ONCOLOGY LETTERS 20: 441-447, 2020

Oncology during the COVID‑19 pandemic: challenges, dilemmas

and the psychosocial impact on cancer patients (Review)
Konstantinos Tsamakis1,2, Maria Gavriatopoulou3, Dimitrios Schizas4,
Athina Stravodimou5, Aikaterini Mougkou6, Dimitrios Tsiptsios7,
Vasileios Sioulas8, Eleftherios Spartalis9, Athanasios D. Sioulas10,
Charalampos Tsamakis11, Nikolaos Charalampakis12, Christoph Mueller2,13,
Donna Arya14, Paul Zarogoulidis15, Demetrios A. Spandidos16,
Meletios A. Dimopoulos17, Charalabos Papageorgiou18 and Emmanouil Rizos1

1
Second Department of Psychiatry, University of Athens, ‘ATTIKON’ University Hospital, 12462 Athens, Greece;
2
King's College London, Institute of Psychiatry, Psychology and Neuroscience, London SE5 8AF, UK;
3
Department of Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens;
4
First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens,
Greece; 5Department of Oncology, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital,
CH‑1011 Lausanne, Switzerland; 6Paediatric Infectious Diseases Dept, Karolinska University Hospital, 171 77 Stockholm,
Sweden; 7Department of Neurophysiology, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR47TP, UK;
8
Department of Gynaecologic Oncology MITERA Hospital, 15123 Athens; 92nd Department of Propaedeutic Surgery,
National and Kapodistrian University of Athens School of Medicine, 11527 Athens; 10Gastroenterology Department,
Hygeia Hospital, 15123 Athens, Greece; 11Department of Dermatology, Luton and Dunstable University Hospital,
Bedfordshire Hospitals NHS Foundation Trust, Luton LU4 0DZ, UK; 12Department of Medical Oncology,
Metaxa Cancer Hospital, Pireas, 18537 Athens, Greece; 13South London and Maudsley NHS Foundation Trust,
London SE5 8AZ; 14Thornford Park, Elysium Healthcare, Berkshire RG19 8ET, UK; 153rd Department of Surgery,
‘AHEPA’ University Hospital, Aristotle University of Thessaloniki, Medical School, 54621 Thessaloniki;
16
Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion;
17
Hematology and Medical Oncology, Department of Clinical Therapeutics, National and
Kapodistrian University of Athens, School of Medicine, 11527 Athens; 18First Department of
Psychiatry, University of Athens, ‘Eginition’ Hospital, 11528 Athens, Greece

Received April 13, 2020; Accepted May 8, 2020

DOI: 10.3892/ol.2020.11599

Abstract. COVID‑19 has caused unprecedented societal cancers in the COVID‑19 era and have reviewed the emerging
turmoil, triggering a rapid, still ongoing, transformation of literature around barriers to care of oncology patients and
healthcare provision on a global level. In this new landscape, how this crisis affects them. Moreover, evolving treatment
it is highly important to acknowledge the challenges this strategies and novel ways of addressing the needs of oncology
pandemic poses on the care of the particularly vulnerable patients in the new context of the pandemic are discussed.
cancer patients and the subsequent psychosocial impact on
them. We have outlined our clinical experience in managing
patients with gastrointestinal, hematological, gynaecological, Contents
dermatological, neurological, thyroid, lung and paediatric
1. Introduction
2. Oncology care in general
3. Challenges in managing specific types of cancers
4. Conclusions
Correspondence to: Dr Konstantinos Tsamakis, Second Department
of Psychiatry, University of Athens, ‘ATTIKON’ University Hospital,
Rimini 1, Chaidari, 12462 Athens, Greece
E‑mail: [email protected] 1. Introduction

Key words: COVID‑19, pandemic, SARS‑Cov‑2, cancer, oncology, Since December 2019 the COVID‑19 pandemic has affected
care, challenges, psychosocial impact, patients, telemedicine all aspects of our lives worldwide. This unparalleled health
crisis (1), for which no healthcare system was fully prepared, has
442 tsamakis et al: Psychosocial impact of COVId-19 pandemic

