Literature is scarce regarding cancer care utilization during the massive outbreak of coronavirus disease 2019 (COVID-19) in the Republic of Korea. We investigated functional impairments in mental health and their relationships with depression, anxiety regarding the viral epidemic, and disruptions in healthcare service utilization among cancer patients in the COVID-19 pandemic era.
We used an online survey with questions related to the disturbances faced by patients with cancer in utilizing healthcare services in the pandemic era. Current mental health status was assessed using the Work and Social Adjustment Scale (WSAS), Stress and Anxiety to Viral Epidemics-6 (SAVE-6) scale, Patient Health Questionnaire-9 (PHQ-9), Insomnia Severity Index (ISI), Brief Resilience Scale (BRS), Cancer-Related Dysfunctional Beliefs about Sleep Scale (C-DBS), and Fear of COVID-19 over Cancer (FCC).
Among the 221 responders, 95 (43.0%) reported disruptions in healthcare service utilization during the COVID-19 pandemic. Logistic regression analysis revealed that functional impairment in the mental health of these patients was expected due to disruptions in healthcare service utilization, high levels of depression, anxiety regarding the viral epidemic, fear of COVID over cancer, and low resilience. Mediation analysis showed that patient resilience and cancer-related dysfunctional beliefs about sleep partially mediated the effects of viral anxiety on functional impairment.
In this pandemic era, patients with cancer experience depression, anxiety regarding the viral epidemic, and disruptions in healthcare service utilization, which may influence their functional impairments in mental health.
Coronaviruses are RNA viruses that are known to infect various species of hosts including humans and mainly cause respiratory and gastrointestinal disorders. The 21st century saw two outbreaks of coronavirus infection caused by viral mutations; namely, severe acute respiratory syndrome and Middle East respiratory syndrome [
In the era of the COVID-19 pandemic, cancer care utilization is changing rapidly due to the shortage of medical personnel, hospital beds, and personal protective equipment (e.g., masks, gowns, and gloves). Moreover, both patients and medical staff need to ensure social distancing to prevent the spread of viral infection. For cancer patients, the direct consequences of treatment delay or non-adherence are later-stage diagnosis or stage shift, which are of utmost importance among clinician precautions [
The main strategies for cancer treatment should include the prevention of COVID-19. The risks and benefits of active interventions in the cancer population must be considered individually. Treatment modalities such as chemotherapy and elective surgery could be delayed in patients at low risk for disease progression. Minimizing the number of outpatient visits by utilizing telemedicine can help prevent potential viral exposure [
In this context, we investigated the functional impairments in mental health and explored their relationships with depression, anxiety regarding the viral epidemic, and disruption in healthcare service utilization among cancer patients in this COVID-19 pandemic era.
This online survey study was carried out between July 15 and August 15, 2020, at Asan Medical Center, Seoul, Korea. The survey contained questions on the disturbances experienced by patients with cancer in utilizing medical facilities in the pandemic era. Data on the subjects’ age, sex, marital status, cancer type, current treatment modalities, cancer stages according to the subjects’ knowledge, psychiatric history, and current psychiatric symptoms were also collected via the online survey. The responders were provided an e-gift coupon valued at approximately $3.
The Stress and Anxiety to Viral Epidemics-6 (SAVE-6) is an anxiety subcategory of the SAVE-9 scale [
The Patient Health Questionnaire-9 (PHQ-9) was developed to assess depressive symptoms. This self-administered scale consists of nine items scored on a three-point scale ranging from 0 (not at all) to 3 (nearly every day) [
The Insomnia Severity Index (ISI) includes seven self-reported questions that evaluate difficulty in falling asleep and staying asleep, problems with waking too early, sleep satisfaction, interference in daily functions and awareness of impairments due to sleep problems, and distress from sleep disturbance [
The Brief Resilience Scale (BRS) was developed to assess resilience, i.e., the ability to recover from stress [
The Cancer-Related Dysfunctional Beliefs about Sleep Scale (C-DBS) is a two-item rating scale developed to evaluate dysfunctional beliefs about sleep in patients with cancer [
The Work and Social Adjustment Scale (WSAS) is a self-reported five-item scale that evaluates impairment in daily functions caused by mental health problems. It assesses abilities in performing work, home management, interpersonal relationships, and leisure activities. Each item is scored between 0 (not at all) and 8 (very severely) [
The question “Are you more afraid of coronavirus than cancer?” was designed for this study to assess the fear of COVID over cancer among patients with cancer. The patients were asked to answer this question using a number from 0 to 10, with a higher score indicating a higher fear of COVID-19 than cancer.
