COVID-19 pandemic shakes the trust between oncologists and their patients.

Being diagnosed with cancer is a major turning point in the life of a patient. It is a true roller coaster ride; a long journey governed by fear, anxiety and uncertainty about the future. Optimal coping with the disease by itself, the treatment and life events (work, family) are essential to minimise the physical and psychological burden on the patient. Both the family caregivers and the oncologist play a vital role in the patients’ support throughout their journey.

Since late December 2019, the world has suffered from a global pandemic caused by COVID‐19 (caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐Cov‐2) virus), which has deeply affected cultural habits, lifestyles and health treatment policies. , Even though the vast majority of COVID‐19 infections are self‐limited, a non‐negligible proportion of patients are at high risk of developing severe complications and death; most particularly the elderly people and the immunocompromised including cancer patients. , Strict measures have been adopted all over the world including total lockdowns, which precluded the transportation of patients to the hospitals and limited physical meetings. Therefore, cancer patient‐oncologist communication and in‐person meetings became seldom. Also, when such encounters did occur, they would be limited in time without the presence of family members and with the implementation of physical barriers such as physical distancing and the use of masks. Moreover, the compassionate interaction and subsequently, the trust were deeply affected by these COVID‐19 pandemic restrictions.

Trust is the essential pillar that governs the relationship and the interaction between the physician and his patient. Moreover, in the oncology field, there is always a particular and sacred connection between the oncologist and his patient to guide his way through his disease from the initial diagnosis until the cure or the terminal phase. Building a solid therapeutic alliance leads to better psychosocial well‐being and treatment adherence, thus leading to better oncological outcomes. Seethramu et al discussed four essential determinants to improve the trust between the cancer patient and his care provider: (1) reducing the potential of shame during consultations (physical examination, causative factors such as smoking leading to lung cancer), (2) optimal use of the power imbalance between the oncologist and his patient without abuse, (3) understanding the psychological and physical suffering related to the disease and (4) understanding the impact of cancer therapy on the patient. Other factors may also strengthen this relationship including professionalism and competency of the physician, psychological status and religious or cultural beliefs of the patients as well as trust in the health care system. , ,

Based on this alliance, the oncologist should face many challenging checkpoints during the disease course starting from the first visit to announce the cancer diagnosis, then discussing the prognosis and the available treatment options, and also the gloomy moments and the agony of disease recurrence or more particularly the transition to palliative or terminal phase. But, now with the pandemic and the nationwide restrictions, adequate communication between the oncologist and the patient with his family is facing many hurdles and limitations, mostly at truly sensitive moments during the disease evolution. “Breaking bad news” is a fundamental point in the bond between patients and their oncologists. Prognostic discussions, notably those with a serious illness such as cancer, constitute a key component in this relationship that would support this alliance and improve the trust between both parties. Bousquet et al published a meta‐synthesis for a better understanding of the complexity and difficulty of delivering bad news to cancer patients by the evaluation of the experiences and perspectives of oncologists. They stated that the oncologist should always adapt his words to the patient, his family and to each situation, taking into consideration the culture and nature of each individual. Also, an important point is that the oncologist should expect the huge emotional burden inflicted by the delivery of bad news, mostly to patients he had acquainted with for many prolonged years. This constitutes a big limitation to online consultations, mostly in sensitive conversations, which can be interrupted by a bad internet connection or by an external intrusion; whilst the face‐to‐face dialogue can lead to emotional interchange at these exact moments of distress (fear, anxiety, anger, disbelief, shock). Delivering bad news with telemedicine is very challenging: lack of privacy (when the elderly patients require assistance with technology), the physical absence of caregivers (resulting from COVID‐19 limitations), lack of physical contact and body language with increased psychological distancing and the technical delays or cuts interrupting delicate and emotional moments. Even though different recommendations were issued to guide the management of these vulnerable patients during the pandemic, there is a pivotal role for the oncologist to screen his patients, mostly because of anxiety and uncertainty during the pandemic, and select those who might benefit from physical meetings.

On the other hand, telemedicine, defined as the delivery of health services using online technology, has been gaining momentum as an alternative means of communication between patients and their physicians. During the pandemic, both physicians and patients showed some satisfaction with the implementation of this technology instead of physical meetings but many challenges are yet to be addressed. The advantages of telemedicine include the reduction in the use of personal protective equipment (PPE), a decrease in the risk of COVID‐19 transmission (less travel time, less hospital or consultation hours) and improvement in the discussion between specialists. But also, there are some drawbacks for employing telemedicine: limited access to the internet for the undermined patients, refusal of receiving care from distance and the absence of appropriate physical exam. Furthermore, some patients reported a sense of nervousness, anxiety and reluctance regarding the use of telemedicine as a new mean of medical consultations. Telemedicine constitutes a true opportunity to optimise the health care system and improve the liaison between the patient and his physician; however, the humane connection, the need to feel the emotions (fear, sadness, pain...), the physical touch and the empathy are certainly lacking. The relationship between the oncologist and his patients is rather particular; the physician sometimes puts himself in his patients’ shoes: not only the happiness of a confirmed response to therapy but also the misery of disease progression. There is nothing more intimate than sharing life decisions with another human being: not only the announcement of the diagnosis, and discussion about the different types of therapy and their impact on life and work decisions, but also the physical and psychological changes, preparing the patient and his caregivers for end‐of‐life decisions in case of incurable disease. Cancer patients have expressed their concerns regarding telehealth and the reduced face‐to‐face interaction whilst stressing on the fact that medical practice might become less humane.

The COVID‐19 pandemic has shaped the lives of all human beings. Worldwide, every aspect of our medical practice has been largely impacted by changing habits regarding emergency care, outpatient consultations and most importantly surgical management with a key role for multidisciplinary approaches. , , Official health authorities had to release strict rules regarding the risk of virus transmission whether by reducing hospital visits, forbidding accompanying patients and social distancing, which has led to a sense of neglect and isolation of the cancer patient with limited support from his family, friends or his oncologist. Also, several international medical societies have recommended treatment disruptions or cancellations (such as surgery or adjuvant chemotherapy) in cancer patients, which would increase the risk of self‐harm, depression and loneliness. , , In fact, during the COVID‐19 pandemic, almost 23% of newly diagnosed cancer patients in China had depression and 17% expressed anxiety with very few patients seeking psychological support, indicating high distress related to the coronavirus outbreak. This psychological distress was also noted among cancer survivors during the implementation of the strict lockdown. Additionally, cancer patients are constantly anxious about a positive PCR COVID‐19 swab that will lead to cancer treatment interruption, the imposition of isolation without any support from the oncologist and their family and the higher risk of COVID‐19‐related complications.

As physicians, there are always endeavours to separate the emotional counterpart from the daily medical practice. Nevertheless, in the oncology world, it is quite different. Oncologists are considered guardian angels who will be there at every up and down to guide the patients towards the right path. The oncologist would feel less effective towards cancer patient care during the pandemic restrictions. Replacing physical consultations and disclosing bad news by online meetings cannot ideally satisfy cancer patients in need of optimal mental and psychological support. International guidelines should take into consideration the vulnerability and the unique characteristics of cancer patients to optimise their cancer care, maintain their quality of life and rebuild mutual trust.

DISCLOSURES

None.