Time, space and technology in radiotherapy departments: how do these factors impact on patients' experiences of radiotherapy?

Holistic Person-Centered Care in Radiotherapy: Protocol for a Scoping Review

BACKGROUND

Several types of health care professionals are responsible for the care of patients with cancer throughout their engagement with the health care system. One such type is the radiotherapist. The radiotherapist not only administers treatment but is also directly involved with the patient during treatment. Despite this direct contact with the patient, the narrative tends to focus more on technical tasks than the actual patient. This task-focused interaction is often due to the highly sophisticated equipment and complex radiotherapy treatment processes involved. This often results in not meeting the psychosocial needs of the patient, and patients have acknowledged noncompliance and delayed treatment as a result.

OBJECTIVE

The scoping review aims to explore, chart, and map the available literature on holistic person-centered care in radiotherapy and to identify and present key concepts, definitions, methodologies, knowledge gaps, and evidence related to holistic person-centered care in radiotherapy.

METHODS

This protocol was developed using previously described methodological frameworks for scoping studies. The review will include both peer-reviewed and gray literature regarding holistic, person-centered care in radiotherapy. A comprehensive search strategy has been developed for MEDLINE (Ovid), which will be translated into the other included databases: Scopus, CINAHL (EBSCO), MEDLINE (PubMed), Embase (Elsevier), Cochrane Library, and the Directory of Open Access Journals. Gray literature searching will include Google (Google Books and Google Scholar), ProQuest, the WorldWideScience website, the OpenGrey website, and various university dissertation and thesis repositories. The title and abstract screening, full-text review, and relevant data extraction will be performed independently by all 3 reviewers using the Covidence (Veritas Health Innovation) software, which will also be used to guide the resolution of conflicts. Sources selected will be imported into ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) for analysis, which will consist of content analysis, narrative analysis, and descriptive synthesis. Results will be presented using narrative, diagrammatic, and tabular formats.

RESULTS

The review is expected to identify research gaps that will inform current and future holistic, person-centered care in radiotherapy. The review commenced in November 2023, and the formal literature search was completed by the end of February 2024. Final results are expected to be published in a peer-reviewed journal by 2025.

CONCLUSIONS

The findings of this review are expected to provide a wide variety of strategies aimed at providing holistic, person-centered care in radiotherapy, as well as to identify some gaps in the literature. These findings will be used to inform future studies aimed at designing, developing, evaluating, and implementing strategies toward improved holistic, person-centered care in radiotherapy.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51338.

Patient-reported perspectives of therapeutic radiographers when undergoing radiotherapy: A European multi-centre study

INTRODUCTION

Radiotherapy is delivered almost exclusively by therapeutic radiographers/radiation therapist (RTTs). Patient's perspectives of RTTs affect levels of trust and confidence in the profession and can have a significant impact on overall radiotherapy experience. The study reports patients' perspectives of RTTs from their experience of undergoing radiotherapy. Four partner sites collaborated in this research and included Malta, Poland, Portugal, and the UK (lead site).

METHODS

A survey was developed to gather information from patients receiving radiotherapy or who had had radiotherapy within the previous 24 months. Participants ranked their responses to 23 statements relating to person-centred care on a 5-point scale of 1 (strongly disagree) to 5 (strongly agree). Mann-Whitney or Kruskal Wallis tests were applied to test differences in responses to 5 key statements for patient characteristics including gender, age group, diagnosis, country, time spent with RTTs and number of fractions remaining at survey completion.

RESULTS

Three hundred and forty-seven surveys are included. Patients report a positive perception of RTTs (95.4% agree with 'I feel cared for'). Statistically significant differences in responses were found between gender, diagnosis, country, time spent with RTTs and fractions of radiotherapy remaining. Patients who had more time with RTTs and completed their surveys during radiotherapy had a more positive perception of RTTs.

