Virtual integration of patient education in radiotherapy (VIPER).

Purpose: Pre-radiotherapy patient education led by Radiation Therapists (RTT) has been shown to improve patients' distress and overall experiences. In an effort to offer a remote delivery method while allowing for visual learning and face-to-face communication, this pilot project evaluated the feasibility and acceptability of using virtual videoconferencing for patient education. Methods: This prospective pilot study integrated virtual patient education into standard care. This workflow consisted of a one-on-one, 45-minute tele-education session with an RTT on the day prior to CT-simulation. For this study, patients were offered the option to complete the session using web-based videoconferencing if they had the capability for it. Feasibility was evaluated as the proportion of patients who agreed to and completed virtual education. To evaluate acceptability, patients and RTTs were then emailed post-intervention surveys evaluating their satisfaction with virtual patient education. Results: Over three months 106 of 139 patients (76%) approached consented to virtual education. The median (range) age was 65 (27-93), 69% were male and most had genitourinary (38%) or head-and-neck (29%) cancers. Ninety patients (85%) completed virtual education as planned, with incompletions due to scheduling (8) or patient technical issues (7), or treatment cancellation (1). Sixty-eight patients completed surveys, with the vast majority agreeing virtual education was clear (94%) and helped them prepare (100%), they were comfortable with the technology (96%) and they were satisfied overall (99%). Twelve RTTs responded, suggesting overall that virtual education was higher quality though less feasible than tele-education, and comparable to in-person education. Conclusion: Offering individual, RTT-led virtual education using videoconferencing to patients pre-radiotherapy was feasible and acceptable in this pilot study, and is therefore being recommended as an option for all our patients. Future work will directly compare the effectiveness of in-person versus virtual education, and incorporate individual patient needs and preferences.

Could knowledge of patient demographics facilitate a personalized approach to radiation therapy patient education?

INTRODUCTION: Using patient demographics to tailor cancer patient education processes results in improved patient outcomes. However, there is little information on how to successfully tailor radiation therapy (RT) educational content and delivery. The aim of this quality improvement project was to describe the information preferences of a diverse group of patients undergoing RT and determine if different RT education processes were associated with certain patient demographics. MATERIALS AND METHODS: An educational needs assessment questionnaire, based on a validated tool, was offered to all patients undergoing RT on a single day. Questionnaire sections included demographics and questions regarding the importance of topics related to RT treatments, desired mode of information delivery, quantity of information, desired timing of information, and satisfaction with information received. Patients were also asked to answer qualitative questions focused on what was working well and what could be improved. Participants' responses were cohorted based on demographic groupings (age, gender, education level) and were tested for statistically significant differences and associations. RESULTS: 130 patients completed the questionnaire. Compared to those over 60 years, more participants who were 50 - 59 years old thought the topics were 'very important' (96% vs 77%, p<0.001) and wanted a higher quantity of information about the topics (80% vs 66%, p<0.001). More participants over 70 years old preferred pamphlets compared to those less than 70 years (48% vs 30%, p<0.047) while more participants under 50 years old preferred one-on-one sessions compared to those older than 50 years (40% vs 25%, p<0.038). Fewer participants <50 years wanted information at their first meeting with the Radiation Oncologist compared to those older than 50 years (57% vs 73%, p<0.001). Compared to the male cohort, more female participants felt the information topics were more important (83% vs 74%, p<0.0001) and had more unmet education needs (29% vs 17%, p<0.001). Compared to those with post-secondary education, more participants with primary or high school education desired a higher quantity of information (76% vs 65%, p<0.001), preferred to receive that information using pamphlets (43% vs 32%, p=0.006) and wanted all the information at the first opportunity (81% vs 67%, p<0.001). CONCLUSIONS: This quality improvement project found that age, gender and education level influenced patient preferences for information quantity, delivery mode and timing of RT education. These findings are promising and support further evaluations to determine a more precise definition of the personal factors that could help to individualize our approach to educating patients receiving RT.

A qualitative descriptive study of patients' experiences of a radiation skin reaction associated with treatment for a head and neck cancer.

