This study has found that women living with and beyond BC have been significantly impacted by the COVID-19 pandemic. One-third of women reported experiencing a high impact of COVID-19 stressors on their daily lives, and those with a high COVID-19 impact experienced more disruption to BC services and lower QoL. However, the impact of COVID-19 was not the same for all women with BC. Younger women and urban living women reported a higher COVID-19 impact, while retired women reported a lower COVID-19 impact. Women in post-active treatment and women further removed from their initial BC diagnosis reported significantly more disrupted BC services. Younger women and non-employed women reported a significantly lower QoL. Lastly, health insurance was found to significantly moderate the impact of COVID-19 on both disruption to BC services and QoL.
Globally, there has been a large disruption to BC services during the pandemic [32], and the current study coincides with this trend. Previous research found that follow-up BC visits decreased by about half from 2019 to 2020 [10]. Existing literature is inconsistent in findings on disruption for active BC treatment, and findings are conditional on the type of BC treatment received [33–36]. For example, one study found that the number of BC surgeries declined during the pandemic [33] while another found that more surgical procedures were performed during the pandemic, and the waiting time to surgery was lower than pre-pandemic times [34]. In addition, one study found that initiation of radiation treatment were lower in 2020 compared to 2019 [35], while another found that the delays during the pandemic for radiation treatment did not different significantly from pre-pandemic [36]. In comparison, our study found that women who were diagnosed within 2020 and/or received active treatment during the pandemic reported less disrupted BC services, suggesting prioritization based on need.
The minimal important difference (MID) for interpreting group differences or changes in QoL over time using the FACT-B is estimated to be in the range of 3–8 points [37], and our findings suggests a large negative impact of COVID-19 on QoL in comparison with other studies conducted prior to the pandemic [30, 38]. Research is limited on QoL during the pandemic, however physical, social, emotional, and cognitive functioning have been shown to be common concerns for women with BC [8, 39]. One study found that women reported lower QoL with increased financial problems such as unemployment due to the pandemic [21] which is consistent with our study; non-employed women reported significantly lower QoL than women who were employed or retired.
For both outcomes (disruption to BC services and QoL), the interaction between COVID-19 impact and health insurance was significant. For both categories of COVID-19 impact (low vs. high), women without private health insurance reported significantly lower QoL than women with private insurance. Women with private insurance and low COVID-19 impact reported the highest QoL, while women without private insurance and high COVID-19 impact reported the lowest QoL. Therefore, the interaction between COVID-19 impact and health insurance status is likely a determinant for QoL for women in our study. There is limited related research conducted during the pandemic, however one study in the USA found health insurance status to be associated with financial well-being for BC patients [21].
The interaction between COVID-19 impact and health insurance was different for disruption to BC services. Not having private insurance was associated with greater disrupted BC services when COVID-19 impact was low; however, when COVID-19 impact was high, having private health insurance was associated with slightly higher disruption compared to not having private insurance. Ireland remains one of the only European countries that does not provide universal health care to its citizens [40]. The Irish health system operates on a complex two-tiered public and private basis; nearly half of the population opt for private insurance, which primarily provides more rapid access to healthcare through private and/or public secondary and tertiary specialist services [41, 42]. During the pandemic, private hospitals in Ireland were used as public hospitals to provide additional hospital capacity to deal with the impact of the pandemic [40]; this may explain the negative effect for women with private insurance and high COVID-19 impact on BC service disruption. Comparably, one study conducted in USA found that women with limited ability to pay (i.e. public health insurance) were three times more likely to experience treatment delays [5], yet this study did not take into the interaction with COVID-19 impact.
This study makes an important contribution to limited evidence of the impact of COVID-19 on women living with and beyond BC in Ireland. The study provides descriptive data on the impact of the pandemic, disruption of BC services, and health-related QoL. Moreover, the current study is one of few studies to consider varied experience by SDH. However, there are limitations, including the potential for bias related to external validity or generalisability. We aimed to make the sample representative of the general BC population by using two different recruitment methods to help reduce this bias: social media campaign and paper-based survey distribution through BC clinics. Participants were able to save and return to the online survey if they preferred, allowing higher completion rates.
In conclusion, the study identifies the impact of the pandemic for women living with and beyond BC in Ireland, a country which experienced severe restrictions and longer lockdowns compared to several other countries [43]. There has been a large disruption to BC services during the pandemic, including active treatment and post-active treatment and this impact, along with a decrease in QoL, was not the same experience for all women. It is important to identify the women who experienced a larger disruption to BC services so they can be reintegrated into proper BC care, along the entire cancer continuum. BC services should involve the multi-disciplinary needs of women to improve QoL, such psychosocial interventions. Web-based (e.g. telemedicine) psychosocial approaches have shown to be beneficial [44] and women with BC were not only satisfied with telemedicine during the pandemic, but found the remote communication with their BC care team to improve anxiety levels [45]. Additionally, follow-up research on QoL is needed to evaluate whether women’s well-being has improved since the government lockdown.