ORİJİNAL MAKALE / ORIGINAL ARTICLE .

Sağlık Bilimlerinde Değer / Sağlık Bil Değer

Value in Health Sciences / Value Health Sci
ISSN: 2792-0542 [email protected] 2023; 13(1): 87-92
doi: https://dx.doi.org/10.33631/sabd.1158643

Anxiety Levels in Cancer Patients during the First Months of the COVID-19
Pandemic

1 1
Seher Nazlı KAZAZ , Atila YILDIRIM

ABSTRACT
Aim: COVID-19 remains the biggest health crisis in the age we live in. It is obvious that this pandemic will cause
psychological and physical disorders. The aim of this study is to investigate the frequency of anxiety caused by the
COVID-19 pandemic in patients with cancer and the factors that may affect it.
Material and Methods: This is an observational, single-center study involving 235 cancer patients admitted to our
outpatient clinic. The Turkish validated "Generalized Anxiety Disorder-7" questionnaire form was preferred to evaluate
patients' anxiety levels. We also asked patients how long they thought about COVID-19 during the day.
Results: More than one-third of the cancer patients had high and severe anxiety levels because of COVID-19. Severe
anxiety was significantly higher in patients with metastatic disease (p<0.001). In addition, the rate of severe anxiety was
higher in patients with ECOG-PS 2-3 versus ECOG-PS 0-1 (p<0.001). Those who thought about COVID-19 for more
than 3 hours per day had severe anxiety scores (p<0.001). There was no significant relationship between the age, gender
or educational status of the patients with the time to focus on COVID-19 and anxiety levels (respectively; p=0.754,
p=0.283, p=0.276 and p=0.689, p=0.628, p=0.626). However, approximately two-thirds of patients (66.40%) were more
concerned about different issues than COVID-19.
Conclusion: In our study, most cancer patients surveyed were significantly concerned about both COVID-19 infection
and delaying active cancer treatments, especially for patients with metastatic disease and poor performance status. In
particular, patients in this group should be provided with more careful psychological support.
Keywords: Anxiety; cancer; COVID-19; pandemic.
COVID-19 Pandemisinin İlk Aylarında Kanser Hastalarında Kaygı Düzeyleri
ÖZ
Amaç: COVID-19, yaşadığımız çağın en büyük sağlık krizi olmaya devam etmektedir. Bu pandeminin psikolojik ve
fiziksel rahatsızlıklara yol açacağı aşikardır. Bu çalışmanın amacı, kanserli hastalarda COVID-19 pandemisinin neden
olduğu anksiyete sıklığını ve bunu etkileyebilecek faktörleri araştırmaktır.
Gereç ve Yöntemler: Çalışmamız, polikliniğimize başvuran 235 kanser hastasını içeren gözlemsel, tek merkezli bir
çalışmadır. Hastaların anksiyete düzeylerini değerlendirmek için Türkçe geçerliliği olan "Genelleştirilmiş Anksiyete
Bozukluğu-7" anket formu tercih edildi. Ayrıca hastalara gün içinde COVID-19 hakkında ne kadar düşündükleri
soruldu.
Bulgular: Kanser hastalarının üçte birinden fazlasının COVID-19 nedeniyle yüksek ve şiddetli anksiyete düzeyleri
vardı. Metastatik hastalığı olan hastalarda şiddetli anksiyete anlamlı olarak daha yüksekti (p<0,001). Ek olarak, ECOG-
PS 0-1'e kıyasla ECOG-PS 2-3 olan hastalarda şiddetli anksiyete oranı daha yüksekti (p<0,001). COVID-19'u günde 3
saatten fazla düşünenlerin ciddi anksiyete puanları vardı (p<0,001). Hastaların yaşı, cinsiyeti, eğitim durumu ile
COVID-19'a odaklanma zamanı arasında ve anksiyete düzeyleri arasında anlamlı bir ilişki bulunmadı (sırasıyla;
p=0,754, p=0,283, p=0,276 ve p=0,689, p=0,628, p=0,626). Bununla birlikte, hastaların yaklaşık üçte ikisi (%66,40)
COVID-19'dan farklı konular hakkında daha fazla endişe duyuyordu.
Sonuç: Çalışmamızda, ankete katılan kanser hastalarının çoğu, özellikle metastatik hastalığı ve düşük performans
durumu olan hastalar, hem COVID-19 enfeksiyonu hem de aktif kanser tedavilerinin ertelenmesi konusunda önemli
ölçüde endişe duymuştur. Özellikle bu gruptaki hastalara daha dikkatli psikolojik destek sağlanmalıdır.
Anahtar Kelimeler: Anksiyete; COVID-19; kanser; pandemi.
1 Karadeniz Technical University School of Medicine, Medical Oncology Department, Trabzon/TURKEY

