Assessment of Knowledge on Side Effects Among Cancer Patients Receiving Radiotherapy in Selected Hospitals of West Bengal

Introduction

There are approximately 20 million new cases of cancer and 9.7 million cancer deaths in 2022. Lung cancer is the most frequently diagnosed cancer and the leading cause of cancer-related death, with almost 2.5 million new cases and approximately 1.8 million deaths. New cancer cases will reach 35 million by 2050, as indicated by demographics-based predictions. In India, breast cancer (26.6%) was the most diagnosed cancer followed by carcinoma in the cervix (17.7%) in females; among males, lip and oral cavity cancer (14.7%) was the most diagnosed cancer followed by lung cancer (8.5%).¹ According to an ICMR report, there were 1,461,427 new cancer cases in 2022 and the crude incidence rate was 11.4 per 1,00,000 individuals.² Available evidence indicates that external beam radiotherapy is required in 52% of cancer patients.^3,4 Radiation therapy is associated with several side effects. It can be acute or chronic. Acute side effects are generally reversible and subside within the first 3-6 months of radiation therapy. Chronic or late side effects are usually evident several months after starting radiotherapy, but they are generally irreversible.

In the skin and mucosa, acute responses include erythema, inflammation, and dry and moist desquamation, which manifest as mucositis, pruritus, hypersensitivity, pain, and ulcers in the mucosa.⁵ In the nervous system, acute effects include fatigue, nausea, vomiting, loss of appetite, headache, and some neurological symptoms due to edema of the irradiated tumor and adjacent tissues. Long-term neurological symptoms can present as cerebrovascular disease, fatigue, impaired cognition and memory loss, emotional and mood disturbances, and secondary malignancies.^6,7 Acute gastrointestinal symptoms include diarrhea, increased mucus secretion, and in long-term cases, rectal bleeding, increased frequency of stool, fistula formation, and pain.⁸ In genitalia, acute side effects include erythema, exudative change, ulceration, and increased infection. The late effects include vaginal stenosis, vaginismus.⁹

Irrespective of the stage of diagnosis or treatment intent, approximately 20% and 10% of cancer patients are affected by depression and anxiety respectively.¹⁰ Radiotherapy has been reported to cause acute side effects like fatigue in 80% of patients, and chronic fatigue can persist for months to years after treatment in up to 30% of cases.¹¹ Alterations of taste occur in more than 70% of patients.¹² Dysphagia is a commonly observed side effect in approximately 40% of cases.^13-15 With the treatment advancements such as intensity modulated radiotherapy, approximately 40% of patients still experience xerostomia, and approximately 36% of patients face moist desquamation.^16,17 Radiation-induced diarrhoea is experienced by approximately 30-50% of patients.¹⁸ In up to 50% of patients some side effects may occur due to radiation at pelvic region, these are diarrhoea, bleeding from the rectum, and fecal incontinence.^19,20 Trismus is seen in approximately 65% and 25% of head and neck cancer patients following radiotherapy at 6 and 12 months.²¹

Awareness of the general population is still poor in both developing and developed countries. Poor awareness may lead to the poor use of screening modalities, which may cause delays in diagnosis. Therefore, the knowledge assessment of cancer patients is necessary to understand the lack of knowledge regarding cancer and its treatment. Being a healthcare provider, we can help them to understand the importance of treatment, the side effects of radiation therapy, and how they can effectively manage these side effects.

Materials and Methods

This descriptive research survey was conducted in the Department of Community Nursing. Patients with cancer receiving radiotherapy in selected medical colleges and hospitals in West Bengal were included in this study. This study was conducted after receiving approval Institutional Review Board (IRB) approval was obtained under reference BMC/IEC/83 on 20th April 2023 at Burdwan Medical College. This study included patients who gave consent for participation, were able to read and apprehend Bengali or English, were more than 18 years of age, and received radiotherapy treatment at the time of data collection. Patients undergoing palliative radiotherapy and those with any psychological illness were excluded from the study. A nonprobability purposive sampling technique was used for sample size calculation. A self-structured validated questionnaire was used for data collection. A total of 171 patients who fulfilled the inclusion criteria were interviewed during the study period. All the collected data from case record forms were transferred to data processing software, Microsoft Excel (Microsoft Inc., USA) and analyzed using statistical software, SPSS (v. 26, IBM Inc, USA). We presented all quantitative data as mean and standard deviation and qualitative data as percentages and frequencies.

