Oncological Patient Anxiety in Imaging Studies: the PET/CT Example

Effects of a 360° virtual counselling environment on patient anxiety and CCTA process time: A randomised controlled trial

INTRODUCTION

This study investigated whether a 360° virtual counselling environment (360°VCE) was more effective at decreasing patients' anxiety than routine standard of care counselling for patients undergoing coronary computed tomography angiography (CCTA), and if there was any difference in the process times for both of these groups.

METHODS

A total of 86 patients underwent CCTA in this randomised controlled trial. Patients were randomly assigned to intervention and control groups. The 360°VCE was developed using spherical panoramic images and non-immersive 360° technology. The primary outcome, anxiety, was measured using the State-Trait Anxiety Inventory (STAI). The secondary outcome, CCTA process time, was measured from the time of arrival in the department until end of examination.

RESULTS

Pre-scan anxiety was lower among patients in the 360°VCE group immediately before CCTA in comparison to patients in the control group (p = 0.015). Women demonstrated higher levels of anxiety than men in both groups. No between-group differences were discerned in CCTA process time.

CONCLUSION

Access to 360°VCE can reduce patients' pre-CCTA anxiety levels.

IMPLICATIONS FOR PRACTICE

The presented results can be used to improve patient counselling and care, reduce anxiety among patients undergoing CCTA, and optimise the CCTA examination procedure.

Scanxiety among Adults with Cancer: A Scoping Review to Guide Research and Interventions

Background: Scan-related anxiety ("scanxiety") is distressing to people living with and beyond cancer. We conducted a scoping review to promote conceptual clarity, identify research practices and gaps, and guide intervention strategies for adults with a current or prior cancer diagnosis. Methods: Following a systematic search, we screened 6820 titles and abstracts, evaluated 152 full-text articles, and selected 36 articles. Definitions, study designs, measurement methods, correlates, and consequences of scanxiety were extracted and summarized. Results: The reviewed articles included individuals living with current cancer (n = 17) and those in the post-treatment phase (n = 19), across a breadth of cancer types and disease stages. In five articles, authors explicitly defined scanxiety. Multiple components of scanxiety were described, including those related to scan procedures (e.g., claustrophobia, physical discomfort) and scan results (e.g., implications for disease status and treatment), suggesting varied intervention approaches may be needed. Twenty-two articles used quantitative methods, nine used qualitative methods, and five used mixed methods. In 17 articles, symptom measures specifically referenced cancer scans; 24 included general measures without reference to scans. Scanxiety tended to be higher among those with lower education levels, less time since diagnosis, and greater baseline anxiety levels (three articles each). Although scanxiety often decreased immediately pre- to post-scan (six articles), participants reported the waiting period between scan and results to be particularly stressful (six articles). Consequences of scanxiety included poorer quality of life and somatic symptoms. Scanxiety promoted follow-up care for some patients yet hindered it for others. Conclusions: Scanxiety is multi-faceted, heightened during the pre-scan and scan-to-results waiting periods, and associated with clinically meaningful outcomes. We discuss how these findings can inform future research directions and intervention approaches.

Audiovisual intervention alleviates anxiety of patients during PET/CT imaging

AIM

to assess if the use of an audiovisual intervention in the uptake room and/or in the scanning room, could help to reduce anxiety during [18F]FDG PET/CT imaging.

METHODS

We prospectively studied 120 patients referred for [18F]FDG PET/CT imaging. Patients were allocated in 4 groups of 30 patients depending on the use of the audiovisual intervention: (1) no audiovisual intervention; (2) audiovisual intervention only in the uptake room; (3) audiovisual intervention only in the scanning room; (4) audiovisual intervention in the uptake and the scanning rooms. In order to measure the anxiety levels of the patients before and after the scan, all patients answered the State-Trait Anxiety Inventory (STAI).

RESULTS

The anxiety status across typical situations on a daily basis (STAI-T) of the 4 groups of patients was comparable with no significant differences. The mean State Anxiety (STAI-S) sum-score at prescan and postscan among groups was: (1) 17.5±8.7 vs. 17.3±8.6, p=0.834; (2) 17.4±10.5 vs. 15.8±9.6, p=0.110; (3) 17.5±11.7 vs. 15.1±9.8, p= 0.013; (4) 17.4±9.7 vs. 14.9±8.1, p= 0.009. The percentage of patients with reduction of the STAI-S score among groups 1-4 was 17%, 47%, 50%, and 66%, respectively. The variation of the percentage of patients with lower scores after intervention among groups was statistically significant (p<0.001).

