key: cord-0971434-aeadjm4i authors: Frey, Melissa K.; Ellis, Annie E.; Zeligs, Kristen; Chapman-Davis, Eloise; Thomas, Charlene; Christos, Paul J.; Kolev, Valentin; Prasad-Hayes, Monica; Cohen, Samantha; Holcomb, Kevin; Blank, Stephanie V. title: Impact of the COVID-19 Pandemic on Quality of Life for Women with Ovarian Cancer date: 2020-06-26 journal: Am J Obstet Gynecol DOI: 10.1016/j.ajog.2020.06.049 sha: 2e0951bd50a9ff5868f8d4a16bd58e15e7e1765f doc_id: 971434 cord_uid: aeadjm4i Abstract Purpose The COVID-19 pandemic has resulted in unprecedented challenges for the oncology community. For people living with cancer, treatments are interrupted, surgeries cancelled and regular oncology evaluations rescheduled. People with cancer and their physicians must balance plausible fears of COVID-19 and cancer treatment with the consequences of delaying cancer care. We aim to evaluate the experience of women with ovarian cancer during the COVID-19 pandemic. Methods Women with a current or prior diagnosis of ovarian cancer completed an online survey focusing on treatment interruptions and quality of life (QOL). QOL was measured with the Cancer Worry Scale and Hospital Anxiety and Depression Scale. The survey was distributed through survivor networks and social media. Univariate and multivariable linear regression analysis were utilized to evaluate the effect of participant characteristics on QOL survey scores. Results Six hundred and three women, from 41 states, visited the survey website between March 30 and April 13, 2020 and 555 (92.0%) completed the survey. The median age was 58 years (range 20-85). Two hundred and seventeen participants (43.3%) were in active treatment at the time of survey completion. One hundred and seventy-five participants (33%) experienced a delay in some component of their cancer care. Ten (26.3%) of the 38 participants scheduled for surgery experienced a delay and 18 (8.3%) of the 217 participants scheuled for nonsurgical cancer treatment. One hundred and thirty-three participants (24.0%) had a delayed physician appointment, 84 (15.1%) laboratory test and 53 (9.6%) cancer related imaging. Among the cohort, 88.6% (489) reported significant cancer worry, 51.4% (285) borderline or abnormal anxiety and 26.5% (147) borderline or abnormal depression. On univariate analysis, age less than 65 years, being scheduled for cancer treatment or cancer surgery, delay in oncology care, self-described as immunocompromised and use of telemedicine were all associated with higher levels of cancer worry. Higher anxiety scores were associated with age less than 65 years and self-described as immunocompromised. Higher depression scores were associated with age less than 65 years, being scheduled for cancer surgery, delay in oncology care, self-described as immunocompromised and use of telemedicine. On multivariable linear regression analysis, age less than 65 and being self-described as immunocompromised were independently predictive of greater cancer worry, anxiety and depression and delay in cancer care was predictive of anxiety and depression. Conclusions The COVID-19 crisis is impacting care of ovarian cancer patients: surgeries, treatments, scheduled physician appointments, laboratory tests and imaging are cancelled or delayed. Younger age, presumed immunocompromise and delay in cancer care were associated with significantly higher levels of cancer worry, anxiety and depression. Providers must work with patients to balance competing risks of COVID-19 and cancer, recognizing that communication is a critical clinical tool to improve quality of life in these times. • 89% reported significant cancer worry during the pandemic. • Younger age, presumed immunocompromise and delay in care were associated with a 63 significant increase in cancer worry, anxiety and depression. physicians will likely become only more critical. 9-12 Physicians treating women with ovarian 126 cancer must remain well-informed on the relationship between COVID-19 and cancer but also 127 appreciate the unique challenges experienced by these survivors during this unprecedented time. The goal of this survey was to evaluate the experience of women with ovarian cancer during the 129 COVID-19 pandemic, assessing the effects of the pandemic on cancer-directed treatment and (1) and other targeted therapy (1). Thirty-eight participants (6.9%) reported that they were 201 scheduled for surgical treatment of ovarian cancer. Among these women, 10 (26.3%) reported 202 that the surgery was delayed due to COVID-19. One hundred and thirty-three participants 203 (24.0%) reported that an appointment with their gynecologic oncologist was postponed, 84 204 (15.1%) that a cancer-related laboratory test was postponed and 53 (9.6%) that cancer-related 205 imaging was postponed. Two hundred and fifty-two (50.1%) of 503 participants responded that they self- The demographics, cancer and treatment history of participants were evaluated for 227 associations with cancer worry, anxiety and depression. On univariate analysis, age less than 65 228 years, being scheduled for cancer treatment or cancer surgery, delay in oncology care, self-229 described as immunocompromised and use of telemedicine were all associated with higher levels 230 of cancer worry. Higher anxiety scores were associated with age less than 65 years and self-231 described as immunocompromised. Higher depression scores were associated with age less than 232 65 years, being scheduled for cancer surgery, delay in oncology care, self-described as 233 immunocompromised and use of telemedicine. Depression scores were significantly lower in 234 participants reporting access to counseling (Table 2) . 