WCRJ 2021; 8: e1840

WORK ABILITY IN HEALTHCARE

WORKERS (HCWS) AFTER BREAST CANCER:
PRELIMINARY DATA OF A PILOT STUDY
F. VELLA1, P. SENIA1, E. VITALE1, A. MARCONI1, L. RAPISARDA2, S. MATERA1,
E. CANNIZZARO3, V. RAPISARDA1
1
Department of Clinical and Experimental Medicine, Occupational Medicine, University of Catania, Catania, Italy
2
Spinal Unit, Cannizzaro Hospital, Sicily, Italy
3
Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical
Specialties “Giuseppe D’Alessandro”, University of Palermo, Palermo, Italy
E. Cannizzaro is co-senior author

Abstract – Objective: Disabilities resulting from breast cancer (BC) treatment often reduce the qual-
ity of daily life and affect working and social life. This study investigated the residual work ability in a
cohort of female healthcare workers (HCWs) suffering from BC.
Patients and Methods: The study analyzed a cohort of female HCW’s operating at a hospital
in Southern Italy. Each HCW underwent a medical examination and routine laboratory tests and a
questionnaire on the Work Ability Index (WAI)
Results: Out of the 663 (100%) HCW’s undergoing health surveillance, 6% (n=40) had been
affected by BC; however, only 75% (n=30) agreed to join the study. 23 (77%) worked night shifts.
The average number of days of absence from work was 155.8 ±205.4 days in nurses/technicians and
128.2 ±239.7 days for doctors/biologists. The WAI score was very low in 2 (7%) cases; moderate in 9
(30%) cases, good in 7 (23%) cases and excellent in 12 (40%) HCW’s. The nursing/technical staff has
lower WAI scores than the other health figures. Arm/shoulder pain, numbness, limited mobility in
the upper limbs and lymphoedema were the main comorbidities reported by HCW’s which affected
WAI score.
Conclusions: A greater absence from work was observed in nurses and technicians compared to
doctors/biologists, also justified by the different professional risks that see them perform a physical-
ly more demanding job, i.e. manual handling of loads. WAI showed lower scores in nurses/techni-
cians than in doctors/biologists. Morbidity in the upper limbs is one of the main complications that
can negatively affect any work activity. This seems to affect the return to work, evident in sick leave
days and in the ability to perform tasks.

KEYWORDS: Work ability, Healthcare workers, Breast cancer, Night shift workers.

INTRODUCTION Between 2003 and 2019, BC incidence rate

was rising slightly (+0.3% year); whereas the
About 371,000 new cases of malignant cancer are mortality rate significantly continues to decline
yearly diagnosed in Italy; 178,000 of these affect (-0.8% year). These data were due to the efficien-
women and breast cancer (BC) represents the cy of new treatments as well to early diagnosis,
30% of the total1. that allows to detect cancer at an early stage1.

