The health and assistance crisis generated by the SARS-CoV2 pandemic has been a serious health problem and a major disruption to the general population, specifically to the most vulnerable groups. Oncological patients are a vulnerable population to COVID-19, for increased likelihood of infection and complications requiring intensive care unit care .
In the present context, COVID-19 can have a double psychological impact on the lives of people with cancer. They must be subjected to quarantine in the same way as the general population, separation from loved ones, the loss of freedom, uncertainty over disease status, and boredom can, on occasion, create dramatic effects. A recent literature review , comprised of 24 studies, analyzed the impact of COVID quarantine on the psychological impact of this measure as a public health action. This paper determined that most reviewed studies reported negative psychological effects including post-traumatic stress and depressive symptoms, confusion, and anger. In addition, the authors identified a few risk factors associated with a higher number of psychopathological manifestations.
On the other hand, the impact of the oncological disease  is compounded by a complex emotional state. Patients experience the need to undergo life-saving treatments and the fear of exposing themselves to the contagion risk . Although no clinical data are currently available, the COVID-19 pandemic could intensify the psychological problems of cancer patients, which are already higher (around 30%) than in the general population. This hypothesis is based on a more intense infection fears from cancer patients (vulnerable group) as well as a higher prevalence of mental disorders, both considered risk factors for psychological problems in quarantine  .
The SARS-CoV2 pandemic is forcing health professionals to face and take on major challenges to maintain the necessary care. The community and public health dimension during the pandemic have made it impossible to provide psychological care in person, given the need to ensure that the virus is contained. For this, telemedicine is considered to be an especially good fit for psychiatric and psychological treatment and has been found to be effective, while improving access to care .
Currently in Spain, the practice of Telepsychology is regulated by the Official College of Psychologists, through the training of members and the preparation of various guides . The different clinical, ethical and legal aspects for the development of this activity are collected.
The main objective of this study was to maintain specialized psychological care for oncology patients. To this end, the Service had to adapt to the circumstances of the quarantine caused by the COVID-19 Pandemic and started a Telepsychology pilot program. And the second aim is to describe the principal psychological difficulties of our oncological patients.
To achieve these goals, the care activity of the units in which a psycho-oncologist was present in GenesisCare Spain since March 10 was reorganized (before the alarm state). Between March 10 and 13, the psychological care of the Castilla La Mancha, Murcia and Madrid Units was reorganized. Therapy was changed from face-to-face to 60 minutes telephone attendance, the activity of the School of Patients was maintained, and an e-mail account was opened for specific consultations or for cases where privacy was not available. All the tele-psychology interventions were registered in the GenesisCare network digital clinical story.
The psychological interventions carried out during this time have had two characteristics: 1) Cognitive-behavioral therapeutic framework demonstrated its scientific evidence in addressing emotional disorders, improving coping and quality of life in cancer patients ; 2) Targeted and specific interventions on issues associated with the COVID-19 pandemic.
Efficiency is maximized in all interventions and according to the following basic principles :
· Generate comprehension: it is necessary to give meaning to what a person feels in a new situation. This helps to normalize it as a previous step to generate changes in the emotional state.
· Promote relief through some strategies of empathy, unconditional acceptance and reinforcement request for help.
· Seeking balances and enhancing resources to cope.
The Psycho-oncology team has conducted an independent qualitative analysis, based on the psychological interviews. The aim was to define the areas of psychological intervention and to determine the main difficulties patients who attended experienced. In this regard, a high consensus has been obtained among the 2.5 Senior psychologists in the categorization of the above.
3.1. Psycho-Oncology Patient Attention by Phone/Digital Media
From March 10 to April 30 (8 weeks) patients and families have been attended to by 2.5 senior psycho-oncologists. A total of 369 psychological services have been attended in Spain in 142 patients, compared to 325 services in the same date the last year in 194 patients. So, during this year period we have attended to fewer patients, but they have required more consultations.
The number of services per patient has ranged from 1 to 4, the median of the long consultation has been 45 minutes, and the adherence to the psychological treatment has been very high, exceeding 95%. The 5% patients who refused the tele-psychology service were due to the face to face preference. Some of them have used the email facility due to the fault of intimacy at home, so we have realized ten psycho-oncology patient attentions by e-mail, with the same concerns and worries.
3.2. Sociodemographic and Clinical Description of the Sample Attended
As our psychologists are not specialized in a single pathology, their scope of action is wide and includes the care of different oncological pathologies. Table 1 shows the characteristics of the patients treated by Telepsychology during this period. At the medical level, people in need of psychological care may be in two situations regarding their illness:
· On treatment: patients undergoing cancer treatment after histopathological confirmation of their diagnosis (postsurgery or radical radiotherapy, chemotherapy or both).
· Follow-up: patient in follow-up after completion of cancer treatment, ranging from 1 month to 48 months. This group includes breast and prostate cancer patients under hormonal therapy.
3.3. Description of Intervention Areas and Psychological Demands
A qualitative analysis, based on a psychological interview, was conducted on the areas of intervention and concerns of the patients served. We have detected the following areas of concern: 1) cancer plus COVID-19; 2) Quarantine plus cancer; 3) Cancer usual worries; 4) Care for relatives of cancer patients. Table 2 shows the definition of the areas of psychological intervention in this Coronavirus pandemic situation. It also includes the most frequent manifestations reported by cancer patients and the number of cases that presented with difficulty in each area.
