key: cord-0920662-mzfh3pyl authors: Sönmez, Özlem; Tezcanli, Evrim; Taşçı, Elif Şenocak; Kazancı, Hande Büşra; Altınok, Ayşe; Toklucu, Elvan; Taşçı, Yusuf; Aydoğdu, Çise; Aydın, Ayşegül Bakır; Yüce, Sabiha; Oyan, Başak title: Coronaphobia: A barrier to ongoing cancer treatment? date: 2022-03-03 journal: Psychooncology DOI: 10.1002/pon.5907 sha: 308aacecccc5b849e20454d21d02ce89c8413565 doc_id: 920662 cord_uid: mzfh3pyl INTRODUCTION: Increased stress levels caused by the pandemic might cause delays in cancer treatment. We conducted a survey among cancer patients undergoing treatment to evaluate their psychological wellbeing and treatment adherence during Coronavirus disease 19 (COVID‐19) pandemic. MATERIAL AND METHODS: Patients receiving active chemotherapy at a private oncology center between January and May 2021 were included. Healthy volunteers were employees of a district health directorate with no history of cancer or chronic disease. Treatment adherence was described as compliant if the prescribed treatment was received within a week and the information was gained from patient charts. Hospital anxiety and depression scale (HADS) and COVID‐19 phobia scale (CP19‐S) were administered to participants. RESULTS: 402 participants were included; 193 (48%) were cancer patients. The mean age of the participants was 44 years old and 68% of the participants were female. All participants' CP19‐S mean score was 47.9. Patient group had significantly lower CP19‐S (p = 0.006). Chronic disease and history of a shocking event were the factors associated with CP19‐S. All participants reporting hospital anxiety were found to have significantly higher COVID‐19 phobia levels (p < 0.05). Patients' mean HADS‐anxiety score was significantly higher (7.3 vs. 6.5, p = 0.027). COVID‐19 phobia was an independent factor increasing the level of anxiety and depression in both groups. Adherence to treatment was 100%. CONCLUSION: The pandemic increased levels of anxiety, however, cancer treatment continued to be a priority in patients' lives. Strategies should be developed to support oncology patients cope with the pandemic and increase their courage to avoid treatment delays. population. Recent studies reported increased prevalence of psychological disorders due to the COVID-19 pandemic. [2] [3] [4] [5] Oncology patients are expected to have additional anxiety since they are identified as a susceptible subgroup for COVID-19 with an increased risk of morbidity and mortality. 6 This information is supported by the studies reported from China and Italy where the case-fatality was higher in patients with cancer than those without (6% vs. 2%, respectively). 7, 8 Systemic treatments, especially cytotoxic therapies, are the cornerstone of cancer treatment in both adjuvant and palliative settings. 9, 10 It is well documented that the patient adherence to treatment plays an important role in the effectiveness. 11 Oncology patients may experience additional psychological burden in terms of contracting the disease since treatments require frequent hospital visits. 5 Additionally, the fear of experiencing a more severe course of COVID-19 infection secondary to immunosuppressive state may prevent patients from applying to health care. For patients who are not receiving active treatment, the social distancing procedures and restrictions in access to care causing delays in surveillance visits may create additional fear of cancer recurrence. 12 The first official COVID- 19 There have been studies reporting the effects of the pandemic on oncology patients psychological wellbeing and its relation to treatment adherence, 13 however, the literature is lacking research on whether oncology patients are more vulnerable to the COVID-19 pandemic. It is important to determine the anxiety levels of oncology patients in order to avoid possible treatment delays due to increased stress levels caused by the pandemic. The main objective of our study was to evaluate the psychological consequences of COVID-19 on oncology patients receiving active systemic treatment. We conducted a survey among oncology patients in Turkey undergoing active cancer treatment in order to evaluate their psychological wellbeing during COVID-19 pandemic and compared their anxiety, depression and COVID-19 phobia scores with healthy individuals. We also aimed to determine if COVID-19 phobia affected treatment adherence. The study consisted of 402 participants of whom 193 were oncology patients undergoing chemotherapy, 209 of the participants were healthy volunteers. Patients receiving active chemotherapy at our oncology center in Istanbul, Turkey between January and May 2021, during the second wave of pandemic, were included in this study. Chemotherapy, targeted