http://doi.org/10.33698/NRF0179 – Harpreet Kaur, Pragya Pathk, Sukhpal Kaur, F D Patel

Abstract: Apart from being diagnosed with cancer, the unfamiliarity of the environment and uncertainty of the treatment procedure are the major contributors for anxiety in patients undergoing radiotherapy for the first time. Orientation and educational programmes regarding diagnosis and treatment modalities of cancer have been found to reduce anxiety levels among these patients. This study investigates the effect of orientation program on anxiety level of patients undergoing radiotherapy for first time in Nehru hospital, PGIMER, Chandigarh. Using total enumeration sampling technique, 100 patients who met the inclusion criteria were enrolled in the study. These were randomly assigned into intervention and control group by computer generated randomization. In intervention group, orientation programme was used as an intervention for the patients before they underwent radiotherapy. However, in control group routine care was provided. Anxiety was assessed in both the groups, before and immediate after radiotherapy using a 4-point, seventeen items Anxiety assessment scale. As per anxiety scores, the patients were categorized as having no, mild, moderate and severe anxiety level. Results revealed that there was significant reduction of anxiety in both the groups after the subjects underwent radiotherapy. However, it was more marked in intervention group i.e. shifting of subjects from severe and moderate anxiety level towards mild anxiety. Orientation of the procedure is thus recommended for patients undergoing radiotherapy for the first time.

Keywords

Cancer, Anxiety, Radiotherapy, Orientation program.

Correspondence at

Dr Sukhpal Kaur

Lecturer

National Institute of Nursing Education PGIMER, Chandigarh

Introduction

In spite of good advancements in prevention, diagnosis and treatment, cancer is still a big threat to human beings.1,2 It is an enormous global health burden, touching every socioeconomic status.3 This is the second most common disease after cardiovascular disorders for maximum deaths in the world.4 The International Agency for Research on Cancer (IARC) recently estimated that 7.6 million deaths were due to cancer and 12.7 million new cases being reported every year worldwide.1,3 Moreover, the global cancer burden is growing at an alarming pace, about 21.4 million new cancer cases and 13.2 million deaths due to cancer are expected to occur; in 2030.1

With the numerous advancements in treatment modalities of cancer, now it is treated in several ways depending on each individual’s medical condition and type of tumour.5 The common treatment modalities for cancer are radiotherapy, chemotherapy, surgery and hormonal therapy.6 Among all these, radiotherapy contributes towards 40% of curative treatment for cancer.7 Furthermore; approximately 50% of all cancer patients receive radiation therapy during their course of illness either alone or in combination with other treatment modaities.8,9

Despite of the improved health care technology and health care educational strategies, the word cancer still evokes a negative emotional response in people.10 Anxiety is one of the most common psychological responses to the cancer experience.11 Although anxiety levels It has been demonstrated that information provision can reduce anxiety and mood disturbances in cancer patient.16 But while preparing cancer patients for threatening medical treatments such as chemotherapy and radiotherapy, information related to the actual facility, treatment procedure and regarding supportive services can be left out from informational/ educational interventions.17,18,19

Informations are required across the continuum of cancer care for patients and family/carers, but information needs of patients are often not well met. Therefore a possible strategy for optimising information is required. So, this study was planned with the objective to generate research based evidence on effect of orientation program on the anxiety level of patients undergoing first time radiotherapy.

Materials and Methods

Quantitative research approach was employed to evaluate the effect of an ‘orientation programme on the anxiety level of patients undergoing f i rst t ime radiotherapy. A randomised control pre test and post test research design was used. (Table 1)

Groups Before Radiotherapy Intervention After Radiotherapy
Intervention Group O1 X O2
Control Group O1 O2

 

decrease over time after subsequent visits for treatment, but the initial visit of a cancer patient to the oncology centre can be

Table 1: Research Design distressing.12 Factors contributing to this anxiety and distress may include recent cancer diagnosis, uncertainty about treatment, needle phobias, concerns about treatment length, and unfamiliarity with the environment and care providers.13 The distressing symptoms of anxiety can impede the patient’s ability to perform daily household tasks and enjoy meals, which indirectly reduce their quality of life.14,15

O1    –                  Assessment of anxiety before radiation therapy in intervention and control group.

