City lockdowns around the globe were imposed with the outbreak of COVID-19 pandemic,
a respiratory infection caused by SARS-CoV-2. While symptoms of this disease are usually
mild to moderate, cancer patients are keener to develop complications and are among
the groups with the highest mortality rates [1]. When the danger of contracting COVID-19
outweighs the benefits of a physical visit to the care facility, telemedicine in oncology
(teleoncology) is widely encouraged [2]. From another side, a third of oncological
patients may be psychologically affected during their treatment thus needing professional
support [3]. While guidelines, advantages and setbacks of teleoncology in times of
the pandemic have been discussed, the psychological aspect of it has not yet been
put under the spotlight. In our article, we review the challenges of cancer patients’
mental health in times where their concerns about risks, treatments and privacy grow
bigger. We also discuss the psychological benefits of teleoncology and the importance
of empathy in creating a patient-centered approach. We conclude by suggesting improvements
applicable to teleoncology practice during the COVID-19 pandemic.
Cancer patients are subject to psychological effects linked to their condition. Indeed,
cancer-related distress, intense unpleasant emotions that interfere with functioning,
has been listed as a common negative consequence of a diagnosis and is closely linked
to uncertainty [4]. Detecting and preventing distress is especially crucial as 10–20%
feel chronic distress, sometimes up to 6 years after the end of the treatment [3].
The challenges for cancer patients in the specific context of COVID-19, add to their
preexisting psychological burden, especially since cancer has a big share (20%) in
COVID-19 mortality rate [1]. A factor of uncertainty also lies in the controversies
on whether anti-cancer treatments, such as immunotherapy, interfere with COVID-19
[5]. Not knowing if the treatment they take may disadvantage them in case they contracted
COVID-19 will put them in much more distress than the average population. Furthermore,
cancer patients are considered a higher risk-group and have specific recommendations
against COVID-19. For example, social distancing or keeping 1.5–2 m of distance from
another person in order to avoid their respiratory droplets, is preconized in many
countries and particularly for cancer patients. While this helps reduce their contamination,
it negatively impacts their emotions and may add to their distress. For example, in
recommendations for palliative care [6], mild pain, lower than 7/10, is not a high
priority to look at. Therefore, patients may be physically suffering while isolated.
Second, the urgent need for therapy at the hospital is an added factor of confusion
since it contradicts the preconized physical distancing [7]. Also, with the suspension
of flights during the pandemic, cancer patients who usually seek care overseas with
more advanced technologies, see their treatment plans compromised. This increases
the psychological burden on patients who are aware that the later they are getting
treated, the worse their prognosis could get. Moreover, in normal times, cancer patients
are among those who are admitted the most to the ICU, either for sepsis or respiratory
difficulties [8]. However, with COVID-19, ICUs are being overwhelmed with the raise
of patients infected with the virus [9]. The scarcity of ICU beds is forcing physicians
to choose between allocating the beds to COVID-19 patients and other patients, oncological
ones included. The news of triage where old cancer patients are less likely to be
prioritized in ICUs might have a heavy impact on patients’ morale and their will to
fight cancer. Thus, the consequences of the COVID-19 pandemic, concerning physical
contact and medical appointments, can increase the feeling of uncertainty and distress,
making it particularly important to address those issues [7].
Parts of this uncertainty, such as information related uncertainty, can be remediated
through good patient–physician communication, which might prevent the uncertainty
from turning into distress [4]. While patient–physician communication is compromised
due to isolation measures, teleoncology could offer a solution. Teleoncology, is the
use of various technologies, such as video calls (e.g., Whatsapp, Zoom, etc.) or health
applications (e.g., MyChart) that allow the oncologists to screen, diagnose, treat,
follow-up and support patients at a distance. At the beginning, it intended to reduce
disparities in the access to oncological care [10]. Over the years, many recommendations
[11] and reports have arisen. From the increase of colorectal cancer screening for
risk groups [12], to psychological behavioral therapy for breast cancer survivors
using video conferencing [13], passing by the successful remote administration of
chemotherapy [14] and the inclusion of non-small-cell lung cancer patients in multimodality
therapies’ clinical trials [15]. While teleoncology seems to hold many promises, until
the beginning of the year it was rarely used out of the context of experimentations.
