Incident Learning in an Academic Radiation Oncology Practice during the COVID Era

PURPOSE/OBJECTIVE(S)

Incident learning is key to developing and maintaining quality and safety in healthcare. We aimed to characterize acute and sustained changes in incident submissions, point of incident origin/detection, severity and associated contributing factors during the COVID-19 pandemic.

HYPOTHESIS

The frequency and pattern of incident origin/detection were changed by altered workflows in response to COVID-19.

MATERIALS/METHODS

Events from our experienced incident learning system were analyzed between three 12-month intervals: pre-COVID (March 1, 2019 - February 29, 2020), early-COVID (March 1, 2020 - February 28, 2021), and late-COVID (March 1, 2021 - February 28, 2022). In addition to review by the department quality and safety committee, at least two physicians reviewed all incidents. Using descriptive statistics and chi-square test as applicable, we compared the reporting rates, incident severity, contributing factors, points of origin/ detection according to time the pre-specified time intervals prior to and during COVID.

RESULTS

See Table.

CONCLUSION

During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. The number of incidents per patient increased with early-COVID altered workflows. This suggests that existing quality and safety checks were effective during early-COVID. The point of incident origin was similar across time periods. During early-COVID, the point of incident detection shifted to earlier points in the care pathway (e.g., pre-RT chart checks vs chart checks during RT), p<0.001. During late-COVID, as clinical workflows adapted, the point of detection shifted to later in the care pathway consistent with pre-COVID patterns. During COVID, workload was implicated in fewer incidents (in the setting of reduced treatment volumes), while communication and hand-offs were more frequently cited as contributing factors (in the setting of remote work). Our data supports the utility of consistent standards, minimizing inter-provider variations and maintaining robust quality and safety checks to optimize communication and safe patient care in radiation oncology.

Results of a Multi-institutional Randomized Phase 3 Trial of Parotid-Sparing Whole Brain Radiotherapy

PURPOSE/OBJECTIVE(S)

Observational studies have reported that xerostomia is common after conventional whole brain radiotherapy (WBRT) and associated with parotid dose. In this multi-institutional, single-blind randomized controlled trial, we hypothesized that patient-reported xerostomia is reduced in patients randomized to parotid-sparing vs. standard WBRT fields.

MATERIALS/METHODS

Between 2018 and 2021, patients receiving conventional WBRT (30-35 Gy in 10-15 fractions) for any diagnosis were enrolled at 3 academic institutions. Patients were randomized between standard WBRT fields covering the C1 vertebra with no prospective parotid delineation (control) vs. parotid-sparing fields without C1 coverage (experimental). Patients completed the University of Michigan Xerostomia Questionnaire (Scored 0-100, higher is worse) at baseline, EndRT, 2 weeks, 1 month, 3 months, and 6 months. Patients were excluded from toxicity analyses if baseline xerostomia score was >50 or if they did not complete any post-baseline questionnaires. The primary endpoint was proportion of patients with ≥15 point absolute increase in xerostomia score from baseline to 1 month; 108 patients were needed for an 80% power to detect a 22% absolute difference (1-sided significance of 0.05). The secondary endpoint was the rate of marginal failures.

RESULTS

The study closed early after 56 patients were randomized. Median survival was 4.6 months. 46 patients (23 in each arm) were eligible for analysis. Mean parotid dose was 17 vs. 10 Gy in the standard vs. parotid-sparing arms, respectively. The table below shows mean xerostomia score and proportion of patients with ≥15 increase in xerostomia score at each time point. There was no difference in the proportion of patients experiencing ≥15 increase in xerostomia score at 1 month, though there was a trend toward lower xerostomia score at 1 month in patients randomized to parotid-sparing fields (p = 0.07, Table). Xerostomia rates were also significantly improved in the parotid-sparing arm at EndRT (p = 0.03), but no longer-term difference was observed with greater attrition at 3 and 6 months. On linear regression, there was a trend toward association between mean parotid dose and xerostomia score at 1 month (p = 0.06). There were no reported marginal failures in either arm.

CONCLUSION

Parotid-sparing without coverage of the C1 vertebra appears safe and may meaningfully reduce acute xerostomia in patients with limited life expectancy who are candidates for conventional WBRT, although the study was underpowered to detect a significant difference at 1 month.

