]
The clinical symptoms of COVID-19 cause an inflammatory
respiratory disease.[] When symptoms
become severe, they have serious effects that result in
death.[] With the emergence and rapid spread of the
virus, risk factors were tried to be defined in a short
time in terms of the fatality of this disease. Among
the risk factors that increase the probability of adverse
prognosis of COVID-19, one of the first identified features
is having a chronic disease. Studies conducted
with patients with cancer, in particular, draw attention
to the fact that these patients may have COVID-19
more severe, and therefore, the risk of death may be
higher. In a study examining the data of 1524 cancer
patients in China, it is stated that the prevalence of COVID-
19 is 2 times more in cancer patients when compared
to the general population.[] Dai.[] In the study which they compared patients diagnosed with cancer
having COVID-19 and people without a diagnosis of
cancer having COVID-19, it was found that morbidity
and mortality in terms of COVID-19 are higher in
patients diagnosed with cancer.
For everyone, including cancer patients, stressors
such as worrying about their own health and the health
of their relatives;[] as a result of restrictive decisions
taken, having to lead a more isolated life, limited social
support resources, and sudden life changes that will
cause economic difficulties;[,] the lack of a definite
treatment method for COVID-19 [] and the uncertainty
about when the process will end[] cause psychological
distress. On the other hand, with the pandemic,
there have been situations such as postponing
treatments and not being able to reach health institutions
or physicians in terms of health. It is indicated
that, in eight UK hospitals, the majority of patients with
or suspected of cancer are unable to access healthcare,
with a 60% reduction in chemotherapy attendance and
a reduction to a large extent such as 76% in emergency
referrals for early diagnosis.[] Cancer patients, who
are already struggling with a difficult disease process
and heavy treatments, may be affected by the COVID-
19 pandemic psychologically negatively, both due
to the disruption of treatment and/or controls, and the
unknown pandemic process, and they may experience
high levels of anxiety, depression, post-traumatic stress
disorder, and psychological distress.[,] Studies
conducted before the COVID-19 pandemic shows that
psychiatric disorders can be seen at rates ranging from
30 to 50% in patients with a cancer diagnosis, and it is
stated that approximately 10-20% of these are adjustment
disorders, 13.4-19.5% are depression and 5-17%
are anxiety disorders.[] In studies conducted during
the COVID-19 pandemic, the incidence of anxiety in
cancer patients is reported at varying rates between
36% and 61.5% and the incidence of depression 35-
70.2%.[,] In a study conducted in Germany during
the pandemic period, it is determined that individuals
with cancer are more likely to report anxiety
symptoms, suicidal ideation, and loneliness compared
to other participants.[] In a study evaluating the psychosocial
perspectives of cancer patients receiving intravenous
therapy in Israel, it was observed that 44%
of patients reported high levels of COVID-19-related
distress at the beginning of the first wave of the COVID-
19 pandemic (March 2020).[]
In the studies examining the psychological effects
of COVID-19, in cancer patients, problems such as
fear of virus sensitivity, difficulty in tolerating the uncertainty brought by COVID-19, and feeling lonely in
relation to social isolation, as well as concerns about
health-care interruptions and information needs come
to the forefront. In the next part of this article, the fear
of COVID-19, uncertainty, and loneliness, which are
the main themes for patients diagnosed with cancer
from the COVID-19 pandemic process, and their effects
will be discussed.
Fear of COVID-19
Fear is a primitive emotion that emerges in the face of
a real or perceived threat and is one of the most characteristic
features that distinguish contagious diseases
from others.[] Because pandemics can trigger feelings
of fear, desperation, illness, and death in individuals.
