New Screening Program Tackles Job Worries of Patients With Metastatic Breast Cancer

A diagnosis of metastatic breast cancer changes everything about a person’s life, and one of the least discussed consequences is what happens at work. Roughly 170,000 women and men are living with metastatic breast cancer in the United States today, a number projected to grow substantially by 2040, and many of them must keep working through ongoing treatment, scans, and side effects. Yet while employment challenges in early-stage breast cancer have been studied for decades, patients with stage IV disease have largely been left out of the conversation. A new quality improvement pilot called RAISE, short for Routine Assessment and Integration of Screening for Employment, set out to change that by systematically asking patients with metastatic breast cancer whether cancer is threatening their livelihood, and then connecting those who need help with practical resources. The results, published in Breast Cancer Research and Treatment, offer both an encouraging proof of concept and a candid look at how hard it is to embed social needs screening into busy oncology clinics.

The stakes are considerable. In a study of cancer patients surveyed at a palliative care clinic cited by the research team, 58 percent reported working, and among those, 40 percent wanted to increase their work hours; among patients who were not working, 56 percent wanted a job. Employment disruption is linked to loss of financial independence, increased financial hardship, and psychological distress, and cancer-associated job loss has been shown to lead to difficulty paying bills, accumulating debt, and even bankruptcy. The burden is not evenly distributed. Black patients with cancer were found to be twice as likely to experience a negative financial impact of cancer and five times more likely to be denied health insurance compared with White patients, while Hispanic patients tend to work in less supportive settings with fewer accommodations, raising their risk of job loss. Helping patients keep working, the authors argue, could blunt an important driver of financial toxicity and health inequity.

The RAISE program was designed and piloted at two outpatient oncology clinics within the NewYork Presbyterian system: Weill Cornell Medicine, an academic medical center on Manhattan’s Upper East Side, and Brooklyn Methodist Hospital, a community hospital in Brooklyn. Eligible patients were English- or Spanish-speaking adults with metastatic breast cancer, whether diagnosed at stage IV from the start or after an early-stage recurrence. The project was structured in three phases guided by the SMART framework, meaning objectives were specific, measurable, attainable, relevant, and timebound. In the development phase, the team built an English and Spanish screening assessment with branching logic directly into the electronic health record, working in partnership with patient advocates. The screener opened with a single, plainly worded question asking whether patients were interested in learning about resources for people who have had challenges at work related to their cancer or who worry about how cancer might affect their job in the future.

Patients who answered yes were asked follow-up multiple-choice questions about whether they had experienced specific employment problems since their diagnosis, such as reduced wages, being laid off, or being encouraged to retire, and whether their ability to work had been negatively affected, for example by treatment-related physical limitations or strained relationships with co-workers. Those who said no were offered the option of being recontacted in six weeks. In the implementation phase, which ran from March 2024 to August 2025, eligible patients received an automated message through their patient portal 48 hours before a follow-up medical oncology appointment, inviting them to complete the screener in advance. Anyone reporting a need for support triggered an alert to a patient navigator, who reached out directly and offered educational resources covering legal assistance, employment rights, disability and health insurance, financial resources, social support, transportation, and symptom management, delivered as a physical booklet, a mobile app, or both, according to patient preference.

The numbers tell a nuanced story. In total, 1,362 unique patients received the screener, including both metastatic and early-stage patients, and 428 completed it, of whom 179 had metastatic breast cancer. Among those 179, 22 patients, or 12.2 percent, requested assistance, met with the navigator, and received employment-related materials. Among the 249 early-stage patients who completed the screener, 35, or 14 percent, requested help and received a resource sheet and referral. The team acknowledged that these uptake figures fell short of projections, and they identified a likely explanation: because screening was not restricted by age or employment status, some respondents were older, retired, or simply less concerned with employment issues, which would dilute the proportion requesting help.

