The study was the first step in the process of developing and implementing employment support services for cancer survivors served by a National Cancer Institute–designated Comprehensive Cancer Center located in a rural region of northern New England. This descriptive study collected qualitative data from individual interviews and focus groups involving cancer survivors, health care providers, and employers. The study had three steps: (1) we conducted individual semistructured interviews with a convenience sample of cancer survivors (target n=15), health care providers (target n=15), and employers (target n=15); (2) we reviewed interview content to summarize program recommendations; and (3) we conducted focus groups with the original participants to present options for program development (drawing on existing social and behavioral intervention delivery models) and obtain their feedback regarding the best ways to proceed in designing services.

The study was reviewed and approved (with exempt status) by 2 institutional review boards (Dartmouth-Hitchcock Health and Massachusetts General Brigham Health), and all participants affirmed their informed consent via signature prior to the first interview. Interview and focus group participants were each offered a US $50 honorarium. Participant data were stored securely and were only accessible by approved study team members on an as-needed basis.

We recruited a convenience sample of participants who live and work in the 2-state catchment area of the Dartmouth Cancer Center located in Lebanon, New Hampshire. The cancer center is situated in a micropolitan area more than 100 miles from the nearest major metropolitan area. Almost half the catchment area population resides in rural areas, with 19% and 28% living in large rural and small rural communities, respectively [15,16]. The population is largely racially homogenous, with more than 94% of the population identifying as White [16]. The inclusion criteria were:

Cancer survivor and employer participants were recruited through flyers, advertisements, e-newsletters, social media posts, direct email invitations, and through outreach via organizations such as chambers of commerce and cancer control organizations. Health care provider participants were recruited through email invitations from the research team members who worked at the Dartmouth Cancer Center. At the end of each interview, the interviewer asked participants if they would share study contact information with others (eg, their employers) who might be willing to participate in the study.

In an earlier publication using the same data set [7], we conducted a thematic analysis using direct quotations to describe overarching themes that depicted commonalities among the experiences of the participants. In contrast, our goal in this analysis was to condense and summarize the full range of perspectives and recommendations of our study’s participants. As such, we performed a content analysis to summarize our data. We used the following steps of meaning condensation and categorization that were described by Bachiochi and Weiner [17]. First, we repeatedly read the transcriptions and notes from the interviews and focus groups. Next, we iteratively developed a coding scheme to categorize the various comments made by participants in response to the open-ended questions. Finally, we made sure that each comment was captured by the coding scheme. Our application of these steps of content analysis are described below and depicted in Figure 1.

During the initial coding of the interview transcripts, described in detail in a related thematic analysis of these data [7], we created a code titled “Suggestions for what might help,” with an operational definition of “Direct advice regarding what should be included in a program designed to support employment goals of cancer survivors.” The coded text included examples of strategies and resources that participants (ie, cancer survivors, health care providers, or employers) either experienced or felt were important resources for us to develop. As we focused potential interventions on supporting survivors to remain in the workforce, we omitted suggestions focused on supporting survivors to take extended time off work, providing financial aid, and helping to file disability paperwork.

The coded text was exported to a Word (Microsoft) document. We then created a bulleted list capturing the essence of each recommendation. The list included the study identification number of the respondents who endorsed each option. Based on existing interventions that we were aware of [18-22], we then clustered items on the list into the following four categories of support: (1) education in the form of workbooks or webinars; (2) individual consultation focused on functional capacity evaluation, self-management, and empowering cancer survivors to build capacity and seek accommodations; (3) services that provide worksite evaluation and guidance to both cancer survivors and their employers; (4) employment-related peer support or advisory groups. After the categories were presented to the focus group participants, we summarized the advantages and disadvantages of developing an intervention focused on each of the 4 categories, and which type of participant identified the advantage or disadvantage. Figure 1 summarizes the analytic process.

Forty-five people participated in semistructured individual interviews: 23 cancer survivors, 17 health care providers, and 5 employers. Fewer people participated in the focus groups: 6 cancer survivors, 4 health care providers, and 2 employers. Among the 23 cancer survivors who participated in interviews, there were 5 office or administrative support professionals, 3 primary or secondary school teachers, 2 health or social service practitioners, 2 top executives at nonprofit organizations, 2 management professionals, 2 business operations specialists, 1 farmer or rancher, 1 education administrator, 1 art and design professional, 1 recreation worker, 1 sales representative, 1 construction trades worker, and 1 truck driver. Additional participant demographics are presented in Table 1.

