Disruption to radiation therapy sessions due to anxiety among patients receiving radiation therapy to the head and neck area can be predicted using patient self-report measures

Open or closed: Experience of head and neck radiotherapy masks - A mixed-methods study

INTRODUCTION

In radiotherapy for head and neck cancer, a mask is used to immobilise the head and shoulders. An open mask that does not cover the face is expected to cause less anxiety, but there is need to further investigate the patients' experience of open versus closed masks. Therefore, the aim of this study is to evaluate patient preferences for open or closed masks and whether an open mask can reduce discomfort and anxiety for patients.

METHODS

Twenty participants were treated in alternating weeks using open and closed masks. Their distress was evaluated through semi-structured interviews and patient-reported outcome measures.

RESULTS

When using the open mask, it took longer to position the patient correctly. The closed mask felt more confining and could induce a sense of claustrophobia. Participants employed both internal and external strategies to cope with the stressful situation. The Hospital Anxiety and Depression Scale (HADS) showed a significant reduction in anxiety over time during the treatment period, but no significant difference between the masks. When participants chose which mask to use for the final treatments, 12 chose the open mask, while 8 chose the closed mask. In addition to the 20 analysed participants, two participants withdrew from the study because they could only tolerate the open mask, one due to anxiety and the other due to swelling.

CONCLUSIONS

The open mask seems to provide a less confined experience but may lead to greater difficulties in achieving the correct treatment position. While both masks can be viable options for most patients, some cannot tolerate closed masks but do tolerate open masks.

Open-Face Masks in Radiotherapy: Enhancing Therapeutic Strategies for Head and Neck and Brain Cancer Patients-A Comprehensive Scoping Review

Introduction: The main goal of radiotherapy (RT) is to deliver a precise dose to the target while sparing the surrounding normal tissue and minimizing side effects. Appropriate patient immobilization is crucial, especially for head and neck cancer (HNC) and Brain Cancer (BC). Conventional closed-face masks (CFMs), while effective in minimizing head motion, can cause significant discomfort, anxiety, and claustrophobia. Open-face masks (OFMs) have been developed to increase patient comfort while providing precise immobilization. Methods: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) extension for scoping reviews and the Arskey and O'Malley framework, an electronic search of EMBASE, PubMed, SCOPUS, and Web of Science was conducted to identify original studies reporting the use and description of OFMs in clinical practice up to April 2024. The inclusion criteria were English-language articles focusing on OFMs for HNC and BC patients undergoing RT. Results: Of 618 titles, 19 articles fulfilled the selection criteria. Most studies were comparative (n = 13) or observational (n = 6). The articles were categorized by treatment site, resulting in three groups: BC (n = 14, 68.4%), HNC (n = 4, 21.4%), and mixed (n = 2, 10.5%), which includes both BC and HNC. Of note, 82.4% (n = 16) of the included studies were published from 2020 onwards, emphasizing the recent adoption of OFM in clinical practice. Conclusions: The reviewed studies show that OFMs, in combination with SGRT, offer significant advantages in terms of patient comfort and positioning accuracy in HNC and BC treatments. Reproducibility in the sub-millimeter and sub-degree range can be achieved, which supports the use of OFMs in clinical practice. Future research should explore innovative combinations of immobilization and monitoring to further improve RT outcomes and ensure precise treatment while increasing patient comfort.

Treatment Reproducibility in Brain Stereotactic Radiotherapy Using a Shim Mask Versus a Standard Mask

Introduction This study aimed to evaluate the setup accuracy of the new shim mask with mouth bite compared to the standard full brain mask in stereotactic radiosurgery (SRS) and radiotherapy (SRT) treatments for brain metastases or tumors. Method A combined retrospective and prospective design was employed, involving 40 patients treated at our center. Patients previously treated using standard head masks formed the retrospective cohort, while those treated with the Shim mask and mouth bite formed the prospective cohort. Daily cone-beam computed tomography (CBCT) scans were obtained before each treatment session to ensure patient setup accuracy. Key metrics included absolute shifts in translational and rotational directions, the number of repeat CBCTs, and the time interval between CBCTs. Results The Shim mask significantly reduced the mean setup errors in the lateral translation (p=0.022) from 0.17 cm (SD=0.10) to 0.10 cm (SD=0.10), and in X-axis rotation (p=0.030) from 0.79° (SD=0.43) to 0.47° (SD=0.47). By considering cutoff points of 1 mm in translational and 1° in rotational directions, the Shim mask was significantly more accurate in the lateral direction (p=0.004). Moreover, while 70% of patients in the standard group required repeat CBCT scans, none in the Shim group did, resulting in an average time saving of 10.4 minutes per patient. Conclusion The Shim mask with mouth bite offers enhanced immobilization accuracy in SRT/SRS treatments, leading to time and potential cost savings by reducing the need for repeat CBCT scans. This underscores the importance of adopting innovative immobilization techniques to optimize patient outcomes.

Impact of background music listening on anxiety in cancer patients undergoing initial radiation therapy: a randomized clinical trial

BACKGROUND

Patients undergoing radiation therapy (RT) often experience anxiety, which may jeopardize the treatment success. The efficacy of music interventions in reducing anxiety remains contentious. This randomized trial aimed to evaluate the impact of music listening on anxiety symptoms in patients undergoing initial RT.

METHODS

First-time RT patients were randomly allocated to experimental and control groups. The Brief Symptom Rating Scale (BSRS-5), Distress Thermometer (DT), and Beck Anxiety Inventory (BAI-C) were administered pre- and post-RT. Changes in physiological anxiety symptoms were monitored over 10 consecutive days starting from the first day of RT. The experimental group received music during RT; the control group did not. The generalized linear mixed model was used to estimate the pre-post difference in the BSRS-5, DT, and BAI-C scores between the music intervention and control group.

RESULTS

This study included 50 patients each in the experimental and control groups. BSRS-5 and DT scores were significantly reduced in the experimental group post-RT (p = 0.0114 and p = 0.0023, respectively). When music listening was discontinued, these scores rebounded. While the posttest BAI-C score was significantly lower in the experimental group (p < 0.0001), the pre-post difference between the two groups was not significant (p = 0.0619). On cessation of music listening, the BAI-C score also rebounded.

CONCLUSIONS

For cancer patients undergoing initial RT, music listening intervention significantly reduced anxiety symptoms measured using the BSRS-5, DT, and BAI-C scores after two weeks. Our results demonstrate the effectiveness of music listening intervention in reducing anxiety symptoms, thereby potentially improving the quality of life of cancer patients undergoing RT.

Unmasking anxiety: a head-to-head comparison of open and closed masks in head and neck cancer radiotherapy

Background

Facemasks accurately immobilise patients with head and neck cancer (HNC) receiving radiotherapy (RT). However, such masks are associated with treatment related distress, a prognostic factor for poorer survival. Open masks offer increased comfort and patient satisfaction. We investigated whether open masks could immobilise patients without affecting treatment accuracy.

Materials and methods

Over an 18-month period, all HNC RT patients with anxiety were offered open masks. Once 30 patients had completed treatment, set-up data was compared to patients in closed masks. The mean displacement and one-dimensional standard deviations (SD) of the mean, systematic and random set-up errors were calculated for translational directions: anterior-posterior (x), superior-inferior (y), medial-lateral (z). The mean and SD of the mean was calculated for rotational displacements. Mann-Whitney U was used to determine any significant differences between set-up data.

