Reducing Anxiety Among Radiation Therapy Patients

The review of literature in a research report is a summary of current knowledge about a particular practice- problem. (Nancy & Burns 2002). A literature review is an organized writer’s presentation of what has been published on a topic by the scholars. The task of reviewing literature involves the identification, selection, critical analysis and reporting of existing information on topic of interest.

The literatures found relevant and useful for the present study have been organized under the following headings.

1. Literature related to prevalence of anxiety among patients receiving radiation therapy.
2. Literature related to interventions used to reduce anxiety of patient receiving radiation therapy.

Literature related to prevalence of anxiety among patients receiving radiation therapy.

Donna B. Jeffe (2010) conducted a study among women who received radiation therapy over a period of five years in United Kingdom. The results showed that 35% of women had significant levels of anxiety or depression prior to radiation therapy. 75% women with high levels of anxiety prior to treatment recorded further high scores over the time period of five years. Out of six women who received radiation therapy, one had high anxiety scores during every follow-up. Very few of the women’s with initial normal anxiety scores developed significant level of anxiety or depression over time. The study concluded that patients with little education showed higher levels of anxiety and depression over time and emphasized the need for education before radiation therapy.

Andersen BL,Tewfik HH (2006) conducted a study to find the psychological reactions towards radiation therapy. Totally 45 patients undergoing external radiation therapy were included in this study. Pre and post radiation assessments of the subject’s were done in the areas of state and trait anxiety, somatic complaints, and treatment side effects. Results showed increase in complaints and side effects reported by all patients at the treatment conclusion. Results also showed that (a) patients with an initial high level of anxiety reported a significant reduction, but they remained the most anxious subgroup; (b) patients with a moderate level of treatment anxiety before radiation therapy reported no change; and (c) patients with low levels of anxiety reported significant increase. The study concludes that patients who were either low or high in state anxiety were also characterized by more anger or hostility than patients with moderate level of treatment anxiety.

Hans Geinitz, FrankB (2003) conducted a study to evaluate fatigue 2.5 years after radiation treatment in patients with breast cancer and to assess its relation to pre- and immediate post-treatment fatigue values. Totally 41 patients were included in this study whose fatigue value was evaluated during the time of radiation therapy. Out of these 41 patients, 38 were alive and free of cancer 2.5 years after radiation therapies, received the Fatigue Assessment Questionnaire, a visual analog scale on fatigue intensity as well as on cancer-related distress scale, the Hospital Anxiety and Depression Scale, and Health Survey per mail. All 38 patients returned their questionnaires. The values were compared to pretreatment and immediate post-treatment levels. Cancer-related distress values correlated with the patient fatigue scores. Results showed that Patients with functional impairment had slightly higher fatigue values. Patients with pretreatment elevated fatigue, anxiety or depression levels were at high risk for chronic fatigue.

Barrie R. Cassileth Ph.D (2009) conducted a study to assess the effectiveness of experience on radiation therapy patients’ desire for information. Information giving and seeking were explored among 160 cancer patients who were receiving or about to receive radiation therapy. Eighty-two new patients and 78 experienced patients completed a questionnaire to find their knowledge of diagnosis and radiation therapy, expectations about treatment, self-assessment of the adequacy of their knowledge, and desire for additional information. Analysis showed that 92% of the patients reported detailed knowledge of diagnoses. Patients were optimistic about treatment: only one person thought that radiation might not be helpful; 50 percent of the patients had a thought that radiation therapy might cure their disease. Patients who had experience with radiation therapy shown with increased knowledge but they had diminished desire to seek information. Most experienced patients had accurate information, but many did not feel well informed. The desire among knowledgeable patients for more information might show the patients’ uncertainty about the radiation treatment.

Lynn kilbride (2007) conducted a study to assess the frequency, severity of anxiety and depression among brain tumor patients between the period of surgery and radiation therapy. Totally 51 patients were included in this study whose anxiety and depression were assessed at three time points; post surgery, three weeks post surgery and prior to radiation therapy. Hospital Anxiety and Depression scale was used. Results indicated a heightened level of anxiety prior to radiation therapy. Five patients had significant depression at the time period between surgery and radiation therapy. Four of the five patients with scores consistent with depression had past histories of depression. The study concluded that a past medical history of depression is a significant predictor of depression before radiation therapy.

Arthur peck, MD (2006) conducted a study to assess the emotional reactions of patients receiving radiation therapy. Totally 55 patients were included in this study. They were interviewed by a psychiatrist. The focus of initial interview was what they told when they were referred to have radiation therapy. Although 60% were informed by their doctors that they had cancer, all arrived at the treatment center without any preparation for the frequency, number, and the procedure of radiation treatment. Most of the patients believed that requiring radiation therapy was very bad news. They had the fear that radiation might cause further damage and possibly cancer. Few of them only expected it to be curative. Again the patients were interviewed after the completion of radiation treatment. The results showed that the incidence of depression and anxiety was even greater than their pretreatment interviews. More than one third of the patients judged the treatment to be ineffective; they were not realizing that their new distress resulted from the side effects of radiation treatment. In this study only one patient suffered damage due to radiation therapy and 60% were free of signs of cancer at follow up, 1 to 2 years later. This study concluded that patients before radiation therapy suffered from irrational fears of disability and death mainly due to their misconceptions about the radiation therapy.