therapies and immunotherapy were included in the treatment protocols. Healthy volunteers were employees of the local Municipal Health Department, the inclusion criteria for this group was no history of cancer or chronic disease. Written informed consent was obtained from all participants after full explanation of the purpose and nature of the data collection. The study was approved by an institutional review board and a special permission was obtained from the Ministry of Health. Participants were asked to complete data collection forms, hospital anxiety and depression scale (HADS) and COVID-19 phobia scale (CP19-S) questionnaires. The surveys were conducted in-person. Second wave was more serious with regards to daily cases, hospitalizations and deaths in Turkey, at the time of this study the peak number of daily cases during this period reached up to 60.000. Although chemotherapy and radiotherapy services were not on hold, there was a shortage of in-patient services as well as limitations to surgeries. Turkey underwent full closure and reinstated the curfew on people aged 65 and older and people 20 and younger. Vaccination program was initiated for health care workers in January 2021, followed by vulnerable patient populations including oncology patients. The in-person surveys included data collection form, HADS and CP19-S questionnaires. 14, 15 The data collection form composed of 20 questions was used to inquire participants' demographic data including age, gender, occupation, education status, current living conditions and source of income. In addition, questions about their co-morbidities and preexisting/existing mental health conditions as well as their families were included. C19P-S was developed by Arpaci et al. in Turkey to assess the severity of COVID-19 phobia. 15 The objects of the scale were created based on a comprehensive review of existing scales on fear, expert opinions, and participant interviews. CP19-S is a 20-item validated self-reporting instrument that measures COVID-19 phobia in 4 parts to include psychological (6 items), psycho-somatic (5 items), economic (4 items) and social (5 items) factors. All items in the scale are rated on a 5-point Likert-scale from "strongly disagree (1)" to "strongly agree (5)". The higher score indicates a greater phobia. HADS is a 14-item validated questionnaire developed by Zigmond and Snaith in 1983. 14 It is used as a screening tool and severity measure for depression and anxiety. Although it was originally developed for patients in hospitals, it is valid in community settings. The validity and reliability study of the scale in Turkey was carried out by Aydemir et al. 16 It is a 14-item instrument rated on a 4-point Likert-scale. Anxiety and depression were independent measures. The possible scores ranged from 0 to 21 for anxiety and depression. The severity of anxiety/depression symptoms score is assessed as follows: 0-7: none, 7-11: mild, >11: severe. From the beginning of the pandemic, as a standard of care all patients had an initial phone consultation with a member of our oncology team (physician or nurse) within a week prior to their first treatment session. Their concerns were addressed and they were given a detailed explanation of the precautions taken in order to ensure their safety. All patients included in the study were followed-up for the duration of the study and their adherence to the treatment was reported. A chemotherapy chart review was used to determine treatment delays and no-shows. Treatment adherence was reported as compliant if the prescribed treatment was received within a week. Patients were classified as 100% adherent versus less than 100% adherent to treatment. Test in groups where the difference was significant. Quantitative data with abnormal distribution was evaluated with the Kruskal-Wallis Test and the Mann-Whitney U test was used for multiple comparisons in groups with significant differences. Chi-Square (Pearson Chi-Square, Continuity Correction, Fisher's Exact Test) tests were used in categorical data analysis. In addition, the level of correlation between two variables was examined with Pearson or Spearman correlation tests. Multivariate regression model was used to analyze the association between demographic and comorbidity data including history of psychiatric illness, loss of a relative and shocking, scary or dangerous event, while the COVID-19 phobia score was the dependent variable. The results were evaluated at the 95% confidence interval and p < 0.05 were considered statistically significant. Four hundred and two (402) participants completed the questionnaires; 193 (48%) were oncology patients and 209 (52%) were healthy volunteers. The mean age of the participants was 43.8 (SD = 13.5) years. 