1. Introduction
In recent history, the global community has confronted unprecedented challenges emanating from the 2019 coronavirus disease (COVID-19) pandemic, that has brought a cumulative number of 770 million cases and almost 7 million deaths, as of late 2023 [
1,
2]. The seismic shifts in daily life routines and the healthcare landscape have had profound implications for individuals dealing with chronic illnesses and cancer [
3], including those with urological malignancies, marked by its intricate association with various physiological and psychological comorbidities [
4,
5,
6]. Currently, urothelial (bladder) cancer stands as the 10th most common cancer worldwide [
7], with a noted increase in incidence, particularly in developed countries where industrial exposures are high [
8,
9].
Regarding bladder epidemiology in Romania, there are very limited data, although the existing reports suggest an age-standardized incidence of 15.4% [
10]. Recent data depict an alarming mortality rate, with an estimated 200,000 deaths annually on a global scale [
11]. In terms of survival, the prognosis varies extensively based on the stage at diagnosis; the 5-year disease-free survival rate can exceed 80% for patients diagnosed at an early, localized stage according to the tumor–node–metastasis (TNM stage 1), but drops precipitously to approximately 15% for those with metastatic disease, similarly to other malignancies [
12,
13,
14,
15,
16]. It is imperative to note that the recurrence rate within 5 years is considerably high, at about 50–70%, necessitating rigorous follow-up strategies post-treatment [
17]. Treatment modalities and outcomes are often gauged by the Eastern Cooperative Oncology Group (ECOG) performance status, which aids in tailoring individual therapeutic approaches ranging from surgical interventions to systemic therapies [
18,
19].
Pre-existing literature has underlined the intricate dynamics between chronic illnesses and various psychological features, further amplified during the times of global crises [
20,
21]. Thus, delineating the nuanced shifts in the quality of life and psychosocial well-being of urothelial cancer patients during the pandemic stands as a critical question. Cancer patients are known to grapple with a constellation of challenges including, but not limited to, anxiety, depression, and decreased quality of life [
22]. Moreover, the COVID-19 pandemic has introduced an additional layer of complexity, imposing unforeseen strains on healthcare systems globally and altering the medical care pathways, potentially exacerbating psychosocial distress among this population [
23,
24]. Psychological distress, uncertainty and loneliness were described by recent studies as important disturbing factors that people experienced during the COVID-19 pandemic [
25,
26]. Therefore, a comprehensive investigation into these dynamics during this unique period warrants a detailed exploration to formulate effective interventions and policy adjustments.
The Healthcare Anxiety and Depression Scale (HADS), a renowned instrument in assessing the dual parameters of anxiety and depression, serves as an invaluable tool in quantifying the psychological distress experienced by individuals with cancer [
27]. Furthermore, assessing the quality of life, an encompassing metric that captures the overall well-being and life satisfaction of patients, constitutes a critical pillar in the management of cancer, as well as in other critically ill patients [
28,
29]. The quality of life, often intertwined with physical health, psychological state, level of independence, and personal beliefs, has been notably impacted during the pandemic [
30]. In the context of urothelial cancer patients, understanding the multifaceted influences on their quality of life during this period can yield insightful data, potentially driving the development of tailored interventions aimed at fostering resilience and well-being.
In pursuance of a deeper understanding of the impacts of the pandemic on this specific cohort of patients with urothelial cancer of the bladder, this study delineates several key hypotheses and objectives. First, it hypothesizes that the pandemic has exerted a significant influence on the quality of life and psychosocial well-being of urothelial cancer patients. Second, it anticipates lower HADS scores, indicating high levels of anxiety and stress at the beginning of the pandemic, decreasing as the pandemic progresses. To fulfil its primary objectives, this study aims to: (1) investigate longitudinal changes in quality of life indexes, (2) analyze the trends in HADS scores over the three-year period, and (3) identify potential correlational patterns between the pandemic progression and levels of anxiety, depression, and stress among urothelial cancer patients.
3. Results
At the end of the study period, a total of 163 completed questionnaires were collected from the eligible participants, out of which 56 were from 2020, 52 from 2021, and 55 from 2022. The mean age of the participants remained relatively stable throughout the years, being 61.8 ± 9.9 years in 2020, increasing marginally to 62.3 ± 9.5 years in 2021, and slightly decreasing to 60.5 ± 10.2 years in 2022; however, the differences were not statistically significant (
p = 0.618). The gender distribution across the three years indicated a majority of male participants, constituting approximately 55.4% in 2020, 53.8% in 2021, and increasing to 60.0% in 2022, albeit without a significant difference (
p = 0.797), as described in
Table 1.
