Edited by: Stephen V. Liu, Georgetown University Medical Center, United States
Reviewed by: Giannis Mountzios, National and Kapodistrian University of Athens, Greece; Martin Dietrich, University of Central Florida, United States
*Correspondence: Chiara Catania,
This article was submitted to Thoracic Oncology, a section of the journal Frontiers in Oncology
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In February 2020, Italy became one of the first countries to be plagued by the SARS-CoV-2 pandemic, COVID-19. In March 2020, the Italian government decreed a lockdown for the whole country, which overturned communication systems, hospital organization, and access to patients and their relatives and carers. This issue had a particular regard for cancer patients. Our Thoracic Oncology Division therefore reorganized patient access in order to reduce the risk of contagion and, at the same time, encourage the continuation of treatment. Our staff contacted all patients to inform them of any changes in treatment planning, check that they were taking safety measures, and ascertain their feelings and whether they had any COVID-19 symptoms. To better understand patients’ fears and expectations of during the pandemic period, we created a nine-question interview, administered from April to May 2020 to 156 patients with lung cancer. Patients were classified by age, sex, comorbidity, disease stage, prior treatment, and treatment type. The survey showed that during the pandemic period some patients experienced fear of COVID-19, in particular: women (55% vs. 33%), patients with comorbidities (24% vs. 9%), and patients who had already received prior insult (radiotherapy or surgery) on the lung (30% vs. 11%). In addition, the patients who received oral treatment at home or for whom intravenous treatment was delayed, experienced a sense of relief (90% and 72% respectively). However, only 21% of the patients were more afraid of COVID-19 than of their cancer, in particular patients with long-term (> 12 months) vs. short-term cancer diagnosis (28% vs. 12.5%, respectively). Furthermore, the quarantine period or even just the lockdown period alone, worsened the quality of life of some patients (40%), especially those in oral treatment (47%). Our data demonstrate how lung cancer patients are more afraid of their disease than of a world pandemic. Also this interview indirectly highlights the clinician’s major guiding principle in correctly and appropriately managing not just the patient’s expectations of their illness and its treatment, but also and especially of the patient’s fears.
In December 2019, a novel coronavirus, known as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), was identified in Wuhan (China) as the cause of coronavirus disease 2019 (COVID-19) (
Moreover, prior administration of chemotherapy (alone or in combination with immunotherapy), steroids, and anticoagulant therapy may increase risk of death (
We carried out this study from April 30, 2020 to May 29, 2020 (
The graphic shows the evolution of contagions and deaths in Italy and in Lombardy during the pandemic period. The interval of all the interviews is represented in the graph.
Our team of thoracic oncologists selected the questions based on continuous discussions we held during our team meetings. Before drawing up the nine questions for the interview, our team interrogated the US National Library of Medicine’s biomedical literature database PubMed, and reviewed all the pertinent literature. We did not find any validated questionnaires aimed at evaluating the real emotional impact of coronavirus in patients with lung cancer. Nine questions were drawn up, and all the interviews conducted by the doctors used the same questions. The possible replies to the first eight questions ranged from “
All the patients referred to the European Institute of Oncology in Milan for a visit or treatment for early/advanced/metastatic lung cancer from April 30, 2020, to May 29, 2020, were eligible. Patients were informed that an interview would be conducted, and we asked them if they would consent to answer some questions. All patients were free to accept or refuse the interview without it affecting the visit or treatment program. All patients were Italian and had a good understanding of the Italian language in order to be able to answer the questions.
The same interview was given to all patients who came to the Day Hospital to receive intravenous treatment, all patients who came to the clinic to receive oral treatment (TKI: tyrosine kinase inhibitors) and all patients who came for check-ups or first visits and therefore had yet to start treatment. Those patients who did not receive a deferral of treatment or visits between February and March 2020 were not asked questions Q5 and Q6 in the interview. Lung cancer patients receiving oral therapy (TKI) in the period February and March 2020 skipped visits and outpatient check-ups. However, they still received care at home without visiting us by receiving phone calls. These patients were asked all of the questions set out in the interview. We felt that skipping the visit with their oncologist, not being able to discuss the side effects of the treatment, have a physical examination or see the CT images immediately, could be considered an alteration/delay compared to what they usually did in the pre-COVID- 19 period. We reasoned that this could have affected their fear and perception about the risk of contagion and their disease (less exposed to the risk of contagion but less monitored by specialists).