CONCLUSION

This study suggests that sufficient time with RTTs is key to ensuring a positive radiotherapy patient experience. RTTs being attentive, understanding, and informative are most predictive of a positive overall patient experience. Timing of survey completion can influence responses.

IMPLICATIONS FOR PRACTICE

RTT education programmes should incorporate training on person-centred care at all levels. Further research into patient experience of RTTs is warranted.

Patient engagement with radiation therapists: Patient perspectives, challenges, and opportunities. A systematic review

INTRODUCTION

Radiotherapy is a major component of cancer care and treatment is delivered almost exclusively by therapeutic radiographers/radiation therapists (RTTs). Numerous government and professional guidance publications have recommended a person-centred approach to healthcare through communication and collaboration between professionals, agencies, and users. With approximately half of patients undergoing radical radiotherapy experiencing some degree of anxiety and distress, RTTs are uniquely placed as frontline cancer professionals to engage with patients regarding their experience. This review seeks to map the available evidence of patient reported views of their experience of being treated by RTTs and any impact, this treatment had on the patient's frame of mind or perception of treatment.

METHODS

In line with the principles of the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) systematic review methodology, a review of relevant literature was conducted. Electronic databases MEDLINE, PROQUEST, EMBASE and CINAHL were searched.

RESULTS

Nine hundred and eighty-eight articles were identified. Twelve papers were included in the final review.

CONCLUSION

Increased time with, and continuity of RTTs during treatment has a positive influence on patients' perspectives of RTTs. A positive patient perspective of their engagement with RTTs can be a strong predictor of overall satisfaction in radiotherapy.

IMPLICATIONS FOR PRACTICE

RTTs should not underestimate the impact of their supportive role in guiding patients through treatment. A standardised method for integrating patients' experience and engagement with RTTs is lacking. Further RTT led research is required in this area.

Men's perceptions and preferences regarding prostate cancer radiation therapy: A systematic scoping review

PURPOSE

To assess the literature on men's preferences and perceptions regarding prostate cancer radiation therapy.

METHODS

A scoping review was undertaken as per JBI guidelines. Searches were conducted in PubMed, CINAHL, Scopus and Science Direct with search terms including "prostate cancer," "radiotherapy," "radiation therapy," "radiation oncology," "patient preferences," "patient perceptions" and "patient experience." The resultant studies were mapped and grouped according to the emergent themes and pathway stages.

RESULTS

A total of 779 titles and abstracts were screened by two independent reviewers. Fifty-two full-text studies were reviewed, with 27 eligible for inclusion. There were 4 pre-treatment, 13 during treatment and 10 post-treatment studies covering broad themes of information needs (n = 3), preferences and decisions (n = 6), general experiences (n = 8), side effects (n = 6), and support (n = 4). There were a mix of methodologies, including 11 qualitative, 14 quantitative (including four preference studies), one mixed methods and one narrative review.

CONCLUSION

There were only four preference studies, with the remaining 23 reporting on perceptions. Overall, there is a paucity of literature regarding patient preferences and perceptions of prostate cancer radiation therapy, particularly when considering how many clinical and technical studies are published in the area. This highlights opportunities for future research.

Radiographers’ perception on the provision of psychosocial support for cancer patients

Introduction:

Therapeutic radiographers are the first point of contact for cancer patients undergoing radiotherapy treatment and therefore have an important role in providing both physical and psychosocial support to these patients. This study aimed to evaluate therapeutic radiographers’ perception about their role in identifying and providing psychosocial support for patients receiving RT treatment.

Method:

The study used a cross-sectional, prospective research design. A self-designed questionnaire was distributed to all therapeutic radiographers (n = 26) working at a radiotherapy department in Malta.

Results:

A total of 21 therapeutic radiographers completed the questionnaire. All participants felt that the provision of psychological care was an important part of their role as therapeutic radiographers. The majority of the participants reported having the most confidence in giving treatment-related symptoms advice rather than psychological support. The most common barrier to providing psychological support was lack of training (95·2%), followed by the lack of an appropriate screening tool (85·7%), availability of private space to talk to patients (76·2%) and a lack of knowledge (61·9%).

