The Lived Experience of Women Returning to Work after Breast Cancer

Breast cancer is a global concern and a common cancer in women. Treatment can involve chemotherapy, surgical intervention with possible radiation therapy. Many breast cancer survivors return to work, even though the availability of health care and occupational health services may be limited. This phenomenological study examined the return to work experience of six breast cancer survivors. In-depth, unstructured interviews were undertaken and analysed using an adapted version of Colaizzi’s (1978) approach. Four themes emerged. Women noted that the impact of their disease on their work continued for some time. Some women gained an inner strength to progress their career on return to work. The provision of occupational health services emerged as a positive influence. These findings have implications for occupational health professionals, particularly the importance of positively supporting women so that the breast cancer return to work experience is fully understood.


Introduction
Breast cancer is a global disease and one that affects women irrespective of ethnicity, socio-economic status or age. In the United Kingdom (UK), incident rates are increasing with 49,936 women diagnosed with breast cancer in 2011 [1], compared with the 39,500 recorded in 1999 [2]. Recent evidence indicates that one in eight women will develop breast cancer at some point in their lives [1]. After gender, the strongest risk factor for breast cancer is age. Nearly 48% of cases are diagnosed within the 50-69 age groups [3]. Over the last 30 years improved detection and treatment interventions have increased five year survival rates in England from 52% to 85% [4].
Many breast cancer survivors may be diagnosed when still in employment and are likely to suffer early stage disease with good prognosis and then return to work (rtw). The full impact cancer has on work may be difficult to fully comprehend as cancer site, treatments and its effects are not homogenous [5]. Breast cancer surgery is often an important method of treatment and can result in body disfigurement. For many women, the change in appearance can substantially influence the rtw process [6]. Even though breast cancer survivors comprise a major component of the work force, the corpus of research examined health beliefs [7], employment characteristics [8], employer disclosure [5], analysis of absence and rates of rtw [9][10][11], with a paucity of evidence on lived experience of rtw [6].
The impact of breast cancer on employment in older women is important especially as current figures indicate that the number of workers aged 65-75 have doubled over the last decade [12]. Given the fact that up to 62% cancer patients rtw, their experience of this process is important as it is regarded as a sign of returning to life [13,14]. The social support generated from the work environment is an important factor that can positively influence early rtw particularly for women who incurred long periods of absence due to breast cancer [1,8,14].
Equally, disclosure of cancer history may be a deciding factor when making choices about medical appointments or negotiating work adjustments [7]. A positive and accommodating employer perception can encourage early rtw whereas perceived employer discrimination can encumber rtw [7,8].
In the UK, the 2010 Fit Note [15], directs recommendations to managers and OH departments to facilitate rtw; working time amendments, duty changes and physical restrictions. Such adjustments are usually organised by line managers with the aim of creating a supportive work environment that enhances the workresumption process [10,16]. However, to what extent work adjustments may actually mask underlying physical complaints such as fatigue and arm pain is questioned [5].
A key driver for rtw is finance [17]. Sickness absence has been related to altered body image and the psychosocial effects of breast cancer [9,10,18]. A change in attitude to work, both positive and negative can impact on relationships with work colleagues [19,20].
Health professional recognition and awareness of the impact of breast cancer on the rtw experience of breast cancer survivors may be limited [6]. Given the global nature of breast cancer in women of working age [1], and the risk of cancer-based discrimination among breast cancer employees, it is an important aspect of work [21]. Despite a recommendation for exploratory studies on the rtw experience among cancer patients [22], there is a paucity of good quality reviews on breast cancer survivors experiences of rtw particularly employers contributions, the facilitation of supportive workplaces and role of and communications with health care professionals [16,23]. With this in mind, this study aimed to explore 'what are the lived experiences of women returning to work following breast cancer?'

