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  Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 54  |  Issue : 2  |  Page : 458-460
 

Barriers affecting adherence to radiation treatment and strategies to overcome those barriers


1 Department of Radiation Oncology, Government Royapettah Hospital, Chennai, Tamil Nadu, India
2 Department of Oncology, Government Royapettah Hospital, Chennai, Tamil Nadu, India

Date of Web Publication21-Feb-2018

Correspondence Address:
Dr. R Rangarajan
Department of Radiation Oncology, Government Royapettah Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_260_17

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 » Abstract 


BACKGROUND: The WHO defines adherence as the extent to which a patient's behavior coincides with recommendations from a health-care provider. Nonadherence to cancer treatment has a major impact on the therapeutic outcome. AIM OF THE STUDY: To assess the prevalence of nonadherence to radiation regimen and to analyze the factors that affect adherence to cancer treatment. MATERIALS AND METHODS: Patients receiving radiation treatment in our hospital were screened for adherence to appointment keeping and to the prescribed radiation regimen and patients who had unplanned treatment breaks during treatment were interviewed. Between January and July 2013, we identified 61 patients who had unplanned breaks during treatment. We analyzed the social, emotional, educational, economic, and therapeutic barriers that led to nonadherence. RESULTS: Of the 61 patients who had unplanned breaks during treatment, 54% were males and 46% were females. Fifty-seven percent of patients had head and neck cancers and 25% had gynecological cancers. Seventy-one percent of patients were planned for concurrent chemoradiation. The number of days of unplanned treatment breaks ranged from 3 to 27 days. Social and therapeutic barriers were found to be the most common factor that led to nonadherence in these patients. CONCLUSION: Identification of barriers that lead to nonadherence, designing strategies to overcome such barriers and effective communication becomes imperative to ensure uninterrupted treatment. Based on the above analysis, we have designed several strategies to improve adherence to treatment among our patients.


Keywords: Adherence, radiation treatment, unplanned treatment breaks


How to cite this article:
Rangarajan R, Jayaraman K. Barriers affecting adherence to radiation treatment and strategies to overcome those barriers. Indian J Cancer 2017;54:458-60

How to cite this URL:
Rangarajan R, Jayaraman K. Barriers affecting adherence to radiation treatment and strategies to overcome those barriers. Indian J Cancer [serial online] 2017 [cited 2021 Oct 18];54:458-60. Available from: https://www.indianjcancer.com/text.asp?2017/54/2/458/225802





 » Introduction Top


Conventional radiotherapy is given over a period of weeks. It ranges from 5 to 8 weeks, depending on the site to be treated, the daily dose of radiation being 1.8–2 Gy. The treatment is usually given from Monday to Friday. The aim of fractionation in radiotherapy is to allow time for recovery of normal cells.[1] Total treatment time is an important factor which influences the outcome of several malignancies.[2],[3] Breaks in treatment can have a detrimental effect by allowing accelerated repopulation of malignant cells.[4],[5],[6] It has been estimated that the tumor stem cell doubling time for some cancers may be as short as 4 days during the time of accelerated repopulation.[4] Altered fractionation modalities such as accelerated fractionation, hyperfractionation and hypofractionation are also being tried to improve the overall outcome.

The serious consequences of treatment interruption during a course of radiotherapy have been reported in literature.[7],[8] Unplanned treatment breaks during the course of radiotherapy in head and neck cancers is associated with worse locoregional control rates, shorter overall survival, and relapse free survival.[2],[9],[10],[11] Prolongation of overall treatment time is associated with dismal outcome in cervical cancers, lung cancers, bladder cancers, esophageal, prostate, and breast cancers.[12],[13],[14],[15] Treatment interruptions during a course of radiotherapy may be due to several factors. Planned interruptions usually occur during equipment maintenance and public holidays.

Unplanned treatment breaks can occur due to disease-related factors such as clinical worsening or disease progression, treatment-related factors such as side effects and toxicity of the treatment regimen, patient-related factors such as social, economic, and educational barriers. Equipment breakdown can also lead to unplanned treatment breaks. Such interruptions are of major concern, especially in rapidly growing squamous cell cancers.

The aim of the present study is to analyze the prevalence of nonadherence to radiation treatment, unplanned treatment breaks during radiotherapy and to analyze the factors that affect adherence to a particular radiation regimen.


 » Materials and Methods Top


Patients receiving radiation treatment in our hospital were screened for adherence to appointment keeping and to the prescribed radiation regimen and patients who had unplanned treatment breaks during treatment were interviewed. All patients received treatment in a telecobalt machine. Scheduled interruptions such as public holidays and weekends were not taken into consideration.

Variables such as age, gender, education, performance status, address, site of the disease, stage of the disease, treatment policy, total dose of radiation planned, administration of concurrent chemotherapy, side effects of treatment, number of days of treatment breaks, and reasons for treatment interruption were recorded.

We analyzed the social, economic, educational, and therapeutic barriers that led to treatment interruptions. The effects of age, gender, site and stage of the disease, concurrent chemotherapy administration, and toxicity profile on the treatment delays were analyzed. The results were tabulated and analyzed.