O2    –                  Assessment of anxiety after radiation therapy in intervention and control group.

X       –                  Information through orientation program in form of booklet to intervention group

The research hypothesis formulated was orientation programme has significant role in reducing the anxiety of patients undergoing first time radiotherapy at 0.05 level of significance. The study was conducted in radiotherapy unit of Nehru hospital, PGIMER, Chandigarh where around 30 patients with various diagnoses undergo radiotherapy daily. Using total enumeration sampling technique study included 100 subjects based on inclusion and exclusion criteria. 50 subjects each were allocated randomly to intervention group and control group by using computer generated randomization method.

The inclusion Criteria was, the patients above18 years of age, undergoing first time radiotherapy, available during the period of data collection and who can read English/ Punjabi/ Hindi. However the subjects who refused to participate in the study and undergoing single fraction of radiotherapy were excluded from the study.

An orientation programme was developed after reviewing the relevant literature from books, national and international journals, consulting with experts in the field of nursing & radiotherapy. It consisted of orienting the patients regarding radiotherapy department, general treatment plan of radiotherapy, procedure of radiotherapy, common side-effects and ways to manage those side effects and nutrition during radiotherapy. The information was delivered by using visual aids such as booklet and a power point presentation. The patients were approached individually and it took 30-35 minutes. The booklet was available in three languages -English, Hindi and Punjabi. The information and teaching about orientation programme was given by the researcher herself. After the orientation programme, the 12-page booklet was given to each patient of intervention group for self study.

Anxiety was measured by using Anxiety assessment scale which was developed by researcher and validated by the experts from department of radiotherapy and nursing. The scale contains 17 positive statements. Each statement is rated on 4 point scale. The maximum attainable score on the scale was A response “not at all” scored 0; “mildly but it doesn’t bother me much” scored 1; “moderately but it is tolerable” scored 2; and “severely it bothers me a lot” scored 3. Total score was further categorized into: No anxiety = 0, Mild anxiety = 1-17, Moderate anxiety = 18-34, Severe anxiety = 35-51. The inter-rater method was used to establish the reliability of tool. Cohn’s kappa test was applied for same. Tool was found to be highly reliable (r = 0.90).

Data was collected in the months of August and September 2013. Radiotherapy staff was informed regarding the study. Every day the investigator contacted the radiation technician and the staff in the radiotherapy department to know the number of cases planned for radiation therapy. Based on the information, patients were approached and selected according to the criteria for sample selection. The identified patients who met the inclusion criteria were enrolled in the study. Written informed consent was obtained from study subjects. Patients were randomly allocated into intervention and control group using computer generated randomization method.Patient identification data, socio- demographic data and clinical profile was collected from the subjects, close relatives and from O.P.D. cards.Preliminary assessment of patient’s anxiety level was done by using anxiety assessment scale, prior to undergoing radiotherapy in both groups. In intervention group, orientation programme was used as part of intervention before undergoing radiotherapy whereas in control group routine care was provided. Level of anxiety was reassessed in both the groups, immediately after the radiotherapy. Information gathered was coded and analyzed by using descriptive and inferential statistics and presented through tables and figures.

Results

As per the socio demographic data the mean age of the subjects in intervention and control group was 53.70±10.87 and 52.68± 10.79 years respectively. The range varied from 32-75 years in both the groups. Two third of study subjects (66%) in intervention group and 56% in control groups were male. Furthermore, 82% and 72% of subjects from intervention and control group respectively were from rural habitat. Half of study subjects in intervention group and 56% in control group were unemployed. More than half of subjects (60%) in intervention group and 66% in control group respectively have educational status up to primary level. Half of subjects in intervention group and 64% in control group were having family income of Rs. 5000/month and 48% and 40% of subjects from intervention and control group respectively were from per capita income of more than Rs.1000/month.Both the groups were comparable as per age, gender, habitat, occupation, education, family and per capita incomeas per chi square test (p >0.05). (Table2)