Method
This phenomenological study aimed to fully capture the perspectives of six women on their rtw experience following breast cancer. This experience focused on motivations for returning to work, the impact of breast cancer, and the role of OH. The significance of the phenomenological approach is based on the exploration of the meaning of individuals' lived experiences through their own description [24]. This generates insightful understanding and description of the phenomena of human experience [25]. It is this lived experience that presents to the individual what is true or real in his or her life and which gives meaning to each individual's perception of a particular phenomenon, influenced by all things external and internal to the individual [26]. The hermeneutic phenomenology of Martin Heidegger (1889-1976) and the existentialist phenomenology of Jean-Paul Sartre  substantiated the approach taken within this study as they not only aim to understand a given phenomenon but also guide interpretation [24]. This study was developed from the literature review which is commensurate with the phenomenological approach. Nurses clearly want to grasp the lived experience of their patients, to enter the world their clients live in and to have an understanding of the basic processes that illuminate health and illness [27]. This sphere of phenomenology aims to gain an insight into the lived experience of others, and was chosen as the approach for this study.

Sample
A purposive sample of six women who met the inclusion criteria participated in interviews. This concurs with the in-depth nature of the phenomenological research approach. The phenomenology method involves studying a small number of participants through deep and prolonged interaction to identify themes and relationships of meaning within the experience [28]. A sample size of six concurs with the nature of qualitative research and an acceptable size for a phenomenological study [29]. Key participants that had lived experience of recovering from breast cancer and had fully returned to work for at least three months were selected. This ensured that the six participants could describe their experience from the point of contemplating rtw until full reintegration into the workplace. All participants were fluent in English. Participants were recruited via email contact with the OH advisors. Women interested in participating in the study were contacted individually by the researcher (AC) who discussed the study aims and ethics of participation. Women were reassured that participation was voluntary. Women had two weeks to respond and confirm their participation. It transpired that only six women who met the inclusion criteria actually consented to the study. Inclusion criteria are presented in Table 1.

Inclusion Criteria:
Permanent employees of the organisation Fluent in English in order for the transcriptions to be credible Women with a definitive diagnosis of breast cancer Treated with curative intent Women who have fully returned to work after breast cancer for three months Women who had lived of breast cancer treatment and experience of the given phenomenon

Exclusion Criteria:
Women who had lived of breast cancer treatment and experience of the given phenomenon Agency workers, Contractors and Secondees who may not be available for the whole of the study timetable

Non-English speakers
Non-sufferers of breast cancer Women known to be under the care of a mental health practitioner which may indicate and increased risk of distress resulting from the interviews Women who had not fully returned to work in the last 3 months Table 1: Inclusion/ Exclusion Criteria All six women chose an alternative name to be referred throughout and are profiled in Table 2. Four of the six women had time off work during treatment. At the time of interview all six women had returned to work and were locally based in the same organization as AC. Demographic details are presented in Table 2.  The data was collected through individual interviews with the participants in order to capture the participant's thoughts and feelings of their essential experience. In-depth, informal, unstructured interviews were conducted to unearth their individual experiences. This concurs with the phenomenological approach [30]. Unstructured interviews commenced with a broad question followed by structural probes [28].

Response
When did you first consider returning to work after breast cancer?
OK, em, I didn't at the time I got diagnosed, work was probably that last thing on my mind.
Employer support I'd managed to get into to work inbetween that for days but obviously I was limited with how much occy health would allow me to come into work which in a way I thought they done it brilliantly because I was, we would have regular meetings and we would sit and talk about what I can and can't do and although they put quite a lot of restriction on me, I was grateful as I'm one of those people that couldn't make that decision myself, if you said to me you know you've got to work this week, I will work.

Impact of breast cancer
They offered me a position to come back into because obviously I was doing physical work and it was a case of you can't be doing that as you need to be physically fit and obviously mentally fit as well and at the time I was neither, but I needed to have some kind of stimulus so going into the office they found me bit jobs to do which at the time I was so grateful for and that helped get through those few early days really and this is prior to having my operation.

