Cancer Patient Satisfaction and Perception of Chemotherapy Services during COVID-19 Pandemic in Central Java, Indonesia

The Indonesian authority declared the first confirmed case of coronavirus disease 2019 (COVID-19) positive patient on 2nd March 2020, a month after the WHO declared the COVID-19 outbreak a public health emergency [1-2]. By Mid July, 80.094 Indonesians were infected with a mortality rate of 4.74% [3]. This highly infectious disease has impacted all aspects of daily life and healthcare services, including cancer care. The delivery of cancer care during the pandemic poses immense challenges, considering the competing risks of mortality related to cancer or the infection of complications related to the SARS-CoV-2 [4]. Early shortage of personal protective equipment (PPE), limited isolation facilities, and lack of testing further complicate Abstract


Introduction
greater psychological stress because of postponed treatment and isolation on top of their inherent disease. Considering the novelty of this disease, there is a paucity of information and experience of cancer management during the pandemic. The objective of this study is to explore cancer patients' perception of oncology service amid the pandemic and to identify key elements that contribute to their level of anxiety or comfort. Obtaining such information may aid policymakers in decisionmaking to create strategies for ensuring better cancer care during the outbreak.

Questionnaire
This qualitative descriptive research aimed to gain information of cancer patient perception on cancer service during the pandemic. Eligible participants were given out a set of questionnaires to be completed during their visit or treatment in our institution. A semistructured questionnaire was developed by a committee of oncologist, institutional COVID-19 task force and approved by the governing Research Ethics Committee. The questionnaire is comprised of 30 multiple-choice questions divided into 2 parts. The first fifteen questions evaluate the subject's general knowledge of COVID-19 pandemic; awareness on the severity of the outbreak, preventive practices undertaken, and how pandemic affects their daily activities and disease. The rest of the questions explore the subject's experience, level of anxiety, and fear of undergoing chemotherapy. This part also evaluates the quality of healthcare service during the outbreak and allows the respondents to give inputs on what could be implemented to improve it. The questionnaire was created in Indonesian. The English version as seen in Table 2 and Table 3 were translated from Indonesian to English by two different researchers and then reconciled by a third reviewer for the best-corrected version.

Study participants, data collection and analysis
Participants included for this study were all cancer patients indicated for chemotherapy (prior, undergoing, or post) in Dr. Kariadi General Hospital, Semarang, Indonesia. Patients who refused to participate or considered to be clinically unfit were excluded. Two researchers unaffiliated with our institution performed data collection within 22 nd June 2020 until 3 rd July 2020; 75 days after the implementation of hospital and treatment policy changes on 9 th April 2020. Using the conveniencesampling method, all subjects were recruited while waiting in the outpatient oncology clinic or undergoing chemotherapy in the ward. Participant's confidentiality was ensured and that their response will not in any way affect the chemotherapy service. Every subject was given an unlimited amount of time to complete the questionnaire that was collected within the same day.
A family member or the researcher was allowed to assist participants in filling the form. Uncompleted questionnaires were excluded from the analysis. Ethical approval was granted by the hospital Ethics Committee

Results
A significant majority of the 221 participants in this study were Javanese females diagnosed with breast cancer with below than average level of income. The patients' demographic data are presented in Table 1   hospital workers (2 out of 221, 0.9%). The majority of patients trusted the new hospital policies (211 out of 221, 95.5%), PPE (215 out of 221, 97.3%) and workers (217 out of 221, 98.2%) for being able to maintain their safety and deliver safe treatment. More than half of the respondents claimed that the quality of both general health care services and chemotherapy remained consistent or even better during the outbreak. Most respondents agreed that more PPE worn by the hospital workers and themselves may improve the quality of chemotherapy service and lower their level of anxiety. Patient perception and satisfaction of oncologic service are presented in Table 3.