Patients’ characteristics and treatments were described by counts and percent, and age by mean and standard deviation (SD). Days from cancer diagnosis to structured interview administration were categorized into three levels (within three months, between three months and one year, and over one year). Answers to the structured interview questions from Q1 to Q9 were cross-tabulated against patient characteristics and treatments and tested for their association by the Fisher’s exact test, taking into account the missing data if their proportion was greater than 5% in any of the cells. A multivariable multinomial logistic regression analysis was performed for all questions, including only the significant factors at the univariate analysis. Answers were categorized into three levels:
During the study period, a total of 156 patients were interviewed. The clinical features of the included population are shown in
Patient’s characteristics and Treatments, N = 156.
Characteristics | Statistics |
|
---|---|---|
Age, years | Mean (SD) | 66.5 (± 10.3) |
<75 | 129 (82.7) | |
≥75 | 27 (17.3) | |
Months from cancer diagnosis | ≤3 | 28 (18.0) |
(3–12] | 32 (20.5) | |
>12 | 96 (61.5) | |
Sex | Female | 69 (44.2) |
Male | 87 (55.8) | |
Histology | Adenocarcinoma | 132 (84.6) |
Squamous carcinoma | 10 (6.4) | |
SCLC | 9 (5.8) | |
LCNEC | 1 (0.6) | |
Other | 4 (2.6) | |
Current stage | Metastatic | 136 (87.7) |
Locally advanced | 14 (9.0) | |
Early | 6 (3.9) | |
ECOG PS | 0 | 48 (30.8) |
1 | 108 (69.2) | |
Smoking status | Never | 46 (29.5) |
Former |
75 (48.1) | |
Current | 35 (22.4) | |
Comorbidities | Cardio-pulmonary | 114 (73.1) |
Region | Lombardia | 107 (69.0) |
Other regions | 49 (31.0) | |
Previous surgery/pulmonary RT | 73 (46.8) | |
Therapy setting | Metastatic | 140 (89.7) |
Adjuvant/Neo-adjuvant | 10 (7.7) | |
CT/RT | 6 (3.9) | |
Therapy | No therapy | 18 (11.5) |
TKI | 55 (35.3) | |
Intravenous | 83 (53.2) | |
CT | 30 (19.2) | |
IO | 35 (22.4) | |
CT+IO | 15 (9.6) | |
CT+RT | 3 (1.9) |
Statistics are: mean (± SD) for age, N (%) otherwise.
Quit smoking for at least 12 months.
TKI, tyrosine kinase inhibitor; CT, chemotherapy; IO, immunotherapy; RT, radiotherapy; SCLC, small cell lung cancer; LCNEC, large cell neuroendocrine carcinoma; SD, standard deviation.
The structured interview is fully shown in
Frequency distribution of answers to the structured interview, all patients N = 156.
Question | Level | N (column %) |
---|---|---|
Q1 | Not at all/a little | 86 (55.1) |
Moderately | 33 (21.2) | |
Quite a bit/extremely | 31 (19.9) | |
6 (3.9) | ||
Q2 | Not at all/a little | 94 (60.3) |
Moderately | 35 (22.4) | |
Quite a bit/extremely | 22 (14.1) | |
5 (3.2) | ||
Q3 | Not at all/a little | 70 (44.9) |
Moderately | 45 (28.9) | |
Quite a bit/extremely | 32 (20.5) | |
9 (5.8) | ||
Q4 | Not at all/a little | 92 (59.0) |
Moderately | 37 (23.7) | |
Quite a bit/extremely | 19 (12.2) | |
8 (5.1) | ||
Q5a | Not at all/a little | 53 (82.8) |
Moderately | 4 (6.3) | |
Quite a bit/extremely | 6 (9.4) | |
1 (1.6) | ||
Q6 |
Not at all/a little | 20 (31.3) |
Moderately | 8 (12.5) | |
Quite a bit/extremely | 34 (53.1) | |
2 (3.1) | ||
Q7 |
Not at all/a little | 101 (73.2) |
Moderately | 12 (8.7) | |
Quite a bit/extremely | 16 (11.6) | |
9 (6.5) | ||
Q8 | Not at all/a little | 88 (56.4) |
Moderately | 28 (18.0) | |
Quite a bit/extremely | 32 (20.5) | |
8 (5.1) | ||
Q9 | COVID | 33 (21.2) |
Oncological disease | 89 (57.1) | |
Both equally | 26 (16.7) | |
8 (5.1) |
Sample Size N = 64 (delayed patients only, see text for details).