Thomas w.decker (2006) conducted a study to assess the impact of stress, anxiety and depression on quality of life of cancer patients undergoing radiation therapy. Totally 82 outpatients who were undergoing radiation therapy were included in this study. The experimental group (34 patients) received some relaxation training and the control group (29 patients) received the standard education and counseling along with the radiation therapy. The results showed that there was significant (p < 0.01) reductions in tension, depression, anger, and fatigue of the experimental group. The study concluded that relaxation training significantly improves the quality of life of patients who are undergoing radiation therapy.

Yu P. Chen, Ngan M. Tsang (2002) conducted a study to find the causes of interruption of Radiation therapy in patients with Nasopharyngeal Carcinoma in Taiwan. A total of 3273 nasopharyngeal carcinoma patients were treated at the Radiation Oncology Department from 1979 to 1996 were included in this study. Among these patients, 276 did not complete the full course of radiation treatment. The medical records of these patients were reviewed to determine the factors contributing to treatment interruption. Results showed that the acute side effects and complications caused by radiation therapy were the major factors influencing patient’s decisions to discontinue the treatment. This study suggested that more attention should be paid to take care of acute side effects of radiation ­therapy and also reinforcing the patient with education is important.

Santhosh K.Chaturvedi (1998) conducted a study to assess the prevalence of anxiety and depression in patients receiving radiation therapy in India. A total of 100 patients referred to radiation therapy were included. All patients were administered the hospital anxiety and depression scale before starting the radiation therapy, after the completion of radiation therapy, and at 3-4 months follow-up. Anxiety and depression were detected frequently in patients receiving radiation therapy both prior to treatment and later during follow up. Frequency of anxiety significantly increased after initiating radiation therapy, but later reduced during follow up assessment.

Hoyle Leigh (1987) conducted a study to assess the psychological factors affecting survival in cancer patients receiving radiation therapy. Totally 101 patients receiving radiation therapy were evaluated for anxiety, depression, and perception of the seriousness of their condition. In 3 years, the survivors were compared to the non survivors. The survivors had significantly higher mean trait anxiety (p < 0.05) than the non survivors. State anxiety and depression scores also tended to be higher in the survivors. Results implied that anxiety may be adaptive in cancer patients, but it is not necessarily a good prognostic sign in cancer patients. However, if anxiety occurs in the context of massive defensive failure, it may be a predictor of poorer outcome.

Literature related to interventions used to reduce anxiety of patient receiving radiation therapy.

Georgia K.B Halkett (2010) conducted a study to assess the effective communication and provision in radiation therapy and role of the radiation therapists. Health professionals have a duty of care to radiotherapy patients in providing them with adequate information before treatment. The aim of the study was to (a) explore how radiation therapists communicate with breast cancer patients during a radiation therapy planning appointment (b) determine what information is provided during this appointment and (c) explore radiation therapists’ perspectives on their role in providing patient information and support. A total of 110 radiation therapists were participated in this survey. They simulated 2 radiotherapy planning appointments and held 2 forums. The study concluded that Radiation therapists play an important role in communicating with patients and providing information, especially if patients exhibit anxiety and distress.

Christie R. Eheman (2010) conducted a study to assess the information-seeking styles among cancer patients before and after treatment by demographics and use of information sources. Totally 731 cancer patients attending outpatient clinics for cancer treatments were surveyed during the pre treatment and post treatment period. The study evaluated the relationships between information-seeking style (active, moderately active, and passive styles) and demographics, cancer type, and health status for the pretreatment and post treatment periods and overall. The generalized estimating equations approach was used to model the log odds of more active to more passive information-seeking preferences taking into consideration both the pretreatment and post treatment periods. The results showed that prior to treatment, 17% reported an active information-seeking style, 69% were moderately active, and 14% were passive.

Raymond Chan (2009) conducted a study to assess the effectiveness of orientation program on levels of anxiety and self efficacy among newly registered cancer patients who were waiting for chemotherapy or radiation therapy in a cancer centre in Australia. A randomized control study was used and interventions given like a face-to-face program which includes introduction to the hospital facilities, introduction to the multi-disciplinary team and an overview of treatment side effects and self care strategies. The aim of the study was to orientate patients to the cancer centre and to meet the health care team. Results showed improvement in self-efficacy of patients and demonstrated potential improvement in health outcomes. The study also reported that there were only limited studies on orientation program for cancer patients particularly with respect to the use of multidisciplinary team members.

Yvonne Zissiadisa (2009) conducted a study to assess the impact of more intensive written information in patients receiving radiation therapy. Totally 194 patients were included in this study. The experimental group (102) received more intensive information and control group (92) received the standard consultation. State trait anxiety scale was completed prior to their first consultation at the time of simulation and at the completion of radiotherapy. Information satisfaction questionnaire to assess the patient’s satisfaction was also completed at the time of simulation prior to radiation therapy. The results showed that there was no significant difference between the groups with regard to mean satisfaction scores with the overall information given. Results showed that more intensive information did not significantly change the patient’s satisfaction, anxiety scores. But the patients were generally very satisfied with the information they received but they were less satisfied with the information on lifestyle issues.

