While COVID-19 pandemic takes place as the first pandemic of the 21st century in the history of medicine, it has also caused a lot of changes within the health system unavoidably. It is not difficult to guess that the anxiety of cancer patients has increased about how they pass this pandemic period and how changes in the health system due to this infection would influence their therapies together with COVID-19 pandemic [9]. While their anxiety was high related to the course of cancer and treatment before COVID-19, anxiety level of patients and their relatives increases now because of the information that the virus influences badly especially the people with advanced age, those having lung cancer, and those with impaired immune system [10].
Differently from the general population, it is known that fear and anxiety disorders in cancer patients are not associated with age or gender [11]. In our study, while the median score of the fear scale of male patients was 21.7, it was found to be 23.2 in females and mildly higher than males in numerical terms; however, this difference has not expressed any statistical significance (p: 0.085). In another study using the FCV-19S scale in cancer patients, the fear level has been found to be higher in females compared with males (22.2 vs. 17.8, p< 0.05) [12].
While the fear score of 131 patients in over-65 years old group that is considered to be at risk for COVID-19 according to data in the literature was 23.7, the score of 355 patients at 65 years old and below has been determined as 22.3 (p: 0.316) [13]. Again, in a study where persons at 60 years old and above were included, it has been seen that fear scores of elderly who feel themselves isolated from others and whose close friends and family were diagnosed COVID-19 were higher [14]. It appears that older adults isolated due to immunosuppression related to cancer treatment before the pandemic required closer follow-up for their psychosocial aspect during the period of the COVID-19 pandemic.
There are studies in the literature indicating that depression and anxiety levels are different according to the type of cancer. It is thought that patients having lung cancer and gynecological cancers are affected more frequently [15]. In our study group, breast cancer, gastrointestinal system cancers, and urogenital cancers are dominant according to rank of frequency; levels of fear have been found as 23.45, 22.37, and 22.73, respectively. Although the fear level is numerically high in patients with breast cancer, any statistically significant difference has not been observed (p: 0.435). Vanni et al. has examined the influence of their anxiety levels on treatment decisions of patients with breast cancer in the COVID-19 course, and they have indicated that fear occurring due to the contagion risk of COVID-19 infection may be a reason for rejecting surgical intervention [16]. This type of data shows that evaluation of the psychological status is also important in the follow-up and treatment process as well as evaluation of tumor in cancer patients.
Cancer patients are prone to infection due to their immunosuppressed condition caused by the disease itself and treatments such as chemotherapy, radiotherapy, and surgery they had. For this reason, cancer patients form a high-risk population for the aspect of COVID-19. According to the knowledge coming from a study including two small and heterogeneous patient groups, it has been reported that 39–54% of cancer patients catching COVID-19 had severe clinical course (treatment in intensive care unit or death) [17]. The outcome of those having cytotoxic treatment 2–4 weeks before development of symptoms of COVID-19 is worse [18]. In our study, any difference has not been determined between fear levels of 146 patients having cytotoxic chemotherapy on the day the scale was used compared with those having other oncological treatments or patients who completed treatment and come for control visits (22.3 and 22.85, respectively). In the study of Sigorski et al., the FCV-19S scale has been used at the second month of the pandemic, and fear level of cancer patients having cytotoxic therapy has been reported as 18.5 which is lower than our population [19]. At the time our study was conducted, the pandemic has completed its 11th month in our country, and the total number of cases has exceeded 2.5 million, and the number of daily new cases was around an average of 7500 [20]. Prolongation of the pandemic process and increase of uncertainties have increased the level of fear, and this may cause the fact that scores have been found higher in our study.
The fear level of 124 patients having hormonal agents which have been considered as one of the safe oncological treatments has been found to be higher compared with patients having immunotherapy, tyrosine kinase inhibitor, and monoclonal antibody during the period of the COVID-19 pandemic, and this difference is statistically significant (p: 0.006, scores are 24.2 vs. 17.4, 22, 20.4, respectively). This difference can be explained by the fact that fear level of these patients is higher, most of whom have early-stage disease, because hormonal agents are used for adjuvant purpose in breast cancer.
While the fear scale score of patients not having metastasis was 23.49, score of those having metastatic disease for 1–5 years has been determined to be 21.03. This observation made us think that metastatic cancer patients have vital anxieties of more priority than those with COVID-19 during the struggle with cancer. The higher level of fear, due to COVID-19, of early-stage patients who have expectations for cure may be related to the anxiety that successful result they can obtain from cancer therapy may be interrupted by COVID-19 infection.
Hemmington et al. have demonstrated that there are severe mental health problems in patients with advanced-stage cancer; in our study, while fear scale scores of patients with diagnosis of metastasis for 0–6 months, 6–12 months, and 1–5 years are 20.70, 21.35, and 21.03, respectively, the score of 6 patients having metastatic diseases for more than 5 years has the highest score with an average of 28.5; but further interpretation has not been made because the number of patients is small in this group (p: 0.350) [6].
It is known that depression and anxiety are at a high level in the acute period when cancer diagnosis was made, and it would decrease with time [21]. While the score from the fear scale of patients included in the study was 22.09 whose duration from the diagnosis is between 5 and 10 years, a score of 23.18 has been determined from those having the diagnosis within the last 6 months. Although it does not reach to a statistically significant value, it can be said that patients newly diagnosed with cancer may cause an increase of COVID-19 fear level, and perception level of patients for both diseases might be influenced consistently with the literature.
Our study has several limitations. Primarily, findings may not be applied to the general oncological patient population because it was conducted in a tertiary oncology clinic, and participation was based on voluntariness principle. Another point is the use of psychotropic drugs that may influence perception of patients towards expression in the scale has not been recorded. Making an evaluation in a relatively large sample of patients in different age groups and tumor types by a validated scale is the strong side of our study.
Cancer patients were familiar with wearing masks in the community, staying away from crowds, and showing isolation behavior also prior to the COVID-19 pandemic. However, because cancer patients, who take precautions to avoid getting infected for a long time, experienced some kind of “precaution tiredness” with the pandemic process, disturbance of treatment compliance and emergence of mental health problems or exacerbation of existing ones are subjects for question. Psychosocial approaches or psychological evaluations towards the mental health of cancer patients should certainly be made for each patient during the pandemic period. Worsening of the immune system due to increase of anxieties and irritability, lack of motivation, tiredness, fatigue, and signs of depression may appear at this period, and these may influence the treatment process and even the prognosis [22]. Randomized controlled studies on how the patients’ anxiety symptoms related to the fear of COVID-19 affect their general condition, laboratory values, and drug responses are needed.