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License

Corresponding Author: Venerando Rapisarda, MD; e-mail: [email protected] 1

 Nowadays, the average survival, five years af- All HCW’s invited to take part in the project
ter the diagnosis, is 87% of total cases. The aver- were informed about the study’s objectives and
age survival 10 years after the diagnosis is 80%1. procedures. Adherence to the study was on a vol-
The total number of new cases of BC registered untary basis. Each subject signed the informed
annually worldwide is about 1,700,0002-4. consent. The study was approved by the Universi-
In the USA, each year about 10,000 new BC ty of Catania’s Ethics Committee (Catania, Italy).
cases (5%) are recorded among women with an For each worker, a careful family, pathological
age <40 years; in Asia, as for the same age range, and work history was carried out, in order to high-
it gets to 13% 2,5,6. BC is also confirmed as the light any occupational exposures that might have
leading cause of death from oncological disease in influenced the tumor onset. Using a questionnaire,
the Italian female population, with about 12,000 the voluptuous habits of each individual worker
deaths/year7. and the activities carried out in her time off were
There are many factors that affect the inci- investigated31.
dence of BC: increased life expectancy; changes In addition, the oncology diary was request-
in reproductive patterns; lifestyle; use of hor- ed for each HCW, updated to the latest therapies
mones during menopause; increasing prevalence and monitoring performed, as well as all genetic,
of obesity; factors related to the socio-cultural en- histological and diagnostic imaging tests already
vironment and increased early diagnosis, mainly made32,33.
due to effective screening programmes1,8. Each HCW underwent medical examination
The main recognized occupational risk factors and routine laboratory tests plus a questionnaire
are ionizing radiation, ethylene oxide and shift/ on the Work Ability Index (WAI)34.
night/ work8-16. These risk factors are often present Shortly, WAI is a synthetic index used to eval-
in healthcare facilities16. uate an operator’s individual work ability with
According to recent scientific literature, there the aim of determining working skills according
are correlations between shift work, especially to age, pathologies, etc35. WAI scores were cal-
night work, and an increase in the incidence of culated based on the standard method provided
BC17,18. Night work, capable of disrupting the by the Finnish Institute of Occupational Health
normal heart rhythm19-22, has been classified by (FIOH)35,36.
the International Agency for Research on Cancer WAI contains 7 questions investigating the fol-
(IARC) as a probable carcinogen factor for hu- lowing areas: current working capacity compared
mans (Group 2A) 8,9,14. with one’s best life period (0-10 points); ability
The treatment of these tumors often involves to work in relation to the job requirements (2-10
surgical therapy combined with chemotherapy points); diagnosed pathologies (1-7 points); reduc-
and radiotherapy23. These therapies are extremely tion of working capacity due to illness, estimated
aggressive with the tumor, often generating local- by the individual (1-6 points); sick leave over the
ized and systemic damage, which also causes se- past 12 months (1-6 points); personal expectations
vere disabilities23. Disabilities resulting from BC of one’s work skills two years onwards (1-7 points);
treatment often reduce the quality of daily life and psychological conditions/resources (1-4 points)37-39.
affect working and social life24-28. The WAI score (score: 7-49) is divided into 4
Some studies29,30 have pointed out that levels: low (score 7-27); moderate (score 28-36);
BC-treated women of lower working classes need good (score 37-43); excellent (score 44-49) 34,35,38.
a longer period of rest from work and an increased A homogeneous 1:1 matching control OS
loss of working capacity. group was selected for anthropometric character-
In this study, the residual working ability was istics, work history, etc. Inclusion criteria: women
investigated in a cohort of female healthcare who had never had BC and still in service. Exclu-
workers (HCWs) who were suffering from BC. sion criterion: presence of systemic diseases such
as heart disease, diabetes, etc.

PATIENTS AND METHODS

Statistical Analysis
The study was conducted in 2018 and it involved
female HCW’s operating at a hospital in Southern Statistical analysis was carried out with SPSS soft-
Italy. Inclusion criterion was women with previ- ware (IBM Corp., SPSS Statistics for Windows,
ous BC diagnosis. Version 23.0. Armonk, NY, USA). The collected
Exclusion criteria were presence of other sys- data were included in an ad hoc built database.
temic diseases such as heart disease; diabetes; not The descriptive statistics was used to characterize
being retired. the groups of subjects in the study and the associa-

2
 WORK ABILITY IN HEALTHCARE WORKERS (HCWS) AFTER BREAST CANCER: PRELIMINARY DATA OF A PILOT STUDY

Fig. 1. Descriptive flow-chart of the studied sample.

