Situational anxiety in head and neck cancer: Rates, patterns and clinical management interventions in a regional cancer setting.

INTRODUCTION: Research indicates that the immobilisation mask required for radiation therapy (RT) for head and neck cancers can provoke intense anxiety. However, little is known about the rates of this anxiety, whether it changes over a course of treatment and how it is managed in clinical practice. This study aimed to describe the rates and patterns of situational anxiety in patients undergoing RT for head and neck cancer and the use of anxiety management interventions in current clinical practice in a major regional cancer setting in New South Wales, Australia. METHODS: Situational anxiety rates and patterns were assessed at five time points using the State-Trait Anxiety Inventory prior to treatment planning (SIM), the first three treatment sessions (Tx 1, Tx 2 and Tx 3) and treatment 20 (Tx 20). Sessions were observed to record the use of general supportive interventions (music and support person) and anxiety-specific interventions (break from the mask, relaxation techniques and anxiolytic medication). Sociodemographic and clinical information was extracted from the medical record. RESULTS: One hundred and one patients were recruited. One-third had clinically significant anxiety at any of the first three time points (33.3-40%), and a quarter at Tx 3 (26.4%) and Tx 20 (23.4%). Of the sample, 55.4% had available data for categorisation into one of four pattern groups: 'No Anxiety' (46.4%); 'Decreasing Anxiety' (35.7%); 'Increasing Anxiety' (7.1%); and 'Stable High Anxiety' (10.7%). Most participants had social support present at SIM (53.5%) and listened to music during treatment (86.7-92.9%). Few participants received relaxation techniques alone (1.2-2.3%). Anxiolytic medication was provided for 10% of patients at some stage during the treatment journey and 5% required a break from the mask at SIM, with frequency decreasing throughout the treatment course. CONCLUSIONS: In this regional cancer setting, situational anxiety was common, but generally decreased throughout treatment. Some patients experience persistent or increasing anxiety, with up to 10% of patients receiving specific anxiety management interventions.

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

Procedural anxiety is a concern for a number of patients undergoing radiation therapy. While procedural anxiety is often treated pharmacologically, there is a clinical need for effective alternative strategies for patients who are contraindicated from medication use, and those who prefer not to take unnecessary medications. OBJECTIVES: The primary objective was to assess the efficacy of nonpharmacological interventions delivered to adults with cancer, in the radiation oncology department, just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety. The secondary objectives were to assess the efficacy of these interventions in reducing physiological symptoms of procedural anxiety and anxiety-related treatment disruptions. DESIGN: Systematic review. DATA SOURCES: Electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials) were searched from inception up until February 2022. INCLUSION CRITERIA: Population: Adult patients with cancer undergoing external beam radiation therapy. INTERVENTION: Nonpharmacological interventions delivered within the radiation therapy department. Comparison: standard care controls, or standard care plus an alternative intervention. OUTCOMES: level of self-reported procedural anxiety (primary), physiological symptoms of anxiety (secondary) and measures of anxiety-related treatment disruptions (secondary). DATA EXTRACTION AND ANALYSIS: Two reviewers independently extracted data. A meta-analysis was originally planned but deemed not feasible as the studies could not be confidently pooled for meta-analysis, due to the variability in the interventions, study designs and the generally low number of studies. Therefore, a narrative synthesis is presented. RESULTS: Screening of 2363 records identified nine studies that met inclusion criteria: six studies of music interventions, two of video-based patient education and one of aromatherapy. Overall, three studies received a global rating of strong methodological quality and low risk of bias. Three studies reported a significant effect of the intervention on reducing the primary outcome of self-reported procedural anxiety: two music interventions (both strong methodological quality), and one video-based patient education (moderate methodological quality). One of the studies (a music intervention) also reported a significant reduction in the secondary outcome of physiological symptoms of procedural anxiety (systolic blood pressure). CONCLUSIONS: The evidence for nonpharmacological interventions delivered to adults with cancer just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety is limited, with very few well-designed studies. There is a need for interventions for procedural anxiety during radiation therapy to be evaluated through rigorous randomised controlled trials.