Fear takes place also among the most frequent
psychological consequences of COVID-19, one of the
deadly outbreaks.[] During the COVID-19 process,
it is observed that individuals are afraid of being infected
and having the illness severely, losing their lives,
having their loved ones to get the illness, and being
stigmatized by others when they get sick.[] Fear,
which is a functional emotion to cope with a potential
threat at a certain level, becomes dysfunctional and
compels individuals when it is a lot according to an actually
existing threat.[] There are studies reporting
that some individuals experience disproportionate fear
during the COVID-19 pandemic[] and that the fear
of being infected may even lead to suicidal ideation
[]. In terms of mental health, the fear of COVID-19
has attracted so much attention that it is defined as Corona
phobia at the clinical level.[] In studies, fear of
COVID-19 is found to be associated with depression,
generalized anxiety disorder, and suicidal ideas.[]
On the other hand, the COVID-19 pandemic has
affected the health system all over the world, and cancer
patients have come to the fore as one of the vulnerable
groups who are at risk of having the disease more severe
if they catch the virus. There are studies reporting that
cancer patients diagnosed with COVID-19 have more
severe symptoms and complications than those not diagnosed
with cancer.[] There was a period, in which
cancer patients became very anxious due to reasons
such as the presence of other comorbidities during the
COVID-19 process, having to take immunosuppressive
treatments, increased risk of infection, postponement
of surgical interventions, the possibility of getting the
disease on the way to and from the hospital, difficulties
in accessing treatment due to the travel restrictions,
changing treatment units due to conversion of some
hospitals into pandemic hospitals, shifting health personnel to other areas, or absence of health personnel
in health institution due to the illness.[] COVID-19,
which creates fear of infection and death even in individuals
who do not have health problems, may cause
much more intense fear for cancer patients. While
anxiety about the course and treatment of cancer was
high before COVID-19, the fear level of patients may
increase due to the knowledge that the virus affects the
elderly, those with lung cancer and those with impaired
immune systems adversely. With an increase in the
level of fear, the decisions of individuals may become
more emotion-oriented, and in this case, it may lead
to fatal consequences such as rejection of oncological
treatments in a special population like cancer patients.
[] In a study conducted with cancer patients in Turkey,
40.1% of the participants reported that they do not
apply to emergency services unless it is necessary, and
40.8% reported that they are afraid of this process.[]
In another study, it was reported that approximately
one-third of cancer patients experience some delay in
their treatment and this situation leads to higher levels
of concern, anxiety, and depression in patients.[]
Cancer patients, who have to receive life-saving
treatments on the one hand, and on the other hand,
who have to be in the hospital environment, where
the virus can be intense, starting from the vehicles that
they use to reach the treatment, which may have psychological
difficulties due to the fear and anxiety of being
exposed to the high risk of infection Erdoğan[]
examined the level of fear of COVID-19 in 486 cancer
patients and found that 66.8% of the patients are very
afraid of the coronavirus, and 66.3% are afraid of losing
their lives due to the coronavirus Steel[] stated that
one of the most important determinants in the negative
evaluation of the pandemic process by cancer patients
and even their relatives is the fear of having COVID-19.
In a study examining psychological distress in adolescent
and young adult cancer patients from different
countries, it was found that approximately 60% reported
feeling more anxious than before COVID-19.[]
The results reported in terms of the factors affecting
the COVID-19 fear levels of cancer patients are contradictory.
There are studies reporting that unlike the
general population, fear and anxiety disorders are not
correlated with age or gender in cancer patients,[] as
well as studies[] where the level of fear of COVID-19
is higher in women than in men. According to the data
in the literature, it is stated that the fear score of cancer
patients over the age of 65, who are considered to be
at risk for COVID-19, is higher.[] In studies dealing
with the relationship between different types of cancer and fear of COVID-19, it is stated that fear of the
risk of contagion of COVID-19 infection may be the
reason for refusing surgical operation in breast cancer
patients.[,] In terms of the cancer stage, the COVID-
19 fear scale scores of patients without metastasis
were found to be higher than the scores of patients
with metastatic disease for 1-5 years.[] This result is
interpreted as the cancer-related vital concerns of metastatic
cancer patients may be of higher priority than
COVID-19, and it is based on the concern that the successful
outcome of early-stage patients" cancer treatments
will be disrupted due to COVID-19 infection. It
is important that patients are adequately informed by
health-care professionals so that they can cope with the
fear of COVID-19. Patients whose fear of getting the
virus is observed to be disproportionate to the existing
situation should be directed to mental health professionals
for psychological support or treatment.
Uncertainty
The pandemic that broke out with the COVID-19 virus
continues to have a negative impact on community
mental health, as it affects many people all over the
world, the virus is constantly mutating and its spread
has not been fully brought under control yet. As one of
the factors that play a role in the emergence of the negative
psychological effects of the pandemic, the uncertainty
experienced in this process, and the difficulty of
tolerating this uncertainty come to the fore. Uncertainty
can be experienced when faced with a new situation
that does not contain clues, as well as when faced with a
complex situation with many clues or a situation where
different clues lead to different information.[] Since
the duration, scope, and expiry date of the measures are
not clear, the pandemic period is perceived by individuals
as an uncertain process.[] Pandemic periods cause
uncertainty and anxiety as they contain new, complex,
and unresolvable experiences for individuals.[] Continuing
changes in knowledge about the pandemic,
with new results observed, contribute to questions and
doubts, as well as confusion, increasing uncertainty and
anxiety about guidelines and preventive efforts.[] In
addition to these experiences, the perception of uncertainty
experienced during pandemic periods due to the
unpredictability of the expiry date can lead to emotional
difficulties such as fear, stress, anxiety, and depression.