Eva J.E. Christensen, B.Sc (2006) conducted a study to find the effectiveness of interventions to relieve pain and anxiety during radiation therapy. The main objective of this study was to assess the discomfort and anxiety during radiation therapy, which can increase patient motion leading to decreased treatment accuracy. Totally 2051 subjects were included in this study. They were given different interventions like placebo, hypnotherapy, aromatherapy, music therapy and guided imagery including pharmacological interventions. Results showed that guided imagery showed benefits in terms of pain. And the study concluded that relaxation therapies may decrease anxiety during radiation therapy, evidence supports the benefit of pharmacological interventions for pain and anxiety for specific radiological procedures and selection of common criteria for reporting pain and anxiety is valuable for further studies.

Cartledge Hoff A, Haaga DA(2005) conducted a study to find the effectiveness of an education program on radiation oncology patients and family. Information was presented in oral and in written form. After the intervention, orientation program participants did not differ significantly from control group members in state anxiety, general distress, treatment adherence, or knowledge of radiation therapy. Orientation group patients reported greater satisfaction with clinic care, and the orientation group had significant utilization of the psychological counseling services within the clinic, as well as outside support.

Jeff Dunnab,(2004) conducted a study to assess the effectiveness of targeted treatment education for cancer patients to promote adjustment through assisting patients to participate in treatment decision making, comply with treatment regimens and cope more effectively with treatment side effects. Totally 92 patients included in this study, randomized into experimental and control groups. The experimental group patients were given video information about radiation therapy. Pre test post test and follow up design was used. Results showed that there were no significant difference between the control and experimental group. However, patients in the intervention group reported high levels of satisfaction with the video and all reported that they would recommend the video to other patients waiting for radiation therapy. In the experimental group 90% of patients reported that most of the information received through the video was new to them.

C.D.Linde, A.D.Stuart (2002) conducted a study to find the effectiveness of cognitive relaxation-visualization intervention in reducing the anxiety of patients receiving radiation therapy. Totally 88 female patients were taken for this study. The aim of the study was to find the effectiveness of the intervention in two groups. One group (N = 72) waiting for being pre-diagnosis and the other group (N = 16) before beginning radiation therapy treatment. Personal anxiety inventory was used to assess the anxiety. The results indicated that the intervention was effective in reducing anxiety for both the groups. It also concluded that patients had perceived the presence of an empathic individual during the time of diagnosis and before radiation treatment as being of greatest value. Taking interventions to reduce the anxiety before diagnosis and cancer treatment was very important.

Lundberg pranne C.PhD,RN (2001) conducted a study among Buddhist patients with cancer undergoing radiation therapy to assess their feelings, satisfaction and coping with nurse provided education and support before radiation therapy. In this study 90 males and 89 females participated. The results showed that the most common feelings about radiation therapy of both the genders were acceptance and women’s felt more anxiety compared to men. The most common ways of coping with the radiation therapy for both genders were rest, relaxation and communicate with their family or friends. The result showed that the satisfaction of patients with nurse provided education and support was higher among the men. The study concluded that when oncology nurses provide education to radiation therapy patients, it is very important that they should be well known about their patients’ characteristics including their cultural values and religious beliefs.

D’ Haese S, Vinh-Hung (2000) conducted a study to assess the timing of provision of information to reduce anxiety and to improve satisfaction of cancer patients receiving radiation treatment. Two sources of information’s were used (a) a booklet with a stepwise overall description of radiation treatment (b) teaching sheets with all the information about the radiation treatment site. Totally 68 patients were included in this study. They were randomly assigned to simultaneous information group and stepwise information group. Assessments were recorded before the simulation (p=0.02) and more satisfied (p=0.0001). Results showed that information given through a stepwise format leads to less anxiety towards the radiation treatment and patients were satisfied more before the simulation procedure.

D’ haese S, Vinh-Hung (2000) conducted a study to assess the timing of provision of information to reduce anxiety and to improve satisfaction of cancer patients receiving radiation treatment. Two sources of information’s were used (a) a booklet with a stepwise overall description of radiation procedure (b) teaching sheets with all the information about the radiation treatment site. Totally 68 patients were included in this study. They were randomly assigned to simultaneous information group and stepwise information group. Assessments were recorded before the simulation, 2nd week and at the end of radiation treatment. Results showed that information given through a stepwise format leads to less anxiety (p=0.002) and satisfaction (0.00001) towards the radiation treatment before the simulation procedure.

Conclusion

The review of literature enlightened the investigator to develop an insight into the radiation therapy anxiety, orientation program and its effects in the review of literature. Many studies were conducted to reduce the level of pre radiation therapy anxiety, particularly the education before radiation therapy have shown more significant results throughout the entire course of treatment. These reviews helped the investigator to gain a deeper knowledge of the research problem and guided in designing the study.