Sample Size N =138 (excluding subjects without therapy).
In the first two questions (Q1 and Q2), patients were asked whether they were worried about COVID-19, at the beginning of the pandemic (Q1) and at the time of the interview (Q2). Most patients (55.1% in Q1 and 60.3% in Q2, respectively) reported
Question number with a significant factor association to the answers to the structured interview.
Question | Factor | Level | N (row %) | p-value | ||||
---|---|---|---|---|---|---|---|---|
N | Not at all/A little | Moderately | Quite a bit/Extremely | |||||
Q1 | Gender | Female | 69 | 30 (45.5) | 17 (25.8) | 19 (28.8) | 3 (4.4) | |
Male | 87 | 56 (66.7) | 16 (19.1) | 12 (14.3) | 3 (4.4) | |||
Comorbidity | No | 42 | 20 (47.6) | 14 (33.3) | 4 (9.5) | 4 (9.5) | ||
Yes | 114 | 66 (57.9) | 19 (16.7) | 27 (23.7) | 2 (1.8) | |||
Previous surgery/pulmonary RT | No | 83 | 52 (62.7) | 17 (20.5) | 9 (10.8) | 5 (6.0) | ||
Yes | 73 | 34 (46.6) | 16 (21.9) | 22 (30.1) | 1 (1.4) | |||
Therapy |
CT,CT+IO,CT+RT | 48 | 30 (62.5) | 12 (25.0) | 6 (12.5) | 0 | ||
IO | 35 | 22 (62.9) | 2 (5.7) | 9 (25.7) | 2 (5.7) | |||
Q2 | Gender | Female | 69 | 31 (47.0) | 22 (33.3) | 13 (19.7) | 3 (4.4) | |
Male | 87 | 63 (74.1) | 13 (15.3) | 9 (10.6) | 2 (2.3) | |||
Comorbidity | No | 42 | 25 (59.5) | 11 (26.2) | 2 (4.8) | 4 (9.5) | ||
Yes | 114 | 69 (60.5) | 24 (21.1) | 20 (17.5) | 1 (0.9) | |||
Q3 | Therapy | No therapy | 18 | 5 (29.4) | 8 (47.1) | 3 (17.7) | 1 (5.9) | |
Intravenous |
83 | 48 (57.1) | 22 (26.2) | 10 (12.1) | 3 (3.6) | |||
TKI | 55 | 17 (30.9) | 15 (27.3) | 18 (32.7) | 5 (9.1) | |||
Months from cancer diagnosis | ≤3 | 28 | 11 (39.3) | 10 (35.7) | 2 (7.1) | 5 (17.9) | ||
(3,12] | 32 | 19 (59.4) | 9 (28.1) | 3 (9.4) | 1 (3.1) | |||
>12 | 96 | 40 (41.7) | 26 (27.1) | 27 (28.1) | 3 (3.1) | |||
Q4 | Months from cancer diagnosis | ≤3 | 28 | 13 (46.4) | 8 (28.6) | 2 (7.1) | 5 (17.9) | |
(3,12] | 32 | 24 (75.0) | 5 (15.6) | 2 (6.3) | 1 (3.1) | |||
>12 | 96 | 55 (57.3) | 24 (25.0) | 15 (15.6) | 2 (2.1) | |||
Q8 | Therapy | Intravenousc | 83 | 34 (70.8) | 7 (14.6) | 7 (14.6) | 0 | |
TKI | 55 | 25 (45.5) | 13 (23.6) | 13 (23.6) | 4 (7.3) |
aN= 83 patients receiving intravenous treatment subgroup; bIntravenous: CT,CT+IO,CT+RT,IO; cIntravenous vs. TKI comparison (excluding No therapy level), p = 0.003;
CT, chemotherapy; IO, immunotherapy; RT, radiotherapy; TKI, tyrosine kinase inhibitors.
Question 9 (Q9) specifically investigated which one of the diseases (COVID-19 vs. lung cancer) worried patients most. Eighty-nine patients (57%) reported being more worried by their lung cancer than by COVID-19, 33 patients (21%) were more worried by COVID-19 and 26 patients (17%) reported to be equally worried by the two conditions (
In univariate analysis, factors significantly associated with answer distribution were: previous thoracic treatment (p = 0.003), systemic treatment type (intravenous vs. oral. P = 0.02) and time to cancer diagnosis (p = 0.006) (
Significant factor associations to the answers to the structured interview question 9.
