A new cancer diagnosis can be life-altering. It can affect one's interpersonal relationships, employment, and leisure. Psychosocial effects are significant: some patients feel a wide range of emotions, including confusion, sadness, and anger, and experience changes in their faith and self-identity. In a study of 4500 cancer patients, the prevalence of psychological distress ranged from 29% to 43%. A major source of distress originates from managing uncertainty. The COVID-19 pandemic has heightened this state of uncertainty.
Uncertainty becomes a fixture in the life of a cancer patient. After the diagnosis, patients face uncertainty regarding their quality and length of life. Ambiguity may continue throughout their treatment. It is uncertain what therapy will be most successful in slowing the growth of their cancer. It is uncertain whether they will have side effects that will affect their livelihood or preclude them from receiving further treatment. It is uncertain whether or when they may develop disease recurrence or emergence of a new malignancy. Uncertainty even continues post-treatment and may account for the majority of the variance of functional and physical wellbeing months after completing treatment. This uncertainty results in many patients feeling a lack of control in their lives and having difficulty planning for the future.
With the start of the COVID-19 pandemic, cancer patients face even greater hurdles. Indeed, cancer patients are at high risk for infection due to their underlying disease, treatment-related immunosuppression, and medical comorbidities. A recent study from China found that COVID-19 patients with cancer, especially those with recent chemotherapy or surgery, have higher risk of severe events (defined as intensive care unit admission, invasive ventilation, or death) than COVID-19 patients without cancer. In a New York hospital system, patients with hematological malignancies and COVID-19 infection had a case fatality rate of 37%, 2 to 3 times the rates in the noncancer COVID-19 population. It is worthwhile to note that both studies had a small sample size and that more research will be needed to fully capture the risks of COVID-19 among this population and to stratify between patients undergoing treatment and those in remission.
Given this vulnerability, cancer patients face difficult decisions. Patients worry about whether they can go for a walk, shop in a grocery store, or spend time with their loved ones safely. With regards to treatment, patients are required to make potential trade-offs. Continuing cancer treatment in the hospital may shrink their tumor but may also expose them to SARS-CoV-2. Delaying treatment minimizes the risk of exposure but may result in progression of their malignancy. Notably, many cancer centers have tested patients for COVID-19 prior to arrival to clinic and created separate areas for those who are being ruled out for infection; these interventions, which have required considerable effort from hospital staff, aim to create safe spaces for patients to receive their treatment. Even reassurance with a risk/benefit analysis from their oncologist may leave some patients anxious about receiving treatment.
To make matters more complicated, uncertainty arises when patients become sick, as it may be difficult to distinguish between possible COVID-19 infection and their underlying malignancy. The virus and the malignancy can both lead to similar symptoms (especially in patients with lung cancer) and exhibit similar radiological findings (ie, bilateral groundglass opacities); ultimately, this poses a challenge in interpreting the clinical presentation of these patients and may lead to a delay in diagnosis of COVID-19 infection.
In addition, less contact with their oncologists during this pandemic may heighten uncertainty. Most patients look to their oncologist for clinical information and emotional support. Furthermore, a close alliance between cancer patients and their oncologists improves psychosocial wellbeing and adherence to treatment. With fewer clinic visits, patients may miss out on the therapeutic comfort and guidance provided by their oncologists.
Telehealth visits can bridge these gaps by de-escalating the strain that the COVID-19 pandemic has added to an already physically and psychologically vulnerable population. A higher level of communication and engagement with patients should be emphasized. Frequent telemedicine visits enable patients to voice their concerns and ask questions regarding timing of treatment. During these visits, patients should receive recommendations regarding next steps to take if they develop new symptoms.
Multidisciplinary efforts with palliative care, social work, and psychiatry services will also be helpful. During mental health assessments, providers should access how well patients are coping with the uncertainty of their cancer treatment with the added stress of the pandemic and potential isolation from quarantining. Behavioral health providers can offer strategies to help manage uncertainty and explore adaptive and maladaptive responses to uncertainty; these strategies will help curtail the development of more debilitating anxiety symptoms. Mindfulness, the relaxation response, and breathing exercises all help to mitigate feelings of powerlessness and helplessness that uncertainty can create. By focusing on what they can do now and what is certain (as opposed to what is not), patients can develop concrete tools to combat the lack of control from uncertainty. Finally, support groups for cancer patients, through zoom and online platforms, can create a supportive, validating community and enable sharing of beneficial coping strategies.
Cancer patients face enormous levels of uncertainty in a high stakes setting. The COVID-19 pandemic has accentuated this vulnerable state and disrupted the lives of many patients. There is reason to believe that the delays in cancer treatment and suboptimal care during this period will have a substantial impact for years to come. Models examining the effects from the COVID-19 pandemic predict an additional 10,000 deaths from breast and colorectal cancer alone over the next decade, an estimate which does not even account for other cancer types or associated morbidity. By understanding how cancer patients are affected by the pandemic, we can begin to find ways of reinforcing best practices, fostering community, and providing needed support for the foreseeable future.
Conflicts of interest
The authors declare that they have no financial conflict of interest with regard to the content of this report.
The authors report no conflicts of interest.
. Zabora J, BrintzenhofeSzoc K, Curbow B, Hooker C, Piantadosi S. The prevalence of psychological distress by cancer site. Psychooncology
. Garofalo JP, Choppala S, Hamann HA, Gjerde J. Uncertainty during the transition from cancer patient to survivor. Cancer Nurs
. Shilling V, Starkings R, Jenkins V, Fallowfield L. The pervasive nature of uncertainty-a qualitative study of patients with advanced cancer and their informal caregivers. J Cancer Surviv
. Mehta V, Goel S, Kabarriti R, et al. Case fatality rate of cancer patients with COVID-19 in a New York hospital system. Cancer Discov
. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol
. Cannistra SA, Haffty BG, Ballman K. Challenges faced by medical journals during the COVID-19 pandemic. J Clin Oncol
. Moujaess E, Kourie HR, Ghosn M. Cancer patients and research during COVID-19 pandemic: a systematic review of current evidence. Crit Rev Oncol Hematol
. Sapir R, Catane R, Kaufman B, et al. Cancer patient expectations of and communication with oncologists and oncology nurses: the experience of an integrated oncology and palliative care service. Support Care Cancer
. Trevino KM, Fasciano K, Prigerson HG. Patient-oncologist alliance, psychosocial well-being, and treatment adherence among young adults with advanced cancer. J Clin Oncol
. Sharpless NE. COVID-19 and cancer. Science