Results

Sixty patients were included (30 open & 30 closed masks). There was no statistically significant difference found in the x (p = 0.701), y (p = 0.246) or z (p = 0.535) direction for the SD of the mean displacements between both masks. No statistically significant difference was found in the SD of means for rotational displacements. The calculated planning target volume (PTV) margin requirements were minimally less for the closed masks 3.5, 2.6, and 2.7 mm (x, y, z, respectively) versus 4.2, 3.2, and 3.7 mm, respectively, for open masks.

Conclusion

Our study demonstrates that open masks maintain accuracy at levels comparable to closed masks in patients with anxiety. The minor difference in the calculated PTV margin could be rectified with daily on-line imaging or surface guided imaging.

The Remove-the-Mask Open-Source head and neck Surface-Guided radiation therapy system

Background and Purpose

Surface Guided Radiotherapy (SGRT) for head and neck radiotherapy is challenging as obstructions are common and non-rigid facial motion can compromise surface accuracy. The purpose of this work was to develop and benchmark the Remove the Mask (RtM) SGRT system, an open-source system especially designed to address the challenges faced in radiotherapy of head and neck cancer.

Materials and Methods

The accuracy of the RtM SGRT system was benchmarked using a head phantom positioned on a robotic motion platform capable of sub-millimetre accuracy which was used to induce unidirectional shifts and to reproduce three real head motion traces. We also assessed the accuracy of the system in ten humans volunteers. The ground truth motion of the volunteers was obtained using a commercial motion capture system with an accuracy < 0.3 mm.

Results

The mean tracking error of the RtM SGRT system for the ten volunteers was of -0.1 ± 0.4 mm -0.6 ± 0.6 mm and 0.3 ± 0.2 mm, and 0.0 ± 0.2° 0.0 ± 0.1° and 0.0 ± 0.2° for translations and rotations along the left-right, superior-inferior and anterior-posterior axes respectively and we also found similar results in measurements with the head phantom. Forced facial motion was associated with lower tracking accuracy. The RtM SGRT system achieved submillimetre accuracy.

Conclusion

The RtM SGRT system is a low-cost, easy to build and open-source SGRT system that can achieve an accuracy that meets international commissioning guidelines. Its open-source and modular design allows for the development and easy translation of novel surface tracking techniques.

A systematic review of nonpharmacological interventions to reduce procedural anxiety among patients undergoing radiation therapy for cancer

Procedural anxiety is a concern for a number of patients undergoing radiation therapy. While procedural anxiety is often treated pharmacologically, there is a clinical need for effective alternative strategies for patients who are contraindicated from medication use, and those who prefer not to take unnecessary medications.

OBJECTIVES

The primary objective was to assess the efficacy of nonpharmacological interventions delivered to adults with cancer, in the radiation oncology department, just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety. The secondary objectives were to assess the efficacy of these interventions in reducing physiological symptoms of procedural anxiety and anxiety-related treatment disruptions.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials) were searched from inception up until February 2022.

INCLUSION CRITERIA

Population: Adult patients with cancer undergoing external beam radiation therapy.

INTERVENTION

Nonpharmacological interventions delivered within the radiation therapy department. Comparison: standard care controls, or standard care plus an alternative intervention.

OUTCOMES

level of self-reported procedural anxiety (primary), physiological symptoms of anxiety (secondary) and measures of anxiety-related treatment disruptions (secondary).

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted data. A meta-analysis was originally planned but deemed not feasible as the studies could not be confidently pooled for meta-analysis, due to the variability in the interventions, study designs and the generally low number of studies. Therefore, a narrative synthesis is presented.

RESULTS

Screening of 2363 records identified nine studies that met inclusion criteria: six studies of music interventions, two of video-based patient education and one of aromatherapy. Overall, three studies received a global rating of strong methodological quality and low risk of bias. Three studies reported a significant effect of the intervention on reducing the primary outcome of self-reported procedural anxiety: two music interventions (both strong methodological quality), and one video-based patient education (moderate methodological quality). One of the studies (a music intervention) also reported a significant reduction in the secondary outcome of physiological symptoms of procedural anxiety (systolic blood pressure).

CONCLUSIONS

The evidence for nonpharmacological interventions delivered to adults with cancer just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety is limited, with very few well-designed studies. There is a need for interventions for procedural anxiety during radiation therapy to be evaluated through rigorous randomised controlled trials.

Changes in satisfaction and anxiety about radiotherapy for pediatric cancer by two-step audio-visual instruction

Objectives

Although radiotherapy is an essential component of pediatric cancer treatment, inadequate radiotherapy information for childhood cancer and unusual treatment situations can negatively affect parental perceptions and emotions. This study aims to investigate the effect of two-step audio-visual instruction system effects introduced by our institution on parent satisfaction and anxiety when initiating radiotherapy.

Methods

The two-step audio-visual instruction system comprised instructive animation using patient avatars and a live video system. The live video system has a 55-inch-wide monitor, and a no-latency sound module. Parents in the radiotherapy division can view the patient in the treatment room through the live video system. This prospective study compared satisfaction and anxiety about radiotherapy introduction before and after two-step audio-visual instruction. We enrolled 20 parents whose child underwent radiotherapy, and they completed a set of questionnaires-Client Satisfaction Questionnaire, State-Trait Anxiety Inventory, and original questionnaires about radiotherapy.

Results

Satisfaction scores improved significantly after two-step audio visual instruction (25.5 ± 3.4) compared with those before the instruction (27.7 ± 3.1) (p = <0.01). Anxiety scores also decreased significantly after the instruction (50 ± 9) compared with those before the instruction (54 ± 11) (p = 0.004). However, anxiety-related personality trait scores did not change drastically before and after viewing (48 ± 8.5 vs. 49 ± 7.5) (p = 0.419).

Conclusion

This single-arm prospective study indicates that two-step audio-visual instruction for radiotherapy is effective in improving parents' anxiety about radiotherapy introductions. However, large-scale and comparative studies are warranted to generalize the benefit of two-step audio visual instruction.

'Having the mask on didn't worry me until … they clamped my head down so I wouldn't move': A qualitative study exploring anxiety in patients with head and neck cancer during radiation therapy

INTRODUCTION

More than 20% of patients undergoing radiation therapy for head and neck cancer report anxiety specifically related to the immobilisation mask, a tight-fighting mask patients are required to wear for the duration of each treatment session. However, limited research has investigated this from the patient perspective. The aim of this study was to better understand patient experiences of mask anxiety during head and neck cancer radiation therapy and to explore patient attitudes toward potential strategies that may reduce mask anxiety during this treatment.

METHODS

Five patients with head and neck cancer, who had self-reported mask anxiety during radiation therapy, participated in semi-structured, qualitative interviews exploring their experiences of anxiety and suggestions for reducing anxiety. A codebook thematic analysis was conducted.

RESULTS

Six main themes were identified: (1) triggers of anxiety; (2) adjusting to radiation therapy; (3) education about the mask; (4) coping; (5) motivation and (6) improving the patient experience.

CONCLUSION

Findings from these interviews provide valuable insight into how and when healthcare providers may be able to assist patients to manage mask anxiety. Recommendations include increased communication from health care providers; delivery of visual information to improve patient preparedness; exposure/opportunities to interact with the masks prior to treatment commencing and increased control of music/soundtrack selection. However, a limitation of this study is the small sample size and further research is warranted.

