|Year : 2019 | Volume
| Issue : 1 | Page : 6-14
Perception, attitude and knowledge regarding radiotherapy among physicians at a tertiary care center
Kuldeep Sharma, Anita Malik
Department of Radiation Oncology, Venkateshwar Hospital, Dwarka, New Delhi, India
|Date of Web Publication||26-Jun-2019|
Dr. Kuldeep Sharma
Department of Radiation Oncology, Venkateshwar Hospital, Sector 18, Dwarka, New Delhi 110075
Source of Support: None, Conflict of Interest: None
Objective: Cancer is a leading health problem of today’s world and radiotherapy (RT) is an integral modality to treat cancers. Unfortunately, RT remains an underutilized specialty worldwide because of the lack of knowledge and wrong perceptions among referring physicians toward this specialty. These concerns and fear may discourage physicians from referring patients for RT. This study was conducted to explore the knowledge, attitude, and perception of non-radiation oncology physicians toward this specialty. Materials and Methods: This was a questionnaire-based study including 63 participants conducted at a tertiary care hospital in New Delhi, India. Results: Although the survey completion rate of 95% was encouraging, our study revealed deficiencies in training and knowledge about cancer, principles of RT, and its beneficial effects. Although most of the participants appreciated the role of RT as a core specialty, many underscored its true potential and cost-effectiveness in cancer care. There were significant concerns regarding its side effects (most important reason for non-referral) and lack of familiarity with this specialty. Conclusion: Fortunately, in spite of knowledge gaps, there was a positive attitude toward learning in future among participants.
Keywords: Cancer, knowledge, oncology, perception, radiotherapy, treatment
|How to cite this article:|
Sharma K, Malik A. Perception, attitude and knowledge regarding radiotherapy among physicians at a tertiary care center. J Curr Oncol 2019;2:6-14
| Introduction|| |
Cancer is an increasing health problem in India and worldwide. The age-standardized prevalence of cancer is estimated to be 97 per 100,000 persons with greater prevalence in urban areas. The World Health Organization has projected an annual incidence of 20 million by 2020 with 12 million deaths. Radiotherapy (RT) or radiation oncology is an essential component for cure and palliation of cancer, which is indicated in approximately 52% cancer cases. The number of patients achieving benefit from RT during their disease course ranges between 40% and 62%. Cancer has become the leading cause of death in developed countries and is the second leading cause in developing countries. A recent report from the International Agency for Research on Cancer confirmed 14.1 million new cancer cases and 8.2 million deaths in 2012. Global Burden of Disease study shows that the number of cancer deaths have increased by 38% between 1990 and 2010, and if no concrete action is taken, it will further increase by 50% by 2030. Therefore, it has become important for every health-care worker to have a basic knowledge of cancer, its prevalence, and available treatment modalities.
Unfortunately, the stigma associated with cancer acts a huge barrier on all fronts of cancer control. Owing to the lack of proper knowledge about cancer and its treatment, oncology interventions are often delayed. This gap in knowledge spans from layperson to the medical professionals and is more toward RT, which is often wrongly considered as too complicated, too expensive, and too toxic modality. In reality, RT is a very safe and effective modality for treating cancer with a potential to achieve the treatment goal in up to 70% cases. There is a significant lack of RT training and education in undergraduate curriculum where infective and nutritional diseases are often given priority over cancer in spite of the fact that over past few decades, cancer has emerged as the biggest killer among noncommunicable diseases. Despite the growing literature favoring use of RT, there remains a problem of limited investment to set new facilities and their underutilization., There is a long-standing perception that cancer is a systemic illness and any investment in local treatment modalities will not be fruitful. Thus, a global effort is necessary to prepare doctors of the new millennium for future challenges in cancer management by educating them to change their perception and attitude toward RT or radiation oncology.
The aim of this study was to analyze the knowledge, perception, and attitude of our non-radiation oncology colleagues (who play an important role in RT utilization) toward RT as a cancer-treating modality.
| Materials and Methods|| |
This cross-sectional study was conducted at the Department of Radiation Oncology of a multispecialty hospital in New Delhi during October to November 2016. This department is equipped with an advanced linear accelerator and a brachytherapy unit with all required supporting accessories and services. The study was conducted during the initial phase when the hospital became functional to understand the baseline perception of physicians toward RT.