tion between the different variables were analyzed The average age of the menarche was 11.7
with chi-square test (X2) or Fisher’s exact test and ±1.2 years; the average age of menopause was
Student’s t-test. The appropriate association mea- 44.7 ±4.9 years, although 3 (10%) HCWs were
sures were estimated by means of the odds ratio still menstruating. 10 HCW’s (33%) were nullip-
(OR; 95% CI). Significant factors/variables to the arous, 20 (66%) had 1.7 ±0.6 children. Of these
univariate analysis and logistic regression models last 20, 18 (90%) had breastfed their children. 11
were applied. Statistical significance was set for (36%) had undergone hormone therapies during
p<0.05. their lifetime. Only 9 (30%) HCW’s reported fa-
miliarity for BC.
A comparison between the cases and controls
RESULTS showed a statistically significant difference in fa-
miliarity for BC and hormone therapy.
Out of the 663 (100%) HCW’s undergoing health At diagnosis, the HCW’s average age was 45.1
surveillance in 2018, 6% (n=40) had been affect- ±7.1 years and an average length of service of
ed by BC. The diagnoses had been made in the 16.6±8.7 years. 23 (77%) HCW’s worked shifts,
period 2002-2017. Only 75% of the 40 HCWs including night work. 53% of HCW’s (n=16) used
(n=30) agreed to join the study. Of the 10 HCW’s oral contraceptives. Table 2 shows the main char-
not joining the study, 9 (90%) refused, for work acteristics of the sample at the time of diagnosis.
reasons, for not having enough time to participate The job-related risks identified for each worker
in the study; 1 (10%) did not want to live a dra- were: 30 (100%) biological risk; 21 (37%) use of
matic event in her life again. Figure 1 shows the video display units; 17 (57%) hand lifting of pa-
descriptive flow-chart of the sample recruitment. tients; 23 (77%) shift work, including night work.
The average age of HCW’s was 53.7 ±7.4 In no case had there been exposure to known car-
years, with service length of 26.1 ±7.5 years. Their cinogens.
average BMI was 25.1 ±2.7 (overweight). Table 1 From the analysis of the association between
shows the main characteristics of the sample. BC and risk factors, only a significant correlation
Out of the HCW’s that took part in the study, with shift work was observed: OR=1.51, CI 95%
23 (77%) worked shifts, including night ones. 11 (1.47-1.56).
(37%) belonged to the medical area, 9 (30%) to Examination of medical records concerning
the surgical area, 10 (33%) to the service area. BC showed that 20 (67%) HCW’s had had BC,
13 (43%) were doctors/biologists, 17 (57%) were histologically classified as Luminal-A (ER+ and/
nurses/technicians. or PgR +HER2-); 4 (13%) HCW’s had the Lu-

3
TABLE 1. Main characteristics of the sample.

HCW’s with previous Control group p-value

BC 30 (100%) 30 (100%)

Average age (years) 53.7 ±7.07 52.9 ±6.9 n.s.
Menarche (years) 11.7±1.2 12.1±1.4 n.s.
Menopause (years) 44.7 ±4.9 45.2 ±4.7 n.s.
Length of service (years) 26.1±7.5 24.9±6.2 n.s.
Shift workers 23 (77%) 15 (50%) n.s.
BMI (Kg/m 2) 25.1 ±2.7 25.3 ± 2.4 n.s.
Smokers 3 (10%) 5 (16%) n.s.
Packages/year 14.5 ±2.5 15.1 ±2.1 n.s.
Alcohol intake 2 (7%) 3 (10%) n.s.
N° Doctors/biologists 13 (43%) 11 (37%) n.s.
N° Nurses/technicians 17 (57%) 19 (63%) n.s.
Surgical area 9 (30%) 8 (27%) n.s.
Medical area 11 (37%) 13 (43%) n.s.
Service area 10 (33%) 9 (30%) n.s.
Nulliparous 10 (33%) 9 (30%) n.s.
BC Familiarity 9 (30%) 1 (3%) p<0.05
Hormonal therapy 11 (36%) 0 p<0.05
Breastfeeding 18 (60%) 16 (54%) n.s.

minal-B form (ER+ and/or PgR+ HER2+) and 6 BC more than 5 years before and were currently
(20%) HCW’s had the Her2+ form. Table 3 sum- undergoing screening programs. At the time of the
marizes the therapy adopted in relation to the his- questionnaire, only one HCW’s was undergoing
tological classification. chemotherapy again, with distant bone and lymph
Mastectomy was necessary in 20% (n=4) node metastases.
HCW’s, with histological classification of Lumi- All 30 (100%) workers had returned to work.
nal-A and in 67% (n=4) HCW’s classified Her2+. The average number of days of absence from
The quadrantectomy had been performed in 80% work was 155.8 ±205.4 days in nurses/techni-
(n=16) of the HCW’s, Luminal-A positive; in cians, compared to 128.2 ±239.7 days for doctors/
100% (n=4) of the positive Luminal-B HCW’s biologists.
and in 33% (n=2) of the Her2+ ones.
Lymphadenectomy was applied in all cases
(n=18) of positive sentinel lymph node. In 23 TABLE 2. Main characteristics of the cases of HCW’s with
(77%) HCW’s, it was necessary to apply a com- BC at the time of diagnosis.
bined chemo and radiotherapy protocol; while in HCW’s with previous
the remaining 7 (23%), all Luminal-A positive, BC=30 (100%)
only the protocol with radiotherapy was applied.
Age at diagnosis 45.1 ±7.1
According to the TNM (Tumor-Nodes-Me-
tastasis) classification40, 30% (n=9) of the Length of service (years) 16.6 ±8.7
HCW’s, at diagnosis, presented stage I tumor Shift workers 23 (77%)
form with no lymph nodes involved and dis- BMI (Kg/m ) 2
23.6 ± 5.1
tant metastasis; 13% (n=4) had a tumor in situ, Smokers 13 (43%)
Stage 0; instead, 20% (n=6) was in Stage II A Packages/year 16.1 ±2.8
and another 20% at Stage II B. 14% (n=4) of
Alcohol intake 9 (30%)
HCW’s at diagnosis were already at Stage III
A and only 1 (3%) at Stage IV. Table 4 shows Nulliparous 12 (40%)
the subdivision of the sample according to the Familiarity BC 9 (30%)
TNM classification. Hormonal contraception 16 (53%)
Only 10 (33%) HCW’s were followed-up with Breastfeeding 18 (60%)
half-yearly periodic checks; 19 OS (64%) had had