The Effect of Video-Based Education on Anxiety of Patients Receiving Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Patients receiving stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may have an anxiety due to unknown aspects of the treatment. We aimed to reduce patient anxiety by using video-based education. Forty patients were divided into 2 groups, with one-to-one information session (n = 20) and one-to-one information session plus video-based education (n = 20). The patients completed the State-Trait Anxiety Inventory (STAI) and visual facial anxiety scale before and after information sessions and after treatment. The setup time and disruptions during treatment sessions were recorded for patients receiving treatment with Novalis® and Cyberknife®, respectively. The patient characteristics and STAI scores before education were similar between groups. The anxiety level was significantly lower in group 1 after treatment (median 38, interquartile range (IQR) 27-45) compared to before (median 43, IQR 36-47) (p = 0.003) and after information sessions (median 42, IQR 36-47) (p = 0.004); however, any difference was not observed in anxiety levels between before and after information sessions (p = 0.317). The anxiety level was significantly lower in group 2 after video-based education (median 25, IQR 22-33) and after treatment (median 25, IQR 20-30) compared to before video-based education (median 35, IQR 31-42) (p < 0.001 for both), while there was no significant difference in anxiety levels between after video-based education and after the treatment (p = 0.407). The interruptions during treatment were observed in 9 (60%) patients in group 1 and 6 (40%) patients in group 2 (p = 0.038). Video-based educations significantly reduce patient anxiety before SRS/SBRT and increase their compliance with the treatment.

Development and validation of a cost-effective virtual reality educational tool to reduce anxiety and improve set-up accuracy in radiotherapy patients

PURPOSE

This study proposes a cost-effective method for educating radiotherapy patients through an immersive virtual reality (VR) system.

METHODS

The VR educational tool comprises VR glasses, a handheld controller, the scientific knowledge of radiotherapy, radiotherapy demonstration, and an audio introduction. To verify its efficacy, 120 radiotherapy patients with tumors were prospectively enrolled and divided into the control group or VR intervention group. After the first treatment, set-up errors, including three translation errors and three rotation errors, were recorded in six directions. In addition, participants were required to complete a questionnaire before radiotherapy to assess anxiety and understanding degrees. The questionnaire was scored using a five-point Likert Scale. Finally, Spearman's rank correlation test was used to evaluate set-up errors and questionnaire scores.

RESULTS

The set-up errors are significantly reduced in AP, SI, total translation, Roll and total rotation in the intervention group compared with the control group (p < 0.05). The scores are higher in the intervention group than in the control group in question 1 (2.1 ± 0.58 vs. 3.3 ± 0.55), question 2 (1.3 ± 0.44 vs. 2.5 ± 0.65), question 4 (2.2 ± 0.65 vs. 3.2 ± 0.82), question 5 (1.8 ± 0.59 vs. 3.1 ± 0.79), and all subscales (5.5 ± 1.2 vs. 8.9 ± 1.3 and 6.4 ± 1.3 vs. 9.2 ± 1.5). The scores of high, moderate, and low correlation are 47 (74%), 15 (23%), and 2 (3%) for the control group and 44 (69%), 17 (26%), and 3 (5%) for the intervention group, respectively.

CONCLUSION

The VR educational tool can significantly improve comprehension and reduce anxiety. There is a strong correlation between set-up errors and questionnaire scores. The VR educational tool may help reduce set-up errors for radiotherapy patients.

Treating Radiation Anxiety with Systematic Desensitization: Head and Neck Cancer Case Reports

Introduction: Head and neck cancer patients have high rates of psychological distress, which may be exacerbated by the treatments they receive. Many patients who undergo radiation therapy report significant anxiety associated with the thermoplastic mask required for immobilization during treatment. Case Description: This report presents two examples of head and neck cancer patients reporting high mask anxiety, along with a history of claustrophobia, who expressed concern about their abilities to initiate and adhere to treatment. Both were referred to supportive care psychology before radiation treatment initiation. With counseling and the use of systematic desensitization, they were successfully able to complete their treatments. Discussion: Results of these case reports highlight the value of integrating early supportive care in the treatment of head and neck cancer and support the need for further study in future randomized controlled trials.

Biofeedback Enabled CALM (BeCALM)-the feasibility of biofeedback on procedural anxiety during radiation therapy: study protocol for a pilot randomised controlled trial

INTRODUCTION

Patients undergoing treatment for cancer who require radiation therapy (RT) report anxiety specifically relating to the RT procedure. Procedural anxiety can be detrimental to treatment delivery, causing disruptions to treatment sessions, or treatment avoidance. Acute procedural anxiety is most commonly managed with anxiolytic medication. There is a need for effective, non-pharmacological interventions for patients not suitable for, or who prefer to avoid, anxiolytic medication. The primary objectives of this pilot trial are to evaluate the: (1) feasibility of conducting the Biofeedback Enabled CALM (BeCALM) intervention during RT treatment sessions; (2) acceptability of the BeCALM intervention among patients; and (3) acceptability of the BeCALM intervention among radiation therapists. The secondary objective of this pilot trial is to examine the potential effectiveness of the BeCALM intervention delivered by radiation therapists to reduce procedural anxiety during RT.

METHODS AND ANALYSIS

This is a pilot randomised controlled trial. A researcher will recruit adult patients with cancer (3-month recruitment period) scheduled to undergo RT and meeting eligibility criteria for procedural anxiety at the Calvary Mater Hospital, Newcastle (NSW), Australia. Participants will be randomly assigned to receive treatment as usual or the BeCALM intervention (biofeedback plus brief breathing techniques). The primary outcomes are feasibility (measured by recruitment, retention rates and percentage of treatment sessions in which the intervention was successfully delivered); radiation therapists perceived feasibility and acceptability (survey responses); and patient perceived acceptability (survey responses). Secondary outcome is potential effectiveness of the intervention (as measured by the State Trait Anxiety Inventory-State subscale; the Distress Thermometer; and an analysis of treatment duration).

ETHICS AND DISSEMINATION

The study protocol has received approval from Hunter New England Health Human Research Ethics Committee (2021/ETH11356). The results will be disseminated via peer-reviewed publications, as well as presentation at relevant conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621001742864.

Novel multi jet fusion 3D-printed patient immobilization for radiation therapy

PURPOSE

Thermoplastic immobilizers are used routinely in radiation therapy to achieve positioning accuracy. These devices are variable in quality as they are dependent on the skill of the human fabricator. We examine the potential multi jet fusion (MJF) 3D printing for the production immobilizers with a focus on the surface dosimetry of several MJF-printed PA12-based material candidates. Materials are compared with the goal of minimizing surface dose with comparison to standard thermoplastic. We introduce a novel metamaterial design for the shell of the immobilizer, with the aims of mechanical robustness and low-dose buildup. We demonstrate first examples of adult and pediatric cranial and head-and-neck immobilizers.

METHODS

Three different PA12 materials were examined and compared to fused deposition modeling-printed polylactic acid (PLA), PLA with density lowered by adding hollow glass microspheres, and to perforated or perforated/stretched and solid status quo thermoplastic samples. Build-up dose measurements were made using a parallel plate chamber. A metamaterial design was established based on a packed hexagonal geometry. Radiochromic film dosimetry was performed to determine the dependence of surface dose on the metamaterial design. Full cranial and head-and-neck prototype immobilizers were designed, printed, and assessed with regard to dimensional accuracy.

RESULTS

Build-up dose measurements demonstrated the superiority of the PA12 material with a light fusing agent, which yielded a ∼15% dose reduction compared to other MJF materials. Metamaterial samples provided dose reductions ranging from 11% to 40% compared to stretched thermoplastic. MJF-printed immobilizers were produced reliably, demonstrated the versatility of digital design, and showed dimensional accuracy with 97% of sampled points within ±2 mm.

