Awareness of Radiotherapy and its Side Effects among Cancer Patients Admitted at Oncology Unit, Teaching Hospital Batticaloa, Sri Lanka.

Awareness of Radiotherapy and its Side Effects among Cancer Patients Admitted at Oncology Unit, Teaching Hospital Batticaloa, Sri Lanka.

S. Ravivarman, N.R. Kumarasinha, G.P. Shehani Fernando, S. Shanmukanathan ^⃰

Eastern University, Sri Lanka.

DOI: https://doi.org/10.51244/IJRSI.2024.1110069

Received: 08 October 2024; Accepted: 21 October 2024; Published: 22 November 2024

ABSTRACT

Radiotherapy is the chief non-surgical method to control malignant tumors, being used in roughly 50% of patients.

This study aimed to assess the awareness of radiotherapy and its side effects among cancer patients admitted to the oncology unit, at Teaching Hospital Batticaloa.

A descriptive study was carried out to assess the awareness of radiotherapy and its side effects among 74 cancer patients admitted at the Oncology unit, Teaching Hospital Batticaloa. A complete enumeration method was used to recruit participants. After obtaining informed consent, data were collected through a pilot-tested validated interviewer-administered questionnaire. Statistical Package of Social Sciences 26 was used to analyze the data.

56.8% of the respondents had a very good awareness level of radiotherapy and there were 4.1% of respondents in the very poor level of awareness category. Only 1.4% of the respondents had a very good awareness level and 58.1% of the respondents had a very poor awareness level of side effects of radiotherapy. Among socio-demographic factors, only educational level (p=0.001) was found to have a significant association with an awareness level of radiotherapy and age (p=0.021), educational level (p=0.044) was found to have a significant association with an awareness level of side-effects of radiotherapy. 59.5% of the respondents received prior information about radiotherapy and 39.2% of the respondents received prior information about side effects of radiotherapy. 43.2% of the respondents received information regarding radiotherapy and 27% of the respondents received information regarding side effects via doctors. Among sources of information, doctors (0=0.036), and nurses (p=0.043) were found to have a significant association with an awareness level of radiotherapy and doctors (p=0.00), nurses (p=0.001), family and relatives (p=0.013), cancer patients (p=0.00) and media (p=0.007) were found to have a significant association with an awareness level of side-effects of radiotherapy.

Based on Findings reveal that more than half of the respondents had a very good level of awareness of radiotherapy and more than half of the respondents had a very low level of awareness of the side effects of radiotherapy. Doctors had a major role in providing information to the patients.

Keywords: Awareness, Radiotherapy, Side-effects. Source of information

ABBREVIATIONS

FHCS – Faculty of Health Care Science

HPV – Human Papilloma Virus

n – Number

RT- Radiotherapy

THB – Teaching Hospital Batticaloa

WHO – World Health Organization

% – Percentage

INTRODUCTION

Background

Cancer is a broad set of illnesses that can begin in practically any organ or tissue of the body when abnormal cells develop uncontrolled, invade neighbouring tissues, and/or spread to other organs. Cancer is the leading cause of mortality in the globe, accounting for almost 10 million deaths in 2020, or one in every six deaths. Breast, lung, colon, and rectum cancers are the most prevalent. Tobacco use, a high body mass index, alcohol use, a lack of fruits and vegetables, and a lack of physical activity causes around one-third of cancer deaths. Infections that cause cancer, such as human papillomavirus (HPV) and hepatitis, contribute to around 30% of cancer cases in low- and lower-middle-income nations. Many cancers can be curable if they are diagnosed early and treated properly (WHO, 2023)

Cancer is becoming more prevalent in Sri Lanka. Over the last 25 years, the total incidence of cancer in Sri Lanka has more than doubled, accompanied by an increase in cancer-related death. Cancer is now the second leading cause of hospital death in Sri Lanka (Jayarajah & Abeygunasekera, 2021).

In Sri Lanka in 2019, a total of 31,848 people were newly diagnosed with cancer. The most common malignancies among men were lip, tongue, and mouth cancers (n=2173), trachea, bronchus, and lung cancers (n=1264), colon and rectum cancers (n=1260), and esophageal cancers (n=1100). Lip, tongue, and mouth cancer accounted for 15% of all male malignancies. Breast cancer (n=4447), thyroid cancer (n=2202), colon and rectum cancers (n=1247), and cervix uterine cancers (n=1114) were the most common malignancies among females. Breast cancers accounted for 26% of all female cancers. There were 780 instances of juvenile malignancies (ages 0 to 19 years), with leukemia accounting for 22.1%. Colombo district (n=4115), Kandy district (n=1914), Kurunegala district (n=1598), Gampaha district (n=1543), and Rathnapura district (n=1136) reported the highest number of malignancies. According to the Annual Health Bulletin (2019), 6296 people died from cancer in government healthcare settings in 2019 (Ministry of Health, 2021).

