Introduction

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first detected in Wuhan, China in December 2019. It quickly escalated to levels that required the World Health Organization (WHO) to declare a pandemic by March 2020 [1]. In a matter of months, this global pandemic has severely impacted healthcare service delivery across the world. In specific, healthcare services associated with non-communicable diseases (NCDs) have been disproportionately and significantly disrupted. A survey of 155 countries, conducted by the WHO, found that 42% of countries reported disruptions to cancer treatment and an astounding 63% reported service disruptions in rehabilitation services, which include survivorship care [2].

It is evident that the impact of COVID-19 extends far beyond that of an infectious disease itself [3]. The emergence of this global pandemic has resulted in radical changes in the global healthcare delivery landscape and has had practical repercussions for cancer survivors because essential components of survivorship care (i.e. ongoing oncological screening and surveillance, physical symptom support, psychosocial symptom support and promotion and guidance on healthy lifestyle maintenance) have traditionally been heavily dependent on in-person healthcare interactions [4]. The current circumstances have reduced the accessibility of already limited support services during a time when anxiety, depression and COVID-19-related fears appear to have increased among survivors [5].

New social distancing requirements imposed by governments based on evidence-based international recommendations and the deferral of non-emergent, elective and preventive medical services have detrimentally impacted to state of survivorship care and exposed fragilities in the current delivery of care [4, 6, 7]. In fact, survivorship visits have been placed at lowest priority in some countries despite the fact that experts have stressed the importance of maintaining the emotional wellbeing of patients through psychosocial support during the pandemic [8, 9]. This has required many survivors, that previously benefited from significant support and guidance from healthcare professionals and experts, to try to self-manage symptoms. Consequently, cancer survivors in this scenario may feel helpless and neglected as their unique needs are being classified as ‘non-urgent’ and are not being addressed in the right place, at the right time, in the right amount and in the right manner. Experts have indicated that such circumstances will detrimentally impact the survivorship “experience and the management of cancer-related symptoms, quality of life and survival” [10, 11].

In fact, anecdotal survivor experiences included in the current and developing literature on the topic have already begun to illuminate the untold toll of the pandemic on patients without COVID-19. Anecdotal information from survivors indicates that they value the “opportunity to learn about social and emotional support services” following active cancer treatment; however, the current situation has necessitated brief interactions over the phone that have left some survivors feeling “overwhelmed and confused” and “the lack of face-to-face interaction, compounded by the unavailability of typical support systems has made it difficult to cope” [12]. Experts and healthcare professionals are calling for increased research efforts to comprehensively understand the consequences of the pandemic on cancer survivors [13].

This systematic rapid living review has been undertaken with the goal of synthesizing the available knowledge regarding the impact of the COVID-19 pandemic in a timely manner. This initial rapid review will present the findings of literature published up to August 27, 2020 and will be updated on a regular basis as new and relevant literature on the subject becomes available.

Methods

Design

Systematic review completed in accordance with PRISMA guidelines [14].

Search strategy

On August 27, 2020, a systematic search of PubMed, Scopus and Google Scholar databases was conducted to identify all articles, available in English language, regarding the impact of the COVID-19 pandemic on cancer survivors who have completed primary anti-cancer treatment and are free of disease, published between December 2019 and August 27, 2020. The search strategy employed included the following search strings: “covid-19 OR coronavirus OR sars-cov-2” with “cancer survivors OR cancer survivorship”. This study has been submitted to PROSPERO (Registration number: CRD42020197012) and was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P).

Study selection

One author (A.J.) independently completed all searches using the pre-established search strategy. In order to identify additional articles of relevance, the references of selected articles were hand searched. Duplicate records were systematically identified and removed. Identification of eligible studies took place in two stages.

During the first screening stage, eligible studies were selected by two authors (A.J., M.C.) based on the relevance of study titles and abstracts. In this review, eligible study titles and abstracts were required to be available in the English language; however, there were no eligible studies that were removed as a consequence of this restriction. The second screening stage involved a careful review of the full-text articles deemed relevant in the first stage. A critical appraisal of each of the full-text articles was conducted to ensure that the selected articles reported on a relevant topic associated with the impact of COVID-19 on cancer survivors who have completed primary anti-cancer treatment and are free of disease. The reference lists of articles were hand searched in an attempt to identify additional relevant articles. Discrepancies and general queries were resolved through consensus with two more authors (R.B., A.L.).

