Communication and collaboration skills training in radiation oncology: A quantitative validation survey.

INTRODUCTION: Communication and collaboration are integral in radiation oncology practice. A recently published qualitative study identified several deficiencies in skills development for Australian/New Zealand trainees. We aim to validate these findings to guide curriculum development. METHODS: A quantitative survey was developed through an iterative process, using themes identified in the previous qualitative investigation. This survey was distributed to radiation oncologists and trainees across Australia and New Zealand via email. Data collection and management utilised the REDCap system. Question types varied to maximise richness of data, including ranking, likert-scales and free-text questions. Results are primarily reported descriptively. RESULTS: Totally 35 participants submitted completed survey responses with broad representation across geography, gender and clinician seniority. To learn communication, participants reported strong preferences towards informal observation (60% agreement) and self-reflection (49% agreement), and against online learning (77% disagreement) methodologies. Nearly 35% acknowledge poor communication at least weekly, with time pressure being a major barrier (63% agreement). Clinical uncertainty and existing patient/family assumptions (both 74% agreement) contribute to difficulties in breaking bad news, with online learning being the only negatively perceived training modality (23% agreement). No participants reported any formal training/mentoring in multi-disciplinary team (MDT) engagement. Conflict was commonly witnessed/experienced (97%) and 26% of participants avoid MDTs due to difficulties experienced. CONCLUSIONS: This study validates the themes previously identified. We identified a strong preference for informal learning methodologies and against online modules, discordant to published literature. Effective collaboration within MDTs is identified as a particular area of need. We recommend future curriculum modification considers these results to maximise efficacy.

Eliciting the views of left breast cancer patients' receiving deep inspiration breath hold radiation therapy to inform the design of multimedia education and improve patient-centred care for prospective patients.

INTRODUCTION: The currently accepted best practice radiation treatment for left breast cancer patients is Deep Inspiration Breath Hold (DIBH) where patients hold a deep breath to reduce late cardiac and pulmonary effects from treatment. DIBH can be challenging and induce or exacerbate anxiety in patients due to the perceived pressure to reduce radiation treatment side effects. This study explored the experiences of patients treated with Deep Inspiration Breath Hold Radiation Therapy (DIBH-RT) to improve patient-centred care and inform the design of multimedia educational tools for future patients undergoing DIBH. METHODS: This descriptive qualitative study was underpinned by a social constructivist approach to create new educational and patient care approaches based on previous patients' experiences. Semi-structured interviews were conducted with patients who had completed DIBH-RT for breast cancer. Data was analysed with reflexive thematical analysis. RESULTS: Twenty-two patients were interviewed with five key themes identified: (1) informational needs, (2) care needs, (3) autonomy, (4) DIBH performance influencers and (5) other centredness. Recommendations were derived from these themes to improve future treatments of DIBH patients. These recommendations revolved around improvements to education, patient-centred care and strategies to improve self-efficacy with breath holding. CONCLUSION: Patients offer a wealth of knowledge regarding their lived experiences with treatment which can enhance future patients' experiences if incorporated into their education and care. Eliciting patients' views of their DIBH-RT treatment highlighted the need to improve patient self-efficacy with DIBH through familiarity with their planned treatment from new multimedia education, and foster patient care to enhance their experience.

What is the effect of a low literacy talking book on patient knowledge, anxiety and communication before radiation therapy starts? A pilot study.