Acceptability among patients who engaged with the program was high. In the evaluation phase, guided by the RE-AIM implementation science framework, the team surveyed 41 patients, 33 of whom had completed the screener and 8 of whom had been sent it but never finished it. Of those who completed the screener, 88 percent reported being somewhat or very satisfied with RAISE, and 79 percent said the screening questions were clear. Patients also had views on timing: 9 percent recommended administering the screener before the first medical oncology visit, 49 percent at that visit, and 42 percent within a month of it. Among the eight non-completers, reasons included not knowing what RAISE was, not remembering the email invitation, receiving the screener at an inconvenient time, thinking the questions did not apply to them, and preferring that a nurse or navigator ask the questions in person rather than completing them online alone.

Interviews added texture to the survey data. Five patient interviews revealed that four of the five respondents used the paper booklet, while none used the mobile app, a striking preference for analog resources in a digital-first intervention. Ten provider and staff interviews surfaced themes around workflow, personnel, and timing, with the primary barriers to screening identified as staffing shortages and constraints related to technology, time, space, and privacy. The community site posed a particular challenge: because most patients there either did not use their online portal or were not accustomed to checking messages from providers online, the navigator contacted patients by phone or in person to administer the screener. That hands-on approach boosted completion, and was feasible at the site’s low volume of roughly two to four eligible patients per week, but the authors caution it may not be sustainable in practices with larger patient loads or fewer resources.

Technology proved to be a double-edged sword. The team had hoped tablet-based in-clinic screening would catch patients who did not complete the screener in advance, and an electronic flag was built into the record to nudge staff at check-in to offer the tablet. In practice, in-clinic screening was inconsistent, largely because no designated staff member was available to identify eligible patients or help patients with technical questions. The authors also describe a diagnostic identification problem: their original algorithm, which relied on ICD codes specific to distant metastatic sites, missed some patients with metastatic disease, prompting an expansion of codes in 2025 that inadvertently swept in some early-stage patients as well. The episode underscores how difficult it is to systematically identify a specific clinical population using billing codes alone, a challenge the team is continuing to work through with informatics specialists.

The pilot also shines a light on digital literacy, which researchers have increasingly described as a super determinant of health. A recent analysis of more than 500 US hospitals found that only about 10 percent offer patient portal access in languages beyond English and Spanish, meaning patients who speak other languages are often locked out of exactly the kind of screening RAISE provides. The team notes that their materials were available only in English and Spanish, limiting their reach, and they plan future translations into languages prevalent in their system, such as Mandarin and Haitian Creole. The broader context is favorable: a 2022 survey found that 79 percent of National Cancer Institute community oncology research practices had implemented screening for health-related social needs such as transportation, housing, and food insecurity, and a national American College of Surgeons collaborative across 194 oncology sites recently demonstrated that tailored, systems-level approaches can reduce missed radiation appointments.

The authors are careful about the limits of their findings. The evaluation surveyed fewer patients than targeted, the five patient interviews may not have reached thematic saturation, and the program ran at only two urban hospitals with unique workflows for less than 18 months, so conclusions about feasibility and acceptability remain preliminary. Still, the lessons are already shaping practice: the experiences from RAISE are informing the rollout of expanded screening for unmet social needs and financial hardship among cancer patients across the NewYork Presbyterian network. For a population living longer than ever with metastatic disease, the message is that asking about work, and then actually doing something about it, is possible, provided clinics invest in the people and workflows that make screening stick.

Subject of Research: Implementation of an electronic health record-based employment needs screening and navigation program for adults with metastatic breast cancer

Article Title: Implementation and evaluation of the Routine Assessment and Integration of Screening for Employment (RAISE) program in adults with metastatic breast cancer

Article References: Pinheiro, L. C., Zeng, C., Dorzhieva, D., Joseph, L., Hamilton, Z., Edick, K., Mercurio, A. M., Walker, D., Blinder, V., & Rosenberg, S. M. (2026). Implementation and evaluation of the Routine Assessment and Integration of Screening for Employment (RAISE) program in adults with metastatic breast cancer. Breast Cancer Research and Treatment, 219(3), Article 27. https://doi.org/10.1007/s10549-026-08089-y

Image Credits: AI Generated

DOI: 10.1007/s10549-026-08089-y

Keywords: metastatic breast cancer, employment screening, electronic health record, patient navigation, health-related social needs, financial toxicity, quality improvement, RE-AIM framework, health equity, digital health literacy, patient portal, cancer survivorship