Comparison of mean anxiety scores of the subjects

Table 3 illustrates comparison of mean anxiety scores between intervention and control group before and after the radiotherapy. Results revealed that after radiotherapy anxiety was significantly (p<0.001)reduced in both groups. But it was more evident in intervention group where mean anxiety scores (11.36±3.02) was significantly reduced than control group (18.88±4.78) after intervention as per independent t test. Before radiotherapy both groups were homogenous in terms of anxiety mean scores as per the independent t-test. (p = >0.05). (Table 3)

Level of anxiety before the intervention in both the groups

Table 4 depicts that most of study subjects were in moderate anxiety level i.e 82% and 86% in intervention and control group respectively. There was no statistically significant difference (p = 0.99) in level of anxiety i.e. both the groups were homogenous in terms of level of anxiety prior to intervention. After intervention there was statistically significant difference (p =<0.001) and clear shift in level of anxiety from moderate and severe anxiety towards mild anxiety level in both the groups. But the shift is more evident in intervention group. (table 4)

Table2: Socio-demographic profile of the subjects

N=100

Demographic Parameters Intervention group n1 (%) Control group n2 (%) c2, df, p
Age (Years)*
31-45 13 (26.0) 12(24.0) 0.72, 2, 0.69
46-60 23 (46.0) 27(54.0)
61-75 14 (28.0) 11 (22.0)
Sex
Male 33 (66.0) 28(56.0) 1.05, 1, 0.30
Female 17(34.0) 22(44.0)
Habitat
Rural 41 (82.0) 36 (72.0) 1.41, 1, 0.23
Urban 09 (18.0) 14 (28.0)
Occupation
Professional/skilled 04 (08.0) 04 (08.0) 0.40, 3, 0.94
Agricultural/clerical/shopkeeper 15 (30.0) 13 (26.0)
Labourer 06 (12.0) 05 (10.0)
Unemployed 25 (50.0) 28 (56.0)
Education
Primary 30 (60.0) 33 (66.0) 0.53 , 3, 0.91
Secondary 09 (18.0) 07 (14.0)
Senior secondary 04 (08.0) 03 (06.0)
Graduate and above 07 (14.0) 07 (14.0)
Total family income (Rs.)**
≤5000 25 (50.0) 32 (64.0) 4.06, 3, 0.25
5001-10000 14 (28.0) 08 (16.0)
10001-15000 05 (10.0) 02 (04.0)
>15000 06 (12.0) 08 (16.0)
Per capita income (Rs.)***
≤500 11 (22.0) 11 (22.0) 0.834, 2, 0.65
501-1000 15 (30.0) 19 (38.0)
>1000 24 (48.0) 20 (40.0)

* Mean ± SD = 53.70 ± 10.87years(intervention group), 52.68 ± 10.79years (control group); Range (32-75)years

** Mean ± SD = Rs. 8124.0 ± 8026, Range (Rs. 1200-45000)

*** Mean ± SD = Rs. 1866.97± 2255, Range (Rs. 240-12500)

Table 3: Comparison of mean anxiety scores of the subjects

N=100

Anxiety scores Intervention group Mean ± SD

n1 (%)

Control group Mean ± SD

n2 (%)

Independent test t, df, p
Pre – intervention 25.24 ± 6.06 25.60 ± 5.67 0.30, 98, 0.76
Post -intervention 11.36 ± 3.029 18.88 ± 4.78 9.39, 98, 0.0001*
Paired t test t, df, p 22.06, 49, 0.0001* 16.46, 49, 0.0001*

 

 

*p<0.001, statistically significant

Table 4: Level of anxiety before the intervention in both the groups

N=100

Anxiety level Intervention group n (%) Control group n (%) c2, df, p
Before intervention Mild anxiety Moderate anxiety Severe anxiety  

05 (10.0)

41 (82.0)

04 (08.0)

 

04 (08.0)

43 (86.0)

03 (06.0)

 

0.01#, 2, 0.99

After intervention Mild anxiety Moderate anxiety  

48 (96.0)

02 (04.0)

 

19 (38.0)

31 (62.0)

 

38.04, 1,

0.0001*

# Yates’ corrected c2 value

Discussion

Anxiety and fear are the most common emotions provoked after being diagnosed with a life-threatening illness such as cancer. These emotions may be associated with the diagnosis of cancer or with its treatment outcomes. During the course of cancer treatment, about two-thirds of patients undergo radiation therapy either as curative or palliative care. Anxiety is one of the most common emotional responses to cancer treatment by the patients.