INTRODUCTION: Radiation therapy is a common cancer treatment, requiring timely information to help patients prepare for treatment. We pilot tested a low literacy, psycho-educational talking book (written booklet, with accompanying audio recording) to examine (i) the effect of the tool on knowledge, anxiety and communication; (ii) acceptability, and (iii) how it was used in appointments. METHODS: A pre-post design was employed. Patients scheduled to receive radiation therapy for any cancer were recruited from two hospitals in Sydney, Australia. Participants were sent the talking book before treatment planning and completed baseline and follow-up surveys, before and after the intervention. RESULTS: Forty participants were recruited, and 39 completed all study assessments. Overall, knowledge increased after receiving the talking book by 3.8 points from 13.9 to 17.7/20 (95% confidence interval (CI) 2.7, 4.8, P < 0.001). Anxiety and concerns were significantly lower after receiving the talking book (P = 0.015 and P = 0.004, respectively). Nearly half of participants (s = 17, 48%) reported using the book during appointments. Most reported finding it easier to communicate (n = 31, 89%) and to ask more questions (n = 21, 62%). CONCLUSION: The talking book shows promise in improving knowledge, reducing anxiety and enhancing communication. Strategies to support the implementation of the talking book are required. Further studies to translate the book into different languages are also planned.

Communication and collaboration skills training in Radiation Oncology in Australia and New Zealand: A qualitative study.

PURPOSE: Effective communication and collaboration with patients, carers and between healthcare professionals improves patient management. This study aimed to explore essential communication and collaboration skills training (CCST) for a radiation oncologist (RO) to inform competencies, learning outcomes and enhance curriculum training methods. MATERIALS AND METHODS: Eight focus group discussions with 10 fellows and 14 trainees of the Faculty of Radiation Oncology, Royal Australian and New Zealand College of Radiologists (FRO RANZCR) were conducted face to face between October 2018 and March 2019. Participants included doctors from culturally and linguistically diverse backgrounds, working in public and private, metropolitan, and rural sectors. Data were recorded, transcribed verbatim, managed in Excel, and coded using a qualitative content analysis framework. The study was approved by South Eastern Sydney Local Health District HREC (18/186). Participants provided informed written consent. RESULTS: After achieving thematic saturation, four predominant themes emerged. These were as follows: (1) Enablers and barriers to effective communication and collaboration; (2) written communication; (3) communicating bad news; and (4) multidisciplinary team meeting collaboration. Managing uncertainty and workplace culture emerged as interconnected sub-themes. CONCLUSIONS: There is a current lack of CCST in radiation oncology in Australia and New Zealand. The most common theme that emerged to improve CCST focused on increasing the exposure to a variety of communication and collaboration clinical scenarios, which are observed and upon which immediate structured feedback is given. Consultants and trainees offered tangible suggestions on how to improve the curriculum. These findings underscore the importance of using a combination of structured teaching methods and work-based assessments. CCST templates are recommended.

Characteristics and Symptom Burden of Patients Accessing Acupuncture Services at a Cancer Hospital.

BACKGROUND: Patients with cancer are often impacted by a significant symptom burden. Cancer hospitals increasingly recognize the value of complementary and integrative therapies to support the management of cancer related symptoms. The aim of this study is to provide a better understanding of the demographic characteristics and symptoms experienced by cancer patients who access acupuncture services in a tertiary hospital in Australia. METHODS: A retrospective audit was conducted of patients that presented to the acupuncture service at Chris O'Brien Lifehouse between July 2017 and December 2018. Edmonton Symptom Assessment Scale (ESAS) and Measure Yourself Concerns and Wellbeing (MYCaW) outcome measures were used. The quantitative data was analyzed using descriptive statistics and Principal Component Analysis. RESULTS: A total of 127 inpatients and outpatients (mean age 55, range 19-85) were included with 441 individual surveys completed (264 ESAS, 177 MYCaW). Patients were predominantly female (76.8%) and breast cancer was the most prevalent primary diagnosis (48%). The most prevalent symptoms in the ESAS were sleep problems (88.6%), fatigue (88.3%), lack of wellbeing (88.1%), and memory difficulty (82.6%). Similarly, symptoms with the highest mean scores were numbness, fatigue, sleep problems and hot flushes, whilst neuropathy, and hot flashes were scored as the most severe (score ≥7) by patients. Cluster analysis yielded 3 symptom clusters, 2 included "physical symptoms" (pain, sleep problems, fatigue and numbness/neuropathy), and (nausea, appetite, general well-being), whilst the third included "psychological" symptoms (anxiety, depression, spiritual pain, financial distress). The most frequent concerns expressed by patients (MyCaW) seeking acupuncture were side effects of chemotherapy (24.6%) and pain (20.8%). CONCLUSION: This audit highlights the most prevalent symptoms, the symptoms with the greatest burden and the types of patients that receive acupuncture services at an Australian tertiary hospital setting. The findings of this audit provide direction for future acupuncture practices and research in hospital settings.

