A systematic review of effectiveness of interventions applicable to radiotherapy that are administered to improve patient comfort, increase patient compliance, and reduce patient distress or anxiety

On Patient Experience and Anxiety During Treatment With Magnetic Resonance-Guided Radiation Therapy

Purpose

To assess patient experience and anxiety during magnetic resonance (MR)-guided radiation therapy (MRgRT) using a hybrid 1.5Tesla (T) MR-guided linear accelerator (MR-Linac) when offered calming video content.

Methods and Materials

A single-center study was conducted within the Multi-Outcome Evaluation of Radiation Therapy Using the MR-Linac (MOMENTUM) cohort. Patients were offered to watch calming video content on a video monitor during treatment. Questionnaires were used to assess patient experience (MR-Linac patient-reported experience) and anxiety (State-Trait Anxiety Inventory, STAI) at first treatment fraction (M1) and at third, fourth, or fifth treatment fraction (M2). Paired t tests were used to test for significant differences, and effect sizes (ESs) were used to estimate the magnitude of the difference.

Results

Between November 2021 and November 2022, 66 patients were included. The majority were men (n = 59, 89%). MRgRT was most frequently delivered to prostate cancer (n = 45, 68%) followed by a lesion in the pancreas (n = 8, 12%). At M1 and M2, 24 of 59 patients (41%) preferred to watch calming video content. One patient was not able to look at the video monitor comfortably at M1. Patient experience was generally favorable or neutral; tingling sensations were reported by 17% of patients. Anxiety levels were high (16%), moderate (18%), or low to none (67%) prior to M1. STAI scores were 33 (SD, 9) prior to M1 and 29 (SD, 7) after M1 (ES, 0.7; P < .001). STAI scores were 32 (SD, 9) prior to M2 and 31 (SD, 8) after M2 (ES, 0.4; P = .009).

Conclusions

Patients were able to comfortably view the video monitor during MRgRT. Consequently, this setup could be used for future applications, such as biofeedback. A sizable minority of patients preferred to watch calming videos that distracted them during treatment. Although the patients' experience was overall excellent, anxiety was reported. Anxiety levels were highest prior to treatment and decreased after treatment.

Randomized self-controlled study comparing open-face vs. closed immobilization masks in fractionated cranial radiotherapy

PURPOSE

To compare patient discomfort and immobilisation performance of open-face and closed immobilization masks in cranial radiotherapy.

MATERIAL AND METHODS

This was a single-center randomized self-controlled clinical trial. At CT simulation, an open-face and closed mask was made for each patient and treatment plans with identical dose prescription were generated for each mask. Patients were randomised to start treatment with an open-face or closed mask. Masks were switched halfway through the treatment course; every patient was their own control. Patients self-reported discomfort, anxiety and pain using the visual analogue scale (VAS). Inter- and intrafraction set-up variability was measured with planar kV imaging and a surface guided radiotherapy (SGRT) system for the open-face masks.

RESULTS

30 patients with primary or metastatic brain tumors were randomized - 29 completed radiotherapy to a median total dose of 54 Gy (range 30-60 Gy). Mean discomfort VAS score was significantly lower with open-face masks (0.5, standard deviation 1.0) vs. closed masks (3.3, standard deviation 2.9), P < 0.0001. Anxiety and pain VAS scores were significantly lower with open-face masks (P < 0.0001). Closed masks caused more discomfort in infraorbital (P < 0.001) and maxillary (P = 0.02) areas. Two patients and 27 patients preferred closed or open-face masks, respectively. Interfraction longitudinal shifts and roll and yaw rotations were significantly smaller and lateral shifts were significantly larger with closed masks in combination with the laser system (P < 0.05) compared to open masks in combination with a SGRT system. Intrafraction variability did not differ between the masks.

CONCLUSIONS

Open-face masks are associated with decreased patient discomfort without compromising patient positioning and immobilisation accuracy.

