Background
Cancer, as well as its sometimes invasive and aggressive treatment, has a great impact on a patient's life. Previous studies have highlighted that cancer patients undergoing radiotherapy treatment (RT) may experience psychosocial problems such as symptoms of depression and anxiety [
1,
2], which may negatively affect health and treatment-related outcomes [
3]. It is important to detect psychosocial problems at an early stage because treatment of sub-clinical symptoms of psychosocial problems may prevent further deterioration in the patient and the development of psychiatric co-morbidity [
4]. Yet, psychosocial problems are often unrecognized and untreated due to the low awareness of the existence of psychosocial problems or pressures of time [
5,
6]. Furthermore, physicians are more focused on physical symptoms [
7‐
9], and may feel more able to help with physical problems than with emotional ones [
10]. Another aspect is that cancer patients do not tend to report psychological problems to their physician; some patients may regard psychosocial care as stigmatizing and on this basis be reluctant to seek help [
6,
11].
Awareness of the need for identifying psychosocial problems is growing, resulting in the development of screening instruments [
12]. Several studies examined the use of screening instruments [
12‐
16]. Most studies reported that using these instruments gave better insight into patients' psychosocial problems and facilitated patient-physician communication on the topics of the instrument [
7,
12,
17]. Our study, a randomized controlled trial recently showed that using a simple screening instrument in a radiation oncology department can be valuable in timely treatment of these problems but, however, no significant effects were observed for the number of referred patients, nor for improvement of the patients-radiotherapist communication (paper submitted, article available on request).
In parallel to this trial, a process evaluation was carried out. The purpose of this process evaluation was to evaluate the feasibility and usefulness of this screening instrument (SIPP: Screening Inventory of Psychosocial Problems) and to identify factors that may explain the lack of effectiveness on referral patterns and patients-radiotherapist communication in patients receiving curative RT. The specific aims were:
1. To gain insight into the procedure of using the SIPP in a radiation oncology department.
2. To investigate the degree to which the SIPP was considered useful and feasible by both radiotherapists and cancer patients. Feasibility, including acceptability, of screening instruments is an important aspect that determines successful implementation of such tools in radiation oncology departments [
18,
19].
To investigate whether perspectives of patients and radiotherapists on the usefulness and feasibility of the SIPP are associated. We hypothesized that more positive attitudes of radiotherapists towards discussing psychosocial problems in daily practice will result in more positive perspectives on the usefulness of the SIPP among patients. Previous studies have reported that the way physicians address psychosocial problems affects how patients perceive the interactions with their physician [
20,
21].
Results
Baseline characteristics of the patients and radiotherapists
Sociodemographic and medical characteristics of the 268 patients are listed in Table
1.
Figure
1 shows the flowchart of the number of patients in each stage of the screening procedure. In total, 23 patients did not complete the SIPP the first (n = 5) or second (n = 18) time, of which one patient did not complete the SIPP at both times. In total, 7 patients (2.6%) did not complete the process evaluation forms.
The SIPP was applied by seven radiotherapists. Three were female. The mean age was 44.6 (SD = 10.0) years (range 30 to 63 years), and on average they had worked for 14.1 years (range 4 to 35 years) as a radiotherapist.
The process evaluation forms on the usefulness and feasibility of the SIPP after each first consultation with the patient were completed by five radiotherapists for 146 patients. Two radiotherapists never completed this form. One radiotherapist never checked the SIPP for potential psychosocial problems for all his 54 participating patients. So, questions in the evaluation form after each first consultation were not applicable for him/her. The other radiotherapist reported that completing the form after each patient took too much time.
Six radiotherapists completed twice the overall (i.e. not patient-specific) process evaluation forms on the usefulness and feasibility of the SIPP. Two radiotherapists did not complete the first or second process evaluation form due to the fact that one radiotherapist had treated only one participating patient and another radiotherapist no longer worked at the BVI at about 8 months after the start of the study.
Psychosocial problems as assessed with the SIPP
Table
2 shows patients' extent of psychosocial problems measured with the SIPP at the two time points before the consultation with the radiotherapists. Furthermore, the numbers of referred patients with symptoms of psychosocial problems to a caregiver are presented. At the end of the RT patients reported a significantly lower extent of psychological and social problems (paired t-test,
P < 0.01 and
P = 0.01, respectively), but significantly more physical complaints (paired t-test,
P < 0.01) than during the first consultation. During the first consultation a total of 33 patients were offered the opportunity to consult a psychosocial care provider as a result of the screening procedure. Of these 33 patients, 31 patients suffered from at least sub-clinical symptoms, of which 28 patients suffered from clinical symptoms (Table
2) and two patients hardly suffered from any symptoms of psychosocial problems at all (not tabulated). Since 28 of the 31 patients suffered from clinical symptoms this indicates that three patients suffered only from sub-clinical symptoms. Twenty-one patients accepted the recommendation and were referred to a psychosocial care provider (not tabulated). During the consultation at the end of the RT, all nine patients who were offered the opportunity to consult a caregiver suffered from clinical symptoms (Table
2).