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.

Patient-reported outcome measures and supportive care need assessment in patients attending an Australian comprehensive care centre: a multi-method study.

PURPOSE: Patient-reported outcome measures (PROMs) are useful clinical tools to recognise symptoms, patient needs and their severity. Whilst PROMs are routinely utilised in integrative oncology (IO) and supportive care (SC) services to improve patient care, they are not as common in general oncology. We explored our patients' symptom burden, the approach taken by clinicians to identify and manage patient needs, and barriers and facilitators to using PROMs in an Australian tertiary comprehensive cancer centre to inform wider implementation of PROMs. METHODS: From 2017 to 2018, PROM data collected for patients accessing IO and SC was retrospectively analysed. Semi-structured interviews with oncology doctors and nurses explored their approach to patient needs assessment and their use of PROMs. RESULTS: A total of 404 patients completed the Edmonton Symptom Assessment Scale (ESAS). The most frequently identified symptoms were sleep disturbance, fatigue and lack of wellbeing. Symptom clusters included drowsiness, fatigue and shortness of breath; anxiety and depression; sleep and pain; appetite and nausea. In total, 9 nurse consultants, 5 surgeons, 7 medical and 5 radiation oncologists were interviewed. Most participants took an intuitive approach to identifying and managing patient needs and did not routinely use PROMs. Perceived risks, barriers and facilitators to using PROMS are presented. CONCLUSIONS: High and complex symptom burden was found in our IO and SC patient population, reinforcing the need for screening. Whilst wider clinical use of PROMs within the hospital may improve clinical outcomes, the barriers and facilitators identified by Health Care Professionals (HCPs) need to be addressed before implementing PROMs more broadly.

A low literacy targeted talking book about radiation therapy for cancer: development and acceptability.

PURPOSE: To develop a low literacy talking book (written book with accompanying audio-recording) about radiation therapy and explore its acceptability with patients and caregivers. METHOD: The talking book was developed iteratively using low literacy design principles and a multidisciplinary committee comprising consumers and experts in radiation oncology, nursing, behavioural sciences, and linguistics. It contained illustrations, photos, and information on: treatment planning, daily treatment, side effects, psychosocial health, and a glossary of medical terms. Semi-structured interviews were conducted with patients who self-reported low functional health literacy and caregivers to explore their views on the resource. Thematic analysis using a framework approach informed the analysis. RESULTS: Participants were very satisfied with the content, illustrations, and language in the resource. Most were unfamiliar with the term 'talking book', but liked the option of different media (text and audio). The resource was seen as facilitating communication with the cancer care team by prompting question-asking and equipping patients and their families with knowledge to communicate confidently. CONCLUSIONS: The low literacy talking book was well accepted by patients and their caregivers. The next step is to examine the effect of the resource on patients' knowledge, anxiety, concerns, and communication with the cancer care team.

Development and pilot of an international survey: 'Radiation Therapists and Psychosocial Support'.