CONCLUSION

Audiovisual intervention decreases anxiety levels of patients referred for PET/CT imaging. The results of our study support a beneficial effect of the audiovisual intervention and its potential to alleviate the anxiety of oncological patients who undergo a PET/CT scan.

Effectiveness of educational videos on patient's preparation for diagnostic procedures: Systematic Review and Meta-Analysis

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Patients’ anxiety and unfamiliarity are barriers to undergoing diagnostic procedures.

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Studies found educational videos more effective than other forms of information.

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Educational videos minimise anxiety and improve patient satisfaction.

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Educational videos enable medical procedures best practices.

Although diagnostic procedures are crucial for secondary prevention and patient disease control, they often trigger fear and anxiety. These reactions highlight the need to adopt effective interventions to improve patients’ experience and satisfaction. Recently, educational videos have been employed in preparing diagnostic procedures; however, there is no integrated understanding of their effects. This systematic review and meta-analysis aimed to assess the effectiveness of educational videos on patients’ anxiety and satisfaction regarding preparation for diagnostic procedures. Three scientific databases (PubMed; Web of Science, Scopus), were used in this systematic review. Studies about educational videos as a form of preparation for patients undergoing diagnostic procedures published between 2000 and 2021 were included. A meta-analysis was also conducted. Sixteen studies met the inclusion criteria for systematic review, and seven were included in the meta-analysis. Nine studies of the total sample were about vascular procedures and seven studies about other medical image procedures. Of the fourteen studies that evaluated the use of educational videos on patients’ anxiety, nine proved to reduce it significantly. Of the thirteen studies that evaluated satisfaction, seven showed a significant increase in the experimental group. Studies included in the meta-analysis show that educational video patient groups had lower anxiety levels than the control groups after the procedure. Although future studies are required, the results suggest that educational videos effectively prepare patients for diagnostic procedures, improving care quality.

Anxiety experienced by oncological patients who undergo 18F-FDG PET CT: A systematic review

INTRODUCTION

Anxiety is an emotional reaction often experienced by patients who undergo Positron Emission Tomography/Computed Tomography (PET/CT) with 18F-2-fluoro-2-deoxy-d-glucose (¹⁸F-FDG). This systematic review aimed to summarise the evidence currently available considering the anxiety experienced by adult oncological patients concerning pre and post ¹⁸F-FDG PET/CT examination and the factors contributing to anxiety.

METHODS

A systematic review search of CINAHL, PsycINFO, PubMed, Scopus and Web Science databases and other manual search sources, was conducted from November to February 2021. The research included articles published from January 2000 to December 2020. It included quantitative studies, which analysed the anxiety experienced by oncological patients who had undergone ¹⁸F-FDG PET/CT.

RESULTS

Ten articles met the inclusion criteria for this systematic review. The studies selected were published between 2011 and 2020 and carried out in five countries. Anxiety experienced by patients was evaluated at the various stages of the ¹⁸F-FDG PET/CT, eight studies assessed it in the pre-examination, seven studies in the post-examination and five studies at both times. Four main anxiety factors were found: patients' clinical situation, first-time patients' examination, scan procedure, and patients concern with the examination result.

CONCLUSION

Moderate to high levels of anxiety are present in most of the patients who undergo the examination. This review also highlights several factors related to the anxiety levels through different procedure moments.

IMPLICATIONS FOR PRACTICE

The results of this research will allow health professionals to adjust non-pharmacological strategies to decrease anxiety levels in oncological patients undergoing ¹⁸F-FDG PET/CT.

Routine PET-CT scans provide early and accurate recurrence detection in asymptomatic stage IIB-III melanoma patients

INTRODUCTION

The use of routine imaging with 18F-FDG PET-CT (PET-CT) in melanoma surveillance is debated and evidence of its diagnostic value and yield in asymptomatic patients is limited. Denmark introduced nationwide routine surveillance with PET-CT in high-risk patients in 2016. The aim of this study was to examine the sensitivity, specificity, negative and positive predictive values, numbers-needed-to-scan and clinical impact of routine PET-CT in the surveillance of asymptomatic stage IIB-III melanoma patients.

MATERIALS AND METHODS

Data was retrieved from the population-based Danish Melanoma Database and patient records. All patients diagnosed with stage IIB-III melanoma at two University Hospitals in 2016 and 2017 were included. Patients underwent surveillance with clinical examinations and PET-CT scans at 6, 12, 24 and 36 months.

