Emotional Distress During the COVID-19 Pandemic: Psycho-Oncology Perspective

July 15, 2020

ABSTRACT Patients with cancer represent a vulnerable population and are at greater risk of developing serious complications as a result of a COVID-19 infection. In response, oncology societies around the world have proposed changes to their standards of care. These changes have helped guide health care providers in prioritizing clinical management of patients with cancer: identifying situations in which urgent intervention is needed and those that can be triaged until the risk of infection has lessened.

The Quandary

The headline “U.S. Deaths Near 100,000, an Incalculable Loss” ran across the front page of TheNew York Times on May 24, 2020, reflecting the ongoing coronavirus disease 2019 (COVID-19) pandemic and the biggest global health crisis faced in our lifetimes. The first symptoms were noted among a group of individuals in China in December 2019,1 with similar cases rapidly appearing in succession throughout the world. On March 11, 2020, the World Health Organization declared COVID-19 to be a pandemic, a crisis that has fundamentally changed the way we live and interact with others, as well as the care we provide for those who are ill.2

Patients with cancer represent a vulnerable population and are at greater risk of developing serious complications as a result of a COVID-19 infection.3-5 In response, oncology societies around the world have proposed changes to their standards of care. These changes have helped guide health care providers in prioritizing clinical management of patients with cancer: identifying situations in which urgent intervention is needed and those that can be triaged until the risk of infection has lessened.

Notably, while these precautions are necessary to protect our patients, COVID-19 has also dramatically impacted the way in which patients and caregivers perceive their own health status; increased their feelings of fear, panic, vulnerability and loss of control; and isolated them from family, friends, and health care providers. Social relations play a critical role in mental health and emotional well-being; indeed, loneliness has been recognized as a risk factor for all causes of morbidity and mortality.6-7 Unfortunately, the psychosocial needs among patients with cancer and COVID-19 remain poorly documented.

Patients fear not only the possibility of contracting COVID-19, but the potential that this pandemic may impact their ability to receive timely care and their ability to access important sources of social and professional support. The pandemic has drastically impacted cancer care. Patients are socially isolated and restricted with regard to their ability to access informal and formal sources of support. These dramatic changes have resulted in fewer patients being enrolled to clinical trials; in more clinic visits and treatments delayed or canceled out of caution; and in many patients hospitalized, or at the end of their life, being alone and isolated. Patients are even experiencing some changes in the way they must report their symptoms, considering that they are presenting less to the hospital.

These changes, and the vulnerability and isolation they have brought with them, will have an enduring impact on those with conditions that place them at higher risk of contracting COVID-19. As a result, psycho-oncology must seek alternative ways in which to identify patients in need, to whom we can provide our services during these unprecedented times and beyond. Clinics around the world have been forced to rapidly re-engineer how they support their patients and help them manage their emotional well-being.

In view of this current reality, how can the field of psycho-oncology contribute to patient care during this pandemic?

A. Virtual screening

B. Remote care

C. Routine follow-up

D. All of the above

The correct answer is

D. All of the above.

Virtual Screening

For more than 20 years, psycho-oncology experts have advocated for distress screening programs to be integrated into routine oncology care, enabling unmet needs to be identified and treated.8 This simple strategy has enabled health care providers to identify the prevalence of distress and most common associated domains (eg, physical, practical, social/familiar) among patients and caregivers during the continuum of cancer care, and to develop psychosocial interventions and programs to mitigate some of these symptoms. However, these programs and support services have often been built around in-person clinic visits and in-person counseling; they need to rapidly adapt to our current circumstances.

Remote screening must now be adopted to identify patients in need of help. Yet barriers exist to such planning; not all programs are electronically based and easily convertible to remote screening, and many patients lack access to the internet or to appropriate devices. Still, many studies have demonstrated the benefit of using electronic devices, phone apps, or internet-based programs to access these patients remotely. The implementation of remote screening can be an integral part of high-quality care, used as a strategy for automated algorithms that can systematize care pathways in real-time, facilitating symptom management and optimizing resources available in each institution and within communities.9-11

Remote Care

Furthermore, we must develop new interventions appropriate to the COVID-19 era and utilize existing online behavioral interventions to the greatest degree possible. The current literature includes resources that potentially could be adapted in these circumstances, including mindfulness programs and those focused on reducing fears of cancer recurrence/progression.12-14 Some of these programs are available without cost during the COVID-19 pandemic, including, for example, the Am Mindfulness app (https://www.midigitaltherapeutics.com/am-mindfulness.html) and the guided meditation and yoga videos offered by the integrative medicine department at Memorial Sloan Kettering Cancer Center in New York.15 Also, beyond finding ways to assist our patients during this time of isolation and fear, we must also prepare for an influx of mental health care needs that are likely to arise once health care services are able to resume some degree of normalcy and the true impact of this pandemic is fully realized.