Sorumlu Yazar / Corresponding Author: Seher Nazlı KAZAZ , e-mail: [email protected]

Geliş Tarihi / Received: 06.08.2022, Kabul Tarihi / Accepted: 14.12.2022

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 KAZAZ and YILDIRIM

INTRODUCTION pandemic conditions. It is a Likert-type quartet scale (0 =

The virus disease COVID-19 (Coronavirus disease-2019) none, 1 = many days, 2 = more than half of the days, 3 =
seen in China in December 2019 was accepted by the almost every day) containing 7 items, which evaluates the
World Health Organization as a pandemic in January experiences asked in the scale items during the last 2
2020 (1). The pathogen has been identified as a novel weeks. According to the answers given to the questions in
enveloped RNA betacoronavirus currently known as the survey, the GAD-7 score of the participants was
severe acute respiratory syndrome coronavirus 2 (SARS- determined. In scoring, 0-4: mild anxiety, 5-9: moderate
CoV-2) (2). COVID-19 continues to exert its influence by anxiety, 10-14: high anxiety and 15-21: severe anxiety.
constantly changing and creating new variants from the Scores of 5, 10, and 15 were taken as the cut-off points
moment it first emerged to the present day. Omicron for mild, moderate, and severe anxiety, respectively. The
variant, the last variant of the COVID-19, emerged in the internal consistency of the GAD-7 was excellent
last quarter of 2021 and has taken the whole world under
its influence (3). As in all over the world, COVID-19 is The Cronbach's alpha coefficient was found to be 0,852
spreading in Turkey, and daily morbidity and mortality for the total score of GAD-7 in the Turkish validated
rates are increasing. GAD-7 questionnaire (10).
The rapid spread of the pandemic has challenged the In addition to examining the demographic characteristics
capacity of the countries’ health systems. However, these of the patients in the study, the patients were asked how
outbreaks cause psychological problems such as anxiety, long they thought of COVID-19 in one day [less than 1
sleep disturbance and fear (4,5). In this process, some hour, 2-3 hours or more than 3 hours]. Patients who
chronic diseases were considered as risk groups. Among underwent routine control or treatment process were
these, cancer patients and especially those receiving included in this study.
chemotherapy and immunosuppressive drugs have more Patients who were over 18 years of age, who did not have
risk for mortality (5). This causes anxiety among cancer organic brain syndrome, who were not in the terminal
patients. Anxiety disorder is a common psychiatric period of cancer, and who agreed to participate in the
disorder in patients diagnosed with cancer (6). In a study study were included in the study. Individuals with brain
conducted by Nikbakhsh N. et al., fear and anxiety were metastases or primary brain tumors were excluded from
observed in 46% of patients with cancer (7). Anxiety the study.
negatively affects the quality of life of cancer patients as Since this was a survey study, when the participants were
well as the general population. In addition, it is known to informed about the study, their verbal consent was
reduce patients' compliance with medical treatment (8). accepted as their completion of the questionnaire. So,
There were only a few studies conducted on the fear and verbal informed consent was obtained before the
anxiety caused by COVID-19 in cancer patients in the interview. The study was approved by the Ethics Board
literature. Committee of Karadeniz Technical University Medical
This study aimed to investigate the frequency of anxiety Faculty (Ref No: 24237859-275 Date: 13.05.2020) and
caused by the COVID-19 outbreak and related factors ethical principles laid down in the Declaration of Helsinki
that may affect it in patients with cancer during the have been followed. The submission of the answered
pandemic (9). questionnaire was regarded as consensual to participate in
MATERIAL AND METHODS the study.
Patients and study design
A cross-sectional prospective single-center study was Statistical Analysis
conducted using a survey to evaluate the anxiety levels of
various types of cancer patients in response to the 23.0” program was used for the analyses. Descriptive
COVID-19 outbreak. This study was approved by statistics were applied to identify the items included in
Karadeniz Technical University Medical Faculty, the questionnaire. We used numbers and percentages
Medical Oncology Outpatient Clinic in July and August when presenting descriptive data. Since the age variable
2020. is not normally distributed, it is given with median,
The sample size was calculated using the open. Epi minimum and maximum values. The Chi-square test was
(Open source epidemiologic Statistics for Public Health) used to compare categorical variables. We admitted
software. The expected prevalence of anxiety is taken as values of p <0.05 in the comparison results between the
60% and deviation as 6%. At a 95% confidence interval, groups as statistically significant.
the calculated sample size was 205 contributors, and we
included 235 participants in the study. Diagnoses and RESULTS
metastasis status of patients were recorded from patients’ The median age of the patients was 59.0 ( min:21,
files. The patients' Eastern Cooperative Oncology Group max:82) years. One hundred fourteen patients (48.50%)
Performance Status (ECOG-PS) was evaluated and noted. were female, and 121 patients (51.50%) were male. The
In our study, we used a screening test called “Generalized patients who had less than middle-high school education
Anxiety Disorder-7", which was validated in the Turkish level were 57%. The most frequent diagnoses of the
language and consisted of 7 questions (10). The GAD-7 patients in this study were gastrointestinal cancers
is a self-administered patient questionnaire, which takes (32.30%) and breast cancer (26.80%). Additionally,
approximately 1-2 minutes to complete. 43.40% of these patients were metastatic; 56.60% were
It was thought to be the most appropriate test for this nonmetastatic. The ECOG performance status of 82.10%
study since it was validated in the Turkish language and of patients was 0-1; the rest was 2-3. The demographic
was a self-administered and short-term questionnaire in