Conclusion:

While most therapeutic radiographers believed that providing psychosocial support was an important aspect of their role, several barriers prevented them from fulfilling this role. Training, the introduction of a psychosocial screening tool and clear referral processes are recommended to improve radiotherapy service.

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.

Silenced: Patients' experiences of voicelessness in head and neck cancer

OBJECTIVES

The objective of this qualitative study was to explore patients' experiences of communicating with health professionals following a diagnosis of head and neck cancer (HNC).

METHODS

A qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with people diagnosed with HNC. Thematic analysis was used to identify themes.

RESULTS

The experience of losing the capacity for speech was experienced by survivors of HNC as distressing and traumatic. Voicelessness was not just a loss of physical speech, but a holistic experience of silencing. A number of tensions emerged including patients' experiences of losing their voice and then finding different ways to verbally express themselves; in interactions with health professionals there was a tension between abrupt, hurried communication and a slower, more mindful communication style. Sub-themes around communication style emerged where disparities between levels of health literacy were unaddressed, and patients' experienced a lack of empathy. Another tension experienced was between an old style medical model and the ideal of person-centred care and the biopsychosocial model of health.

CONCLUSION

Whether HNC patients lose their voice temporarily, have periods of voicelessness, or are able to speak, but feel unheard, the treatment experience is too often one of disempowerment and silencing of their perspectives.

PRACTICE IMPLICATIONS

Health professionals are challenged to find creative communication methods, to practice mindful listening, source speech pathology and adaptive technologies, and to facilitate communication that supports patients in expressing their values, preferences and needs.

Exploring the cancer patients' experiences during external radiotherapy: A systematic review and thematic synthesis of qualitative and quantitative evidence

PURPOSE

To investigate the subjective experience of adult cancer patients undergoing external radiotherapy and provide evidence for better practices in radiotherapy services.

METHODS

A systematic review was performed according to the PRISMA Statement Guidelines. Qualitative and mixed studies were identified through five electronic databases (CINAHL, PsychINFO, Medline, Scopus and Web of Science), between March and April 2020, using defined criteria. Methodological quality assessment was conducted, and the data integrated into a thematic synthesis.

RESULTS

Of the 886 studies identified, 13 met our inclusion criteria. Patients experiences were described into four main themes: (1) Time, (2) Physical Environment, (3) Treatment Concerns and (4) Radiotherapy Team. Time refers to waiting time and treatment time; Physical Environment states temperature in the treatment room and equipment; Treatment Concerns included side effects, daily activities, positioning and immobilization and treatment preparation (e.g., bladder filling); radiotherapy team comprised patients support; response to patients needs and recognized team. The generating analytical phase of thematic analysis allowed us to recognize that the effectiveness of the radiotherapy team operates as a facilitator of the patients' experience. In contrast, time in the waiting room, the treatment preparation when is required, and the positioning and immobilization, specifically for the neck and head patients, act as barriers.

CONCLUSION

Four distinct themes were identified to be positively and negatively associated with patients' experience during external radiotherapy. The evidence provides valuable recommendations to improved radiotherapy services organization, as well as to the delivery of more patient-centred care adjusted to the concerns and needs of patients.

How do radiation therapists detect and manage patients experiencing anxiety in the radiation oncology setting? A vignette study

PURPOSE

Anxiety is commonly observed in oncology patients but infrequently screened, assessed or addressed. According to psychosocial guidelines, all healthcare professionals, including radiation therapists, are responsible for the psychosocial care of patients. Radiation therapists (RTs) interact with patients daily throughout treatment; however, little research exists to evaluate RTs' ability to identify and manage patients' psychosocial needs. This study aimed to determine if RTs can detect and manage patient anxiety.