Data extraction

One author (A.J.) independently extracted data and information from the eligible studies using a data extraction table generated in Microsoft Excel. Data extracted from the selected articles included (if applicable): (1) article citation; (2) study design; (3) study aim; (4) study/target population; (5) study/target setting; (6) country of origin and (7) relevant content/main findings. The quality of the included studies was not appraised.

Analysis

A narrative synthesis of the results and conclusions of the eligible studies was conducted.

Results

Of the 1639 articles identified through a database search, 19 were included in the qualitative synthesis. Figure 1 indicates the specific study screening process.

Fig. 1
figure 1

PRISMA flow diagram depicting the study screening process

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The selected articles present information related to the impact of the COVID-19 pandemic on cancer survivors directly or indirectly. Of the 19 selected articles, there are 12 expert opinions (including editorials, calls to action, clinical correspondence), two literature reviews, two prospective cohort studies, one retrospective cohort study, one descriptive study and one pooled meta-analysis. Overall, 16 of the articles comment on the impact of the COVID-19 pandemic on the physical wellbeing of cancer survivors, 15 address the impact of the pandemic on the psychosocial wellbeing of survivors and three focus on the economic consequences of the COVID-19 pandemic related to the financial wellbeing of survivors. These articles originate from the USA (n = 9), USA and Canada (n = 2), Hong Kong (n = 2), Canada (n = 1), Australia (n = 1), China (n = 1), Sri Lanka (n = 1) and multinational collaboration (n = 2). Relevant findings and conclusions of each of the 19 articles are contained in Table 1. These articles have been categorised based on specific content areas related to the impact of the COVID-19 pandemic on cancer survivors. Some of the articles fall into multiple categories as a result of the breadth of information covered in specific publications.

Table 1 Relevant findings and conclusions of the 19 articles included in this rapid review of the impact of COVID-19 on cancer survivors
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Survivorship care delivery

The first category is comprised of articles addressing significant changes to the care that survivors receive and the channels through which it is delivered. These articles provide insight into how survivorship care has evolved in response to the new challenges presented by the COVID-19 pandemic and in an attempt to reduce the risk of infection transmission. Calvillo-Argüelles et al. [6] and Dietz et al. [8] point out that the current recommendation based on available evidence is the temporary modification or postponement of routine surveillance and follow-up of asymptomatic cancer survivors. Chan et al. [7] and Koczwara [11] indicate that survivors have seen significant delays and cancellations of follow-up appointments and the replacement of most in person interactions with telehealth. However, Chan et al. [7] have noted that many barriers continue to impede widespread implementation of telehealth, and great disparities exist in how patient needs are being triaged amid the pandemic. Ratnasekra et al. [26] have also highlighted that lockdown restrictions imposed due to COVID-19 have impacted the availability and accessibility or routine healthcare services for cancer patients and survivors. In fact, Papautsky and Hamlish [25] conducted a survey of breast cancer survivors in which 44% reported delays across all aspects of cancer care and treatment. Flannigan et al. [19], Jhaveri et al. [21] and Nilsen et al. [24] demonstrate how the pandemic has necessitated drastic changes in the delivery of some cancer survivorship programs. While there has been an effort to rapidly transition to delivering elements of survivorship care (e.g. physical activity, nutrition support, stress management and spiritual wellness) through telehealth, some elements of operations have been temporarily suspended, postponed or removed by necessity. As such, the COVID-19 pandemic has drastically reduced the frequency and types of care survivors are able to access as jurisdictions attempt to reduce risk of COVID-19 transmission through in-person healthcare encounters.