A panel consisting of two radiation oncologists (one with a training in palliative oncology) developed a 30-item questionnaire (Appendix A [Additional file 1]) that was designed to assess the following aspects:
- Type of practice/training with respect to oncology: 2 questions
- Awareness toward RT facility in own hospital/neighborhood: 10 questions
- Perception regarding effectiveness and utilization of RT: 10 questions
- Trends/barriers toward referring patients for RT: 5 questions
- Measures to improve awareness/referrals in RT: 3 questions
Participants were asked about their specialty, designation, and professional experience after graduation. Confidentiality of the participants was maintained and they were ensured that the results would be used only for a scientific purpose. The completed questionnaires were collected within 1 week with maximum two reminders during this period. Correct answers were determined by the radiation oncology experts in consultation with the currently available literature and the results were collated.
Statistical analysis was performed using the SPSS software, version 18.0, for Windows descriptive statistics including frequency distribution, mean, standard deviation, and percentages. Levels of knowledge, attitude, and practices were calculated as a percentage of correct answers in each section. Levels less than 50% were considered poor knowledge, unsafe practices, or negative attitude.
| Observations|| |
Total 63 questionnaires were served to the participants and 60 completed questionnaires were received back, with a survey completion rate of 95%. The characteristics of the participants are shown in [Table 1].
Type of practice/training in radiation oncology
Although about half of the participants regularly see cancer patients in their practice as primary physicians, only 9% had received any training in radiation oncology (mainly the medical or surgical oncologists) [Table 1].
Awareness toward RT facility in own hospital/neighborhood
Overall, 76% participants reported that they were aware of the nearest RT facilities in the area [Table 2]. Although 97% participants reported that they were aware of the existence of RT facility within the hospital, only 48% could correctly identify the location. Regarding services available in RT department, only 25% answered correctly, 35% were partially correct, and 40% were incorrect.
Overall, 77% participants reported that they know the difference between teletherapy and brachytherapy. Regarding the latest RT technologies, 27% reported full awareness, 38% reported none, and the remaining 35% reported to have some idea.
Regarding specific machines, only 12% answered correctly. Majority of the participants were unclear regarding the difference between linear accelerator, cobalt-60, or proton therapy.
When asked about the specific departmental activities, only 15% participants were correct. Although 90% participants believed that visiting the RT department is not hazardous for a person, only 43% had ever visited any RT department personally.
Perception regarding effectiveness and utilization of RT
All participants except two believed that latest RT technologies have a potential to improve outcome of cancer treatment. Ninety-two percent participants disagree with the statement that RT is indicated only in very advanced cancer cases.
Although 25% participants had correct perception that 50–75% of cancer patients require RT, 29 (48%) participants underestimated these figures and the remaining 27% were unsure about it. Likewise, 25% participants correctly perceived that RT achieves desired goal of treatment in 50–75% cases. Among others, 41% underestimated and 14% overestimated the potential of RT whereas 20% were unsure about it.
Overall, 89% participants agreed (strongly agree or agree) with the fact that RT plays definitive role (equivalent or better than surgery) in radical treatment for certain cancers. The remaining 11% believed otherwise (neither agree nor disagree or disagree). Similarly, most (93%) participants agreed with the statement that RT should be considered as a core department in any tertiary care hospitals.
When asked regarding the indications of palliative RT for symptom control, merely 8% participants answered correctly. The remaining were either partially correct (84%) or unsure (8%). Likewise, 74% participants agreed with the fact that RT is the most effective treatment in certain oncological emergencies. Among others, 5% disagreed with it and 21% had neutral opinion.
About half (53%) of the participants agreed (strongly agree or agree) with the fact that modern RT is cost-effective. Among others, 7% disagreed whereas 40% were not sure about this fact.
Most (63%) participants agreed (strongly agree or agree) with the statement that RT remains an underutilized modality in cancer treatment. The remaining 7% disagreed whereas 30% were unsure about it.
Trends/barriers toward referring patients for RT
Although 33% participants reported that they frequently refer patients for RT, remaining 66% rarely or never made RT referrals. The indication for referral were adjuvant (60%), neo-adjuvant (12%), definitive (12%), and palliative (12%). Remaining (5%) participants were not sure about the indications. Only two participants referred the patient to an outside facility as they were not aware of the available facility/technique in-house.