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 KAZAZ and YILDIRIM

characteristics of the study participants are shown in The Cronbach alpha value of the GAD-7 scale used in
Table 1. this study was found to be 0.928. The average time to
Table 1. Socio-demographic characteristics of the 235 focus on the COVID-19 outbreak in a day and
cancer patients enrolled in the study generalized anxiety disorder (GAD) status of the patients
n (%) are given in Table 2. According to the GAD-7 score,
Sex 44.70% of the patients were classified as "mild anxiety",
Female 114 (48.5) 20% as "moderate anxiety", 9.80% as "high anxiety" and
Male 121 (51.5) one-fourth of the patients were classified as "severe
Age (years) anxiety".
18-35 11 (4.7) The responses of the patients for GAD-7 scale items are
36-50 45 (19.1)
given in Table 3. More than half (57.40%) of the patients
51-65 127 (54)
>65 52 (22.2) expressed varying rates of nervousness, concern, and
Martial Status anxiety during the day. Approximately two-thirds
Married 208 (88.5) (66.40%) of the patients said that they were more
Never-Married 15 (6.4) concerned about issues other than COVID-19. More than
Others* 12 (5.1) half (56.60%) of the patients became angry quickly or
Who lives with uneasy because of COVID-19. 53.60% of the patients
Living with family 231 (98.3) said that they were afraid that something very bad would
Living alone 4 (1.7) happen because of COVID-19.
Educational Background The relation between the demographic characteristics of
Illiterate 15 (6.4) patients and their anxiety scores is shown in Table 4.
Primary school 119 (50.6)
Severe anxiety was observed with a higher rate in patients
High school 69 (29.4)
University 32 (13.6)
with metastatic disease, while mild anxiety was more
Job common in patients without metastasis (p <0.001).
Working 33 (14) Severe anxiety was higher in patients with ECOG-PS 2-3,
Not-working 202 (86) and mild anxiety was higher in patients with ECOG-PS
Comorbidities 0-1 (p <0.001). However, when the patients' age, gender,
Absent 116 (49.4) and educational status were compared with the time to
Present 119 (50.6) focus on COVID-19, no significant relationship was
ECOG-PS found between these parameters (respectively; p=0.754,
0-1 193 (82.1) p=0.283, p=0.276). Although most people with metastatic
2-3 42 (17.9) diseases thought about COVID-19 for more than 3 hours
Cancer types a day, most of the patients who did not have metastatic
Gastrointestinal System 76 (32.3) diseases thought about less than 1 hour a day, which was
Breast 63 (26.8)
statistically significant (p<0.001). The time to think about
Lung 44 (18.7)
Others** 52 (22.2) COVID-19 was significantly higher in those with ECOG-
Stages PS 2-3 than in those with ECOG-PS 1-2 (p=0.001).
Non-metastatic 133 (56.6) When we consider the relationship between the times to
Metastatic 102 (43.4) focus on COVID-19 thinking periods and anxiety scores,
* “Others” included widowed and divorced. ** “Others” included; it was seen that patients with long COVID-19 thinking
prostate carcinoma, malignant melanoma, renal cell carcinoma, over periods during the day also had higher anxiety scores, and
carcinoma, sarkoma, head and neck cancers, testis cancer, bladder
cancer, timoma, endometrium cancer and thyroid cancer
this was statistically significant. In other words, those
who thought about COVID-19 for more than 3 hours per
day had severe anxiety scores (p<0.001) (Table 5).
Table 2. Average time to focus on the COVID-19 DISCUSSION
outbreak in a day and Generalized anxiety disorder status In this study, we evaluated the anxiety levels of cancer
of the participants patients about COVID-19. Our survey study shows a high
prevalence of GAD in cancer patients treated in our clinic
Time to focus on the COVID-19 n (%) during COVID-19 pandemic. Anxiety symptoms were
more likely to occur in patients with metastatic disease
<1 hour 120 (51.1) and ECOG-PS 2-3 and those who spent too much time
1-2 hours 49 (20.8) focusing on the pandemic.
The Coronavirus Disease-2019 pandemic, which is still
≥3 hours 66 (28.1) ongoing with variants (11), affected the whole world and
killed thousands of people. Just like it disrupted the
Anxiety score of the participants physical health of many people, it also caused
Mild anxiety (0-4) 105 (44.7)
psychological problems such as anxiety, panic, and sleep
disorders in many people. Cancer is a disease in which
Moderate anxiety (5-9) 47 (20) psychiatric disorders are likely to appear (12). In a study
conducted by Zhang et al. in China, the mortality rates
High anxiety (10-14) 23 (9.8) due to COVID-19 infection were approximately 10 times
Severe anxiety (15-21) 60 (25.5)
higher in cancer patients compared to the normal
population (13).

