key: cord-1040436-zmphhr3x authors: Rajan, Shiv; Akhtar, Naseem; Tripathi, Abhilasha; Kumar, Vijay; Chaturvedi, Arun; Mishra, Prabhaker; Sharma, Sonali; Misra, Sanjeev; Gupta, Sameer; Singh, Mohit title: Impact of COVID‐19 pandemic on cancer surgery: Patient's perspective date: 2021-02-16 journal: J Surg Oncol DOI: 10.1002/jso.26429 sha: af4d798e74ec2b867967f32dbc6cb1a4c1017f86 doc_id: 1040436 cord_uid: zmphhr3x BACKGROUND: Coronavirus disease 2019 (COVID‐19) has impacted cancer care globally. The aim of this study is to analyze the impact of COVID‐19 on cancer healthcare from the perspective of patients with cancer. METHODS: A cross‐sectional survey was conducted between June 19, 2020, to August 7, 2020, using a questionnaire designed by patients awaiting cancer surgery. We examined the impact of COVID‐19 on five domains (financial status, healthcare access, stress, anxiety, and depression) and their relationship with various patient‐related variables. Factors likely to determine the influence of COVID‐19 on patient care were analyzed. RESULTS: A significant adverse impact was noted in all five domains (p = < 0.05), with the maximal impact felt in the domain of financial status followed by healthcare access. Patients with income levels of INR < 35 K (adjusted odds ratio [AOR] = 1.61, p < 0.05), and 35K‐ 100 K (AOR = 1.96, p < 0.05), married patients (AOR = 3.30, p < 0.05), and rural patients (AOR = 2.82, p < 0.05) experienced the most adverse COVID‐19‐related impact. CONCLUSION: Delivering quality cancer care in low to middle‐income countries is a challenge even in normal times. During this pandemic, deficiencies in this fragile healthcare delivery system were exacerbated. Identification of vulnerable groups of patients and strategic utilization of available resources becomes even more important during global catastrophes, such as the current COVID‐19 pandemic. Further work is required in these avenues to not only address the current pandemic but also any potential future crises. In the second week of December 2019, a cluster of patients infected with a novel coronavirus was identified in Wuhan city, Hubei province in China. 1 This unique virus was named the severe acute respiratory syndrome coronavirus 2. 2 The condition was described as Coronavirus Disease (COVID-19) by the World Health Organization (WHO), which declared its outbreak a global pandemic on 11 March 2020. 3, 4 There have been more than 100 million people infected, and over 2 million lives have been lost due to this virus worldwide. After the United States, the number of infected cases has been second highest in India. 5 This global pandemic has created one of the most difficult challenges to both the developed as well as developing nations of the world. It has not only affected the healthcare system of countries but has also created immense problems related to economic and developmental issues. The problem in healthcare is not only limited to the control and saving the lives of patients infected with COVID-19 but also to deliver medical care to patients with other non-COVID-19related health problems. In this scenario, the care of patients with cancer has been severely disrupted since the emergence of the novel COVID virus. 6, 7 It has been noted that the disruption in cancer services has been proportional to the spread of this infection. 8 Unique challenges have emerged in terms of access to oncology facilities by the patients and the inability of the COVID-19 overwhelmed medical systems to deliver care to patients with a cancer diagnosis. Additionally, loss of jobs or family earnings, social isolation, and loneliness caused by the COVID-19 pandemic has worsened the already existing distress prevalent in the lives of cancer patients. 9 To date, we are not aware of any study that has attempted to analyze and quantify the type and scope of problems that are faced by patients with cancer in accessing care in a low to middle-income country. Analyzing the adverse impacts of COVID-19 from a patient's perspective is very important to develop solutions that can guide health professionals and ultimately benefit the patients. The aim of this study is to analyze the impact of the COVID-19 pandemic on disruptions in cancer care delivery from the patient's perspective by utilizing a patient-designed questionnaire. This interviewer-administered, paper-based, cross-sectional questionnaire survey was conducted in the Department of Surgical Oncology, at a tertiary care referral center, from June 19, 2020, to August 7, 2020. The study was started after receiving approval from the Institutional Ethics Committee (reference code: 5th ECMIB-COVID-19/P2). Informed consent was obtained from all patients. Full anonymity of the study participants and confidentiality of data was maintained throughout the study. We followed the Standards for Reporting Qualitative Research (SRQR) guidelines for reporting this study. 