The Breast Cancer and the Workforce Communication App: A randomized controlled trial of an English/Spanish intervention to promote long-term job retention

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ABSTRACT Job loss is one of the most impactful, yet understudied, stressors associated with a breast cancer diagnosis. Long-term financial consequences can include difficulty paying bills, accumulation of debt, and bankruptcy. Importantly, bankruptcy in cancer survivors has been linked to increased mortality. Women with access to work accommodations, such as schedule flexibility, are more likely to work during chemotherapy and to retain their jobs in the long term. Similarly, women with adequate sick leave may choose to take time off while maintaining job security. However, low-income minorities are less likely to have such accommodations, leading to higher rates of job loss and financial distress. For these patients, finding a way to continue to work during treatment is critical. In the Breast Cancer and the Workforce study, which focuses on immigrant and minority women, only 57% of pre-diagnosis employed low-income women retained their jobs after treatment completion, compared to 93% of higher-income women. Low-income women were less than half as likely as higher-income women to have accommodating employers and only one-fourth as likely to retain their jobs. However, patients whose confidence in asking for work accommodations improved over time were more than five times as likely to retain their jobs than those whose confidence did not improve. Based on these data, we developed the Breast Cancer and the Workforce Communication App. The goal of the parent study is to evaluate the effectiveness of this app in promoting job retention among women undergoing adjuvant (curative) breast cancer chemotherapy. For the proposed extension, we will build on the funded study by extending the follow-up of participants to 3 years, providing a long-term view of work in the post-treatment survivorship period. Additionally, we will evaluate the effect of our app on overall financial hardship in the long term, providing critical knowledge that will enhance our understanding of the relationship between work and financial hardship and of the role that interventions focused on work (such as ours) may have in attenuating financial hardship. The proposed extension has two main components that will allow us to study long-term work outcomes and better understand the effect of decreased wages and job loss on long-term financial hardship. In Aim 1, we will extend post- treatment follow-up to 3 years to 1) gain a longer-term perspective of work outcomes in breast cancer survivors, 2) evaluate changes in access to accommodations over time, and 3) evaluate work outcomes based on receipt of extended post-operative chemotherapy (which has become the standard of care for some patients in the time since the parent study was funded). In Aim 2, we will measure the relationship between work and financial hardship by correlating patient-reported changes in employment (work status, work hours, and earnings) to subjective and objective indicators of financial hardship. Additionally, we will conduct semi- structured interviews with a subset of study participants to identify pathways leading to financial hardship and to better understand the relationship between work and financial hardship.