Cancer treatment comes in a variety of methods. Surgery, radiation, chemotherapy, hormones, and immunotherapy are all used to treat cancer. Nowadays, radiation is a hallmark of cancer therapy, curing or palliating around 50% of cancer patients. Ionizing radiation, which is utilized in Radiotherapy, damages all live cells, whether normal or cancerous (Güleser et al., 2012).

Different malignancies require various doses of radiation. The quantity of radiation provided to the patient may vary depending on the size of the tumor, kind of surgery, involvement of lymph nodes, and cancer characteristics (Mohan et al., 2019).

The ultimate objective of treatment planning is to optimize cell death in the tumor while reducing damage induced in the normal tissue around the tumor (Löbrich & Kiefer, 2006). However, the reduction in quality of life was larger immediately following radiation than 5 years later (Jensen et al., 1994). One disadvantage of radiation is the inevitable damage done to normal, non-cancer cells, which might cause adverse effects (Löbrich & Kiefer, 2006). The degree of late side effects is determined by the overall radiation dosage, fractionation type, and volume irradiated (Jensen et al., 1994). Acute responses occur during and soon after therapy, affecting the skin and mucous membranes and producing discomfort, swallowing difficulty, and voice issues. These initial adverse effects are reversible and can be alleviated in a variety of ways (Löbrich & Kiefer, 2006). However, the harmful effects of chemotherapy and radiation, such as oral mucositis, gastrointestinal toxicity, hepatotoxicity, nephrotoxicity, hematological system damage, cardiotoxicity, and neurotoxicity, restrict clinical utilization. As a result, these negative effects frequently decrease cancer patients’ quality of life and may lead to therapy withdrawal (Zhang et al., 2018).

Radiotherapy side effects are categorized as acute (immediate), consequential, or late effects on normal tissues over time (Majeed Hafsa, 2022). Most patients develop side effects and complications as a result of therapy during and soon after RT. Patients’ quality of life may also be affected by radiotherapy. There is a wide range of radiotherapy-related symptoms, including tiredness, discomfort, sleep difficulties, loss of appetite, nausea and vomiting, and oral issues (Güleser et al., 2012).

Acute radiation damage mainly affects rapidly proliferating cells, such as epithelial skin or digestive tract surfaces. It generally appears a few weeks after therapy and affects inter-mitotic cells (skin and mucosa). As a result, compensatory hyperplasia inside stem cells leads to healing. As a result, symptoms subside over a few weeks (Majeed Hafsa, 2022). When the dosage is restricted and tissue turnover is fast, such as in the oral mucosa and gut, early side effects are generally reversible, or partially reversible, as in the lungs (pneumonitis), skin, and brain (memory loss and fatigue) (Barazzuol Lara, Coppes Rob P, 2020).

Consequential effects were seen when acute problems are not managed and create long-term harm (Majeed Hafsa, 2022)

Late complications appear months to years after exposure and are usually characterized by the involvement of post-mitotic cells (liver, kidney, heart, muscle, and bone). Radiation harms stem cells, resulting in tissue loss as part of regular cell turnover but insufficient replacement by stem cells owing to radiation damage. This causes a breakdown in the protective barrier, most typically in the skin, oral mucosa, and gastrointestinal system, especially 1-5 years after radiation. Such lesions are significant late consequences when acute injury fails to heal fully and lingers into the late stage (Majeed Hafsa, 2022)

The appearance of late normal tissue side effects several months to years after radiation defines them. Late adverse effects are typically persistent and progressive, resulting in a decrease in patients’ quality of life following therapy. As a result, they are frequently used to estimate radiation exposure limits. Unlike early side effects, the time to react of late-responding tissues is dosage dependent and influenced by processes such as cellular senescence, chronic inflammation, hypoxia, and fibrosis. All of these reactions, in effect, impair the tissue’s regeneration ability. Fibrosis is important in the pathophysiology of adverse effects in most tissues, including the heart, lungs, and liver (Barazzuol Lara, Coppes Rob P, 2020).