CONCLUSIONS

MJF is a promising technology for an automated fabrication of patient immobilizers. Material selection and metamaterial design can be leveraged to yield surface dose reduction of up to 40%. Immobilizer design is highly customizable, and the first examples of MJF-printed immobilizers demonstrate excellent dimensional accuracy.

Comparing patient acceptability of MR-guided radiotherapy to conventional CBCT on two Elekta systems: a questionnaire-based survey

Background and Purpose:

The magnetic resonance linear accelerator system (MR Linac) is a novel piece of radiotherapy (RT) equipment allowing the routine application of daily MR-guided treatment adaptation. The hardware design required for such technical capabilities and the increased complexity of the treatment workflow entails a notable departure from cone beam computed tomography (CBCT)-based RT. Patient tolerability of treatment is paramount to RT practice where high compliance is required. Presented is a comparative analysis of how such modality specific characteristics may ultimately impact the patient experience of treatment.

Materials and Methods:

Forty patients undergoing RT for prostate cancer (PCa) on either the MR Linac (n = 20) or a CBCT-based linac (n = 20) were provided with a validated patient reported outcomes measures (PROM’s) questionnaire at fraction 1 and fraction 20. The 18-item questionnaire provided patient responses recorded using a 4-point Likert scale, 0 denoting a response of ‘Not at all’, 1 ‘Slightly’, 2 ‘Moderately’ and 3 signifying ‘Very’. The analysis provided insight into both comparisons between modalities at singular time points (fractions 1 and 20), as well as a temporal analysis within a single modality, denoting changing patient experience.

Results:

Patients generally found the MR Linac treatment couch more comfortable, however, found the increase in treatment duration harder to tolerate. Responses for all items remained stable between first and last fraction across both cohorts, indicating minimal temporal variation within a single modality. None of the responses were statistically significant at the 0·01 level.

Conclusion:

Whether radiotherapy for PCa is delivered on a CBCT linac or the MR Linac, there is little difference in patient experience with minimal experiential variation within a single modality.

Trajectory of anxiety related to radiation therapy mask immobilization and treatment delivery in head and neck cancer and radiation therapists’ ability to detect this anxiety. “Anxiety during radiation therapy with mask”

Purpose

Receiving radiation therapy treatment with an immobilization mask is a source of anxiety in people with head and neck cancer (HNC). This study aimed to document the trajectory of situational anxiety during HNC treatment delivery and explore radiation therapists’ (RTs’) ability to identify it.

Methods and Materials

Participants with HNC commencing radiation therapy completed the state-trait anxiety inventory at their mask-making session, and once each week immediately before and after their radiation treatment. Treating RTs independently rated their perception of participant's anxiety at the same time points. Participant- and RT-rated anxiety scores were calculated at each time point together with the proportion of participants reporting clinically significant anxiety (state-trait anxiety inventory ≥ 40). Intraclass correlations were calculated to assess concordance between participant- and RT-ratings.

Results

Sixty-five participants and 16 RTs took part in this study. Participants were classified into 1 of 5 trajectory groups: stable high (16%), increasing (19%), decreasing (27%), fluctuating (19%), and no anxiety (19%). Nearly half (43%) of participants reported clinically significant anxiety before their mask-making session, and between 30% and 43% across trajectories reported significant anxiety immediately before treatments. Intraclass correlation values indicated poor agreement between participant- and RT-ratings.

Conclusions

Situational anxiety is prevalent in people receiving HNC radiation therapy with mask immobilization. RTs did not reliably capture patients’ situational anxiety. There is no single best time point to provide intervention, suggesting people should be screened for anxiety regularly throughout their treatment. Resources and education should also be available to improve RT skills in providing psychosocial support.

Not as simple as "fear of the unknown": A qualitative study exploring anxiety in the radiotherapy department

OBJECTIVE

Little is understood about the anxiety experienced by cancer patients undergoing radiotherapy or investigative imaging. Our aim was to identify sources of anxiety, the points along the cancer journey where anxiety occurred and methods to alleviate it.

METHODS

Six focus groups were conducted with cancer patients (n = 17), caregivers (n = 3) and healthcare practitioners (HCPs; n = 10) in the radiotherapy department. Patients described specific elements in the care pathway which induced anxiety, while HCPs focused on their perception of the patient experience. Thematic analysis was used to analyse data.

RESULTS

Three broad themes emerged: The Environment, The Individual and The Unknown. The physical environment of the hospital, inside the scanner for example, emerged as a key source of anxiety. The impact of cancer on patients' individual lives was significant, with many feeling isolated. The majority of participants described anxiety associated with the unknown. HCPs reported difficulty in identifying the anxious patient.

CONCLUSIONS

Anxiety is experienced throughout the cancer pathway. Common sources include the physical environment and the uncertainty associated with having cancer. Identifying both anxiety-inducing factors, and the anxious patients themselves, is crucial to enable targeted interventions to alleviate anxiety.

Screening and Psycho-Oncological Support for Patients With Head and Neck Cancer and Brain Malignancies Before Radiotherapy With Mask Fixation: Results of a Feasibility Study

This single-center, single-arm trial investigates the feasibility of a psycho-oncological care program, which aims to reduce psychological distress and improve compliance with radiotherapy with mask fixation in patients with head and neck cancer or brain malignancies. The care program comprised (1) a screening/needs assessment and (2) the provision of a psycho-oncological intervention using imaginative stabilization techniques for distressed patients (distress due to anxiety ≥5) or in a case of subjective interest in the psycho-oncological intervention. Another allocation path to the intervention was directly through the radiation oncologist in charge who classified the patient as: in need of support to tolerate the immobilization device. Of a total of 1,020 screened patients, 257 (25.2%) patients indicated a distress ≥5 and 141 (13.8%) patients reported panic attacks. 25% of the patients reported a subjective interest in psycho-oncological support. A total of 35 patients received the psycho-oncological intervention, of which 74% were assigned by radiation oncologists. In this small patient cohort, no significant pre-post effects in terms of depression, anxiety, distress, and quality of life (mental and physical component scores) could be detected. Our results indicate a good feasibility (interdisciplinary workflow and cooperation, allocation by physicians in charge) of the psycho-oncological care program for this cohort of patients before radiotherapy with mask fixation. The screening results underline the high psychological distress and demand for psycho-oncological support. However, since the utilization of our intervention was low, future studies should reduce the barriers and improve compliance to psycho-oncological services by these patients.Clinical Trial Registration: https://www.drks.de/drks_web/setLocale_EN.do #DRKS00013493

Investigation of the Spiritual Care Effects on Anxiety, Depression, Psychological Distress and Spiritual Levels of Turkish Muslim Radiotherapy Patients

The aim of this study is to examine the spiritual care support given to Muslim cancer patients undergoing radiotherapy with an experimental study on the spirituality, anxiety, depression and distress levels of these patients. In this study, experimental research design with experimental control group was used. Personal information form designed by researchers, HAD scale, DT scale and Spirituality Scale was used for personal information. In conclusion, it was determined that the support for Islamic spiritual care had positive effects on hospitalized radiotherapy patients. According to the results obtained, it is recommended to examine in larger sample groups in different treatment programs in order to reveal the effect of spiritual care support.

Occupational therapy for people with mask anxiety undergoing radiotherapy

INTRODUCTION

Up to one third of people with head and neck cancer undergoing radiation therapy experience mask anxiety. However, there is limited literature guiding the role of health professionals, including occupational therapists, in managing mask anxiety. This study aimed to explore the content of occupational therapy interactions with people who have identified mask anxiety.

