Background

The novel coronavirus SARS-CoV-2 has caused a global COVID-19 pandemic, leading to worldwide changes in public health measures. In addition to changes in the public sector (lockdowns, contact restrictions), hospitals modified care to minimize risk of infection and to mobilize resources for COVID-19 patients. Patients with thoracic malignancies may be particularly affected by public health measures. On the one hand these patients may be at risk of severe COVID complications due to advanced age and comorbidities [1, 15].

A survey across several European countries measured the willingness to get vaccinated against COVID-19 in more than 7500 people. They found an overall willingness in 74% of respondents, the willingness in Germany was 70% [16]. According to the Germany COVID-19 Snapshot Monitoring (COSMO Germany) the willingness to get vaccinated in the German population has declined from around 79% in April to 50% in October 2020 [17]. In our survey respondents, the willingness to get vaccinated was higher (80%) than the general German population. This higher proportion may reflect thoracic oncology patient perceptions of their individual risk for complications from COVID-19. Additionally, older patients were more likely to indicate a willingness to get vaccinated. Advanced age as well as having a cancer diagnosis are risk factors for complications from COVID-19 [1, 2].

The survey reported here was conducted in a single lung cancer center in Bavaria, Germany. While the results offer a snapshot of the patient experience in Munich, experiences during the pandemic are likely to vary regionally and may also vary between centers in a region. The survey was intended to capture a broad range of patient experiences and was, therefore, mailed out to patients with all types of primary thoracic malignancy and all stages of disease. It included patients with NSCLC, SCLC, mesothelioma and thymus tumors, with patients currently undergoing treatment as well as patients under surveillance and follow-up care. However, as not all surveys were returned, the results may include an element of bias based on patients’ willingness to participate in the survey. However, we did not find that respondents and non-respondents were significantly different regarding age, gender, histology, and stage. However, the definition of our study exclusion criteria may have introduced a selection bias to patients included and excluded for the study. As lung cancer has a median survival time of less than a year and we looked at tumor board records from the previous three years, a higher proportion of patients with lower stage at diagnosis were left to include after excluding deceased patients and patients who were likely deceased. As can be seen in Fig. 1, the majority of patients excluded were patients with metastatic disease who did not visit our center during the 6 months prior to the begin of our study. We expected that these patients most probably were deceased, and we did not want to risk addressing questionnaires to grieving family members. Additionally, as our questionnaire was mailed out only in the German language, there might be an underrepresentation of patients with non-German first language. Nevertheless, apart from stage, basic demographic parameters suggest that the survey respondents were similar to the average lung cancer patient. Mean age of the respondents was 66.7 years which is close to the mean age at diagnosis of German lung cancer patients (male: 69.3, female: 68.3) [18].The proportion of male patients in our study (60%) was comparable to the proportion of male patients among newly diagnosed patients in Germany in 2016 which was 65% [18].

This is the first study to measure specific consequences of the COVID-19 pandemic on ambulatory services as well as in- and outpatient visits from the perspective of thoracic oncology patients in Germany, and, to our knowledge, internationally. Additionally, the study evaluated effects on patient health and patient’s behavior, views and feelings towards social distancing, mask wearing and vaccination. While several studies have reported the physician perspective and described changes to the provision of care, the patient perspective is particularly valuable in demonstrating the effects of those changes, as well as compliance with distancing and lock-down recommendations. In many respects, our results are reassuring and show that, while the pandemic has forced some changes in care, the majority of patients were able to receive most aspects of care as planed and have coped well with the changes that occurred. Other results, such as the relatively high proportion of patients who report not having limited social or family contacts, imply a need for further public health education measures aimed at specific patient groups. Alternatives to mask-wearing should be investigated for those patients who experience respiratory difficulties during extended periods of community mask use.

Conclusion

This survey of patient experiences demonstrates that the subjective impact of the COVID-19 pandemic on tumor-directed care and general patient health for thoracic oncology patients was minimal. Access to some ambulatory allied health services was greatly reduced. Many patients did not reduce social or family contacts. Most patients wore masks, although many patients reported respiratory symptoms during mask-wearing. The willingness to get vaccinated against SARS-CoV-2 was high. This information is of high relevance to both policy makers and healthcare providers.