INTRODUCTION: Up to one third of radiation therapy patients are reported to have unmet psychosocial needs. Radiation therapists (RTs) have daily contact with patients and can provide daily psychosocial support to reduce patient anxiety, fear and loneliness. However, RTs vary in their values, skills, training, knowledge and involvement in providing psychosocial support. The aims of this study were to: (1) develop an online survey instrument to explore RT values, skills, training and knowledge regarding patient anxiety and psychosocial support, and (2) pilot the instrument with RT professionals to assess content validity, functionality and length. METHOD: An online cross-sectional survey, titled 'Radiation therapists and psychosocial support' was developed. Items included patient vignettes, embedded items from RT research, and the Professional Quality of Life Scale (ProQOL5). Four radiation oncology departments volunteered to pilot the survey; each nominated four RT staff to participate. Survey data were analysed descriptively and qualitative feedback grouped and coded to determine whether the survey needed to be refined. RESULTS: Thirteen of sixteen RTs completed the pilot survey and feedback form. Median time to completion was 35 mins, with 54% of respondents stating this was too long. Respondents reported content, questions and response options were relevant and appropriate. Feedback was used to: refine the survey instrument, minimise responder burden and drop out and improve functionality and quality of data collection. CONCLUSION: This pilot of the 'Radiation therapists and psychosocial support' survey instrument demonstrated content validity and usability. The main survey will be circulated to a representative sample of RTs for completion.

Assessment of voluntary deep inspiration breath-hold with CINE imaging for breast radiotherapy.

Deep Inspiration Breath-Hold (DIBH) techniques for breast cancer radiation therapy (RT) have reduced cardiac dose compared to Free Breathing (FB). Recently, a voluntary deep inspiration breath-hold (vDIBH) technique was established using in-room lasers and skin tattoos to monitor breath-hold. An in-house quality assessment of positional reproducibility during RT delivery with vDIBH in patients with left-sided breast cancer was evaluated. The electronic portal imaging device (EPID) was used in cinematographic (CINE) mode to capture a sequence of images during beam delivery. Weekly CINE images were retrospectively assessed for 20 left-sided breast cancer patients receiving RT in vDIBH, and compared with CINE images of 20 patients treated in FB. The intra-beam motion was assessed and the distance from the beam central axis (CA) to the internal chest wall (ICW) was measured on each CINE image. These were then compared to the planned distance on digitally reconstructed radiograph (DRR). The maximum intra-beam motion for any one patient measurement was 0.30 cm for vDIBH and 0.20 cm for FB. The mean difference between the distance from the CA to ICW on DRR and the equivalent distance on CINE imaging (as treated) was 0.28 cm (SD 0.17) for vDIBH patients and 0.25 cm (SD 0.14) for FB patients (P = 0.458). The measured values were comparable for patients undergoing RT in vDIBH, and for those in FB. This quality assessment showed that using in-room lasers and skin tattoos to independently monitor breath-hold in vDIBH as detected by 'on-treatment' CINE imaging is safe and effective.

Reduced patient anxiety as a result of radiation therapist-led psychosocial support: a systematic review.

Up to 49% of patients attending radiation therapy appointments may experience anxiety and distress. Anxiety is heightened during the first few visits to radiation oncology. Radiation therapists (RT) are the only health professionals in direct daily contact with patients during treatment, placing them in a unique position to explore patients' psychosocial needs. This review aims to synthesise literature regarding the effect of RT-led psychosocial support on patient anxiety. In May 2015, we searched the following electronic databases: Medline, PsycINFO, Embase, CINAHL, PubMed and Cochrane library. Radiation therapy-specific journals were hand-searched, and reference lists of identified studies searched. This review complies with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search identified 263 articles, of which 251 were excluded based on non-English language, duplicate article or relevance. A total of 12 articles involving 1363 patients were included and categorised into three broad themes: 'Patient Perspectives' 3 articles, 'Patient Information and Education' 5 articles and 'Screening and Needs Assessment' 4 articles. Two publications referred to the same sample and data. Quality ratings were mixed, with one study rated 'high' quality, seven 'moderate' and four 'low'. Methodological weaknesses were identified in relation to workflow, sample size and responder bias. RTs have a role in psychosocial support through increased communication and information sharing, which can benefit both patients and staff. RT-led practices such as relationship building, patient education sessions and screening and needs assessments are feasible and can reduce anxiety.