Safety and Efficacy of Stereotactic Radiosurgery with Concurrent Targeted Systemic Therapy for Brain Metastases

PURPOSE/OBJECTIVE(S)

Data describing the safety and efficacy of central nervous system (CNS)-active targeted systemic therapies in combination with stereotactic radiosurgery (SRS, 1 fraction) and/or radiotherapy (SRT, 3-5 fractions) for brain metastases are emerging but limited. We report rates of local and intracranial failure and radiation necrosis in patients receiving CNS-active targeted systemic therapy and SRS/SRT.

MATERIALS/METHODS

We retrospectively identified patients with intact brain metastases at two institutions from 2009-2022 who were treated with SRS/SRT and CNS-active targeted systemic therapy in any sequence. Patients were followed for a minimum of 3 months after SRS/SRT with brain MRI. Patients typically stopped the targeted agent 2-4 days prior to radiation and resumed 2-4 days after. Targeted therapies included inhibitors of ALK/ROS1 (Alectinib, Ceritinib, Crizotinib, Lorlatinib), EGFR (Afatinib, Erlotinib, Gefitinib, Osimertinib), BRAF (Dabrafenib, Encorafenib, Vemurafenib), MEK (Binimetinib, Trametinib), CDK 4/6 (Abemaciclib, Palbociclib, Ribociclib), HER2 (Afatinib, Lapatinib, Neratinib, Pertuzumab, Trastuzumab, T-DM1, T-DXd, Tucatinib), KRAS (Adagrasib and Sotorasib), PARP (Niraparib, Olaparib), VEGF(R) (Axitinib, Bevacizumab, Ramucirumab), and less-selective tyrosine (receptor) kinase inhibitors (Bosutinib, Brigatinib, Entrectinib, Lenvatinib, Pazopanib, Sorafenib, Sunitinib). Local failure (LF) and radiation necrosis were determined radiographically with clinical impression (grade 2 (symptomatic) or higher (G2+)) and compared between different systemic agents.

RESULTS

The study included 95 patients with 310 metastases (SRS 246, SRT 64 metastases). Most common primary histologies were non-small cell lung cancer (36% 34/95), breast cancer (28% 27/95), and melanoma (16% 15/95). Overall survival at 1 and 2 years was 80% (76/95) and 55% (52/95), respectively. Median follow-up was 16.6 (range 3-91) months. Median tumor size was 7mm (range 1-75mm). Median number of brain metastases per patient was 2.5 (range 1-12). The G2+ radiation necrosis rate was 5.8% (18/310) while the LF rate was 9.7% (30/310) per metastasis. There was no significant difference in G2+ radiation necrosis by class of targeted therapy. Sixty-two percent (59/95) of patients experienced distant intracranial failure. Median intracranial progression free survival (PFS) was 8.0 (range 0.4-61.4) months.

CONCLUSION

Although heterogeneous, patients treated with SRS/SRT and ongoing CNS-active targeted systemic therapies have on average >6 month intracranial PFS and little evidence of significant toxicity. We observed <6% G2+ radiation necrosis for this cohort, and no particular class of agent was associated with a significantly higher rate of G2+ radiation necrosis.

Genomic Characterization of Low and High Grade Cervical Intraepithelial Neoplasia in Comparison to Cervical Cancer

PURPOSE/OBJECTIVE(S)

Screening reduces incidence of cervical cancer (CC) through identification and treatment of cervical intraepithelial neoplasia (CIN). Triage of CIN must balance between overtreatment versus progression as invasive therapies increase the risk of side effects including obstetric complications. The majority of CIN 1-2 lesions regress and a subset of CIN 3 lesions progress, however, due to inability to differentiate lesions likely to progress, the majority of CIN 2-3 lesions are treated with resection. Improved genomic and molecular identifiers of disease represent an urgent unmet clinical need.

MATERIALS/METHODS

Using next generation sequencing of a targeted exome panel of 1109 genes (previously validated), we characterized somatic mutations in 36 CIN (14 CIN 1, 11 CIN 2, 11 CIN 3) and 13 CC samples. Sequencing of CIN samples was performed on exfoliated cervical cells. CIN diagnosis and grade was confirmed on biopsy. Mutation profiles between CIN grades and CC were compared to identify genomic patterns that distinguish these groups.