Textbox 1 contains the first category of recommendations for intervention development that involved education for cancer survivors, health care providers, and employers. This included a request for a toolkit that explains benefits and rights, examples of accommodations, and typical emotions and experiences that accompany the return to work. Notably, the list of recommendations contained several items that specifically targeted employers. For example, participants of all types felt it was important for employers to understand the diversity across types of cancers, their corresponding treatments, and how people respond to and recover from treatment. They also said it was important to illustrate how working can contribute to recovery from cancer and how workplace loyalty can be generated via support and goodwill from employers during cancer recovery.

In the focus groups, each type of participant acknowledged the value of providing education, and both cancer survivors and employers noted that education resources could be crafted to facilitate better interactions between survivors and employers (eg, a template for disclosure conversations). However, two important caveats were identified in the focus groups: (1) health care providers noted the challenge involved with making educational materials that can be understood by diverse populations and that apply to people with various types of jobs. (2) Cancer survivors noted that they are often overloaded with information regarding their diagnosis, and it can be challenging to read and independently apply educational information when they are undergoing treatment and not feeling well.

Textbox 2 contains suggestions that involved individualized consultations between cancer survivors and specialists (eg, occupational therapists, social workers, and vocational rehabilitation specialists) that could evaluate and help survivors maximize work capacity, monitor progress, and identify accommodations. Other suggestions in this category indicated an interest in a program that would help cancer survivors evaluate the role of work in their lives and how they might navigate the decision to leave the workforce, change jobs, or adjust their job to better fit their priorities. The suggestions involving individual consultation and self-management approaches were all generated by cancer survivors and health care providers, which is reasonable considering employers may have little to no involvement in this type of program.

Focus group participants appreciated the individualized nature of this type of approach and its potential to reduce stress by directly addressing cancer survivors’ issues; however, cancer survivors and health care providers had concerns about the cost of these services and how they might be funded. Employers and survivors voiced concern that the specialist would suggest strategies to the cancer survivor that would be unacceptable to the employer, and health care providers worried about liability issues that might accompany providing advice about rights and accommodations.

Textbox 3 contains recommendations from cancer survivors, health care providers, and employers in which a specialist would interact with both cancer survivors and employers to identify accommodations and ways to support work performance and satisfaction. This reflected a desire to improve communication and to have both parties understand and respect the other’s point of view to come to mutual solutions.

Employers voiced an appreciation of the ability of this approach to enhance communication, and they liked being part of the solution. The potential drawbacks included the hurdles of coordinating appointments and communication among more people and the ability to interface with all types of workers and workplaces. For example, cancer survivors wanted to be sure that this type of resource would be available to people who are self-employed, and both cancer survivors and health care providers worried that such a service could conflict or compete with existing services an employer might offer.

The final recommendation came from cancer survivors who voiced an interest in a group experience—potentially peer-led—where cancer survivors could share their ideas and experiences (Textbox 4). Survivors and health care providers saw the benefits that come with group interactions in terms of the efficiency of reaching many people at one time and the efficacy of peer support. Yet, they also voiced concerns that work and the financial aspects of work can be sensitive subjects. Thus, discomfort talking about these topics with others or a distaste for group interactions might limit the accessibility of this approach. Employers also voiced a concern that group meetings could involve even more time away from work.

The results demonstrate many areas of convergence, where the 3 types of participants agreed upon the needs, benefits, and drawbacks of certain approaches for supporting cancer survivors’ employment goals. For example, both health care providers and cancer survivors wanted to ensure any proposed program would meet the needs of diverse patients. Providers advocated for making sure materials were able to be read and understood by people with varying levels of literacy and survivors advocated for making sure programs met the needs of people who are self-employed.

There were some aspects in which the opinions of the 3 types of participants diverged. Health care providers pointed out some drawbacks not raised in the other focus groups. They were attuned to issues of efficiency (ie, that groups could allow them to help more patients in the same amount of time), liability (ie, a fear of providing inaccurate information), and scalability (ie, advocating for a self-management model that would fit within the realm of health care). The cancer survivors were the only group to voice the concern that, while education is important, survivors often experience information overload during diagnosis and treatment; therefore, information alone may not be helpful to survivors. Cancer survivors also worried about receiving recommendations from an individual consultation that an employer would not be able to fulfill. Interestingly, that concern seemed to be a reason employers voiced the greatest support for the third option (services that provide consultation and guidance to both a cancer survivor and their employer), where they could be part of the discussion and involved in identifying reasonable accommodations. Finally, employers worried about the logistics and time demands of peer-based and group support because they might have less flexibility in scheduling group programs around the demands of any given worker’s job and assignments.