235 We performed a multivariable linear regression model incorporating age less than 65 236 years, living alone, COVID-19 case volume by state, cancer stage, scheduled for cancer 237 treatment or surgery, delay in oncology care, medical comorbidities, access to counseling, self-238 described as immunocompromised and use of telemedicine for oncology care. On multivariable 239 analysis, cancer worry was independently associated with age less than 65, being scheduled for 240 cancer treatment and self-described as immunocompromised. Anxiety was independently 241 associated with age less than 65, delay in oncology care and self-described as 242 immunocompromised. Depression was independently associated with age less than 65 years, 243 living alone, delay in oncology care, lack of access to counseling and self-described as 244 immunocompromised (Table 3) . pandemic did not seem to negatively impact anxiety and depression, however, these results may 282 be due to our patient population being super users of counseling (56%) and survivor networking 283 (80%) and possibly, as demonstrated by their willingness to complete a 65-item survey during 284 these times, especially generous, a character trait associated with happiness. 26 On multivariable regression analysis, age less than 65 years and self-describing as 286 immunocompromised were associated with higher levels of cancer worry, anxiety and 287 depression. It was surprising to find younger age associated with increased worry, anxiety and 288 depression during the COVID-19 crisis as preliminary reports suggest that older age is associated 289 with increased COVID-19 mortality. 27-29 However, pre-COVID-19 literature on QOL and age for 290 women with ovarian cancer is inconsistent. Several studies confirm our findings that younger age 291 is associated with higher cancer worry, depression and anxiety, often suggesting that the threat of 292 aggressive illness and its consequences is greater for younger women. 19, 21 Other studies have 293 found no difference based on age or even greater depression with older age. 22, 25, 30 The 294 association between self-describing as immunocompromised and heightened worry, anxiety and 295 depression was less surprising as the CDC includes individuals who are immunocompromised 296 due to cancer treatment among those at highest risk for severe COVID-19 illness. 31 Delay in 297 oncology care was predictive of both anxiety and depression. It is important that gynecologic 298 oncologists consider this because, although the intent behind postponing oncology-related 299 appointments may be to minimize COVID-19 infection in a vulnerable patient population, this 300 decision may negatively impact QOL. Interestingly, living in a higher burden COVID-19 state 301 did not negatively impact QOL on any of the measures used, although this may be due to our 302 cohort being comprised of a small number of women from low-volume COVID-19 states. Education, cancer stage and medical comorbidities were not significantly associated with QOL 304 scores. At the conclusion of the survey, participants were asked to share their top concerns 306 during the COVID-19 pandemic. The most commonly cited concerns were about COVID-19, 307 cancer recurrence and the safety of family members. The fourth most commonly shared concern, 308 reported by 17% of participants, was the financial implications of the crisis. Limited data on cost 309 of care for ovarian cancer suggest substantial overall costs as well as survivor out-of-pocket 310 expenditure. 32, 33 A recent study demonstrated that individuals with a cancer diagnosis were 2.5 311 times more likely to file for bankruptcy than individuals without cancer. 34 The country is only Covid-19 -Navigating the Uncharted Challenges Faced by Medical Journals During the COVID-19 363 Pandemic Cancer patients in SARS-CoV-2 infection: a nationwide analysis in 365 China SARS-CoV-2 Transmission in Patients With Cancer at a Tertiary 367 Care Hospital in Wuhan, China Cancer Information and Support Centres: fixing parts cancer drugs 369 cannot reach Perspectives from older adults receiving cancer treatment 371 about the cancer-related information they receive A qualitative study of ovarian cancer survivors' perceptions of 373 endpoints and goals of care Bridging the Gap: A Priorities 375 Assessment Tool to Support Shared Decision Making, Maximize Appointment Time, and Increase 376 Patient Satisfaction in Women With Ovarian Cancer Risk of COVID-19 for cancer patients Risk of COVID-19 for patients with cancer A War on Two Fronts: 380 Cancer Care in the Time of COVID-19 Coronavirus Concerns: What do Women with Gynecologic Cancer Need to 382 ZIGMOND AS, SNAITH RP. The hospital anxiety and depression scale Re-validation and screening 386 capacity of the 6-item version of the Cancer Worry Scale Attitudes about genetic testing for breast-ovarian cancer 388 susceptibility Ovarian cancer survivors' acceptance of treatment side 390 effects evolves as goals of care change over the cancer continuum Fear of cancer recurrence in ovarian cancer survivors Fear of recurrence among 396 older breast, ovarian, endometrial, and colorectal cancer survivors: Findings from the WHI LILAC 397 study Depression, anxiety 399 and body image after treatment for invasive stage one epithelial ovarian cancer Social support, anxiety and depression after 402 chemotherapy for ovarian cancer: a prospective study Mental distress, quality of life and social support in 404 recurrent ovarian cancer patients during active chemotherapy Symptoms of posttraumatic stress in 407 Australian women with ovarian cancer Long-term survival from gynecologic cancer: psychosocial 409 outcomes, supportive care needs and positive outcomes Anxiety and depression in patients with advanced 411 ovarian cancer: a prospective study Characteristics of and Important Lessons From the Coronavirus Disease 415 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese 416 Center for Disease Control and Prevention Case-Fatality Rate and Characteristics of Patients Dying in 418 Relation to COVID-19 in Italy United States Prevalence and predictors of anxiety and depression in 422 women with invasive ovarian cancer and their caregivers Cost of Care for the Initial Management of Ovarian 426 Cancer Medicare Patients With Advanced Ovarian Cancer Washington State cancer patients found to be at greater 430 risk for bankruptcy than people without a cancer diagnosis Combating COVID-19: health equity matters The COVID-19 Pandemic: a Call to Action to Identify and Address 437 Racial and Ethnic Disparities. J Racial Ethn Health Disparities 2020 Promoting health equity in the era of COVID-19 Value Tools 441 for Patients in Cancer Care