Study of psychological state of cancer patients undergoing radiation therapy during novel coronavirus outbreak and effects of nursing intervention

Abstract Objective To investigate psychological state of hospitalized cancer patients undergoing radiation therapy and evaluate effects of customized psychological intervention on patients' psychological state during novel Coronavirus (COVID‐19) outbreak. Method Fifty‐eight hospitalized head and neck cancer patients undergoing radiation therapy were included and received online and offline psychological intervention. General information questionnaire and the Self‐Report Symptom Inventory, Symptom Check‐List90 (SCL‐90) were utilized to investigate and analyze psychological state of hospitalized head and neck cancer patients undergoing radiation therapy before and after intervention. Self‐Rating Depression Scale (SDS) and Self‐Rating Anxiety Scale (SAS) were used to evaluate depression severity and anxiety severity of them. Results Overall psychological state of patients (include nine symptom dimensions: somatization, obsessive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) was improved significantly after intervention (P < .05). Moreover, scores of SAS and SDS were lowered. Conclusion Customized psychological intervention helped to improve overall psychological state of hospitalized cancer patients undergoing radiation therapy during COVID‐19 outbreak and showed encouraging effects on reduction severity of depression and anxiety.

may be adversely affected by the stressful events of "COVID-19 outbreak," "self-isolation," and "social distancing," and this may aggravate pre-existing psychological distress such as anxiety and depression. 7 This fact may cause cancer patients to experience increased psychological burden and result in a series of detrimental emotional states. Therefore, cancer and COVID-19, present a doubled challenge for medical staff, as patients' stable psychological state is essential for ensuring that patients can receive effective and regular cancer treatment. Thus, the psychological state of head and neck cancer inpatients of the Radiotherapy Department of Jiangsu Cancer Hospital were investigated during COVID-19 outbreak and the effects of the psychological intervention are elucidated in the following article.

| Establishment of research group
Research group included two researchers, one research assistants, and four psychology nurse specialists as intervention nurses. Purpose and significance of this research were introduced and explained. Also, the use and precautions of Symptom Check-List90, Self-Rating Depression Scale and Self-Rating Anxiety Scale were explained.
Researchers and research assistants were responsible for the screening and communication of enrolled patients. Research assistants and intervention nurses were responsible for distribution and recollection of the questionnaires, and for implementation of psychological intervention.

2.
Offline: through one-to-one interview, patients were encouraged to talk about their concerns and worries with intervention nurses in the counseling office (a closed but safe environment). See Table 1 for detailed intervention strategies.

General information questionnaire
According to the purpose of this study, a questionnaire was designed by researchers to investigate general information of patients include age, gender, marital status, and education level.

Symptom checklist 90
Current version of Self-Report Symptom Inventory (Symptom Checklist 90, SCL-90) was developed by Delogatis in 1973 from Cornell Medical Index. The scale has been proved to have good reliability and validity, as well as adequate sensitivity. 11 SCL-90 includes 90 items to evaluate the symptoms of nine main dimensions by using a 5-point rating scale, including somatization, obsession, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. During the administration, it is important to make sure that patients are fully understand the content of the checklist, then carefully read and rate each of the items. The total score is the sum of the items. [12][13][14] Self-rating depression scale and self-rating anxiety scale Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were developed by Zung in 1965 and 1971 and revised several times. Both SDS and SAS were proved to have good reliability and validity. 15,16 Both scales include 20 items and each item can be rated with a 4-point scale from 1 to 4. The total raw score of 20 items in each scale need to be multiplied by 1.25 to get an index score. In SDS, a score lower than 53 indicates no depression, a score from 53 to 62 indicates mild depression, a score from 63 to 72 indicates moderate depression, a score higher than 72 indicates severe depression. In SAS, a score lower than 50 indicates no anxiety, a score from 50 to 59 indicates mild anxiety, a score from 60 to 69 indicates moderate anxiety, and a score higher than 90 indicates severe anxiety. 13,15