RESULTS

Across the 49 samples sequenced, we identified a total of 5142 somatic mutations, including 2178 missense, 2522 synonymous, 171 nonsense, 62 splice site, 135 inframe indels, and 74 frameshift mutations. The mutation frequency was significantly higher in CC vs CIN1-3 (Table), p<0.01 (Wilcoxon signed-rank test). The difference in mutation frequency and type (Table) was not significant between CIN grades 1, 2 and 3 (p = 0.07, Kruskal-Wallis test). Cancer related pathway signatures were analyzed for the percentage of CC vs CIN samples with at least one altered variant as follows: RTK-RAS (92% vs 31%), PI3K (92% vs 17%), NOTCH (100% vs 39%), WNT (85% vs 14%) and cell cycle (53% vs 3%). Ninety percent of CC samples versus only 30% of CINs had nonsynonymous variants in the RTK-RAS and NOTCH pathways as well as the PI3K pathway which is implicated as a late event in cervical carcinogenesis. We observed recurrent missense variants in ABL1, IGF1R, TSC2 in the CIN2, CIN3 and CC samples, particularly in genes that belong to the RTK-RAS, PI3K, NOTCH pathway signatures. Potential driver mutations in EGFR, PIK3CA, ERBB4, MTOR, CSF1R genes were exclusive to CC samples.

CONCLUSION

Our results show that there is a clear distinction of mutational burden and type between cervical cancer and CIN1-3. However, the pathologic grading of CIN is not consistently associated with dynamic changes in overall mutation burden, type, or specific genes with escalating CIN grade. This data supports the hypothesis that late genetic events in CIN accompany a transition to invasive cervical cancer.

Factors Associated with Short Interval from Treatment to Death in Patients Treated with Stereotactic Body Radiotherapy for Lung Metastases: Experience at a Large Academic Facility

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is increasingly used to treat patients with lung metastases, as several studies have demonstrated a survival benefit in patients with oligometastatic disease, while in other cases it is used for palliation as in the re-irradiation setting. With increasing use, we queried whether SBRT is given more frequently toward the end of life for patients with lung metastases and assessed factors associated with a shorter interval from SBRT to death.

MATERIALS/METHODS

A sample of patients who received stereotactic body radiation therapy (SBRT) to lung metastases between 2014-2022 at a single academic institution were identified. Medical records were reviewed for patient demographic, disease, and treatment details, including age, sex, race, insurance status, Karnofsky performance status (KPS), and time from SBRT to death. Descriptive statistics including chi-square and t-test analyses were used to compare patients who did versus did not die within 180 days of completion of SBRT.

RESULTS

A total of 81 episodes of SBRT for lung metastases were identified. Of these, median age was 68 years (range 22-86), 82.7% had KPS >70, a majority had Medicare/Medicaid (61.7%, 50/81) or private insurance (33.3%, 27/81), and 63% were male. Only 9 of the 81 patients (11.1%) died within 180 days of SBRT completion. Death within 180 days occurred in 7.3% of treatments prior to 2018 compared to 15.0% of more recent treatments, but this difference was not statistically significant (p = 0.27; Table 1). Non-White race, KPS ≤70, and lack of insurance were all associated with increased likelihood of death within 180 days of SBRT (p<0.001 all comparisons).

CONCLUSION

Few patients treated with SBRT for lung metastases in our series died within 180 days of SBRT completion, and there did not appear to be a significant increase in 180-day mortality post-SBRT in recent years. While limited by the small number of events, race, KPS, and insurance status were significantly associated with likelihood of death within 180 days of SBRT. Additional work is needed to better appreciate what patients may benefit from SBRT for lung metastases. Table 1: Characteristics of patients that did versus did not die within 180 days of SBRT for lung metastases.

Prospective Characterization of Circulating Tumor Cell Kinetics in Patients with Localized Lung Cancer Treated with Radiotherapy or Chemoradiotherapy with Definitive Intent

PURPOSE/OBJECTIVE(S)

To characterize circulating tumor cell (CTC) kinetics in response to definitive therapy in patients with local or locoregional lung cancer and identify CTC kinetic profiles associated with favorable disease response versus progression.