10 The framework of this study was based on the theory of phenomenology and a constructivist approach. Due to the limitation of time and resources during the COVID-19 pandemic, a nonprobability purposive sampling method was selected. We restricted the study period to 50 days, and that explains the criteria for sampling saturation. Our group included five expert clinicians with more than ten years of experience in patient care and research. To avoid bias, one of the nonclinical coauthor conducted all the interviews. The sole interviewer had no prior contact or relationship with the patients. Our study population consisted of cancer patients more than 18 years of age with an Eastern Cooperative Oncology Group performance status of 0, 1, or 2 scheduled to be seen in our Surgical Oncology Clinic. To avoid any psychological distress that can potentially affect the responses to the questionnaire, it was mandatory for patients to be aware of their cancer diagnosis before being interviewed. With these inclusion criteria, our initial cohort consisted of 1117 patients. The following exclusion criteria were applied: confirmed or clinically suspected COVID-19 diagnosis, any previous neurological or psychiatric disorders, patients with advanced or metastatic disease that may have required a noncurative or palliative treatment, which can increase the psychological stress and those that refused to provide consent. After excluding these cases, we were left with a cohort of 403 patients. Due to the time-compressed nature of our clinic schedules (where the survey was conducted), some patients were unable to complete the survey completely. This led to a total number of 310 patients that were included in the study for analysis. The questionnaire was developed after face-to-face in-depth inter- 2). The body of the questionnaire was divided into a total of five domains, namely financial domain, access to healthcare, anxiety, stress, and depression. All questions were closed-ended. Before the start of the study, a researcher was trained by the principal investigator on how to conduct this survey. Patients were screened in the clinics. All eligible patients were then sent to a RAJAN ET AL. | 1189 separate room. The questionnaire was administered to the patients by the trained researcher. Only if the patient was unable to read the local language, the questionnaire was read out to the patient and the interviewer used visual aids for the responses. During this process, no one else was present besides the patient and researcher. Only one patient was interviewed at a time. To avoid any coercion, clinicians were kept unaware of the patient's consent to participate in the survey. No attempts were made to analyze the data until the enrollment of the last patient. Descriptive statistics were used to describe the demographic characteristics of patients and responses obtained from the questionnaire. The value assigned for a response was used to generate a COVID-19 "Impact score" for each domain. The difference in the mean impact score of each domain was compared between groups using an unpaired t-test and analysis of variance (ANOVA; repeated-measures ANOVA, or one-way ANOVA test). A χ 2 test was used to test the association between two categorical variables. To identify the factors predicting the impact of COVID on the cancer patients, binary logistic regression analysis was used, followed by univariate and multivariate analysis. A p value < 0.05 was considered statistically significant. All statistical analysis was performed using statistical software "Statistical package for social sciences" version-23 (SPSS-23, IBM). In this study, 310 cancer patients were surveyed and included for analysis. The baseline demographic characteristics are shown in Table 1 . The majority of our patients were male (60.3%), from rural locations (73.2%) and married (89.2%). Nearly one-third of our patients were self-employed and approximately 35% were illiterate. Table 2 summarizes the responses to the questionnaire. All the patients (n = 310, 100%) were aware of the spread of COVID-19 (Question 1). The effect of the COVID-19 pandemic was studied on the five major domains of the survey instrument. The impact score measuring this effect on various domains showed statistically significant different scores, with the maximum score for the financial domain (59.68 ± 16.52), followed by healthcare access domain (34.23 ± 15.38). The least effect was noticed on the stress domain (20.54 ± 13.53). These findings are shown in Figure 1 The impact score of all five domains was calculated for each of the demographic variables. The association between them was statistically significant for each demographic variable (P ≤ 0.001 each). Comparison of the individual domain was also performed with each demographic variable ( Table 3 ). The maximum impact score in the financial domain was seen in the age group of 31-50 years, males, married, daily wagers, having a senior secondary level of education, and patients with an annual income of INR 35K-100K. The maximum impact score in the access to healthcare domain was seen in patients of age group 31-50 years, those coming from rural areas, daily wagers, patients with annual income INR < 35 K, and those with education below the secondary school. The maximum impact score in the stress domain was seen in patients aged between 18 and 30 years, unmarried, and those with an annual income of INR < 35 K. The maximum impact score in the anxiety domain was seen in patients aged between 18 and 30 years and married patients. The maximum impact score in the depression domain was seen in the group of patients aged between 18 and 30 years and those with an annual income of INR < 35 K (Table 3 ). From the demographic data that was analyzed, we noted that income groups, marital status, and area of residence had a statistically significant impact on univariate analysis (p < 0.05). In multivariate analysis, all these three variables maintained their significance as independent factors associated with the impact of COVID-19 ( 11 More than 80% of our patients were middle-aged, and the majority of them were between 31 and 50 years of age group. These findings were observed because of the high incidence of tobacco-related cancers in these age groups. About two-thirds of our patients were literate. As we see patients predominantly from rural areas, the literacy rate is consistent with the prevailing literacy rate in the rural parts of our state. We of them believed that it would be difficult for them to utilize these funds due to the ongoing pandemic. Nearly one-fifth of our patients faced denial of treatment by other hospitals due to fear of an ongoing pandemic. In a study from Turkey, more than 80% of cancer patients were concerned about treatment interruption. 