caused a tremendous strain in healthcare services (2), affecting perceived uncertainty increases individual emotional distress,
directly and indirectly the course and treatment of many and this, in turn, has negative effects on clinical outcomes in
common illnesses (3). Oncology patients have been particu- cancer patients (20‑22).
larly affected, since they are regarded a highly vulnerable
group in the current pandemic, due to their immunocompro- Altering treatments and guidelines. Oncology societies and
mised status caused by both cancer and various anticancer national authorities have been quick to issue guidelines on
treatments (4,5). Data from China and Italy show that the case cancer care during the pandemic. The prioritization in the
fatality (defined as the number of deaths in COVID‑19 posi- delivery of cancer therapies is strongly influenced by both
tive patients, divided by the number of those tested positive) is the magnitude of potential treatment benefits and therapeutic
significantly higher in patients with cancer than those without intent, while patient‑level factors such as age, comorbidities, and
(6 vs. 2%) (6,7). In addition, two recent studies demonstrated patient preferences have to be considered in the general frame-
that patients with cancer are at an increased risk of more work (23). Strategies such as reducing the number of clinical
severe infection and subsequent complications, particularly visits, shortening radiotherapy fractionation, converting intra-
if surgery or chemotherapy are performed within the month venous to oral systemic therapy, and even stopping or reducing
preceding SARS‑Cov‑2, while an underlying cancer diagnosis the frequency of selected maintenance treatments have been
is associated with an increased risk of death and/or intensive implemented in most of the oncology clinics.
care unit (ICU) admission (8,9).
Although the benefits of cancer therapies remain the same Addressing patients' needs. Addressing the concerns of
in the current crisis, the risks have increased substantially, patients poses another challenge to the oncology institutes.
warranting careful reconsideration of clinical practices (10). During this crisis, ensuring the well‑being of the patients and
As such, the COVID‑19 pandemic has significantly altered caregivers, providing a safe environment and effective and
cancer patient management (11) as evidenced by local (12), compassionate care are more important than ever. Patients have
national (13), European (14) and American (15) guidelines or been encouraged to explore creative ways to cope with stress,
recommendations that have been recently published. including physical activity, a balanced diet, adequate sleep,
The present review explores the challenges to Oncology mindful‑based strategies, avoiding overload of information
care that these new changes generate, and the subsequent and social connectedness. Additional support through mental
psychosocial impact this has on cancer patients. health services should be available if the aforementioned
measures are not sufficient. Virtual community and patient
2. Oncology care in general support groups can be excellent sources of encouragement and
support, both for oncology patients and their caregivers (24).
New realities. In this new landscape, the cancer community is
steering a difficult course amid several challenges: revisiting Communication, remote care and e‑Health. In this turmoil,
optimal standards of cancer care, facing persistently evolving better and efficient communication between oncologists and
shortages and acknowledging the paradoxical need to keep their patients is of utmost priority. Telemedicine has been used
patients away from health care facilities. An ongoing chal- by oncologists and patients with a positive experience in both
lenge is balancing the risk of admission to the hospital with the groups (25,26). Although its effectiveness at reducing the spread
possible risk of a SARS Cov 2 infection, which has an emotional of infection and improving outcomes is not yet proven (27),
impact not only on patients, but also on medical staff. Clinicians it increases access to care. Interacting with patients via tele-
are under intense pressure and scrutiny during the COVID‑19 medicine and providing useful advice both on somatic and
pandemic, with oncology physicians particularly pressured, as mental matters could help avoid non‑essential admissions to
they are facing several ethical dilemmas, as well as physical hospital (28). Telemedicine is also used by onco‑psychologists
isolation from friends and family, increased risk of disease and onco‑psychiatrists to guarantee psychological support for
transmission, clinical challenges and competing demands (16). individual patients, while limiting visits to the cancer institute.
In response to cancer patients' increased need of efficient
Psychological impact on patients. Patients themselves have and helpful communication, also highlighted by cancer patient
been deeply affected by the new realities; in particular by the groups, the websites of most cancer institutes have added a
knowledge of the higher risk of serious complications if infected regularly updated question‑and‑answer COVID‑19 section,
by SARS‑Cov‑2 and the underlying fear of how the potential whilst social media campaigns and press releases offer addi-
healthcare‑capacity issues will interfere with the optimal treat- tional channels to reach out to patients. In particular, the use
ment of their disease. COVID‑19 can trigger anxiety and distress, of social media could help overcome certain barriers posed
which may be of increased intensity in vulnerable patient groups, by the COVID‑19 pandemic, as previous experience in cancer
such as the oncology patients. Cancer patients feel isolated and patients shows that social media use had a positive impact
can even experience emotions of guilt if their family provides on psychosocial health outcomes, e.g., larger social support
help with daily living activities, which can be opposed to the networks were associated with better prognosis after breast
recommended social distancing (26). Quarantine, a common cancer treatment. More specifically, a study by Shim et al
reality during the COVID‑19 pandemic, may precipitate anxiety, found that those who disclosed personal insights about breast
irritability and depression, especially when implemented for cancer in an online support group experienced higher health
prolonged periods (17). The social isolation and the need to ‘stay self‑efficacy and emotional and functional well-being (29),
at home’ cause loneliness, which is associated with a higher risk while users of a Twitter breast cancer support group also
of mortality in cancer patients (18,19). It is well documented that reported decreased anxiety after tweet chats (30).
 ONCOLOGY LETTERS 20: 441-447, 2020 443

