ABSTRACT
Background: The COVID-19 pandemic has led to disruptions in cancer treatment delivery among breast cancer patients in the U.S. However, it is currently unknown whether racial/ethnic disparities exist in cancer treatment disruptions among patients with breast cancer and SARS-CoV-2 infection. Methods: We obtained data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021) describing breast cancer patients diagnosed with SARS-CoV-2 during their care treated at 46 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, breast cancer characteristics, and modifications to cancer treatment plans. Breast cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the originally scheduled date. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, number of comorbidities, cancer extent, ECOG performance score, pandemic period based on case peaks (< 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity (death/hospitalization/ICU admission/mechanical ventilation). Results: Breast cancer patients (n = 804) with SARS-CoV-2 were mostly aged 50 years and above (75%) and urban residents (83%). The racial/ethnic makeup of the sample included: 13.3% non-Hispanic Black/African American (NH-Black), 11.7% Hispanic/Latinx, 4.9% American Indian/Alaskan Native (NH-AI/ AN), 4.6% NH-Asian, and 65% NH-White. At SARS-CoV-2 diagnosis, 736 patients (91%) were scheduled to receive drug-based therapy (78%), radiation therapy (8%), or surgery (6%), of whom 39% experienced TDD. Across treatment modalities, the most commonly reported TDD reason from the clinic perspective was the patient's COVID-19 disease (∼90%). Overall, NH-Black (62%), Hispanic/Latinx (44%), and NH-Asian (42%) adults with breast cancer and SARS-CoV-2 were more likely to experience TDD versus NH-White adults (34%) (p < 0.001). In multivariable analyses, NH-Black cancer patients were more likely to experience TDD compared to NH-White patients (aOR: 3.12, 95% CI: 1.96-5.47). The data suggest Hispanic/Latinx (aOR: 1.34, 95% CI: 0.78-2.30) breast cancer patients may also experience TDD, although not statistically significant. No association was observed among NH-Asian (aOR: 1.16, 95% CI: 0.50-2.73) or NH-AI/AN (aOR: 0.64, 95% CI: 0.28-1.52) breast cancer patients with TDD. Conclusions: Black or African American breast cancer patients are more likely to experience cancer care disruptions during the pandemic. Future research should evaluate the long-term impacts of care disruptions on breast cancer outcomes among minoritized US communities.
ABSTRACT
Background: U.S. rural cancer patients experience multifactorial barriers to cancer treatment;however, little is known about the impact of the pandemic on cancer treatment delays or discontinuations (TDD) in the rural context. Our objective was to evaluate the role of rurality at both the patient and clinic level on cancer TDD among patients living with cancer with SARS-CoV-2 infection. Methods: We used data from the ASCO Survey on COVID-19 in Oncology Registry (March 2020-July 2021), which includes cancer patients diagnosed with SARS-CoV-2 (n = 3193). Data included patient demographics, SARSCoV- 2 treatment, cancer characteristics, and modifications to cancer treatment plans. Cancer-related TDD was defined as any treatment postponed > two weeks from the original scheduled date. Rurality was defined using the USDA Rural-Urban Commuting Area schema. We compared cancer characteristics, COVID-19 outcomes, and TDD by rurality of cancer patients, and TDD by rurality of oncology practices. We computed adjusted odds ratios (aOR) using multivariable logistic regression to evaluate rurality with TDD adjusting for age, race/ethnicity, sex, comorbidities, ECOG score, cancer extent, pandemic time period based on case peaks (< 06/2020, 06-12/2020, 01-07/2021), and COVID-19 severity. Results: Rural cancer patients (n = 499, 16%) with SARS-CoV-2 were mostly over 50 years (87%), female (57%), and NH-White (81%) with solid tumors (76%). Most rural patients received oncology treatment in urban areas (65%, p < 0.001). Rural patients were less likely to receive care through telemedicine (18%) compared to urban patients (26%) (p < 0.001). At SARS-CoV-2 diagnosis, rural patients were scheduled to receive drug-based therapy (72%), radiation therapy (8%), surgery (4%), or transplant (1%). Rural versus urban cancer patients with SARS-CoV-2 were less likely to experience TDD (41% vs. 51%) (p < 0.001). Among patients treated at rural oncology clinics, urban cancer patients were more likely to experience TDD (65%) compared with rural patients (47%) (p < 0.001). Similarly, among patients treated at urban oncology clinics, urban cancer patients were also more likely to experience TDD (51%) compared with rural patients (38%) (p < 0.001). In multivariable analyses, rural cancer patients were 28% less likely to experience TDD (aOR:0.72, 95% CI: 0.55- 0.94) than urban cancer patients. Oncology practice rurality was not associated with TDD (aOR: 1.19, 95% CI: 0.81-1.76). Conclusions: Rural cancer patients were less likely to experience TDD than urban patients supporting the urban-rural paradox i.e., geographic distance to cancer care facilities is not consistently associated with treatment delivery in expected ways. Future work should focus on area-level factors of the rural cancer patient experience to disentangle potential reasons for TDD during the pandemic.
