People With Cancer Experience Worse Psychosocial and Financial Consequences of COVID-19 Compared With Other Chronic Disease Populations: Findings From the International COVID-19 Awareness and Response Evaluation Survey Study

PURPOSE The COVID-19 pandemic is likely to have profound psychosocial impacts across the globe. In this analysis of the International COVID-19 Awareness and Response Evaluation (iCARE) survey study, we comparatively investigated the psychosocial effects of COVID-19 on individuals with cancer and people with other chronic illness. METHODS iCARE study respondents were divided into two groups on the basis of self-reported health status: (1) active/current cancer (with or without any other chronic condition: heart disease, lung disease, hypertension, diabetes, severe obesity, immunity disease, and depressive or anxiety disorder); and (2) other chronic condition, but not cancer. Linear regressions were conducted to evaluate the associations between health status and outcomes. RESULTS Worldwide, 18,154 iCARE study respondents (mean age, 50.8 years) from 175 countries were included in the analysis. Among them, 3.8% (n = 677) identified as having active/current cancer and 96.2% (n = 17,477) identified as having other chronic condition. Multivariate analyses showed significant associations between having cancer and declined mental (β = .364; P < .0001) and physical (β = .317; P < .0001) health since the start of the COVID-19 pandemic, relative to those with other chronic illness. Moreover, individuals with cancer demonstrated a higher likelihood of reporting maladaptive coping mechanisms such as increased alcohol use (β = .457; P < .0001) and financial hardships such as not paying rent/mortgage (β = .476; P < .0001), compared with people with other chronic illness. CONCLUSION Individuals with cancer worldwide tended to have worse psychosocial and financial challenges during the COVID-19 pandemic, compared with other chronic disease populations. Clinicians need to be aware of the importance of attending to the specific mental health needs of individuals with cancer during and after COVID-19–related restrictions.


INTRODUCTION
Across the general population and all ages, COVID-19 has given rise to high psychological distress and deteriorated mental health. 1,2Numerous general population studies have showed significant levels of fear and anxiety surrounding health outcomes for oneself and others, unemployment, and financials issues, as well as major adjustments to lifestyle (social distancing, persistent lockdowns, etc). 1,2r those suffering from chronic illness such as cancer, diabetes, and cardiovascular disease, the psychosocial impacts may be more significant than for the general population.[5][6] For individuals living with cancer, the adverse effects of COVID-19 on mental health may be even more severe. 5 recent multinational general population survey study (N 5 41,212) showed that relative to healthy individuals, significant associations have been found between having cancer and symptoms of anxiety and depression, as well as worsened overall quality of life (QOL) during the COVID-19 pandemic. 7Patients receiving active cancer treatment are often immunocompromised, potentially making them vulnerable to COVID-19 disease or related health complications. 4In addition, many individuals with cancer are required to visit health centers frequently, sometimes on a daily basis, thereby increasing their risk of exposure to the virus.Caregiver access may also be reduced in many circumstances for both inpatients and outpatients, thereby impeding the vital support that patients often require.Moreover, patients may be fearful of their own disease prognosis and status as many appointments deemed nonessential have been delayed since the start of the pandemic.
][10] Recent studies show that health behaviors (eg, substance use and smoking) have been adversely affected by COVID-19. 2,11[10] Individuals with cancer may face a unique set of stressful circumstances that other chronic disease patients may not experience.To our knowledge, to date, no comparative studies have evaluated the psychosocial impact of COVID-19 on individuals with cancer and chronic disease populations on a global scale.][10][11][12] This study benefits the literature by providing novel data regarding the comparative psychosocial well-being and subsequent health behaviors between these two groups in a large, multinational survey sample.This study can aid in understanding what type of psychosocial support is needed, and for which individuals, and provide further insight to the physical, psychological, and social health outcomes of the COVID-19 pandemic.

Objectives
The objectives of this analysis of the International COVID-19 Awareness and Response Evaluation (iCARE) survey data 13

METHODS iCARE Study
The iCARE study 14 is an ongoing study led by investigators from the Montreal Behavioural Medicine Centre in collaboration with over 200 researchers from more than 40 countries. 13The study uses a cross-sectional, multicohort survey design and primarily aims to capture key data on people's awareness, attitudes, and behaviors as they relate to COVID-19 policies. 13

Study Design
Using a cross-sectional, multicohort design, the current analysis covered iCARE surveys 1 through 7 and comprised data collected at multiple time points, spanning from March

CONTEXT Key Objective
Our study aims to address the following question: "How do the psychological and behavioral responses to the COVID-19 pandemic vary between patients with cancer and those with other chronic illnesses globally?"Unlike previous, smaller-scale studies, our multinational analysis of the psychosocial experiences of these groups gives stakeholders valuable insights for tailored interventions.