Following years of treatment, chromosomal abnormalities are one of the most serious side effects of RT in cancer patients. Cancer patients who have received RT exhibit structural chromosomal abnormalities as well as numerical or copy number changes (Mohan et al., 2019).

Several experts believe that knowledge is critical to the successful treatment and rehabilitation of cancer patients (Ream & Richardson, 1996). Specific information needs vary based on the treatment site, length of therapy, and patient characteristics. Informational support is especially crucial in the case of therapies such as radiation therapy, and patients’ negative emotion is at their peak before treatment begins, showing the need for psychological preparation for radiation therapy (Güleser et al., 2012).

Before treatment begins, patients should be informed about their condition, and the potential advantages and negative effects of the planned therapy, and their consent should be obtained. Relevant and clear information is required for patients to have sufficient knowledge to participate actively in shared decision-making, adhere to the treatment plan, be aware of potential side effects, and understand what to do if adverse effects occur (Berger et al., 2018). New radiation patients desire detailed information during their initial session. Adequate information on therapy, procedures, side effects, and the prognosis is very important. Yet, information should be customized to the patient’s background, comprehension, and anxiety (Zeguers et al., 2012).

More than half of the patients had not received information regarding radiotherapy; however, patients (83.2%) who experienced issues during therapy desired information. The majority of patients who received information identified doctors as their primary source. The patients’ top information requirements were all elements of their diagnosis, therapy, and RT side effects. Most patients want to know about their therapy and have encountered a range of symptoms. Patient education and knowledge are critical components of therapy. The advantages of knowledge for cancer patients include decreased anxiety, easier adjustment, and better illness management. Accurate, relevant, and timely information would allow for improved control of therapeutic side effects, decreasing physical adverse effects (Güleser et al., 2012).

It is intriguing, and maybe disappointing, that the nurse was not used as a source of information, and the majority of the patients learned about adverse effects from personal experience and it may help to avoid and alleviate worries and misconceptions by giving sensitive and accurate information as well as psychological support (Güleser et al., 2012) Because the media’s message is mostly negative. Of course, this does not entail that anything is incorrect; it might just be out of context and/or imbalanced. On the positive side, given healthcare providers’ willingness to answer patients’ concerns openly and honestly, information from the media can offer substance to such inquiries (Hammick et al., 1998).

Healthcare practitioners are responsible for providing accurate, current, trustworthy, and relevant information to individual patients (Güleser et al., 2012). The types and quantity of information and support that patients require may vary depending on the type of cancer, the level of disease progression, the type of therapy they get(Sharma & Malik, 2019), and changes in their cancer journey (Jansen et al., 2007). A list of potential information sources was presented, which included professional sources (clinic nurses, general practitioners, radiation therapy technologists (RTs), media sources (magazines, newspapers, television/radio), written information (leaflets, medical books), and other patients, and family/friends (Güleser et al., 2012).

Nurses have a crucial role in providing cancer patients with information and support on treatment (Jansen et al., 2007) and promoting involvement and choice. Nurses may develop patients’ sense of control by giving them the belief that they can change or influence results. It can improve control and self-efficacy, encourage self-care, aid in symptom relief, and reduce anxiety. These relationships are strengthened when medical and nursing professionals accurately analyze and meet their patients’ particular information needs (Ream & Richardson, 1996). Mass public education regarding the benefits and risks of radiological diagnostics in illness treatment may provide more reassurance to patients and support them in making the right decisions when necessary (Almatared et al., 2017).

Justification

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 radiotherapy during their disease course ranges between 40% and 62% (Sharma & Malik, 2019).

There are several research article about knowledge on radiotherapy and its side effects among patients, most have indicated that patients have low level of knowledge about radiotherapy and its side effects. According to (Almatared et al., 2017) There is relatively low knowledge and awareness of the risks associated with Ionizing Radiation among patients in the study population (Soko et al., 2019) state that public awareness of radiotherapy in Dar es Salaam is low, and negative perceptions prevail. Low levels of awareness and negative perceptions have a negative effect on the use of Radiotherapy. When we obtained patients history during our clinical appointment, we realized that there was a lack of knowledge about radiotherapy and side effects.

Even though radiotherapy is widely used around the world, it leads to many side effects (Mohan et al., 2019).