Psychosocial and physical wellbeing

The second group includes articles that comment on the impact of the pandemic on the psychosocial and physical wellbeing of cancer survivors. Boakye et al. [16] and Huang et al. [20] noted that postponement of surveillance and other elective procedures to improve quality of life may lead to increase anxiety, delayed diagnosis of disease recurrence and reduced quality of life. Chan et al. [7] indicated that some healthcare providers have noted increased anxiety and distress among survivors in relation to using telehealth, and Jhaveri et al. [21] noted that some survivors have expressed an increased need for behavioural health and social support during the pandemic. Nekhlyudov et al. [13] highlighted that the pandemic may disproportionately impact the physical and psychosocial wellbeing of cancer survivors due to the requirement to maintain physical distancing from their social and support networks and increased anxiety related to cancellation, postponement or modification of follow-up visits and cancer surveillance. Notably, Ng et al. [23] found that cancer survivors demonstrated greater catastrophizing and health anxiety (but less psychological distress) compared to healthy controls. According to Koczwara [11], cancer survivors experience greater psychological distress and difficulty managing physical symptoms than the general public and may be unable to continue to adhere to lifestyle recommendations due to pandemic restrictions that have limited physical examinations and required survivors to self-administer exercise programs previously delivered by healthcare professionals. Ratnasekra et al. [26] noted that oral cancer survivors experiencing pain and difficulty swallowing faced difficulties in accessing routine treatment and medication due to lockdown restrictions. Cheung et al. [17] highlighted that paediatric cancer survivors believed to have increased susceptibility to COVID-19 have found themselves confined to their homes which may result in downstream adverse health outcomes and poor psychological wellbeing. Young et al. [27] pointed out that cancer survivors also may have trouble difficulty determining whether experienced symptoms are the result of COVID-19 or cancer recurrence and whether to report them. A study by Zhou et al. [28] noted reduced insomnia severity among young adult cancer survivors following COVID-19 lockdown restrictions and highlighted the need to identify factors contributing to better sleep and increased anxiety and depression during the pandemic.

A subset of included articles provides preliminary results indicating that cancer patients and survivors may have increased susceptibility to COVID-19 infection. Liang et al. [22] noted that cancer patients and survivorship with current or past cancer diagnosis may be at increased risk of significant morbidity (including ICU admission, requirement for invasive ventilation or death) compared to patients without cancer. A pooled meta-analysis by Desai et al. [18] also found that patients with cancer and cancer survivors were at increased risk of acquiring COVID-19 and although evidence regarding the association between COVID-19 and cancer is unclear, greater precautions to protect such individuals may be warranted. As such, based on the potential increased susceptibility of cancer survivors to COVID-19, necessity of any interventions must be compared to the risk of inadvertent exposure to COVID-19.

Financial wellbeing

The final category includes articles that comment on the economic consequences of the pandemic on cancer survivors. Baddour et al. [15] notes that the pandemic and its economic consequences may disproportionately impact cancer survivors and their overall health-related quality of life and mortality. Boakye et al. [16], Nekhlyudov et al. [13] and Koczwara [11] indicate that cancer survivors may be more economically vulnerable and face greater financial hardship during the COVID-19 pandemic.

Discussion

This is the first systematic review of the available literature regarding the wide-ranging impact of the COVID-19 pandemic on cancer survivors. As this review has been conducted as a living rapid review, it will be updated regularly as new and relevant literature on the subject becomes available. Despite the fact that a combination of terms were employed as part of the search strategy and the reference lists of appropriate articles were hand searched, a very limited amount of relevant literature published till August 27, 2020 was found. Furthermore, most of the selected articles (63%) depend on expert opinions, presented in various forms, that explore specific aspects of the impact of the COVID-19 pandemic on cancer survivors. Very few of the selected papers expressly examine the potential wide-ranging impacts of the COVID-19 pandemic in any great detail.

In spite of the current lack of extensive and definitive research in the field, the articles identified through this rapid review provide preliminary information regarding potential impacts of the COVID-19 pandemic on cancer survivors. Foremost, the available literature highlights drastic changes to survivorship care services accessible to survivors and the medium by which they are delivered during the pandemic. Survivors have been subject to significant delays and cancellations of follow-up appointments and the rapid transition of in-person healthcare interactions to telehealth in resource settings that permit its widespread implementation [7, 11, 19, 21, 24,25,26]. As such, the pandemic has affected the availability and accessibility of routine healthcare services. Particularly, physical examinations and some elements of survivorship care (e.g. exercise programs) cannot be effectively delivered remotely and have been temporarily suspended, postponed or removed from survivorship care plans [19, 21, 24]. As efforts are made to reduce risk of nosocomial COVID-19 transmission, significant changes have been made to the normal standard of care (in terms of frequency, types of care and mode of delivery) that some survivors have grown to depend on. Any changes to a trusted source of care, which may have previously been perceived as a source of confidence and stability, may become the source of increased distress and anxiety.