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Table 3. The Responses of the patients for “The generalized anxiety disorder-7 (GAD-7)” scale items
Not at all Several Days More than half Nearly every
the days day
n (%) n (%) n (%) n (%)
1. Feeling nervous, anxious or on edge 100(42.6) 49(20.8) 53 (22.6) 33 (14.0)
2. Not being able to stop or control worrying 124(52.8) 33 (14.0) 67 (28.5) 11 (4.7)
3. Worrying too much about different things 79 (33.6) 33 (14.0) 25 (10.6) 98 (41.8)
4. Trouble relaxing 111(47.2) 53 (22.5) 57 (24.3) 14 (6.0)
5. Being so restless that it is hard to sit still 132(56.1) 35 (14.9) 61 (26.0) 7 (3.0)
6. Becoming easily annoyed or irritable 102(43.4) 49 (20.9) 37 (15.7) 47 (20.0)
7. Feeling afraid as if something awful might happen 109(46.4) 46 (19.6) 28 (11.9) 52 (22.1)

Table 4. Relation between socio-demographic characteristics of cancer patients and their anxiety scores about COVID-
19
Socio-demographic Anxiety score of the participants p value
Characteristics
Mild anxiety (0-4) Moderate anxiety High anxiety (10- Severe anxiety (15-21)
n (%) (5-9) 14) n (%)
n (%) n (%)
Sex
Female 55 (48.2) 23 (20.2) 9 (7.9) 27 (23.7)
0.628
Male 50 (41.3) 24 (19.8) 14 (11.6) 33 (27.3)
Age (years)
18-35 7 (63,6) 1 (9.1) 1 (9.1) 2 (18.2)
36-50 21 (46.7) 6 (13.3) 4 (8.9) 14 (31.1)
0.689
51-65 53 (41.7) 30 (23.6) 15 (11.8) 29 (22.9)
>65 24 (46.2) 10 (19.2) 3 (5.8) 15 (28.8)
Martial Status
Married 93 (44.7) 46 (22.1) 18 (8.7) 51 (24.5)
Never-Married 6 (40.0) 0 (0.0) 4 (26.7) 5 (33.3) 0.259
Others* 6 (50) 1 (12.5) 1 (6.25) 4 (31.25)
Who lives with
Living with family 103 (44.6) 47 (20.3) 23 (10.0) 58 (25.1) 0.534
Living alone 2 (50.0) 0 (0.0) 0 (0.0) 2 (50.0)
Educational Background
Illiterate 8 (53.3) 3 (20.0) 0 (0.0) 4 (26.7)
Primary school 49 (41.2) 25 (21.0) 15 (12.6) 30 (25.2)
0.626
High school 35 (50.7) 14 (20.3) 6 (8.7) 14 (20.3)
University 13 (40.6) 5 (15.6) 2 (6.3) 12 (37.5)
Job
Working 12 (36.4) 6 (18.2) 4 (12.1) 11 (33.3)
0.617
Not-working 93 (46.0) 41 (20.3) 19 (9.4) 49 (24.3)
Comorbidities
Absent 59 (49.7) 21 (17.6) 13 (10.9) 26 (21.8)
0.312
Present 46 (39.7) 26 (22.4) 10 (8.6) 34 (29.3)
Stage
Metastatik 33 (32.4) 17 (16.7) 14 (13.7) 38 (37.1)
<0.001
Non-metastatic 72 (54.1) 30 (22.6) 9 (6.8) 22 (16.5)
ECOG-PS
0-1 94 (48.7) 44 (22.8) 15 (7.8) 40 (20.7)
<0.001
2-3 11 ( 26.2) 3 ( 7.1) 8 (19.0) 20 (47.7)
*”Others” included widowed ans divorced.