METHODS

A cohort of 20 participants with identified mask anxiety engaged in semi-structured interviews with occupational therapists. Theoretical thematic analysis and the framework provided by the Canadian Model of Occupational Performance and Engagement (CMOP-E) were employed to explore the content of occupational therapy interactions with people experiencing mask anxiety.

RESULTS

Theoretical thematic analysis identified 13 relevant themes with 49 codes relating to the interaction between participants and occupational therapists. Analysis of these interactions identified the occupational therapy role to be holistic and multifaceted. The cognitive, affective, and institutional components of the CMOP-E were dominantly explored by the occupational therapists with participants. Occupation, spirituality, and the cultural environment were either not addressed or minimally discussed with participants.

CONCLUSION

The management of mask anxiety during radiation therapy is a novel area of practice for occupational therapists. The results of this study suggest that the occupational therapy profession explores a range of factors with the person undergoing radiation therapy with mask anxiety, and that the CMOP-E model can be used to guide these interactions. Future research is required to further define this role and its efficacy in managing mask anxiety.

Quantifying false positional corrections due to facial motion using SGRT with open-face Masks

Purpose

Studies have evaluated the viability of using open‐face masks as an immobilization technique to treat intracranial and head and neck cancers. This method offers less stress to the patient with comparable accuracy to closed‐face masks. Open‐face masks permit implementation of surface guided radiation therapy (SGRT) to assist in positioning and motion management. Research suggests that changes in patient facial expressions may influence the SGRT system to generate false positional corrections. This study aims to quantify these errors produced by the SGRT system due to face motion.

Methods

Ten human subjects were immobilized using open‐face masks. Four discrete SGRT regions of interest (ROIs) were analyzed based on anatomical features to simulate different mask openings. The largest ROI was lateral to the cheeks, superior to the eyebrows, and inferior to the mouth. The smallest ROI included only the eyes and bridge of the nose. Subjects were asked to open and close their eyes and simulate fear and annoyance and peak isocenter shifts were recorded. This was performed in both standard and SRS specific resolutions with the C‐RAD Catalyst HD system.

Results

All four ROIs analyzed in SRS and Standard resolutions demonstrated an average deviation of 0.3 ± 0.3 mm for eyes closed and 0.4 ± 0.4 mm shift for eyes open, and 0.3 ± 0.3 mm for eyes closed and 0.8 ± 0.9 mm shift for eyes open. The average deviation observed due to changing facial expressions was 1.4 ± 0.9 mm for SRS specific and 1.6 ± 1.6 mm for standard resolution.

Conclusion

The SGRT system can generate false positional corrections for face motion and this is amplified at lower resolutions and smaller ROIs. These errors should be considered in the overall tolerances and treatment plan when using open‐face masks with SGRT and may warrant additional radiographic imaging.

A Prospective Randomized Trial of the Influence of Music on Anxiety in Patients Starting Radiation Therapy for Cancer

PURPOSE

One of the most downloaded articles in 2017 from the International Journal of Radiation Oncology, Biology, and Physics was a study suggesting that music therapy during radiation therapy (RT) simulation substantially reduces anxiety. To further evaluate the potential of music's clinical efficacy in the context of radiation therapy, we conducted a randomized trial evaluating the influence of genre-based music chosen by the study participant on anxiety during the first RT treatment session with a method that is applicable to routine clinical practice.

METHODS AND MATERIALS

We conducted a prospective randomized trial of music versus no music during the first RT treatment for cancer. We limited the study to women because prior studies document a higher rate of anxiety in female patients with cancer. Anxiety was evaluated before and after the first RT treatment using the State-Trait Anxiety Inventory (STAI) and Symptom Distress Thermometer (SDT). Patients randomized to music had their preferred genre of music played from a web-based application while in the treatment vault.

RESULTS

In the study, 102 females were enrolled (51 with and 51 without music). Baseline high anxiety score before RT was recorded in 48% of patients using the STAI and 58% using the SDT. The percent decrease in mean STAI score was 16% with music versus 10% without music (P = .2197). The mean SDT percent changes were a 13% decrease with music versus a 2% increase without music (P = .3298).

CONCLUSIONS

This study documents that high anxiety is common in women receiving RT for cancer and that music, as used in this study, does not reduce anxiety to a meaningful degree.

Non-pharmacological approaches to procedural anxiety reduction for patients undergoing radiotherapy for cancer: systematic review protocol

INTRODUCTION

Procedural anxiety relates to an affective state of anxiety or fear in relation to a medical procedure. Various treatment-related factors may elicit anxiety among oncology patients, including fear of diagnostic imaging (such as MRI scans) and impending treatment and medical procedures (such as chemotherapy and radiotherapy). It is common in oncology settings to manage acute anxiety relating to medical procedures with anxiolytic medication. However, pharmacological approaches are not suitable for many patients. Despite this, non-pharmacological interventions are infrequently used. The aim of this systematic review is to determine whether non-pharmacological interventions delivered prior to, or during, radiotherapy are effective in reducing procedural anxiety.

METHODS AND ANALYSIS

Data sources will include the bibliographic databases CINAHL, MEDLINE, EMBASE, PsycINFO and Cochrane Central Register of Controlled trials (CENTRAL) (from inception onward). Eligible studies will include adult patients with cancer undergoing radiotherapy treatment. Included studies will be those which employ a non-pharmacological intervention, delivered within existing radiotherapy appointments, with the aim of reducing procedural anxiety related to radiotherapy. All research designs with a control or other comparison group will be included. The primary outcome will be change in levels of self-reported procedural anxiety. Secondary outcomes will be changes in scores on physiological measures of anxiety and/or changes in treatment completion and/or changes in treatment duration and/or changes in psychological distress. Two investigators will independently complete title and abstract screening, full-text screening, data extraction and assessment of methodological quality. If appropriate, a meta-analyses will be performed. Any important amendments to this protocol will be updated in the PROSPERO registration and documented in the resulting review publication.

ETHICS AND DISSEMINATION

No ethical issues are anticipated from this review. The findings will be disseminated through peer-reviewed publication and at conferences by presentation.

SYSTEMATIC REVIEW REGISTRATION

CRD42019112941.

A comparative study between open-face and closed-face masks for head and neck cancer (HNC) in radiation therapy

Aim

To determine the setup reproducibility in the radiation treatment of Head and Neck (HN) patients using open face head and shoulder masks (OHSM) with customized headrest (CHR) versus standard closed head and shoulder masks (CHSM) and to determine the patient's level of comfort and satisfaction for both masks.

Methods

Forty patients were prospectively randomized into two groups using simple random sampling. Group 1 was assigned with CHSMs, immobilized with a standard HR (SHR) while Group 2 was assigned with OHSMs, and immobilized with CHR. Cone beam computed tomography (CBCT) was taken the first 3 days, followed by weekly CBCT (prior treatment) with results registered to the planning CT to determine translational and rotational inter-fraction shifts and to verify accuracy. Mean (M) and standard deviation (SD) of the systematic and random setup errors of the 2 arms in the translational and rotational directions were analyzed, using Independent t-test and Mann-Whitney U test. Patient comfort was measured using a Likert questionnaire.

Results

The vertical, lateral, longitudinal and Z/roll rotational shifts were not significantly different between the two masks. X/yaw and Y/pitch rotational shifts were significantly greater in Group 2 versus Group 1, for both systematic (p = 0.009 and 0.046, respectively) and random settings (p = 0.016 and 0.020) but still within three degrees. Patients reported higher neck and shoulder comfort (p = 0.020) and overall satisfaction (p = 0.026) using the OHSM with the CHR versus the CHSM with the SHR during CT simulation.