All patients presented with difficulties in more than one area and, despite the pandemic, for more than 60%, their main source of concern was aspects related to the oncological disease. The most frequent were oncological pain, fear of death and/or disease recurrence, and problems in managing the limitations and sequelae of the disease and treatments. A similar number of patients presented with emotional difficulties associated with quarantine, mainly emotional distress associated with COVID-19 overload of information; boredom and frustration; perception of high loneliness. In relation to family members, the most frequent problems were: stress due to overloading of care tasks; fear that the cancer patient will get infected within coronavirus and worsening of the previous grieving process.
Table 1. Sociodemographic and clinical description.
Table 2. Description of intervention areas and psychological demands.
Finally, almost 20% of patients stated that the experience of the oncological disease process had helped them to use positive and strong coping mechanisms. The most important revelations were: easier change adaptation; better loss elaboration and higher perception of strong support and social care (friends and family). It is important to emphasize that cancer patients and family members positively valued the possibility of funeral ceremony their deceased just before the pandemic according to Spanish cultural norms.
This pilot study reflects that Telepsychology is a viable option to maintain specialized psychological treatments in oncological patients. The Department of Psycho-Oncology of GenesisCare Spain has been able to organize and adapt to this need quickly during quarantine time for the COVID19. For this purpose, the therapy was changed from face-to-face to telephone attendance, the psychoeducation activities were maintained, and an e-mail account was opened for specific consultations or for cases where privacy was not available. However, the urgency of the situation has not allowed yet data to be provided on the effectiveness of this new strategy of working and its impact on the emotional wellbeing of patients.
These results are consistent with those reflected in the existing literature which indicates that the telematic care is considered an especially good fit for psychiatric and psychological treatment and improving access to care . Although telemedicine offers a great potential for delivering treatment during the COVID-19 pandemic, older technologies, such as telephonic communication and email, offer immediate and easy-to-use ways of providing care remotely . Research on telephone-delivered psychotherapy has found no decline in effectiveness compared to face-to-face therapy, in addition to an advantage for telephonic treatment in completion rates . In a complementary way, email is typically used for brief exchanges with patients.
The main concerns of our program had focused on the following areas: cancer plus coronavirus; quarantine; cancer usual worries and care for relatives of oncological patients. The concerns expressed by the users of this Telepsychology service can be associated with the six basic needs for psychological well-being in the theory of self-determination  . These can be compromised in stressful situations, such as cancer disease, a pandemic, or both: 1) self-acceptance; 2) positive relations with others; 3) autonomy (understood as self-determining); 4) environmental mastery; 5) purpose in life (understood as has goals in life and a sense of directness); 6) personal growth (understood as a feeling of continued development). This information together with that on stressors could guide psychological interventions, both in the general population and in the most vulnerable groups. Stressors included longer quarantine duration (cut-off point >10 days), infection fears, frustration, boredom, inadequate supplies, effectiveness in self-care guidelines, inadequate information, financial loss, and stigma . In agreement with the statement that the COVID-19 pandemic could intensify the psychological problems of cancer patients, which are already higher (around 30%) than in the general population, we have found that the main concerns (80%) were related to quarantine as emotional distress associated overload of information (53%) and on aspects specific to the oncological disease as fear of death and disease recurrence (52%).
One user group (about 20%) has expressed resilience. These patients have verbalized that the learning during cancer experience has made it easier for them to cope with the difficulties of the Coronavirus pandemic. A result that needs more evidence but is striking, is that the pandemic situation has helped some relatives to improve the previous grieving process. They have positively valued being able to care for their loved one, accompany them and be able to perform the farewell rites (established social-cultural norms). Therefore, these aspects are defined as essential to elaborate an adaptive grief.
As highlights of the clinical work, emphasis is placed on the rapid adaptation of the psychological care service that took place three days before the state of alarm in Spain (March 14). In addition, the collaboration of the GenesisCare Spain Contact Center was essential in planning and remembering the appointments. This issue, along with other clinical factors, has been able to positively influence the adherence to Telepsychology. Finally, it has been possible to compare the assistance activity with that of the previous year, concluding that during the pandemic the psychological care service has not stopped but has adapted (369 psychological services in 142 patients vs 325 services in 194 patients the last year).
However, this paper presents some limitations to be considered. Firstly, the need for rapid adaptation to the situation has made it impossible to assess, by means of psychometric questionnaires, the emotional impact of the pandemic and the outcome of psychological interventions. This has not allowed us to obtain yet objective results on the efficiency of Telepsychology in the oncological population. Secondly, it has not been possible to carry out psychological care by video call because we do not have a platform that complies with the rules of confidentiality and privacy of information. Finally, although we have increased our geographical coverage, psychological care has not been able to cover all patients in GenesisCare Spain due to the limited number of human resources in its Department of Psycho-Oncology.
Future lines should be directed at resolving these limitations. Psychometric measures should be included to assess the psychological state and psychosocial adjustment of Telepsychology users. In addition, to improve this service and facilitate better access, new technologies and the use of video call platforms should be incorporated. In the short term, it will be necessary to analyze compassionate fatigue in GenesisCare professionals due to the high intensity of clinical activity during the time of the pandemic.
In conclusion, this is a pilot study and a record of our new strategy to improve psychological care for cancer patients thanks to Telepsychology, which can remain a model of comprehensive care and improve access to a wide range of users. 80% of Oncological patients have shown highly structured negative emotional responses to COVID-19, but 20% have shown a resilient response to this stressful situation. Professionals have made a great effort to adapt and attend to the needs of patients and the consequences of this care will have to be analyzed in future work.
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