ABSTRACT
Background: Due to societal factors in the US, racial/ethnic minority adults are disproportionately impacted by the COVID-19 pandemic, particularly those with existing comorbid conditions such as cancer. It is currently unknown whether disparities exist in cancer treatment delivery among racial/ethnic minority patients with cancer and SARS-CoV-2. Methods: Data were obtained from the ASCO COVID-19 and Cancer Registry (March 2020-July 2021), including data from cancer patients diagnosed with SARS-CoV-2 during their care (n=3193) at 60 practices across the US. Data included patient demographics, SARS-CoV-2 diagnosis and treatment, cancer clinical characteristics, and modifications to cancer treatment plans. Cancer treatment delay or discontinuation (TDD) was defined as any treatment postponed more than two weeks from the original scheduled date. We descriptively evaluated demographic and clinical characteristics, compared disparities in TDD by race/ethnicity and urban/rural residency, and evaluated reasons for TDD as reported by the clinics. We computed adjusted odds ratios (aOR) using multivariable logistic regression, accounting for non-independence of patients within hospitals to evaluate racial/ethnic disparities of TDD. Multivariable models were adjusted for age, sex, body mass index, number of comorbidities, cancer type, cancer extent, cancer status at SARS-CoV-2 diagnosis (progressing/stable) and SARS-CoV-2 severity (death/hospitalization/ICU admission/mechanical ventilation). Results: Cancer patients with SARS-CoV-2were mostly female (57%), urban residents (84%), and NH-White (66%);49% were 65+ years old. Most patients had solid tumors (75%). At SARS-CoV-2 diagnosis, 2403 patients (76%) were scheduled to receive drug-based therapy (69%), radiation therapy (7%), surgery (4%), or transplant (0.7%), of whom 49% experienced TDD. The most reported TDD reason from the clinic perspective was the patient's COVID-19 disease (90%). Overall, NH-Black (64%) and Hispanic (57%) with SARS-CoV-2 were more likely to experience TDD versus NH-White adults (46%) (p<0.001). This disparity was also observed across urban residing adults (p<0.001). Among rural adults, NH-AI/AN (75%) and NH-Black (61%) were more likely to experience TDD versus NH-White patients (39%). In multivariable analyses, disparities persisted, by NH-Black cancer patients with 92% (aOR:1.92, 95% CI:1.24-2.96) and Hispanic patients with 41% (aOR:1.41, 95% CI:1.03-1.91) higher odds of experiencing TDD. We observed consistent results among urban and rural subgroups. Conclusion: Racial/ethnic disparities exist in TDD among cancer patients with SARS-CoV-2 in urban and rural care settings. Future studies should evaluate the impacts of delays to cancer treatment delivery on cancer outcomes among minoritized communities in the US.
