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Viewpoint
July 23, 2020

Distancing Without Isolating—Connection in the Era of COVID-19

Author Affiliations
  • 1Department of Radiation Medicine, Oregon Health & Science University, Portland
JAMA Oncol. Published online July 23, 2020. doi:10.1001/jamaoncol.2020.2725

Caring for patients with cancer can be difficult at the best of times. The delicate interplay between a complex disease, multidisciplinary management, social barriers, family support, and mental health makes the field of oncology uniquely challenging and rewarding. On March 11, 2020, the World Health Organization declared the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its accompanying illness, coronavirus disease 2019 (COVID-19), a global pandemic. To adequately care for patients, we now must add the pandemic’s accompanying medical, social, and economic challenges to the mosaic of obstacles. Although our commitment to curing patients’ cancer is unwavering, our focus has undeniably shifted. In the pre–COVID-19 era, we aimed to support patients both medically and emotionally through the safest and most effective treatment possible. Today we may be asking ourselves, “How much can I minimize a patient’s contact with the health care system while still providing quality care?” or “Are we willing to accept a slightly higher risk of toxic effects to minimize a patient’s exposure to the virus?” or importantly, “How can I keep patients from feeling isolated while insisting on their social isolation?”

Many patients feel particularly isolated fighting cancer during a pandemic. This remoteness is enhanced by the environment in which they must navigate the health care system. If their visits are in person, patients are typically asked to present alone, without the support of family or friends as they receive information about their diagnosis, go over adverse effects, or discuss changes to their treatment plan. These interactions are conducted in a large room to facilitate social distancing (at least 6 feet apart), with all parties masked and sometimes gowned—a sterile environment. Waiting rooms are either closed or quiet and austere, with chairs far apart. Patients are screened for symptoms and asked to take their temperature prior to entering the clinic. Although many patients express understanding and gratitude at these measures and are consciously aware of their necessity, the segregation between patients and clinicians is detrimental to a physician’s ability to establish rapport and provide emotional support through social expression and body language.

The prevalence of psychological distress in patients with cancer ranges from 20% to 47% depending on the cancer diagnosis and extent of disease.1 Patients at increased risk of psychological distress are those with prior psychiatric disorders, depression, substance abuse, severe comorbid illness, or communication barriers, as well as those with social characteristics such as younger age, female sex, and living alone. Psychological distress reduces quality of life and can negatively influence survival.2 The current COVID-19 outbreak has negatively affected mental health globally,3 with dramatic increases in anxiety, depression, stress, insomnia, and fear.

Many ambulatory clinicians have appropriately transitioned to telephone or virtual patient encounters to enforce social distancing and comply with shelter-in-place mandates. However, within radiation oncology, even while attenuating treatment as much as possible,4 many patients continue to require daily visits to the medical center or radiation facility to receive treatment. The authors of this article see the vast majority of breast and gynecologic cancers at our institution; diseases that are, for the most part, curable or controllable. However, over the preceding weeks, we have seen a dramatic increase in psychological distress among the patients in our care. Specific fears they have voiced include wondering if their cancer is being managed appropriately, feelings of isolation, worries about their immune status and risks of contracting COVID-19, concerns about the department continuing to stay open, and even concern about the well-being of their health care clinicians.

Experts around the globe have exhaustively pored over data and held discussions to determine the optimal oncology care while also minimizing the risk of exposure.5,6 For clinicians, these guidelines provide a slightly more stable foundation from which to conduct care in a constantly shifting landscape. Patients, unaware of this constant stream of discussion, may feel adrift in a sea of uncertainty or, worse, abandoned by their care team. It is up to us to find the appropriate method of communication that continues to make patients feel supported during a time when they are dealing with multiple layers of stress. Navigating the needs of women with breast and gynecologic cancers during this time has given us insight into some of the techniques that can be effective (Table). Importantly, when we are limited in our ability to demonstrate care and concern with our usual social interaction, spending extra time in virtual or telephone visits in which we give space for patients to express their anxieties can be invaluable. They often use this time to ask questions about COVID-19 or share fears about their cancer care being lost in the shuffle during the pandemic. It is important to validate and normalize their fears and share concrete information when applicable. Feelings of abandonment may be somewhat mitigated by checking in more frequently with remote methods of communication, such as direct electronic medical record messaging or telephone calls. Calling family members separately or conducting conference calls can promote feelings of inclusiveness and ease the burden of receiving information in isolation. If patients want to continue the conversation with others, many virtual support groups have been established.