Patients' perspectives on the usefulness and feasibility of the SIPP
Ratings of patients' perspectives about completing and discussing the SIPP after the first consultation are described in Table
3. On average, completing the SIPP took 5.3 minutes and 71.6% of the patients completed the SIPP in five minutes or less (not tabulated). Patients were positive about the content of the SIPP. The mean scores on the three items of the instruments' content subscale (items 2-4) varied from 8.0 to 8.9. Regarding communication aspects, most patients (67.5%) were positive about the importance of discussing items of the SIPP with their radiotherapist. However, patients were not positive about the usefulness of the SIPP to discuss psychosocial complaints and sexual problems.
Patients' suggestions for improvement of the SIPP
Five patients made suggestions for improvement. One patient suggested adding an item on cognitive functioning, and one patient suggested adding an item about medication use. Furthermore, one patient considered it important to ask about problems at work, while another patient reported that questions on specific tumours or treatment of specific complaints were lacking. One patient would have preferred an item about receiving care at home.
Radiotherapists' perspectives on the usefulness and feasibility of the SIPP
Ratings of radiotherapists' perspectives on using the SIPP after the first consultation are presented in the upper part of Table
4.
In 90.1% of all consultations, the time required to discuss the instrument was less than five minutes (not tabulated). With respect to specific evaluation after each consult, radiotherapists were most positive about the fact that the SIPP gave better insight into the psychosocial well-being of the patient. They were less positive about the fact that the SIPP invited them to ask about the patients' psychosocial well-being.
Radiotherapists' overall perspectives on using the SIPP were measured at two time points: about seven and 13 months after the start of the study. Their overall perspectives on the usefulness and feasibility of the SIPP was mixed (mean scores varied from 1.5 to 6.0; see lower part of Table
4). Three radiotherapists considered the SIPP to be useful and feasible. None of the radiotherapists was positive about changing their communication style by using the SIPP.
Radiotherapists' suggestions for improvement of the SIPP
Two radiotherapists made suggestions for improvement. One preferred a tumour-specific questionnaire above a disease-specific questionnaire and another suggested an item about whether patients already received psychosocial support. Regarding feasibility, one radiotherapist suggested that physician-assistants should discuss the screening instrument with the patients.
Associations between patients' and radiotherapists' perspectives on the usefulness of the screening instrument
Radiotherapists who considered the screening instrument a useful tool to ask about psychosocial well-being aspects (Table
4 item 8) were more likely to discuss psychosocial complaints (r = 0.2,
P = 0.01) and sexual problems (r = 0.3,
P < 0.01) with their patients (Table
3 items 7 and 8, respectively). Patients were more likely to report that discussing the items of the SIPP with their radiotherapist was pleasant (Table
3 item 12) if the radiotherapist considered the SIPP to be a useful tool to ask about psychosocial well-being (r = 0.2,
P < 0.05) (Table
4 item 8).
Discussion
This study explored the usefulness and feasibility of using a screening instrument as the SIPP in a radiation oncology department according to radiotherapists and patients. Nearly all patients completed the SIPP twice, at the beginning and at the end of RT, which is an indication of an acceptable feasibility of the screening instrument. Just as previous studies reported that not all radiotherapists were willing to use psychosocial screening instruments [
19,
28] in our study also one radiotherapist was not willing to use the screening instrument.