ABSTRACT
Background: Food insecurity can negatively impact adherence to and receipt of high-quality cancer care. The purpose of the study was to (1) compare the prevalence of COVID-19 associated food insecurity among cancer survivors to adults without a history of cancer and (2) examine determinants associated with COVID-19 related food insecurity among cancer survivors. Methods: We used nationally-representative data from the COVID-19 Household Impact Survey (n = 10,760), collected at three time points: April 20-26, May 4-10, and May 30-June 8 of 2020. Our primary exposure was cancer survivor status, based on participant's self-report of a cancer diagnosis (n=854, 7.1%). Primary outcomes of food insecurity were categorized on how often (response options: often true, sometimes true, never true) participants reported the following: “We worried our food would run out before we got money to buy more” or “The food that we bought just didn't last, and we didn't have money to get more”;respondents were categorized as food insecure if they chose often true or sometimes true. We also examined use of food pantry assistance or Supplemental Nutrition Assistance Program benefits during the pandemic period;respondents were also categorized as food insecure if they received or applied for these benefits. We compared reported food insecurity among cancer survivors to other U.S. adults using Chi-square tests. Multivariable Poisson regression was used to identify demographic determinants of food insecurity among cancer survivors. Results: Thirty-two percent of cancer survivors were food insecure. Cancer survivors aged 30-44 years and those aged ≥60 were more likely to report being food insecure compared to respondents without a history of cancer in the same age categories (30-44 years, 59.9% versus 41.2% p = 0.01, ≥60 years 27.2% versus 20.2%, p = 0.01). Cancer survivors without a high school diploma were more likely to report food insecurity compared to adults without a high school diploma and no history of cancer (87.0% versus 64.1%, p = 0.001). In examining determinants of food insecurity among cancer survivors, adults aged 45-49 years when compared to those ages ≥60 (aPR = 1.54, 95% CI 1.16-2.03), adults with no high school diploma (aPR = 2.63, 95% CI 1.53-4.50) or a high school degree (aPR = 1.94, 95% CI 1.08-3.49) compared to those with a baccalaureate or above, adults with an annual household income <$30,000 (aPR: 2.16, 95% CI: 1.15-4.07) compared to those earning ≥$100,000, and cancer survivors in rural areas (aPR = 1.51, 95% CI 1.07-2.12) compared those living in urban areas were more likely to report being food insecure. Uninsured cancer survivors (aPR: 2.39, 95% CI: 1.46-3.92) and those on Medicaid (aPR: 2.10, 95% CI: 1.40-3.17) were more likely to report being food insecure than their counterparts. Conclusions: Food insecurity during the COVID-19 pandemic is vast but varies considerably among cancer survivors and adults without a history of cancer. Among cancer survivors, differences in food insecurity were observed by age, SES, and area of residence.
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Background: Cancer survivors often experience financial hardship due to high costs associated with cancer treatment. Our objective was to (1) identify determinants of financial hardship, and to (2) evaluate the impact of financial hardship on mental health symptoms among cancer survivors during the COVID-19 pandemic. Methods: We used nationally representative data from the COVID-19 Household Impact Survey collected at three-time points: April 20-26, May 4-10, and May 30th -June 8 th of 2020. Our primary exposure was cancer survivor status, based on participant's self-report of a cancer diagnosis (n=854, 7.1%). We defined financial hardship using the following question: “Suppose you have an unexpected expense that costs $400. Based on your current financial situation, how would you pay for this expense?” Respondents were categorized as experiencing financial hardship if they chose the following options: I wouldn't be able to pay for it right now;sell something;use a payday loan, deposit advance, or overdraft;borrow from a friend or family member. Chi-square (χ2 ) tests were used to compare reported financial hardship among cancer survivors to other U.S. adults. Multivariable Poisson regression was used to identify determinants of financial hardship among cancer survivors. We used multinomial logistic regression to evaluate associations of financial hardship on mental health symptoms of cancer survivors. Results: Eighteen percent of cancer survivors reported experiencing financial hardship. Cancer survivors aged 30-44 (44.8%) and 45-59 years (25.9%) more frequently reported financial hardship compared to adults without cancer (23.4%, 16.7%, respectively, χ2p<0.05). Compared to cancer survivors aged 60+ years, those aged 18-29 (aPR: 2.54, 95% CI;1.51-4.28), 30-44 (aPR:3.41, 95% CI:2.26-5.16), and 45-59 years (aPR:3.66, 95% CI:2.26-5.16) were more likely to experience financial hardship. Cancer survivors on Medicaid (aPR: 1.76, 95% CI: 1.16-2.66) were more likely to experience financial hardship compared to their counterparts. Compared to those without a high school degree, cancer survivors with some college education (aPR: 0.30, 95% CI: 0.18-0.47) and with a ≥Baccalaureate degree (aPR:0.05, 95% CI: 0.02- 0.14) were less likely to experience financial hardship. Rural cancer survivors had 61% higher prevalence of financial hardship compared to urban residents (aPR: 1.61, 95% CI:1.00-2.58), however, suburban residents were less likely to experience financial hardship compared to cancer survivors living in urban areas (aPR: 0.65, 95% CI:0.44-0.98). Cancer survivors who experienced financial hardship were more likely to report feeling depressed (aOR: 2.78, 95% CI: 1.39-5.56), lonely (aOR: 3.06, 95% CI: 1.39-6.72), and hopeless (aOR: 3.16, 95% CI: 1.36-7.37) 3-7 days during the last 7 days. Conclusion: Lower SES measures and younger age were determinants of experiencing financial hardship among cancer survivors. During the COVID-19 pandemic, there is a high burden of mental health symptoms among cancer survivors experiencing financial hardship.