Predicting the Effectiveness of a Mindfulness Virtual Community Intervention for University Students: Machine Learning Model

BACKGROUND

Students' mental health crisis was recognized before the COVID-19 pandemic. Mindfulness virtual community (MVC), an 8-week web-based mindfulness and cognitive behavioral therapy program, has proven to be an effective web-based program to reduce symptoms of depression, anxiety, and stress. Predicting the success of MVC before a student enrolls in the program is essential to advise students accordingly.

OBJECTIVE

The objectives of this study were to investigate (1) whether we can predict MVC's effectiveness using sociodemographic and self-reported features and (2) whether exposure to mindfulness videos is highly predictive of the intervention's success.

METHODS

Machine learning models were developed to predict MVC's effectiveness, defined as success in reducing symptoms of depression, anxiety, and stress as measured using the Patient Health Questionnaire-9 (PHQ-9), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS), to at least the minimal clinically important difference. A data set representing a sample of undergraduate students (N=209) who took the MVC intervention between fall 2017 and fall 2018 was used for this secondary analysis. Random forest was used to measure the features' importance.

RESULTS

Gradient boosting achieved the best performance both in terms of area under the curve (AUC) and accuracy for predicting PHQ-9 (AUC=0.85 and accuracy=0.83) and PSS (AUC=1 and accuracy=1), and random forest had the best performance for predicting BAI (AUC=0.93 and accuracy=0.93). Exposure to online mindfulness videos was the most important predictor for the intervention's effectiveness for PHQ-9, BAI, and PSS, followed by the number of working hours per week.

CONCLUSIONS

The performance of the models to predict MVC intervention effectiveness for depression, anxiety, and stress is high. These models might be helpful for professionals to advise students early enough on taking the intervention or choosing other alternatives. The students' exposure to online mindfulness videos is the most important predictor for the effectiveness of the MVC intervention.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12249616; https://www.isrctn.com/ISRCTN12249616.

A thematic exploration of patient and radiation therapist solutions to improve comfort during radiotherapy: A qualitative study

PURPOSE

Patients undergoing radiotherapy are positioned to restrict motion, ensuring treatment accuracy. Immobilisation can be uncomfortable which may impact treatment accuracy. Therapeutic radiographers (TR) are responsible for managing patient comfort, yet there is little evidence to guide practice. The objective was to explore patient and RT experience of comfort management during radiotherapy and identify solutions for how comfort may be managed.

MATERIALS AND METHODS

Twenty-five adult patients were purposefully recruited from Somerset NHS FT (SFT NHS) from those referred for, receiving or who had received radiotherapy within 3 months. Further criteria were that treatment delivery time on the couch exceeded 10 min (the time the patient was immobilised on the radiotherapy couch). 25 practicing TRs were recruited across the United Kingdom (UK) with experience of treatment delivery times exceeding 10 min. Semi structured interviews were conducted by the researcher at SFT NHS or in patients own homes and via telephone for TRs. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was performed by SG and after familiarisation with data, generation of codes, the themes defined were reviewed by researchers and patient partners.

FINDINGS

For patients, the three themes were: Supported Coping, Modification to Position or Immobilisation and Information Communication and Preparation. For TRs three main themes emerged: Supported Coping, Supporting and Adjusting Patients to Maintain Position and Preparational Approaches.

CONCLUSION

This qualitative paper provided a shared voice of how comfort can be best managed from the perspective of patients and TRs. Patient and TR views of how comfort is best managed has provided solutions that may be used during radiotherapy. The study has highlighted some of the positive and negative experiences of comfort solutions based on current UK practice. This information will be used to develop recommendations in a radiotherapy comfort intervention package.

Identifying core components of a radiotherapy comfort intervention package using nominal group technique

INTRODUCTION

A comfortable treatment position in radiotherapy may promote patient stability and improve outcomes such as accuracy. The aim of this study was to identify, prioritise and determine the feasibility of delivery of intervention components as part of a radiotherapy comfort intervention package.

