Psychosocial needs and responses for breast cancer patients during COVID‐19 pandemic in a hospital of Southern Europe

As the Medical Oncology centre for Navarre (Spain) and a centre for psychosocial research, we offer our experience in managing the challenges involved in assisting breast cancer (BC) patients and describe our results in this area during the COVID‐19 pandemic. Special attention is paid to aspects of consultations, information needs, patient quality of life (QoL) and staff emotional status where our experience may be of interest.

Navarre was among the worst‐hit areas in Europe. Cumulated incidences of confirmed symptomatic cases (updated May 24) were 0.87% (PCR tests) and 1.4% (PCR or serologic tests) of the population. Sampled seroprevalence studies indicate past infection in 6.4% despite the strict lockdown in Spain declared on March 16th.

BC inpatients in our oncology ward are usually few and were even fewer during the outbreak. Most contingency planning therefore focused on outpatients.

Telemedicine was strongly advised for consultations with outpatients in specific BC guidelines during the pandemic. ¹ We therefore conducted phone consultations (mainly for follow‐up appointments) with most patients in the first days of the outbreak. However, many outpatients preferred face‐to‐face appointments, perhaps because the accessibility, confidence and support provided by these appointments were greater than fear of contagion, especially among patients with advanced disease.

Some oncologists also preferred to discontinue phone consultations after the peak of the outbreak in order to ensure information interchange between patients and professionals and adequate care for all patients with grave challenges or severe symptoms. Telemedicine was therefore conducted on a case‐by‐case basis.

The minimum distance between doctor and patient for outpatient appointments is now 1.5 m. Due to problems with communication in this setting, we broke this rule when giving bad news, explaining new treatments, or dealing with patients with visual, acoustic or communication barriers or who had severe concerns about diagnosis, prognosis and therapies. We also improved in‐room communication by incorporating whiteboards, decision aids for explaining the potential value of therapies (such as the NHS Predict tool, which shows how different treatments are expected to improve survival rates), leaflets and audiovisual materials.

Initially, accompanying persons were not allowed at outpatient appointments. However, this policy was troublesome for staff and patients and implemented only for a short time. One (sometimes two) accompanying persons were allowed provided they used face masks and practised physical distancing, since this improved support and communication with the patient.

Except with symptomatic or high‐risk women, routine physical breast examinations were reduced for outpatients due to their poor sensitivity and specificity for detecting breast relapses and to pandemic‐related safety concerns. This paradigm shift has also been described for general medicine. ² Most patients agreed with this measure, which provides more time to attend to medical and psychosocial concerns.

We identified three main information needs in patients: risk of infection, severity of disease and ability to continue treatment.

Patients and advocacy groups inquired about the impact of COVID‐19 on BC patients in our region. Spanish legislation on electronic medical records is strict, and access outside of an appointment agenda is prohibited. Our prior research on the psychosocial aspects of BC patients was therefore invaluable since we already had their legal consent to evaluate these patients, including their data on social factors, comorbidities and QoL. For example, an update on one of our previous studies on health‐related QoL in elderly (> 65 years) BC patients revealed an incidence (April 22) of COVID‐19 in 9/251 (3.5%) of these patients, most of whom were living in community accommodation, including four Catholic nuns (one of whom died) and two living in care homes. We therefore expected a low impact from the disease among home‐confined patients not living in communities.

Another aspect is the patient's need for specific, updated information about the impact of COVID‐19 on cancer patients. Good‐quality references were sometimes hard to find but immensely encouraging for our women. For instance, young BC patients expressed great relief on learning that no Italian COVID‐19 death among patients less than 40 years old had previously been diagnosed with cancer (data accessed from the Italian Istituto Superiore di Sanità, updated April 20).

Despite the rumours, and except for a brief alert about the potential shortage of midazolam for terminal sedation when used massively in overwhelmed COVID‐19 intensive care units, the supply chain for anticancer and supportive drugs remained strong during the peak of the pandemic. This information was highly appreciated by our patients.

BC patients remained committed to QoL aspects during the outbreak. For example, they were proactive towards scalp‐cooling for preventing chemotherapy‐induced alopecia, a key psychological aspect for these patients. After a brief period in which this supportive measure was suspended, we were asked to reintroduce the technique and received good patient feedback when we did so. Improved interest in QoL issues was also evident among our staff, and new clinical and research initiatives are being initiated.

Another challenge was emotional support for our staff. It seems counterintuitive, but one study has shown that oncologists on usual oncology wards displayed more distress and burnout than those displaced to specific wards for COVID‐19 assistance. ³ Our staff's reactions to the pandemic were not uniform, and rigid action protocols for oncologists were deemed unsuccessful. Our hospital chose to rely on the decisions of individual physicians on oncologic care during the outbreak, allowing them the freedom to incorporate or exclude specific points from institutional or academic guides for cancer care according to their diverse needs and situations.

Another important point in preventing burnout during the pandemic is moral injury related to impairment in decision‐making in a difficult setting. This refers to a sense of guilt and shame when breaking accepted rules that were established for taking decisions in normal conditions. Our BC tumour board meetings were suspended for 2 months, and shared multidisciplinary evaluations were even less frequent. This was an additional source of distress for some oncologists, so we are working to deploy new technologies to enable good‐quality virtual tumour boards to be held.

In conclusion, the COVID‐19 pandemic required rapid changes in relation to outpatient consultations, information and interventions for supporting patient QoL. The prevention of burnout among healthcare workers and the preservation of shared decision‐making were other major factors. Implementing these changes was sometimes challenging and success depended on specific features of our organisation, healthcare workers and patients. The prolonged elimination of face‐to‐face appointments was especially difficult to achieve. Cultural and societal values regarding interactions between the institution, physicians and patients remained strong during the pandemic. We believe this should be borne in mind when planning and implementing changes in the care of patients.

Key Points.

• Breast cancer outpatients preferred face‐to‐face appointments to telemedicine due to their positive effect on support and information interchange.

• Accompanying persons were reintroduced to consultations to improve support and communication.

• Breast cancer patients appreciated receiving reassuring information about COVID‐19.

• Quality of Life is important for breast cancer patients also during the COVID‐19 pandemic.

• Teleconferencing and flexible organisation have reduced burnout in clinicians caused by the pandemic.

ETHICS

The rules of the Servicio Navarro de Salud have been followed.

Illarramendi JJ, Arraras JI, Zarandona U. Psychosocial needs and responses for breast cancer patients during COVID‐19 pandemic in a hospital of Southern Europe. Psycho‐Oncology. 2020;29:1416–1417. 10.1002/pon.5465

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.