ABSTRACT
Background: The use of medical cannabis represents an opportunity to improve access to equitable cancer treatment among minoritized populations who frequently face barriers to traditional palliative care options or mental health treatments. Poor mental health among cancer survivors is of concern as it reduces adherence to cancer survivorship treatment and can reduce overall survival. The COVID-19 pandemic has highlighted the importance of access to palliative care due to the increase of mental health symptoms among cancer survivors. Despite the potential benefits of medicinal cannabis, data describing the use of cannabis to manage mental health symptoms among cancer survivors is limited, particularly in the context of the COVID-19 pandemic. Objective: Our objective was to examine the prevalence of mental health symptoms and the behavioral impacts of the COVID-19 pandemic on cancer survivors who endorse cannabis use. Methods: Our participants included adults (≥18 years) who self-reported medicinal cannabis use and responded to our internet-based questionnaire (03/21/2020-03/24/2021). Overall, we received 3,594 responses. For this study, data included 158 participants including 79 cancer survivors (2.2%) along with age-matched medicinal cannabis users without a history of cancer (N = 79). Descriptive statistics were used to compare demographic characteristics, prevalence of generalized anxiety (GAD-7), and depression (CES-D-10), changes in behavior during the COVID-19 pandemic, and self-reported coping mechanisms by cancer survivorship status. Results: Overall, 61% and 48% of cancer survivors self-reported to use medicinal cannabis to manage their anxiety and depression, respectively. Additionally, 54% of cancer survivors reported cannabis use to manage their chronic pain. Probable clinical depression (CES-D-10 score ≥ 10) and anxiety (GAD-7 score ≥ 10) were identified in 50.7% and 38.9% of cancer survivors, respectively. Cancer survivors were more likely to report that their anxiety symptoms made it very or extremely difficult to work, take care of things at home, or get along with other people (23.0% vs. 11.8%, p = 0.015) than adults without a history of cancer. Pandemic-related coping mechanisms frequently reported by cancer survivors with anxiety or depression included more sleep (47.5%), practicing meditation/mindfulness (47.5%), physical activity (47.5%), talking to family and friends (42.5%), overeating or stress-eating (25.0%), and using more cannabis (25.0%). Cancer survivors with anxiety and depression reported to be more likely to fear giving COVID-19 to someone else (47.5% vs. 23.1%, p=0.023) and to fear being diagnosed with COVID-19 (77.5% vs. 38.5%, p<0.001) compared to cancer survivors without mental health conditions. Conclusion: Given the prevalence of anxiety and depression symptoms reported among cancer survivors and their use of cannabis, further research is recommended to evaluate its use as palliative care to improve mental health and quality of life among cancer survivors.