4
TABLE 3. Therapy carried out in relation to the cancer histological classification.

Luminal-A Luminal-B Her 2+

N° HCW’s 20 (67%) 4 (13%) 6 (20%)
Mastectomy 4 (20%) 0 4 (67%)
Quadrantectomy 16 (80%) 4 (100%) 2 (33%)
Lymphadenectomy 10 (50%) 4 (100%) 4 (67%)
Chemotherapy / / /
Radiotherapy 7 (35%) / /
Chemo/Radiotherapy 13 (65%) 4 (100%) 6 (100%)

Therefore, the return to work of nurses/techni- Moreover, the nursing/technical staff revealed
cians took an average time that was longer but not lower WAI scores than other health employees.
statistically significant, compared to the medical/ Arm/shoulder pain, numbness, limited mobil-
biologist staff. ity in the upper limbs and lymphoedema were the
WAI average score was good in HCW’s with main comorbidities reported by the HCW’s that
BC (37.8 ±7.7) but lower than those obtained with affected WAI score.
the HCW’s control group (38.2 ±7.7). In particu-
lar, the WAI score was very low in 2 (7%) cases;
moderate in 9 (30%) cases, good in 7 (23%) cases DISCUSSION
and excellent in 12 (40%) HCW’s with BC. The
values observed in BC subjects were lower than Over the previous 3 decades, BC survival has sig-
those found in the control group, but in a non- sta- nificantly increased due to scientific and techno-
tistically significant way (data not shown). There- logical evolution in both diagnostic and therapeutic
fore, in the HCW’s group with previous BC there fields23,41,42. However, these treatments, often used
had been a good functional recovery. Table 5 re- in combination, have several side effects which,
ports the results of the WAI questionnaire in rela- added to the effects produced by the disease, cause
tion to the therapy adopted. temporary and permanent inabilities43-45.
By analyzing the type of therapy and the The state of inability raises the question of
residual working ability, it was observed that reintroducing the BC patient to the workplace,
HCW’s treated with quadrantectomy (n=23) enhancing the residual working ability. The in-
had a higher WAI score than those who had un- tegration at work of this group of people causes
dergone a mastectomy (n=7); moreover, HCW’s objective but also subjective difficulties, often
who underwent radiotherapy (n=7) had a higher related to psychological block and insecurities
WAI score than those who underwent chemo/ which, at times, generate in the patient the idea of
radiotherapy (n=23). refusing going back to work 46,47.

TABLE 4. TNM staging and classification.

N° HCW’s
STAGE 0 Tis N0 M0 4 (13%)
STAGE I T1 N0 M0 9 (30%)
STAGE II A T0 N1 M0 /
T1 N1 M0 5 (17%)
T2 N0 M0 1 (3%)
STAGE IIB T2 N1 M0 3 (10%)
T3 N M0 3 (10%)
STAGE III A T0 N2 M0 /
T1 N2 M0 2 (8%)
T2 N2 M0 1 (3%)
T3 N1,N2 M0 1 (3%)
STAGE III B T4 N1,N2,N3 M0 /
STAGE III C Ogni T N3 M0 /
STAGE IV Ogni T Ogni N M1 1 (3%)