Upon analyzing the body mass index (BMI) of participants, it was observed that the mean BMI underwent a slight upward trend, from 26.4 ± 3.9 kg/m2 in 2020 to 26.9 ± 4.1 kg/m2 in 2021, followed by a dip to 25.8 ± 4.3 kg/m2 in 2022, with the variations not attaining statistical significance (p = 0.379). Substance use behaviors remained fairly consistent over the years, with chronic smoking being reported in 32.1%, 34.6%, and 27.3% of participants across the respective years (p = 0.705), and chronic alcohol use recorded in 8.9%, 5.8%, and 10.9% (p = 0.634), respectively.
A majority of the participants originated from urban areas, constituting 62.5% in 2020, 57.7% in 2021, and notably increasing to 70.9% in 2022, though these changes were not statistically significant (p = 0.352). Regarding the referral sources, a majority were from secondary care throughout the study period, comprising about 69.6%, 63.5%, and 70.9% in each year, respectively, with no significant difference in the referral patterns (p = 0.678). A notable finding was the increase in COVID-19 vaccination rates among the participants, where no vaccinations were reported in 2020, followed by a 23.1% vaccination rate in 2021, and a significant jump to 50.9% in 2022, showcasing a statistically significant increase (p = 0.003). When assessing the comorbidities, it was discerned that most participants had up to two comorbidities throughout the three years, and there was no substantial change in the distribution of the number of comorbidities (p > 0.05). Nevertheless, the majority of patients were married or in a relationship, although without significant differences regarding relationship status between the three studies years.
Due to the selection process, before surveying the patients, all participants were classified as having TNM stage 1 disease, with an ECOG performance status of 1, indicating that they were fully ambulatory and capable of carrying out work of a light or sedentary nature. Furthermore, all individuals underwent a transurethral resection of the bladder tumor (TURBT), a standard procedure in managing stage 1 bladder cancer. In the context of tumor grading, a slight fluctuation in the distribution of low- and high-grade tumors was noted over the three years. In 2020, 37.5% of patients were diagnosed with low-grade tumors, a fraction that decreased slightly to 34.6% in 2021, before undergoing a rise to 41.8% in 2022. Conversely, high-grade tumors constituted 33.9% in 2020, increasing to 38.5% in 2021, and subsequently decreased to 27.3% in 2022. Furthermore, there was a consistent proportion of cases where the tumor grade remained unknown, oscillating around 28–31% over the years. However, these variations in tumor grading did not attain statistical significance, as indicated by a
p-value of 0.818, as presented in
Table 2.
Additionally, an assessment of the mean hospitalization days revealed a slight upward trend across the three years. Patients hospitalized in 2020 had an average stay of 3.6 ± 2.1 days, which increased marginally to 3.8 ± 2.5 days in 2021, and further to 4.0 ± 2.4 days in 2022. However, this incremental elevation did not translate to a significant difference statistically, with a p-value of 0.663, denoting that the differences could be due to random variation.
In terms of experiencing changes in the frequency or severity of urinary symptoms since the onset of the pandemic, there was a gradual increase in the percentage of affirmative responses, from 28.6% in 2020, through 36.5% in 2021, to 38.2% in 2022. However, this increasing trend was not statistically significant, as evidenced by a p-value of 0.523. The belief that current symptoms might be associated with the COVID-19 pandemic increased markedly from 37.5% in 2020 to 63.5% in 2021, followed by a decrease to 50.9% in 2022, and was statistically significant with a p-value of 0.026. Similarly, changes in access to or quality of medical care were reported consistently by over 70% of respondents in the first two years, with a significant decline to 52.7% reporting changes in 2022, a trend that was found to be significant (p = 0.033).
