A Prospective Survey to Understand the Preferences and Perspectives of Patients with Hematological Malignancies in a Tertiary Cancer Care Setting in India (CANCOV SURVEY)
Authors: Sharma Dr. Neha , Jain Dr. Hasmukh , Muthuluri Dr. Hemanth , Bonda Dr. Avinash , Sengar Dr. Manju , Thorat Dr. Jayashree , Nayak Dr. Lingaraj , Bagal Dr. Bhausaheb 
Published: November 2021

Abstract
Introduction:
From its emergence in China on 31 st December 2019, the COVID-19 infection has spread to affect more than 185 million people across the world with approximately 4 million deaths.
A systematic review and meta-analysis which included various studies across the world showed that the risk of mortality in cancer patients with COVID-19 infection is 21.1% and the risk of severe disease and mortality due to COVID-19 appears to be higher in patients with hematological malignancies likely due to immunosuppression induced by both the underlying disease and intensive treatment.
The experts suggest individualization of treatment based on the prevalence of COVID-19 infection, available infrastructure and social support. Guidelines are driven by opinion from a clinician's perspective. There is a need to evaluate a patient's preference in the present situation when they are faced with the dual problem of cancer and a potentially life-threatening infection.
Purpose of study:
To document the patients preferences and perspectives using a structured questionnaire when they are on cancer-directed chemo/immune or targeted therapy or treatment naive in our hospital during the current COVID-19 pandemic.
Objectives:
The primary objective was to determine the proportion of patients who opt to continue on full intensity therapy.
The secondary objectives were - to study the factors that lead to treatment discontinuation or dose reduction, to study the level of perceived risk at which patients opt for treatment discontinuation or dose reduction, to study the preferences for treatment continuation in different scenarios (COVID-19 adverse event and different relapse risk) (table 2 and 3) and to understand the difference in preferences for therapy between patients and oncologists/hematologists.
Material and methods:
This prospective survey was conducted between July 10, 2020 and October 16, 2020. A preconceived standard questionnaire was administered to each patient along with their caregivers (Figure 1). Along with this, we subjected the survey questionnaire separately to the set of medical oncologists/hematologists who were not a part of the patient's treating team and the responses were recorded and studied.
Sample Size
Assuming that 50% of the patients will continue the full intensity therapy, a sample of 203 will produce a two-sided 90% confidence interval with a precision of 12%. Considering a non-response proportion of 5%, a sample size of 213 was required to achieve primary objective.
Results:
A total of 200 patients were enrolled in this study with male to female ratio of 1.9:1 and a median age of 42 years (15- 78). Most common hematological malignancy in our study is acute leukemia (29%) followed by CML (23%), NHL (22%), multiple myeloma (16%). Baseline details are represented in Table 1. In this study, 47% patients were willing to receive full intensity chemotherapy (95% CI: 40.4 -54.7). Nature of disease (slow growing vs fast growing) and the intent of treatment (cure vs control of disease) were shown to significantly affect preferences of patients. There was no impact of various socio-economic or logistic factors in their preference for therapy. As high as 50% of the patients were willing to accept only 5% risk of covid 19 related complications to receive full intensity therapy. The acceptable risk of relapse over and above the baseline to receive lesser intensity chemotherapy was 5% for almost 1/3 rd of the patients. If covid related complications are mild, 40% of patients are ready to accept only 1 % risk of relapse to receive lesser intensity chemotherapy. As the risk of covid related complications increases from mild to severe, almost 50% of the patients are ready to accept ≥ 20% risk of relapse to receive lesser intensity chemotherapy (table 4). There was a statistically significant disagreement between physician and patient responses at 5%, 20%, 30% and 40% risk of covid related complications to receive full intensity therapy. When we consider the risk of relapse if lesser intensity therapy is opted, patient and physician responses are in good agreement at 1, 5, 10 and 20% risk levels.
Conclusion:
Almost 50% of patients are willing to opt for reduced intensity therapy because of fear of covid related complications and there is significant disagreement between patient and physician perspectives in certain clinical contexts.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.