 » Results Top


Between January and July 2013, we identified 61 patients who had unplanned treatment breaks. The ages of patients who had treatment breaks ranged from 30 to 85 years with a median age of 52.5 years. Of the 61 patients with unplanned breaks, 54% were males and 46% were females. Forty-three percent of patients were from urban areas and 57% were from neighboring village areas.

Around 51% of patients had completed only primary education and around 44% were illiterate. Only 5% of patients had completed high school education. Majority (98%) of patients belonged to the lower socioeconomic class.

Fifty-seven percent of patients who had treatment breaks had head and neck cancers. Twenty-five percent of patients had gynecological cancers. Esophageal cancer patients constituted 7% of total followed by breast cancer patients (4.9%). Myeloma, soft tissue sarcoma, and rectal cancers constituted 1.6% each of the total patients. Among head and neck cancer patients, 34.2% of patients had oral cavity cancers followed by oropharyngeal cancers which constituted 25.7%. Hypopharyngeal and laryngeal cancer patients constituted 14.28% of the total head and neck cancer patients. Among gynecological cancer patients, 73.3% of patients had cervical cancers [Figure 1].
Figure 1: Most common cancers with unplanned treatment breaks

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Sixty-nine percent of patients had Stage III disease at presentation. Stage IV disease was seen in 18% of patients. Ten percent had Stage II and 3% had Stage I disease. The treatment aim was curative in 89% of patients and palliative in 11% of patients. Concurrent chemotherapy was administered in 71% of patients. Nine percent of patients received adjuvant radiotherapy. Twenty percent of patients were planned for radiotherapy alone.

The number of days of treatment breaks ranged between 3 and 27 days. The social barriers to adherence include lack of family support and financial constraints. The therapeutic barriers include side effects of treatment and the regimen duration. Educational barrier includes poor understanding of the treatment and emotional barrier includes depression and anxiety because of the illness and other factors.

37.71% of patients had socioeconomic barriers and 21.31% of patients had therapeutic barriers. 3.28% of patients had emotional barriers and 8.2% of patients had educational barriers. More than one barrier was seen in 29.5% of patients [Figure 2].
Figure 2: Barriers affecting adherence to treatment

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 » Discussion Top


Prolongation of overall treatment time is associated with an adverse outcome, especially in tumors with rapid growth rates. It has been reported in head and neck cancers that 1 day treatment prolongation can result in 1.4% decrease in local control rate.[16],[17] Other malignancies where treatment prolongation can be detrimental include cervical cancers, lung cancers, esophageal cancers, medulloblastomas, and glioblastomas. Evidence shows that overall treatment time for squamous cell cancers of cervix should not exceed a period of 8 weeks.

In our study, a large majority of patients who had unplanned treatment breaks had head and neck/gynecological cancers which have a high cell turnover. Majority of patients in our study had treatment breaks during the end phase of a radical radiotherapy schedule. This again is a matter of concern as accelerated repopulation of tumor cells occurs after 28 days of radiation treatment. The longer the duration of an unplanned treatment break, the more dismal is the outcome.

Hence, it is very important to conduct internal audits in a department to screen patients for adherence to appointment keeping and to the prescribed radiation regimen. Individual strategies should be designed to prevent unplanned treatment breaks and individual Department Protocols should be framed to compensate for such unplanned interruptions which can lead to a detrimental effect on the final outcome of the disease.

Educational barrier to adherence is due to a poor understanding of the nature of the disease and the treatment. It can be overcome by arranging orientation sessions for the patients at the time of reporting for treatment. A Department Counselor should explain the treatment aspects, the expected side effects profile of the treatment and the importance of adherence to the treatment schedule. An information material or a pamphlet containing information about the entire treatment for a specific site can be provided to the patient and attenders. Placards and posters can be displayed in the patients waiting hall. An audiovisual aid explaining the nature of the treatment can also be provided in the waiting room.

Socioeconomic barriers can be overcome by providing counseling to both patients and the attenders about the treatment. A social welfare officer should discuss all the logistic issues with the patient and attenders at the beginning of treatment. For patients having logistic issues, a hospital van or ambulance can be arranged to ensure treatment compliance. Alternatively, patients may be admitted in the ward and advised to undergo treatment as hospital inpatients to ensure compliance to treatment.

Therapeutic barrier poses a real challenge to the treating physician. The importance of weight maintenance should be explained to the patients at the beginning of treatment, especially for patients with head and neck and GI malignancies. A nutritional and diet counseling should be given by a Department Nutritionist. Weekly assessment of weight, diet, and fluid intake should be done. A proper mouth care regimen should be designed for all head and neck cancer patients undergoing radiation.

The prevalence of depression and anxiety should be assessed by the treating physician or the radiation nurse and appropriate counseling should be given by a psycho-oncologist.

For patients who have unplanned treatment breaks early in the course of treatment an accelerated treatment schedule can be planned by delivering twice a day treatment or by treating during weekends to compensate for the interruption. For patients with interruptions in the late phase of treatment, appropriate radiobiology-based calculations should be made and an increased total dose should be delivered to compensate for the radiation wasted due to accelerated repopulation.