Knowledge Generated
Globally, during the COVID-19 pandemic, individuals with cancer faced more psychosocial distress and disruptions in medical care than those with other chronic illnesses.Nonetheless, individuals with cancer reported a mix of coping behaviors, adopting both negative mechanisms, such as increased use of recreational drugs, and positive strategies, including a healthier diet and more exercise, suggesting a nuanced and complex response to pandemic-induced challenges.iCARE investigators.The survey (Data Supplement, File S1) was designed to measure constructs consistent with the COM-B model, a health psychology theory that cites capability (C), opportunity (O), and motivation (M) as three key factors leading to behavior (B) change, 15 and the health belief model, a psychological and behavioral theory that posits six constructs to predict health behavior: risk susceptibility, risk severity, benefits to action, barriers to action, self-efficacy, and cues to action. 16

Data Collection
Since its launch on March 27, 2020, 12 variations of the iCARE survey have been distributed in waves approximately 6 weeks apart. 15Survey data are collected by all global collaborators using a convenience sampling approach (globally) and parallel representative sampling in countries where funds are available. 15The survey is available in 34 languages and distributed through a number of channels, including professional organizations and networks, social media platforms, universities and schools, health care settings, and community organizations. 13

Variables
To address our research objectives, the following variables from the iCARE survey data were included in the analysis.
Sociodemographic information: Sociodemographic characteristics collected from the iCARE survey data included sex, age, type of residential area (urban/rural/suburban), level of education, and employment status.
Health status: To analyze the stated research objectives, we used information on respondents' health status to differentiate between individuals with cancer and other chronic illness patients.Specifically, the iCARE survey included a question that asked respondents to report any chronic mental or physical health condition, including cancer, heart disease, lung disease, hypertension, diabetes, severe obesity, immunity disease, and depressive or anxiety disorder.On the basis of self-reported health status, we divided respondents into two groups: (1) active/current cancer with or without any other chronic mental or physical health condition and (2) no active/current cancer but has one or more other chronic mental or physical health condition.
Psychosocial health, QOL, and health behaviors: For the purposes of comparing the psychosocial implications of COVID-19 between individuals with cancer and other chronic disease populations, we used the following questions from the iCARE survey data to evaluate participants' psychosocial health, QOL, and health behaviors during the pandemic.
Objective 1: Impacts of COVID-19 on Psychosocial Health and QOL