ABSTRACT
Introduction: The COVID-19 pandemic has affected the mental health of adults in the United States (U.S.) due to recommended preventive behaviors such as social distancing. Our objective was to evaluate mental health symptoms and determinants of mental health symptoms among cancer survivors during the COVID-19 pandemic in the U.S. Methods: We used nationally-representative data of 10,760 U.S. adults from the COVID-19 Impact Survey. We defined cancer survivors as a self-reported diagnosis of cancer (n 854, 7.6%). We estimated the association of mental health symptoms among cancer survivors using multinomial logistic regression and calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). We estimated determinants of experiencing at least one mental health symptom 3-7 times in the last seven days among cancer survivors using Poisson regression models to estimated adjusted prevalence ratios (aPR) and 95% CI. Results: Most cancer survivors were over the age of 60 (65%), NH-White (74%), female (52%), and married or living with a partner (57%). Among cancer survivors who spoke to their neighbors basically every day prior to the start of the COVID-19 pandemic, 62% continued this behavior, and 34% reported to speak to their neighbors only a few times a week in the last month. Among cancer survivors, 16% felt depressed, 14% felt lonely, and 13% felt hopeless about the future in the last seven days. Cancer survivors were more likely to report feeling nervous, anxious or on edge (aOR:1.42, 95% CI: 1,07-1.90), depressed (aOR:1.69, 95% CI: 1.28-2.24), lonely (aOR:1.47, 95% CI: 1.09-1.98), and hopeless (aOR:1.55, 95% CI: 1.14-2.10) 3-7 days per week in the last seven days when compared to adults without cancer. Among cancer survivors, adults aged 30-44 years (aPR: 1.87, 95% CI: 1.18-2.95), females (aPR:1.55, 95% CI: 1.12-2.13), without a high school degree (aOR: 1.79, 95% CI;1.05-3.04), and adults with limited social interaction (aPR:1.40, 95% CI: 1.01-1.95) were more likely to experience mental health symptoms 3-7 days/week in the last week. Conclusions: Cancer survivors are experiencing mental health symptoms during the COVID-19 pandemic, particularly young adults, adults without a high school degree, females, and survivors with limited social support.
ABSTRACT
Background: Cancer survivors are at high risk of contracting severe acute respiratory syndrome coronavirus 2(SARS-CoV-2), the infection that leads to COVID-19, as they are generally older and cancer therapies frequentlylead to immunosuppression. Recently, to mitigate exposure the CDC recommended avoiding nonessential doctorappointments, which may lead to barriers in effective continuity of care and surveillance of cancer survivors duringthe COVID-19 pandemic. The patterns of COVID-19 preventive behaviors practiced by cancer survivors areunknown, including practices related to canceling doctors' appointments. Objective: Our objective was to evaluate COVID-19-related preventive behaviors among cancer survivors in theUnited States (US). We further examined behaviors related to canceling or postponing activities, specifically doctors'appointments. Methods: We utilized nationally representative weighted data from a sample of 4,428 US adults from the COVID-19Impact Survey collected during Week 1 (April 20-26, 2020) and Week (May 4-10, 2020). We defined cancersurvivors as those with a self-reported prior diagnosis of cancer. We presented frequencies and used χ2 tests tocompare COVID-19-related preventive behaviors among cancer survivors to other adults. We calculated prevalenceratios with 95% confidence intervals using Poisson regression and robust estimation of standard errors to estimatedeterminants of canceling doctors' appointments among cancer survivors. Results: Cancer survivors were mostly over the age of 60 years (62%), female (53%), non-Hispanic White (62%), and resided in urban areas (72%). Cancer survivors adhered to most recommended COVID-19-related preventivebehaviors and were more likely to maintain social distancing (92%, χ2 p-value=0.005), wear a face mask (89%, χ2p-value=0.001), and avoid crowded areas (84%, χ2 p-value=0.048) compared to other adults. Additionally, we foundthat cancer survivors are more likely to cancel their doctors' appointments (44%, χ2 p-value=0.001) whereas they were less likely to cancel other social activities such as work (20%, χ2 p-value=0.001) and school-related (12%, χ2p-value=0.002) activities, even among those below the age of 60. However, cancer survivors were more likely toreport symptoms in the last 7 days, including muscle or body aches (χ2 p-value=0.003). The proportion of cancerpatients who have canceled doctors' appointments due to COVID-19 rose from the month of April (35%) to May(52%). Younger adults aged 18-29 years, females, and rural cancer survivors were more likely to cancel theirdoctors' appointments, whereas NH-Blacks are less likely to cancel a doctor's appointment when compared to NH-Whites. Conclusion: Cancer survivors are adhering to recommended preventive behaviors. Cancer survivors' continuity ofcare may be impacted by COVID-19, specifically young adults, females, and rural residents.