Concern regarding side-effects of RT was the most common barrier for referring patients for RT. Overall, 18% participants had come across some RT-related side effects that discouraged them from considering RT for their patients. Other major barriers reported by participants are listed in [Table 3].
|Table 3: Common barriers for physicians while considering RT in cancer patients|
Click here to view
Measures to improve awareness/referrals in RT
Overall, 28 participants reported that they have come across information material regarding RT facility in the hospital and majority (78%) of them desired to have more information about the facility in future. The remaining 22% were not interested in further information. The most common suggestions were to increase awareness regarding RT among primary caregivers and counseling of patients and families by a radiation oncologist.
| Discussion|| |
The survey completion rate of 95% was encouraging and suggests that the participants were eager to contribute toward research/academic activity.
Type of practice/training in radiation oncology
This study also highlighted the general lack of training and education of radiation oncology among referring physicians as in many other countries. The most important reason is the suboptimal representation of this subject in the undergraduate curriculum. Worldwide studies have also shown significant deficiencies in oncology teaching. Even in the United States, there are no designed or structured classes devoted to cancer prevention or detection in medical colleges. Only 16% family physicians in Eastern Ontario and 62% pediatric oncologists in Canada reported having any formal training in RT.
There is an urgent need to improve oncology teaching to enhance the RT utilization rates, as studies suggest that clinicians with training and greater knowledge of RT are more likely to refer needy patients for the same. In a study, 94% of trained physicians made required RT referrals, as opposed to 73% without training.
Awareness toward RT facility in own hospital/neighborhood
Although many participants claimed that they know about the RT facility in the hospital, very few knew about the exact location and facilities available there. There was a gross nonclarity between radiation oncology, medical oncology, or nuclear medicine as separate departments among participants.
Similar results from other studies suggest that underutilization of RT may be due to lack of knowledge of resource availability rather than the perceived lack of benefit. An important reason for poor awareness and visits to RT department is the misconceptions about radiation hazards causing fear and concerns among physicians, which may negatively impact patient care. In a study among graduated students, almost a third (29%) rarely visited RT department. In our study, although majority accepted that visiting RT facility is harmless, only 43% had ever visited any RT facility. Thus, there is a need to understand and disseminate radiation safety principles among health-care workers and to carefully educate these future opinion shapers.
Perception regarding effectiveness of RT
Although majority of our participants considered RT is an effective modality for cancer treatment, only one-fourth had correctly perceived its effectiveness with majority of others underestimating it. Delaney et al. defined RT as a necessary component of treatment. The impact of RT on cancer survival, alone or in conjunction with other treatments, has been estimated at 40%, compared to 49% of patients being cured by surgery and 11% by systemic treatments.
The knowledge regarding palliative RT and its indication was relatively poor in our study. As a fact, palliative RT is an essential component of any comprehensive palliative care program, where it can represent about 30–50% of the total workload of a department., While bone/brain metastases and malignant cord compression are better known indications for palliative RT, other indications like hemoptysis, tumor bleeding and painful soft-tissue lesions are lesser understood by referring physicians.,
Fortunately, a good number of participants were aware that RT is an important modality in certain cancer emergencies. This is encouraging as the urgent referral and treatment for emergencies such as cord compression is of utmost importance in preserving neurologic function.
Although majority of our participants considered RT as a core department, only about half considered it as a cost-effective modality. Worldwide also, RT is perceived as an expensive modality requiring costly equipment and specially trained personnel, but it is not true. Even when priced in high-income countries, RT has been found as one of the more cost-effective interventions for cancer care, where one machine can treat thousands of patients over many years. The hope for a better systemic therapy has often detracted policy-makers from investing in RT and while the “magic” systemic therapy is still awaited, cancer patients are dying from the lack of access to existing and proven modalities.
Trends/barriers toward referring patients for RT
Unlike other studies in literature, our participants acknowledged the fact that RT remains an underutilized specialty. Published studies, have attributed side effects such as vomiting, mucositis, and ulceration for underutilization of RT. This concern was also reported by 18% of our participants. Other reasons for underutilization of RT in our study were lack of personal knowledge regarding RT procedures and uncertainty regarding its effectiveness. Similar barriers have been reported in literature.,,,,, Tucker et al. reported family reluctance, distance and transportation difficulties, doubt about toxicity, and effect on quality of life among 51% of Canadian pediatric oncologists.
In addition, socioeconomic and cultural factors also affect RT utilization. Although the lack of resources (as in government setups) stimulates the use of less complex and fewer RT fractions, the plentiful resources may lead to more frequent use of complex, costly, and potentially inappropriate treatments. It has been seen that in Vietnam and Pakistan, religious beliefs among patients often lead to refusal of RT whereas it is not known whether such fears and beliefs do exist among physicians too. Tyldesley et al. argued that “physicians may be inaccurate in judging patient preference.” Thus, a referring physician should not hold a patient’s referral for RT believing that patient would refuse or be inconvenienced.