Difficulties experienced
You never know after chemo how long your going to feel good for and each chemo gets worse and worse so you start off with going, ok its only one rough week, I've now got two weeks before my next chemo I can go to work now, you do start to feel a bit better, that was the early days, but as the chemo builds in your system, you swear that their making it stronger every time, and you know I'd didn't even really worry about the physical effects of the chemo, for me its always been inside my head….   Table 3. There are no pre-determined answers within phenomenology until you start researching [31]. Therefore, no time limit was set for the interviews to ensure that all avenues of thought could be explored and the researcher could immerse herself within the phenomenon. Interviews were digitally recorded. The interview duration was 30 to 60 minutes. The interviews were not interrupted and there were no requests for breaks or withdrawal from the study. Participants were reassured that they could refuse to answer questions and decline participation at any stage without impacting future OH care. Interviews took place at a convenient time and location in the workplace. Participants were interviewed once. Interviews were transcribed using a Windows XP programme. Respondent validation was used to ensure accuracy of interview interpretation. This was implemented to eliminate the risk of the researcher imposing her own ideas and distorting the meaning of the informant's accounts [28]. All participants were given the opportunity to request a copy of the final report once complete.

Data analysis
Interviews were transcribed verbatim by AC to allow immersion into the data and create an opportunity to grasp the issues of most importance [28]. This proved effective in enabling the researcher to comprehend the 'life world' of the participant. Data were analysed using [32] seven stages of analysis. Colaizzi's model allows for categories to be generated in order to comprehend the data but also to ensure credibility within the analysis when the identified themes are returned to the participants. Due to the sensitive nature of the subject, only the transcripts and not the findings were returned to the informants, therefore [32] method of analysis was modified to include the unique elements of this study. This form of modification allows the researcher to be flexible with the stages of data analysis [24].
Where possible there was minimal questioning by the researcher and analysis of data permitted trends to emerge rather than be searched for [30]. This permitted the exploration of the whole experience and how the themes inter-relate. The credibility of the research was enhanced through the use of independent coding, review across the research team (AC, MB) and the use of direct quotations to illustrate key findings [33,34].
Four overriding themes emerged from the data with several subcategories which were novel findings. Even though findings enrich understanding of the lived rtw experience of six breast cancer employees and form the basis of future research [35], it is not assumed the findings will be transferable to all breast cancer employees. The University Research Ethics Committee approved the study.

Results
Four themes emerged from the analysis these included; employer perception and employer interventions, occupational health and employer support, difficulties encountered due to breast cancer and career progression.

Employer perception and interventions
The Fit Note [15], provided GPs with opportunities to recommend extra support from employers to assist employees to rtw through phased returns, flexible working, amended duties and workplace adaptations. This recent change demonstrates the increased value of the employer in facilitating the rtw of sick employees.

Employer perception
The findings indicate that a positive employer perception encourages and motivates rtw during and after ill-health. Bryony reflects on witnessing a colleague's rtw experience and indicates that without such high employer perception she may well have chosen not to rtw. Phoebe compares her employer with other patients' experiences and is grateful for her situation: I saw how she was looked after… it seemed that she was being treated very well and she was being allowed to ease back in… the Office actually does take its duty of care very seriously, so it never really occurred to me that there would be a problem, I completely trusted the Office to get it right' (Bryony) 'when I listen to other women at the hospital in there talking about their companies that they work for and how badly they're treated and how poor the service… they're getting I, I can't tell them what mines like because all it'll do is depress them even more' (Phoebe)

Employer interventions
Despite the Fit Note [15], recommendations being applicable to only Bryony and Phoebe's rtw, all women reported having shortened hours implemented following their rtw. For some, OH had recommended this, for others this was locally arranged with management. Women felt the reduced hours could ease them back into working without added pressure or risk of tiredness. Not travelling during rush hour in Central London was also a perceived benefit of shorter working hours: 'The experience of returning to commuting, rather than returning to work, em was probably more difficult… the first couple of times I travelled in I wouldn't travel at peak rush hour' (Bryony) 'I didn't have to stand up on the tube for an hour and a half kind of in the rush hour, so that made quite a difference to whether or not I was able to come in, really' (Claire)