The majority of patients receiving radiation therapy will experience a radiation skin reaction, ranging from mild erythema to severe moist desquamation. The anticipated skin reaction will vary by cancer diagnosis, dose of radiation, size of treatment field, and other treatment-and patient-related factors. Recently, research has dispelled long-held myths about avoiding skin care products prior to treatment, and the use of deodorant or antiperspirant during treatment for breast cancer and any potential for an increased skin dose with the use of skin care products. Patients no longer are restricted in using these products. Most of the research regarding skin reactions due to radiation has been conducted with women with breast cancer. No research has been found on the experience of a radiation skin reaction in patients with head and neck cancer (HNC), who often get the most severe skin reactions across all patient groups. Using the qualitative interpretive descriptive approach based on the methodological work by Thorne (1997), nine participants were interviewed about their experience of having a radiation skin reaction resulting from their treatment for HNC. Three themes emerged from the interviews, including 1) the symptom experience, 2) comparison to others, and 3) the experience of support and information. Implications include recommendations for practice and patient education.

Patient perspectives on frame versus mask immobilization for gamma knife stereotactic radiosurgery.

PURPOSE: To assess patient experiences and perspectives following Gamma Knife (GK) stereotactic radiosurgery (SRS) using frame versus mask immobilization. METHODS: Patients who received GK-SRS using both frame and mask immobilization were included in this study. One-on-one semi-structured interviews, led by a third-party expert, were used to gain insight into the patient experience. To reduce memory bias of either immobilization device, patients underwent the interview at their follow-up appointment. Initial assessment of patient transcriptions was completed by one study staff; a second member reviewed transcripts for thematic saturation. All interviews were independently coded for themes to minimize interpretation bias. RESULTS: Fifteen patients were consented; 12 were successfully interviewed (3 lost due to deteriorating health status). Interviews ranged from 30 to 60 min in duration. The most common patient concern regarding the frame was pain (9 patients), while the primary concerns with the mask system were the ability to remain still (6 patients) and claustrophobia (4 patients). Eleven patients chose the mask as their preferred choice in terms of their overall experience. Two themes emerged during the interviews that spoke to patient satisfaction with each process: unexpected pain with frame placement; and tightness experienced while wearing the mask during treatment. CONCLUSIONS: From the patient perspective there was overwhelming agreement that the mask was the preferred choice for GK-SRS. The patient experience could be improved by enhanced education to better prepare patients on what to expect during the frame placement and mask treatment processes.

A Canadian Survey of the Management of Radiation-Induced Skin Reactions.

INTRODUCTION: Radiation therapy skin reactions are one of the most common side effects and can cause patient distress. In some cases, a severe radiation-induced skin reaction may limit delivered dose and potentially compromise treatment outcomes. There are some established best practices, but approaches and patient advice appear to have changed little over the years and are often based on tradition, not evidence. Canadian radiation therapy departments use different skin care products and approaches, and there has been little previous work to examine national practice patterns. MATERIALS AND METHODS: This study used a 42-item electronic survey based on a questionnaire designed by the UK Society and College of Radiographers. Practice data were collected related to assessment and prophylactics, interventions for prevention and management, and use of tools and guidelines. The final survey version was distributed to an identified radiation therapist-registered nurse dyad at each radiation therapy department in Canada (n = 44). RESULTS: Thirty-three departments responded (75% response rate). Results suggest a variation in national management. A number of departments continue to advise patients not to wash or use deodorant/antiperspirant despite having evidence to the contrary. There are also unnecessary restrictions on the use and timing of application of lotions as well as conflicting postradiotherapy skin care instructions regarding sun exposure. CONCLUSION: The study demonstrated variation in practice across Canadian radiation therapy departments. National interprofessional guidelines could improve uptake of best practices. Where there is little evidence, a stress-reduction approach with more collaborative decision-making should be used to minimize patient disruption.

Collaboration in Health Care.