There are different interventions such as hypnotherapy20, meditation21, guided imagery22, orientation programme23,24 and music therapy25,26 which are helpful in reducing anxiety of patients. Among all these, orientation programme is the only intervention which orients the cancer patient throughout the continuum of care. But the evidences related to effect of orientation programs on reduction of anxiety in cancer patients are low. So, the present study was selected in order to generate research based evidence on effect of orientation programme on anxiety level of cancer patients. Hundred patients undergoing first time radiotherapy were included in the present study whereas in a study conducted by Raymond Chan et al, patients undergoing chemotherapy and/or radiation therapy for the first time were included.23

Previous research studies had demonstrated that information provision and orientation to treatment can reduce anxiety in cancer patients.16 Information may reduce anxiety by enhancing patient’s sense of control. An enhanced sense of control, in turn, relieves anxiety and helps in management of illness.19 Meredith et al also reported in their study that cancer patients wanted detailed information on treatment. So, the need for being informed exists across the continuum of cancer care.27 Similar findings were found in present study in which the anxiety level of intervention group was significantly reduced from 25.24 to 11.36 after orientation programme. (p<0.0001)

Total enumeration sampling technique was used by researcher in the present study due to time constraints and for adequate sample size which was consistent with sampling technique adopted by Raymond Chan et al in their study23. In the present study random allocation of study subjects in intervention and control was done by computer generated random number table method whereas blocked randomisation method with a block size of four for random allocation of study subjects was used in another similar study.23

The outcome measure to assess the level of anxiety and evaluate the effectiveness of orientation programme used in present study was a 4-point anxiety assessment Chan and McQuellon documented the use of strait trait anxiety inventory.23,29

In the present study, patient’s anxiety level was measured before and immediate after the radiotherapy only. Harrison etal28 measured general anxiety of patients on the first and last day of treatment, and 6weeks after radiotherapy. In their trial, Raymond Chan et al measured patients’ anxiety three times i.e. at the time of recruitment (T1), on the day of first treatment (T2), and on the seventh day of treatment (T3).23

In the present study, orientation programme was provided to the intervention group in the form of booklet along with verbal instructions before radiotherapy which was consistent with the interventions used by Mohide et al(1996)12, McQuellon et al (1998)29 Hoff and Haaga (2005)30, in their studies.In terms of delivery of orientation programme, face to face interaction was used by the researcher which was similar in studies conducted by McQuellon et al (1998)29 Hoff and Haaga in (2005)30

Although radiotherapy is aimed at providing curative and palliative care but it has a strong negative impact on cancer patients’ i.e. physical side effects and anxiety due to unfamiliar environment. Addressing these problems, the components of orientation programme in the present study comprised of orientation to O.P.D, radiotherapy department and procedure, general treatment plan, common side effects of radiotherapy, ways to manage those side- effects and nutrition during radiotherapy. Raymond Chan et al (2009)23, McQuellon et al scale. Harrison et. al28 in their study used the (1998)29 Hoff and Haaga (2005)30 in their anxiety subscale of the Hospital Anxiety and Depression Scale to measure the general anxiety of patients. Other trials by Raymond studies had included information about the health care team, a clinic tour, information about the actual facility (e.g. map, parking and opening hours), description of clinical procedures, information about supportive services available in the cancer centre and provided by external organisations followed by a question and answer session.

The content of orientation programme in the present study was delivered by the researcher herself whereas Hoff and Haaga (2005)30 appointed oncology nurses who worked in the oncology department to deliver the program and McQuellon et al (1998)29 had taken the help of an oncology counsellor. Anxiety assessment scale was used to collect data of patient’s anxiety before and immediately after the radiotherapy. Both the groups were comparable based on their demographic characteristics. The mean age of subjects in control and intervention group was 53.19 ± 10.87 and 52.68 ± 10.79 and the range varied from 32– 75 years in both the groups. Harrison etal28 in 2001 had used videotape for providing information of radiotherapy in which the mean age of study subjects was 66 years. Majority of the subjects were male in both the groups in the present study. Similar findings were seen in the study.