MATERIALS/METHODS

In this single-institution prospective correlative biomarker study, we enrolled patients receiving definitive intent radiotherapy (RT) or chemoradiotherapy for non-metastatic lung cancer. Blood specimens were collected prior to RT (baseline), during RT and at follow up visits up to 24 months post RT. Subsequent lines of therapy were administered per standard of care. CTCs were captured and enumerated using a previously reported nanotechnology-based assay functionalized with aEpCAM, aHER-2, and aEGFR to facilitate biomimetic cell rolling and dendrimer-mediated multivalent binding. Disease status was assessed per RECIST 1.1 criteria. CTC kinetics and absolute values were analyzed to identify patterns associated with disease control versus progression.

RESULTS

We enrolled 24 patients with median follow up of 8 months corresponding to 114 CTC measurements. Seven patients (30%) had biopsy proven disease, while 17 (70%) were diagnosed based on clinical and radiographic features alone. Nineteen patients (79%) received stereotactic body radiation therapy. Median baseline CTC count was 12.6 CTCs/ml (range 0-290) and post RT decreased to median 4 CTCs/ml (0-42.7). For 95% of patients, a favorable kinetic profile (defined as stable CTC count, decreased CTC count or <24 CTCs/ml corresponding to the 80th percentile) during radiotherapy or at the time of first follow up corresponded to local control of the irradiated lesion. Five patients (20%) experienced disease progression within the follow up period. In the two patients with local progression of the irradiated lesion, the CTC count rose >10 fold prior to or at the time of radiographic detection of progression. In the three patients with systemic progression, CTC count rose 1.46-5.8-fold at the time of progression. Notably, four of the five patients with disease progression did not have initial biopsy confirmation of disease but did experience a CTC elevation at the time of progression.

CONCLUSION

Our data suggests CTCs may serve as a biomarker for response to therapy in patients being treated with RT with definitive intent for early stage or locally advanced lung cancer. This finding is of importance given important limitations in obtaining pathologic confirmation of disease in select patients and challenges distinguishing disease progression versus benign post radiotherapy radiographic changes. Further studies are needed to characterize the predictive and prognostic value of circulating biomarker levels and kinetics in lung cancer.

The Need for Patience When Making Operational Changes to Address Quality

PURPOSE/OBJECTIVE(S)

There is increasing recognition in the value of systematically addressing operational issues to improve quality. However, the time necessary for these initiatives has not been well described. Here we report the time necessary to implement meaningful operational changes based on our institutional incident reporting system.

MATERIALS/METHODS

Our department has a robust quality improvement/assurance program where all team members are encouraged to report operational challenges through our "Good Catch Program". A multidisciplinary committee composed of MDs, physicists, dosimetrists, RTTs, RNs, administrators, and industrial engineers meets weekly to review new Good Catches and prior unresolved Good Catches. Each Good Catch was assigned a "Champion" to oversee responses and lead subsequent initiatives. The software tracked when a Good Catch is submitted, each time a note is added (reflecting an individual's comment or summary of group discussion), and when it is "closed". Good Catch closure occurred upon implementation of a change in workflow, development of a new policy, or decision to take no action. In cases where a change in workflow or policy was the consensus decision of the committee, the Good Catch was kept open and re-reviewed at subsequent weekly meetings until a new workflow was in place and relevant teams were onboarded.

RESULTS

From Jan 2015 - Dec 2022, 2748 Good Catches were reported (see Table). Most Good Catches were discussed at only one weekly multidisciplinary committee meeting and closed within 7 days of reporting (69%). For the 854 Good Catches that took >1 week to close, the median time to closure was 16 days (range 7-588 days). In general, the number of notes was higher for Good Catches that took longer to close; however, some Good Catches that closed rapidly had more than 10 notes in a short period of time and other Good Catches with lengthy time to closure had minimal resulting documentation (see Table). Most Good Catches were assigned a Champion who was an MD, Physicist, or RTT, and there was no significant difference in Champion assignments for those good catches that closed quickly (< 8 days) and those that had a longer duration to closure.

CONCLUSION

The majority of operational Good Catches are resolved quickly; speaking to the value of regular weekly multidisciplinary meetings. However, many operational issues require multiple discussion over many weeks and emphasizes that such efforts are challenging and require patience, dedication, and commitment to implement changes in workflow.

Assessing the Sustainability of Initiatives Aimed to Enhance Patient Safety Culture: A > 10-year Experience with Multifaceted Interventions

PURPOSE/OBJECTIVE(S)

Culture is a key factor in maintaining high-quality care. We have instituted a series of mutually-reinforcing initiatives aimed to improve operations, and patient and staff safety. We herein review the impact of these initiatives on our Patient Safety Culture over 14 years. We hypothesize that these initiatives can lead to sustained improvements in Culture.