Health care involves the participation of patients, family, and a diverse team of often highly specialized health care professionals. Involvement of all these team members in a cooperative and coordinated way is essential to providing exceptional care. This article introduces key concepts relating to interprofessional collaborative teamwork. Approaches to measuring and studying collaboration and evidence demonstrating the benefits of collaboration are presented. The structural, psychological, and educational factors which may determine collaborative behaviour are described. LEARNING OBJECTIVES: By the end of this CME article, participants will be able to 1. Distinguish between multifunctional and interdisciplinary teams, 2. Define collaboration in a health care setting, 3. Describe the value of collaboration to patients, staff, and organizations, 4. Understand approaches to measuring collaboration, and 5. Identify factors that determine the ability of teams to collaborate. This article is a CME article and provides the equivalent of 2 hours of continuing education that may be applied to your professional development credit system. A 20-question multiple choice quiz follows this reading, and answers can be found on page 216. Please note that no formalized credit (Category A) is available from CAMRT.

From Computed Tomography-Guided to Magnetic Resonance Imaging-Guided Intracavitary Brachytherapy for Cervical Cancer: What Do the Key Stakeholders Have to Say about the Transition?

BACKGROUND: International brachytherapy consortiums are advocating for the incorporation of magnetic resonance imaging (MRI) into the cervical brachytherapy process as a standard-of-care. Although some evaluations have been performed to quantify the effect on procedural time, little is known about the views and experiences of key stakeholders during the transition from computed tomography to MR-guided brachytherapy. This qualitative research project explored insights from key stakeholders related to a change in the gynaecologic brachytherapy process. METHODS AND MATERIALS: Semi-structured interviews were designed using Lean Methodology principles and all key members in the gynaecologic brachytherapy team were approached for participation: radiation oncologists, medical physicists, radiation therapists, the lead MR technologist, and the ward nurse manager. Interviews were recorded and transcribed, and analysis was performed to identify themes from the data. RESULTS: Ten of 12 (83% participation rate) key members of the team were interviewed. Four themes emerged from the data: challenges to efficiency, staff availability, patient history and disease characteristics, and team communication. The stakeholders expressed that the challenges during this transition were procedural inefficiency (sharing of the MRI scanner and increased procedure length because of increased complexity in contouring and planning), and staff availability (radiation oncologist and transportation staff). The clinical team identified the value of communicating patient history and disease characteristics ahead of the brachytherapy procedure day and also using an inclusive mode of communication during the procedure was beneficial. CONCLUSIONS: This research provides nuanced insights into process and practice changes that occur when one imaging technology is simply swapped for another, emphasizing how intertwined and complex brachytherapy procedures can be. It emphasizes that not all challenges to efficiency are considered Lean Wastes, and that seemingly simple procedural changes can result in unanticipated differences in staff availability, communication pathways, and knowledge requirements.

Development and Implementation of an Electronic Learning Module for Volumetric Image-Guided Radiation Therapy.

BACKGROUND: Image-guided radiation therapy (IGRT) through daily cone-beam computed tomography (CBCT) has significantly impacted the role of the radiation therapist at our institution; continuing education is crucial to ensure safe practice of technology in the clinical environment. The purpose of this work was to develop and implement an electronic learning (eLearning) module as a yearly refresher for CBCT-practicing radiation therapists. METHODS: To provide an innovative interface to engage the learner's interest, a module themed "Myths in Cone Beam Computed Tomography Practice" was developed by content experts at our institution. The eLearning tool focused on the technical aspects and fundamental theory of CBCT acquisition, with an aim to refresh the user's knowledge and confidence in image fusion and assessment. Ten myths were identified in the module and evidence-based content was referenced within each myth to support theory. Evaluation of the learner was performed through a multiple choice quiz at the end of the module. The tool and 12 multiple choice questions were reviewed and validated by subject matter and non-subject matter experts in CBCT-IGRT before departmental implementation. RESULTS: The CBCT eLearning module has been clinically implemented and used over the last 3 years by radiation therapists in our department. Completion of the tool is an annual mandatory requirement for CBCT-practicing therapists; over 100 participants completed the module per year. The median time for module completion decreased over the 3-year interval, from 42 minutes 25 seconds during the first year of implementation to 20 minutes and 48 seconds in the third year. CONCLUSIONS: An electronic online training tool for CBCT refresher training has been developed and implemented at our institution, with an aim to equip staff with the critical thinking skills and clinical judgment required to operate in a CBCT-IGRT environment. The module's format ensures delivery of consistent information as a component of yearly continuing education for radiation therapists.

