Oncological patients' reactions to COVID‐19 pandemic: A single institution prospective study

Abstract Background The spread of the COVID‐19 pandemic has led to a rapid reorganization in all human and hospital activities, with impact on cancer patients. Aim An analysis of cancer patients fears, and awareness of COVID‐19 has been done in this study. Methods and results We analyzed cancer patients' reactions to the pandemic and their perception of oncological care reorganization, through a 12‐item survey, proposed at the peak of pandemic and 3 months later. Overall, 237 patients were included in the study. During the peak of pandemic 34.6% of patients were more worried about COVID‐19 than cancer versus 26.4% in the post‐acute phase (p = .013). Although 49.8% of patients in the acute phase and 42.3% in the post‐acute phase considered their risk of death if infected ≥50%, and more than 70% of patients thought to be at higher risk of complications, the majority of them did not consider the possibility to stop or delay their treatment. Patients were more interested in following news about COVID‐19 than cancer and they complied with all preventive measures in more than 90% of the cases. Conclusions Although cancer patients worried about COVID‐19 and evaluated the risk of complication or death due to COVID‐19 as extremely high, they were still asking for the best oncological treatment.


| Patients selection and data collection
Patients admitted for systemic treatment for solid cancers to the day care unit of the University Hospital of Liège in Belgium were prospectively included in the study.
Inclusion criteria were: age ≥18 years; diagnosis of solid tumor, irrespective of the stage; treatment at the day care unit between April 14 and April 30, 2020; ability to answer a written questionnaire in French language. Exclusion criteria were: access to the day care unit for reasons other than cancer treatment, treatment with oral therapies, no understanding of French language. April 30, 2020 (acute phase of the pandemic) and approximately 3 months later, between July 13 and August 12 (post-acute phase of the pandemic). The first questionnaire was carried out in person (paper questionnaire self-administered by the patients) at the time of access to the day care unit. The second questionnaire was carried out in person for patients still undergoing treatment between July and August 2020 and by phone for patients whose treatment was over.
The questionnaire inquired about the fear of COVID-19 infection (question 1), the perception to be protected in the hospital (question 2), the measures taken by the patients, the hospital, and their household to minimize the risk of infection (questions [3][4][5], the awareness about oncological treatment choices (questions 6, 7, 10), the risk of complications or death due to 9), and acquisition of information about COVID-19 and cancer (questions 11,12).
Information about sex, age, cancer type, treatment intent, and type of treatment were collected in the medical charts.
The study was performed in compliance with the Helsinki Declaration, was approved by the local Ethics Committee with the reference number 2020/129, and all patients signed an informed consent before inclusion in the study.

| Statistical analysis
Descriptive statistics were performed for each item. Differences in response to the second questionnaire performed in July-August 2020 from the baseline performed in April 2020 were analyzed by means of a   Table 1.

| RESULTS
Forty fewer questionnaires were collected in July/August as compared to April due to death (n = 10), patients' refusal (n = 24), and inability to reach the patients because of deteriorated clinical conditions (n = 6).

| Worries about COVID-19
Patients were more worried about COVID-19 in the acute phase compared with the post-acute phase (34.6% vs. 22.9%), where patients were more worried about cancer (39.2% vs. 45.8% in the acute and post-acute phase, respectively), with a statistically significant difference (p = .013, Figure 1). No significant differences were observed at baseline according to age group, sex, and primary cancer site (Table S1). Patients in palliative care were more worried about cancer than COVID-19 (40.7% vs.
During the post-acute phase, no significant differences were observed according to sex, treatment intent, treatment type, and cancer site (Table S1). Nevertheless, patients younger than 65 years were more worried about cancer than older patients (58.9% vs. 44.7%) and less worried about COVID-19 (19.6% vs. 35.3%, p = .041).