Careful explanation of the treatment and toxicities to the referring physicians, patient, and family can sometimes alleviate reluctance and encourage patients to consider RT.
Measures to improve awareness/referrals in RT
The majority of health-care providers in our and other studies have agreed that they might benefit from further information about RT., Studies have found an increasing interest among the students to have more information about RT.
The unanswered issues should be addressed using initiatives such as improved education and training, better communication with patients and families, better coordination of care (among health-care professionals to reduce patient’s inconvenience), and development and adherence to treatment guidelines.
It should be the cancer center’s responsibility to ensure that the referring PCPs should have a basic preexisting knowledge of oncology and the available infrastructure in the premises and vicinity. Facility rounds to the new joiners and continued medical education workshops on RT should be offered periodically.
Although this study was well conducted and appreciated by participants, it has certain limitations. The study could not evaluate the true radiotherapy utilization rates but uncovered certain perceptions that lead to underutilization of RT. The retrospective evaluations mean that physician recall may be unreliable and actual referrals for RT could not be verified. Another limitation was a self-administered questionnaire-based study where there was a possible risk of manipulating answers. Relatively small sample size may be another limitation. Moreover, the study was conducted in the initial phase of the hospital operation and a repeat study after a certain period may bring a different picture.
| Conclusion|| |
Our survey has shown deficiencies in the knowledge, exposure, and attitude among nonradiation oncology physicians toward RT. This finding is in sync with other studies in literature but a recognition of this fact among participants and their positive attitude toward learning seems encouraging. Most of our participants still favored RT as a core department in any tertiary care facility and understands its value in case of oncologic emergency. It seems the participants understand that RT is a potential modality but lacks the specific need, indications, and utility.
Reforms in existing undergraduate medical curriculum regarding cancer education seem necessary and urgent where a national effort to establish a uniform cancer-teaching module to undergraduate students will go a long way. In future, large multiinstitutional study (involving different geographical and political regions) with larger population size and using online mode of survey may provide further insight into this issue.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rajpal S, Kumar A, Joe W. Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014. PLoS One 2018;13:e0193320. https://doi.org/10.1371/journal.pone.0193320
World Health Organization. The World Health Report 1999—Making a difference. Geneva, Switzerland: World Health Organization; 1999.
Gospodarowicz M. Radiotherapy in global cancer control. Cancer Control. Canada: UICC; 2014.
Anand P, Kunnumakkara AB, Sundaram C, Harikumar KB, Tharakan ST, Lai OS, et al
. Cancer is a preventable disease that requires major lifestyle changes. Pharm Res 2008;25:2097-116.
Arain AN, Ghaffar ZA, Naveed-ur-Rehman, Siddiqui MN, Rehman R. Knowledge and understanding of medical students about radiotherapy and palliative care. Professional Med J. 2014;21:325-32.
Barton MB, Glare PA. Delays in referral for palliative radiotherapy. Med J Aust 1998;169:12-3.
Porter A, Aref A, Chodounsky Z, Elzawawy A, Manatrakul N, Ngoma T, et al
. A global strategy for radiotherapy: A WHO consultation. Clin Oncol (R Coll Radiol) 1999;11:368-70.
Skolnick AA. New study suggests radiation often underused for palliation. JAMA 1998;279:343-4.
McCloskey SA, Tao ML, Rose CM, Fink A, Amadeo AM. National survey of perspectives of palliative radiation therapy: Role, barriers, and needs. Cancer J 2007;13:130-7.
Robinson E. Results of UICC undergraduate cancer education survey. In: Robinson E, Sherman CD, Love RR editors. Cancer education for undergraduate medical students. Geneva: International Union Against Cancer; 1994. pp. 13-16.
Abdellah RF, Attia SA, Fouad AM, Abdel-Halim AW. Assessment of physicians’ knowledge, attitude and practices of radiation safety at Suez Canal University Hospital, Egypt. Open J Radiol 2015;5:250-8.
Biswal BM, Zakaria A, Baba AA, Ja’afar R. Assessment of knowledge, attitude and exposure to oncology and palliative care in undergraduate medical students. Med J Malaysia 2004;59:78-83.
Bosman FT. Integrated oncology course for first-year medical students. J Cancer Educ 1987;2:129-33.
Ahluwalia KP, Yellowitz JA, Goodman HS, Horowitz AM. An assessment of oral cancer prevention curricula in U.S. medical schools. J Cancer Educ 1998;13:90-5.