Late adverse effects are typically persistent and progressive, resulting in a decrease in patients’ quality of life following therapy (Barazzuol Lara, Coppes Rob P, 2020) knowledge about side effects of radiotherapy is much important to reduce the severity and improve the quality of life. Because side effects can be worsening and became fatal if untreated. In the studies by (Güleser et al., 2012) the overall quality of life of the patients receiving radiotherapy was affected negatively by fatigue.

Though many studies have been conducted worldwide to assess the awareness of radiotherapy and practices to overcome the side effects, in Batticaloa no or rare extensive study has been done on this research topic so far. Therefore, we have decided to conduct a research among patients who admitted for radiotherapy at oncology unit, Teaching Hospital Batticaloa to assess the knowledge on radiotherapy and its side effects.

We hope the findings of our study will help doctors, nurses and radiotherapists to encourage for teaching about benefits and risk associated with radiotherapy and it may leads to reduce the refusal of radiotherapy among radiotherapy patients and also patients can improve their knowledge on attitudes and practices to overcome the side effects.

Objectives

General objective

To assess the awareness on radiotherapy and its side effects among cancer patients admitted at the oncology unit, Teaching Hospital Batticaloa.

Specific objectives

1. To assess the awareness on radiotherapy among cancer patients admitted for radiotherapy.
2. To assess the awareness regarding side effects among cancer patients admitted for radiotherapy.
3. To analyze the relationship between awareness and different socio-demographic factors.
4. To identify the sources of information about radiotherapy and its side effects.

LITERATURE REVIEW

Cancer is the most prevalent cause of mortality in developed countries and the second most common cause of death in underdeveloped countries. Cancer awareness and education, as well as the need for cancer screening and early diagnosis, can minimize the risk of cancer-related mortality. (Samat et al., 2014) predicts that the number of new cancer cases per year would climb to 22.2 million by 2030, with around 12 million people who receive as part of their treatment.(Barazzuol Lara , Coppes Rob P, 2020) Cancer knowledge and awareness are critical for successful detection and treatment. This study also investigates respondents’ awareness of cancer and cancer screening. According to the findings, 96% (522 respondents) have heard of cancer and have some awareness about it. Respondents are aware that cancer is serious and can be lethal, and that curing and treating it is difficult. Merely 4% (Soko et al., 2019) of the people surveyed had never heard of cancer. Just 3.0% (3) of urban respondents had never heard of cancer, whereas 97.6% (121) have heard of it. Rural respondents are somewhat less likely than urban respondents to have heard of cancer. That is, 95.5% (401 respondents) have heard of cancer, while 4.5% (19 respondents) have never heard of cancer. As compared to other places, respondents in metropolitan areas reported having more information about cancer (Samat et al., 2014).

Before treatment begins, patients should be informed about their condition, and the potential advantages and negative effects of the planned therapy, and their agreement should be obtained. Relevant and clear information is required for patients to gain sufficient knowledge to participate actively in shared decision-making, follow the treatment plan, be aware of potential side effects, and understand what to do if adverse effects occur. 98 people were included in this trial. Patients with a greater level of education, everyday Internet access, and a paid job had the highest baseline knowledge scores (Berger et al., 2018).

The National Cancer Institute in Maharagama performed descriptive cross-sectional research. The majority (49) of patients were optimistic that cancer might be treated with adequate therapy. Just three patients had doubts about this, and four were unsure about the treatment’s effectiveness in managing the condition. Rejection might explain why 55.56% of the study’s entire population was unaware of existing cancer. None of the patients were aware of the most recent prognostic statistics. They had alternative opinions on this element of the condition (de Silva S K L A, de Silva P M K R, Lakshan M T D, 2006).

Awareness on radiotherapy

Ionizing radiation is an effective cancer treatment. The curative effect is mostly determined by the ability of ionizing radiation to destroy cancer cells. (Löbrich & Kiefer, 2006). Radiation oncology is a highly specialized treatment field that necessitates extensive radio physical, radiobiological, and clinical understanding. Ionizing radiation, primarily X-rays, gamma rays, accelerated electrons, and their interactions with biological matter are used as therapeutic methods in radiotherapy.(Lorenzo Federico , Miralda Georgina, Aguiar Sergio, 2019) A cross-sectional study was conducted in Dar es Salaam, Tanzania, with 629 participants, involving 53 cancer patients, 129 health professionals, 127 medical and nursing students, and 320 general public respondents. The average correct response rate across all 13 awareness items was 35.6%. The majority of respondents (83.1%) thought that RT would shorten their lives. The item with the greatest percentage of right responses was “Radiation is simply like light and doesn’t treat, it’s merely administered to deceive patients,” which received a scoreline of 46.6%. According to the findings, 33.9% of respondents had low degrees of awareness regarding radiotherapy, while 42.8% and 23.2% had medium and high levels of awareness, respectively. Medical/nursing students, younger respondents, single or cohabiting respondents, and those with a college or higher degree had better awareness. Overall, 52% would accept radiotherapy as part of their therapy if it was advised. Individuals who would tolerate getting radiotherapy were more likely to be knowledgeable of and favorable about it (Soko et al., 2019)