 » Conclusion Top


Identification of barriers that lead to nonadherence, designing strategies to overcome such barriers and effective communication becomes imperative to ensure uninterrupted treatment. A smartphone-based application, a planning chart, short messaging service to patients, and phone calls can be used to monitor daily treatments and ensure treatment compliance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Sedeño BP, Jiménez PC. Generalidades en oncología radioterápica (I): Radiobiologia. Biocáncer 2004;1:1-21.  Back to cited text no. 1
    
2.
Suwinski R, Sowa A, Rutkowski T, Wydmanski J, Tarnawski R, Maciejewski B, et al. Time factor in postoperative radiotherapy: A multivariate locoregional control analysis in 868 patients. Int J Radiat Oncol Biol Phys 2003;56:399-412.  Back to cited text no. 2
    
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González-San Segundo C, Calvo Manuel FA, Santos Miranda JA. Retrasos e interrupciones: la dificultad para irradiar en el tiempo ideal. Clin Transl Oncol 2005;7:47-54.  Back to cited text no. 3
    
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Withers HR, Taylor JM, Maciejewski B. The hazard of accelerated tumor clonogen repopulation during radiotherapy. Acta Oncol 1988;27:131-46.  Back to cited text no. 4
    
5.
Tarnawski R, Fowler J, Skladowski K, Swierniak A, Suwiński R, Maciejewski B, et al. How fast is repopulation of tumor cells during the treatment gap? Int J Radiat Oncol Biol Phys 2002;54:229-36.  Back to cited text no. 5
    
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Schmidt-Ullrich RK, Contessa JN, Dent P, Mikkelsen RB, Valerie K, Reardon DB, et al. Molecular mechanisms of radiation-induced accelerated repopulation. Radiat Oncol Investig 1999;7:321-30.  Back to cited text no. 6
    
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Dale RG, Hendry JH, Jones B, Robertson AG, Deehan C, Sinclair JA, et al. Practical methods for compensating for missed treatment days in radiotherapy, with particular reference to head and neck schedules. Clin Oncol (R Coll Radiol) 2002;14:382-93.  Back to cited text no. 7
    
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Hendry JH, Bentzen SM, Dale RG, Fowler JF, Wheldon TE, Jones B, et al. A modelled comparison of the effects of using different ways to compensate for missed treatment days in radiotherapy. Clin Oncol (R Coll Radiol) 1996;8:297-307.  Back to cited text no. 8
    
9.
Robertson AG, Robertson C, Perone C, Clarke K, Dewar J, Elia MH, et al. Effect of gap length and position on results of treatment of cancer of the larynx in Scotland by radiotherapy: A linear quadratic analysis. Radiother Oncol 1998;48:165-73.  Back to cited text no. 9
    
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Robertson C, Robertson AG, Hendry JH, Roberts SA, Slevin NJ, Duncan WB, et al. Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers. Int J Radiat Oncol Biol Phys 1998;40:319-29.  Back to cited text no. 10
    
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Groome PA, O'Sullivan B, Mackillop WJ, Jackson LD, Schulze K, Irish JC, et al. Compromised local control due to treatment interruptions and late treatment breaks in early glottic cancer: Population-based outcomes study supporting need for intensified treatment schedules. Int J Radiat Oncol Biol Phys 2006;64:1002-12.  Back to cited text no. 11
    
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Videtic GM, Fung K, Tomiak AT, Stitt LW, Dar AR, Truong PT, et al. Using treatment interruptions to palliate the toxicity from concurrent chemoradiation for limited small cell lung cancer decreases survival and disease control. Lung Cancer 2001;33:249-58.  Back to cited text no. 12
    
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Chen M, Jiang GL, Fu XL, Wang LJ, Qian H, Chen GY, et al. The impact of overall treatment time on outcomes in radiation therapy for non-small cell lung cancer. Lung Cancer 2000;28:11-9.  Back to cited text no. 13
    
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Perez CA, Michalski J, Mansur D, Lockett MA. Impact of elapsed treatment time on outcome of external-beam radiation therapy for localized carcinoma of the prostate. Cancer J 2004;10:349-56.  Back to cited text no. 14
    
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Maciejewski B, Majewski S. Dose fractionation and tumour repopulation in radiotherapy for bladder cancer. Radiother Oncol 1991;21:163-70.  Back to cited text no. 15
    
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Hendry JH, Roberts SA, Slevin NJ, Keane TJ, Barton MB, Agren-Cronqvist A, et al. Influence of radiotherapy treatment time on control of laryngeal cancer: Comparisons between centres in Manchester, UK and Toronto, Canada. Radiother Oncol 1994;31:14-22.  Back to cited text no. 16
    
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Roberts SA, Hendry JH, Brewster AE, Slevin NJ. The influence of radiotherapy treatment time on the control of laryngeal cancer: A direct analysis of data from two British Institute of Radiology trials to calculate the lag period and the time factor. Br J Radiol 1994;67:790-4.  Back to cited text no. 17
    


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