Strategies for Patient Comfort, Position Holding, and Compliance During Radiotherapy Treatments

Patient comfort and calm play an important role in effective position holding and compliance with treatment plans in radiation oncology. Patients must remain still in sometimes unnatural and uncomfortable body positions. Discomfort and anxiety can reduce position-holds and disrupt treatment.

Fixation devices, supports, and restraints all help maintain planned patient positions for precise delivery of radiation to target volumes while minimizing irradiation of healthy, nontarget tissues; however, patient compliance with position-holding remains an important component of successful treatment. But surprisingly little clinical research has been undertaken to identify effective patient comfort strategies specifically in radiotherapy settings. The relevant evidence base remains frustratingly scant.

Identifying effective interventions “is crucial for complex radiotherapy that necessitates more demand and attention to patient comfort to ensure stability for targeted treatment,” a team of researchers stated in a recently published systematic review.¹

To identify which patient comfort strategies might help patients sustain a given position for more than 10 minutes, the researchers initially reviewed 46 studies of a total of 13 different audiovisual, psychological, and physical interventions, as well as patient education and aromatherapy that could be applied in radiation oncology treatment settings to improve patient comfort, ease anxiety, and thereby improve compliance with sustained positioning instructions.¹ The study is a rare systematic review of patient comfort interventions from across clinical disciplines that could be applied to radiotherapy settings.

However, the authors acknowledged that the identified studies had research quality issues that precluded a formal pooling of outcomes data for meta-analysis. Eight randomized clinical trials found to have a high likelihood of selection bias were excluded from the assessment.¹ The strategies reviewed in this analysis included:

• Audiovisual interventions such as music, nature sounds, comedies, quiz shows, and computer games.
• Psychological interventions ranged from guided breathing techniques, cognitive behavioral therapy, and hypnosis to distraction and empathetic attention (eg, verbally expressed empathy and touch).
• Physical interventions included squeeze stress balls, massage, and therapeutic touch.
• Patient education interventionsincluded informational videos, an audio recording about the procedure, and life and multimedia presentations.
• Aromatherapy interventionsincluded lavender, sandalwood, peppermint, and citrus essential oils.

Most interventions did not meet the researchers’ criteria for clinically significant benefits. Many comfort interventions produced statistically significant improvement in patient anxiety but did not demonstrate clinical significance, the researchers noted. However, aromatherapy showed some promise, at least in terms of reducing patient anxiety, and is worthy of additional study.

“The majority of aromatherapy interventions were clinically significant; and they can be potentially considered for radiotherapy [procedures] that require patients to sustain and endure the same position over time.” the researchers concluded.¹

Inhalation aromatherapy during radiotherapy was proposed and studied close to 20 years ago and has been a periodic topic of study across cancer care disciplines.^1,2 “Aromatherapy used in colonoscopy, interventional radiology, and minor surgery demonstrated both statistical and clinical significance and could be used in radiotherapy with careful consideration of applications,” the researchers reported.¹

Contraindications to the use of aromatherapy vaporizing systems include potential for skin irritation, allergies linked to radiation-induced skin toxicity, or vapor damage to radiation therapy equipment. The researchers suggest “a clothing tab infused with aromatherapy oils, found to be favorable in previous clinical trials, may be more appropriate in radiotherapy.” Lavender‐sandalwood aromatherapy tabs were associated with reduced anxiety during image-guided breast biopsy in 87 women.^1,3

Communication skills training for radiation oncology teams has been associated with improved empathetic interactions in a study of 80 radiotherapy healthcare workers.^1,4 Trained team members used more spoken communications and empathetic and emotional words, and more spoken assessment utterances during patient interactions.⁴

Massage during radiotherapy was associated with reduced levels of anxiety, anger, and depression among breast cancer patients in one reviewed study.^1,5 (The authors did not discuss in what radiotherapeutic settings this might be a practical strategy, however.)

Both hypnosis and cognitive behavioral therapy have been shown to reduce patient anxiety during prostate needle biopsy, conscious surgery, and cancer bone marrow procedures and might be useful before or during radiotherapy.^1,6-8

Several audio and audiovisual strategies were also effective and deserve further study as well. But radiotherapy often requires verbal communication between the healthcare team and the patient, such as instructions about the timing of patient breath holds, raising questions about the practicality of therapy-concurrent audiovisual distraction strategies, as opposed to patient education or instruction prior to radiotherapy sessions. Similarly, physical distraction techniques, such as the use of squeezable stress balls, involve patient movement that could be incompatible with sustained position holding and could conceivably cause motion in and around the targeted organs during external beam radiotherapy.¹

Sadly, other clinical settings seem to offer few strong candidates for radiotherapy patient comfort strategies.

References

1. Goldsworthy S, Palmer S, Latour JM, McNair H, Cramp M. A systematic review of effectiveness of interventions applicable to radiotherapy that are administered to improve patient comfort, increase patient compliance, and reduce patient distress or anxiety. Radiography. 2020;26(4):314-324. doi:10.1016/j.radi.2020.03.002
2. Trambert R, Kowalski MO, Wu B, Mehta N, Friedman P. A randomized controlled trial provides evidence to support aromatherapy to minimize anxiety in women undergoing breast biopsy. Worldviews Evid Based Nursing. 2017;14(5):394-402. doi:10.1111/wvn.12229
3. Graham PH, Browne L, Cox H, Graham J. Inhalation aromatherapy during radiotherapy: results of a placebo-controlled double-blind randomized trial. J Clin Oncol. 2003;21(12):2372-2376. doi:1200/JCO.2003.10.126
4. Gibon A, Merckaert I, Lienard A, et al. Is it possible to improve radiotherapy team members’ communication skills? A randomized study assessing the efficacy of a 38-h communication skills training program. Radiother Oncol. 2013;109(1):170-177. doi:10.1016/j.radonc.2013.08.019
5. Schnur J, David D, Kangas M, Green S, Bovbjerg DH, Montgomery GH. A randomized trial of a cognitive-behavioral therapy and hypnosis intervention on positive and negative affect during breast cancer radiotherapy. J Clin Psychol. 2009;65(4):443-455. doi:10.1002/jclp.20559
6. Hizli F, Ozcan O, Selvi I, et al. The effects of hypnotherapy during transrectal ultrasound-guided prostate needle biopsy for pain and anxiety. Int Urol Nephrol. 2015;47(11):1773-1777. doi:10.1007/s11255-015-1111-0
7. Hudson BF, Ogden J, Whiteley MS. Randomized controlled trial to compare the effect of simple distraction interventions on pain and anxiety experienced during conscious surgery. Eur J Pain. 2015;19(10):1447-1455. doi:10.1002/ejp.675
8. Snow A, Dorfman D, Warbet R, et al. A randomized trial of hypnosis for relief of pain and anxiety in adult cancer patients undergoing bone marrow procedures. J Psychosoc Oncol. 2012;30(3):281-293. doi:10.1080/07347332.2012.664261