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156 Journal of Cancer Education, 23:156–160, 2008 Copyright © AACE and EACE ISSN: 0885-8195 print / 1543-0154 online DOI: 10.1080/08858190802039136 HJCE Palliative Radiotherapy Knowledge Among Community Family Physicians and Nurses Survey of Palliative Radiotherapy Knowledge TANYA BERRANG, BS, MD, FRCPC, RAJIV SAMANT, MD, FRCPC Abstract—Background. Primary care physicians and nurses care for patients with advanced cancer and need to be aware of the role for palliative radiotherapy (PR). Methods. We surveyed 250 family physicians, family medicine residents, and nurses attending oncology educational symposia to determine their knowledge of PR. Results. The survey response rate was 59%, and most respon- dents (77%) were involved with the care of cancer patients. Many (58%) thought that their knowledge of PR was insufficient for their needs. Although bone metastasis and spinal cord compression were frequently recognized indications for PR, only 50% of other assessed indications for PR were correctly identified. Almost all respondents stated that they wanted to learn more about PR. Conclusions. More education regarding PR is required for primary care physicians and nurses caring for cancer patients. J Cancer Educ. 2008; 23:156-160. adiotherapy is well recognized as an effective tool to palliate symptoms from advanced cancer. 1–5 It has been shown to successfully alleviate symptoms in 60% to 80% of patients with bone metastases, hemopty- sis, spinal cord compression, superior vena caval obstruc- tion, and brain metastases. 1–4 These problems commonly arise in patients during the palliative phase of illness due to cancer, and treatment is generally simple to administer with few side effects. 5–7 Up to 60% of all cancer patients could derive some benefit from radiotherapy, 8–10 yet only a fraction of this number ultimately receive radiation. 9,11,12 Previous published studies 13–15 have assessed problems associated with referral of patients to cancer centers for pal- liative radiotherapy (PR). A variety of factors have been identified as potential barriers to patient referral including anticipated inconvenience for patients, uncertainty regard- ing benefits and side effects, 13–15 and deficiencies in educa- tion among referring physicians. 13 Cases in which patients could benefit from PR, a basic understanding of how much time is involved, expected side effects, and indications of PR could facilitate referral of patients by community health care workers to a radiation oncologist. 14,15 Symptomatic improvement from PR can be delayed, such as with painful bone metastasis, 2 so misunder- standing the time frame of expected benefit could lead one to incorrectly interpret the treatment as having been inef- fective. Family physicians who are more knowledgeable regarding radiotherapy are more likely to refer patients for this form of treatment. 13 Although most referrals come through physicians, nurses are often involved in the day-to-day care of patients with advanced cancer, whether in patients’ homes, nursing homes, or palliative care facilities. 16–18 Facilitating good communication between physicians and nurses would likely increase referral for PR once an indication was identified by nursing staff. 19 It has previously been shown that knowl- edge and end-of-life care can be improved through pallia- tive care education for both nurses and physicians. 18,20–22 An aging population, more aggressive treatment strate- gies, and longer schedules are likely to increase demands on cancer centers. 23–26 With the continued shift of pallia- tive care from the tertiary cancer center setting to the community at large, 27–30 nurses and family physicians are increasingly going to be the first line for patients requiring end-of-life care. A basic understanding of PR, facilitating recognition of situations in which cancer patients could benefit from referral, would optimize patient access to this type of treatment. As the primary care of patients with advanced cancer requires a multidisciplinary approach, we assessed the PR knowledge of both community physicians and nurses. Received from The Ottawa Regional Cancer Centre, Ottawa, Ontario, Canada and the University of Ottawa, Ottawa, Ontario, Canada (TB, RS). Presented at the Canadian Association of Radiation Oncology (CARO) Annual Conference, Oral Presentation, September 2003, Mont- real, Quebec, Canada. Address correspondence and reprint requests to: Rajiv Samant, Ottawa Regional Cancer Centre, 503 Smyth Road, Ottawa, Ontario, K1H 1C4, Canada; phone: (613) 737-8899, ext 70212; fax: (613) 247-3511; e-mail: <[email protected]>. R

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156

Journal of Cancer Education, 23:156–160, 2008Copyright © AACE and EACEISSN: 0885-8195 print / 1543-0154 onlineDOI: 10.1080/08858190802039136

