Background
Cancer is a major health concern worldwide, affecting millions of people each year. Cancer treatment typically involves a combination of surgery, radiation therapy, and chemotherapy. However, natural disasters such as earthquakes can have a significant impact on cancer treatment and care. Reference Man, Lack and Wyatt1
In some disasters such as nuclear disasters, earthquakes, hurricanes, and floods, increased movement of people may occur, which may result in loss of contact with family, and friends, as well as relatives; this can result in difficulties in retrieving medical information of patients. Also, there may be social isolation and traffic restrictions in times of these incidences such as pandemics. Reference Ozaki and Tsubokura2–Reference Ozaki, Nomura and Leppold5 Two earthquakes which struck Eastern Turkey resulted in a humanitarian tragedy on February 6 and 20, 2023. Seventeen cities were affected by over 50 000 deaths and 100 000 injuries occurred. After the destruction of 345 000 buildings, more than 2 million survivors were evacuated to nearby cities, such as Antalya, and Konya, as well as Mersin, and Niğde.6 The International Organization for Migration has speculated that nearly 3 million people need new homes. 6,7 Ten state and university hospitals with high oncologic treatment capacity were destroyed or out of order after the earthquake. 8
During the great earthquake in 2011 in Japan, medical facilities provided immediate treatments for disaster survivors. Facility destruction, as well as loss of medical information, may have additional effects on cancer treatment. In addition to this phenomenon, after the restoration of the facilities, lifelines, and transportation, the life of cancer patients significantly changed compared to pre-disaster time. Reference Yilmaz9,Reference Sato and Sato10 Cancer patients need a good life balance to control adverse events, cancer-related symptoms, and drug availability. Reference Hopkinson11
Traumatic events have negative effects on psychology such as depression, anxiety, and post-traumatic stress disorder. Reference Berger, Coutinho and Figueira12,Reference Johnson and Thompson13 The intervention on patients’ psychosociology may improve the quality of life and decrease the symptoms of depression and anxiety. Reference Cardoso, Kyriakides and Ohno14,Reference Charalampopoulou, Kritseli and Chrousos15 Hospital Anxiety and Depression Scale (HADS) is used to measure the depression and anxiety levels of the patient; affecting their quality of life while suffering from cancer. Reference Shim, Lee and Cho16 Prior studies showed 10 - 50% of cancer patients suffer from psychosocial disorders such as social isolation, despair, anxiety, and depression which worsen with the stage of cancer. Reference Peng, Huang and Zhang17 Depression was shown to harm treatment outcomes and quality of life in cancer patients. Also, anxiety is frequently accompanied by cancer, resulting in psychological symptoms. Although ineffective coping strategies result in increased depression and anxiety, patients with high social support have decreased levels of depression and anxiety. Reference Tang, Fu and Gao18–Reference Hashemi, Hormozi and Allahyari20
The objective of the study was to evaluate the psychological effect of the earthquake on cancer patients who moved from disaster zones and compare with resident cancer patients who are not affected from the disaster.
Methods
Study Population
The study is based on the records of patients’ who were referred to Alanya Alaaddin Keykubat University, Department of Medical Oncology, for treatment after February 6, 2023. Alanya city center is in the eastern part of Antalya province, 600 km away from the disaster zone and was not affected by the earthquakes. Fifty thousand earthquake survivors from Hatay and İskenderun, including cancer patients were evacuated via sea route and placed in the hotels in Alanya. Cancer patients who were evacuated from earthquake sites and referred for the continuation of their treatment and resident cancer patients who live in Alanya were included in the study. The resident cancer patients were compared with the study population as the control group. The patients who were treated between February 6 and March 17, 2023, were matched. The earthquake survivor cancer patients were relocated to other cities after March 17, 2023. Patients’ (study and control group) demographics status, diagnosis, stages, and ongoing treatments were recorded.
Psychological Evaluation
DASS-21 evaluation forms were filled based on patients’ declarations. DASS-21 is a form-based scale evaluating depression anxiety and stress. Each category has 7 questions, and each answer has points between 0 and 3. Higher points indicate worse outcomes. Cumulative points were translated into categories for each group for depression, anxiety, and stress: normal, mild, moderate, and severe, as well as very severe. The Turkish version of DASS-21 is translated and validated in prior studies. 21 The questionnaire form is available in the appendix.
Ethics
The study was approved by the local ethics committee of Alanya Alaaddin Keykubat University, and the trial was conducted in accordance with the Declaration of Helsinki’s Principles (Ethic committee decision date and number is March 22, 2023 and 5-07 respectively).
Statistics
The statistical analysis of the study was performed with SPSS software (Statistical Package for the Social Sciences, version 22.0; SPSS Inc., Chicago, IL, USA) and E-PICOS. The Kolmogorov–Smirnov test was used to determine whether data conformed to a normal distribution. Descriptive data was presented as either means or median for continuous variables, and frequencies and percentages are reported for categorical variables. Z-test was performed to confirm the difference in the Chi-square test.
Results
Forty-six patients were earthquake survivors and 55 were regular patients. There was no significant difference between earthquake survivor cancer patients and the control group in terms of age, gender, diagnosis, and marital or educational status. The groups showed significant difference in stage and ongoing treatment. The comparable information of the study population was demonstrated in Table 1.
Table 1. The comparable features of the patient and control group
a/b: Statistically significant subgroups.