Statistical analyses were conducted using IBM SPSS Statistics for Windows ver. 21.0 (IBM Corp., Armonk, NY). Clinical characteristics were summarized as mean±standard deviation. The level of significance for all analyses was defined as two-tailed p-values < 0.05. We performed Student’s t tests for continuous variables and chi-squared tests for categorical variables for between-group analyses. Spearman correlation analysis was conducted to assess the relationships between clinical characteristics and mental health symptoms. Logistic regression analysis was performed to explore the expected factors related to patients’ functional impairment of mental health during the COVID-19 pandemic. Finally, to explore the mediating effect of resilience on the relationship of depression with functional impairment, the bootstrap method with 2,000 resamples was implemented.
Among the 221 responders, 104 (47.1%) reported functional impairments in mental health (WSAS ≥ 11) and 95 (43.0%) reported having experienced disturbances in healthcare service utilization during the COVID-19 pandemic (
There were no significant differences in the proportions of cancer stages, cancer types, and cancer treatment between responders with (WSAS ≥ 11) and without functional impairment (WSAS < 11). The proportions of patients currently needed help for their mood state, and PHQ-9, SAVE-6, ISI, C-DBS, and Fear of COVID-19 over Cancer (FCC) scores were higher and the resilience was lower in the functional impairment group (
Among the 95 patients who reported disruption of hospital utilization, the most common causes of disruption were “worried about visiting the hospital because of the risk of COVID-19 infection” (n=63, 66.3%), “repetitive COVID-19 swab screening tests and examination” (n=40, 42.1%), “more disturbed than before when treated in the emergency room” (n=11, 11.6%), “lack of patient education on the disease and treatment” (n=9, 9.5%), “delay in the outpatient department (OPD) schedule and treatment schedule” (n=9, 9.5%), and “lack of explanation about my treatment plan” (n=8, 8.4%) (
Furthermore, among all subjects, 22 reported delays in their OPD or treatment schedules. Among them, 12 patients (54.5%) reported a delay in their OPD schedule, resulting in a delayed decision on their treatment plan. Four patients reported delays in their operation schedule, four patients reported delays in their chemotherapy plan, and one patient reported a delay in the radiation treatment plan. The periods of delay were 1 week (n=8, 36.4%), 2 weeks (n=7, 31.8%), and over 3 weeks (n=5, 22.7%). Nineteen patients (86.4%) reported fear of disease recurrence or progression because of the delayed schedule.
Patient functional impairment, as measured by the WSAS, was significantly associated with high depression level, anxiety regarding the viral epidemic, insomnia, cancer-related dysfunctional beliefs to sleep, FCC, and low BRS (
Logistic regression analysis revealed that functional impairment in mental health of cancer patients was expected following disruption in healthcare service utilization (adjusted odds ratio [aOR], 2.54; 95% confidence interval [CI], 1.19 to 5.43), high depression level (aOR, 1.12; 95% CI, 1.02 to 1.23), anxiety regarding the viral epidemic (aOR, 1.21; 95% CI, 1.08 to 1.35), fear of COVID over cancer (aOR, 1.14; 95% CI, 1.01 to 1.28), and low resilience (aOR, 0.87; 95% CI, 0.76 to 1.00) (
Mediation analysis showed that the complete pathway from anxiety regarding the viral epidemic (independent variable) to resilience and dysfunctional beliefs to sleep (mediator) to functional impairment of cancer patients (dependent variable) was significant (z=7.71, p < 0.001) (
This study explored the disruptions experienced by patients with cancer in healthcare service utilization during the COVID-19 pandemic. Nearly half of the patients (43%) experienced disruptions. Moreover, the functional impairment in the mental health of patients with cancer was predicted by disruptions in healthcare service utilization, high depression level, anxiety regarding the viral epidemic, fear of COVID over cancer, and low resilience. Mediation analysis showed that patient resilience and cancer-related dysfunctional beliefs about sleep partially mediated the effects of anxiety regarding the viral epidemic on functional impairment.