Results

A total of 171 patients were interviewed and included in this study. The demographic variables are presented in Table 1.

The majority of patients (42.7%) were in the 44-56 years age group, followed by 57-69 years (36.8%). Female patients were in majority (55%) than male patients. Based on educational status, the majority (44.4%) had no formal education and 43.3% had education up to the primary level. A total of 50.87% of patients lived in rural areas and 49.12% of patients lived in urban areas. Of the families, 40.93% belonged to Class IV (lower middle class), 39.76% belonged to Class V (lower class), and 19.29% belonged to Class III (middle class). A total of 57.3% of patients had an addiction history. A family history of cancer was reported in 18.1% of patients. No prior information regarding radiotherapy was available for 87.1% of patients. Of the patients, 43.18% received radiotherapy in the head-neck region, 29.82% of patients received radiotherapy in the chest wall, and 26.89% of patients received radiotherapy in the pelvic region.

Table 2 shows the frequency and percentage of knowledge of the side effects of radiotherapy. 25.1 Of the cancer patients, 25.1% had poor knowledge, 24% of cancer patients had average knowledge, 22.2% of cancer patients had good knowledge, 21.1% of cancer patients had very good knowledge, and 7.6% had excellent knowledge. Therefore, it can be interpreted that most cancer patients had poor knowledge of the side effects of radiotherapy.

The obtained range of knowledge of cancer patients on side effects of radiotherapy was 4-17 with a mean knowledge score of 11.3, calculated median value of 12, which could be interpreted as the obtained data being almost normally distributed. The standard deviation of knowledge of cancer patients was ±3.06, which indicates that the obtained data were mildly dispersed with negative skewness (-0.68), as shown in Table 3.

Table 4 shows the association between knowledge of the side effects of radiotherapy and the selected demographic variables. The Chi-square test showed that the sex of the patient had an impact on knowledge, as males had significantly higher knowledge scores than females (P<0.001). In addition, there was a strong association between knowledge and educational status, place of residence, family history of cancer, and duration of radiotherapy, at the 0.001 level of significance. Patients with prior information regarding radiotherapy before diagnosis had a higher knowledge score at 0.01 level of significance. There was no significant association between age and knowledge of radiotherapy.

Discussion

The results revealed that there were 51.1% of patients with poor knowledge, and 48.6% had average knowledge on the side effects of radiotherapy, which is similar to a study conducted by Murkute et al., Similar findings were also noted by Chetan Priya et al. that the majority of oral cancer patients had inadequate knowledge (score less than 50%).^22,23 We found that knowledge of side effects among cancer patients receiving radiotherapy was associated with selected demographic variables in terms of gender, educational status, place of residence, family history of cancer, duration of radiotherapy, and any prior information regarding radiotherapy before diagnosis; similar findings were also noted by Jyothi Makara B et al.²⁴ This is only a study from West Bengal on knowledge of the side effects of radiotherapy to the best of our knowledge.

Conclusion

In this study, we assessed the side effects of radiotherapy, which are necessary for every cancer patient to cope with and manage. The results showed that the majority of the patients had a poor level of knowledge. Nursing is a total care process that covers assessment, diagnosis, planning, implementation, and evaluation; hence, nurses play a major role in educating cancer patients about the side effects of radiotherapy, managing these side effects, and improving their quality of life. However, this study was limited to a particular setup and population. Further studies with larger sample sizes and different populations are required to understand this knowledge and awareness. The findings of the present study can be applied to various areas of nursing education, practice, administration, and research.

Conflict of interest

Nil

Source of funding

Nil

Acknowledgment

We acknowledge all the patients for their responses to contribute to this study, the Department of Radiation Oncology, and all the members for their support.