METHOD

A cross-sectional, mixed-methods survey containing two clinically relevant vignettes was developed. Two fictitious patients were presented to elicit responses reflective of RTs' experiences and judgements in the recognition and management of anxiety. Surveys were distributed via email in Australia, New Zealand and Canada. Ethical approval was obtained from the University of Sydney (2016/227) and informed consent was obtained from participants.

RESULTS

Eligible and complete surveys were received from 582 respondents (240 (41.2%) from Australia; 78 (13.4%) New Zealand; 264 (45.4%) Canada). Almost all respondents endorsed a relevant descriptor of anxiety (vignette 1, 577 (99.1%); vignette 2, 579 (99.5%)). For both vignettes, the most frequently endorsed management strategy was to acknowledge the patients' feelings and encourage them to express their concerns (vignette 1, 548 (94.2%); vignette 2, 455 (78.2%)).

CONCLUSION

RTs in Australia, New Zealand and Canada are able to detect anxiety and endorse a strategy to manage patients experiencing anxiety depicted in written vignettes. Exploring RTs' abilities to detect and manage patient anxiety whilst in the high-pressure clinical environment is an important next step.

A Qualitative Exploration of Seriously Ill Patients' Experiences of Goals of Care Discussions in Australian Hospital Settings

BACKGROUND

Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions.

OBJECTIVE

This study explored patients' perspectives of the GOC discussion in the hospital setting.

DESIGN

An explorative qualitative design was used within a social constructionist framework.

PARTICIPANTS

Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview.

APPROACH

Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes.

KEY RESULTS

Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most patients viewed the conversation as necessary and valued having their preferences heard. Effective communication strategies and a safe, private setting were facilitators of the GOC discussion. Deficits in any of these key elements functioned as a barrier to the process.

CONCLUSIONS

Effective communication, and patients' values and expectations set the stage for goals of care discussions; however, the environment plays a significant role. Communication skills training and education designed to equip clinicians to negotiate GOC interactions effectively are essential. These interventions must also be accompanied by systemic changes including building a culture supportive of GOC, clear policies and guidelines, and champions who facilitate uptake of GOC discussions.

Patients' experiences of radiotherapy: Insights from Twitter

INTRODUCTION

Understanding how patients experience radiotherapy is a key element in improving care. People with cancer are increasingly using social media to share information and discuss healthcare matters. Twitter may provide a rich source of data on how people experience radiotherapy. The aims of this research were to better understand the role of social media in this context and establish what can be learnt about the experience of undergoing radiotherapy from a novel digital data source.

METHODS

A qualitative content analysis was conducted to describe how and why Twitter is being used by patients in relation to radiotherapy. Twitter was queried with "radiotherapy" and a purposive subsample of tweets, authored primarily by patients was collected over one randomly generated composite month in 2016. Thematic analysis was performed to interpret the data.

RESULTS

442 unique tweets authored by patients and their families were sampled and six themes were developed. Three core themes represented the radiotherapy pathway; pre- during- and post-treatment. Underlying themes were emotional and informational support, impact on loved ones and giving thanks.

CONCLUSION

Patients and their loved ones use Twitter to share their experience of radiotherapy. They describe the physical and psychological impact of undergoing treatment and seek informational and emotional support through social media. There is opportunity for greater engagement from radiotherapy professionals and organisations to improve informational support for patients online.

IMPLICATIONS FOR PRACTICE

Increased engagement between radiotherapy professionals and patient communities on Twitter has the potential to build patient-practitioner trust, promote self-management and raise the social profile of radiotherapy and its professions.

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.

Radiation therapy patient education using VERT: combination of technology with human care

The Virtual Environment for Radiotherapy Training (VERT) system is a recently available tool for radiation therapy education. The majority of research regarding VERT-based education is focused on students, with a growing area of research being VERT's role in patient education. Because large differences in educational requirements exist between students and patients, focused resources and subsequent evaluations are necessary to provide solid justification for the unique benefits and challenges posed by VERT in a patient education context. This commentary article examines VERT's role in patient education, with a focus on salient visual features, VERT's ability to address some of the spatial challenges associated with RT patient education and how to combine technology with human care.