68% of the participants were female and 32% were male. Majority of them (70%) were married and living with family (92%). Two-hundred and forty-six (61%) participants were university graduates and 58% were employed. Patient group consisted of breast cancer patients (53%), lung cancer patients (20%), gastrointestinal tumors (10%), gynecological tumors (9%) and others (8%). Patients receiving adjuvant/neoadjuvant treatment with curative intent were 67% while 33% were being treated for metastatic disease. The detailed demographic characteristics are presented in Table 1 . The mean anxiety score of all participants was 6.9 (sd = 4, range = 0-20). Anxiety scores of 250 (62%) participants were within normal ranges, 84 (21%) were mild and 68 (17%) were severe. While there was no difference between two groups in terms of anxiety levels, it was determined that the mean HADSanxiety score of the patients was significantly higher All participants' CP19-S mean score was 47.9 (sd = 15.1, range: 20-100); subgroup analysis is given in Table 2 . The patient group had significantly lower CP19-S scores when compared to healthy individuals (mean = 45.8, sd = 5 vs. mean = 49.9, sd = 14.9, Patients with chronic disease and a history of a shocking, scary, or dangerous event had significantly higher CP19-S levels (p = 0.025 and p = 0.009). In the linear regression analysis, independent factors associated with CP19-S were found to be chronic disease (β = 0.14, t = 2.02, p = 0.045) and a history of a shocking event (β = 0.17, t = 2.45, p = 0.015; Table 3 ). According to the independent sample t-test results, female gender (p = 0.003), having a chronic disease (p = 0.042), diagnosis of psychiatric illness (p = 0.048) and being exposed to a shocking, scary, or dangerous event (p = 0.005) were statistically related to higher CP19-S levels in the healthy group. Moreover, in the multilinear factors increasing CP19-S. CP19-S evaluation details for both groups are presented in Table 4 . All participants reporting hospital anxiety were found to have significantly higher COVID-19 phobia levels (p < 0.05). There was no statistically significant correlation between depression levels and hospital anxiety among healthy volunteers (p > 0.05). However, the patients with hospital anxiety had significantly higher depression levels when compared to patients not reporting increased anxiety (p < 0.05). This correlation is presented in Table 4 . All patients (100%) received their assigned treatments within a week of their appointment showing 100% adherence to treatment. Our study has some limitations. Patients included in the present study were heterogeneous in terms of their cancer diagnoses and our control group selection itself might introduce a bias. Although we did not aim to make a case-control study, one can criticize the distinct characteristics of two groups included in this study. The rate of breast cancer patients being highest among the patient group created a gender imbalance with potential effects on coronophobia and HADS scores. Another weakness of our study is that we did not have a baseline pre-pandemic psychological evaluation, and neither of our questions addressed their psychological status before COVID-19. Oncology patients are already vulnerable for depression and anxiety, the disease itself carries the stigma of a chronic, potentially fatal illness. Although the pandemic increased levels of anxiety, cancer treatment continued to be a priority in our patients' lives and they aimed to continue their ongoing treatments without interruptions. Our study supports that strategies including phone consults should be developed in order to aid oncology patients coping with the pandemic and increase their courage to avoid treatment delays. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the SÖNMEZ ET AL. manuscript. No writing assistance was utilized in the production of this manuscript. N/A. The authors state that they have obtained appropriate institutional review board approval and have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. It was approved by Acibadem University Ethics Committee (approval reference number: 2020-25/23). O Sonmez conceived and designed the study. All contributed to the design, analysis and interpretation of the data. E Tezcanli prepared the first draft and all contributed to subsequent drafts and the final paper. All authors read and approved the final manuscript. Informed consent was obtained from all individual participants included in the study. The data that support the findings of this study are available from the corresponding author upon reasonable request. 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