| Data collection
Patients who meet the inclusion criteria were asked to complete questionnaires before and after the psychological intervention.
Before filling in the questionnaire, uniform instructions were given.
After the questionnaire was sent out, the research assistants left and patients were allowed to respond the questionnaire independently. Patients were encouraged to complete questionnaires within 1 hour. Two patients requested orally assistance from families to read questionnaire for them because of fatigue.
One day before intervention, 60 valid questionnaires were collected. One day after psychological intervention, data were collected by sending out paper-based questionnaire, electronic questionnaire through WeChat, or through telephone follow-ups.
In order to ensure the accuracy and validity of the questionnaire, contents of questionnaire were screened by members of research team immediately and clarify ambiguities if there was any. In the process of research, one patient refused to continue to participate and one patient could not be reached. Therefore, there were two dropouts in this research, completion rate was 96.67%. To help patients to avoid unnecessary concerns and worries and to achieve the goal of emotion stability Regain of gratitude, happiness, and sense of achievement Online sharing and discussion Through WeChat, patients were encouraged to recall, share and describe their personal experiences of gratitude, happiness or sense of achievement. Also, to tell their families about their true feelings. Patients were taught to actively recall such events when they are depressed.
Through recalling, retelling, and sharing experience that is positive, grateful, happy, or can bring sense of achievement to help patients to build confidence, retrieve hope and happiness Relieve bad mood Offline one-to one interview Through one-to one offline interview with psychology nurse specialists, patients were encouraged to freely express their worries, concerns, struggles and other emotions in the counseling room. Understandings and support for the patients were expressed by psychology nurse specialists and potential solutions were discussed.
While protecting the privacy and maintaining the dignity of patients, they were allowed to vent their negative emotions, encouraged to face the difficulties, and accept imperfections in their lives. From the perspective of patients, their psychological demands should be understood, and personalized and effective intervention need to be carried out.

| Statistical methods
The SPSS 22.0 software was used to analyze data. Categorical data were described by frequency and percentage; measurement data were described by mean ± SD, and t-test was used for group compari- 3.3 | Changes in scores of anxiety and depression before and after psychological intervention SAS total index scores and SDS total index scores of head and neck cancer patients undergoing radiotherapy during COVID-19 outbreak before and after intervention were compared. As shown in Table 3

| Changes in severity of anxiety and depression before and after psychological intervention
Changes in severity of anxiety and depression of head and neck cancer patients undergoing radiotherapy during COVID-19 outbreak before and after psychological intervention were compared as shown in  Also, one-to-one interviews promote the establishment of relationships between patients and medical staff.
Research shows accurate and reliable information sharing facilitates the alleviation of a sense of panic and loss caused by lack of information. 17 Appropriate social activities have shown to promote the secretion of noradrenaline and 5-hydroxytryptamine, regulate signals of limbic system, reduce excessive secretion of cortisol, and ameliorate emotional disorders. 18 Recalling past positive personal experiences can help patients increase their adaptability to the current situation, reduce the level of anxiety and depression, and improve their overall quality of life. [19][20][21][22][23][24][25] Encouraging patients to vent their negative emotions can help them to achieve catharsis and thus relieving psychological pressure. 26

| Psychological state of cancer patients undergoing radiotherapy during the Covid-19 outbreak
Patients enrolled in this research were all with newly diagnosed head and neck cancer (including stages II, III, and IV at the point of diagnosis). All of the patients were in the process of undergoing 6 to 7 weeks of radiotherapy treatment with total doses of 69 to 72 Gy.
Through a comparison with National norm of SCL-90, scores corresponding to the nine dimensions (somatization, obsessive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism) of the patients were observed to be higher than the scores of the national norm (

| CONCLUSION
Local or systemic metastatic cancer is characterized by its long course and severity. Therefore, cancer patients are at high-risk for severe illness from COVID-19; they are more likely to develop severe complications and multiple organ failures which lead to high mortality rates. 32 Thus, cancer patients, as a susceptible population, tend to suffer more from psychological distress in the event of public health crises. 33 Under premise of implementing protective measures during the outbreak, multi-level, multi-channel, and diversified psychological intervention measures should be carried out proactively for cancer patients as early as possible. 34 Furthermore, it is critical to prioritize the minimization of psychologically adverse effects caused by an outbreak on cancer patients with the objective of achieving mental stability, a positive psychological state, a reduction of depression, anxiety, and other negative emotions. It has been proven that, for cancer survival, social isolation has a significant impact and it is necessary to maintain patients' social infrastructure as much as possible. 35,36 For cancer patients, psychological intervention is recommended, and it is critical during the outbreak for hospitals and medical staff to employ developed systems assisting in maintaining patients as psychologically stable throughout the outbreak. 37 Currently, many countries have established theories about psychological intervention against public health events, but there is a lack of unified technical standards. 38,39 In the future, we need to increase the number of samples and follow-up from time to time to conduct more in-depth, detailed research.

ACKNOWLEDGMENTS
This research was supported by the Jiangsu Cancer Hospital, China.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest regarding this article.

AUTHOR CONTRIBUTIONS
Dejing Xu contributed to the concept of the study; Shuchang Lou contributed to contributed significantly to analysis and wrote the manuscript; Xiaodong Li and Yan Huan performed the experiment and data analysis; Jun Li helped the design of the experiment with constructive discussion and instruction.

ETHICS STATEMENT
The study was approved by the Jiangsu Cancer Hospital Ethics Committee and all patients gave written informed consent.