Oncological Patient Anxiety in Imaging Studies: the PET/CT Example

The present study provided detailed understanding of the anxiety levels during a PET/CT scan. Our results indicate that cancer patients experience anxiety during the PET/CT scan. Anxiety levels were higher prior to the scan (6.4 ± 2.7), probably reflecting initial anxiety related to the scan procedure and environment. Post scan anxiety levels were significantly lower (5.7 ± 2.6), suggesting that a considerable part of the anxiety felt by the patient is related with the imaging procedure itself. Lledó et al. [10], in a research with patients that underwent conventional NM scans, obtained a perception of anxiety result of 4.3 while the procedure was being carried out. The average levels of anxiety in our study are clearly higher than those found by Lledó et al. [10], whether before or after the scan. This difference may be related with the inclusion criteria of both studies: in our study only oncological patients were included whereas in Lledó et al. [10] patients were randomly included from all the NM procedures, suggesting that oncological patients are exposed to higher levels of anxiety. In fact, our results are in accordance with the literature [11], showing that the majority of the patients performed the PET/CT scan for initial staging of an oncological disease and, for the remaining patients, the reasons for performing the PECT/CT scan were directly related with the progression of the disease. In both cases, the outcome of the scan will provide information regarding the disease and so, anxiety appears as a response to the uncertainty towards this result [1, 2]. Additionally, the anxiety results are above the midpoint on the Likert scale and, therefore, should not be disregarded as it is known that high anxiety levels affect ¹⁸F-FDG biodistribution (e.g. uptake of ¹⁸F-FDG in muscles or brown adipose tissue), interfering with the accurate results of the PET/CT. Also, considering that muscular tension associated with anxiety can cause pain and discomfort in a scan like PET/CT [12], it is important to emphasise anxiety as a relevant factor for patient safety.

Despite being the first PET/CT for 71.1 % of the subjects, we found no statistically significant differences in the subjective perception of anxiety between these patients and those who had already undergone PET/CT previously. Previous research has demonstrated that even patients who had undergone PET/CT previously also experience high levels of anxiety, which was thought to be related with an anticipatory effect regarding its possible negative result [2]. Further, the anxiety levels of patients who underwent PET/CT for the first time could be related to the lack of knowledge about the procedure, possible side effects and its result [2]. With reference to the reason behind performing the scan, it was established that the majority of the patients’ scans were carried out in the context of initial staging of an oncology disease. Considering that almost two thirds of the patients in our study performed the scan for their first time, a possible justification for the high pre-procedure anxiety levels is the fear of the unknown regarding the procedure and the effects of radiation. Although the levels of anxiety decrease post-procedure, these should not be ignored.

Although almost 20 % of patients included in our study reported not receiving any information before the procedure, the information provided by the professionals was felt to be adequate (7.3 ± 2.2). This seems to be an unusual result since the patient’s lack of understanding of a PET/CT with ¹⁸F-FDG and conventional NM is a recurring theme in literature. According to Nightingale et al. [13], during the administration of a cardiac SPECT/CT, some patients at the NM department appeared to have an incomplete understanding of the procedures, some of which seemed surprised during the explanation of such procedures. The lack of understanding in relation to the scan was also previously identified by Groves et al. [14], who noticed patients were astounded by the complexity of the scan and were consequently poorly prepared for it. On the other hand, our results disagree with what Domènech et al. [1] found, who reported that the quality of information influences the perception of anxiety.

From our results, 69 % of the patients admitted not having looked up information relevant to the scan before undergoing the procedure. In agreement with De Man et al. [15], it is possible that these patients avoided researching information as a coping strategy. In addition, the result attained foresees that the majority of patients count on the AHP as the main source of information, which highlights the essential role they have in preparing for the scan. In this way, the AHP during the initial contact with the patient should assess whether there has been prior research for information and whether the patient needs any clarification. It is common knowledge that a negative effect can be caused by anxiety on clinical outcomes and the general patient experience. The execution of a diagnostic scan such as a PET/CT, where the information transmitted is extensive, requires effective communication that allows the patient to understand and memorise the information as well as anticipating emotional reactions. In a scan with the PET/CT characteristics, the absence of information may be considered serious as it could jeopardise the patient’s safety and the quality of the scan.

Very few studies evaluating prior awareness of PET/CT scan were found when reviewing the literature [16, 17]. Similarly to our study, the results obtained by Andersson et al. [16] show that, despite 26 % of the patients not having a prior knowledge of PET/CT, the image quality was not affected.

In accordance with what Pifarré et al. [2] found in their PET-CT study, in our research, it was found that men evince greater anxiety than women (U = 5641, p = 0.033). More investigation is needed to further explore the difference in anxiety between gender, as this is not a common result in other studies [13, 18].

The insight to the treatment being received at the NM department is fundamental for patient satisfaction. The degree of global satisfaction with the NM department was 6.8 ± 2.4. In fact, 61.4 % of patients felt that they had the chance to explain their concerns to an AHP, who is also reported by Andersson et al. [16] who found that 65–70 % of the patients were satisfied with the interaction with the nursing staff, their communication abilities and professional skills. Although the satisfaction in our study was high, Reyes-Perez [19] obtained a higher satisfaction level (8.96). According to Lledó et al. [10], patients that have the chance to explain themselves feel more satisfied.

Considering the levels of anxiety both pre- and post-procedure found in our study, it suggests that AHP should focus on implementing specific strategies to reduce anxiety related to PET/CT, and possibly interfere with patients’ well-being and diagnostic accuracy.

Anxiety reduction strategies, like the following, have been proved to be valuable in this regard. For information improvement, Andersson et al. [20] suggest a website with information about PET/CT procedures to increase patient knowledge before the scan. Information should be understandable and not include details about radiation, risks factors and potential adverse reactions of intravenous radiopharmaceutical since these matters increase the patient’s anxiety level [20]. Furthermore, information needs to be complemented with positive interaction (trust and reassurance) between AHP and patient. Acuff et al. [21] found that making patients aware that they can contact the AHP during imaging helps to lower their anxiety. Apart from using audiovisual imagery in the PET/CT uptake room [8], which has proved to lower patient anxiety, the use of music as environmental distraction may also be used as a coping strategy for the patient [21]. Habituation in a PET/CT simulator before the scan [22], a visit to the control room before imaging, a device to signal for adjustment of music volume and a clock visible during scan procedure [20, 23] are also relatively simple changes that have been introduced with success in MR imaging and could be used in PET/CT. Further research including these strategies would make possible to investigate the association between oncological patients referred for staging and anxiety.