RESULTS

In 138 patients, 243 routine PET-CTs were performed within a median follow-up time of 17.7 months. Routine PET-CT detected recurrence at least once in 25 patients (18.1%), including distant recurrence in 19 patients (13.8%). Stage IIB patients had the lowest recurrence rate (11.1%). Numbers-needed-to-scan to detect one distant recurrence was 12.8 patients and median time-to-recurrence was 6.8 months. Sensitivity was 100%, specificity was 94.7% and negative and positive predictive values were 100% and 74.4%, respectively. False positive findings prompted 22 additional investigations (of which ten invasive) in 17 patients (12.3%).

CONCLUSION

Routine PET-CT has a high sensitivity and specificity when used in high-risk melanoma surveillance. Time-to-recurrence and stage-specific recurrence rates indicate high gain of early routine imaging at six months especially for stage IIC and III patients.

Scanxiety: a scoping review about scan-associated anxiety

OBJECTIVES

To identify available literature on prevalence, severity and contributing factors of scan-associated anxiety ('scanxiety') and interventions to reduce it.

DESIGN

Systematic scoping review.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Scopus, EBSCO CINAHL and PubMed up to July 2020.

STUDY SELECTION

Eligible studies recruited people having cancer-related non-invasive scans (including screening) and contained a quantitative assessment of scanxiety.

DATA EXTRACTION

Demographics and scanxiety outcomes were recorded, and data were summarised by descriptive statistics.

RESULTS

Of 26 693 citations, 57 studies were included across a range of scan types (mammogram: 26/57, 46%; positron-emission tomography: 14/57, 25%; CT: 14/57, 25%) and designs (observation: 47/57, 82%; intervention: 10/57, 18%). Eighty-one measurement tools were used to quantify prevalence and/or severity of scanxiety, including purpose-designed Likert scales (17/81, 21%); the State Trait Anxiety Inventory (14/81, 17%) and the Hospital Anxiety and Depression Scale (9/81, 11%). Scanxiety prevalence ranged from 0% to 64% (above prespecified thresholds) or from 13% to 83% ('any' anxiety, if no threshold). Mean severity scores appeared low in almost all measures that quantitatively measured scanxiety (54/62, 87%), regardless of whether anxiety thresholds were prespecified. Moderate to severe scanxiety occurred in 4%-28% of people in studies using descriptive measures. Nine of 20 studies assessing scanxiety prescan and postscan reported significant postscan reduction in scanxiety. Lower education, smoking, higher levels of pain, higher perceived risk of cancer and diagnostic scans (vs screening scans) consistently correlated with higher scanxiety severity but not age, gender, ethnicity or marital status. Interventions included relaxation, distraction, education and psychological support. Six of 10 interventions showed a reduction in scanxiety.

CONCLUSIONS

Prevalence and severity of scanxiety varied widely likely due to heterogeneous methods of measurement. A uniform approach to evaluating scanxiety will improve understanding of the phenomenon and help guide interventions.

Patients', radiographers' and radiography students' experiences of 360° virtual counselling environment for the coronary computed tomography angiography: A qualitative study

INTRODUCTION

The aim of this study was to describe patients', radiographers' and radiography students' experiences of the developed 360° virtual counselling environment (360°VCE) for the coronary computed tomography angiography (cCTA).

METHODS

A descriptive qualitative approach was used. The participants were cCTA patients (n = 10), radiographers (n = 10) and radiography students (n = 10) who used the 360°VCE and visited or worked at a university hospital in Finland. The 360°VCE, resembling the authentic environments of a CT imaging unit, included digital counselling materials in text, image, animation and video formats. Data were gathered through thematic interviews individually to obtain an understanding of participants' perspectives and analyzed by inductive content analysis.

RESULTS

Five main categories and 15 categories were identified. Identified benefits of the 360°VCE for patients included improvements in knowledge, spatial and environmental orientation, and senses of security and self-efficacy, with reductions in fear and nervousness. Patients found the counselling materials engaging, and that the 360° technology conveniently provided reassuring familiarity with the environment before their visit. Identified benefits for radiographers and radiography students included improvements in patients' mental preparedness, knowledge, spatial and environmental orientation, and reductions in patients' fear, which eased procedures and enhanced diagnostic success. The 360°VCE also provided useful information and familiarization with the cCTA unit for students during clinical practice and staff of referring units.  CONCLUSION: It seems that patients', radiographers' and radiography students' experiences of 360°VCE respond to patients' needs by improved knowledge and reduced fears. Thus, current counselling practices can be usefully complemented with spherical panoramic imaging technology and online information delivery.

IMPLICATIONS FOR PRACTICE

The results may be used to improve patient counselling and care, thereby optimizing the cCTA examination procedure and reducing fear. However, further research is needed to characterize experiences of the 360° VCE more comprehensively.