OH and employer support
Current OH research has focused on interventions rather than the rtw experience of breast cancer survivors [36,37]. Employers often delegate the task of recommending interventions to an OH provider. This not only facilitates the employer who will receive recommendations and advice from OH, but it also offers a confidential service for employees to access. Women's experiences of rtw and OH were positive, caring and appreciated often resulting in shorter working hours, follow up appointments and verbal support to ensure that they were coping with their workload. Regular supportive contact from employers while sick surfaced as a fundamental factor in easing the participants' rtw. Contact via letter, phone or person created a sense of inclusion within the workforce and assisted rtw: 'I got the odd em sort of envelope from the Office with, sort of keeping me up to date… I just felt it was nice that people hadn't forgotten me completely… I thought he was really good to bother to come to my house… if I hadn't had anything like that, if there had just been the odd letter and there hadn't been any personal contact I would have felt it incredibly difficult to come back' (Claire).
'I've got such a nice line manager who's sympathetic; I know I could just say to my line manager… "this part if the job is really pooping me out, I can't, I'm so tired I can't cope" then she would do something immediately' (Bryony)

Difficulties during RTW after breast cancer
Although work ability problems encountered after rtw from cancer have previously been acknowledged 17,19,20], research is limited to the experience of breast cancer survivors [6,16,37]. Breast cancer treatment can involve breast surgery and an extensive chemotherapy regime that can lead to extreme tiredness and cognitive dysfunction; both can last for several months post treatment. Three subthemes focused on the potential difficulties encountered during the rtw experience.

Confidence and anxiety surrounding work
When preparing to rtw during or after breast cancer treatment, some of the women reported feeling anxious and concerned about their abilities. Some women associated this with childhood experiences at school. Other women related their rtw experience with a loss of confidence and self-belief in their abilities and interactions with colleagues but also the fear of making mistakes. This continued for some time and meant that they found it difficult to progress in their respective careers: 'I probably felt trapped, I'd lost confidence… it got to a point I think where I'd almost avoid a meeting if there was one because I couldn't quite face it… I knew I could, but I didn't know how to start… I didn't know how to climb back out, find more challenging work that I felt confident I could do, so that was kind of like, this blinking thing came along and changed my life and I wasn't sure I quite liked how it had changed it' (Claire).
'When I first came back I was aware that I was very …cautious about my work, I was double checking and treble checking everything… I was spending much longer on it making sure I did it right, there is a slight dent in your confidence and your anxiety levels are a little bit higher' (Felicity)

Body image concerns
All of the women disclosed concerns about their physical appearance at work and how they would be viewed by colleagues and fellow commuters. Issues surrounding body image and mastectomy emerged from earlier studies [6] although anxieties connected with hair loss led to illness disclosure.. The following extracts illustrate these points: 'They're certain moments of trepidation throughout the whole experience…. probably the worst part of my experience was losing my hair which is just horrible for a woman, but I managed and got through and I wore my wig to work… I liked the fact that it made me feel ordinary, like everyone else and I didn't feel different at all' (Felicity).
'It didn't bother me that I didn't have any hair but I didn't want all the fuss… I was wearing a head scarf so they'll get a bit of a shock when I returned to work anyway with missing hair so they may as well know… my physical appearance had changed, short hair and stuff so at first I remember a couple of the team members saying "oh who's that over there?" not instantly recognising me' (Aleve).
Perception of body image following breast surgery was also a significant factor that impacted on the rtw experience particularly as the breast is such a visible and external organ and treatment may reduce its size or remove it completely; both are noticeable. Women also coped through the careful selection of clothes to wear to work or by comparing their experience with soldiers having lost other body parts who had to adjust to their situation: 'Everybody kind of looks at your breasts because they know its breast cancer, when you walk in, the eyes, you can't help it, you notice, the eyes will look at your chest' (Phoebe) 'A lot of my work clothes that I had before, I can't just put them on, I have to think about what I'm wearing underneath… it's the wrong shape neckline and it sounds terrible, sort of flippant and sort of you know not a serious thing to worry about but actually when your in a hurry first thing in the morning' (Bryony) 'The newspapers are full of all the soldiers that were coming back from Iraq with bits missing you know, so in a way that was horrible but it was quite a worry, there's always somebody worse off than you' (Anne)