Discussion
The COVID-19 pandemic is an ongoing International concern that created unprecedented media attention and coverage. Never before a disease entity created such interests from the global population across all socioeconomic backgrounds. In Indonesia, the COVID-19 received substantial social publications across all platforms, chiefly the television, internet (including social media, mobile communication app) newspaper (paper and electronic), radio, and mural advertising educating the people with the basic knowledge of coronavirus epidemiology, virology, and prevention [12]. The mass media proved to be a very efficient way of information transfer, as supported by the findings of this survey. Almost all patients (213 out of 221, 96.4%) obtained information about COVID-19 from either the television or the internet. They claimed to be well-informed and successfully practiced social isolation, physical distancing, improved hand, and respiratory hygiene. On the other hand, less than 40% of patients reported being adequately educated by the chemotherapy unit workers (doctors, nurses, ward officers). In this extraordinary circumstance, the mass media is undoubtedly faster and more efficient compared to the direct doctor-to-patient education system. However, the deficiency in doctor-to-patient education should be addressed considering the media does not broadcast in-depth knowledge such as the relationship between COVID-19, cancer, and chemotherapy.
Only 27 (12.2%) patients in our study claimed to be educated their physicians in regard to this matter. Access and comprehension of advanced medical information are limited to healthcare professionals. Extensive media coverage of the coronavirus outbreak may also be counterproductive by creating exacerbated public fear, panic, and stress [13]. Thus physicians play a major role in patient education by being able to practice evidence-based medicine, filter fallacious information, and control patient apprehension. In short, it is advisable for policymakers to capitalize on effective educational platforms (e.g. hospital televised infomercial, hospital mobile app), without abandoning the physician's pivotal role in direct patient education.
Following the declaration of COVID-19 as a global emergency, the Indonesian Government created the COVID-19 Response Acceleration Task Force (CRATF) in an effort to accelerate the mitigation of coronavirus disease. Coordinated by the Indonesian National Board for Disaster Management, Ministry of Health, National Police and Armed force, the task force published a series of guidelines for all sectors aiming to manage the outbreak [14]. The guideline for health care sector was formulated from collective information from several of the Nation's medical specialist associations [15]. Hospitals are advised to follow this guideline, however, it can be adjusted based on the available human resources and medical facilities of each region. As a tertiary referral hospital, our oncology center adhered to the local hospital guideline that is in concordance with the COVID-19 guideline published by the National Task Force.
Online reservation for clinical follow-up or chemotherapy was made mandatory since the pandemic. All patients were instructed to come at most 15 minutes before the designated time and instructed to directly go home after they are done. Before entering the building, all patients were screened by trained personnel using the COVID-19 early warning score (EWS) screening tool [16] and classified into one of the four patient categories based on their relation with COVID-19: person without symptom (PWS), person under monitoring (PUM), patient under surveillance (PUS), and confirmed case. Case definitions and initial approaches are summarized in Table 4.
Only those who are not suspected of COVID-19 were allowed inside to continue their treatment otherwise, the patient is directed to a dedicated COVID-19 management area within the hospital complex. All hospital staffs within the premise continuously enforce facemask usage and physical distancing. Such precautionary measures would have been a major inconvenience for patients in the pre-COVID era by creating longer queues and discomfort. Anxiety is a common problem in cancer patients and will negatively impact their quality of life, treatment satisfaction, and outcome [17]. The fear of contracting coronavirus aggravates this problem, as shown in our study that 81% of the patients were afraid of being infected while undergoing chemotherapy. Some of them even thought of stopping chemotherapy (30 out of 221, 13.6%) or coming to the clinic for follow-up altogether (28 out of 221, 12.7%). Although COVID-19 preventive measures are not 100% effective in preventing disease transmission, we think its application is detrimental for patients by creating a "sense of security" reducing their level of anxiety and fear. Almost all respondents trusted the hospital's policy in handling COVID-19 and put confidence in the hospital staff for maintaining their safety. Based on this survey, PPE worn by the healthcare personnel and patient is the major anxiety-reducing factor while undergoing chemotherapy. The level of PPE worn by hospital personnel was deemed adequate by 97.3% of respondents. However interestingly, half of them think that more PPE worn by hospital workers can further improve the quality of service. Our institution was able to maintain the quality of chemotherapy service during the pandemic. About half of the respondents (113 out of 221, 51.1%) think the quality of service remains the same and even improved during the pandemic. Most patients in our study (154 out of 221, 69.7%) were able to resume their chemotherapy normally since the pandemic. Some patients (42 out of 221, 19%) patients had problems coming to the hospital from neighboring cities because of the inter-city travel bans imposed by the government from late April until early June.