HJCE

Palliative Radiotherapy Knowledge Among Community Family Physicians and Nurses

Survey of Palliative Radiotherapy Knowledge TANYA BERRANG, BS, MD, FRCPC, RAJIV SAMANT, MD, FRCPC

Abstract—Background. Primary care physicians and nurses care for patients with advanced cancerand need to be aware of the role for palliative radiotherapy (PR). Methods. We surveyed 250 familyphysicians, family medicine residents, and nurses attending oncology educational symposia todetermine their knowledge of PR. Results. The survey response rate was 59%, and most respon-dents (77%) were involved with the care of cancer patients. Many (58%) thought that theirknowledge of PR was insufficient for their needs. Although bone metastasis and spinal cordcompression were frequently recognized indications for PR, only 50% of other assessed indicationsfor PR were correctly identified. Almost all respondents stated that they wanted to learn moreabout PR. Conclusions. More education regarding PR is required for primary care physicians andnurses caring for cancer patients. J Cancer Educ. 2008; 23:156-160.

adiotherapy is well recognized as an effective toolto palliate symptoms from advanced cancer.1–5 Ithas been shown to successfully alleviate symptoms

in 60% to 80% of patients with bone metastases, hemopty-sis, spinal cord compression, superior vena caval obstruc-tion, and brain metastases.1–4 These problems commonlyarise in patients during the palliative phase of illness due tocancer, and treatment is generally simple to administerwith few side effects.5–7 Up to 60% of all cancer patientscould derive some benefit from radiotherapy,8–10 yet only afraction of this number ultimately receive radiation.9,11,12

Previous published studies13–15 have assessed problemsassociated with referral of patients to cancer centers for pal-liative radiotherapy (PR). A variety of factors have beenidentified as potential barriers to patient referral includinganticipated inconvenience for patients, uncertainty regard-ing benefits and side effects,13–15 and deficiencies in educa-tion among referring physicians.13

Cases in which patients could benefit from PR, a basicunderstanding of how much time is involved, expected sideeffects, and indications of PR could facilitate referral of

patients by community health care workers to a radiationoncologist.14,15 Symptomatic improvement from PR can bedelayed, such as with painful bone metastasis,2 so misunder-standing the time frame of expected benefit could lead oneto incorrectly interpret the treatment as having been inef-fective. Family physicians who are more knowledgeableregarding radiotherapy are more likely to refer patients forthis form of treatment.13

Although most referrals come through physicians, nursesare often involved in the day-to-day care of patients withadvanced cancer, whether in patients’ homes, nursinghomes, or palliative care facilities.16–18 Facilitating goodcommunication between physicians and nurses would likelyincrease referral for PR once an indication was identified bynursing staff.19 It has previously been shown that knowl-edge and end-of-life care can be improved through pallia-tive care education for both nurses and physicians.18,20–22

An aging population, more aggressive treatment strate-gies, and longer schedules are likely to increase demandson cancer centers.23–26 With the continued shift of pallia-tive care from the tertiary cancer center setting to thecommunity at large,27–30 nurses and family physicians areincreasingly going to be the first line for patients requiringend-of-life care. A basic understanding of PR, facilitatingrecognition of situations in which cancer patients couldbenefit from referral, would optimize patient access to thistype of treatment. As the primary care of patients withadvanced cancer requires a multidisciplinary approach, weassessed the PR knowledge of both community physiciansand nurses.

Received from The Ottawa Regional Cancer Centre, Ottawa, Ontario,Canada and the University of Ottawa, Ottawa, Ontario, Canada (TB, RS).

Presented at the Canadian Association of Radiation Oncology(CARO) Annual Conference, Oral Presentation, September 2003, Mont-real, Quebec, Canada.

Address correspondence and reprint requests to: Rajiv Samant, OttawaRegional Cancer Centre, 503 Smyth Road, Ottawa, Ontario, K1H 1C4,Canada; phone: (613) 737-8899, ext 70212; fax: (613) 247-3511; e-mail:<[email protected]>.