METHODS

Prior research, consisting of a systematic review and qualitative interviews with patient and therapeutic radiographers, was triangulated and 15 intervention components developed. An online nominal group technique consensus meeting with 7 patients who received radiotherapy exceeding 10 min for one of three anatomical cancer sites and 3 therapeutic radiographers (TRs) participated. Four activities were undertaken: 1) discussion of comfort intervention components; 2) initial vote; 3) prioritisation of intervention components; and 4) discussion of feasibility in radiotherapy and were analysed using established quantitative and qualitative methods.

RESULTS

One intervention component was added from initial discussions to the 15 pre-determined components being discussed. 11 components were recommended as 'accepted' (n = 5) or 'accepted with caution' (n = 6) to proceed to development. The highest scoring intervention components were 'Compassionate & empathetic communication training for TRs' and 'Tailored information, e.g., TRs provide the required information only as part of preparation for treatment'. Anther that followed closely was 'Adjustments & supports provided for arms or legs during treatment by TRs'. Those 'accepted with caution' included 'Soft pads/mattress under the body to alleviate body discomfort managed by TRs'. Qualitative analysis highlighted concerns over the radiation environment and emphasised the importance of resources such as equipment, training, and time.

CONCLUSION

The recommended comfort interventions have potential to improve patient comfort during radiotherapy and should be considered to incorporate into positioning and immobilisation guidelines. However, specific intervention strategies to address these components will need to be developed and robustly evaluated.

IMPLICATIONS FOR PRACTICE

Comfort interventions might help patients relax and stay still during treatment, which could improve treatment accuracy and efficacy. Introducing these comfort interventions in practice have potential to lead to a more positive patient experience and improved overall quality of care during radiotherapy.

Empathy, emotional intelligence and interprofessional skills in healthcare education

According to the World Health Organization (WHO), health professionals maintain the health of citizens through evidence-based medicine and caring. Students enroled in health professional programmes are required to have successfully attained all core learning outcomes by reaching key milestones throughout the course of their studies, demonstrating they have developed the required graduate skills and attributes upon completion of the programme. While some of the knowledge, skills and competencies that make up these learning outcomes are very discipline specific, there are more general professional skills across all disciplines which are difficult to define, such as empathy, emotional intelligence and interprofessional skills. These are at the heart of all health professional programmes that once defined, can be mapped through curricula and further evaluated. Literature will be presented on these three professional skills: empathy, emotional intelligence, and interprofessional skills, based on studies that focussed primarily in health professional programmes and highlight some of the key findings and issues at undergraduate and postgraduate levels. The paper will present the need for these skills to be defined and then mapped through curricula so that students are better supported in their professional development. Empathy, emotional intelligence and interprofessional skills transcend the discipline specific skills and as such it is important that all educators consider how best these may be fostered. Efforts should also be made to further the integration of these professional skills within curricula to produce health professionals with an enhanced focus on person-centred care.

Application effect of "six heart" nursing model intervention in combination with comfort nursing in patients with primary liver cancer undergoing radiotherapy

To investigate the effects of combining a "six heart" nursing model intervention with comfortable nursing in patients suffering from primary liver cancer receiving radiotherapy. Between March 2017 to March 2022, 70 patients having liver cancer who received radiotherapy at our hospital were chosen and separated into observation and control groups employing the random number table technique, and each group consisted of 35 cases. Patients of the observation group received "six heart" nursing model intervention in addition to comfort nursing based on conventional intervention, while the control group's patients received standard nursing intervention during radiotherapy. After the intervention, the observation groups' scores and total scores of physical and emotional burden and the scores of escaping and yielding were significantly lower than those of the control group, with statistically significant differences (P<0.05). Following the intervention, each dimension's scores, total score and of the resilience scale and the scores of general well-being and quality of life of the observation group were significantly greater in comparison to the control group, with statistically significant differences (P<0.05). The observation group's overall nursing satisfaction rate was 100.00%, which showed a statistically significant difference from the control group's 85.71 (P<0.05). "Six heart" nursing model intervention combined with comfortable nursing can help reduce patients' self-perceived burden, improve psychological resilience, improve patients' general well-being and quality of life.