A recent study on the impact of COVID-19 on oncological care showed that 30% of cancer patients reported a conversion of oncological treatment from hospital visits to mobile consultation [
Although the present study was conducted in a single hospital in Korea, 43% of patients reported disruptions in healthcare service utilization during the COVID-19 pandemic. The most common causes of disruption were “risk of COVID-19 infection” and “repetitive COVID-19 swab screening tests” rather than delay or disturbance in clinical practice. Surprisingly, the clinic and therapeutic schedules were not significantly delayed. This finding might be due to the relatively smaller number of confirmed cases in Korea compared to those in other countries or that the hospitals in Korea rapidly developed prevention plans. Furthermore, in this study, cancer diagnosis, treatment type, and cancer stage were not significantly associated with the patients’ daily mental function. However, depression, anxiety regarding the viral epidemic, insomnia, and resilience were associated with mental functional impairment in patients with cancer. Approximately 40% of responders reported depression and anxiety and only 22.2% reported feeling a need for help regarding their mood state. From the perspective of cancer patients, compared to the healthy population, the COVID-19 pandemic has additional impacts; thus, it is critical to be aware of the emotional state and actively intervene to improve these symptoms in patients with cancer during the COVID-19 pandemic era.
High levels of worry about COVID-19 infection prevented patients from visiting the hospital. A study in the US showed that adults were more likely to have both anxiety and depression during the COVID-19 pandemic than during the first half of 2019. Interestingly, anxiety symptoms were more pronounced than depressive symptoms [
In this study, the functional impairments in the mental health of patients with cancer were also predicted by the high levels of depression, anxiety, and fear of COVID over cancer and low resilience. Since the WSAS, which indicates functional impairment, includes assessments of leisure activities and interpersonal relationships, patients who are anxious about the viral epidemic might be withdrawn and isolated from social activities; therefore, their daily mental function might be impaired. These findings are consistent with those of previous studies reporting that anxiety, fear, and depression could be problematic during times of infectious epidemic crisis [
This study had several limitations. First, although this study included more than 10 types of cancer, breast cancer accounted for 40% of the study sample; thus, selection bias is possible. Second, information on cancer stages/types was gathered from patients’ self-report and not by chart review; thus, there was a possibility that inaccurate information was reported. Third, owing to the cross-sectional study design, it was difficult to compare the mental status of patients with cancer before and after the COVID-19 pandemic. Fourth, in the pandemic era, while about one-tenth of the patients reported delays in their treatment schedules, most of their schedules were rearranged within 2 weeks. The delay was shorter than expected, possibly because of the relatively small number of patients with COVID-19 in the Republic of Korea compared to that in other countries. Although this study was conducted in a high-volume tertiary medical center that partially represents the nationwide medical condition, it is difficult to generalize our results. Further studies are needed to estimate the effect of disturbances in various medical environments.
In conclusion, in this pandemic era, about half of the cancer patients experienced functional impairment due to emotional problems as well as disruptions in healthcare service utilization. These disturbances and functional impairment were strongly associated with anxiety and depression levels. Since the daily mental function and emotional problems affect the cancer patients’ progress, the psychological demands of patients in both acute stage of the disease and with stable status should be addressed to relieve their concerns. Thus, the care system should be managed to help cancer patients during the pandemic era.
The study protocol was approved by the Institutional Review Board, which waived the requirement for written informed consent (2020-1055).
Conceived and designed the analysis: Ahn MH, Son KY, Kim JE, Kim HJ, Yoo SM, Kim SH, Kwon MJ, Koh SJ, Seo S, Chung S.
Collected the data: Kim SH, Kwon MJ, Seo S, Chung S.