A systematic review of non-pharmacologic interventions to reduce anxiety in adults in advance of diagnostic imaging procedures

OBJECTIVES

Anticipation of a diagnostic imaging (DI) procedure, particularly one involving advanced technology, can provoke feelings of anxiety in patients. Anxiolytics (anxiety reducing drugs) can be used to reduce pre-procedural anxiety in patients, however there are several known disadvantages to this approach. The aim of this systematic review was to identify and evaluate any preparatory non-pharmacological interventions used to reduce patient anxiety in advance of DI procedures.

KEY FINDINGS

Database searches revealed twelve studies met the eligibility criteria and were included in the review. A narrative synthesis identified three intervention categories: patient information/education, cognitive strategies (i.e. guided imagery, breathing techniques, imaginative visualisation) and music therapy.

CONCLUSION

The current review demonstrates that despite the existence of a number of studies providing some evidence for the effectiveness of a range of anxiety reducing interventions for patients prior to DI, the small number and overall low quality of studies identified makes it difficult to draw firm conclusions regarding the application of a specific intervention in clinical practice.

IMPLICATIONS FOR PRACTICE

The majority of interventions included in this review were shown to be practical for inclusion in the clinical setting and did have some positive effect on patient anxiety levels. As a result those professionals working with adults undergoing advanced technology DI procedures may consider implementing some of the strategies that have been discussed within their practice.

Cancer Patient Experience in a Nuclear Medicine Department: Comparison Between Bone Scintigraphy and 18F-FDG PET/CT

Our objective was to assess the anxiety level in cancer patients undergoing nuclear medicine exams and to identify how professionals can improve patient experience. Methods: In total, 94 patients undergoing ^99mTc-hydroxymethylene diphosphonate (^99mTc-HDP) bone scintigraphy (BS) or ¹⁸F-FDG PET/CT completed 2 scan-experience questionnaires and the Spielberger State Anxiety Inventory (STAI-S) before the scan and after image acquisition. Results: Before the exam, the mean anxiety levels were higher for the ^99mTc-HDP BS group than for the ¹⁸F-FDG PET/CT group. After the exam, the opposite was true. Both groups experienced a reduction in anxiety after the scan (prescan score, 51.75 for ^99mTc-HDP BS and 44.67 for ¹⁸F-FDG PET/CT; postscan score, 36.70 for ^99mTc-HDP BS and 38.82 for ¹⁸F-FDG PET/CT). The greatest anxiety factor for the ^99mTc-HDP BS group was the duration of the exam (mean ± SD, 5.34 ± 2.08), whereas for the ¹⁸F-FDG PET/CT group it was the result (5.40 ± 1.80). Conclusion: Patients undergoing nuclear medicine exams in an oncologic context had significant anxiety levels before and after their scans. However, ^99mTc-HDP BS and ¹⁸F-FDG PET/CT had different triggers. It is of extreme importance that health-care professionals be aware of these peculiarities and adjust their procedures accordingly.

Radiation Exposure in Pediatric Sarcoma Patients Receiving Initial Curative Chemotherapy

The objective of our study is to estimate the radiation exposure to pediatric patients with sarcoma getting required (or highly recommended) ionizing radiation scans during initial chemotherapy and to determine how often distant progressive disease was discovered. Data from the last 25 years from the Children's Oncology Group open phase III protocols were reviewed for the most common pediatric sarcomas: osteosarcoma, Ewing's sarcoma, and rhabdomyosarcoma. The number of required/recommended ionizing radiation scans, including chest radiographs, chest computed tomography, positron emission tomography scans, and bone scans during induction, consolidation, and maintenance chemotherapy, were recorded and the total radiation dose per patient was calculated. In addition, the number of patients who were removed from protocol during chemotherapy because of new or distant progressive disease was documented. In our analysis of 5845 patients, the average pediatric patient with sarcoma on protocol was exposed to an ionizing radiation dose of 37.1 mGy, equivalent to the lifetime dose of nuclear power plant workers, whereas the progression of disease was detected at most in 5.4% of the patients. Our study is meant to inform pediatric oncologists more precisely of the actual risks and benefits of mandated surveillance scans during chemotherapy in patients with sarcoma.