Furthermore, the survey addressed adherence to treatment regimens during the pandemic. The data showed a fluctuation in the responses, with 33.9% affirming challenges in 2020, increasing to 46.2% in 2021, and then decreasing to 27.3% in 2022; this trend, however, did not achieve statistical significance (p = 0.118). Similarly, alterations in emotional well-being were noted, though the changes over the years did not amount to statistical significance (p = 0.183). In assessing the impact of the pandemic on physical activities or maintaining a healthy lifestyle, the participants rated their experiences on a scale of 1 to 10. A significant downward trend was observed in the scores, moving from 7.3 ± 2.6 in 2020, to 6.5 ± 2.9 in 2021, and then to 6.0 ± 2.4 in 2022 (p = 0.034). Meanwhile, the reported levels of stress and anxiety experienced during the pandemic remained relatively stable across the three years, with no significant difference in scores (p = 0.466).
When asked to rate their overall quality of life since the onset of the pandemic compared to before, there was a significant upward trend in scores from 2020 to 2022 (
p = 0.049). Despite these fluctuations, the belief that the pandemic would influence their cancer prognosis and treatment outcomes did not significantly change over the three years (
p = 0.213). Lastly, changes in social support during the pandemic were noted, with a significant variation in responses over the three years (
p = 0.019), as presented in
Table 3.
Upon observing the physical component of the SF-36 survey, there appeared to be an increasing trend in scores over the years. In 2020, the mean score was 53.0 ± 7.7, which significantly increased to 56.6 ± 7.5 in 2021, and slightly reduced to 55.7 ± 8.0 in 2022. The increment in the scores from 2020 to 2021 and a slight decrease in 2022 indicates a potential variation in the physical health status of urothelial cancer patients during the pandemic years, which was statistically significant, with a p-value of 0.043.
Similarly, the mental component of the survey demonstrated an upward trend across the years. The scores exhibited a gradual rise from 51.0 ± 8.1 in 2020 to 53.2 ± 8.4 in 2021, and further to 54.9 ± 8.6 in 2022. This progression suggests a potential improvement in the mental health status of the respondents throughout the pandemic, which was corroborated by a p-value of 0.049, denoting statistical significance.
Lastly, the analysis of the total score from the SF-36 survey indicated an upward trajectory in the perceived health status and quality of life over the three years. The mean score exhibited a climb from 55.9 ± 8.9 in 2020 to 58.9 ± 8.0 in 2021, with a slight further increase to 59.3 ± 8.8 in 2022. Although this trend suggests a possible enhancement in the overall quality of life throughout the pandemic years, this change was not statistically significant, as seen in
Table 4 and
Figure 1.
When examining the anxiety domain of the HADS survey, we noticed a statistically significant decline in the scores across the three years. In 2020, the mean score was 7.8, which significantly reduced to 6.3 in 2021, and slightly further to 6.5 in 2022. This continuous decrease in the scores signifies a decrease in the levels of anxiety experienced by the participants over the pandemic years, validated by a p-value of 0.008, denoting a statistically significant trend. When it comes to the depression domain of the HADS survey, a downward trend in the scores across the years was observed. In 2020, the mean score stood at 6.6, which decreased to 6.0 in 2021 and then to 5.8 in 2022. However, this decline was not statistically significant (p = 0.201).
Lastly, analyzing the total score from the HADS survey (the aggregate of both the anxiety and depression scores), a gradual decrease was evident from 11.5 in 2020 to 10.3 in 2021, with a further slight reduction to 10.8 in 2022. This trend potentially suggests a decrease in the overall levels of distress among the study participants during the pandemic years. Nevertheless, this change was not statistically significant, with a
p-value of 0.541, as presented in
Table 5 and
Figure 2.
A scrutiny of the GAD-7 survey results, which is designed to identify potential cases of generalized anxiety disorder, presents a discernible downward trend over the years of the study. In 2020, the participants registered a mean score of 7.8 ± 2.5, which decreased to 6.9 ± 2.2 in 2021 and further to 6.6 ± 2.8 in 2022 (
p = 0.034). This could potentially signify that the participants experienced a diminution in anxiety symptoms, possibly reflecting adaptive responses or coping strategies that were developed over the period of the pandemic. Turning to the PHQ-9 survey results, which assess the severity of depression symptoms, a marginal decrease in mean scores is observed from 4.7 ± 2.2 in 2020 to 4.2 ± 2.6 in 2021, further decreasing to 4.0 ± 2.3 in 2022. However, this decreasing trend is not statistically significant (
p = 0.276), as presented in
Table 6 and
Figure 3.