We have provided data on post-COVID fatigue, dependence for ADLs, psychological symptoms, as well as speech, swallowing and dysphagia in a cancer population using prospective and longitudinal data. Our cohort presented high levels of fatigue, anxious/depressive and PTSD symptoms, and of nutritional risk at the time of discharge, with improvement of fatigue and functionality for ADL, and some aggravation of speech, swallowing and psychological symptoms in the following 12 months.
Data about COVID-19 impairments in cancer patients stems from a few studies, and comparison with our findings is limited due to population heterogeneity. Post-COVID symptoms and impairments were reported by a large retrospective European multicenter registry study that assessed 2,634 cancer patients for respiratory symptoms, fatigue, weight loss and neurocognitive disfunctions (including taste and olfactory) 1–2 months after hospital discharge [31]. They found that 15% of patients presented at least one sequela from COVID-19, most commonly respiratory symptoms and fatigue, compared to 72% of our cohort. However, direct comparison between those numbers is probably inappropriate, due to the several differences between those two studies: First, they included patients with more advanced cancer than our cohort (metastasis in 50% vs 26.5%). Second, only 48.3% of their sample required hospitalization due to COVID-19, compared to 100% of our sample. Third, the only outcome measurement present in both of our studies was fatigue, which was defined as any report of fatigue in their study, compared with BFI ≥ 1 in ours. Data on post-COVID symptoms and disability 12 months after hospital discharge were reported by a Chinese study that compared 166 cancer patients to 498 non-cancer patients [4]. At least one symptom was present in 23% of participants 12 months after COVID hospitalization, similar to non-cancer patients hospitalized for the same issue. Curiously, cancer patients had less fatigue (4% vs 12%, p = 0.016) and anxiety (0% vs 5%, p = 0.021) than non-cancer 12 months after COVID-19 hospitalization. As a comparison, fatigue after 12 months was present in 34.2% of our sample. Participants in our study had more severe COVID presentation, requiring mechanical ventilation in 25% vs 14% of the cases in the Chinese study. Also, our criteria for diagnosing fatigue (BFI ≥ 1) is probably more sensitive than in this other study (“often feeling fatigue”).
Level of independence for ADLs was not impaired in our population. Over 92% of participants reported no/mild limitation prior to COVID-19 infection, and no statistically significant change was observed in the following 12 months, in line with previous studies [14, 23].
Nutritional risk at discharge was present in 45% of our cohort, compared with 97% in a previous study from Spain [33]. However, individuals from the Spanish cohort had more severe COVID-19 presentation than ours (admission to the ICU of 87% vs 29%), as well as longer length of ICU stay. Screening for nutritional risk is paramount in treating the cancer population, as it identifies the optimal time for introducing efficacious nutritional interventions.
Voice, speech or swallowing impairments were present in about 20% of our sample at the time of discharge, in line with previous studies [12, 15, 16, 22, 39]. Those symptoms became more prevalent in the following 12 months, inflicting at least 30% of our sample. We do not have a reasonable explanation for those findings. Head and neck cancer patients comprised only 11.8% of those presenting voice or swallowing symptoms after 12 months in our sample; and we could not find significant differences between in speech/swallowing outcomes when comparing individuals admitted to the ICU and the ward.
Anxious/depressive and PTSD symptoms were common in our cohort, affecting 15.7–49.0% of the individuals across all time points. Previous studies have showed similarly high levels of those symptoms in individuals hospitalized due to COVID.[38] A recent populational study from UK assessing over 8 million adults for clinically diagnosed neuropsychiatric sequelae after COVID-19 hospitalization found much lower figures for new-onset anxiety (0.74%) and depression (0.05%) [9]. Nevertheless, they found that COVID-19 survivors had higher risk of new-onset anxiety (hazard ratio [HR] = 2.36) and use of antidepressants (HR = 3.24) in the first 12 months following hospital discharge, when compared to the general population. In that study, the risk for newly diagnosed neuropsychiatric conditions was similar between those admitted for COVID-19 and those admitted for other severe acute respiratory infections. In contrast to our study, which used questionnaires to identify individuals with psychological symptoms, the abovementioned study relied on a diagnosis by a clinician on a regular visit, which may explain the difference between these data.
Limitations
Our study has several limitations. We did not assess the presence of symptoms before COVID-19 infection, nor we had a control group hospitalized for other reasons. Therefore, it is possible that some individuals already presented symptoms prior to the infection. And in those who presented symptoms only after COVID-19 infection, it is not possible to establish a causation relationship, since there are several other possible explanations for such symptoms, for instance, being hospitalized, being a cancer survivor, and living during a pandemic.
Our cohort had a small sample size, and a loss to follow-up of about 20%. This creates uncertainty in the generalizability of the figures obtained, which could have been under or overestimated.
We did not assess for sequelae now known to be important, such as respiratory, cardiovascular and neurocognitive, which could be frequent and disabling after COVID-19.