Additional virtual care tools, such as webinars, can also be patients before admission undergo ‘COVID‑19 screening’ with
used to support patients. Although synchronous (e.g., ‘Zoom body temperature, O2 saturation, C‑reactive protein, SGOT,
groups’) and asynchronous (e.g., Facebook) cancer specific SGPT levels, complete cell blood count, chest radiography,
groups may be viable options, it is essential to consider issues pharyngeal SARS‑CoV‑2 swab and a thorough interview. This
of privacy and credibility of information shared. The rapid has resulted in the treatment of a high volume of COVID‑19
need for implementation of virtual care during the COVID‑19 negative patients and high levels of patient satisfaction (35)
pandemic will necessitate further research to help improve our In places where COVID‑19 free centers are not available,
understanding of e‑Health effectiveness in cancer patients. current management is based on triage. Telephone or video
visits are utilized in order to assess routine follow‑ups and
3. Challenges in managing specific types of cancers management of asymptomatic benign or low‑grade tumors is
postponed until a safer time, whereas malignant tumors and
Haematological cancer patients. COVID‑19 is expected to be emergency cases are treated as in the pre‑COVID‑19 era. In
a devastating infection in many patients with solid tumours and order to avoid occupational exposure all patients requiring
hematologic malignancies due to older age, comorbidities and surgery should undergo ‘COVID‑19 screening’. If they are
immunocompromised status and therefore should be managed COVID‑19 positive they need to be transferred to dedicated
appropriately without jeopardizing the curative chance of these COVID‑19 hospitals or wards where appropriate personal
patients. In the COVID‑19 oncology era, difficult clinical deci- protective equipment for health care professionals, as well as
sions regarding delay or initiation of chemotherapy need to be negative pressure operating rooms (ORs) and corresponding
carefully evaluated. Adjuvant therapy with curative objective ICU are available (36).
should proceed during the pandemic, while for metastatic For patients undergoing chemotherapy conservative dosing
disease, any delays might lead to further progression and is recommended in order to avoid immunosuppression. If viral
ineligibility for further treatment (31). The American Society of symptoms occur patients should be immediately tested for
Clinical Oncology recommends rescheduling routine follow‑up SARS‑CoV‑2 and in case of positivity chemotherapy should
visits of patients that are not currently receiving treatment. be held until the patient fully recovers from the infection.
Home collection of lab samples should be considered to avoid Risks and benefits of therapy should then be re‑evaluated (37),
additional visits to the clinic (32). If possible, it is considered however, in some centers two negative SARS‑CoV‑2 tests
reasonable to delay highly immunosuppressive treatment are required before re‑initiation of chemotherapy. Finally,
strategies such as allogeneic or autologous stem cell transplan- concerning radiation therapy, strict institutional policies are
tation (33). Chemotherapy protocols are being revised in order required in order to guarantee patient and health care workers'
to minimize frequency of visits and depth of immunosuppres- safety, as daily hospital visits are needed. In patients with