Design of 3D-printed universal oral stent for tongue immobilization in head and neck radiotherapy

The primary treatment for head and neck cancer is radiotherapy, which can cause complications and effects, such as the ability to speak, taste, produce saliva, and swallow. An oral stent is an immobilization tool for minimizing the dose in the tongue (or hard palate) by locking the tongue position during radiation delivery. It can improve the treatment accuracy due to less uncertainty caused by tongue position uncertainty between treatment fractions. However, commercial oral stents are not widely adopted in developing countries due to their unaffordable price. This study aimed to design the universal oral stent (UOS) to achieve high efficiency, ease to use, and low-cost fabrication based on 3D printing technology. There were five experiments to evaluate the UOS design and fabrication versus the modified cut syringe, including finite element analysis (FEA), the usability test, the micro Vickers hardness test, single beam dose analysis, and dose calculation on treatment plan simulations. The proposed UOS design and fabrication presented a high capability to apply for clinical use.

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.

Effect of New Nursing on Patients with Acute Cerebral Infarction

Objective. To explore the effect of the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health on the quality of life (QOL) and psychological status of patients with acute cerebral infarction (ACI). Methods. 90 ACI patients treated in our hospital (June 2019-June 2020) were chosen and equally split into the experimental group (EG) and control group (CG) according to the order of admission. CG received routine nursing, while EG received the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health to compare the clinical indexes between the two groups. Results. Compared with CG, EG after intervention achieved obviously higher SS-QOL, ESCA, and GCQ scores ( $P<0.001$ ), and lower MSSNS and NIHSS scores ( $P<0.001$ ). Conclusion. The application of the comfortable intervention-based nursing mode under the quality nursing intervention combined with Internet mobile health effectively improves QOL and alleviates the negative emotions of patients. Compared with routine nursing, this model has higher application value, and further research of the joint intervention will help build better a solution for patients.

Effect of "timing it right" on comprehensive unmet needs and psychological pain in patients with head and neck cancer undergoing radiotherapy: a randomized controlled trial

PURPOSE

We assessed the effectiveness of "timing it right" (TIR) applications in patients undergoing radiotherapy for head and neck cancer through a carefully designed TIR intervention program. The assessment in this study emphasized the impact of the TIR intervention on the unmet needs and psychological pain of patients with head and neck cancer at different stages of radiotherapy.

METHODS

In total, 140 radiotherapy patients were randomly recruited into two study groups: (1) the TIR intervention group received routine nursing follow-up and comprehensive nursing intervention based on TIR, and (2) the control group received routine nursing care. Assessments were conducted at baseline, before discharge, and 3 months and 6 months after discharge. The comprehensive needs and psychological pain of patients with radiotherapy were measured using the Comprehensive Needs Assessment Tool in Cancer for Patients (CNAT) and the Distress Thermometer (DT), respectively. A linear mixed model was applied to analyze the effects.

RESULTS

A total of 137 patients completed the study. Compared to the control group, the TIR group showed significant improvements in information needs, health and psychological problems, healthcare staff, physical symptoms, health facilities and services, religious/spiritual support, and psychological pain (F=8.503, p=0.004; F=1.896, p=0.003; F=12.422, p<0.001; F=9.634, p=0.001; F=7.310, p=0.006; F=1.684, p=0.009; F=1.692, p=0.041). In addition to practical support, the remaining indicators differed significantly by time point, group, and group-time interaction.

CONCLUSIONS

The patient support application based on TIR can effectively address unmet needs and improve psychological pain, supporting TIR as an effective psychological management and intervention strategy for radiotherapy patients in the early stage of long-term rehabilitation.

TRIAL REGISTRATION

Chictr.org.cn Chi CTR2100047960.