Conclusion

Open masks provide comparable yet comfortable immobilization to closed masks for HN radiotherapy.

Exploring head and neck cancer patients' experiences with radiation therapy immobilisation masks: A qualitative study

OBJECTIVE

Head and neck cancer (HNC) patients commonly undergo radiation therapy requiring immobilisation by a mask. Some find the mask distressing, and this can disrupt treatment sessions. This study aimed to explore the patient experience of immobilisation masks in the Australian and New Zealand (ANZ) context, to guide possible intervention.

METHODS

Semi-structured interviews were conducted with HNC patients who had completed radiation therapy, recruited via hospitals and social media. Interviews continued until data saturation; then, three further interviews were conducted for member-checking purposes. Qualitative methodology with thematic analysis was used to identify themes in the data.

RESULTS

Twenty HNC survivors participated in interviews, and seven themes were identified: information received by participants, potential predictors of mask anxiety, participant reactions to the mask, trajectories of mask anxiety, supportive behaviour and communication of health professionals, coping with the mask, and thoughts and feelings about the mask.

CONCLUSIONS

Participant experiences of the immobilisation mask were diverse. The findings fit with Lazarus and Folkman's (Stress, appraisal, and coping. New York, NY: Springer Pub. Co) transactional model of stress and coping, as participants appeared to make cognitive appraisals of the mask and their coping abilities throughout treatment, resulting in varied levels of mask-related distress. Complex intervention is recommended to reduce mask anxiety in HNC patients across ANZ.

Unmasking Anxiety: A Qualitative Investigation of Health Professionals; Perspectives of Mask Anxiety in Head and Neck Cancer

BACKGROUND

To ensure precision of treatment, patients requiring radiation therapy for treatment of head and neck cancer (HNC) are stabilized using a fitted thermoplastic immobilization mask. Despite evidence that many patients experience significant anxiety when restrained in the mask, there is a lack of proven interventions to prevent or manage mask-related anxiety. The Promoting Action on Research Implementation in Health Services implementation framework promotes consideration of context and culture when developing interventions to ensure successful implementation if proven effective. Health professionals (HPs) play a crucial role in the management of patients' psychological concerns, yet no studies have explored their perspectives of mask anxiety and how it should be managed. The aim of this study, therefore, was to elicit and analyse HPs' perspectives of mask anxiety, using the Promoting Action on Research Implementation in Health Services framework, to guide the development of implementation-ready interventions to reduce mask anxiety.

METHODS

Semistructured interviews were conducted with 20 HPs involved in the care of HNC patients, including radiation oncologists, radiation therapists, nurses, and psychologists, from nine hospitals in NSW, Australia. Framework analysis methods were used.

RESULTS

Participants were on average 40 years old (range, 27-56), the majority were female (75%), and they had worked from 1 to 22 years with HNC patients. Six emergent themes were identified: (1) Mask anxiety is a significant problem but is easily missed; (2) Context matters; (3) Trust is critical; (4) Choice and control facilitate adjustment; (5) Psychological strategies are valued; and (6) Culture matters. Subgroup analysis also highlighted differences in perspectives between specialties.

CONCLUSIONS

Participants identified key principles underlying successful intervention. Two significant barriers to mask-anxiety intervention were identified: (1) a lack of empirical evidence surrounding its prevalence and predictors and (2) contextual and systematic hurdles making the health system potentially unresponsive to change. These data suggest a need for further descriptive studies and careful development of interventions which will address these hurdles.

A prospective examination of mask anxiety during radiotherapy for head and neck cancer and patient perceptions of management strategies

INTRODUCTION

Distress related to wearing an immobilisation mask for radiotherapy treatment (RT) is a common experience for the person undergoing RT for head and neck cancer (HNC). Described as 'mask anxiety', there is little known about the patterns of this distress through the course of the treatment or what strategies are being used by people to help alleviate mask anxiety.

METHODS

The study used a prospective cohort design to examine the patterns of patient-reported mask anxiety during the course of RT, using a modified Distress Thermometer (DT) and a survey to explore strategies patients used to assist their mask anxiety.

RESULTS

Thirty-five participants, who identified as experiencing mask anxiety, were followed throughout RT treatment. At baseline, females were more likely to experience higher mask anxiety (P = 0.03). Across the course of treatment, mask anxiety significantly (P < 0.001) reduced within the total cohort. In 72% of participants, the level of initial distress was found to reduce over time. Only 22% experienced mask anxiety that remained constant. Few (6%) experienced an increase in mask anxiety across the course of RT. Participants reported relying on intervention from health professionals, self-taught strategies, music, visualisation and medication to manage their mask anxiety.

CONCLUSIONS

Due to its high prevalence and variable patterns over time, it is recommended that routine screening for mask anxiety be implemented as standard care throughout the course of RT for HNC. Multiple, diverse strategies are being used by patients and studies are needed to develop effective interventions for managing mask anxiety.

Assessing the cost-effectiveness of RT Prepare: A radiation therapist-delivered intervention for reducing psychological distress prior to radiotherapy

OBJECTIVE

To determine the cost-effectiveness of RT Prepare in reducing breast cancer patients' psychological distress before treatment, compared with usual care.

METHODS

RT Prepare, an intervention involving patient education and support consultations with a radiation therapist (RT), was implemented at three Australian sites (Australian New Zealand Clinical Trials Registration: ACTRN12611001000998). The primary outcome was change in psychological distress using the Hospital Anxiety and Depression Scale (HADS); secondary outcomes were changes in quality of life (QoL) and additional health service use. Costs (2015 $AU) included consultation time and training delivery. Between-group comparisons of HADS and QoL used generalised linear mixed models, and comparisons of health service use used negative binomial regression. Incremental cost-effectiveness ratios (ICERs) indicated mean costs per 1-point decrease in HADS score. Sensitivity analyses explored variation in facility size and uncertainty in intervention effectiveness.

RESULTS

Among 218 controls and 189 intervention participants, the intervention significantly lowered HADS scores at treatment commencement (adjusted mean difference 1.06 points). There was no significant effect on QoL or additional service use. Mean intervention costs were AU$171 per participant (US$130, €119) mostly related to RT training (approximately AU$142 (US$108, €99). An ICER of $158 (US$120, €110) was estimated. Cost-effectiveness improved in a sensitivity analysis representing a large facility with higher patient numbers.

CONCLUSION

This study provides new data on the cost-effectiveness of an RT-delivered intervention to reduce psychological distress prior to treatment, which will be useful to inform delivery of similar services. As most costs were upfront, cost-effectiveness would likely improve if implemented as standard care.

Exploring the prevalence and experience of mask anxiety for the person with head and neck cancer undergoing radiotherapy

INTRODUCTION

While use of a thermoplastic mask during radiotherapy (RT) treatment for head and neck cancer (HNC) is an essential component of safe patient care, there is little understanding of the extent to which this evokes anxiety (i.e. "mask anxiety") for the person undergoing treatment.

METHODS

A mixed method, convergent design was used to examine the prevalence and experience of mask anxiety using two clinical cohorts. In phase one, a cohort of 100 patients undergoing RT for HNC were assessed for self-perceived mask anxiety using a modified distress thermometer screening tool. In phase two, a separate cohort of 20 patients who identified as having mask anxiety participated in individual interpretative descriptive interviews to explore the nature of their experience.