sion. Oral regimens should be preferred, especially for elderly suspected or confirmed SARS‑CoV‑2 infection radiotherapy
and frail patients. Watchful waiting should be considered for can be either withheld, or continue as long as their disease
patients with asymptomatic and slow progressions. is mild and the radiation facility has measures in place that
Another challenge is that patients under cytoreductive treat- prevent potential spread to other patients and staff. On the
ment or immunotherapy, as well as patients with lung cancer other hand, in cases with significant viral symptoms, treatment
or metastatic lesions, might present with symptoms similar to should be halted and resumed only after patient recovery (38).
COVID‑19, either due to other infectious diseases or to the
underlying malignancy. Therefore, it is of utmost importance Gastrointestinal (GI) cancer patients. Gastrointestinal (GI)
to educate cancer patients accordingly and evaluate them in the cancer is a very serious condition and the recent COVID‑19
most appropriate way. Patients need to be informed regarding outbreak is an additional obstacle in the management of such
the symptoms of COVID‑19, trained in proper hand washing patients. Of note, 1% of all patients who contracted COVID‑19
hygiene and guided on using personal protective equipment had a history of cancer. In addition, a previous history of
whenever they go out in public places or the hospital. cancer has been associated with an increased risk of morbidity
and mortality following SARS‑CoV‑2 infection, which has
Neurological cancer patients. Apart from social isolation and caused considerable distress among GI cancer patients (39).
physical distancing resulting in anxiety and distress, the quality The fear of spread of this novel disease, alongside the effort
of life of patients with brain tumors, who often have to travel to to preserve hospital resources, including ventilators, personal
hospitals in endemic areas, is significantly affected by the fear protective equipment (PPE), critical care resources, and blood
of facing this pandemic with an immune system that is signifi- products, has led many institutions to limit or postpone elective
cantly weakened by their disease, steroids, radiotherapy or cancer procedures and cancel outpatient clinics. Lockdown and
chemotherapy (34). Neuro‑oncologists and neurosurgeons not disruptions in transportation have made access to diagnostic
only face the ethical dilemma of treating their immunocompro- procedures, such as biopsies difficult. Consequently cancer
mised patients at the same hospital as COVID‑19 patients, but patients are experiencing an unexpected delay in diagnosis,
also realize that they cannot effectively deliver their services, staging and cancer therapy, causing a further psychological
as most neurosurgical oncology cases demand ICU admission burden (28) which is aggravated by the ‘combined’ fear of
in the early postoperative period. This is often impossible, as both cancer and COVID‑19 (40). Depression rates appear
ICUs prioritize and reserve capacity for COVID‑19 patients. In to have increased in GI cancer patients, as the relationship
a highly endemic area, such as Lombardy, Italy, these difficul- with their treating clinician has become more limited due to
ties have been effectively addressed by designating a regional quarantine and social distancing and support from relatives is
dedicated COVID‑19 free neuro‑oncology center where all missing (41).
444 tsamakis et al: Psychosocial impact of COVId-19 pandemic