Development and results of a patient-reported treatment experience questionnaire on a 1.5 T MR-Linac

INTRODUCTION

With the implementation of new radiotherapy technology, it is imperative that patient experience is investigated alongside efficacy and outcomes. This paper presents the development of a specifically designed validated questionnaire and a first report of international multi-institutional preliminary patient experience of MRI-guided adaptive radiotherapy (MRgART) on the 1.5 T MR-Linac (MRL).

METHODS

A patient experience questionnaire was developed and validated before being distributed to the Elekta MRL Consortium, to gather first patient-reported experience from participating centres worldwide. The final version of the questionnaire contains 18 questions covering a range of themes and was scored on a Likert scale of 0-3. Responses were post-processed so that a score of 0 represents a negative response and 3 represents the most favourable response. These results were analysed for patient-reported experience of treatment on the MRL. Results were also analysed for internal consistency of the questionnaire using Chronbach's Alpha and the questionnaire contents were validated for relevance using content validity indexes (CVI).

RESULTS

170 responses were received from five centres, representing patients with a wide range of tumour treatment sites from four different countries. MRgART was well tolerated with an 84% favourable response across all questions and respondents. When analysed by theme, all reported the highest percentage of results in the favourable categories (2 and 3). Internal consistency in the questionnaire was high (Cronbach's α = 0.8) and the item-level CVI for each question was 0.78 or above and the Scale-level CVI was 0.93, representing relevant content.

CONCLUSION

The developed questionnaire has been validated as relevant and appropriate for use in reporting experience of patients undergoing treatment on the MRL. The overall patient-reported experience and satisfaction from multiple centres within the Elekta MRL Consortium was consistently high. These results can reinforce user confidence in continuing to expand and develop MRL use in adaptive radiotherapy.

A Sentence Classification Framework to Identify Geometric Errors in Radiation Therapy from Relevant Literature

The objective of systematic reviews is to address a research question by summarizing relevant studies following a detailed, comprehensive, and transparent plan and search protocol to reduce bias. Systematic reviews are very useful in the biomedical and healthcare domain; however, the data extraction phase of the systematic review process necessitates substantive expertise and is labour-intensive and time-consuming. The aim of this work is to partially automate the process of building systematic radiotherapy treatment literature reviews by summarizing the required data elements of geometric errors of radiotherapy from relevant literature using machine learning and natural language processing (NLP) approaches. A framework is developed in this study that initially builds a training corpus by extracting sentences containing different types of geometric errors of radiotherapy from relevant publications. The publications are retrieved from PubMed following a given set of rules defined by a domain expert. Subsequently, the method develops a training corpus by extracting relevant sentences using a sentence similarity measure. A support vector machine (SVM) classifier is then trained on this training corpus to extract the sentences from new publications which contain relevant geometric errors. To demonstrate the proposed approach, we have used 60 publications containing geometric errors in radiotherapy to automatically extract the sentences stating the mean and standard deviation of different types of errors between planned and executed radiotherapy. The experimental results show that the recall and precision of the proposed framework are, respectively, 97% and 72%. The results clearly show that the framework is able to extract almost all sentences containing required data of geometric errors.

The potential for haptic touch technology to supplement human empathetic touch during radiotherapy

Radiotherapy for cancer is an effective treatment but requires precise delivery. Patients are required to remain still in the same position during procedure which may be uncomfortable. This combined with high anxiety experienced by patients, and feelings of isolation, have indicated a need for comfort interventions. Care conveyed through empathetic touch promotes comfort, individual attention and presence and provides both psychological and physical comfort at the same time. Evidence in nursing and care literature showed that empathetic touch interventions have a significant role in promoting comfort, facilitating communication between care recipients and caregivers. However, the application of empathetic touch interventions may be challenging to administer due to the safety concern in the radiotherapy environment. The emergence of haptic technologies that enable the communication of touch remotely may have a potential to fill this gap. We take inspiration from both clinical empathetic touch in radiotherapy practice, as well as affective haptic technologies to envision the opportunities for haptic technologies as a complimentary comfort intervention to supplement human empathetic touch during radiotherapy.