Digest commentator: Tori Langmuir, BSc, clinical research coordinator at the Ottawa Hospital Research Institute and the University of Ottawa
The impact of the COVID-19 pandemic on the health care system needs no introduction; it has been unprecedented. During the early months of the pandemic, Canada, the Netherlands, and the United Kingdom reported sharp decreases in cancer diagnoses, screening, and surgeries, leading many experts to express concern about “a tsunami of cancer” after the pandemic. Delayed appointments due to increased real or perceived barriers to accessing health care may negatively affect a patient’s psychosocial and physical wellbeing, as well as their prognosis. Among cancer patients and survivors, symptoms of anxiety and/or depression have been shown to negatively affect health care consumption, particularly during a health threat as significant as COVID-19. The present study measured the prevalence of anxiety and depression among a large cohort of breast cancer survivors during the early months of the COVID-19 pandemic, as well as the association between the presence of these symptoms and health care consumption impacted by COVID-19.
This cross-sectional study was conducted with a large prospective observational multi-centre cohort of ex-breast cancer patients called the “Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion” (UMBRELLA). All participants completed self-report questionnaires including the Hospital Anxiety and Depression Scale (HADS) at regular time points during and after their breast cancer treatment. Active participants who enrolled in the UMBRELLA cohort between October 2013 and April 2020 were sent an online survey on April 7, 2020 that included the HADS and COVID-19-related questionnaires.
Of the 3239 participants enrolled in the UMBRELLA cohort, 1595 met the inclusion criteria. Of those, 1051 (66.0%) completed the COVID-19-specific questionnaire. Overall, 284 (27.0%) of participants experienced clinically relevant symptoms of anxiety and/or depression during COVID-19. Of the participants who experienced symptoms of anxiety and/or depression during COVID-19, 62.7% (n = 156) had experienced these symptoms prior to the COVID-19 pandemic. During the pandemic, a total of 18.2% (n = 191) of all participants reported symptoms of anxiety and 16.0% (n = 168) reported symptoms of depression. The reported rates of anxiety and/or depression were slightly but significantly lower than before the pandemic (23.4%, n = 220). Factors associated with anxiety and/or depression during COVID-19 were lower age, higher stage of cancer, receipt of systemic therapy or radiotherapy and pre-existing symptoms of anxiety or depression.
Participants with anxiety and/or depression reported significantly higher barriers to contacting their general practitioner (GP; 47.5% vs. 25.0%, resp.) and their oncologists (26.8% vs. 11.2%, resp.) compared to patients without these symptoms. A higher proportion of participants with anxiety and/or depression reported that their current treatment (or follow-up treatment) was affected by COVID-19 compared to those without symptoms (32.7% vs. 20.5%, resp.).
Why I liked this article
This study has two important findings. First, breast cancer survivors experienced increased barriers to accessing important health care services during the COVID-19 pandemic, and those who have reported symptoms of depression and/or anxiety were more likely to report barriers. Second, survivors with pre-existing anxiety and/or depression were more likely to report increased symptoms of anxiety and depression during the COVID-19 pandemic. These survivors may have a higher risk of not only experiencing increased distress during the pandemic [relative to their non-anxious and/or depressed counterparts], but of not accessing health care services. These two groups may benefit from psychosocial support to improve their mental well-being and decrease perceived barriers to accessing health care.
I also would like to acknowledge the use of the phrase “(ex-)breast cancer patients” used throughout this article. In my interactions with cancer survivors, some have expressed disdain or frustration with the term “survivor”; it seems to trigger the occasional emotional reaction. Consequently, in some of our research, we have replaced the term with “patients who have completed cancer treatment”. The phrase “ex-breast cancer patients” could be a useful alternative.
The data collection for this study began on April 7, 2020 and it is unclear when data collection ended. The article was submitted to the journal in late October, so one could estimate that data collection lasted no longer than a few months. It is worth considering that symptoms of anxiety and/or depression in ex-breast cancer patients (including those with pre-existing symptoms) may have been higher during the early spring months of the COVID-19 pandemic, which were marked by global uncertainty and fear, compared to the later summer months, when case numbers decreased, or the fall months, when vaccines were announced. It is possible that symptoms of anxiety and/or depression may have continued to decrease throughout the course of the pandemic, impacted by factors such as habituation, coping, and increased public knowledge/preventative measures (masks, social distancing, lockdowns). This of course would be mediated by several factors including employment, social support, financial support, diagnosis, and severity of pre-existing symptoms.
Additionally, this study was conducted with breast-cancer patients only, therefore generalization to men, or other cancer diagnoses, is not direct.
Mink van der Molen, D. R., Bargon, C. A., Batenburg, M., Gal, R., Young-Afat, D. A., van Stam, L. E., van Dam, I. E., van der Leij, F., Baas, I. O., Ernst, M. F., Maarse, W., Vermulst, N., Schoenmaeckers, E., van Dalen, T., Bijlsma, R. M., Doeksen, A., Verkooijen, H. M., & UMBRELLA study group (2021). (Ex-)breast cancer patients with (pre-existing) symptoms of anxiety and/or depression experience higher barriers to contact health care providers during the COVID-19 pandemic. Breast cancer research and treatment, 186(2), 577–583. https://doi.org/10.1007/s10549-021-06112-y
Other articles mentioned:
Hogan, S., & Glanz, M. (2020, December 17). Oncologist fears ‘tsunami of cancer’ after COVID-19 lockdowns limited screening. CBC News. https://www.cbc.ca/news/health/cancer-tsunami-screening-delays-covid-1.5844708
St. Philip, E., Favaro, A., & Cousins, B. (2020, August 13). 'Collateral damage': Doctors worry patients diagnosed with more advanced cancers because of delays. CTV News. https://www.ctvnews.ca/health/coronavirus/collateral-damage-doctors-worry-patients-diagnosed-with-more-advanced-cancers-because-of-delays-1.5063815