To our knowledge this is the first study comparing the HADS and CP19P-S scores of oncology patients with healthy volunteers. Pandemic is a traumatic life event that affected all of the population. Cancer patients and survivors are especially prone to chronic distress and they experience long term psychological problems which are usually neglected. Regardless of cancer stage, whether curative or palliative, 10–20% of patients experience depression and anxiety [13]. Detection and prevention of distress is important since it can affect treatment adherence [14]. Several previously reported studies linked anxiety disorders to postponement of chemotherapy [15, 16].
Healthcare systems all around the world have been challenged by the COVID-19 pandemic. Although several precautions and adjustments were taken for the safety of oncology patients, they continued to experience high stress levels due to losses related to COVID-19. The initial studies that reported higher mortality rates for cancer patients added to the preexisting anxiety and depression of our patients, challenging them to make decisions between cancer and COVID [17].
In the current study, cancer patients had higher HADS scores when compared to the control group. However, their Covid-19 anxiety was significantly lower, which might have resulted in limited hospital anxiety leading to no treatment deferrals. Cancer remains to be the main life-threatening disease even during a pandemic, as COVID is a probability whereas cancer is a reality for our patient population. We attributed lower CP19-S scores to our telemedicine visits which aimed to address concerns of patients regarding safety measures for COVID-19. Informing our patients appropriately had critical importance in our pandemic strategy. Using telemedicine since the beginning of the pandemic resulted in no treatment postponements among our patients, although their wellbeing is affected more during the second wave of the pandemic. Karacin et al. [18], also used telemedicine as an important tool for the management of pandemic and investigated the effects of pandemic on the chemotherapy adherence. They reported lower chemotherapy deferral rates after this strategy was implemented.
Zhang et al. [19] investigated the psychological effects of chemotherapy interruption due to COVID-19 and they reported that especially patients with advanced refractory tumors had higher anxiety levels. They suggested phone counselling as a strategy to offer relief while reducing the psychological harm caused by treatment interruption. Although we found telemedicine interactions helpful, we agree that further psycho-social support should be provided for oncology patients in order to help them cope with the uncertainty. However, Rodrigues-Oliveiraet al. [20] investigated the effect of COVID-19 on the anxiety levels of patients receiving RT for head and neck cancer using the HAD scale. His results suggested complying with treatment schedules despite increased COVID 19 anxieties. Although the radiotherapy treatment modality has a potentially more concerning schedule that necessitates a patient's daily presence at the hospital, when compared with chemotherapy, these patients also did not defer the RT even though telemedicine was not used.
Patients and healthy participants that reported increased anxiety for hospital visits, had significantly higher HAD anxiety, HAD depression and CP19-S scores. Although there wasn’t any significant correlation among healthy participants in terms of anxiety and depression scores, cancer patients reporting anxiety were also found to have significant levels of depression. We can speculate that a reason for increased depression can be the possibility of treatment interruption which led to fear of cancer recurrence and mortality. It is important to define the contributing factors as well as coping strategies. A periodical virtual mood assessment can help us define the patients at risk for depression. Although not shown in our study, depression may lead to treatment refusal and deferral. Giese-Davis et al. [21] reported longer survival in metastatic breast cancer patients when their depression is managed.
Several studies showed the link between depression and cancer survival. Survival after a cancer diagnosis is multifactorial and depends on several factors such as treatment adherence, immunity as well as self-care including smoking cessation, exercise and diet. Zimmaro et al. [22] reported shorter survival when head and neck cancer patients were depressed.
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. Another weakness of our study is that we did not have a baseline pre-pandemic psych evaluation, and neither of our questions addressed their psychological status before COVID.