Research hypothesis i.e orientation programme has significant role in reducing the anxiety of patients undergoing first time radiotherapy at 0.05 level of significance was accepted. As the findings of the present study revealed that there was significant reduction of anxiety in both the groups after radiotherapy. Reduction in control group anxiety might be attributed to the experience they gained during radiotherapy. However, reduction in anxiety level was more marked i.e. shifting of subjects from severe and moderate anxiety level towards mild anxiety in intervention group.

Findings of the present study demonstrated that anxiety level was reduced in patients after orientation programme which were consistent with the findings of randomized control trial conducted by Raymond Chan et al (2009)23 and McQuellon et al (1998)29.

The focus of the present study was only on one variable i.e. anxiety to assess the effectiveness of orientation programme. Future trials are required to test interventions focussing on other important outcomes such as knowledge acquisition, retention of information, ability to recall information, satisfaction level and quality of life. Measurement at longer time points beyond treatment (e.g. 1 month, 6 months and 12 months) can be included in future trials.

Anxiety is a common psychological problem among patients undergoing radiotherapy for first time and certain interventions could prove useful in reducing the anxiety. It seems logical to orient the cancer patients regarding treatment facilities and what they may expect during the first visit.

Patients were anxious before undergoing radiotherapy for the first time. This unpleasant feeling of anxiety may be linked with unfamiliar environment, less knowledge regarding treatment procedure, side-effects and their management. The result of this randomized trial demonstrated that there was significant reduction of anxiety in both the groups after undergoing radiotherapy. However, it was more marked i.e. shifting of subjects from severe and moderate anxiety level towards mild anxiety, in intervention group after orientation programme. Present research study provides empirical evidence that orientation programme is helpful in reducing the anxiety of  patients undergoing f i rst t ime radiotherapy. So, Orientation programme before radiotherapy must be included in the routine practice in radiotherapy unit and booklets for orientating the cancer patients to radiotherapy must be provided in OPDs and oncology wards.