The new reality has forced the medical community to or immunotherapy in an adjuvant or palliative setting (49).
prioritize and explore alternative, non‑surgical therapeutic Considering that these cancer related treatments may cause
approaches for GI cancer patients. In advanced staged GI immunosuppression, patients' anxiety increases further as they
cancer patients in particular, initiation or continuing of feel more vulnerable to contracting COVID‑19. Experience
chemotherapy has been implemented, although the induced from patient support groups shows that many melanoma survi-
immunosuppression raises the risk for increased morbidity vors express stress and feelings of helplessness due to the new
and death in the event of a SARS‑CoV‑2 infection (42). On the pandemic. This is further aggravated by the fact that mela-
other hand, delays in treatment for GI cancer patients could noma support groups are no longer able to meet (50). Amid
result in unfavorable clinical outcomes, as a number of elec- this overwhelming pandemic though, community support
tive surgeries for GI cancer become urgent as time passes (43). groups consisting of volunteers are being set up, in order to
After all, a ‘reasonable’ time‑frame should be maintained for support isolated melanoma patients (51).
GI cancer patients, if the medical community does not want to
report such patients as the ‘occult pandemic victims’. Gynaecological cancers. As with other malignancies, the
care of women suffering from gynaecological cancers has
Lung cancer patients. COVID‑19 pandemic has affected the been severely affected by the COVID‑19 pandemic. Several
management of patients with lung cancer rather significantly. modalities are used in the treatment of gynaecological cancers:
Risk factors for COVID‑19 related complications in this surgery, radiation and intravenous systemic therapy, including
patient group include older age, significant cardiovascular chemotherapy, targeted therapies and immunotherapy. From the
and respiratory co‑morbidities, smoking‑related lung damage, surgical point of view, the availability of OR space and personnel
poor nutritional status and treatment related immunosuppres- for prolonged operations, blood bank resources and ICU beds
sion (8,44). One of the most critical issues of managing lung may directly impact the decision of whether to proceed with
cancer patients during this pandemic, is the overlap between an operable case, weighed against the oncological safety of its
the radiological manifestations and especially the CT findings delay (52,53). Even the theoretical pneumoperitoneum‑related
of COVID‑19 induced pneumonia, with those that are often risks of minimally invasive surgery in the COVID‑19 context
found upon disease progression, or onset of concomitant should be carefully weighed against the higher morbidity
pneumonia due to overlapping opportunistic infections, or linked to laparotomy, along with the latter's need for prolonged
immune‑checkpoint related pneumonitis (45,46). As a result, hospitalization (52,54) As far as chemotherapy and other
distinguishing lung cancer progression or a drug‑related anti‑cancer treatments are concerned, the possible immuno-
complication from potential COVID‑19 infection is a great compromising of patients may increase their susceptibility to
challenge for clinicians, especially since different therapeutic viral infections and severe clinical manifestations (52,55). Of
approaches (47) and strategies are required on each occa- note, experience of oncology patients in Wuhan lends support
sion. Thus, the management of lung cancer patients should to the above (8,44). Lastly, barriers pertaining to the access to
undoubtedly involve increased attention to their clinical and diagnosis and treatment for patients with symptoms indicative
radiological pulmonary signs. of gynaecological cancer should not be underestimated.
In this context, and considering the high transmissibility To maximize the quality of gynaecological cancer care,
rate of SARS‑Cov‑2, standard‑of‑care treatment regimens alongside the safety of the patients, their families and health
have been adapted for lung cancer patients, mainly in order professionals, all the major societies in the field released
to minimize the number of hospital visits and hospitalization guidelines that, in general, focus on: ‘less surgery, less hospital
and to prevent anticancer treatment‑induced complications. visits and more protective measures against the COVID‑19
Furthermore, oncology canters have implemented several spread’ (52,53,55,56). The application of these recommenda-
strategies, also followed on other types of cancer, such as tions to current clinical practice is highly dependent on the
converting intravenous treatments to oral regimens whenever local/regional pandemic statistics, infrastructure of health
possible, switching cytotoxic chemotherapy to less toxic treat- services and individual patient's needs. Importantly, the formula-
ments, pausing therapies once the disease has become stable tion of the treatment plan should follow an open and meticulous
and replacing oncological surgery with stereotaxic radio- discussion with the patient, extending from the pre‑pandemic
therapy in early stage disease (IA‑IB). standard of care to the oncologic implications of the emerging
alternatives and the risks of SARS‑CoV‑2 infection.
Patients with malignant melanoma. The COVID‑19 pandemic
has posed new challenges in managing patients with malignant Thyroid cancer. Despite progress in thyroid cancer diagnosis
melanoma, a less common but far more dangerous type of skin and treatment resulting in increased operative options and
cancer, because of its ability to metastasize to other organs, if not improved surveillance strategies, it should be kept in mind
treated at an early stage (48). During this novel pandemic, sched- that every hospital visit, diagnostic intervention or opera-
uled follow‑up appointments for melanoma patients have been tion, exposes patients and health care providers to the risk of
cancelled or replaced by telephone consultations. Frequently contracting COVID‑19. The American College of Surgeons
there are temporary delays in organizing surgical procedures for (ACS) (57) issued a statement calling for a thoughtful review
removal of suspicious moles and imaging tests, including staging of all scheduled elective procedures with a plan to minimize,
CT and MRI scans. This further increases the uncertainty postpone, or cancel electively scheduled operations, endos-
patients and their caregivers are already experiencing. copies, or other invasive procedures, until there is confidence
Many of the melanoma patients, especially those with that the health care infrastructure can support a potentially
advanced disease, are being treated with targeted therapy rapid and overwhelming uptick in critical patient care needs.
 ONCOLOGY LETTERS 20: 441-447, 2020 445