External beam radiotherapy for unresectable hepatocellular carcinoma, an international multicenter phase I trial, SAKK 77/07 and SASL 26.

PURPOSE: To assess feasibility and safety of conventionally fractionated radiotherapy (cfRT) in patients with hepatocellular carcinoma (HCC). METHODS: Patients with histologically confirmed stage cT1-4, cN0-1 HCC and Child-Pugh Score (CPS) A or B disease were included in a phase I multicenter trial. Metastatic HCC were allowed if ≥90% of total tumor volume was located within the liver. Patients were enrolled onto five dose-escalation levels (54-70Gy in 2Gy fractions) based on a modified 3 + 3 design, with cohorts of five patients instead of three patients in dose levels 4 and 5. Primary trial endpoint was dose-limiting toxicity (DLT), as specifically defined for 17 clinical and nine laboratory parameters as grade ≥3 or ≥4 toxicity (CTCAE vs. 3). The threshold to declare a dose level as maximum tolerated dose (MTD) was defined as a DLT rate of ≤16.7% in dose levels 1-3, and ≤10% in dose levels 4-5. Best objective response of target liver lesions and adverse events (AE's) were assessed as secondary endpoints. RESULTS: The trial was terminated early in DL 3 due to low accrual. Nineteen patients were recruited. Fifteen patients were evaluable for the primary and 18 for the secondary endpoints. Maximum tolerated dose was not reached. One patient in dose level 1, and one patient in dose level 2 experienced DLT (lipase > 5xULN, and neutrophils <500/µL respectively). However, dose level 3 (62Gy) was completed, with no DLTs in 3 patients. Overall, 56% of patients had a partial response and 28% showed stable disease according to RECIST. No signs of radiation induced liver disease (RILD). Two patients in dose level 3 experienced lymphocytopenia grade 4, with no clinical impact. CONCLUSION: Conventionally fractionated radiotherapy of 58Gy to even large HCC was safe for patients with CPS A and B. 62Gy was delivered to three patients without any sign of clinically relevant increased toxicity. The maximum tolerated dose could not be determined. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00777894 , registered October 21st, 2008.

Impact of cognitive function on communication in patients with primary or secondary brain tumours.

Communication support tools (CST) improve patient outcomes in oncology including: knowledge, satisfaction, self-management, and adherence to planned treatment. Little is known about communication support tools use in patients with primary or secondary brain tumours. We aimed to explore cognitive function and communication support tool use in this population. This prospective survey involved patients, caregivers and health professionals. Questionnaires were completed after initial brain radiotherapy consultation and 1-2 weeks later. Patients completed the Montreal Cognitive Assessment (MoCA). Descriptive statistics are reported. Fifty-three patients participated, median age 62 years, ECOG status 0-2 (90 %), with 75 % having secondary brain metastasis. 21/53 (40 %) patients reported needing help reading medical information. Only 28 % patients had normal cognition (MoCA score ≥ 26/30). Initially, 82 % of patients and 87 % of caregivers reported the consultation was 'extremely/quite clear, and 69 % of their health professionals thought consultation 'extremely/quite clear' to patient. At follow-up, fewer patients (75 %) reported health professionals' explanation as 'extremely/quite clear'. Although patients recalled discussed illness and treatment details, 82 % recalled treatment-related side effects and management thereof by 46 %. CST use was reported by 22 % patients, 19 % caregivers, and 27 %health professionals. When used, tools improved understanding according to 92 % patients, 100 % caregivers, and 91 % health professionals. The majority of patients have some level of cognitive impairment. Information discussed appears clear to most patients, but this is not sustained, and recall of treatment toxicity management is poor. Few CSTs are used in consultations, but when used, are reported as helpful by all.

Sentinel lymph node mapping for defining site and extent of elective radiotherapy management of regional nodes in Merkel cell carcinoma: a pilot case series.