Communicating with Emotional Patients: Thoughts, Skills, and Influencing Factors for Ontario Radiation Therapists.

PURPOSE: Patients receiving radiation therapy are subject to high anxiety levels. Radiation Therapists (RTs) are uniquely positioned to support patients as they progress through treatment, but little is known about therapists' ability to perform this important task. This research was designed to describe RTs' ability to communicate with cancer patients during emotional interactions and to determine what intrinsic and extrinsic factors influence that ability. METHODS: Single-centre focus groups were used to develop themes for a questionnaire. That questionnaire was then distributed throughout 13 Ontario cancer centres. Themes evaluated included intrinsic factors (demographics, value, and so forth) and extrinsic factors (work environment, resources, and so forth). A validated clinical vignette was used to evaluate actual respondent communication skill and a validated scale reported various aspects of emotional intelligence. RESULTS: One hundred ninety-nine responses were received from 13 cancer centres distributed across Ontario. Response rate was low (31%), but wave analysis indicated a lack of nonresponse bias. Based on the clinical vignette, RTs showed a high degree of skill when communicating with emotional patients, reporting minimal use of blocking or controlling behaviours. Factors shown to significantly influence the ability to communicate with emotional patients included personal sociability and years of experience, organizational provision of time, private space, and support (P < .05). CONCLUSIONS: RT respondents were particularly skilled at communicating with emotional patients. That skill level was significantly influenced by both personal and organizational factors. The most important of these were experience and time. These findings are consistent with the literature for other professions and are likely generalizable throughout Canada and similar international practice environments.

Exploring the Experiences of Left-Sided Breast Cancer Patients Receiving Radiation Therapy Using the Active Breathing Coordinator.

BACKGROUND: The Active Breathing Coordinator (ABC) to induce breath hold during radiation therapy is used with the intent to reduce the risk of long-term, radiation-induced cardiovascular morbidity. Many studies have explored the dosimetric and toxicity benefits of using the device, but limited research has been done on the patient's perspective. The aim of this study was to explore the patient's experience using the ABC device and to evaluate the teaching provided. METHODS AND MATERIALS: Following Research Ethics Board approval and written informed consent, paper questionnaires were used, and cross-sectional data were collected from 30 English-speaking women receiving radiation therapy for left-sided breast cancer using the ABC device. Questions were both quantitative (a 10-point Likert scale) and qualitative in nature and evaluated patient-reported anxiety levels, confidence levels, and suggestions for process improvement. Descriptive and inferential statistics were used to analyze the results, with thematic analysis of qualitative comments. RESULTS: Fifty-three percent of patients reported higher than 5 on the Likert scale for anxiety related to using the ABC device. Half the sample indicated that they were equally anxious about using the ABC as they were about receiving radiation therapy, a third reported being more anxious about using ABC than they were about receiving radiation therapy. Participants under 50 years were significantly more likely to feel "highly" anxious about using ABC than those older than 50 years (37% vs. 5%; P = 0.001). Half the participants indicated that their confidence level increased as treatment progressed, and suggested that the inclusion of a training video, practice sessions and constant communication via the treatment unit intercom would be helpful in reducing their anxiety. CONCLUSIONS: This hypothesis generating study suggests that moderate-to-high levels of anxiety were common for left-sided breast cancer patients using the ABC device, particularly for patients younger than 50 years. As treatment progressed, patients seemed to become less anxious and more confident using the device. These preliminary findings support the need for further research in this area, using formal validated anxiety scoring tools.

Patient and staff assessment of an audiovisual education tool for head and neck radiation therapy.