It is highly probable that cancer morbidity or even mortality tion to reduce the transmission of infectious agents is good
will rise, not only because of the direct implications of hand hygiene. Unfortunately low adherence to hand hygiene
SARS‑CoV‑2 infections, but also because of deviations from protocols can occur in paediatric oncology departments
usual cancer care pathways. Previous experience shows that, as demonstrated by Kouni et al (69) in a study where only
during pandemics, healthcare systems implement a triage 25.7% of staff practiced appropriate hand hygiene measures
system that could potentially deny critical care treatment to while caring for children with cancer. However, since the
some seriously ill patients (58). emergence of SARS‑CoV‑2 there has been an increasing
COVID‑19 has entered mainstream consciousness and investment in capacity building, education and training in
disrupted normal flow of thyroid surgeries. Furthermore, it hand hygiene measures. This might be a positive outcome
increased patient's anxiety regarding diagnosis and prompt of the pandemic after all, with lessons on the importance of
treatment. Elective interventions and non‑emergency opera- prevention of infections learned both by healthcare staff and
tions are deferred (59) and further new challenges have arisen. the general public.
For instance, a mild airway compression from large goiters
is subacute or chronic, and does not cause symptoms (60); 4. Conclusions
but what if such a patient requires immediate intubation due
to acute COVID‑19‑induced respiratory distress? This could Oncology patients deserve particular attention during the
result in significant and probably fatal airway compromise current pandemic as they are immunocompromised and
and subsequently many patients with large goiters are very vulnerable to severe of outcomes of a SARS‑CoV‑2 infection,
concerned about their postponed surgeries. due to both the underlying malignancy and various anticancer
In addition, most differentiated (DTC) and medullary treatments.
thyroid cancers (MTC) are slow‑growing tumors that do not Cancer therapies are of proven benefit, but in light of the
cause significant short‑term morbidity, but there is a subset of serious consequences of potential concurrent SARS‑CoV‑2
more aggressive cancers that progress more rapidly. Therefore, infection, risk‑to‑benefit considerations are becoming increas-
clinical correlation with rate of progression, size, invasiveness ingly important. For each individual patient their disease
of surrounding structures, and proximity to critical structures status, age, frailty, and comorbidities (10) should be consid-
is recommended in the COVID‑19 context (61). In patients ered, as well as the potential of alternative strategies of care
living with such types of asymptomatic cancer, the disease delivery. When possible, oral regimens should be preferred,
might progress in the absence of treatment. This might lead and regimen administration intervals could be redefined,
to metastatic disease or even death, or make more complex while postponing treatments or other invasive investigations
operations necessary, with increased complication rates (i.e., could be considered for patients with asymptomatic and slow
MTC or some rare invasive types of DTC) (62‑64). progressing cancers.
Telemedicine is increasingly being used by oncologists
Paediatric oncology. Although attention on the consequences and patients with largely positive experiences for both
of the COVID‑19 pandemic has mainly focused on adult groups. This process needs to be accelerated, increasing
patients, children, especially those in high risk groups such accessibility and quality of the interaction and data gath-
as the immunocompromised, are also affected mentally and ered. Furthermore, the threshold for patients with signs or
physically. Bouffet et al (65) highlighted the need for urgent symptoms of potential underlying malignancies accessing
preparedness to protect the paediatric oncology population diagnosis and treatment should be kept as low as possible.
by sharing knowledge and experience on the impact of the The psychological impact of not only the cancer, but also the
pandemic on these patients. An international paediatric haema- increased social distancing and shielding measures many
tology/oncology group provided data on COVID‑19 incidence of the patients face, requires consideration. Patient support
in almost 10,000 children treated with chemotherapy or inten- groups online and access to supportive and more formal
sive immunosuppression. Of 200 symptomatic children tested, psychological help need to be planned and be accessible.
only 8 patients were found to be positive for the SARS‑CoV‑2, Lastly, the current situation of the pandemic will force clini-
leading to the proposition that a SARS‑CoV‑2 infection might cians to make difficult decisions; however, if decisions are
be expressed as mild disease in children with cancer (66). made thoughtfully, transparently and in collaboration with
However, the indirect impact of the COVID‑19 pandemic patients and carers (70) confidence in the healthcare system
on children with cancer and their families should not be will remain high.
overlooked. A recent study in cancer patients in Milan, which
involved adolescents among other young participants, revealed Acknowledgements
that a large proportion of patients with cancer were worried and
felt personally at risk of severe complications, with their parents' Not applicable.
concern for them as an additional burden (67). In addition, the
reduction of resources, in both materials and staff, has resulted Funding
in decreased access to routine care. An overwhelmed healthcare
system could lead to limited support for the multiple needs of No funding was received.
this vulnerable population, such as intravenous treatments at
home, palliative care and low‑threshold access to hospital. Availability of data and materials
Moreover, paediatric oncology patients face an increased
risk of infections (68). The single most effective interven- Not applicable.
446 tsamakis et al: Psychosocial impact of COVId-19 pandemic

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