Merkel cell carcinoma is a rare and aggressive skin malignancy. We discuss sentinel lymph node mapping which is a valuable decision aid for radiotherapy management and planning of treatment volumes as illustrated by four cases.

Results of concurrent radio-chemotherapy for the treatment of head and neck squamous cell carcinoma in everyday clinical practice with special reference to early mortality.

BACKGROUND: Randomized controlled trials have established concurrent chemo-radiotherapy as the preferred treatment option for inoperable local-regionally advanced head and neck squamous cell carcinomas (HNSCCs). Because many patients have multiple co-morbidities and would not fulfill the eligibility criteria of clinical trials, the results need to be re-evaluated in daily clinical practice with special reference to early mortality. METHODS: 167 consecutive patients with HNSCC who received concurrent chemo-radiotherapy at the Basel University Hospital between 1988 and 2006 were analyzed retrospectively with a special focus on early deaths and risk factors for an unfavorable outcome. RESULTS: In our cohort, the 3- and 5-year overall survival rates were 54% and 47%, respectively. The therapy was associated with relevant toxicity and an early mortality rate of 5.4%. Patients dying early were analyzed individually for the cause of death. Patients with elevated white blood cell counts (HR: 2.66 p=0,016) and vascular co-morbidities (HR: 5.3, p=0,047) showed significantly worse survival rates. The same factors were associated with a trend toward increased treatment-related mortality. The 3-year survival rate improved from approximately 43% for patients treated before the year 2000 to 65% for patients treated after the year 2000 (Fisher's exact test p=0.01). CONCLUSIONS: Although many patients who received concurrent chemo-radiotherapy would not have qualified for clinical trials, the outcome was favorable and has significantly improved in recent years. However the early mortality was slightly worse than what is described in the literature.

[Adjuvant radiotherapy in breast cancer]. / Die adjuvante Bestrahlung beim Mammakarzinom.

During the last decades the treatment of breast cancer has changed considerably. Radical surgical procedures have increasingly been replaced by breast conserving therapy including radiation therapy of the whole breast (WBI). This change in treatment approach is partly due to clinical study results and pathological observations. The current indications and guidelines in the treatment of breast cancer by radiation are shown along with the ensuing implications for patient and physician. More recently, growing interest has been noted in partial breast irradiation. The different techniques for partial breast irradiation (APBI), their advantages and drawbacks are outlined.

Boost radiotherapy in young women with ductal carcinoma in situ: a multicentre, retrospective study of the Rare Cancer Network.

BACKGROUND: Outcome data in young women with ductal carcinoma in situ (DCIS) are rare. The benefits of boost radiotherapy in this group are also unknown. We aimed to assess the effect of boost radiotherapy in young patients with DCIS. METHODS: We included 373 women from 18 institutions who met the following inclusion criteria: having tumour status Tis and nodal status (N)0, age 45 years or younger at diagnosis, and having had breast-conserving surgery. 57 (15%) patients had no radiotherapy after surgery, 166 (45%) had radiotherapy without boost (median dose 50 Gy [range 40-60]), and 150 (40%) had radiotherapy with boost (60 Gy [53-76]). The primary outcome was local relapse-free survival. FINDINGS: Median follow-up was 72 months (range 1-281). 55 (15%) patients had local relapse. Local relapse-free survival at 10 years was 46% (95% CI 24-67) for patients given no radiotherapy, 72% (61-83) for those given radiotherapy without boost, and 86% (78-93) for those given radiotherapy and boost (difference between all three groups, p<0.0001). Age, margin status, and radiotherapy dose were significant predictors of local relapse-free survival. Compared with patients who had no radiotherapy, those who had radiotherapy had a decreased risk of local relapse (without boost, hazard ratio 0.33 [95% CI 0.16-0.71], p=0.004; with boost, 0.15 [0.06-0.36], p<0.0001). INTERPRETATION: In the absence of randomised trials, boost radiotherapy should be considered in addition to surgery for breast-conserving treatment for DCIS.