RESULTS

In phase one, 26% of participants self-identified as being anxious about the use of a thermoplastic mask. In phase two thematic analysis of the interviews revealed two over-arching themes relating to the person's experience of mask anxiety: contributors to the mask anxiety (vulnerability, response to experience and expectations); and how the person was going to manage the mask anxiety during treatment (strategies and mindset).

CONCLUSIONS

Mask anxiety impacted a quarter of participants undergoing radiotherapy for HNC. In line with the themes elicited from the participants, implementation of routine screening to ensure early identification, and patient education to assist preparation for wearing the mask during RT are strategies that could improve current management of mask anxiety.

Development and pilot of an international survey: 'Radiation Therapists and Psychosocial Support'

INTRODUCTION

Up to one third of radiation therapy patients are reported to have unmet psychosocial needs. Radiation therapists (RTs) have daily contact with patients and can provide daily psychosocial support to reduce patient anxiety, fear and loneliness. However, RTs vary in their values, skills, training, knowledge and involvement in providing psychosocial support. The aims of this study were to: (1) develop an online survey instrument to explore RT values, skills, training and knowledge regarding patient anxiety and psychosocial support, and (2) pilot the instrument with RT professionals to assess content validity, functionality and length.

METHOD

An online cross-sectional survey, titled 'Radiation therapists and psychosocial support' was developed. Items included patient vignettes, embedded items from RT research, and the Professional Quality of Life Scale (ProQOL5). Four radiation oncology departments volunteered to pilot the survey; each nominated four RT staff to participate. Survey data were analysed descriptively and qualitative feedback grouped and coded to determine whether the survey needed to be refined.

RESULTS

Thirteen of sixteen RTs completed the pilot survey and feedback form. Median time to completion was 35 mins, with 54% of respondents stating this was too long. Respondents reported content, questions and response options were relevant and appropriate. Feedback was used to: refine the survey instrument, minimise responder burden and drop out and improve functionality and quality of data collection.

CONCLUSION

This pilot of the 'Radiation therapists and psychosocial support' survey instrument demonstrated content validity and usability. The main survey will be circulated to a representative sample of RTs for completion.

RT Prepare: a radiation therapist-delivered intervention reduces psychological distress in women with breast cancer referred for radiotherapy

BACKGROUND

The aims of this study were to determine whether a radiation therapist-led patient education intervention (RT Prepare) reduced breasts cancer patients' psychological distress (primary endpoint); anxiety, depression and concerns about radiotherapy, and increased knowledge of radiotherapy and preparedness (secondary endpoints). Patient health system usage and costs were also assessed.

METHODS

A multiple-baseline study across three sites. The RT Prepare intervention comprised two consultations with a radiation therapist: prior to treatment planning and on the first day of treatment. Radiation therapists focused on providing sensory and procedural information and addressing patients' pre-treatment anxiety. Usual care data were collected prior to intervention commencement. Data collection occurred: after meeting their radiation oncologist, prior to treatment planning, first day of treatment and after treatment completion. Multilevel mixed effects regression models were used.

RESULTS

In total, 218 usual care and 190 intervention patients participated. Compared with usual care, intervention participants reported lower psychological distress at treatment commencement (p = 0.01); lower concerns about radiotherapy (p < 0.01); higher patient knowledge (p < 0.001); higher preparedness for procedural concerns (p < 0.001) and higher preparedness for sensory-psychological concerns at treatment planning (p < 0.001). Mean within-trial costs per patient were estimated at $AU159 (US$120); mean ongoing costs at $AU35 (US$26).

CONCLUSION

The RT Prepare intervention was effective in reducing breast cancer patients' psychological distress and preparing patients for treatment. This intervention provides an opportunity for radiation therapists to extend their role into providing patients with information and support prior to treatment to reduce psychological distress.

Psychiatric Care of the Radiation Oncology Patient

BACKGROUND

In recent decades, psychiatrists have become increasingly involved in the care of patients with cancer. Psychiatrists are often less familiar with the field of radiation oncology than with other medical specialties.

OBJECTIVE

Therefore, it is beneficial for consulting psychiatrists to be familiar with the basic principles of radiation therapy (RT) and its potential neuropsychiatric sequelae.

METHODS

We performed a PubMed search to identify articles describing neuropsychiatric symptoms resulting from RT, including anxiety, claustrophobia, posttraumatic stress disorder, and neurocognitive impairment. We also searched for other sequelae of RT that may produce psychiatric symptoms, such as radiation necrosis and endocrinopathies. We provide a basic introduction to the delivery of RT.

RESULTS

Psychiatrists may be involved in the treatment of patients before, during, or after RT, and each phase of treatment produces unique considerations. Anxiety about the treatment, especially the need for immobilization with a mask, can be treatment-limiting. Adverse effects from treatment, including cognitive impairment and endocrinopathies, can result in psychiatric symptoms.

CONCLUSIONS

Consulting psychiatrists should be familiar with the basic principles of RT and the neuropsychiatric sequelae that may result from the treatment. Further research is needed to identify strategies to help patients tolerate RT and to identify additional preventive and therapeutic options for RT-induced cognitive impairment.

Reduced patient anxiety as a result of radiation therapist-led psychosocial support: a systematic review

Up to 49% of patients attending radiation therapy appointments may experience anxiety and distress. Anxiety is heightened during the first few visits to radiation oncology. Radiation therapists (RT) are the only health professionals in direct daily contact with patients during treatment, placing them in a unique position to explore patients' psychosocial needs. This review aims to synthesise literature regarding the effect of RT-led psychosocial support on patient anxiety. In May 2015, we searched the following electronic databases: Medline, PsycINFO, Embase, CINAHL, PubMed and Cochrane library. Radiation therapy-specific journals were hand-searched, and reference lists of identified studies searched. This review complies with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search identified 263 articles, of which 251 were excluded based on non-English language, duplicate article or relevance. A total of 12 articles involving 1363 patients were included and categorised into three broad themes: 'Patient Perspectives' 3 articles, 'Patient Information and Education' 5 articles and 'Screening and Needs Assessment' 4 articles. Two publications referred to the same sample and data. Quality ratings were mixed, with one study rated 'high' quality, seven 'moderate' and four 'low'. Methodological weaknesses were identified in relation to workflow, sample size and responder bias. RTs have a role in psychosocial support through increased communication and information sharing, which can benefit both patients and staff. RT-led practices such as relationship building, patient education sessions and screening and needs assessments are feasible and can reduce anxiety.

Development and psychometric testing of an instrument to measure the patient's experience of external radiotherapy: The Radiotherapy Experience Questionnaire (RTEQ)

•

A new instrument to measure the patient’s comfort and experiences during RT.

•

The instrument gains the patients’ perspectives of the RT procedures.

•

RTEQ has a possible application for evaluation of newly introduced techniques.

Background

The patient’s perception of external radiotherapy (RT) procedures and equipment is important to evaluate as a complement to endpoints such as treatment outcome and reproducibility. There is a lack of a proper, psychometrically robust instrument to evaluate the patient’s comfort and experience of the external RT procedure. Hence, this study aimed to develop and test an instrument to measure the patient’s experience during external RT.

Material and Methods

A preliminary 34-item questionnaire was generated from research literature, expert consultations and patient interviews, and it was distributed to patients (n = 825) at 8 RT units in Sweden. The answers were subjected to item analysis and reduction by using exploratory factor analysis. The reliability of the final questionnaire was evaluated using Cronbach’s alpha. Mean scale scores were compared across gender, length of RT and treatment area.