Table 5. Relation between time to focus on the COVID-19 between the stage, ECOG-PS and anxiety score of the
participants
Time to focus on the COVID-19
< 1 hour 1-2 hours ≥3 hours
p value
n (%) n (%) n (%)
Stage
Metastatik 35 (34.3) 27 (26.5) 40 (39.2)
<0.001
Non-metastatic 85 (63.9) 22 (16.5) 26 (19.6)
ECOG-PS
0-1 109 (56.5) 37 (19.1) 47 (24.4)
<0.001
2-3 11 (26.2) 12 (28.6) 19 (45.2)
Anxiety score of the participants
Mild anxiety (0-4) 95 (79.2) 10 (20.5) 0 (0.0)
Moderate anxiety (5-9) 24 (20.0) 18 (36.7) 5 (7.6)
<0.001
High anxiety (10-14) 1 (0.8) 15 (30.6) 7 (10.6)
Severe anxiety (15-21) 0 (0.0) 6 (12.2) 54 (81.8)

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We believe that anxiety is gaining more importance in spend thinking about COVID-19 during the day and
cancer patients and their relatives during COVID-19 GAD, in line with the results of our study.
pandemic. In this study, we evaluated the general anxiety When the limitations of our study are considered, the
disorder in cancer patients about COVID-19. GAD-7 has analysis results indicate a snapshot of a particular time
been evaluated in many studies for screening for anxiety period and 220 patients, and there are no comparisons of
in cancer patients and has demonstrated adequate how they change in time during this pandemic period.
diagnostic accuracy area under the curve (AUC) and is Because the GAD-7 questionnaire is a screening test,
therefore applicable for screening for GAD in cancer patients with high scores should be evaluated by
patients (14,15). psychiatrists. Despite these limitations, the present study
In a study in which 218 cancer patients were included, is very important in terms of determining the anxiety
and the same scale was used, anxiety was observed in levels in cancer patients during COVID-19. Because the
35.80% of the patients (15). In our study, the anxiety rate pandemic continues with variants, there is an increasing
in cancer patients was 55.30%. In light of this concern and anxiety in risky populations such as cancer.
information, the anxiety rate was found to be very high For that reason, it is important that this group should be
during the COVID-19 pandemic period. We believe that determined with such studies and directed by the primary
the high mortality and morbidity of COVID-19, as well physicians to psychologist in order to provide
as the necessity of strict isolation measures and psychological support to the patients who need it.
quarantines in the country, increased fear and anxiety in CONCLUSION
society. In our study, most participants were significantly
Anxiety in cancer patients, unlike the general population, concerned about COVID-19 infection and delaying active
was not found to be associated with age, gender, or cancer treatments, especially for patients with metastasis
educational status (16). Our study was also found in and poor performance status. In particular, patients in this
accordance with this literature. However, anxiety has group should be provided with more careful
been associated with metastatic disease in some types of psychological support.
cancer (17). In our study, anxiety symptoms were Funding: None
significantly higher in patients with advanced-stage Conflict of interest
metastatic cancer and in those with high ECOG None of the authors received any type of financial
performance scores (ECOG 3-4). support that could be considered potential conflict of
When asked about the time they spent thinking about interest regarding the manuscript or its submission.
COVID-19 during the day, significant relations were Authors’s Contributions: Idea/Concept: S.N.K.;
detected in metastatic patients and those with ECOG Design: S.N.K.; Data Collection and/or Processing:
performance scores between 3-4. Also, positive relations S.N.K., A.Y.; Analysis and/or Interpretation: S.N.K.,
were detected between the COVID-19 thinking period A.Y.; Literature Review: S.N.K., A.Y.; Writing the
and the GAD-7 scale in our study. Article: S.N.K., A.Y.; Critical Review: S.N.K.
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