This study of cancer survivors, health care providers, and employers explored the acceptability of potential interventions to support cancer survivors to continue working during and after cancer treatment. Our goal in this study was not to seek consensus on the exact intervention that should be developed at our cancer center; rather, we sought to gather stakeholder perspectives on approaches to work interventions in the cancer context by highlighting barriers that may need to be addressed as well as identifying both common and unique selling points across varied stakeholders to assist in promoting the uptake of new programs.

These data help to identify the needs and priorities of different stakeholders, many of which have been noted in other studies in the United States and other countries. For example, a qualitative study of employers in Denmark reported inadequate information about how to support cancer survivors at work and emphasized that interventions must also address employers’ needs in tandem with the needs of cancer survivors [23]. Similarly, a US study highlighted employers’ lack of specific knowledge about cancer and the recovery process as a barrier to cancer survivors returning to work [24]. Our findings contribute to a small but growing literature on employment support for cancer survivors in rural environments, where job markets and available resources may differ from those in urban settings [25,26].

Each proposed delivery model has advantages in the eyes of our participants, and whichever intervention we choose to develop will need to be carefully crafted. For example, educational interventions can be helpful but often need to be augmented within a multidisciplinary intervention to be maximally effective [27]. Approaches to increasing rigor in the development of such interventions may include grounding in theory or using frameworks such as the Behavior Change Wheel [28] or the Rehabilitation Treatment Specification System [29] to identify the desired targets and evidence-based behavior change techniques to affect those targets. Principles of effective approaches to improving employment outcomes in other contexts, including job crafting among workers with disabilities [30], cognitive behavioral therapy addressing work challenges among people with mood disorders [31], and individual placement and support for people with serious mental illness and other health conditions [32], may help inform such an intervention.

The feedback gathered in this study can help us to identify implementation strategies that might help us move forward with pilot testing and the development of an employment support program that is feasible and sustainable within our cancer center. The Expert Recommendations for Implementing Change compilation [33] offers a list of implementation strategies that can help systems as they develop or adopt innovations. For example, to maximize the adaptability of any intervention we develop, we could consider having both generic and tailored content available and having rapid tests of change involving “champions” or “early adopters” from a specific demographic who can guide tailoring to their needs (eg, challenges created by certain types of cancer) and environments (eg, types of workplaces). Strategies that can address concerns about compatibility involve finding ways to assess local resources and readiness for change and identify local champions.

The 2-stage design of our interview and focus group study allowed for an iterative data collection process along with member checking of key interview findings at the focus group stage. However, a lag of over 6 months between interview completion and focus group scheduling may have contributed to attrition and the small focus group samples, which differed from the interview samples in terms of gender, age, and educational backgrounds. Additionally, these are best described as convenience samples. All 3 participant groups had minimal racial and educational diversity, though cancer survivor demographics were largely consistent with the catchment area of our cancer center. While we oversampled cancer survivors and health care providers, we were unable to acquire our target sample of employers. Few employers responded to our postings, some of them we contacted reported that privacy regulations prevented them from knowing whether any of their employees have had cancer, and others were interested in participating but unavailable at the time of the scheduled focus group sessions.

Regarding the content of the focus groups, we focused on interventions that support survivors remaining in the workforce. We, therefore, omitted suggestions focused on supporting survivors to take extended time off work, providing financial aid, and helping to file disability paperwork. We did not include the perspectives of cancer survivors who left the workforce and may later want to return. We also did not include perspectives from family members of cancer survivors in this study. Furthermore, we decided to map interview participants’ suggestions onto existing intervention delivery models that could be tailored and implemented in a cancer context. The 4 categories of interventions about which we sought feedback were not mutually exclusive; for example, educational approaches could be included in any of the other 3 intervention types. Furthermore, we grouped recommended resources and supports in ways that reflected the number of people involved in their delivery, which may appear superficial or arbitrary; an alternate method of grouping these potential interventions may have produced different results. This design allowed us to gather feedback on a range of interventions from low-touch to high-touch, and to explore pros and cons along this continuum. Any intervention development in this area will benefit from grounding in theory [28] and future work will need to determine which theoretical framing is best suited for informing hypothesized relationships between interventions, mechanisms of action, and employment outcomes for both cancer survivors and employers.

The variety of intervention advantages and disadvantages identified across participant groups in this study represent potential facilitators and barriers to implementing these types of interventions in practice. Further intervention development, particularly pilot testing stages, would benefit from the application of implementation science perspectives to address these facilitators and barriers.