There was no difference observed in the anxiety and depression scores of both groups. Stress scores had significant differences between groups which was higher in earthquake survivors. (P = 0.021) In contrast, there was no difference in stratified groups due to DASS-21 categorization in stress scores while depression and anxiety subgroups had significant differences. More earthquake survivor cancer patients had severe anxiety and depression compared to resident cancer patients. (P = 0.012; P < 0.001) Also, women significantly had a worse outcome in the depression and anxiety categories (P = 0.028; P = 0.021) while no difference was observed in men. The comparable difference is described in Table 2.
Table 2. The comparable difference in depression, anxiety, and stress between groups
¶ Mean with standard deviation;
ά median with minimum and maximum values;
* statistically significant subgroup in test;
a/b: statistically significant subgroups.
Limitations
The study was performed at the acute onset of the earthquake and had a limited study population. Information on the social status of the study population was absent such as social support, monthly income, loss of family during the earthquake, and receiving psychological support. Also, the long-standing psychological effect of destruction may not be seen in the acute phase of the disaster. Our study did not evaluate the partners’ status due to the acute onset of the disaster. Also, the prior psychological diseases and treatment per patient were not evaluated which decreased the value of the information gathered.
Discussion
To our knowledge, this is the first study evaluating the psychological effect of earthquakes on cancer patients. Although the psychological problems such as depression, anxiety, and stress have been extensively studied, there is a paucity of literature examining the effects of natural disasters on this patient group. Reference Alacacioglu, Tarhan and Alacacioglu22
The hazardous effects of natural disasters are determined by the number of individuals impacted and their vulnerability status, with insufficiency being a key factor. Reference Shi23 In terms of natural disasters, the social community collapses, and especially vulnerable people such as cancer patients are affected more compared with the other parts of the population. Reference Raeissi, Sharifi and Khosravizadeh24 Patients with chronic conditions such as diabetes, respiratory diseases, cancer, and cardiovascular diseases are the most vulnerable patient groups during natural or man-made disasters. Reference Kessler, Wang and Kendrick25,Reference Heidari and Ghodusi26 In a meta-analysis, it was observed that natural disasters have negative effects on cancer care, and it is advised to have special precautions for oncology patient care and infrastructure. Reference Man, Lack and Wyatt1 In a large meta-analysis mainly investigating the Wenchuan earthquake, prior illness was shown to be a risk factor for post-disaster depression in both adults and children. Reference Tang, Liu and Liu27 There is limited data reporting the negative effect of earthquakes on cancer care in Turkey after disasters. Reference Ünsal, Yazici and Özdemir28 There is no published data for the possible negative psychological outcome of cancer patients after an earthquake.
In breast cancer patients, stress, depression, and anxiety are frequently observed. The prevalence was 14.7%, 28.4%, and 43.2% respectively. Reference Hashemi, Rafiemanesh and Aghamohammadi29 Also, depression in partners of patients increased among breast cancer patients. Reference Nakaya, Saito-Nakaya and Bidstrup30 In a Japanese study investigating the effect of the Fukushima earthquake on chronic diseases, cancer patients had an increased risk for psychological depression. Also, in another study, couples receiving cancer treatment had been negatively affected by the Fukushima earthquake. Women were more prone to psychological distress compared to men. Reference Nakaya, Nakamura and Tsuchiya31,Reference Nakaya, Narita and Tsuchiya32 In a study evaluating Hispanic cancer survivors and the normal population after Hurricane Maria in Puerto Rico, no difference was observed in terms of psychological health. Interestingly this study showed increased inflammatory markers in cancer survivors compared to the control group. The median time after the disaster was 7 months which may hide the psychological effects of disaster on survivors. Also, the cancer patients in this study were in remission and not receiving any treatment. Reference Rodriguez-Rabassa, Hernandez and Rodriguez33 Results showed that depression, anxiety, and stress problems were observed by more than 50% of earthquake survivors. Although there was a significant difference in terms of the stage between the study and control group, end-stage diseases were the same across groups and were considered to have zero effect on psychological status. Also, the earthquake survivors were on lower chemotherapy doses compared to the resident group which may have positive effect on psychological status and would be unrelated with chemotherapy associated anxiety. Even though earthquake survivors received less chemotherapy than resident patients, they had worse psychological outcomes which may be attributed to the earthquakes. In accordance with other studies, women had worse depression and anxiety categories when compared to the control group. Nakaya et al. reported that there was an increased partner burden in chronic conditions resulting in psychological problems. Reference Nakaya, Narita and Tsuchiya32 This study showed increased stress, depression, and anxiety among cancer patients who are earthquake survivors. As the study hypothesized, earthquake-survivor cancer patients need more psychological support compared to regular cancer patients and may have worse outcomes compared to earthquake survivors without cancer. There may be need of more psychological and social support for cancer patients experienced earthquakes.
Conclusion
Recent earthquakes in Turkey had psychological negative effects on oncology patients. The increased stress, depression, and anxiety levels were observed in earthquake survivors who were evacuated from the disaster zone compared to the control group. More intensive studies are needed to investigate the long-term psychological effect of disasters on cancer patients.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/dmp.2024.62
Acknowledgments
Thank you to Miss Nurten Borazan for collecting data information.
Funding statement
The study did not receive any funding from non-commercial or commercial organizations.
Competing interests
The author does not declare any conflict of interest.