5
TABLE 5. Results of the WAI questionnaire in relation to the therapy.

WAI Score 7-27 28-36 37-43 44-49

(Low) (Moderate) (Good) (Excellent)
Quadrantectomy 1 (3%) 6 (20%) 5 (17%) 10 (33%)
Mastectomy / 1 (3%) 5(17%) 2 (7%)
Lymphadenectomy 1 (3%) 5 (17%) 3 (10%) 5 (17%)
Chemotherapy / / / /
Radiotherapy / 1 (3%) 2 (7%) 4 (13%)
Chemo/Radiotherapy 4 (13) 6 (20%) 10 (33%) 3 (10%)

Indeed, chemotherapy, radiotherapy, hormonal literature, the so-called “blue-collar employees”

therapy and biological-immunological therapies rather than the “white-collar ones” are those who
in various combinations have influenced survival, delay the return to work the most29,30. Confirming
increasing it by 30%, compared to all the disease this, the administration of the WAI questionnaire
stages43,44. BC treatment side effects arise in 80% showed lower scores in nurses and technicians
of patients and may persist even after the end of than doctors and biologists.
therapy44,46,48,49. Morbidity in the upper limbs is A significant variation was also observed in
one of the main complications that can negative- the WAI index score in relation to the type of
ly affect one’s working activity, the psychosocial treatment: the most disabling one (mastectomy
sphere and generally the quality of life46,48. + chemotherapy + radiotherapy) had led to such
Arm/shoulder pain, numbness, limited mobil- massive presence of side effects as to affect work-
ity in the upper limbs and lymphedema are the ing capacity. The type of treatment received, sur-
main comorbidities detectable after therapy44,50. gery, chemotherapy, radiotherapy and hormone
This seems to affect the return to work, evident therapy, significantly influenced recovery times
in sick leave days and in the ability to perform and their return to work; according to Gregorow-
one’s task51. Actually, few studies have analyzed itsch et al53, patients’ reported working capacity
residual working ability upon returning to work51. is severely reduced during breast cancer treatment
The purpose of this study was to analyze a and further reduced when undergoing chemother-
cohort of HCW’s, with previous BC, in order to apy or lymphadenectomy. It turned out that che-
assess residual working abilities in relation to age motherapy had been the most disabling treatment,
and pathology, considering the return to work as increasing the absence due to its side effects.
an important part of the recovery process. Arm/shoulder pain, numbness, limited mobility
The average age of the sample was around 54 in the upper limbs and lymphedema are the main
years, in accordance with the data of the scientific comorbidities reported by the HCW’s (n=14) un-
literature that identifies the post-menopausal age as dergoing lymphadenectomy, with negative impact
the most at risk29. From the analysis of the sample on normal daily life activities, as well the psycho-
studied, 77% of the HCW’s were shift-workers. logical sphere and, not least, their working activi-
Voluptuous habits such as smoking and alcohol ties. Since these are people who fall into the eco-
were not very significant due to the low frequency nomically active domain, an early return, besides
in the sample (3 out of 30 women smoked and 2 facilitating the recovery of the worker’s healthy
said they usually took alcoholic beverages). conditions, reduces chronicization risks which
Instead, the OR analysis confirms that night would further aggravate her condition.
work seems to be a risk factor52 for the onset of About 50% of the HCW’s had a stage 0-1 tu-
BC, according to the IARC, which confirms that mor at diagnosis, certainly thanks to the important
night shift work is probably carcinogenic to hu- screening programs that have allowed, over the
mans (Group 2 A)14. years, a diagnosis of the disease at an increasingly
There was a higher frequency of BC among earlier stage.
nurses and technicians than other health employ- From the analysis of the economic impact for
ees. In the same way, a greater absence from work the hospital, it is highlighted that the average cost
was observed in nurses and technicians compared of lost working days amounts to approximately
to doctors/biologists, also justified by the different € 9,828.00; while a loss of productivity of about
professional risks that see them perform a physi- 30% was observed with an annual economic dam-
cally more demanding job, such as for example age of € 32830,15 which must be calculated for
manual handling of loads. As reported by the the remaining years of work.

6
 WORK ABILITY IN HEALTHCARE WORKERS (HCWS) AFTER BREAST CANCER: PRELIMINARY DATA OF A PILOT STUDY

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modulation of 8-oxoguanine DNA damage repair. Sci
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