Results

Most items were highly skewed towards positive responses. Scree plot analyses of the 34-item correlation matrix identified six underlying themes explaining 68% of the total variance. After item reduction, the 6 themes explained 73% of the variance in a 23-item questionnaire. Cronbach’s alpha was satisfactory for all themes (between 0.79 and 0.9). Significant differences between treatment areas were found for two scales: situational unease and situational repose.

Conclusion

The RT Experience Questionnaire is a tentatively valid and reliable instrument to measure how patients experience the external RT session process and the environment in the treatment room.

The Impact of Music Therapy on Anxiety in Cancer Patients Undergoing Simulation for Radiation Therapy

PURPOSE

Radiation therapy (RT) is associated with high stress levels. The role of music therapy (MT) for patients receiving RT is not well described. This study evaluates the impact of MT on anxiety and distress during simulation in patients with newly diagnosed head and neck or breast cancer.

METHODS AND MATERIALS

This institutional review board-approved randomized trial of MT versus no MT at the time of simulation included the pre-State-Trait Anxiety Inventory (STAI-S Anxiety) questionnaire and Symptom Distress Thermometer (SDT). Patients randomized to MT received a consultation with a music therapist, during which music of the patients' choice to be played during simulation was selected. The no-MT patients did not receive the MT consultation, nor did they hear prerecorded music during simulation. Subsequent to the simulation, all patients repeated the STAI-S Anxiety questionnaire and the SDT.

RESULTS

Of the 78 patients enrolled (39 in MT group and 39 in no-MT group), 38 had breast cancer and 40 had head and neck cancer. The male-female ratio was 27:51. The overall mean pre- and post-simulation STAI-S scores were 38.7 (range, 20-60) and 35.2 (range, 20-72), respectively. The overall mean pre- and post-simulation SDT scores were 3.2 (range, 0-10) and 2.5 (range, 0-10), respectively. The MT group had mean pre- and post-simulation STAI-S scores of 39.1 and 31.0, respectively (P<.0001), and the mean SDT scores before and after simulation were 3.2 and 1.7, respectively (P<.0001). The no-MT group's mean pre- and post-simulation STAI-S scores were 38.3 and 39.5, respectively (P=.46), and the mean SDT scores were 3 and 3.2, respectively (P=.51).

CONCLUSIONS

MT significantly lowered patient anxiety and distress during the simulation procedure on the basis of the STAI-S questionnaire and SDT. Incorporating culturally centered individualized MT may be an effective intervention to reduce stressors. Continued research defining the role of MT intervention in improving the patient experience by reducing anxiety is warranted.

Breathing guidance in radiation oncology and radiology: A systematic review of patient and healthy volunteer studies

PURPOSE

The advent of image-guided radiation therapy has led to dramatic improvements in the accuracy of treatment delivery in radiotherapy. Such advancements have highlighted the deleterious impact tumor motion can have on both image quality and radiation treatment delivery. One approach to reducing tumor motion irregularities is the use of breathing guidance systems during imaging and treatment. These systems aim to facilitate regular respiratory motion which in turn improves image quality and radiation treatment accuracy. A review of such research has yet to be performed; it was therefore their aim to perform a systematic review of breathing guidance interventions within the fields of radiation oncology and radiology.

METHODS

From August 1-14, 2014, the following online databases were searched: Medline, Embase, PubMed, and Web of Science. Results of these searches were filtered in accordance to a set of eligibility criteria. The search, filtration, and analysis of articles were conducted in accordance with preferred reporting items for systematic reviews and meta-analyses. Reference lists of included articles, and repeat authors of included articles, were hand-searched.

RESULTS

The systematic search yielded a total of 480 articles, which were filtered down to 27 relevant articles in accordance to the eligibility criteria. These 27 articles detailed the intervention of breathing guidance strategies in controlled studies assessing its impact on such outcomes as breathing regularity, image quality, target coverage, and treatment margins, recruiting either healthy adult volunteers or patients with thoracic or abdominal lesions. In 21/27 studies, significant (p < 0.05) improvements from the use of breathing guidance were observed.

CONCLUSIONS

There is a trend toward the number of breathing guidance studies increasing with time, indicating a growing clinical interest. The results found here indicate that further clinical studies are warranted that quantify the clinical impact of breathing guidance, along with the health technology assessment to determine the advantages and disadvantages of breathing guidance.

PracticeCALM: Coaching Anxiety Lessening Methods for Radiation Therapists: A Pilot Study of a Skills-Based Training Program in Radiation Oncology

PracticeCALM is an 8-week on-the-job training program to teach radiation therapists (RTs) techniques for assisting patients who are experiencing treatment-related anxiety. Twelve clinical RTs in a regional oncology program were recruited on a volunteer basis to participate in the training. A mixed-method approach was undertaken to evaluate perceived benefits to clinical practice. The quantitative findings from the Perceived Stress Scale (PSS) showed there were no changes before and after training. Qualitative findings showed significant benefits to RTs, including (1) ability to empathically attune more effectively and earlier to signs of anxiety in patients; (2) improved confidence and self-efficacy for effectively intervening in difficult treatment situations; and (3) enhanced creative problem solving in partnership with patients to assist the acutely anxious patient. The PSS results suggest that intrinsic and extrinsic stressors are a variable but consistent part of the everyday reality of RT practice. A training program focusing on the therapeutic presence dimension of RT practice has a direct impact on effectiveness in assisting anxious patients undergoing RT. When embedded in the clinical life of a radiation therapy department, such a training program has the potential to capture the lived practice wisdom and creative skills of RTs, and effectively mediate these skills across a team through group discussions and documentation on patient charts.

Caregiver-reported neuropsychiatric symptoms in patients undergoing treatment for head and neck cancer: a pilot study

BACKGROUND

Patients with cancer experience multiple neuropsychiatric symptoms. Whereas individual symptoms have been studied in patients with head and neck cancer, the broader context of neuropsychiatric symptoms needs to be explored.

OBJECTIVE

The aims of this pilot study were to (a) determine the caregiver-reported prevalence and severity of neuropsychiatric symptoms in patients with head and neck cancer, (b) determine the associated level of caregiver distress, and (c) describe the effects of neuropsychiatric symptoms on patients and their caregivers.

METHODS

Twenty-three family caregivers of patients with head and neck cancer completed the Neuropsychiatric Inventory Questionnaire and participated in a semistructured interview.

RESULTS

All caregivers reported that patients experienced at least 1 neuropsychiatric symptom (mean, 7.5; range, 1-12). The most frequently reported symptoms were trouble with appetite and eating (95.7%), altered nighttime behaviors (82.6%), depression/dysphoria (78.3%), decreased alertness (69.6%), inattention (60.9%), apathy/indifference (56.5%), anxiety (56.5%), irritability/lability (52.5%), agitation/aggression (52.2%), and slowed behavior (43.5%). The mean severity rating for 9 symptoms was moderate to severe. Most symptoms caused mild to moderate levels of caregiver distress. Qualitative data indicated that neuropsychiatric symptoms negatively affected patients, their caregivers, and other family members. Patients required more caregiver support resulting in increased caregiver burden and distress.

CONCLUSIONS

Neuropsychiatric symptoms are common and troubling in patients with head and neck cancer during treatment. Further investigation of their effects on patients and family caregivers is needed.

IMPLICATIONS FOR PRACTICE

Clinicians should monitor for and treat neuropsychiatric symptoms throughout treatment and provide caregiver and patient education and support.