The main dilemma for continuing chemotherapy during the crisis is the potential infection of COVID-19. Limited data from the Chinese population suggest cancer patients who contracted COVID-19 suffered from higher rates of severe events and mortality compared to their counterparts [18][19]. However, a current systematic review does not support interruption of chemotherapy or immunotherapy for cancer patients and does not recommend withholding anticancer therapy for those who do not have COVID-19 [20]. One prospective cohort study suggests that mortality from COVID-19 in cancer patients is more driven by age, gender, and comorbidities [21]. Solid data is lacking to draw any conclusion in the potential harm from interrupting chemotherapy versus the benefits of possibly preventing COVID-19 infection. In this light, many clinical resources have recently been published guidelines for health care professionals on the proper recommendations to deliver safe and effective oncologic services.
Major guidelines generally advise the approach should be individualized based on the patient's level of priority. The American Society of Clinical Oncology (ASCO) advised clinical decision to be based on cancer curability, risk of recurrence with treatment modification   [3], c Since 14 July 2020 the Indonesian COVID-19 patient category system followed the case definitions as defined by the WHO [24]. ± at least one positive; PUS, patient under surveillance; PUM, person under monitoring; PWS, person without symptom; CBC, complete blood count; WBCD, white blood cell differential; CXR, chest x-ray; NPS, 2 consecutive days of nasopharyngeal swabs for RT-PCR assays. or interruption, the number of cycles already completed, and patient's tolerance to treatment. Chemotherapy recommendations set forth by ASCO include stopping chemotherapy as an option for those in deep remission receiving maintenance therapy or in cases where the clinical benefit of adjuvant chemotherapy is expected to be small, start oral chemotherapy or home infusion, alter treatment schedule for fewer visits, and to be selective in using drugs that inhibit B cells such as anti-CD20 monoclonal antibodies [9].  (10). For example prioritization, treatment, and triage of breast cancer patients is consistent with the recommendations made by the American Society of Breast Surgeons (ASBrS) [22]. Thyroid cancer management is based on the British Association of Endocrine and Thyroid Surgeons (BAETS) statement [23]. Management of melanoma and sarcoma adhered to the guidelines published by ESMO [6]. In our institution, the decision whether or not to postpone cancer treatment were made on a patient-by-patient basis by the oncologists' clinical judgment. Current local hospital guideline does not dictate specifically in regards to this matter. To which practice guidelines each oncologist follow was not recorded and is beyond the scope of this study. Only 5 (2.3%) patients experienced treatment postponement during the course of this survey that suggests treatment interruption is uncommon. The oncology working groups to meet and reach a conclusion on which guideline that they are going to follow to maintain service quality.
The inherent limitation of this study is the small size convenience sampling that is not translatable to the general population. Since the majority of cancer patients in our hospital were breast, head, and neck cancers, there may be selection bias caused by venue selection to distribute the questionnaires. Since data collection was performed in a cross-sectional fashion the causal relationship between the variables cannot be made.
In conclusion, the COVID-19 pandemic significantly alters all aspects of life, including health care services. Changes in hospital treatment policies in an attempt to manage disease transmission may inadvertently impose a greater level of anxiety and unnecessary treatment interruption for cancer patients. The effectiveness of the media in spreading general knowledge about of COVID-19 is undeniable. However, information sharing through this platform may backfire by being misinterpreted and creates exaggerated fear. Findings from this study suggest that the majority of Indonesian cancer patients in Central Java possess adequate knowledge and successfully practiced appropriate preventive measures towards the COVID-19 pandemic. They expressed a positive attitude towards the changes in hospital policies and were generally happy with the consistency of chemotherapy services during the pandemic. So far, alterations in the treatment program were individualized for each cancer type by the oncologists in accordance with their respective specialist association guidelines. Definitive data on the risks and benefits of altering chemotherapy for cancer patients during COVID-19 remains to be elucidated and will require longer prospective observations from cases all around the world.

Funding
No funding