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

INTRODUCTION: Patients undergoing treatment for cancer who require radiation therapy (RT) report anxiety specifically relating to the RT procedure. Procedural anxiety can be detrimental to treatment delivery, causing disruptions to treatment sessions, or treatment avoidance. Acute procedural anxiety is most commonly managed with anxiolytic medication. There is a need for effective, non-pharmacological interventions for patients not suitable for, or who prefer to avoid, anxiolytic medication. The primary objectives of this pilot trial are to evaluate the: (1) feasibility of conducting the Biofeedback Enabled CALM (BeCALM) intervention during RT treatment sessions; (2) acceptability of the BeCALM intervention among patients; and (3) acceptability of the BeCALM intervention among radiation therapists. The secondary objective of this pilot trial is to examine the potential effectiveness of the BeCALM intervention delivered by radiation therapists to reduce procedural anxiety during RT. METHODS AND ANALYSIS: This is a pilot randomised controlled trial. A researcher will recruit adult patients with cancer (3-month recruitment period) scheduled to undergo RT and meeting eligibility criteria for procedural anxiety at the Calvary Mater Hospital, Newcastle (NSW), Australia. Participants will be randomly assigned to receive treatment as usual or the BeCALM intervention (biofeedback plus brief breathing techniques). The primary outcomes are feasibility (measured by recruitment, retention rates and percentage of treatment sessions in which the intervention was successfully delivered); radiation therapists perceived feasibility and acceptability (survey responses); and patient perceived acceptability (survey responses). Secondary outcome is potential effectiveness of the intervention (as measured by the State Trait Anxiety Inventory-State subscale; the Distress Thermometer; and an analysis of treatment duration). ETHICS AND DISSEMINATION: The study protocol has received approval from Hunter New England Health Human Research Ethics Committee (2021/ETH11356). The results will be disseminated via peer-reviewed publications, as well as presentation at relevant conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001742864.

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

INTRODUCTION: Procedural anxiety relates to an affective state of anxiety or fear in relation to a medical procedure. Various treatment-related factors may elicit anxiety among oncology patients, including fear of diagnostic imaging (such as MRI scans) and impending treatment and medical procedures (such as chemotherapy and radiotherapy). It is common in oncology settings to manage acute anxiety relating to medical procedures with anxiolytic medication. However, pharmacological approaches are not suitable for many patients. Despite this, non-pharmacological interventions are infrequently used. The aim of this systematic review is to determine whether non-pharmacological interventions delivered prior to, or during, radiotherapy are effective in reducing procedural anxiety. METHODS AND ANALYSIS: Data sources will include the bibliographic databases CINAHL, MEDLINE, EMBASE, PsycINFO and Cochrane Central Register of Controlled trials (CENTRAL) (from inception onward). Eligible studies will include adult patients with cancer undergoing radiotherapy treatment. Included studies will be those which employ a non-pharmacological intervention, delivered within existing radiotherapy appointments, with the aim of reducing procedural anxiety related to radiotherapy. All research designs with a control or other comparison group will be included. The primary outcome will be change in levels of self-reported procedural anxiety. Secondary outcomes will be changes in scores on physiological measures of anxiety and/or changes in treatment completion and/or changes in treatment duration and/or changes in psychological distress. Two investigators will independently complete title and abstract screening, full-text screening, data extraction and assessment of methodological quality. If appropriate, a meta-analyses will be performed. Any important amendments to this protocol will be updated in the PROSPERO registration and documented in the resulting review publication. ETHICS AND DISSEMINATION: No ethical issues are anticipated from this review. The findings will be disseminated through peer-reviewed publication and at conferences by presentation. SYSTEMATIC REVIEW REGISTRATION: CRD42019112941.

Comparing Breast Conservation Surgery Seromas Contoured by Radiation Therapists versus those Contoured by a Radiation Oncologist in Radiation Therapy Planning for Early-Stage Breast Cancer.

INTRODUCTION: In the management of early-stage breast cancer using radiation therapy, computed tomography (CT) simulation is used to identify the breast conservation surgery (BCS) seroma as a proxy for the tumour bed. The delineation or contouring of the seroma is generally a task performed by a radiation oncologist (RO). With increasing patient numbers and other demands placed on ROs, the scope of practice for radiation therapists (RTs) is continually expanding, and the need for skills transfer from one profession to another has been investigated in recent years. This study aims to compare the BCS seroma volumes contoured by RTs with those contoured by ROs to add evidence in support of expanding the RTs' role in the treatment planning process in the management of early-stage breast cancer. METHODS: A study was undertaken using the CT-simulation (CT-sim) data sets of patients with early-stage breast cancer treated in 2013. The CT-sim data sets had BCS seromas contoured by 1 of 5 ROs as part of routine clinical management. This study involved 4 RTs who each used the patient information to identify and contour breast seromas on 50 deidentified CT-sim data sets. Metrics used to compare RT versus RO contours included volume size, overlap between volumes, and geographical distance from the centre of volumes. RESULTS: There were 50 CT-sim data sets with 1 RO contour and 4 RT contours analysed. The contour volumes of the 4 RTs and the ROs were assessed. Although there were 50 CT-sim data sets presented to each RT, analysis was carried out on 45, 43, 46, and 45 CT-sim data sets. There were no comparisons made where contours were not delineated. The contour volumes of the 4 RTs and the ROs were assessed with an interclass correlation coefficient, with a result of excellent reliability (0.975, 95% [0.963, 0.985]). The DICE similarity coefficient was used to compare the overlap of each RT contour with the RO contour; the results were favourable with mean (95% CI) DSCs 0.685, 0.640, 0.678, and 0.681, respectively. Comparing the RT and RO geographical centre of the seroma volumes, good to excellent reliability between the RTs and ROs was demonstrated (95% CI mean RO vs RT distances (mm): 3.75, 4.99, 7.71, and 3.39). There was no statistically significant difference between the distances (P = 0.65). CONCLUSION: BCS seromas contoured by RTs compared well with those contoured by an RO. This research has provided further evidence to support RTs in assuming additional contouring responsibilities in radiation therapy planning for patients with early-stage breast cancer.