In addition, the current literature indicates that the COVID-19 pandemic may detrimentally impact the psychosocial and physical wellbeing of cancer survivors. Preliminary research in the field indicates that cancer patients and survivors may have increased susceptibility to COVID-19 infection [18, 22] and as a result, the necessity of interventions must be weighed against the potential risk of inadvertent COVID-19 exposure [18]. In an attempt to protect cancer survivors and due to the redirection of healthcare resources, cancer surveillance and other elements of survivorship care have been postponed or cancelled [7, 11, 19, 21, 24,25,26]. This may result in increased anxiety, diminished quality of life and delayed diagnosis of any disease recurrence or secondary malignancies [16]. Available articles also highlight that increased anxiety and distress has been observed among some survivors with respect to accessing telehealth services and doubts related to the quality of care available through the remote medium [7]. Strict social distancing restrictions across jurisdictions have also reduced access to social and support networks that some survivors may have previously depended upon for physical and psychosocial support [13]. Preliminary research also indicates that cancer survivors are more prone to catastrophising and health anxiety in relation to COVID-19 compared to healthy controls [23]. Thus, the limited literature currently available provides initial indications that the COVID-19 pandemic may detrimentally affect the psychosocial and physical wellbeing of some survivors.

Furthermore, available literature notes that the COVID-19 pandemic may disproportionately impact cancer survivors from an economic standpoint [11, 13, 15, 16]. The pandemic has significantly impacted national economies and has resulted in widespread unemployment. However, some cancer survivors with the option to continue to work during the pandemic may have had to leave work due to immunocompromised status putting them at increased risk of COVID-19 infection. Survivors that have lost their jobs due to the pandemic may be experiencing greater economic burden than the general population due to costs incurred during treatment and recovery [11, 13, 16]. Increased financial hardships may in turn, result of detrimental downstream psychosocial and physical impacts on survivors [15].

Overall, the presently available literature provides preliminary indications of wide-ranging impacts of COVID-19 pandemic on cancer survivors with respect to the requirement to adapt to new means of healthcare delivery as well as their physical, psychosocial and economic wellbeing. The COVID-19 pandemic has left survivors dealing with the consequences of rigorous cancer treatment in the context of new challenges related to social isolation, financial hardship and uncertainty with respect to their ongoing care. The challenges presented by the global pandemic may disproportionately impact the overall wellbeing of cancer survivors, which may result in unintended long-term consequences [29].

Study limitations

A key limitation of this systematic living rapid review is the fact that study selection was restricted to articles published following the initial detection of SARS-CoV-2 given the nature of the subject at hand. Given the limited time frame under consideration and the significant resource demands imposed by the COVID-19 pandemic, limited rigorously designed studies are currently available on the impact of the COVID-19 pandemic on cancer survivors, and the present rapid review had to depend heavily upon various forms of expert opinion articles and preliminary studies highlighting some of the short-term impacts of the pandemic on survivors. As a relatively limited amount of time has elapsed since the beginning of the pandemic, the long-term impacts of the COVID-19 pandemic cannot be examined. The authors acknowledge that due to the limited literature currently available, a critical appraisal of available evidence could not be conducted. However, this is a living review that will be updated frequently as the evidence based develops.

Conclusions

Currently, limited definitive or conclusive evidence exists regarding the impact of the COVID-19 pandemic on cancer survivors. Overall, the presently available literature provides preliminary indications of wide-ranging impacts of COVID-19 pandemic on cancer survivors with respect to the requirement to adapt to new means of healthcare delivery as well as their physical, psychosocial and economic wellbeing. The COVID-19 pandemic has left survivors dealing with the consequences of rigorous cancer treatment in the context of new challenges related to social isolation, financial hardship and uncertainty with respect to their ongoing care. The challenges presented by the global pandemic may disproportionately impact the overall wellbeing of cancer survivors, which may result in unintended long-term consequences [29]. Increased rigorously designed research initiatives are required to elucidate the impact of the pandemic on cancer survivors.