| Security and measures to minimize the risk of infection
Most patients considered the hospital safe (Table 2) during both the acute phase (83.5%) and the post-acute phase (91.4%), with a nonsignificant difference between the two timepoints (p = .081). Subgroup analysis showed significant differences during the acute phase according to age (p = .002), with a lower proportion of patients younger than 65 years considering the hospital safe (79.7%) than older

| Oncological treatment
Most patients disagreed with the possibility of stopping treatment due to infectious risk (Figure 2A) during both the acute phase (92.0%) and the post-acute phase (90.4%), without significant differences between the two timepoints (p = .707) and across the various subgroups (Table S2). Moreover, 86.1% of the patients declared that it is important to receive the best treatment during the acute phase and 88.8% during the post-acute phase (p = .266, Figure 2B). No significant differences were observed across subgroups (Table S3).
In case of infection, 12.7% of patients during the acute phase and 10.2% during the post-acute phase declared that the oncological treatment should be definitely discontinued ( Figure 2C), with no significant difference between the two timepoints (p = 0.812). No differences were observed according to patients' characteristics (Table S4).
During the post-acute phase, a higher proportion of men than women thought that treatment should be permanently discontinued if infected by SARS-CoV-2 (16.4% vs. 7.0%, p = .043).

| Risk of complications and death
The majority of cancer patients were aware of belonging to a high-risk category, with the majority stating to have a death risk of approximately 50% if infected by SARS-CoV-2 ( Figure 3A). There were no statistically significant differences in the perception of the risk of death during the acute and the post-acute phase (p = .138

| Information about COVID-19 and cancer
Most  the prevention and treatment of the disease were established and the level of information was increasing. These aspects probably contributed to the responses given by patients, in particular both the awareness of improved treatment and the reduction in cases led patients to be more afraid by the tumor than by the COVID-19 in the second phase of the study.
In our study, patients showed a higher level of concern for COVID-19 than for cancer, mainly if older, receiving a treatment with curative intent, chemo-or targeted therapy. predictive of a more severe disease, whereas chemotherapy was not. 22 One possible explanation for this attitude could be related to the type of treatment, which leads patients to think that their immune system is stimulated in general, and therefore also against infections.
The stage of the disease could be a possible explanation for their greater concern with cancer than with COVID-19, considering that F I G U R E 2 Patients' perception about oncological treatment. Bar graphs representing the patients' perception about the possibility to stop treatment due to the infectious risk (A), the importance to receive the best treatment (B), and the possibility to permanently discontinue the treatment if infected by Sars-Cov-2 (C) most patients receive immunotherapy in the palliative setting. In this context, we must consider that in our study about one third of patients received immunotherapy in the adjuvant setting.
All patients showed awareness to be at higher risk for death and complications than the general population. These concerns are likely to prompt cancer patients to take all necessary precautions to avoid infection. The same observation has been previously reported in another study, where cancer patients followed hygiene requirements and avoided public spaces more frequently than healthy subjects. 19 It is interesting to note that patients felt safe in our hospital, where all the necessary hygiene measures were taken. A direct consequence of the extreme attention paid in our oncology department and by patients in complying preventive measures is the low infection rate recorded among these patients, which, although slightly higher than in the general population, remains lower than expected. 23,24 Remarkably, although cancer patients are scared of COVID-19 and aware that they are at greater risk of complications, they still expect to receive the best oncological treatment and have not considered the possibility of discontinuing or postponing treatment due to the pandemic. This is in contrast with what was done in most cancer units, where treatment was modulated to minimize the number of hospital accesses and palliative treatment was more frequently discontinued in the final stages of disease. 9 This could lead to problems in the physician-patient relationship, as well to legal issues. In this context, psychological support, optimal communication, and sharing of decisions with the patient could help overcome this issue. 25 Patients acknowledged they were following all the news related to COVID-19 closely more than for cancer. This response was expected, considering the huge mediatic resonance of the COVID-19 outbreak. Neither the type of information nor the authenticity of the