The prevalence rate of psychosocial problems among patients receiving RT with curative intent was in line with previous studies [
1,
29]. During the treatment trajectory patients seemed to experience different problems at different time points; the extent of psychological and social problems was lower at the end of RT, while the extent of physical complaints was higher at this time point. The latter was probably due to the high extent of side-effects at the end of RT since patients had received the maximum radiation doses. Displaying similarities with other studies [
30‐
32], a relative small proportion of patients suffering from at least sub-clinical (7.1%-20.8%) or clinical (9.3%-30.1%) symptoms of psychosocial problems were offered the opportunity to visit a psychosocial care provider by their radiotherapist (Table
2). An explanation might be that psychosocial problems were discussed sufficiently during the consultation, which meant that receiving psychosocial support by a psychosocial care provider was not considered necessary any more [
33]. Another explanation might be that according to Livingston and colleagues, physicians may be uncomfortable referring patients at a time when patients are overloaded with information (e.g. treatment, and side-effects) [
34], as is the case during a first consultation. Also, physicians tend to ignore raw scores on questionnaires when they have to add them up and interpret them themselves, resulting in under diagnosis of patients suffering from psychosocial problems [
35]. The latter can be prevented by using a computer-based screening instrument that forwards the screening data and presents the results directly to physicians. However, Boyes and colleagues reported that giving physicians feedback about patients' psychosocial well-being rarely contributed to physicians' decision making about patient management [
28]. Furthermore, contrary to other studies [
31,
36‐
41], our results showed that when offered during the first consultation, the majority of the patients (63.6%) accepted psychosocial care. It seemed that receiving psychosocial support was acceptable for patients at that time point. A previous study reported that patients' need and acceptance for psychosocial support seemed to be related to timing [
38]. Still, it should be taken into account that about one-third of the patients did not wish to be referred to a psychosocial care provider, which may imply that for some patients a barrier emerged that impeded acceptance of referral [
40].
There is a discrepancy between radiotherapists' and patients' perspectives of the usefulness and feasibility of the SIPP. Patients' perspectives of the usefulness and feasibility of the SIPP were moderate to good in general. Comparable with the study of Pruyn and colleagues [
25], two-thirds of the patients were very positive on the importance of discussing the screening instrument with their radiotherapist. Regarding the radiotherapists' perspectives, only a minority of radiotherapists considered the SIPP to be useful and feasible. Despite the latter, it is important to note that our outcomes showed a positive association between radiotherapists' opinion about the scores as good indicators into patients' well-being and discussing psychological problems. However, it can be vice versa: radiotherapists who traditionally more often discuss psychosocial problems were those who indicated that the screening instrument gave better insight into patients' problems. Furthermore, discussing the screening instrument was more pleasant for patients when the radiotherapists were positive about discussing it. This confirms our hypothesis that if radiotherapists have positive attitudes towards discussing psychosocial problems patients' perspectives of the usefulness of the tool will be more positive. Moreover, it also indicates the importance of patient-physician communication for high-quality care, as it may influence patients' satisfaction with care [
13,
20,
42].
Some results of this study were remarkable. Radiotherapists were quite positive about the usefulness and feasibility of the screening instrument when they evaluated the SIPP directly after each first consultation with their patient, but more negative when the usefulness and feasibility was evaluated in general and not related to a specific consultation. A reasonable explanation is the different numbers of radiotherapists who completed the questionnaires in both situations. As reported earlier, two radiotherapists did not report their opinion after each consultation. Yet, despite the assumption that using a screening instrument may initiate better communication between patients and medical staff [
7,
12], none of the radiotherapists were convinced that using the screening instrument would change their communication style.
This study has several strong elements: the large number of patients that was included as well as the perspectives of both patients and radiotherapists. The study has limitations as well. First, the study was conducted in a single radiotherapy department, and although the number of patients was large, the number of radiotherapists was limited. This reduces the options for generalization of the results. Second, because the SIPP had not yet been incorporated into routine care, the radiotherapists might have gained insufficient experience to check the SIPP scores and patients' needs for psychosocial care. Partly, this could explain why radiotherapists considered the usefulness and feasibility of the screening instrument generally as low, while actual scores were mixed.
Recommendations for improving the use of a screening instrument in practice include encouraging screening at several time points as patients' needs and extent of psychosocial problems may change during the treatment trajectory. Furthermore, an important issue is to change and improve the physicians' attitudes regarding psychosocial care. This is relevant since physicians' attitudes toward discussing emotional problems may influence detection of psychosocial problems [
21] and are linked with patients' satisfaction [
13]. Additional skills training among physicians may be needed to improve recognition and management of psychosocial problems in cancer patients [
43]. However, it could also be that nurses rather than physicians prove to be the most suitable health care professionals to discuss psychosocial problems with cancer patients. Studies reported that nurses were more willing to use screening tools than physicians [
19]. Further research is necessary to optimize the use of screening instruments that may identify cancer patients' extent of psychosocial problems and improve health-related outcomes.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LL and GK obtained funding together with FG, RH, DE and AB. GK, LL, FG, RH, and AB were involved in conception and design of the study. AB is the investigator and works under supervision of GK and LL. LL, GK, FG and AB designed some questionnaires. AB and DE coordinated the entry and validation of the data. AB has made substantial contribution to statistical analyses and interpretation of the data. RH was advisor in the statistical analysis plan. GK, LL, DE and RH have made contribution to interpretation of the data. AB drafted the manuscript, with input from the other authors. All authors mentioned in the manuscript read and approved the final version.