DISCUSSION
The purpose of this study was to comparatively investigate the impacts of COVID-19 on adults living with cancer and adults living with chronic illness, as well as to compare the health behaviors of these two groups during the COVID-19 pandemic.The results demonstrate that an active diagnosis of cancer was significantly associated with adverse COVID-19-related psychosocial symptoms.On a global scale, those with cancer experience further decline in mental health than those with other chronic conditions.This is not atypical for this population when compared with other groups, as the prevalence of comorbid psychosocial conditions are higher among people living with cancer generally. 18,19 a recent systematic review of COVID-19-related anxiety prevalence in individuals with cancer, the authors found that rates of psychological distress and comorbid disorders have increased during the pandemic and were related to fears of worsened conditions, delays and interruptions in treatment schedules, and fear of contracting COVID-19. 20Findings from our much larger international study align with this review, as those with cancer experienced more psychosocial issues related to COVID-19, such as fear of dying from the virus, concerns about interrupted medical care, and experiencing separation or divorce.
The QOL for many individuals with cancer might have been affected by the COVID-19 pandemic, primarily because of increased levels of isolation and loneliness. 21,22Results of an American survey study of 187 individuals with cancer found that 53% were reportedly lonely on the University of California, Los Angeles, loneliness scale. 23Findings from the current study corroborate that, relative to other chronic disease populations, individuals with cancer were more prone to reporting difficulties in seeing family or friends due to COVID-19-related restrictions.However, our results show that individuals with other chronic illness have experienced a more significant decrease in their QOL since the start of the COVID-19 pandemic, compared with those with cancer.One possible explanation for this finding, which contradicts the majority of our results regarding psychosocial aspects, could be that individuals with cancer might have already been experiencing a compromised QOL before the onset of COVID-19.As a result, the significant impacts of the pandemic on their well-being might not have been perceived as dramatically altering their preexisting poor QOL.
In addition to higher rates of psychosocial problems, financial hardship was found to be of particular concern, where an inability to pay rent/mortgage, troubles paying for food/supplies, and general fears of not having enough money for food or rent were reported significantly more by people living with cancer.Financial hardship is a common issue experienced by many older adults who are no longer in the workforce as well as by others who are unemployed; however, the prevalence of financial hardship is indisputably more common for people living with cancer, as is supported in our findings where individuals with cancer were significantly older than the other group and nearly half (48.5%) were retired or homemakers.In addition to a lack of consistent income, individuals with cancer are often burdened with expensive treatments, medications, and inpatient costs, which for many can be financially crippling. 24e negative psychosocial and financial outcomes observed among individuals with cancer may partially explain our findings that utilization of certain negative health behaviors (eg, increased alcohol use) was significantly associated with having cancer, compared with people with other chronic illness.Nevertheless, people with cancer also reported an increased adoption of positive coping strategies, such as maintaining a healthy diet and engaging in physical activity.These mixed results might be attributed to the various coping approaches among participants in the initial year of the pandemic, alternating between positive and negative strategies.
There are several noteworthy limitations of this study.First, individuals reporting any chronic illness (excluding an active cancer diagnosis) were broadly categorized into one group.Furthermore, since the iCARE study was not designed to specifically assess the impact of the pandemic on individuals with cancer, the single question about cancer was general (active/current cancer), and in addition to not providing nuance into the type or stage of disease, the survey might not have captured all those with a history of a past cancer diagnosis.Hence, the results are largely applicable to current patients, rather than cancer survivors more generally.More interesting findings may have been discovered concerning relationships between various cancer types or specific chronic illnesses (eg, diabetes and heart disease) and the impacts of COVID-19 if data were available.Third, because it was not possible to know the number of people who received the study invitation, the response rate could not be measured.Fourth, response bias might have influenced the results.Last, although not evaluating the psychometric properties of the study survey might be considered a limitation, the iCARE study investigators made this choice to capture relevant constructs in real time.
Notwithstanding the above limitations, this study provides unique insight to the psychological, social, and financial challenges that individuals with cancer have faced since the start of the COVID-19 pandemic.Comparing these data to adults with other chronic illness has enabled a point of reference to be made, which, as discerned from our findings, indicates the need for better resources, assistance, and overall awareness for individuals with cancer during the pandemic.Our study provides evidence that necessary steps need to be taken to identify those living with cancer who are facing considerable hardship, and furthermore, provide the much-needed health and social services.However, we recognize that in some countries, limitations in the social safety net might hinder the ability to carry out these actions effectively.There are several important future steps for this research.First, a further investigation of the gaps in provision of mental health services in the cancer system and the avenues to make these services more accessible to patients is warranted.Moreover, scientific inquiry on strategies to promote and maintain healthy lifestyles for individuals with cancer during the pandemic would dually serve to benefit this vulnerable patient population now and in the case of future similar global events.
In conclusion, the current analysis of the iCARE study found that people with cancer were significantly older and more likely to be retired or unemployed, compared with other chronic disease populations.Relative to people with other chronic illness, those with cancer were found to have more adverse psychological symptoms related to COVID-19, as well as more social problems such as separation, divorce, and increased distrust of others.Additionally, those with cancer were more susceptible to financial hardship.Oncology and primary care clinicians need to be aware of the importance of attending to the psychosocial challenges experienced by individuals with cancer during the future restrictions related to this or future pandemics.
Clinicians should prioritize addressing gaps in mental health and psychosocial support for individuals with cancer and seek strategies to promote healthier lifestyles and resilience in the face of future similar global events.Study flow diagram.iCARE, International COVID-19 Awareness and Response Evaluation.
, such as names or contact details.Subject consent was waived because of the nonidentifiable nature of the collected data.The present paper is presented in line with the Consensus-Based Checklist for Reporting of Survey Studies 17 (Data Supplement, File S2).
1. Question 1: 19 items assessing COVID-19-related concerns (Because of COVID-19, I am concerned about being etc), each with five answer options (I do this a lot more; I do this more; I do this as much as before; I do this less; I do this a lot less).Data Analysis Data were analyzed using SAS statistical software package (version 9.4, SAS Institute Inc., Cary, NC).The means and standard deviations from each group (cancer and chronic illness) were first summarized using descriptive statistics.Means/analysis of variance for continuous data and frequencies/chi square tests for categorical data were used to compare sociodemographic characteristics between groups.Committee at the Centre int égr é universitaire de sant é et de services sociaux du Nord-de-l' Île-de-Montr éal (CIUSSS-NIM; REB No.: 2020-2099/03-25-2020).The current analysis was approved by the Health Research Ethics Board of Alberta (HREBA)-Cancer Committee (CC; REB No.: HRE-BA.CC-21-0267).The iCARE survey did not include any potentially identifiable information(mean age, 47.1 years; P < .001).Additionally, the majority of individuals with cancer were retired or homemakers (48.5%), whereas most of the respondents with other chronic illness were employed (37%; P < .001).Participant characteristics are summarized in Table 1.Objective 1: Impacts of COVID-19 on Psychosocial Health and QOL Table 2 shows the results of the multivariate analyses, examining the associations between health status and psychosocial outcomes.Individuals with cancer were more likely than other chronic disease populations to report arguments with family members (b 5 .243;P < .0001),suspicion and distrust of others (b 5 .182;P < .0001),getting separated or divorced (b 5 .645;P 5 .004),declined mental health (b 5 .364;P < .0001),and declined physical health (b 5 .317;P < .Furthermore, in comparison with other chronic disease populations, individuals with cancer were more likely to report concerns regarding their ability to go to school or university (b 5 .074;P < .05),finding enough food left on shelves (b 5 .252;P < .0001),and the time needed for life to return to a prepandemic normal (b 5 .126;P < .0001).

TABLE 1 .
Participant Characteristics (N5 18,154) a Difference between groups.b Difference within groups.

TABLE 2 .
Linear Regression Model Summaries Showing the Significance of Health Status as a Predictor of Psychosocial Outcomes

TABLE 2 .
Linear Regression Model Summaries Showing the Significance of Health Status as a Predictor of Psychosocial Outcomes (continued) a Unstandardized beta coefficient.b Statistically significant (P < .05).