Factor | Level | N (row %) | p-value | ||||
---|---|---|---|---|---|---|---|
N | COVID-19 | Oncological Disease | Both equally | ||||
Previous Surgery/Pulmonary RT | No | 83 | 11 (13.3) | 48 (57.8) | 16 (19.3) | 8 (9.6) | |
Yes | 73 | 22 (30.1) | 41 (56.2) | 10 (13.7) | 0 | ||
Therapy | Intravenous |
83 | 5 (10.4) | 30 (62.5) | 11 (27.1) | 2 (4.2) | |
TKI | 55 | 14 (25.5) | 35 (63.6) | 4 (7.3) | 2 (3.6) | ||
Months from cancer diagnosis | ≤3 | 28 | 2 (7.1) | 20 (71.4) | 5 (17.9) | 1 (3.6) | |
(3,12] | 32 | 4 (12.5) | 14 (43.8) | 10 (31.3) | 4 (12.5) | ||
>12 | 96 | 27 (28.1) | 55 (57.3) | 11 (11.5) | 3 (3.1) |
Intravenous: CT, CT+IO, CT+RT, IO.
TKI, tyrosine kinase inhibitor; CT, chemotherapy; IO, immunotherapy; RT, radiotherapy.
In particular, despite the overall main worry about the oncological disease, 22 (30%) patients with previous thoracic treatment compared to 11 (13%) without, reported to be most worried by COVID-19, similarly 14 (25.5%) patients with Oral TKI treatment compared to 5 (10%) IV patients (p = 0.02) and 27 (28%) long-term lung (> 12 months) cancer diagnosis vs. 4 (12.5%) middle-term (3 to 12 months) vs. 2 (7%) short-term (≤ 3 months) (p = 0.006) lung cancer diagnosis reported to be most worried by COVID-19 (
Multivariable multinomial logistic regression analysis of distribution of answers to the structured interview.
Question | Answers compared to the reference level |
Odds Ratio (95% CI) | p-value | |
---|---|---|---|---|
Q1 | Female vs. Male | Moderately | 1.73 (0.75–4.00) | 0.20 |
Quite a bit/Extremely | 3.08 (1.26–7.52) | |||
Comorbidity vs. No comorbidity | Moderately | 0.46 (0.19–1.10) | 0.08 | |
Quite a bit/Extremely | 2.85 (0.83–9.76) | 0.10 | ||
Previous surgery/pulmonary RT | Moderately | 1.29 (0.56–2.96) | 0.55 | |
Quite a bit/Extremely | 3.75 (1.50–9.37) | |||
Q2 | Female vs. Male | Moderately | 3.43 (1.51–7.79) | 0.003 |
Quite a bit/Extremely | 3.42 (1.29–9.07) | 0.01 | ||
Comorbidity vs. No comorbidity | Moderately | 0.98 (0.40–2.39) | 0.97 | |
Quite a bit/Extremely | 4.51 (0.95–21.0) | 0.06 | ||
Q3 | Comorbidity vs. No comorbidity | Moderately | 1.04 (0.40–2.79) | 0.94 |
Quite a bit/Extremely | 1.52 (0.49–4.67) | 0.47 | ||
Intravenous |
Moderately | 0.51 (0.19–1.38) | 0.18 | |
Quite a bit/Extremely | 0.23 (0.08–0.68) | |||
Months from cancer diagnosis: (3,12] vs. ≤ 3 | Moderately | 0.72 (0.18–2.91) | 0.64 | |
Quite a bit/Extremely | 1.20 (0.11–13.7) | 0.88 | ||
>12 vs. ≤3 | Moderately | 0.83 (0.23–3.03) | 0.78 | |
Quite a bit/Extremely | 2.70 (0.29–24.8) | 0.38 | ||
Q9 | Previous surgery/pulmonary RT | COVID-19 | 1.52 (0.61–3.81) | 0.37 |
Both equally | 0.79 (0.29–2.17) | 0.64 | ||
Intravenous |
COVID-19 | 0.91 (0.36–2.30) | 0.84 | |
Both equally | 2.93 (0.85–10.1) | 0.09 | ||
Months from cancer diagnosis: (3,12] vs. ≤ 3 | COVID-19 | 4.43 (0.61–32.7) | 0.14 | |
Both equally | 3.75 (0.92–15.2) | 0.06 | ||
12 vs. ≤3 | COVID-19 | 6.58 (1.08–40.1) | 0.04 | |
Both equally | 1.53 (0.37–6.34) | 0.56 |
aReference levels are: not at all/a little for Q1, Q2, and Q3, Oncological disease for Q9; bIntravenous: CT,CT+IO, CT+RT, IO.