Randomized Controlled Trial Examining Effects of Web-Based Information on Patient Satisfaction and Image Quality in 18F-FDG PET/CT Examinations

Our aim was to compare the effect that having access, versus not having access, to web-based patient information on ¹⁸F-FDG PET/CT has on image quality and on patient satisfaction with their care during and knowledge about the examination, as well as to explore whether patients utilized and were satisfied with the web-based information. Methods: We recruited 148 patients between October 2015 and December 2016 and randomly assigned them to a standard-care group or an intervention group. Both groups received standard information about the ¹⁸F-FDG PET/CT examination, but the intervention group also received access to web-based information. A questionnaire was used to evaluate patient satisfaction with, knowledge about, and discomfort during the examination, and a masked assessment of image quality was conducted. Results: Overall satisfaction was high in both groups. The lowest satisfaction was with information about how the patients would receive the results of the examination. More patients in the intervention group than in the standard-care group knew how the ¹⁸F-FDG PET/CT examination would be conducted. Descriptive data suggest that image quality was slightly better in the intervention group than in the standard-care group, but none of the outcomes significantly differed between the groups. However, several obstacles were encountered during recruitment that led to insufficient power to detect differences. Also, only 54 of 75 patients (72%) in the intervention group utilized the web-based information. However, those who did utilize the information were satisfied with it and found it helpful. Conclusion: The effects of web-based information need to be investigated in a larger sample of patients. Having access to improved information before undergoing ¹⁸F-FDG PET/CT may help patients prepare for and undergo the examination. It may also improve image quality. However, this possibility needs to be investigated using image quality as the primary outcome. The results may be used to improve patient information and care and thereby optimize the ¹⁸F-FDG PET/CT procedure.

Perceived patient burden and acceptability of whole body MRI for staging lung and colorectal cancer; comparison with standard staging investigations

Objective:

To evaluate perceived patient burden and acceptability of whole body MRI (WB-MRI) compared to standard staging investigations, and identify predictors of reduced tolerance.

Methods:

Patients recruited to multicentre trials comparing WB-MRI with standard staging scans for lung and colorectal cancer were invited to complete two questionnaires: a baseline questionnaire at recruitment, measuring demographics, comorbidities, and distress; and a follow-up questionnaire after staging, measuring recovery time, comparative acceptability/satisfaction between WB-MRI and CT (colorectal cancer) and PET-CT (lung cancer), and perceived scan burden (scored 1, low; 7, high). 

Results:

115 patients (median age 66.3 years; 67 males) completed follow up and 103 baseline questionnaires. 69 (63.9%) reported “immediate” recovery from WB-MRI and 73 (65.2%) judged it “very acceptable”. Perceived WB-MRI burden was greater than for CT (p < 0.001) and PET-CT (p < 0.001). High distress and comorbidities were associated with greater WB-MRI burden in adjusted analyses, with deprivation only approaching significance (adjusted regression β = 0.223, p = 0.025; β = 0.191, p = 0.048; β = −0.186, p = 0.059 respectively). Age (p = 0.535), gender (p = 0.389), ethnicity (p = 0.081) and cancer type (p = 0.201) were not predictive of WB-MRI burden.

Conclusion:

 WB-MRI is marginally less acceptable and more burdensome than standard scans, particularly for patients with pre-existing distress and comorbidities. 

Advances in knowledge:

This research shows that WB-MRI scan burden, although low, is higher than for current staging modalities among patients with suspected colorectal or lung cancer. Psychological and physical comorbidities adversely impact on patient experience of WB-MRI. Patients with high distress or comorbid illness may need additional support to undergo a WB-MRI.

Anxiety in Cancer Patients during 18F-FDG PET/CT Low Dose: A Comparison of Anxiety Levels before and after Imaging Studies

Objective. Assessing the level of anxiety in oncology patients who underwent ¹⁸F-FDG PET/CT low dose scan and identifying the main reasons that generate anxiety. Material and Method. The study included 81 cancer patients submitted to the ¹⁸F-FDG PET/CT low dose scan. Patients filled in the Scan Experience Questionnaire and the State-Trait Anxiety Inventory (STAI) before and after ¹⁸F-FDG PET/CT low dose scan. Results. Substantial levels of anxiety were detected both before and after ¹⁸F-FDG PET/CT low dose scan (STAI mean > 30), with a significant increase in the state of anxiety after scan performance (p < 0.0001, Median_pre = 31.1, and Median_pos = 33.0). ¹⁸F-FDG PET/CT low dose results are the main cause of anxiety both before (79.1%) and after (86.9%) the scan. The information provided by staff both before and on the ¹⁸F-FDG PET/CT low dose day was classified mostly as completely understandable (70.5% and 75.3%, resp.) and as very useful (70.5% and 72.6%, resp.) and correlated positively with patients' overall satisfaction with NM Department (r_S = 0.372, p = 0.004 and r_S = 0.528, p = 0.000, resp.), but not with anxiety levels. Conclusions. Patients perceive high levels of anxiety during the ¹⁸F-FDG PET/CT low dose scan and the concern with scan results was pointed out as the main factor for that emotional reaction.