With the restrictions following the course of the COVID-19 pandemic, teleoncology,
that is considered at least equivalent to physical clinical care [10], is recommended
while not neglecting ethical considerations.
The first concern with teleoncology lays in its’ accessibility. Cancer patients who
are usually older than the general population may lack the knowledge to connect to
a video consultation while patients from low-income families may lack the financial
means to do so. A second concern is that online sharing of information can jeopardize
patients’ privacy, especially in times of COVID-19, where more health data is transferred
online, thus raising the interest of hackers in physicians’ accounts. Consequently,
patients fear that information they give may reach unwanted parties.
On a brighter note, with teleoncology, patients can receive appropriate care at a
distance. In the past they had to travel long distances to get to specialized centers,
a high price to pay for personalized therapies. This did not only affect diagnosis
and treatment but the quality of life too [16]. Teleoncology reduces stressful travel,
thus eventually improving their mental health. With COVID-19 and the switch to telehealth,
the time spared from commuting between care centers, can make the oncologists keener
to actively listen and give detailed explanations to patients and involve them in
the decisional process. This creates a patient-centered communication, which is known
to positively impact survival [17]. It also provides a more comprehensive approach,
including emotional and psychological support.
Suggestions
Advice for the patients
Support groups consist of cancer patients or survivors who share their experiences
and information. They usually give nondiscriminative moral support and serve as a
shield against isolation and loneliness [4]. They remain crucial, even for patients
who do not need psychotherapy. The COVID-19 pandemic limits physical support group
meetings. Oncologists should encourage their patients to organize and attend virtual
group meetings, using video conferencing (Zoom, Skype, etc.) as soon as possible since
technical barriers are minimal.
Advice for the oncologists
Oncologists need to keep in mind that their patients might still be lacking the support
that they previously benefited from. Consequently, they need to be even more sensitive
to the concerns of their patients and the challenges those might face. Those challenges
can include distress and aspects that can lead to it, such as residual physical symptoms,
the quality of the support system around the patient and previous coping mechanisms.
We suggest two screening tools to evaluate distress and facilitate early intervention.
One is the distress thermometer that was developed by the National Comprehensive Cancer
Network [18]. The other one is the emotion thermometer developed by Hinz and colleagues
[19]. Both are free, accessible online, available in several languages and only require
a few minutes. Oncologists can thus easily administer them to the patients during
the video conference.
Finally, empathy plays an important role in the interaction between healthcare professionals
and patients. An empathic interaction requires a patient to send socio-emotional cues
to share an affective state, the physician to feel and convey empathy and the patient
to perceive this empathy. However, video consultations can cause filtering effects
that prevent the perception of those socioemotional cues, meaning that empathy might
either not be shown or simply not perceived [19]. To remediate the loss of signals
needed for an empathic interaction and thus improve the quality of telecommunication,
different strategies are immediately implementable by the oncologists in interaction
with their patients.
First, there are technicalities, such as finding a quiet place with a stable connection,
setting the webcam as close as possible to the patient's image on the screen for a
better eye contact, while also showing the whole upper body of the oncologist.
Second, to facilitate the perception of socioemotional cues of the patients, attention
should be payed to vocal tone variations and they should be encouraged to exaggerate
facial expressions. This last point is also important for the physician to show affective
resonance.
Lastly, empathy can be conveyed by matching the language style of the patient, showing
body gestures that are congruent with the affective state of the patient, maintaining
eye contact and an active posture, making positive statements and asking open questions
[20].
Conclusion
In conclusion, teleoncology is challenging from a mental health perspective. Nevertheless,
few adjustments in its presentation and modality can make it more acceptable to the
patients and teleoncology may even become a new norm in the coming years. While medical
and psychological issues are being tackled at a fast rate, the main question is whether
governments will be able to provide access to telehealth without racial, sexual, religious,
regional or economical discrimination.