TKI, tyrosine kinase inhibitors; CT, chemotherapy; IO, immunotherapy; RT, radiotherapy.
The patients’ perception of the impact of the COVID-19 pandemic on lung cancer was investigated by questions 3 and 4 (Q3-Q4). Patients were asked whether they were worried about the evolution of their cancer at the beginning of the pandemic (Q3) and at the time of our interview (Q4). Overall, 70 (45%) of patients in Q3 and 92 (59%) in Q4 reported
In univariate analysis, factors significantly associated with answer distribution were anticancer treatment type (p = 0.003), and time to cancer diagnosis (p = 0.01) (
Similar findings were observed among patients with long-term compared to short-term cancer diagnosis both in Q3 and Q4 with 27 (28%) vs. 2 (7%) patients (Q3) and 15 (16%) vs. 2 (7%) (Q4) respectively (
Questions 5 and 6 (Q5-Q6) were put to patients (N = 64) whose treatment/visit was delayed at least once during the pandemic, to investigate whether they were worried about the possibility of disease progression (Q5) or relieved about SARS-CoV-2 contagion risk reduction (Q6) with this adopted measure. Fifty-three (83%) patients reported
The potential impact of the COVID-19 pandemic on quality of life (QoL) was investigated by question 8 (Q8), asking patients whether the quarantine limitations had worsened their QoL. Eighty-eight (56%) patients reported
This study is the first to assess various aspects of the SARS-CoV2 pandemic impact on lung cancer patients. The aspects studied were: the fear of falling ill with COVID-19 compared to the fear of their disease, how much the COVID-19 emergency had changed patients’ lives, and whether they were more afraid of COVID-19 than lung cancer. After the end of the lockdown period, patients were interviewed. The interview explored both the time of the interview itself and the previous period of maximum contagion and restrictions. A key element revealed in the interviews was a widespread fear of the pandemic, and the persistence of this fear even after – and despite - the progressive improvement in public knowledge regarding the pandemic picture in Italy and its gradually decreasing severity over time. When the pandemic was announced, a significant percentage of patients (40%) were afraid of COVID-19. At that time, Italian news channels presented the number of deaths every day, broadcasting images of coffins with the unburied dead, intensive care units filled to over-capacity, and reporting the unavailability of swab tests, and the difficulty to get a CT scan. After the end of the most severe period and the end of the lockdown, even though the news broadcasts reported a progressive improvement of all these aspects, this did not reassure most of the patients interviewed, with fears remaining unallayed in a high percentage of patients (36%).
Analyzing the responses by subgroups, we found that those who were very afraid of COVID-19, both during and after the emergency period, were predominantly women: 55% vs. 33% and 53% vs. 26%, respectively. In discussions with patients, it emerged that women, often mothers of young children or adolescents, feel responsible for their loved ones, and the fear of infecting their parents or grandparents. In the interviews, it was often the women who spoke about the fear of becoming ill with COVID-19 and with the added risk of infecting others in the family: children, grandchildren, mothers, fathers, and spouses.
Patients with comorbidity formed the majority of those
Many patients explained that despite the acute emergency phase being over, their fear was maintained by the failure to return to normal, the still-ongoing risk of becoming infected, and the inability to shake hands with their doctor and simply see his or her smile, both parties of course having their faces hidden beneath a mask and protective glasses.
The referral oncologists phoned each patient during the pandemic peak to discuss and explain the reasons behind postponements or modifications of therapies and scheduled visits, and explain any possible impact of such procedures on the patient’s outcome (
These telephone calls were made before the patients received the information from the appointments secretaries regarding the logistics of the postponement of treatment/visit. Only 9% of the 64 patients said they were extremely concerned about the planned postponements/modifications. In the meantime, more than half (53%) of the patients felt reassured by these decisions because of a reduction of risk of contagion.