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Journal of Cancer Education 2008, Volume 23, Number 3 157

METHODS

A survey to assess knowledge of PR among family physi-cians and nurses was designed by radiation oncologistsworking at a regional Canadian cancer center, and ethicsapproval was obtained prior to distributing the survey. Thesurvey was administered at 3 separate continuing educationevents in Ottawa, Ontario, Canada during the 2003 aca-demic year. Each of these events had a component ofoncology-related education. The surveys were solicitedfrom event attendees who were asked to voluntarily fill outa 2-page questionnaire. Questions included demographics(career, age, and gender), self-assessment of PR knowledge,and 20 multiple-choice questions regarding general radia-tion knowledge (common side effects, indications for, andexpected outcomes of PR). Response rate was determinedbased on a ratio of collected surveys to overall number ofattendees at the conference. The completed surveys werecollected and responses collated in an SPSS Inc. (Chicago,IL) database. Analysis was performed using SPSS to deter-mine the pattern of responses among the family physicians,family medicine residents, and nurses as well as the overallscore for the respondents. Overall scores were based on thenumber of correctly answered questions out of a potentialtotal of 20. Analysis of variance and least significant differ-ence (LSD) post hoc comparison tests were used to analyzevariance and compare means between group scores (nurses,residents, and physicians).

RESULTS

Of approximately 250 physician and nursing partici-pants, 147 surveys were completed and returned for aresponse rate was 59%. A total of 70 surveys were by nurses,36 by family physicians, and 41 by family medicine resi-dents. Surveys completed by other health care professionalsincluding pharmacists, medical students, specialist physi-cians, social workers, etc (33 in total) were excluded fromthe analysis due to their diversity and limited numbers. Theprofiles of the respondents analyzed are shown in Table 1.The average age of respondents was 41 years, with 77%being female. Overall, 77% of respondents were involved inthe care of cancer patients. In the self-assessment, family

medicine residents were less confident regarding how muchthey knew about the benefits of radiotherapy, with 76%reporting that they knew “very little”; this compares to 56%for family physicians and 49% for nurses. A majority (92%)of respondents were interested in learning more about PR.

The number of all cancer patients that could potentiallybenefit from radiotherapy was correctly identified as being41% to 80% by 67% of respondents, underestimated by 26%and overestimated by 7%. Most of those surveyed correctlyindicated that radiotherapy is usually given daily (69%)rather than weekly (29%) or monthly (1%). Most correctlyindicated that a typical radiotherapy treatment takes severalminutes (70%) rather then several hours (4%), several days(23%), or several seconds (3%). The side effects of PR wereconsidered to be moderate by 23%, mild by 73%, and noneby 4% of respondents. There was little variation in responsesbetween groups with respect to the specific side effects ofPR; overall results are shown in Table 2.

Bone metastasis and spinal cord compression were recog-nized indications for PR by approximately 90% of respon-dents. Fewer than 50% of respondents, however, identifiedhemoptysis or brain metastasis as symptoms that couldderive benefit from PR (Figure 1). Over 50% of respondentsincorrectly identified hypercalcemia, diffuse liver metasta-sis, diffuse lung metastasis, and febrile neutropenia asindications for PR (Figure 2). The time required to see sig-nificant improvement in pain for most patients after PR forsymptomatic bone metastasis was underestimated by 47% ofrespondents. The family physicians scored significantlyhigher (mean total score 68%) than either nurses (60%) orresidents (60%). LSD post hoc comparison tests confirmedthat the largest differences between groups were betweenphysicians and nurses (P=.005) and physicians and resi-dents (P=.039).

DISCUSSION

This survey provides a preliminary analysis of PR knowl-edge among community health care professionals, specifi-cally, family physicians and nurses. The 59% response rateamong respondents is a limitation of the study, but we weresatisfied with this because it is comparable to other surveysin the published literature.31,32 It is our belief that the

TABLE 1. Respondent Demographics and Self-Assessment

Family Physicians*

Family Medicine Residents† Nurses‡

Median age, y (range) 45 (30–55) 27 (25–50) 48 (23–60)Female (%) 56 59 99Involved with care of cancer patients? % Yes 94 59 76Knowledge of PR adequate for needs? %Yes 50 29 46Would you like to learn more about PR? %Yes 97 83 96

*N=36.†N=41.‡N=70.