Communication skills training for radiation therapists: preparing patients for radiation therapy

INTRODUCTION

Patients sometimes present for radiation therapy with high levels of anxiety. Communication skills training may assist radiation therapists to conduct more effective consultations with patients prior to treatment planning and treatment commencement. The overall aim of our research is to examine the effectiveness of a preparatory programme 'RT Prepare' delivered by radiation therapists to reduce patient psychological distress. The purpose of this manuscript was to describe the communication skills workshops developed for radiation therapists and evaluate participants' feedback.

METHODS

Radiation therapists were invited to participate in two communication skills workshops run on the same day: (1) Consultation skills in radiation therapy and (2) Eliciting and responding to patients' emotional cues. Evaluation forms were completed. Radiation therapists' consultations with patients were then audio-recorded and evaluated prior to providing a follow-up workshop with participants.

RESULTS

Nine full day workshops were held. Sixty radiation therapists participated. Positive feedback was received for both workshops with 88% or more participants agreeing or strongly agreeing with all the statements about the different components of the two workshops. Radiation therapists highlighted participating in role play with an actor, discussing issues; receiving feedback; acquiring new skills and knowledge; watching others role play and practicing with checklist were their favourite aspects of the initial workshop. The follow-up workshops provided radiation therapists with feedback on how they identified and addressed patients' psychological concerns; time spent with patients during consultations and the importance of finding private space for consultations.

CONCLUSION

Communication skills training consisting of preparing patients for radiation therapy and eliciting and responding to emotional cues with follow-up workshops has the potential to improve radiation therapists' interactions with patients undergoing radiation therapy. Further research is warranted, similar to the RT Prepare study, to determine whether patient anxiety can be reduced as a result of improving communication and information provision.

A longitudinal study on anxiety, depressive and adjustment disorder, suicide ideation and symptoms of emotional distress in patients with cancer undergoing radiotherapy

BACKGROUND

The aim of this study is to evaluate the presence of anxiety, depressive and adjustment disorders, suicide ideation, and symptoms of anxiety and depression in patients with cancer before (T1), and after radiotherapy (T2) and at the 1-month follow-up (T3).

METHODS

A longitudinal study on 103 patients with cancer treated as outpatients undergoing radiotherapy was carried out, evaluating them three times (T1-T2-T3) according to DSM-IV criteria with the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale.

RESULTS

Prevalence of the depressive disorders was: T1=6.8%, T2=3.9% and T3=3.9%; for anxiety disorders: T1=16.5%, T2=18.4% and T3=16.5%; for adjustment disorder: 10.7%, 5.8% and 7.8%; and for suicide ideation: T1=11.7%, T2=7.8% and T3=7.8%. In all, the presence of disorders was: T1=35%, T2=26.2%0.4% and T3=29.1%. At least one mental disorder was diagnosed in 46.6% of patients in one of the three times of the study. In relation to the symptoms, the prevalence of the possible cases of clinical anxiety was: T1=35.9%, T2=18.4% and T3=22.3%; the prevalence of possible cases of clinical depression was 19.4%, 16.5% and 10.7%, respectively; and the prevalence of emotional distress was 27.2%, 17.5% and 18.4%, respectively. All symptoms decreased significantly from T1 to T2 and from T1 to T3, with moderate effect sizes. No changes were observed between the end of the radiotherapy and the follow-up period.

CONCLUSIONS

High prevalence of mental disorders and symptoms of anxiety, depression and distress were observed in the patients with cancer before finishing radiotherapy treatment and during the follow-up.

FUNDING

Basurto University Hospital and Basque Foundation for Innovation and Research in Health-BIOEF.