Career progression
All women acknowledged that their illness had altered their perspective on work life balance and also their career aspirations. Although the rtw experience was predominately positive, some women experienced obstacles associated with career progression. The organisation employees were categorised as generalists that involved frequent post rotation adapted to suit different working patterns and adjusted via OH recommendation. Although this work feature could involve job restructuring, all aspects were viewed positively, challenging, an incentive to work hard by women returning from long-term sickness but also a recognition of the impact of their illness on work and managerial ability to handle women in this situation. In some cases, women felt that their new roles could be demeaning as they involved light duties which underutilised their skills and knowledge and could result in negative work experiences: 'I was given a project to do which meant working on my own… it wasn't something anyone had done before… maybe there just wasn't room for me in the team and that wasn't a very nice feeling… I would have preferred to come straight back to what I had done before… someone had taken what, the role I had occupied before… so I could kind of see what was going on in that team and, I found that really difficult… I could hear everyone chatting and discussing various issues and desperately wanting to get involved but it wasn't actually my role… I didn't have meetings scheduled… nobody phoned me up very often… I don't think anyone realised, I certainly didn't tell anyone that I was struggling. But I think it's only, in the last couple of years that I've been able to see what was going on, then… I kind of felt really invisible for a long time' (Claire).

Discussion
Bouknight et al. [8], indicate that employers have a pivotal role in breast cancer patients successful return to work. Findings, as acknowledged by Phoebe and Bryony, signify that a positive employer perception with ability to accommodate and appreciate individual health needs motivated rtw. The sense of loyalty and desire to rtw was due to the accommodation of their illness and employer support [8]. However, some women's perception of the organisation was less positive and the stimulus for rtw was financial. It is unclear whether this apprehension related to negative employer perception.
The findings of this study concur with the view that workplace interventions and employer accommodation can facilitate the reintegration of cancer survivors into the workforce [5,8,17]. Adaptations to the work environment can provide opportunities to stimulate rtw [22], pecifically reduced working hours. This adjustment was an influential feature in the rtw process for women as it minimised pressure and anxieties, relieved commuting difficulties and assisted the resumption of work tasks. This concurs with the view that modified working hours supports the re-integration process [5,16].
The positive influence of workplace accommodations to facilitate rtw from breast cancer is substantiated [5,8,22]. However, the implementation of evidence based standardised interventions is limited [36,37]. All women in this study acknowledged the need for shortened hours, albeit their working practices differed in this regard. Some women described their reduced hours as an OH adjustment and others as a local agreement by line management. Despite these schedules appearing to have a positive influence on rtw, there is no clear indication if work-related interventions are better than others [36], particularly as they are rarely structured [37]. This study supports the notion that reduced working hours positively influence the rtw experience. [5] substantiate this but question whether work adjustments may buffer negative physical or psychological health outcomes.
Although the role of health professionals in preparing cancer patients to rtw is widely advocated [6,17,21,22,], the position of OH has received negligible attention. The impact of the OH Physician upon rtw is discussed, rather than an evaluation of OH as an intervention [10,22]. This study indicates that in some cases, women's interactions with OH staff were wholly positive; they felt protected from over working and supported through the stages of the rtw process [6]. (1999) posited concern that breast cancer employees rarely discuss rtw from breast cancer with health professionals, even though discussion may positively influence their work experience. In contrast women in this study, welcomed opportunities for discussion with OH staff, appreciated their support and the professional behaviour of health professionals. Women also acknowledged and appreciated the regular contact empathic concern and employer support offered by line managers, as well as the services offered by welfare officers and health professionals. The provision of a supportive work environment is necessary for the successful integration in the work place and the resumption of work [16].
Communication from employers and human resources during absence can resolve women's concerns and uncertainties on rtw [16]. Supportive communication and regular employer contact appeared to positively influence rtw experiences; Claire felt like she hadn't been forgotten and Phoebe felt valued. Similarly, the narratives generated from [14], study also emphasise the importance of employer and employee social support. [18], further corroborates the impact of employer support and suggests it can also identify any hindrances to rtw. The positive employer support offered to all six participants studied here appears to contest [16] notion that women do not discuss rtw with employers.