The purpose of this study was to understand and compare patient and staff perceptions of a video-based preparatory education tool for head and neck radiotherapy. Patients and staff completed a questionnaire assessing their perceptions of whether the education tool was relevant, clear, complete and reassuring. Staff rated the video's accuracy and anticipated impact on future patient information needs. Demographic information was collected. Open-ended questions were used to elicit additional feedback. Quantitative responses from 50 patients and 48 staff were very positive and not significantly different between the two groups. Content analysis of the qualitative data provided insight into the information and approaches valued by patients and staff and how these differed. Staff members were more critical of the production quality and completeness of information related to procedures and treatment side effects. Patients valued seeing procedures acted out and desired more information about what these experiences would feel like and how to engage in self-care. Although staff-driven development may be an effective method of designing the content and approach of a preparatory education video, care should be taken to consider differences between patient and staff perceptions of information needs.

Evaluation of the Effects of Pre-Treatment Education on Self-Efficacy and Anxiety in Patients Receiving Radiation Therapy: A Pilot Study.

INTRODUCTION: Patients receiving radiation therapy for cancer treatment have been reported to experience increased anxiety before starting therapy and often have diminished feelings of control. An evaluation was done to measure the impact of an educational class that was designed to lower patient and family anxiety and to help them know what to expect before starting radiation therapy. METHODS: A single-centre, cross-sectional study was conducted from January to March 2011 at an ambulatory radiation therapy clinic. The study used the Cancer Behavior Inventory Brief (CBI-B) and State-Trait Anxiety Inventory-State (STAI-S) to investigate the effect of the class on the participant's perceived self-efficacy and anxiety, respectively. Participant demographics and an evaluation of the course content and the teaching skills of the facilitators were collected. RESULTS: Twenty-four responses were analyzed. Although the course was designed for those starting treatment, 11 participants had already begun. The majority of participants were non-immigrant patients with high socioeconomic status. Patient self-efficacy scores increased significantly P ≤ .001 and anxiety scores decreased significantly P ≤ .001 after completion of the pre-treatment class. Overall, participants rated the content and delivery of the class highly. CONCLUSION: This study has shown that pre-treatment education may reduce anxiety and increase self-efficacy in patients starting and those already receiving radiation therapy. This information may provide support for the delivery of pre-treatment patient education in ambulatory radiotherapy clinics.

The Effects of Post-Radiation Education Pamphlet On Self-efficacy in Cancer Patients.

Cancer patients undergoing radiotherapy often experience anxiety and a sense of loss of control immediately after completion of their active treatment. This study aims to evaluate, using a cross-sectional survey, the effects of a post-radiation education pamphlet on the self-efficacy of cancer patients in terms of seeking/understanding medical information, seeking support, and coping with radiation side effects. Forty-eight patients from various age groups with a variety of cancer diagnoses were recruited from the Radiation Medicine Program at Princess Margaret Hospital. Descriptive analysis of 35 survey responses suggests that the pamphlet improved patient self-efficacy in terms of seeking and understanding medical information, seeking support, and coping with radiation side effects. The benefits of the pamphlet were also found to be independent of patients' education level. Despite the small sample size, this study demonstrates the effectiveness of the education pamphlet in improving patient self-efficacy and gives support to the pamphlet's utility in improving the transition care of cancer patients finishing radiotherapy. In parallel, 40 Princess Margaret Hospital Radiation Medicine Program staff members were also asked, via online surveys, about their awareness of the pamphlet, and its usefulness in terms of content, format, and timing of the information provided. More than 90% of the staff indicated that the pamphlet was an effective tool. Only 57% of oncologists were aware of the pamphlet's existence.

The Key Psychosocial Issues Faced by Men with Testicular Cancer.

Testicular cancer is the most common solid tumour in 15- to 35-year-old white males; however, it only accounts for 1%-2% of all male cancers. During the past few years, there have been huge advances in the treatment of testicular cancer. Survival rates for early stage disease are higher than 95%, and for all disease stages combined the survival rates are over 90%. With these improved rates has come the recognition that long-term side effects and quality-of-life issues are more important than ever. The disease presents at a peak period in men's reproductive life, which coincides with planning for a career and a family. Efforts have focused on improving treatment outcomes and not on quality-of-life issues; however, as with many cancer sites, the focus has moved to dealing with the psychosocial issues faced by survivors. The key issues of sexuality, fertility, and, subsequently, family or partner relationships are of concern to this group of patients and their partners and will be discussed in this article.