Routine Follow-Up

Given the current state of oncologic care, routine follow-up discussions and efficient communication among patients, caregivers, and health care professionals are critical in easing concerns and anxiety. Psycho-oncologists can be integral to these broader relationships, helping to address barriers to care, exploring alternatives to attenuate biopsychosocial distress, addressing patient needs, and ensuring that patients feel heard by and connected to their care team during this stressful time. Further, through routine follow-up, psycho-oncologists can help ensure that patients and caregivers understand and communicate their treatment preferences. They can offer tips on managing general distress, including fear and uncertainty, and contribute to shared decision making during this pandemic.


1. Bogoch II, Watts A, Thomas-Bachli A, et al. Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel. J Travel Med. 2020;27(2):taaa008. doi:10.1093/jtm/taaa008

2.WHO director-general’s opening remarks at the media briefing on COVID-19 - 11 March 2020. World Health Organization. March 11, 2020.Accessed June 30, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020

3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062. doi:10.1016/S0140-6736(20)30566-3. Published corrections appear in Lancet. 2020;395(10229):1038. doi:10.1016/S0140-6736(20)30606-1 and Lancet. 2020;395(10229):1038. doi:10.1016/S0140-6736(20)30638-3

4. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. doi:10.1016/S1470-2045(20)30096-6

5. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China. Published online March 25, 2020. JAMA Oncol. doi:10.1001/jamaoncol.2020.0980

6. Andersson L. Loneliness research and interventions: a review of the literature. Aging Ment Health. 1998;2(4):264-274. doi:10.1080/13607869856506

7. Cacioppo JT, Hawkley LC, Norman GJ, Berntson GG. Social isolation. Ann N Y Acad Sci. 2011;1231(1):17-22. doi:10.1111/j.1749-6632.2011.06028.x

8. Bultz BD, Johansen C. Screening for distress, the 6th vital sign: where are we, and where are we going? Psychooncology. 2011;20(6):569‐571. doi:10.1002/pon.1986

9. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):197-198. doi:10.1001/jama.2017.7156

10. Girgis A, Durcinoska I, Koh E-S, et al; PROMPT-Care Pathways Working Group. Development of health pathways to standardize cancer care pathways informed by patient-reported outcomes and clinical practice guidelines. JCO Clin Cancer Inform. 2018;2:1‐13. doi:10.1200/CCI.18.00024

11. Hurria A, Akiba C, Kim J, et al. Reliability, validity, and feasibility of a computer-based geriatric assessment for older adults with cancer. J Oncol Pract. 2016;12(12):e1025‐e1034. doi:10.1200/JOP.2016.013136

12. Carlson LE, Subnis UB, Piedalue KL, et al. The ONE-MIND Study: rationale and protocol for assessing the effects of ONlinE MINDfulness-based cancer recovery for the prevention of fatigue and other common side effects during chemotherapy. Eur J Cancer Care (Engl). 2019;28(4):e13074. doi:10.1111/ecc.13074

13. Carlson LE, Zelinski EL, Speca M, et al. Protocol for the MATCH study (Mindfulness and Tai Chi for cancer health): a preference-based multi-site randomized comparative effectiveness trial (CET) of mindfulness-based cancer recovery (MBCR) vs. tai chi/qigong (TCQ) for cancer survivors. Contemp Clin Trials. 2017;59:64‐76. doi:10.1016/j.cct.2017.05.015

14. Butow PN, Turner J, Gilchrist J, et al. Randomized trial of ConquerFear: a novel, theoretically based psychosocial intervention for fear of cancer recurrence. J Clin Oncol. 2017;35(36):4066‐4077. doi:10.1200/JCO.2017.73.1257

15. Meditations. Memorial Sloan Kettering Cancer Center. Accesed June 30, 2020. https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/multimedia/meditations

FINANCIAL DISCLOSURE: The authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

Cristiane Decat Bergerot, PhD Centro de Câncer de Brasília, SMH/N Quadra 02 Bl. A – Ed de Clínicas – 12º, Andar, Brasília, DF, Brazil 70.710-100, Email: crisbergerot@gmail.com
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