We conducted a cross-sectional Internet-based survey aimed at understanding mental and psychosocial health impacts of the COVID-19 pandemic among individuals undergoing active cancer treatment, with findings suggesting substantial proportions of participants experiencing anxiety (26.6%), depression (30.0%), loneliness (43.3%), and social isolation (19.8%). Unique to our study, comparing how the COVID-19 pandemic impacted individuals diagnosed with cancer <50 and ≥50 years of age, revealed differences between groups. Specifically, we found that younger participants were more likely to experience anxiety, have expenses that they were worried about paying, and use mental health. We additionally found that older participants were more likely to experience social isolation during the COVID-19 pandemic. We also noted higher utilization of mental health care from specialist providers among participants <50 as compared to those ≥50 years. Altogether our findings provide better understanding of the mental health burden during the COVID-19 pandemic among individuals undergoing active treatment for cancer, with implications for informing areas for better support.
With anecdotal reports on the mental health impacts of the COVID-19 pandemic among patients with cancer, an implication of our study was quantifying the extent of these, particularly with respect to anxiety in 26.6% of participants and depression in 30.0%. With respect to anxiety, we found age at cancer diagnosis is a significant predictor, with younger participants having higher average scores on the GAD-7. This finding is supported by results from a 2012 Canadian mental health survey which found that that generalized anxiety disorder is most prevalent among middle-aged adults (35-54 years).17 Furthermore, research on the general population during the COVID-19 pandemic has shown that a younger age is a predictor of anxiety.18-20 Indeed, as an already vulnerable patient population, mental health disorders among patients with cancer have been associated with negative outcomes including poor treatment adherence, decreased quality of life, and suicide ideation.21 As such, higher levels of anxiety (29.7% <50 years, 23.0% ≥50 years) and depression (32.2% <50 years, 27.4% ≥50 years) during a global pandemic, as suggested by our findings, may have significant negative implications for health outcomes, particularly among younger patients with cancer. Aside from age at diagnosis, other significant determinants of anxiety as suggested by multiple linear regression models included worries about paying household expenses and concomitant depression. Other potential contributing factors may include delays in treatment and changes in oncology care which have been reported during the COVID-19 pandemic.22, 23 With respect to depression, associated factors were level of education and social isolation, an important psychosocial factor that we also assessed in our study and discuss further below.
Relatedly, we assessed patterns of mental health care utilization among individuals with cancer during the COVID-19 pandemic. Of note, 29.8% of participants indicated that they were currently receiving care for anxiety or depression (at the time of survey completion). Furthermore, 31.5% of participants indicated use of medication(s), such as antidepressants and anxiolytics. These findings reflect the increase in the demand for mental health care, shown globally in the general population.1, 2 We noted a greater tendency for patients <50 years of age, as compared to those ≥50 years, to access care from specialists (e.g., psychiatrists, psychologists) as well as use virtual methods of care. As many aspects of healthcare have been forced to move online during the COVID-19 pandemic, vulnerable populations, such as older adults, have experienced access barriers. A study by the Pew Research Center in 2019 found that 27% of older adults in the United States are not on the Internet.24 A lack of an Internet connection creates a barrier to receiving care from patients’ perspectives. From providers’ perspectives studies have also suggested challenges such as telehealth training and patient privacy.25 Taken together, these barriers may explain why cancer patients, particularly those who are older, may not be accessing/receiving necessary mental health care during the COVID-19 pandemic.
Aside from mental health outcomes, we assessed psychosocial outcomes, particularly loneliness and social isolation. These are particularly relevant given that in efforts to slow the transmission of COVID-19, public health measures, such as physical distancing, have been implemented across jurisdictions26. However, approaches at the individual (e.g., self-isolation) and community (e.g., closures) levels27 significantly affect social structures and healthcare interactions, particularly for vulnerable patient populations such as patients with cancer who have with high degrees of need. In particular, we found that social isolation was more frequently reported among participants ≥50 years. Our finding of 26.8% of participants ≥50 years being classified as isolated is similar to findings by Aoki et al.28 in which they found that the rate of social isolation in older adults within the general population in Japan during the COVID-19 pandemic was 27.3%. Previous research has shown that social isolation can have negative health outcomes including early mortality, particularly among older adults.29-31 Furthermore, Fleisch Marcus et al.29 conducted a population based study in 2017 in the United States and found that that social isolation was associated with increased cancer mortality (hazard ratio 1.25, 95% confidence interval 1.01 to 1.54). As an already vulnerable population during the COVID-19 pandemic, it is important to understand the availability of social interactions and/or supports to cancer patients, particularly those who are older.
The strengths and limitations of our study warrant discussion. We recruited participants across the age spectrum and representing many different types of cancer. By hosting the survey online, we acknowledge that our study sample is biased towards individuals with Internet access. The COVID-19 pandemic created a challenge as normally we would try to mitigate this bias by issuing in person paper surveys; however, with physical distancing measures in place, this was not possible. Additionally, despite our ability to recruit participants worldwide, our sample is largely based on residents in high-income countries with a post-secondary education. We recognize that these participants may have more access to mental health and social services when compared to low-income countries and populations. Furthermore, findings of gaps in mental health care may be even more exacerbated in such low resource settings.
Altogether, results of our study demonstrate the negative impact that the COVID-19 pandemic has had on the mental and psychosocial health of patients with cancer undergoing active treatment across the age spectrum. Identifying unique vulnerabilities in each age group have implications for informing specific areas for supporting patients through the COVID-19 pandemic.