MATERIALS/METHODS

In ≈ 2009, our department, with help of dedicated quality improvement coaches from our internal Division of Healthcare Engineering (with knowledge of Lean-Six Sigma and High Reliability methods and tools), instituted (and largely sustained) initiatives aimed to improve our operations, and to improve patient/staff safety; including: (a) daily multidisciplinary team huddles, (b) daily pre-planning/treatment peer review, (c) a robust Incident Learning System, (d) weekly meetings to review reported incidents, (e) monthly department-wide meetings to review the highlights from the weekly incident review meetings, (f) celebration/recognitions for staff participation and (g) leader Gemba walks. Culture was quantitatively assessed via the AHRQ (Agency for Healthcare Research and Quality) Patient Safety Culture Survey (with 51 questions) which was sent to the department every two years (2021 was skipped due to Covid). Changes in the summary survey results over time were assessed using 2-tailed chi-square.

RESULTS

Within 2-4 years of starting of our initiatives, there was an increase in the number of survey respondents, and an increase in the % of favorable responses (vs. pre-initiative data from 2009), for most comparisons (see Table with representative data). The % favorable responses plateaued in ≈ 2013-2015, and there was a non-significant decline in % favorable responses in later years (vs. the high scores in 2015).

CONCLUSION

A series of mutually reinforcing initiatives aimed to improve operations, and to improve patient/staff safety, can lead to improvements in Patient Safety Culture; and these improvements can be largely sustained over time. Some of the modest non-significant decline in later years may reflect staff changes, fatigue, increasing practice complexity, financial pressures, and/or Covid-related issues (in the 2022 survey). This speaks to the importance of maintaining quality/safety initiatives through transitions in leadership, staff and external stressors.

Anxiety sensitivity levels: a predictor of treatment compliance or avoidance

The goal of this article is to stress the importance of understanding the presence of varying levels of pretreatment anxiety sensitivity to certain anticipated dental events and the role it plays as a predictor of anxious behavior and patient responses when individuals are confronted with fear-causing events, such as dental treatment. The varying intensity of anxiety sensitivity levels (ASL) in individuals serves to lessen or heighten the anxious and fearful response to potentially anxiety-provoking stimuli, such as pain. This level of anxiety sensitivity can often be traced back to the degree of knowledge or lack of information possessed by the patient regarding anticipated treatment and the practitioner's degree of acumen and completeness in history gathering. It has been suggested clinically that the level of anxiety sensitivity is directly related to the ability to predict whether or not treatment compliance will be achieved in an individual. Knowing the factors-either physiological or psychological-that are in play and that produce negative and aversive responses within a patient before and during treatment is key to solving these barriers to dental care.

Fears and concerns of individuals contemplating esthetic restorative dentistry

Questionnaires that focus on the fear of dental treatment typically include a narrow list of previous treatment-related factors. By omitting items concerned with psychologic, emotional, and interpersonal traits that impact treatment, practitioners often fail to gain additional valuable information on related anxiety issues. This study was undertaken to identify previously unrecognized or poorly discussed sources of fear and anxiety in patients seeking esthetic dental treatment. The Esthetic Clinic at Tufts University School of Dental Medicine recruited 62 participants who were asked to score their level of anxieties and concerns based on 24 different items on a 0 to 5 Likert scale. In addition, age, gender, and type of procedure in consideration were the only other variables recorded. The item that elicited the highest level of anxiety was "not feeling happy with my new smile." Thirty-eight respondents (61.3%) said they feel "markedly anxious"or "severely anxious" or answered "avoid completely." Concerns "that the outcome might look false and unnatural" or "that the dentist might not redo it if I am not satisfied with the outcome" both received 37 out of 62 (59.7%) similar responses. These results suggest obstacles to treatment exist not only in areas typically investigated but also in factors rarely discussed during the patient-practitioner encounter. The practitioner needs to consider a broader range of issues when addressing the patient's concerns.

Patient-perceived anxiety levels associated with use of selective serotonin and serotonin norepinephrine reuptake inhibitors

Dental practitioners are sometimes reluctant to treat patients who are on psychopharmacological agents, due perhaps to the belief that these patients will be difficult to deal with. However patients whose medical history indicates emotional and psychiatric disorders and who are being treated with SSRI or SSNRI agents may actually present a more positive and more receptive attitude to treatment than what was sometimes previously encountered in these same individuals.