From October to November 2016, cross-sectional research was undertaken in the Department of Radiation Oncology at a multispecialty hospital in New Delhi. The purpose of this study was to examine non-radiation oncology colleagues’ knowledge, perceptions, and attitudes about radiotherapy as a cancer treatment technique. Overall, 76% of participants were aware of the closest Radiotherapy facilities in the region. Even though 97% of participants were aware of the presence of a Radiotherapy facility within the hospital, only 48% could properly identify the location. Only 25% of the services accessible in the radiotherapy department were correctly answered, 35% were somewhat accurate, and 40% were wrong. Among all, 77% of participants said they understand the difference between teletherapy and brachytherapy. About the most recent radiotherapy technologies, 27% indicated complete awareness, 38% reported none, and the other 35% expressed some awareness (Sharma & Malik, 2019)

This cross-sectional study includes 375 consecutive patients and was done over 4 months at the radiology unit of King Khalid Hospital in Najran using self-administered questionnaires. Three-quarters (60%) of patients reported being unconcerned about undergoing radiological testing. If they can manage the sickness, the same number of patients would not undergo radiological exams. Over half of the respondents (50%) claimed that they would be dissatisfied if no more radioactive tests were necessary, and 52% did not believe that radiological treatments may pose risks and have negative effects on the body. Furthermore, more than half of the patients (53%) reported not understanding that radiological exams might cause cancer; 48% would not repeat radiological tests within six months; and around 69% were unaware of the value of Radiology for diagnosis. The study population has relatively poor knowledge and awareness of the dangers associated with Ionizing Radiation. As a result, there is a need to educate the general population, not only medical staff, about radiation exposure and its related hazards. The most unexpected conclusion of this study is that a huge number (69%) of respondents, compared to just 18% of respondents, are unaware of the value of Radiology for diagnosis, indicating a lack of patient education in clinics on the side of physicians regarding the hazards connected with radiation. Even though, more than half of the respondents (51%) can identify between the various radiological examinations, but not the hazards connected with these tests (Almatared et al., 2017)

During of one month, descriptive cross-sectional research was carried out at the National Cancer Institute, Maharagama, utilizing an interviewer-administered questionnaire. The treatment plan of each patient in the research sample was collected from the clinicians in charge of them, supervised by the consultant oncologist, and the patient’s understanding of his or her specific management plan was evaluated. In 42 cases, radiation might be used to manage the patient at the current stage of the disease. In 29 of these cases, the patients were aware of this, whereas three thought it was impossible. The remaining ten were unsure if it was possible. Among the 14 patients for whom radiation was not an option for treatment, 04 thought it was still advantageous, 05 were unsure, and the remaining 05 were conscious of the actual situation. Only 07 of the 29 people who were presently receiving radiation or knew it was a treatment possibility were aware of the accompanying negative effects. 02 people claimed radiation had no adverse effects, while 20 were unsure. Among the 07 patients who agreed that radiation had side effects, 05 accurately identified at least one adverse effect. One patient’s information was incorrect, while the other patient was unaware of any negative effects (de Silva S K L A, de Silva P M K R, Lakshan M T D, 2006)

Awareness on Side effects

Radiotherapy is the most often used nonsurgical treatment for treating malignant tumors. Since radiotherapy is a significant adjuvant non-invasive therapy, it has certain unfavorable side effects. (Mohan et al., 2019) It causes DNA damage and, as a result, cell death. This has a greater impact on cancer cells than on normal cells (Majeed Hafsa, 2022)

This descriptive research was carried out at Erciyes University Gevher Nesibe Hospital and M. Kemal Dedeman Cancer Hospital in Kayseri, Turkey. A total of 450 patients were administered radiotherapy, with 345 of them agreeing to participate in the research. According to the findings of this study, the majority of patients (80.9%) suffered radiotherapy adverse effects. For the entire group, the most commonly mentioned adverse symptoms were fatigue (86.0%), nausea and vomiting (59.9%), and a lack of appetite (50.9%). 32.3% of the patients felt mouth soreness, while 27.3% received radiotherapy in the head and neck area. Outpatients’ most frequent complaints were fatigue, nausea and vomiting, and lack of appetite (Güleser et al., 2012)

A telephone interviewer research with a short questionnaire was done to examine the impact of late side effects on the everyday life of patients who had undergone radiation treatment several years before. The research included 389 individuals with laryngeal or pharyngeal squamous cell carcinomas treated alone with radiation. Just a few (10%) reported major treatment-related issues. Voice issues and severe xerostomia were specifically noted. Half of the patients treated for pharyngeal cancer experienced xerostomia and occasionally felt handicapped. 10% of the patients’ social relationships were affected, and 10% had retired because of cancer or therapy-related side effects. All but 04 individuals remembered major adverse effects they encountered during radiation. Among early major side effects, xerostomia (44%), tiredness (37%), and taste changes were often stated, although psychological issues and pain were of great concern in 10 cases (23%). According to the patients, they encountered negative effects during radiation. They differed significantly across individuals with laryngeal and pharyngeal carcinoma, as predicted. Due to radiation side effects, one laryngectomy was done. Xerostomia and a weak voice were not only the most common side effects, but they also caused the most difficulty in daily life. It is determined that radiation appears to be a well-tolerated treatment with little impact on everyday life in patients with laryngeal cancer (Jensen et al., 1994)

Early detection and treatment of acute adverse effects can contribute to minimizing their persistence in the long term (Majeed Hafsa, 2022)

Source of information about Radiotherapy and Side-effects

Cancer information, provided in a caring and sensitive manner, is an essential source of emotional support for cancer patients. What patients want to know about their diagnosis and treatment, and whom they want to tell them, has been widely researched elsewhere (Hammick et al., 1998) The attitude of the patients after getting information is a key aspect of the illness’s prognosis. The feeling of being able to limit the condition motivation to cope with it more successfully and permits for adaptation (Güleser et al., 2012)

From October to November 2016, a questionnaire-based cross-sectional survey involving 63 participants was done in a tertiary care hospital in New Delhi. Overall, 28 participants reported having come across information material on the radiotherapy facility in the hospital, with the majority (78%) desiring to know more about it in the future. The remaining 22% were uninterested in learning more. The most prevalent recommendations were to raise radiotherapy knowledge among primary caregivers and to advise patients and families through a radiation oncologist. The majority of healthcare practitioners in this and earlier research believed that more information regarding radiotherapy would be beneficial. According to studies, students are becoming progressively interested in learning more about radiotherapy. Unanswered questions should be addressed through initiatives such as better education and training, improved communication with patients and families, improved coordination of care (among healthcare professionals to reduce patient inconvenience), and the development and compliance with treatment guidelines. A thorough explanation of the treatment and its dangers to the referring physician, patient, and family can sometimes relieve reluctance and encourage patients to try radiotherapy. (Sharma & Malik, 2019) A semi-structured interview format was used to perform descriptive research on 345 cancer patients at Erciyes University Gevher Nesibe Hospital and M. Kemal Dedeman Cancer Hospital in Kayseri, Turkey. This method was used to encourage patients to share their own experiences and informative requirements. The respondents reported the most important information requirements as treatment side effects, side effect management, and nutrition guidance. According to the findings of this study, 45.2% (n=156) of respondents had received the knowledge of radiotherapy, whereas 54.8% (189) had not. The majority of respondents said they received their information from more than one source. Just 0.6% of patients received information from the nurse, whereas 85.2% received it from the doctor. Two hundred and seventy-nine patients (80.9%) showed a desire for knowledge. Two hundred twenty-three patients (79.9%) said they would like to know everything about their diagnosis and therapy. One hundred fifty-seven patients (56.2%) requested knowledge about radiotherapy’s negative effects. There were no significant changes in patients’ information preferences based on age, gender, education, cancer location, or time since diagnosis. More than half of the patients (54.5%) said they were aware of the negative effects of radiotherapy. 42.9% of the patients said they got this information from self experience, 31.9% from the doctor, 28.1% from other patients, and 1.5% from the nurse. 44.6% of patients having radiotherapy reported that their source of knowledge was other cancer patients.

91.2% of patients who got just incomplete information regarding radiotherapy indicated the need for more information. There was a strong link between these two groups. On radiotherapy, 83.2% of those who had issues and 71.2% of those who did not have problems expressed the desire to have information. Patients suffering adverse effects were more likely to request further information (83.2% vs. 71.2%), and the difference in percentage between the groups was statistically significant. When patients experienced symptoms, they consulted a clinical professional; 74.1% called a doctor, 23.0% contacted a radiotherapist, and just 5.1% contacted an oncology nurse.81% of patients want information about their therapy. The perspectives expressed by this group of patients are typical of the majority, indicating that providing the information is the most important issue for patients receiving radiotherapy. Numerous studies suggest that providing information about the disease to patients and families promotes therapy responsiveness, and as a result, patients show positive improvements in dealing with illness. Providing information also helps to reduce illness recurrence (Güleser et al., 2012) Semi-structured interviews were used to perform a qualitative study among 300 patients who attended the treatment simulator to prepare for their first course of radiation. Nearly all of the patients (90%) reported they had received information regarding radiation from their doctor(s), treatment radiographers, or unspecified hospital staff. Even so, three were unsure who had informed them about the treatment they were scheduled to get and were unsure whether they had been informed about radiation. Five patients stated that they learned about radiation through other people, either family members who are doctors or friends who have undergone radiotherapy. Three people highlighted the written material that was accessible at the hospital. ‘Information overload,’ one person said. Most patients were happy with the information they had received regarding their therapy and felt they could ask the physicians and radiographers more questions if required. One-third of those questioned would have preferred additional information, such as the long- and short-term impacts of the therapy, the selection of the treatment unit, how the technology works, and the location of the machinery (Hammick et al., 1998)

According Cassileth et al. (1980), the study reported that they explored the desire for information and involvement in 256 cancer patients. The value of knowledge is constantly emphasized by researchers studying the requirements of cancer patients. Among the patients interviewed, 62.9% said they ‘needed’ to know about potential adverse effects of therapy, 62.1% thought they ‘needed’ to know what the treatment would achieve, and 60.5% thought they ‘needed’ to know if they had cancer. Just 2% said they ‘didn’t want to know’ about their diagnosis, side effects, or therapy (Ream & Richardson, 1996)

A study conducted in North Carolina in 2019 among 20 individuals who had undergone or are currently undergoing medical radiation. Semi structured interviewed format was used to perform this qualitative study.

Purpose of this study is to explore patients’ awareness and knowledge of information regarding medical radiation. Among participants, most patients were generally aware of the negative effects of medical radiation, but some may not consider them serious enough. Notable number reported a lack of accurate information and knowledge available as a barrier.

Twelve (60%) of the participants were aware of the seriousness of the medical concerns related to medical radiation exposure if not managed or controlled, while five (25%) once again expressed having no fear or concerns on medical radiation exposure effects (Mann, 2019)

In 2020 a study was conducted with 40 participants to assess the effectiveness of a structured teaching program on knowledge and attitude regarding radiation therapy among cancer patients receiving radiation therapy residing in selected communities, in Bharatpur. Patients with cancer may be at risk for the development of late complications, knowledge of radiation therapy is essential for the various treatment modalities and awareness of the risks for developing late complications of their treatment. More than 70% of the cases report for diagnostic and treatment services in the advanced stages of the disease, which has led to poor survival and a high mortality rate. 27 (68%) had adequate knowledge and none of the subjects had inadequate knowledge. This difference in the pretest knowledge scores and post-test knowledge scores could be due to the structured teaching program regarding radiation therapy. (Tara & Rajasudhakar, 2020)

METHODOLOGY

Study design

This study was a cross-sectional descriptive study   

Study setting & Area

The study was conducted at the Oncology Unit, Teaching Hospital Batticaloa   

Study population

Cancer patients of all stages and both genders who were waiting for radiotherapy at the oncology unit, Teaching Hospital Batticaloa during one month (October 09 – November 08, 2023) and who were between 21 to 70 years of age.  

Inclusion criteria

Data were collected from

• Both male and female cancer patients who were waiting for radiotherapy at the oncology unit, Teaching Hospital, Batticaloa during the study period.
• Cancer patients who had given their consent to participate in this study.

Exclusion criteria 

• Patients with altered levels of consciousness due to severity of illness.
• Patients who had taken part in the pilot study.
• Cancer patients who were not given their consent to participate in this study.