The increased survival rate of working age cancer patients has inspired research focusing on the problems survivors may encounter, which may in turn facilitate rtw [22]. Difficulties of rtw from cancer have been acknowledged [17,19,22], however limited research has explored work problems experienced by employees with breast cancer [6,16,37].
Aleve, Bryony and Claire described apprehensions when contemplating rtw. Aleve and Claire both felt they had lost confidence and Felicity describes being over-cautious with her work, fearful of making a mistake. This is not a new finding, [6] found women had productivity concerns and were apprehensive of being less competent in their work. Similarly, women are often uncertain about their ability to work [16]. In earlier studies, a fear of being less competent on rtw led to concern surrounding job loss and unemployment [6,16,17]. None of the six women here felt their jobs were at risk although Phoebe contemplated whether she would be considered a valuable team member and worthy of development. The women studied here largely portrayed positive employer perceptions which may have eliminated apprehensions regarding possible job loss.
The findings generated from this study corroborate earlier research and emphasize that women who rtw after breast cancer are concerned about body image and physical appearance [6,7,16,17]. The women's experiences of losing their hair indicate that this issue had a greater impact upon body image than breast surgery. This is not unique; hair loss was reported among cancer patients as one of the worst things that can happen [17]. Felicity and Aleve felt hair loss was a symbol of ill-health which affected their decision to rtw during treatment. [16] also found that uncertainties about physical appearance affect women's decisions about work [16].
Aleve, Bryony and Felicity explained how hair loss forced the disclosure of breast cancer amongst colleagues when choosing to work during treatment. This substantiates earlier work which indicates disclosure to colleagues is associated with continuing to work during treatment [5,7,21] indicate that breast cancer survivors can feel pressured to leave their jobs if they experience inadequate reactions from their managers when disclosing their illness. This infers that women are apprehensive about being forced to disclose breast cancer when dealing with changes to their physical appearance.
Only Bryony and Claire underwent surgical mastectomies, though some women divulged how they would often find colleagues staring at their chests. Uncomfortable work situations surrounding body image after breast cancer is not uncommon [6]. Aleve revealed how her colleagues would talk about her breasts and how unnatural this was to experience.
The introduction of shortened hours to assist the women during their rtw was perceived to minimise the physical effects of the illness and treatment. This was the case for all women. [5] suggest whether managing illness and work may increase poor physical health outcomes and question if work adjustments actually buffer the effect of these. The negative effect of breast cancer upon long-term employment and career progression has previously been explored [6,37]. Anxieties surrounding career progression were experienced by Claire and Phoebe, however it was Claire who encountered the most difficulties when she was posted into an unbefitting role where she struggled to regain confidence. Felicity also described being allocated a menial role which she felt was a consequence of having breast cancer. This substantiates the work of [21] Stewart et al. (2001) who report that 56% of women believed cancer had affected their work or career. Similarly, [6] report that breast cancer survivors experience unwanted task changes, altered job responsibilities and demotion upon rtw. Felicity described working harder and doing more than was expected to avoid being treated differently and to prove she was capable of progressing. Phoebe demonstrates similar traits when she describes participating in the training course for her new role. This may have emerged from a fear of being less competent in carrying out their duties compared to before breast cancer. [6], also found women work harder after breast cancer in fear of disappointing employers and job loss which could explain Felicity and Phoebe's behaviours.
Women have reported negative experiences and feeling discriminated against when returning to work form breast cancer [16]. Here, Phoebe successfully secured a new job during her treatment however did express angst that she may not have been considered for the role due to her health. This is however quite unsettling and can easily be interpreted as a form of discrimination. This has previously been identified by [16], although conversely, [38], report job discrimination was not experienced by their participants.
Previous studies report that breast cancer survivors bring about fundamental changes in the way they view life [39]. They experience a greater gratitude for life and have altered responsibilities [40]. Breast cancer can also adjust the importance of work [6,14,16], encourage a more equal work-life balance [19] and alter work priorities and ambitions [21]. The findings generated here largely substantiate the findings of earlier work; Aleve and Phoebe describe putting work into perspective and Felicity declares being more assertive in work and putting a greater emphasis on work life balance.