Samant RS, Fitzgibbon E, Meng J, Graham ID. Family physicians’ perspectives regarding palliative radiotherapy. Radiother Oncol 2006;78:101-6.
Tucker TL, Samant RS, Fitzgibbon EJ. Knowledge and utilization of palliative radiotherapy by pediatric oncologists. Curr Oncol 2010;17:48-55.
Baker JN, Torkildson C, Baillargeon JG, Olney CA, Kane JR. National survey of pediatric residency program directors and residents regarding education in palliative medicine and end-of-life care. J Palliat Med 2007;10:420-9.
Dauer LT, Kelvin JF, Horan CL, St Germain J. Evaluating the effectiveness of a radiation safety training intervention for oncology nurses: A pretest-intervention-posttest study. BMC Med Educ 2006;6:32.
Freudenberg LS, Beyer T. Subjective perception of radiation risk. J Nucl Med 2011;52 (suppl 2):29S-35S.
Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment: Estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 2005;104:1129-37.
SBU. The Swedish council on technology assessment in health care: Radiotherapy for cancer. Acta Oncol 1996;1:35.
Huang J, Zhou S, Groome P, Tyldesley S, Zhang-Solomans J, Mackillop WJ. Factors affecting the use of palliative radiotherapy in Ontario. J Clin Oncol 2001;19:137-44.
Hoegler D. Radiotherapy for palliation of symptoms in incurable cancer. Curr Probl Cancer 1997;21:129-83.
Janjan NA. An emerging respect for palliative care in radiation oncology. J Palliat Med 1998;1:83-8.
Barnes EA, Parliament M, Hanson J, Watanabe S, Palmer JL, Bruera E. Palliative radiotherapy for patients with bone metastases: Survey of primary care physicians. Radiother Oncol 2003;67:221-3.
Sangster JF, Gerace TM, Hoddinott SN. Family physicians’ perspective of patient care at the London regional cancer clinic. Can Fam Physician 1987;33:71-4.
Stålhammar J, Holmberg L, Svärdsudd K, Tibblin G. Written communication from specialists to general practitioners in cancer care. What are the expectations and how are they met? Scand J Prim Health Care 1998;16:154-9.
Gillan C, Briggs K, Goytisolo Pazos A, Maurus M, Harnett N, Catton P, et al
. Barriers to accessing radiation therapy in Canada: A systematic review. Radiat Oncol 2012;7:167.
Lutz S, Spence C, Chow E, Janjan N, Connor S. Survey on use of palliative radiotherapy in hospice care. J Clin Oncol 2004;22:3581-6.
Lievens Y, Grau C. Health economics in radiation oncology: Introducing the ESTRO HERO project. Radiother Oncol 2012;103:109-12.
Tyldesley S, Zhang-Salomons J, Groome PA, Zhou S, Schulze K, Paszat LF, et al
. Association between age and the utilization of radiotherapy in Ontario. Int J Radiat Oncol Biol Phys 2000;47:469-80.
Szumacher E, Barbera L, Barnes E, Keighley-Clarke T, Presnail B, Matyas Y. Matyas, et al
: Improving access to radiotherapy services in the Simcoe-Muskoka region of Ontario: Needs assessment study. Can J Med Radiat Technol 2007;38:7-16.
Dworkind M, Shvartzman P, Adler PS, Franco ED. Urban family physicians and the care of cancer patients. Can Fam Physician 1994;40:47-50.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||Using ePROMs for follow-up after palliative radiotherapy: an exploratory study with patients and health care providers.
| ||Eva Oldenburger, Inge Neyens, Annemarie Coolbrandt, Sofie Isebaert, Aline Sevenants, Chantal Van Audenhove, Karin Haustermans |
| ||Patient Education and Counseling. 2021; |
|[Pubmed] | [DOI]|
||Palliative care physicians and palliative radiotherapy, knowledge and barriers for referring: a cross-sectional study.
| ||Andrés Vargas,Carolina Torres,Anna Küller-Bosch,Belén Villena |
| ||Journal of Pain and Symptom Management. 2020; |
|[Pubmed] | [DOI]|
||Public Awareness and Perceptions of Radiotherapy and Their Influence on the Use of Radiotherapy in Dar es Salaam, Tanzania
| ||Geofrey F. Soko,Anthony B. Burambo,Mpanda M. Mngoya,Burhani A. Abdul |
| ||Journal of Global Oncology. 2019; (5): 1 |
|[Pubmed] | [DOI]|