: (i) demographic factors; (ii) impairments to health status such as physical symptoms; (iii) psychosocial factors like psychological well-being and social support; (iv) motivational factors like work satisfaction; (v) work-related factors like job type, work environment, employer accommodation, and relationship with co-workers; and (vi) work-related interventions like counseling and vocational training services. Given the varying regional contexts that may shape these influences, the next question is if this European model of BCW survivorship is applicable to Chinese BCW. For example, legal protection, medical costs and employer accommodation of employee needs, and perceptions of sick roles may vary, affecting both RTW delay and productivity.

Here we prospectively examine work-related outcomes (RTW rate, time to RTW, work productivity loss, and activity impairment) among Chinese BCW in the first year following primary surgery and identify factors predicting these outcomes. We hypothesized that certain sociodemographics (older age, lower educational attainment, being married, and higher personal financial toxicity), medical factors (cancer stage and treatment type), impaired physical and psychosocial functioning, lower work satisfaction and RTW self-efficacy, and unfavorable work-related factors (higher work demand and poorer work conditions) would be associated with poorer work-related outcomes. Negative illness perceptions affecting the “sick role” of cancer patients may hinder RTW and also lead to a greater loss of work productivity (17, 19), so illness perception was also assessed.

In this first longitudinally documented RTW study of Chinese BCW during the initial recovery stage following primary breast surgery, we observed upward trending RTW rates over time (12, 19) from 23.2% at 4-weeks to 68.2% at 12-month post-surgery. Approximately 2-in-3 BCW (68%) successfully RTW at the first year following surgery, comparable with the global mean RTW rates of 63.4% regardless of time since diagnosis from a systematic review of mixed cancer types (12), and within the 43%-93% BCW RTW range reported within 12 months of diagnosis elsewhere (18); both reviews being of predominantly western contexts. The observed RTW rate was relatively higher compared to other studies of Asian populations that reported rates of 21–59% (22, 24, 25). However, direct comparisons are challenging due to ambiguous or different RTW assessment timepoints used across these studies. Median time to RTW after BC in this study was ~183 days, comparable with BCW RTW studies in the early diagnostic and active treatment phases in developed countries such as France (155 days) (40) and the United Kingdom (210 days) (20), where statutory sick pay is available.

Adjuvant radiotherapy and chemotherapy, and physical impairment were associated with poor RTW outcomes, partially consistent with Mehnert's model (12). Radiotherapy can cause arm pain and limit movement. Chemotherapy-induced neuropathy or fatigue may impair to return to work (19, 21, 41). Poorer physical functioning is associated with RTW delay (17). Body image concerns, and societal expectations and stigmas surrounding BC can damage self-esteem and psychological well-being, resulting in the decision not to RTW (11, 18, 33).

In contrast, higher household income, white-collar work, favorable work conditions, and greater RTW self-efficacy promoted RTW outcomes. While higher household income can reflect employment (21, 26), it may also imply higher educational attainment, potentially higher job security, flexibility and less manual work, facilitating earlier resumption (7, 26). Similarly, favorable work conditions such as desk work, are less physically demanding, alleviating physical handicaps from BC treatments, smoothing return into the workforce (18, 21). Enhanced RTW self-efficacy also significantly contributed to early RTW, substantiating reports of lower self-efficacy among those not RTW in previous qualitative studies (27, 42). Poorer RTW self-efficacy reflects both perceived impaired working capability, and worries about potential workplace demands, impeding RTW (43). Job type influenced decisions on RTW but not duration of RTW. White-collar workers were more able to RTW after BC than were blue-collar workers (36). Blue-collar workers may face job loss and/or challenges in finding new employment due to both cancer and treatment impacts restricting more physically-skilled work (44, 45).

Work productivity loss in RTW BCW is common. Our sample reported a 20% reduction of their work productivity at 12-month post-surgery. Pain was weakly associated with work productivity loss, resonating with previous studies that unmanaged physical symptoms distress reduced working hours (46) and hindered work productivity (17, 47–49). Physically demanding work may exacerbate treatment-induced physical symptoms including pain, limiting work performance (12, 47, 50). Concern about physically demanding work causing upper-body lymphedema might further impair BCW productivity (49). Higher role functioning seemingly enhances work productivity loss, contradicting previous reports (51). Better role functioning may lead to taking on more responsibilities, generating more work-related stress and exhaustion (52), adversely affecting work performance (53). In contrast, job satisfaction was the sole protective predictor of work productivity among BCW. A supportive work environment and better interpersonal relationships at work facilitate work commitment and motivation, enhancing productivity (23, 54).

BCW commonly report cancer/treatment impacts on daily physical activities (55), affecting work-related outcomes (56). At 12-month post-surgery, BCW reporting reduced activity functioning had received hormonal therapy, experiencing severe sleep disturbance symptoms, lower RTW self-efficacy, poorer financial well-being, and negative cognitive representation of illness. Lymphedema is a common side effect of hormonal therapy (57) that cause swelling, pain, and limit range of motion in the affected arm or shoulder (58), impairing physical functioning and routine task performance (59). Sleep disturbance was inversely related to daytime alertness and quality of life (60), which might further worsen capacity to perform daily activities especially during daytime (61). Financial constraints restrict utilization of healthcare, social welfare and other resources (62). Post-hoc analysis suggested that patients experiencing greater financial difficulties tended not to have health insurance. Financial stress likely amplifies psychological distress in BCW, compounding cancer's impact on daily activities (62). Furthermore, negative illness perceptions were associated with greater activity impairment, perhaps attributable to lower perceived social support and well-being (63). Negative illness perception might also reflect residual symptoms which compound psychological distress (63), further impairing recovery.

Early RTW after BC was relatively uncommon, with prolonged RTW delays, significant work productivity loss and activity impairment reported within the first year following surgery, highlighting the need for evidence-based rehabilitation interventions to support RTW and facilitate social reintegration (17). Work-related outcomes after BC evidenced multidimensional relationships with demographics, treatment-induced side effect and physical symptoms, financial well-being, work environment and satisfaction, RTW self-efficacy, and illness perception. These findings suggest that the development of a multifactorial, multidisciplinary RTW intervention might benefit Chinese BCW rehabilitation.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by HKU/HA HKW Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

DN: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft. SS: Data curation, Writing – review & editing. RF: Conceptualization, Supervision, Writing – review & editing. AM-T: Conceptualization, Validation, Writing – review & editing. AK: Resources, Writing – review & editing. DS: Resources, Writing – review & editing. LW: Resources, Writing – review & editing. SF: Resources, Writing – review & editing. OC: Resources, Writing – review & editing. DF: Writing – review & editing. SC: Resources, Writing – review & editing. AM: Writing – review & editing. WS: Writing – review & editing. WL: Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing.