In total 5383 references were imported into Rayyan, and 243 duplicates were removed. A total of 5140 records were screened by title and abstract by reviewers in two pairs (AL and AM; AK and FJD) and independently assessed against the inclusion criteria. In sum, 732 studies were identified for full-text review; 167 were considered for inclusion of which 56 report on the economic, social, and psychological impacts of COVID-19  (see Fig. 1).
Of these, 96% were single-country studies, predominately from the USA (20%), Italy (18%), India (11%), and China (11%). The remainder were from elsewhere in Europe (19%), Middle East (11%), Asia (4%), Brazil (4%), or Canada (2%). Most studies included patients with multiple cancer types (64%). Others focus on specific cancer sites: breast (18%), gynaecological (5%), head and neck (3.6%), lung (3.6%), thyroid (1.8%), colorectal (1.8%), or lymphoma (1.8%).
Social and psychological impacts of COVID-19 on cancer patients
Worry and fear
The most common mental health domain(s) identified were worry and/or fear around their cancer and getting COVID-19. Firstly, there was a heightened sense of fear of cancer recurrence or disease progression due to COVID-19-related disruptions or delays in cancer care [7,8,9,10,11,12,13,14]. Instruments used to measure fear and the level of fear experienced varied. For example, in a survey of 16 European countries, 71% of patients were concerned about cancer progression if their treatment/follow-up was cancelled/postponed . In contrast, a survey in India reported fear of treatment delays and cancer progression as mostly moderate or minimal .
Secondly, there was fear and worry around getting COVID-19 amongst cancer patients [7,8,9, 11,12,13, 15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35]. A Singaporean study reported that 66% of patients had an elevated level fear of COVID-19 . Gheorghe et al.  found that 68.5% of Romanian cancer patients were “very” or “somewhat worried” about COVID-19 compared to the influenza virus. Biagioli et al.  found that 37.3% of Italian cancer patients were “very or extremely” afraid of going to hospital because of an increased risk of contracting COVID-19 there, and 24.5% were “very or completely” afraid that their cancer care would become less important than being protected against COVID-19 infection, which would then have a negative impact on their prognosis. They also found that 53.8% believed they were at a higher risk of COVID-19 infection than the general population. Similarly, Erdem and Karaman  report that one-third of Turkish cancer patients were afraid to leave their house. These were more likely to be > 65 years, female, with stage 1 cancer, and with low education attainment. Those that did attend hospital appointments (~ 33%) were more likely to have stage 4 cancer; wore a mask (67%); and preferred not to use public transport owing to COVID-19 risk (95%). The majority (97%) did not accept visitors to their houses and washed their hands more often than usual (97.3%). Those finished treatment (radiotherapy or surgery) with co-morbidities (40%) were also afraid of COVID-19, in particular, females . Higher levels of worry were found among females and older patients in Italy [16, 30], patients with comorbidities, immunocompromised and on active treatment in Denmark, the USA, and China [24, 28, 33], and amongst those with higher stress levels in Iran .
Patients tended to prioritise their cancer care over fear of contracting COVID-19, suggesting they were more afraid of delayed treatment and cancer progression than COVID-19 . However, some sub-groups were willing to postpone/delay appointments and treatments [16, 21, 32].
Worryingly, as much as 61.8% were found to fear both COVID-19 infection and cancer progression equally . In practice, the two fears/worries are intertwined, with patients reporting fear of getting COVID-19 infection when in hospital for treatment  and fearing that chemotherapy treatment could increase risk of COVID-19 infection (27% of Italian cancer patients sampled ). Disparity also existed amongst those who worried more about COVID-19 infection than their cancer, low socioeconomic groups , those undergoing palliative care , older [8, 16], frailer patients with co-morbidities , or those with a good understanding of immunosuppression .
Distress, anxiety, and depression
Košir et al.  conducted an international survey and found those currently or undergoing treatment within the last 6 months reporting higher levels of psychological distress on average; the most common concern being contracting COVID-19. Some American cancer patients found attending in-person appointments or treatment alone, and the cancellation or movement to virtual social support groups was emotionally challenging and distressing . In France, being unemployed aggravated psychological distress further .
Several studies reported anxiety amongst samples of all cancer patients during the pandemic [29, 36, 42, 44]. Additionally, higher levels of anxiety were found amongst female patients in the UK, USA, Poland, and China [19, 26, 33, 35, 43, 45]; patients from lower income households ; older and more vulnerable patients in the Netherlands and Northern Italy [18, 30]; married patients in Singapore ; and patients with lower educational attainment in Italy, Singapore, and China [35, 36, 46]. In contrast, younger Chinese cancer patients demonstrated elevated levels of anxiety, suicide ideation, and low sleep quality, during the pandemic . While in China, Wang et al.  found those employed had a lower risk of anxiety and depression.
Higher levels of depression were reported amongst female patients in China , older patients in Turkey , those from lower income households in South Korea and India [11, 44], patients who were unemployed in China , and unmarried non-parents in South Korea .
Social isolation and loneliness
Several studies reported social isolation and loneliness amongst cancer patients [9, 20, 38, 48, 49] which was mediated by detachment from loved ones, lack of social interaction, loneliness, fear of infection, worries about the future, and economic difficulties . Several at-risk groups identified as feeling isolated and anxious. These included American women with ovarian cancer (10%)  and young cancer patients (aged 18–39) undergoing cancer care who felt more isolated (52%) than pre-pandemic, specifically missing social interactions . Elran-Barak and Mozeikov  reported that lower levels of education and living without minor children in Israel were associated with feelings of loneliness and isolation. Leach et al.  in the USA found cancer patients experiencing social distancing and living alone had feelings of loneliness, while disruptions to cancer care were associated with increased loneliness and social isolation [26, 49]. Some patients’ perceived risk of COVID-19 infection caused them to engage in extreme levels of social isolation where they had no visitors and lived alone . For others, the pandemic exasperated underlying situations. For example, Miaskowski et al.  upon comparing a more stressed group to a less stressed group found the former reported significantly higher levels of loneliness and social isolation and less resilience than the less stressed group.
Implications of social and psychological impacts
The review revealed that depression and anxiety progression might be associated with deliberate appointment delays . When delays were at post-treatment follow-up or palliative care, this was exasperated further . Also, Shinan‐Altman et al.  found that while incidences were low, patients with higher anxiety had more contact with healthcare professionals during the pandemic. Nevertheless, amongst the sample, anxiety did not directly influence healthcare decision-making.
Changes to the way healthcare organisations altered cancer care, to reduced COVID-19 transmission and increased uncertainty, for which tolerance and resilience varied. Hill et al.  found COVID-19 fear and intolerance of uncertainty were strongly correlated. Studies reported that health management changes to treatment plans increased patients’ psychological burden [9, 14, 20, 40, 43, 50,51,52,53]. These changes also increased uncertainty with an association between intolerance of uncertainty and anxiety, depressive symptoms, and stress . While uncertainties can be reduced with additional information, health literacy is influenced by socio-economic factors. Erdem and Karaman  found that higher educational status was associated with better knowledge of COVID-19 transmission. Better knowledge of COVID-19 was associated with patients aged 40–54 years, in higher education, being female, living in urban areas, with a profession, and a higher income amongst a sample of Romanian cancer patients .
Collectively, adverse effects on specific mental health domains had a broad impact. For example, loneliness and isolation amongst cancer patients contributed to declines in general mental health  and translated into declines in QoL [15, 20]. Several studies found deterioration in QoL due to COVID-19 compounded by the effects of treatment and financial implications in terms of affordability of care [20, 26]. Despite some respondents being aware of and worried about their QoL , those with higher stress levels concerning COVID-19 had worse QoL . Lower QoL and emotional functioning scores were correlated with concerns about contracting COVID-19 , with negative spill-over effects found on general health status and physical health in Italy  and Israel , respectively. Aggravating this further was postponement of care, which negatively impacted QoL . Socio-economic differences were found here too. A higher QoL was correlated with patients who were older , employed, with fewer co-morbidities, and not receiving treatment within the last two months . Patients with brain tumours, endometrial/cervical/vulva, and thoracic cancers had lower QoL scores . Being female, having lower educational attainment, crowded housing conditions, and longer illness duration also negatively affected self-reported health status among patients in Israel .
Economic impact of COVID-19 on cancer patients and care
From an individual perspective where treatments are not covered under government schemes or insurance, patients experience a large financial burden, in-terms of out-of-pocket expenses, expensive health insurance premiums, or deductibles . This was the case for a considerable proportion of cancer patients in India  and Jordan . While this is not a new phenomenon, it has been exasperated by COVID-19. Modified workflows and redistributed cancer care resources saw widespread use of telemedicine, with mixed effects. Transition to telemedicine saved US patients’ time and money ($170) . In contrast, Bakkar et al.  found that treatment changes incurred additional patient costs in Jordan. Globally, testing for COVID-19 (negative results were required to attend appointments) introduced varying fee structures with additional costs experienced amongst cancer patients in India  and South Korea . These costs affected patients’ decision to undergo cancer treatment particularly in poorer countries .
Widespread lockdowns during COVID-19 Wave I caused an economic downturn, with negative implications on labour markets. Cancer patients in India (22.2%) expressed fears around losing their jobs and the implications of the expected economic crisis for their family . Similarly, in the USA, cancer patients reported concerns with maintaining employment. These economic conditions exasperated pre-existing cancer financial burdens, including paying for prescriptions and high insurance deductibles in private healthcare markets in the USA . US patients were also concerned with affordability of treatments and transportation to medical facilities . Reduced earnings caused some patients to choose not to attend medical appointments. For example, 46% of cancer patients in India reported financial difficulties as the primary reason for missed consultations .
Several studies identified socio-economic factors associated with the economic impacts of COVID-19. Patients that were unemployed, with low educational attainment, or with lower incomes, or were under financial pressure had greater difficulties accessing care in India . In the USA, non-Hispanic white, married, more educated, and older cancer patients were less likely to cite financial worries . These socio-economic inequalities coupled with increased financial burden create barriers to accessing care .
Payers and providers
The consequences of COVID-19-related healthcare changes are potentially worsening patients’ clinical condition, which also has economic consequences at the provider level with implications for patients. For example, there is an increased likelihood of post-operative ICU following delayed surgery . During the pandemic, demands for services like respiratory assistance increased. This dual increase in demand had resource implications for healthcare providers; reduced resources limit choices to delivering post-operative cancer care or care for COVID-19 patients .
The introduction and expansion of telemedicine during the pandemic had mixed effects for healthcare providers and payers. Parikh et al.  reported the transition to telemedicine saved hospitals time and money in the USA. However, Goenka et al.  report that while it did ensure continuation of care, its cost and financial impacts must be considered. It may not be financially suitable for all care due to implementation and maintenance costs compared with reimbursement received, cost savings to patients (direct and indirect), and care coordination. Mahl et al.  found similar results for tele-consultation technologies for palliative and follow-up services in Brazil. Furthermore, the high prevalence of anxieties and fears discussed above culminated in increased demand for support services and information, as demonstrated by the increased volume of calls, emails, and messages found in one North American study . One Italian study found such communications tended to have more negative than positive messages (57% vs 43%) .
Innovations to mitigate impacts
Social and psychological impacts, along with modified workflows that redistributed healthcare resources, had an economic impact on patients and healthcare systems. US patients experiencing higher stress had more financial concerns , and COVID-19 exasperated existing financial burden associated with cancer on families, with some not being able to afford to attend consultations . Studies revealed coping strategies adopted by cancer survivors and patients to deal with the impact of the pandemic [20, 61]. Mechanisms used to cope included connection to family and friends, spirituality/prayer, music therapy, emotional supports, positive reframing, and daily routine, including self-care, hobbies, and planning [30, 61, 62]. These strategies were an important predictor of QoL  and positive health behaviours. Positive lifestyle choices were likely to alleviate mental health burden and improve HRQoL [30, 35, 54], while others employed avoidance coping strategies, including self-distraction and substance use .
Using positive coping strategies was important as delivery of support services was adversely impacted by COVID-19 [13, 51, 61]. Such supports included psychological and peer group support services, counseling for patients [13, 51, 61], and caregiver supports . Maintaining or quickly resuming these supports during the pandemic was associated with less anxiety  and distress . Additionally, patients with higher social support had more contact with healthcare professionals during the COVID-19 pandemic .