Contributed data or analysis tools: Kim K, Lee J, Kim SH, Kwon MJ, Kim HJ, Koh SJ, Seo S, Chung S.
Performed the analysis: Kim K, Kim H, Lee J, Cho IK, Kim HJ, Seo S, Chung S.
Wrote the paper: Kim K, Kim H, Lee J, Cho IK, Ahn MH, Son KY, Kim JE, Kim HJ, Yoo SM, Kim HJ, Koh SJ, Seo S, Chung S.
Conflict of interest relevant to this article was not reported.
Disruption in healthcare service utilization during the coronavirus disease 2019 (COVID-19) pandemic.
Mediation model showing that the effect of anxiety related to the viral epidemic (independent variable) on functional impairment (outcome) is mediated by resilience and dysfunctional beliefs about sleep (mediator). *p < 0.05, **p < 0.01.
Clinical characteristics of the study subjects (n=221)
Variable | WSAS < 11 (n=117) | WSAS ≥ 11 (n=104) | p-value |
---|---|---|---|
84 (71.8) | 84 (80.8) | 0.10 | |
50.8±12.1 | 49.3±14.6 | 0.40 | |
99 (84.6) | 79 (76.0) | 0.10 | |
3.5±3.7 | 3.0±3.3 | 0.34 | |
Breast | 47 (40.2) | 42 (40.4) | 0.42 |
Gastro-intestinal and pancreato-biliary | 30 (25.6) | 22 (21.2) | |
Other | 40 (34.2) | 40 (38.5) | |
0, I, II, III | 72 (61.5) | 66 (63.5) | 0.17 |
IV | 17 (14.5) | 21 (20.2) | |
Unknown or non-TNM staging | 28 (23.9) | 17 (16.3) | |
Systemic chemotherapy | 54 (46.2) | 45 (43.3) | 0.50 |
Radiation therapy | 30 (25.6) | 39 (37.5) | 0.08 |
Hormone therapy | 18 (15.4) | 20 (19.2) | 0.52 |
Operation | |||
Operation performed | 80 (68.4) | 73 (70.2) | 0.10 |
Waiting for operation | 15 (12.8) | 8 (7.7) | |
Inoperable | 1 (0.9) | 5 (4.8) | |
Currently no treatment | 27 (23.1) | 23 (22.1) | 0.76 |
Patient Health Questionnaire-9 | 4.9±4.7 | 10.3±5.2 | < 0.001 |
Stress and Anxiety to Viral Epidemics-6 | 12.4±4.4 | 16.3±3.5 | < 0.001 |
Insomnia Severity Index | 8.6±5.6 | 12.3±4.9 | < 0.001 |
Brief Resilience Scale | 19.8±3.3 | 17.5±3.3 | < 0.001 |
Cancer-related Dysfunctional Beliefs about Sleep | 12.0±5.4 | 14.2±4.7 | 0.01 |
Are you more afraid of COVID-19 than cancer? | 2.7±2.9 | 4.2±3.5 | 0.01 |
19 (16.2) | 30 (28.8) | 0.03 | |
22 (18.8) | 24 (23.1) | 0.28 |
Values are presented as number (%) or mean±standard deviation. COVID-19, coronavirus disease 2019; WSAS, Work and Social Adjustment Scale.
Spearman’s correlation coefficients for each variable
Variable | Age | WSAS | PHQ-9 | SAVE-6 | ISI | BRS | C-DBS |
---|---|---|---|---|---|---|---|
Age | 1.000 | ||||||
WSAS | −0.11 | 1.000 | |||||
PHQ-9 | −0.08 | 0.54 |
1.000 | ||||
SAVE-6 | −0.02 | 0.48 |
0.38 |
1.000 | |||
ISI | −0.06 | 0.36 |
0.62 |
0.21 |
1.000 | ||
BRS | 0.06 | −0.35 |
−0.56 |
−0.20 |
−0.40 |
1.000 | |
C-DBS | −0.06 | 0.31 |
0.36 |
0.32 |
0.33 |
−0.25 |
1.000 |
FCC | 0.11 | 0.19 |
0.08 | 0.17 |
0.06 | 0.01 | 0.03 |
BRS, Brief Resilience Scale; C-DBS, Cancer-Related Dysfunctional Beliefs about Sleep Scale; FCC, Fear of COVID-19 over Cancer; ISI, Insomnia Severity Index; PHQ-9, Patient Health Questionnaire-9; SAVE-6, Stress and Anxiety to Viral Epidemics-6 items; WSAS, Work and Social
Adjustment Scale.
p < 0.05,
p < 0.01.
