PATIENT PERCEPTION OF ONCOLOGY CARE DURING THE COVID-19 PANDEMIC: A PROSPECTIVE OBSERVATIONAL STUDY FROM MOROCCO

……………………………………………………………… Background: The first case of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Morocco was detected in Casablanca on March 2, 2020; since then, our country has implemented restrictions on population movement to slow the spread of the virus. The management of cancers must be adapted to this context. Materials and methods: All patients who are treated At the Radio-Oncology Unit of the Sheikh Khalifa Hospital at Casablanca were included in this prospective observational study for a questionnaire-based survey to evaluate the worries and perceptions of patients about changes and delays in their treatments during covid-19 Pandemic Results: Total of 53 cancer patients participated in this study. The majority of patients possess adequate knowledge and practice appropriate preventive actions. However, they expressed their negative emotions and worries about the impact of changing their treatment on the prognosis of the disease and they considered cancer more deadly than covid-19. Conclusion: The present study shows the need to look for other solutions that ensure continuity of care such as telemedicine, while reducing exposure for health care workers and other patients

The entire global has been profoundly affected by the health crisis, but the pandemic has a more severe impact on people in third world countries because of limited resources and weak health system such as the low number of hospital beds especially in intensive care units, insufficient number of medical and paramedical staff as well as protective equipment against the virus [1].
The Moroccan Government has taken a number of necessary measures including shutting down schools, closing places where people gather and advising its citizens for voluntary quarantine and social distancing, when the first case was declared.

ISSN: 2320-5407
Int. J. Adv. Res. 8(12), 780-785 781 Multiple recent papers have shown that patients with cancers are considered as a highly vulnerable group in the current COVID-19 pandemic with significantly increased severity outcomes, including higher rates of hospitalization and death [2], [3]. The risk increase even more if the cancer patient is elderly (>60 years of age), or has associated comorbidities like diabetes, heart or chronic lung disease.
During the pandemic period, cancer patients are faced with a serious challenges and dilemmas, since staying at home could increase the tumor progression, while going to the hospital and taking their cancer treatments witch may increase the risk of severe illness from COVID-19 [4], [5].
At the Radio-Oncology Unit of the Sheikh Khalifa Hospital at Casablanca, the economic capital of Morocco, more protocol changed in our approach to the treatment of our patients. The present study aimed to address the challenges and sufferings faced byMoroccan patients with cancer during their treatment in the current COVID-19 pandemic and their perception at the protocol change.

Materials and Methods:
Study participants: All patients age ≥ 18 years who are actively undergoing radiotherapy with or without systemic therapy for solid malignancies in the department of radio-oncologyof the Sheikh Khalifa Hospital at Casablancafrom April 2020 to Mai 2020 were included in this prospective monoinstitutional, observational study for a questionnaire-based survey. Were excluded from the study: 1. The patients who refused to participate to the study 2. Illiterate patients or non-French or Arabic speaking. 3. The patients with poor physical statusbecause of cancer, or therapy-related complications. In total, 53 participants completed the questionnaire.

Questionnaire:
It consisted of 25 multiple-choice questions, including 5 questions about the patient characteristics, 3 questions about site and current state of the disease,5 questions about general knowledge of COVID-19 pandemic and preventive practices undertaken. The rest of the questions are specific to patients' perceptions and feeling of changes in their treatment protocol and its impact on the prognosis of their disease, level of anxiety to get the virus in the hospital.
Eligible participants were given out the questionnaire to be completed during their visit for treatment in our institution.Questionnaires were fill out in the medical consultation room.
Sufficient time was allowed for participants to read, comprehend and answer all the questions.

Ethical considerations:
The survey is voluntary and completely anonymous. All research participants must give their permission to be part of a study.

Statistical Analysis:
Data were tabulated and analyzed using Microsoft Excel for Mac 2017. Continuous variables are presented as total number (n) and percentage (%) unless stated otherwise

Results:-
The median age of our study was 62 (30 -75) years, and 62 % of the patients were males. The baseline demographic features are listed in Table 1.
While the majority of patients had advanced disease, most of them (78%) were receiving curative treatment.  All patients questioned considered themselves to be more at risk of contracting the virus and developing a severe form than other people due to the immunosuppression caused by the anti-cancer treatments that they are receiving( Table 2).

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More than three quarters of patients (83%) patientsare afraid to visit the hospital during the pandemic. Contrariwise, they considered cancer more deadly than covid-19, and delaying surgery or any other therapeutic intervention made them more anxious about their diseaseoutcome.
A higher percentage of patients (83%) considered the protective measures applied by the hospital as sufficient, while some patients need for furtherprecautions to feel safe asdistribution of masks, further limit the number of patients treated per day, initiate telehealth services.

Discussion:-
The COVID-19 pandemic led to major changes in the structure of oncologic care for the patients.
Hence, several expert groups have outlined recommendations for treating patients with cancer during the COVID-19 pandemic such as the American college of surgeons, the European Society for Medical Oncology (ESMO) [6], National Comprehensive Cancer Network (NCCN) [7], the European and American Society for Radiotherapy and Oncology (ESTRO-ASTRO) [8] and others national groups. The main modifications proposed were: 1. Systematic use of granulocyte colony-stimulating factors (GCSF) to prevent severe neutropenia 2. favor oral therapies as much as possible. 3. Prioritize hypo-fractionated radiotherapy protocols, in particular for breast, prostate, and rectum cancers. 4. Limit unnecessary hospitalizations. 5. Favor telemedicine consultations for routine follow up.
However, the patient's perception of these changes are rarely evaluated by their treating physicians. This study is the first of its kind in Morocco to evaluate the perspectives, knowledge sources of cancer patients about COVID-19.
In this study, we found that almost all of our patients are afraid of contracting the virus and consider themselves more vulnerable than others to have serious or even fatal complications from the coronavirus.
However, they consider that they risk dying from cancer more than from the coronavirus by risk of progression of their disease and that the evolution of their cancer will not wait for the arrival of the vaccine against the coronavirus. Furthermore, the patients preferred to continue their treatment than to deferit, despite the pandemic,and proposed to improve the hospital's preventive measures such as introduce telemedicine for routine follow up.
Our results agree perfectly with the literature. In a Indonesian study by Prajoko and al , [9], the authors explore the knowledge of 221 cancer patients on COVID-19, their perceptions towards the changes in oncology service. The majority of patients possess adequate knowledge and practice appropriate preventive actions. however, treatment interruption contributes to improve level of anxiety or comfort for cancer patients.
In another Indian study conducted by Ghosh and al [10], a total of 302 patients were included for a questionnairebased survey to evaluate the willingness to continue chemotherapy during this pandemic and factors influencing the decisions.
785 Treatment was curative in 150 patients and palliative in 152. A total of 203 patients wanted to continue chemotherapy, 40 wanted to defer, and 56 wanted the physician to decide. The worry about catching SARS-CoV-2 was high in those with controlled disease. Worry about disease progression was more with palliative intent (P, .001).

Conclusion:-
In conclusion, this study shows that our patientsconsider themselves to be more at risk of contracting the virus and developing a severe form than other people due to the immunosuppression caused by the anti-cancer treatments. However, theyare more worried about cancer progression than SARS-CoV-2 infection.
Our hospital has made every effort to continue the care of all our patients while ensuring all the means of protection necessary to reduce the risk of contracting the coronaviruswhile waiting for the hope of stopping the pandemic by the long-awaited COVID -19 vaccine.