A Feasibility Study on the Identification of Postlumpectomy Seromas by a Radiation Therapist Compared with That by Radiation Oncologists in Radiation Therapy Planning for Early Stage Breast Cancer.

INTRODUCTION: Computed tomography (CT) simulation is currently used to identify the tumour bed in patients with early stage breast cancer requiring whole-breast and boost radiation therapy. Postlumpectomy breast seromas as visible on CT data have been identified as a proxy for the tumour bed. This study aims to quantify the incidence of postsurgical tumour bed seromas identified at CT simulation and report how well a radiation therapist (RT) is able to identify these seromas compared with those contoured by radiation oncologists (ROs). METHODS AND MATERIALS: A study was undertaken on electronic patient records and the CT-simulation datasets of early stage breast cancer patients treated in 2013 at the Calvary Mater Newcastle to identify the presence of seromas. Patient and tumour characteristics were reviewed. Data analysed included seroma volumes, as contoured by the ROs, as part of the standard voluming procedure. One RT rated seroma visibility based on the level of difficulty when viewing the seroma. RESULTS: Out of 108 CT datasets, an RT was able to identify the presence of a seroma in 102 cases vs. 104 as contoured by ROs. The number of observed agreements was 106 (98.15% of the observations), and the number of agreements expected by chance was 98.4 (91.15% of the observations). The Kappa statistics equalled 0.791 (SE of kappa = 0.143). The strength of agreement is considered to be "substantial." CONCLUSION: RTs play an integral role in contouring during the planning process, and there is scope to expand this role. This research introduced the first step by confirming that a radiation therapist is able to identify seromas on CT-simulation data when compared those contoured by an RO.

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

OBJECTIVE: This analysis sought to determine whether patient self-report measures were associated with disruption to radiation therapy sessions due to anxiety among cancer patients undergoing radiation therapy to the head and neck region. METHOD: A cohort of patients undergoing radiation therapy to the head and neck region at a major regional radiation oncology treatment centre (ROTC) in Australia completed self-report measures of anxiety, history of panic and fears relevant to use of an immobilising mask. The treating Radiation Therapist (RT) rated the level of session disruption due to patient anxiety during the Computerised Tomography/Simulation (CT/Sim) (baseline) session and first treatment session. RESULTS: Complete data were obtained for 90 patients. RTs rated 11 and 24% of patients as having some level of session disruption session due to anxiety at baseline and Treatment 1, respectively. Five factors were significantly associated with session disruption at baseline in bivariate analyses: currently taking psycho-active medication (p=0.008); fear of enclosed spaces (p=0.006); fear of face being covered up (p=0.006); fear of movement restriction (p=0.041) and ever had an anxiety attack (p=0.034). Sensitivity ranged from 0.57 to 0.75 and specificity ranged from 0.68 to 0.90. Only session disruption at baseline predicted disruption at Treatment 1 (p<0.01). CONCLUSIONS: This study offers some preliminary insights into the prevalence of patient anxiety severe enough to cause session disruption and patient self-report measures which might be used to flag patients for prophylactic treatment. Further development and replication in a larger sample is warranted before introduction of these measures into routine practice.

Piloting E-Learning in a Radiation Oncology Department.

Radiation therapy is an ever-evolving profession that requires radiation therapists to continually update their knowledge and skills to provide quality patient care. In 2006, the radiation therapy educators (RTE) at the Calvary Mater Newcastle Hospital in Australia piloted the delivery of in-service education using an e-learning format. To investigate the effectiveness of e-learning compared with the traditional face-to-face method of education, the RTEs chose to compare two cohorts of professional development year (PDY) as the sample. In Australia, graduates are required to complete a PDY before being eligible for full accreditation with the appropriate professional association. The department orientation and treatment planning introduction were the programs used for the investigation. The first PDY cohort received these programs using the traditional face-to- face method and the following years' cohort was presented the material using an e-learning platform. Although the project was limited by a small sample size, the results indicated that e-learning delivered the same content in a more efficient manner than face-to-face while ensuring the same learning outcomes were met.