[] In a study on uncertainty and its psychological effects,
it was found that the stress of uncertainty during
COVID-19 is positively correlated with depression and
anxiety symptoms.[] In a study conducted by Ben
Salah[44] during the COVID-19 pandemic and included 3786 participants from 94 different countries, it was
observed that higher perceived uncertainty is correlated
with more depression and anxiety symptoms.
While the uncertainty experienced during and after
treatment for cancer patients can leave room for hope,
it can also contribute to the emotional distress and anxiety
experienced during the cancer process.[] Considering
that they already experience an uncertainty
about the treatment process and results of the disease
due to the nature of cancer, the perceived threat and
related psychological distress of cancer patients may
increase with the addition of the uncertainty originating
from COVID-19 to this uncertainty.[] It is determined
that cancer patients experience distress with
the "unknowns" of the future, such as whether they
will be infected with COVID-19 during the pandemic,
whether this infection will be fatal, and when their cancer
care will return to normal.[,] If not managed
properly, this distress may lead to impaired functionality
and problems of compliance to treatment,[] poorer
symptom management, and impaired health-related
quality of life.[,] To reduce the psychological and
emotional distress caused by uncertainty, it is asserted
that the communication of clinicians with patients and
the support they give patients will help patients cope
with uncertainty and find ways to tolerate uncertainty.
[] Communication strategies that clinicians can use
to help patients manage uncertainty include exploring
patient concerns, normalizing uncertainty, helping patients
regain a sense of control, being clear about what
is known and not known, and stating possible outcomes.
At this point, recognizing and reflecting on the
feelings of patients with an empathetic attitude, emphasizing
that they are not alone and reassuring them
can contribute significantly to emotional well-being.
Loneliness
Interpersonal interaction and communication are important
and universal needs of people. Lack of face-toface
contact and being away from other people can lead
not only to physical distance in relationships but also
to emotional loneliness. As a subjective concept, loneliness
can be a situation that everyone experiences from
time to time, therefore inevitable and personally painful.
During the COVID-19 pandemic, many governments
banned social and physical activities, especially
meeting face-to-face and in groups, and loneliness became
a current issue intensively as a result of obligatory
isolation around the world. Social isolation and loneliness
can have negative psychological and even physical
effects. Studies conducted before the pandemic process demonstrate that isolation, and especially loneliness, is
associated with poor coping skills, weaker immunity,
and a higher risk of death.[,]
In cases of medical illness, especially in groups that
are considered at risk for COVID-19, such as cancer
patients, isolation experiences based on restrictions, or
efforts to take precautions can be experienced much
more intensely. Isolation processes can cause individuals
to be deprived of social sharing and support resources.
It was found that this situation has a significant
impact on people living with cancer who seek or receive
support from their social environment.[] It was
revealed that cancer patients and survivors experience
increased loneliness during the pandemic compared
to family members and the general population[,]
and worsening mental health, including depression,
anxiety, and stress.[] In a study dealing with cancer
patients and their caregivers, it was reported that the
most important determinant of negative evaluation of
the pandemic process is experiencing more loneliness.
[] Ciazynska[] found that cancer patients living
alone have a higher risk of anxiety. In a longitudinal
study that started before COVID-19 and included the
pandemic process, it was indicated that cancer patients
have a high risk of suffering depression during COVID-
19, and feelings of isolation are the most important
risk factors for depression in this process.[] In this
study, pre-COVID-19 loneliness explains depression at
the level of 12%, while it is determined that those who
experienced loneliness during the pandemic are at 4.5
times higher risk in terms of existing depression symptoms.
As a result of a study comparing cancer patients
and people without a cancer diagnosis, it was reported
that loneliness experienced during the pandemic is
correlated with an increase in depression and anxiety
symptoms and high-stress levels, and also, there is no
difference between participants with and without a
cancer diagnosis.[] Online support groups or peer
groups can be organized for cancer patients so that they
can cope with the feeling of social isolation and loneliness.
Such sharing can encourage patients to share their
feelings as well as relieve the feeling of loneliness. If the
feeling of loneliness is accompanied by symptoms of
depression and anxiety, it would be appropriate to refer
these patients for psychological treatment.