Conclusion
The rtw journey begins when women and their employer prepare for making a return to the workplace. Throughout the study it became apparent that the employer plays a pivotal role within the rtw experience, with support, interventions and OH provision having an assured influence. The role of OH within the experience of rtw after breast cancer has received little attention in the literature; the findings generated here portray the positive effect of OH involvement. The rtw journey after breast cancer focussed upon addressing and managing any difficulties that arose in their work. It was here that many of the work-impacting problems of breast cancer previously highlighted in the literature review emerged. Although the problems reported by the women did not appear to have a major negative impact on their experience, they were significant enough to recall. The problems could easily be grouped into three categories, physical complaints, body image concerns and career progression. The most noteworthy and concerning problems involved Claire and Felicity's inappropriate posting allocations and the potential job discrimination experienced by Anne. A positive employer perception appeared to minimise the effect of the reported problems. Finally, the findings generated here substantiate earlier work which implies breast cancer alters women's attitudes and perspectives of work.
It is envisaged that the study will provide much needed information about how women experience their rtw and capture their complete experience holistically. The view-point taken in the study described is that it is only the women who have lived through rtw after breast cancer that can describe what it meant for them. Throughout the study much of the research clearly identified problems and implications of having breast cancer, and as a result, an awareness of this is essential in order to help future sufferers. OH is in the ideal position to inform, educate and support both employees and employers through breast cancer. This study describes, from the perspectives of six women, the experience of returning to work after breast cancer including the role of OH and the impact of breast cancer on this experience. This study confirmed previously reported aids and problems within the rtw after breast cancer but also identified the importance of the role, of OH and their influence on the experience. The generalizability of the findings generated here are certainly limited but nonetheless offer further insight into the rtw experience among women working for this organisation and may form the basis of future research.

Limitations of the study
This study is restricted to the experiences of only six women; however this is in-keeping with the in-depth nature of the phenomenological research approach. All six participants within the study were British Nationals and employees of a British organisation. The study does not capture alternative breast cancer experiences among women of different origins, ethnicities and belonging to alternative employment which limits the generalizability of the study findings.
The descriptive and interpretive elements of phenomenology limit the predictive ability of the findings, however understanding the workrelated issues and concerns of breast cancer employees may help anticipate future problems. Studies evaluating the rtw experience in breast cancer survivors are scarce. The identification of new factors affecting the rtw underlines the pertinence of employer provision to facilitate women with breast cancer at this time. By having an awareness of the stages of returning to work after breast cancer which emerged from this study it may assist OH professionals and other health care workers to assess and address the specific needs of breast cancer employees. This may aid successful early rtw and on a larger scale, potentially reduce employer sickness absence costs associated with breast cancer. It is hoped that the findings from the present study can be used alongside or in conjunction with other studies exploring the lived experience of rtw.
Employer support I'd managed to get into to work in-between that for days but obviously I was limited with how much occy health would allow me to come into work which in a way I thought they done it brilliantly because I was, we would have regular meetings and we would sit and talk about what I can and can't do and although they put quite a lot of restriction on me, I was grateful as I'm one of those people that couldn't make that decision myself, if you said to me you know you've got to work this week, I will work.

Impact of breast cancer
They offered me a position to come back into because obviously I was doing physical work and it was a case of you can't be doing that as you need to be physically fit and obviously mentally fit as well and at the time I was neither, but I needed to have some kind of stimulus so going into the office they found me bit jobs to do which at the time I was so grateful for and that helped get through those few early days really and this is prior to having my operation.

Difficulties experienced
You never know after chemo how long your going to feel good for and each chemo gets worse and worse so you start off with going, ok its only one rough week, I've now got two weeks before my next chemo I can go to work now, you do start to feel a bit better, that was the early days, but as the chemo builds in your system, you swear that their making it stronger every time, and you know I'd didn't even really worry about the physical effects of the chemo, for me its always been inside my head…. you know physically I didn't really care what people thought I looked like at the time because I only looked the way I felt so it didn't really matter. I think if I'd, because I was fortunate that I only had a lumpectomy, I think if I'd have had the mastectomy I think that would have probably been quite hard to come back with.