Univariate analyses were used to evaluate demographic characteristics and close-ended questions. Open-ended questions were coded into relevant higher order themes and sub-themes and analyzed through qualitative content theme analysis [20]. After the initial coding scheme was developed by the research team, analysis was conducted by each team member individually and then compared, ensuring group consensus to improve reliability.

This study makes an important contribution to the literature by providing detailed information on cancer patient navigators’ assessment of the cancer and employment issues faced by their clients as well as navigators’ training needs on the same topic. Similar to other research [18, 21], navigators in this study reported that financial burdens, work leave, insurance, and work-cancer fit were common concerns among their patients, with more nuanced findings highlighting the significant monetary burden cancer and its treatment places on patients [17]. Feedback from the navigators indicated a complex interplay of employment challenges that threaten the financial and overall wellbeing of patients. These challenges have the potential to influence patients’ successful completion of cancer treatment, and can impact health outcomes, career trajectories, and job security.

Employment issues can have a significant impact on the lives of cancer patients, yet many patient navigators in this study indicated that they did not feel equipped to provide the necessary guidance to patients regarding these issues. As such, it is evident training, education, and resources are needed to help navigators understand the work, legal, governmental, financial, and insurance matters commonly faced by employed cancer patients and to assist patients in successfully co-managing cancer care and employment. On a micro level, patient navigators must be prepared to help patients access the financial resources necessary to afford cancer treatment and meet other financial obligations, especially when treatment requires patients to reduce their work hours. On a mezzo level, navigators help support patients in addressing day-to-day work-cancer care challenges such as scheduling medical appointments that coincide with one's work schedule, requesting workplace accommodations through their human resources department or supervisor/manager, and managing side effects that could negatively impact work performance. Formalized training on these topics could help patients more effectively manage cancer care and employment responsibilities [10]. On a macro level, many of the patient navigators in this study expressed concern regarding their lack of detailed legal or public policy knowledge, making training on supports offered by federal and state policies that can assist employed cancer patients (e.g. Family Medical Leave Act (FMLA) and Americans with Disabilities Act (ADA), Social Security, Medicare, Medicaid, etc.) vital to the success of patient navigators. Professional organizations (e.g., National Cancer Legal Services Network), academic centers (e.g., George Washington University's Executive Training on Navigation and Survivorship), and non-profit groups (e.g., Cancer and Careers; American Cancer Society; National Coalition for Cancer Survivorship) are well-poised to provide CEU offerings to support the educational needs of patient navigators and potentially other healthcare professionals working with patients navigating chronic illnesses.

Navigators are an ideal member of the oncology care team to help patients manage the challenges of managing work and cancer, considering they are pivotal to the provision of care beyond defined clinical necessity [17]. Indeed, patients who work with navigators have reported that they are better prepared for the future, have a greater understanding of how cancer impacts their lives, and are more engaged in their care [22]. However, it is imperative that navigators be prepared with the necessary knowledge and resources concerning cancer and employment, so they can proactively identify and address the challenges that their employed patients are likely to encounter in this area, and are able to work effectively with employers within the context of Health Insurance Portability and Accountability Act (HIPAA) guidelines.

This study provides important results regarding the cancer and employment issues faced by patients which commonly challenge cancer patient navigators as well as the training these navigators feel would be most helpful in addressing these issues. However, there are several study limitations that should be considered. This study was conducted in one state, with a small and largely homogenous sample; therefore, generalizability may be limited. Although we consider the patient concerns reported by navigators regarding cancer and employment to be accurate, they may not perfectly reflect all patient concerns in this area. Additionally, related to scope of practice, we did not collect information on overall tenure as a navigator or the number of patients seen annually, and navigator experiences may differ in relation to these factors. These limitations are largely reflective of the exploratory nature of this study, however, they provide valuable guidance for future research.

Given the increasing importance of patient navigators in the delivery of cancer care, it is interesting to observe the varying definitions of navigation, the lack of consensus regarding what patient navigators do, and inconsistency in required job qualifications [12]. As the navigator role evolves, it is essential that any job changes are based on empirically sound evidence [23] and future research should guide this role development by further defining how navigators handle the cancer and work concerns of their patients. Future studies could expand the current findings by the systematic study of nationally representative samples, as well as examining the variation in responsibilities of navigators due to educational background and training. Agreement regarding the training needs of navigators has also yet to be reached [12, 24], providing a key opportunity to include resources regarding the effective management of cancer and employment in the training provided to navigators that is currently under development.

Despite the limitations of this study, our findings regarding the challenges cancer patient navigators encounter when helping patients with cancer and work issues and the training they feel is necessary to surmount these challenges is an important contribution to the field of patient navigation. Cancer patient navigators have the potential to fill the gap that has historically existed between what providers offered, in terms of work-related guidance, and what patients felt they needed, creating a connection between our fragmented health care system and the complicated biopsychosocial needs of patients [25]. Given the increases in cancer survival rates, [1-2], the fact that employment issues remain one of the most common unmet need of cancer survivors [7], and the increasing presence of patient navigators in U.S. cancer programs [15-16], it will only become more important to address the role of navigators in meeting the needs of patients regarding cancer and employment and ensuring they have the needed training and resources to do so in an effective manner.