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Abstract
The rapid spread of COVID-19 infection and its negative effects on human health caused a great change in oncology practice. Although oncologists respond quickly to this change, anxiety caused by pandemics in some patients prevented cancer treatment. Although patients know that delaying cancer treatment can be life-threatening, they are concerned about contacting the hospital because they are afraid of becoming infected with COVID-19. Here, we would like to present three patients with delayed admission to the hospital to draw attention to the harmful consequences of COVID-19 fear in the community. These patients with cancer-related anxiety may exaggerate protective attitudes during the pandemic process, leading to delayed oncological treatment and poor prognosis of the patient.
- cancer
- prognosis
- quality of life
- psychological care
- supportive care
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Introduction
Coronovirus infection appeared in China, spread rapidly all over the world and was identified as a COVID-19 pandemic in February 2020. The first case was reported in Turkey in March 2020, stimulating a series of measures by the government. The rapid spread of the disease led to widespread fear and anxiety.
Management of the immunosuppressed, especially patients with cancer, has become difficult with the pandemic. In a Chinese study, patients with cancer infected with COVID-19 needed 3.5 times more intensive care resources than other patients.1 In addition, patients with cancer who need a multimodal approach like chemotherapy, radiotherapy and surgery may need frequent hospital admission. Adjuvant therapy in local disease and palliative chemotherapy in metastatic disease are associated with longer overall survival. Treatment compliance is the most important factor that determines success.2
Oncology associations made management recommendations during the pandemic and cancer treatments were planned accordingly. However, it is common for patients with cancer to be diagnosed late due to fear of COVID-19 transmission. We present three patients with a delayed diagnosis due to this.
Case reports
Patient 1
A 60-year-old woman presented to the oncology outpatient clinic with a painful lesion on her left chest. She reported swelling and movement restriction in her left arm that started 3 months ago. She had been afraid of going to the hospital because of COVID-19. About a month ago, she had palpated a hard swelling in her left chest and axilla. The breast lesion’s colour began to change and had grown about fourfold during the last 2 weeks (figure 1). She underwent tru-cut biopsy and was diagnosed with invasive ductal adenocarcinoma (luminal B type). On positron emission tomography (PET/CT), metastases were detected in the lungs and bones. Multiple metastatic lymph nodes were found on the left axis. Chemotherapy and zoledronic acid were initiated.
Dramatic progression of patients from the period of COVID-19 pandemic.
Patient 2
A 60-year-old man with malignant melanoma presented with large head lesions and foul-smelling discharge (figure 1). Surgery was done 6 months ago. Immunotherapy was the first-line treatment for residual tumour after surgery. Lesions progressed under immunotherapy, so oral temozolomide was started. He was afraid to come to the hospital due to COVID-19, but he had had temozolomide for 4 months. He was afraid to come to the hospital despite the growths. After fewer patients were infected with COVID-19 in the city, he decided to visit and palliative radiotherapy treatment was applied.
Patient 3
A 22-year-old woman was being followed up for colon cancer. She was diagnosed with stage II (T2N1M0) disease a year ago, and six cycles of adjuvant capecitabine postsurgical resection were scheduled. The patient, whose treatment was completed 6 months ago and was checked at 3 month intervals, did not come to the clinic on March due to the COVID-19 pandemic. Although abdominal pain began in April, she attributed this to treatment and avoided visits. She was admitted to the hospital on July, as her symptoms gradually increased. On physical examination, ascites was detected and peritoneal carcinomatosis was evident on abdominal tomography. 5-Fluorouracil, leucovorin and irinotecan chemotherapy was started.
Discussion
By this mini patient series, we illustrate the fear of COVID-19 and its negative effects on oncological prognosis.
Most patients with cancer experience emotional distress, such as anxiety and depression. Even as a cancer diagnosis emotionally burdens patients, side effects of chemotherapy, economic conditions and shortcomings in social support further increase emotional problems. The COVID-19 pandemic further affects patients psychologically and decreases treatment adherence. In one study, the causes of postponing chemotherapies were evaluated, and it was found that COVID-19-associated anxiety was the third most common.3 The cases we present suggest that treatment delays from COVID-19 may be even more common.
Fear of nosocomial COVID-19 infection not only affects patients but also oncology management. Mortality was four times higher in patients who underwent chemotherapy up to 14 days before COVID-19 infection in one report.4 Although consequences such as delaying adjuvant treatments and keeping radiotherapy periods short may arise, their effects in preventing nosocomial infection have not been shown. In a study in Italy, the data of 1257 patients who underwent cancer treatment during the pandemic were evaluated.5 Nine were found to be infected with COVID-19 and two died. Transmission of COVID-19 can be kept low by measures like patient and doctor both wearing a surgical mask and keeping social distances.
The number of patients with cancer who delay their medical care because of fear or anxiety of COVID-19 is uncertain, since it is not systematically monitored. In this report, three patients with obvious disease progression are presented, which reflect only the tip of the iceberg. We believe patients can make mistakes due to the fear of COVID-19 and emphasise the importance of close follow-up. Preventing delays in hospital access and social and psychological support to patients with cancer have become even more important during the pandemic. Cancer treatment is indispensable and delay can lead to irreversible consequences.
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Footnotes
Contributors All authors contributed to the study conception and design. Material preparation and data collection were performed by OS and OY. The first draft of the manuscript was written by OS and OY, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.