Moreover, after discussing the possible impact of the ongoing anticancer treatment on the risk of contagion, over 70% of the 138 treated patients did not feel more greatly exposed to the risk of infection due to cancer treatment.
These results underlined that physicians’ personalized and tailored communication enabled them to manage the possible emotional impact of such decisions. It therefore became possible to instill a state of calm for the patients, who placed their trust in the doctor’s judgment.
It should be noted that patients on oral therapy, for whom the continuity of treatment was maintained thanks to the resupply carried out at home, experienced a sense of relief from the postponement of hospital access in over 90% of cases.
A considerable proportion of those patients on intravenous therapy who needed to have treatment delayed for a few weeks to avoid the risk of viral infection reported that they were not worried about omitting treatment (72%). Indeed, many (44%) were reassured. This could underline the importance of accurately and carefully selecting the subgroup of patients to defer: patients who were well, who had had the disease under control for a long time, and who had been receiving treatment for a long time. In addition, our intervention of phone calls and sharing with our patients the choices we made, led patients to understand our position and our efforts to protect them from infection. The patients trusted us. We believe it is crucial, especially in these times of emergency - an unprecedented experience for our generation - to express to patients our difficulties and proffer our professional advice on how they may protect themselves. The value of this individualized contact with the patient is also supported by data from a study by Ghosh et al. which they investigated a population with different cultures and affected by several solid tumors and not only lung cancer (
In our study, patients receiving immunotherapy alone, compared with those receiving intravenous chemotherapy or immune-chemotherapy, showed no statistically significant differences in interview responses, except for the percentage of patients most frightened by COVID-19 at the time of emergency (Extremely: 26% vs. 12%). Some of the patients who were very afraid of COVID-19 stated that it was because they were scared of losing their survival advantage (“now that I’ve made it and they found the right drug!”) conferred by the immunotherapy if they got infected. Overall, quarantine worsened the quality of life in many patients (40%), especially in patients on oral therapy (47%). This was less so in those on intravenous therapy (29%). The main reason patients gave for this difference seemed to be that on intravenous treatment they had already adopted restrictive habits in their daily life, regardless of the risk of infection, so that the restrictions imposed by the pandemic did not substantially change their day-to-day living.
Other interesting issues were captured by this interview and should be considered whenever oncologists discuss with patients with cancer in this COVID-19 era, because these fears are not often made explicit.
Many patients reported that they were afraid that they might not receive treatment for COVID-19 because they had lung cancer and, in a time of emergency, a selection would be made of who would be chosen to survive COVID-19. The decision, they maintained, would surely fall in favor of healthy people.
Moreover, many patients (21%) were more worried about COVID-19 than the tumor itself. In a subgroup analysis, this appeared much more frequently in patients with a diagnosis of lung cancer made more than 12 months previously, than in patients with a recent diagnosis (<3 months). The most frequently collected reasons were manifold. The pandemic was more frightening than cancer because the virus is invisible to our senses, there is no COVID-19 standardized treatment, and it is often difficult to diagnose. Moreover, in the event of a severe infection and subsequent death from COVID-19, they would be isolated, perhaps treated, kept permanently in isolation, and then die alone without having the opportunity to embrace their loved ones. Death from cancer is often expected, and very often gives the patient more time to organize the affairs of those who remain (children, wives, husbands, family members, etc.) and above all to embrace and say their goodbyes to everyone. They would not die alone but would have their loved ones close by. Death from lung cancer, although undoubtedly tragic, would at least be experienced with less fear and less loneliness.
The results gathered from this survey can help to understand objectively the many conflicting fears harbored by lung cancer patients concerning the experience of COVID-19, the possible spread of their cancer due to the pandemic and the fear of a possible delay in treatment. It is important to share with the patients themselves, in an individualized manner, both the choices made in terms of changes regarding the pre-COVID-19 routine within the hospital and the difficulties that the doctors themselves face in an emergency crisis. Awareness improves understanding, and increases confidence in the doctor. It can also reduce the risk of contagion of patients.
All datasets presented in this study are included in the article/
Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.
CC, FM, GS, ES, IA, VS, LG, and SM designed the study, analyzed the data, and wrote the manuscript. DR, IA, CC, and GS collected and analyzed the data. CC and FM edited the manuscript. All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the article and approved the submitted version.
This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5x1000 funds.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at:
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
not at all, a little, moderately, quite a bit, extremely, not evaluable
COVID-19, cancer, both equally