Table.  Common Distress Themes and Recommendations in Patients With Cancer During the Coronavirus Disease 2019 (COVID-19) Pandemic
Common Distress Themes and Recommendations in Patients With Cancer During the Coronavirus Disease 2019 (COVID-19) Pandemic

COVID-19 has drastically changed the way we practice medicine and will undoubtedly result in permanent shifts both in our medical and general societal interactions. As we start to navigate post–COVID-19 oncology, we are faced with yet another myriad of challenges: assessing the effects of the pandemic on patients with cancer, using what we have learned to guide future treatment techniques, navigating hospital resource utilization, and ensuring adequate preparation for future events, just to name a few. Given oncologists’ ability to find delight and meaning in solving complicated problems, we are confident in the ability of our field to successfully rise to the challenge. However, here we draw attention to these early signs of distress to ensure that we do not lose sight of the fundamental need for human connection as we move into a new era of patient care. It remains our duty and privilege to be present for patients, now more than ever.

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Article Information

Corresponding Author: Kiri A. Cook, MD, Department of Radiation Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (cooki@ohsu.edu).

Published Online: July 23, 2020. doi:10.1001/jamaoncol.2020.2725

Conflict of Interest Disclosures: None reported.

References
1.
Holland  JC, Andersen  B, Breitbart  WS,  et al.  Distress management.   J Natl Compr Canc Netw. 2013;11(2):190-209. doi:10.6004/jnccn.2013.0027PubMedGoogle ScholarCrossref
2.
Mitchell  AJ, Chan  M, Bhatti  H,  et al.  Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies.   Lancet Oncol. 2011;12(2):160-174. doi:10.1016/S1470-2045(11)70002-XPubMedGoogle ScholarCrossref
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Torales  J, O’Higgins  M, Castaldelli-Maia  JM, Ventriglio  A.  The outbreak of COVID-19 coronavirus and its impact on global mental health.   Int J Soc Psychiatry. 2020;66(4):317-320. doi:10.1177/0020764020915212PubMedGoogle ScholarCrossref
4.
American Society for Radiation Oncology. COVID-19 clinical guidance. Accessed June 22, 2020. https://www.astro.org/Daily-Practice/COVID-19-Recommendations-and-Information/Clinical-Guidance
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Coles  CE, Aristei  C, Bliss  J,  et al.  International guidelines on radiation therapy for breast cancer during the COVID-19 pandemic.   Clin Oncol (R Coll Radiol). 2020;32(5):279-281. doi:10.1016/j.clon.2020.03.006PubMedGoogle ScholarCrossref
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Braunstein  LZ, Gillespie  EF, Hong  L,  et al.  Breast radiotherapy under COVID-19 pandemic resource constraints—approaches to defer or shorten treatment from a comprehensive cancer center in the United States.   Adv Radiat Oncol. Published online April 1, 2020. doi:10.1016/j.adro.2020.03.013PubMedGoogle Scholar
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    1 Comment for this article
    EXPAND ALL
    Social Distancing, Self Isolation, Conscientious Discipline and Respect During COVID-19
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    The sensitive and compassionate Viewpoint by two radiation medical specialists highlights the key issues associated with care for cancer patients, which involves social distancing and self isolation, among other responsible actions, in a COVID-19 world.

    The difficult suppression and the highly unlikely elimination strategies require conscientious discipline and respect for each other in a COVID-19 world by all members of society, starting from the most senior government administrators, and leading medical and public healthcare officials.

    Providing quality healthcare for cancer patients with compromised immune systems is demanding of seemingly tireless and heroic healthcare workers at the best of
    times.

    However, their inner strength and compassion are called upon more heavily when faced with the extreme likelihood that their patients, as well as they themselves, face the distinct prospect of contracting COVID-19.

    On a related issue facing the community, social distancing and self isolation are mandatory in many states, but the wearing of masks is not.

    Even where masks might be required, there always seem to be exemptions, including joggers and cyclists, which make consistent healthcare advice seemingly ambiguous and confusing.

    The psychological anxiety, distress and pain suffered by cancer patients, who might also be denied human connection, can be dramatically worsened when faced with the risk of COVID-19.

    It is at times like these that oncologists, chemotherapy and radiation therapists, oncology nurses, related healthcare professionals, and healthcare and homecare providers demonstrate most poignantly that their career choices are life-saving and dutiful missions for all who need their calming presence and understanding the most, for which we are truly humbled and grateful.
    CONFLICT OF INTEREST: None Reported
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