Potential fear-provoking patient experiences during treatment

During a four-month period in 1998, 250 new patients arriving at the General Dentistry Clinic of Tufts University School of Dental Medicine were asked to complete a questionnaire regarding behavior by dental professionals and its effect on dental care. Surveys were returned by 121 women and 82 men, who evaluated seven behaviors from five previously determined categories of anxiety. Age and gender were the only factors considered in analyzing the results. The data suggest that dentists often may exhibit a variety of negative behaviors and attitudes. These can cause increased levels of concern in patients and may act as fear-provoking stimuli, leading to increased fear and avoidance of dental treatment.

Survey examines patients' fear of dental treatment

From September through November 1996, 158 of 844 patients at the general dentistry clinic of Tufts University School of Dental Medicine completed surveys concerning their fear of dental treatment. High levels of dental fear affected 65 percent of the respondents, with patients under the age of 45 reporting higher levels of fear than patients ages 45 years and older. Results showed that the four most common causes of fear in patients occur when the dentist seems rushed (65 percent), when the patient feels uninformed (50 percent), when the patient worries if the local anesthetic will be effective (43 percent), and when the patient's feelings are neglected (40 percent).

Dental anxiety: differentiation, identification and behavioral management

Dental anxiety has always been and still is a major impediment to regular dental care for a significant proportion of the general public. In years past, dental professionals could afford, by and large, to ignore this problem. Practices could flourish based on their technical virtuosity, and fearful or anxious patients might be considered a burden rather than a concern. Today, however, the laws of supply and demand are causing dentists to pay increased attention to aspects of the profession that extend beyond the science of clinical technique. A successful practice now depends on interpersonal as well as technical skills, particularly the ability to manage dental anxiety. Despite this, most dentists admit to a surprising lack of confidence when it comes to understanding the nature of anxiety and the modern methods advocated for its everyday management, which generally rely on behavioral modes of intervention. This paper is designed to familiarize practitioners with some of the basic elements of dental fear and anxiety, and their day to day management.

Differentiating anxiety-panic disorders from psychologic dental anxiety

It has always been believed that fear and anxiety of dental treatment was a simple continuum of experience that occurs in mild, moderate, or severe form. Past and present studies that attempt to both trace etiology and measure it reflect this view. The numerous studies that are concerned with methods of management are based on this accepted philosophy regarding the etiology of dental fear and anxiety. To a large extent, this may be true. However, there are some notable exceptions, and it is these cases that present the greatest management problem. Omitting the symptoms of fear and anxiety related to physical illness, drug withdrawal, or major mental illness, they present anxiety as a unidimensional learned problem usually conditioned by externally negative forces or experiences. They postulate that the fear and anxiety seen is due to a variety of factors. The interpretation of the definitions of fear, anxiety, and phobias by many in the profession that are presented in this issue also reflect the view that fear, anxiety, and phobias are learned or conditioned responses. This single-minded view has determined much of our understanding and subsequent management of this problem in dentistry.

Dental anxiety--the development of a measurement model

A more detailed measurement instrument for dental anxiety has been developed. To investigate the dimensionability of the response, two instruments were administered to 452 persons. The first set of items (33) concerned stimuli which might prove fearsome to patients. Some of these were dental specific, others were not. A second instrument (20 items) elicited the anxiety symptoms experienced. By comparing separate Kaiser-Caffrey Alpha Factor Analyses two factors were identified within each instrument. These were labelled "generalized" phobias and "dental specific" phobias; and "endogenous" and "exogenous" (anticipatory) anxiety symptoms. Four scales were constructed using simple summations of highly loaded variables. The scales are quite reliable. Although correlations among the scales proved to be significant they are all quite low, indicating that the four scales give more or less non-redundant information about the patient. The scale had discriminating validity in differentiating between patients who acknowledge experiencing spontaneous panic/anxiety attacks and those who did not. The data confirm that dental fears are relatively independent of other generalized anticipatory fears. The results cast doubt on previously held assumptions regarding the unidimensionality of anxiety. They are consistent with a new classification of anxiety and phobic disorders presented elsewhere. The implications for research and patient management are discussed.