14 Most of our patients (80%) were scared of getting exposed to coronavirus infection during the hospital stay. In another study, 60% of patients expressed concern about getting exposed to COVID-19 while receiving chemotherapy in the hospital. 11 Around two-third of patients experienced some difficulty in reaching the hospital, and about 60% faced problems in arranging accommodation. This is because the majority of our patients come from rural areas. Approximately 80% of patients expressed concern that their subsequent follow-up would not be on time. Gebbia et al. 15 found that 37% of their patients suggested postponing their followup visit due to the pandemic. The majority (93%) of our patients T A B L E 3 (Continued) Almost 70% of patients expressed anger thinking about the pandemic. Nearly 25% of our patients suffered from insomnia as compared to 30% reported by Shi et al. 16 During daily activities, about 64% of patients in our study did not have any problem concentrating on their work. In contrast, Buntzel et al. 17 noted that 61% of patients in their study experienced restrictions in carrying out their daily activities. Anxiety due to the pandemic was detected in 62% of patients with cancer, 18 which is much higher than the rate (one-third) noted in the general population. 13, 16 In our study, about 88% of patients were anxious about their future, whereas 81% felt sad and helpless. Depression was the commonest symptom, followed by stress and anxiety, respectively. Studies in the general population showed a greater psychological impact of COVID-19 in young people. 19, 20 Higher impact in financial and healthcare access domain was seen in patients aged 31-50 years (Table 3) . About 52% of our patients experienced financial difficulties compared to Romito et al study in which only 5% of patients had financial difficulties. 12 Males were much more impacted financially than females (mean difference, 63 vs. 54, p < 0.001; Table 3 ). This could be due to current practices in some parts of India, where males tend to be the main earning members in the family. Our study did not show any difference in the levels of anxiety, stress, and depression between males and females. This is similar to the findings noted by Ozamiz-Etxebarria et al., 19 where gender played no role in the psychological impact. In contrast, some other authors documented that females reported more anxiety, stress, and fear compared to male patients with cancer. 12, 21 Patients who belonged to rural areas were impacted sig- Those having education below a secondary school level and illiterate patients had more problems in healthcare access. Those with senior secondary education were more impacted financially. Overall, illiterate and those with below secondary school of education were impacted the most due to COVID-19. The level of education was not associated with psychological impact. Our study showed higher odds of COVID-19 impact in the following patient populations: those with a low annual income (below INR 100 K), married patients, and patients from rural areas. This is not surprising as patients from the higher-income bracket were able to obtain better care due to their financial stability. There are several limitations to this study. The major limitation of the present study is in the generalizability of the study results to other situations, with different levels of COVID burden, variations in hospital setting and practices, and differences in the patient population. In addition, the results of the survey should be interpreted with caution as patients were participating in the survey at a time of high stress. However, it did truly reflect the experiences of the patients being treated by us in a government-funded tertiary care facility in the most populous state in India, with over 220 million inhabitants. In conclusion, the COVID-19 pandemic has impacted the surgical care for cancer patients to a great extent. This impact is evident in all five key domains studied. Our study has identified patients at higher risk due to this pandemic. This information can serve as a guiding tool for the hospitals to prioritize cancer care during this pandemic when the entire focus has been shifted to addressing the COVID-19 pandemic. Also, it is critical to understand the difficulties encountered by the patients by knowing their perspective, as highlighted by the present study. While the hospitals should continue providing COVID-19 treatment, they should also be diligent in maintaining timely and quality cancer care without any delay. It is essential to develop patient-oriented policies, which can prioritize cancer care even during global crises such as the current COVID-19 pandemic. The study was started after the approval of the Institutional Ethics Committee (reference code: 55th ECMIB-COVID-19/P2). No financial support or grant was utilized. The data will be made available by the corresponding author after a reasonable request. 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