References

  1. Ali I, Waseem A, Wani, Saleem Cancer Scenario in India with Future Perspectives. Cancer Therapy. 2011; 8(1):56.
  2. Kotnis A, Sarin R, Mulherkar R .Genotype, phenotype and cancer: Role of low penetrance genes and environment in tumour susceptibility.JBiosci. 2005; 30(1):93.
  1. American cancer society [homepage on the internet].Cancer Facts & Atlanta The Society; 2012 [updated 2013; cited 2013 Feb 17]. Available from http://www.cancer.org/.
  2. Jemal A, Bray F, Melissa M. Global cancer Cancer j clin. 2011;61:69-75
  3. Baskar R, Lee KA, Yeo R, Yeoh Cancer and Radiation Therapy: Current Advances and Future Directions. Int J Med Sci 2012; 9(3):193-99.
  4. Treatment modalities – VCU Massey Cancer Center.[online] [cited 2013 Nov 23]. Available from: http://www.massey.vcu.edu/ treatment-modalities.htm.
  5. Barnett GC, West CM, Dunning AM, Elliott RM, Coles CE, Pharoah PD al. Normal tissue reactions to radiotherapy: towards tailoring treatment dose by genotype. Nat Rev Cancer. 2009; 9:134-42.
  6. Delaney G, Jacob S, Featherstone C, Barton The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer. 2005; 104: 1129-37.
  7. Begg AC, Stewart FA, Vens Strategies to improve radiotherapy with targeted drugs. Nat Rev Cancer. 2011; 11: 239-53.
  8. Allen, Kim S. The Effect of Cancer Diagnosis Information on the Anxiety of Patients with an Initial Diagnosis of First Master’s Thesis [serial on internet]. 1997[cited 2013 feb 12]:308. Available from: http://scholarworks.gvsu.edu/ theses/308.
  9. Mock , Dow KH, Meares CJ, Grimm PM., Dienemann JA, Haisfield-Wolfe ME et al. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncology Nursing Forum.(1997); 24(6):991–1000
  10. Mohide E, WhelanT, Rath D, Gafni A, Willan A, Czukar A randomised trial of two information packages distributed to new cancer patients before their initial appointment at a regional cancer centre. British Journal of Cancer.1996;73:1588-93.
  11. Carelle N, Piotto E, Bellanger A, Germanaud J, Thuillier A, Khayat Changing patients perceptions of the side effects of cancer chemotherapy. Cancer .2002; 104:155- 63.
  12. Chakraburtty A. Anxiety and Cancer [online]2011 mar[cited on 2013 Apr 15]. Available from: http://www.webmd.com/ anxiety-panic/ anxiety-in-cancer-patients? page=2.
  13. Brown LK. Does Yoga Aid in the Reduction of Short-Term Anxiety in Adult Female Breast Cancer Patients. PCOM. 2012 Dec; Paper
  14. Mills ME, Sullivan The importance of information giving for patients newly diagnosed with cancer: a review of the literature. Journal of Clinical Nursing.1999;8 (6):631-42.
  15. Dunn J, Steginga SK, Rose P, Scott J, Allison Evaluating patient education materials about radiation therapy in patient education and counseling.2004;8:325-32
  16. Schofield P, Jefford M, Carey M, Thomson K, Evans M, Baravelli C, et Preparing patients for threatening medical treatments: effects of a chemotherapy educational DVD on anxiety, unmet needs, and self-efficacy. Supportive Care in Cancer. 2008; 16 (1):37-45.
  17. Chelf J, Agre P, Axelrod A, Cheney L, Cole D, Conrad K: Cancer related patient education: An overview of the last decade of evaluation and research. Oncology Nursing 2001; 28:1139-47.
  18. Stalpers LJ, da-Costa HC, Merbis MA, Fortuin AA, Muller MJ, Van-Dam Hypnotherapy in radiotherapy patients: a randomized trial. Int J RadiatOncolBiol Phys. 2005 Feb1;61(2):499-506.
  19. Kim YH, Kim HJ, Ahn SD, Seo YJ, Kim Effects of meditation on anxiety, depression, fatigue, and quality of life of women undergoing radiation therapy for breast cancer. Complement Ther Med. 2013 Aug; 21(4):379- 87.
  20. Nunes DF, Rodriguez AL, da-Silva HF, Luz C, Braga AP, Muller MC, al. Relaxation and guided imagery program in patients with breast cancer undergoing radiotherapy is not associated with neuroimmunomodulatory effects. J Psychosom Res. 2007 Dec; 63(6):647-55.
  21. Raymond C, Joana W, Linda B. Effects and feasibility of a multi-disciplinary orientation program for newly registered cancer patients: design of a randomised controlled BMC Health Services Research .2009; 9: 203.
  1. Deshler A, Fee-Schroeder K, Dowdy J, Mettler T, Novotny P, Zhao X, al. A patient orientation program at a comprehensive cancer centre.Oncology Nursing Forum.2006;33(3): 569-78.
  2. Chen LC, Wang TF, Shih YN, Wu Fifteen-minute music intervention reduces pre- radiotherapy anxiety in oncology patients. Eur J OncolNurs. 2013 Aug; 17(4):436-41.
  3. O’Callaghan C, Sproston M, Wilkinson K, Willis D, Milner A, Grocke D, al. Effect of self-selected music on adults’ anxiety and subjective experiences during initial radiotherapy treatment: a randomised controlled trial and qualitative research. J Med Imaging Radiat Oncol.2012 Aug; 56(4):473-7.
  4. Meredith C, Symonds P, Webster L, Lamont D et al (1996) Information needs for cancer patients in West Scotland: cross sectional surveys of patients’ views.BMJ313: 724–6
  5. Harrison, P Dey, NJ Slevin, A Eardley, A Gibbs, R Cowan.et.al.Randomized controlled trial to assess the effectiveness of a videotape about British Journal of Cancer 2001; 84(1): 8–10.
  6. McQuellon R, Wells M, Hoffman S, Craven B, Russell G, Cruz J, al. Reducing distress in cancer patients with an orientation program. Psycho-oncology.1998; 7: 207-17.
  7. C Hoff A, Haaga Effects of an education program on radiation oncology patients and families. J PsychosocOncol. 2005; 23(4):61-79.