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158 BERRANG, SAMANT ■ Survey of Palliative Radiotherapy Knowledge

results probably do reflect the situation in our regionbecause some of the findings have been previously docu-mented in our region.33

Although a majority of respondents had an accurategeneral understanding of PR, there was considerable uncer-tainty in identifying the appropriate indications for PR.Previous surveys have looked at specific indications butoften included only “true” indications as options.14,15 Inac-curate identification of symptoms that do not benefit fromPR suggests that respondents may be “checking” all options;this would indicate that the level of understanding for truePR indications might be overestimated. The reporting offalse indications as well as the high percentage of people

reporting “Depends” to questions (Table 2) indicates over-all lack of clarity regarding PR. This represents a significantopportunity for increased education and likely shouldinclude many groups of health care professionals and not belimited just to physicians and nurses who were the primaryfocus for this study.

As the survey was conducted at voluntary educationevents with a component of oncology, the results could besubject to a selection bias. Specifically, the level of priorknowledge about PR in the survey population may be apotential source of bias and could limit the ability to gener-alize our findings. Respondents were selected from eventswith oncology-related educational components and maythus represent a group with increased interest and previousknowledge in the area of oncology. This effect could resultin an overestimation of PR knowledge among primary care

TABLE 2. Side-Effects of Palliative Radiotherapy (All Groups Combined)*

Survey Question % No % Yes % Depends % Unsure

Is radiotherpay itself painful? 76 4 13 7Does PR usually cause nausea or vomitting? 38 15 40 7Does PR usualy cause hair loss? 48 7 40 5Are patients receiving PR usually significantly

immunocompromised or at very high risk of infection?46 15 21 18

Do patients usually become radioactive after PR? 74 12 5 9

*PR indicates palliative radiotherapy.

FIGURE 1. Indications for palliative radiotherapy: Percentof responents correctly answering “YES.”

0

10

20

30

40

50

60

70

80

90

100

Bone M

ets

Brian M

ets

SVCO

Spina

l Cor

d Com

pres

sion

Hemop

tysis

Resident Physician Nurse

FIGURE 2. Incorrect indications for palliative radiotherapy:Percent of respondents incorrectly answering “YES.”

0

10

20

30

40

50

60

70

80

Hyper

calce

mia

Diffus

e Liv

er M

etsDiff

use L

ung M

etsFeb

rile N

eutro

peni

a

Resident Physician Nurse

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Journal of Cancer Education 2008, Volume 23, Number 3 159

physicians and nurses. Conversely, one could argue that theparticipants might have had very little prior knowledge ofPR (perhaps less than average) and were attending the edu-cation events in part to rectify this deficiency.

Most respondents reported their knowledge regardingPR to be inadequate for their needs and reported a desirefor more education in this area. Statistics in the Ottawaregion indicate that radiotherapy is underutilized,12,34 andour results suggest that inadequate knowledge of PR may bea contributing factor. Although the absolute number ofhealth care professionals in our region willing to attendadditional training is uncertain, the results of our survey doindicate potential receptiveness to educational programs orawareness campaigns regarding PR.

With the changing landscape of medicine, end-of-lifecare is shifting from specialized cancer centers to the com-munity at large.28–30 Both primary care nurses and familyphysicians are caring for most patients with advanced can-cer,14–18,27 and referral for radiotherapy is made when it isconsidered to be required. Health care professionals makingreferrals can benefit from knowledge of effective optionsfor the treatment of oncologic symptoms.13,19 Althoughadditional training is now available to those wishing tospecialize in palliative care, most physicians and nurses car-ing for patients with cancer do not have this additionaltraining.16,18,35–39 Community educational events are 1resource for front line health care workers, but these areinfrequent sessions, attended by only a fraction of thoseinvolved in direct patient care.

Community health care professions are very busy andhave very real time constraints and other commitmentsthat demand their attention. Also, with medical knowl-edge expanding at a rapid pace, they have limited time toallocate to ongoing education, especially in very uniqueareas such as radiotherapy. No doubt, there are manyother areas in which better knowledge would be useful forthem. Therefore, as has been mentioned elsewhere,19,27

innovative ways of education and medical support needto be developed to provide the necessary basic informa-tion to those health care professionals caring for patientswith advanced cancer at the community level withoutrequiring excessive amounts of time commitment ortraining.

In closing, inadequate knowledge of PR will limit its use,and for symptomatic patients with cancer, an underutiliza-tion of radiation therapy does not provide optimal care. Webelieve our study highlights an information gap in PRknowledge and an opportunity for research and medicaleducation to develop programs aimed at improving aware-ness and ultimately patient care.

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