Logistic regression analysis to explore factors predicting functional impairment in the mental health of patients with cancer during COVID-19 pandemic
Variable | cOR (95% CI) | p-value | aOR (95% CI) | p-value |
---|---|---|---|---|
Age | 0.99 (0.97–1.01) | 0.40 | 1.00 (0.97–1.03) | 0.98 |
Duration of illness | 0.96 (0.89–1.04) | 0.34 | 0.98 (0.87–1.09) | 0.66 |
Cancer stages | 1.35 (0.66–2.77) | 0.42 | 1.91 (0.68–5.35) | 0.22 |
Currently need help for mood | 2.05 (1.07–3.92) | 0.03 | 0.48 (0.18–1.28) | 0.14 |
Disruption in healthcare service utilization | 3.76 (2.14–6.59) | < 0.001 | 2.54 (1.19–5.43) | 0.02 |
PHQ-9 | 1.23 (1.15–1.31) | < 0.001 | 1.12 (1.02–1.23) | 0.02 |
SAVE-6 | 1.30 (1.19–1.42) | < 0.001 | 1.21 (1.08–1.35) | 0.001 |
ISI | 1.14 (1.08–1.21) | < 0.001 | 1.05 (0.97–1.14) | 0.20 |
BRS | 0.80 (0.72–0.88) | < 0.001 | 0.87 (0.76–1.00) | 0.04 |
C-DBS | 1.09 (1.03–1.15) | 0.002 | 0.99 (0.92–1.08) | 0.88 |
FCC | 1.15 (1.06–1.25) | 0.001 | 1.14 (1.01–1.28) | 0.04 |
aOR, adjusted odds ratio; BRS, Brief Resilience Scale; C-DBS, Cancer-related Dysfunctional Beliefs about Sleep Scale; CI, confidence interval; cOR, crude odds ratio; COVID-19, coronavirus disease 2019; FCC, Fear of COVID-19 over Cancer; ISI, Insomnia Severity Index; PHQ-9, Patient Health Questionnaire-9; SAVE-6, Stress and Anxiety to Viral Epidemics-6 items.
The results of direct, indirect, and total effects on mediation analysis
Effect | Standardized estimator | S.E. | Z-value | p-value | 95% CI |
---|---|---|---|---|---|
SAVE-6 → WSAS | 0.38 | 0.12 | 6.14 | < 0.001 | 0.12 to 0.52 |
SAVE-6 → BRS → WSAS | 0.05 | 0.04 | 2.37 | 0.018 | 0.02 to 0.17 |
SAVE-6 → C-DBS → WSAS | 0.04 | 0.04 | 1.96 | 0.05 | 0.001 to 0.17 |
SAVE-6 → BRS | −0.19 | 0.05 | −4.07 | 0.004 | −0.25 to −0.05 |
BRS → WSAS | −0.24 | 0.15 | −4.07 | < 0.001 | −0.90 to −0.32 |
SAVE-6 → C-DBS | 0.33 | 0.07 | 5.16 | < 0.001 | 0.24 to 0.53 |
C-DBS → WSAS | 0.13 | 0.10 | 2.12 | 0.03 | 0.02 to 0.42 |
SAVE-6 → WSAS | 0.46 | 0.12 | 7.71 | < 0.001 | 0.70 to 1.17 |
BRS, Brief Resilience Scale; C-DBS, Cancer-related Dysfunctional Beliefs about Sleep Scale; CI, confidenceinterval; SAVE-6, Stress and Anxiety to Viral Epidemics-6 items; S.E., standard error; WSAS, Work and Social Adjustment Scale.