Sample Size

Complete enumeration (N=74)

Study period

November 2022- December 2023

Study Instruments

An interviewer-administered validated questionnaire was used to collect data among cancer patients. The questionnaire was prepared in all three languages (English, Tamil, Sinhala).

The questionnaire has 4 sections.

The questionnaire consists of,

Section A: Consists of questions on socio-demographic details.

Section B: Consists of questions on awareness of radiotherapy

Section C: Consists of questions on awareness of side effects of radiotherapy

Section D: Consists of questions on the source of information about radiotherapy and its side effects  

The content validity of the questionnaire was done based on the experts ’opinions,

For the content validation, each question in the questionnaire was rated by using a rating scale as follows

Table 1: Content validation rating scale

Response	Rate
Not at all relevant to the study	1
Not relevant to the study	2
Undecided	3
Somewhat relevant to the study	4
Very relevant to the study	5

For each response in scale, marks were given as follows

Table 2: Content validation rating scale by marks

Response	Marks
Not at all relevant to the study	1
Not relevant to the study	2
Undecided	3
Somewhat relevant to the study	4
Very relevant to the study	5

They were asked to give an overall opinion on the questionnaire and suggestions to add further relevant questions to improve the questionnaire.

The content validity index was calculated for each question. Each question would have a minimum of 0 to 15 as the maximum raw score, which was converted to a percentage. The questionnaire was modified as follows,

1. The questions which graded less than 50% were removed from the questionnaire.
2. The questions graded between 50% to 75% were added to the questionnaire with the necessary changes
3. The questions which graded between 75% to100percent were used in the questionnaire without any changes.

According to the faculty review committee’s suggestion questionnaire was modified. The remaining questions, with any additional questions suggested by the experts, were forwarded to the pilot study. The finalized questionnaire was tested in the pilot study before use.

Table 3: Content validation of questionnaire

Specific Objective	Question Number	Rate			Marks	Grade %
		Expert 1	Expert 2	Expert 3
Section A: Socio-demographic factors	01	5	5	5	15/15	100%
	02	5	5	5	15/15	100%
	03	5	4	5	14/15	93.33%
	04	5	5	5	15/15	100%
	05	5	5	5	15/15	100%
	06	5	5	5	15/15	100%
Section B: Awareness of radiotherapy	07	4	5	5	14/15	93.33%
	08	5	5	5	15/15	100%
	09	5	5	5	15/15	100%
	10	5	5	3	13/15	86.67%
	11	5	5	5	15/15	100%
	12	5	5	5	15/15	100%
Section C: Awareness of side effects of radiotherapy	13	5	5	5	15/15	100%
	14	3	5	5	13/15	86.67%
	15	5	5	5	15/15	100%
	16	5	5	5	15/15	100%
	17	5	5	5	15/15	100%
	18	5	5	5	15/15	100%
	19	5	5	5	15/15	100%
Section D: Source of information about radiotherapy and its side effects	20	5	5	5	15/15	100%
	21	5	5	5	15/15	100%
	22	5	5	5	15/15	100%
	23	5	5	5	15/15	100%

Data collection period

One month (October 9 to November 8, 2023)

Data collection

Permission for data collection was obtained from the Director of the Teaching hospital, Batticaloa. The purpose and the benefit of the study were explained to the respondents by using an information sheet (Annexure III) and consent sheet (Annexure II). Consent was obtained from the participant before the data collection and data were collected through a structured interviewer-administered questionnaire prior to radiotherapy. A suitable time and duration, comfortable environment, and needed facilities were arranged for the participants.

Pilot study

A pilot study was conducted to test the questionnaire, its feasibility, and its applicability.

The pilot study was conducted among 15 cancer patients admitted for radiotherapy at Teaching Hospital Batticaloa. These patients were excluded from the research.

The questionnaire was modified based on the pilot study findings.

Data analysis

Data entering, analysing, and interpreting were done using the statistical package for Social Science version 25 (SPSS V.25). Percentage of awareness, mean awareness level & and standard deviation were analyzed. Independent variables were age, education level, residence & and occupation. To assess the level of awareness, a scoring system was used in the questionnaire for each section. For sections B and C,

Table 4: Response rating scale

YES	1
NO	0
DON’T KNOW	0

According to the mean value, the level of awareness was graded into five categories.

Table 5: Scores and Grades

Score	Grade
0 – 20	Very poor
21 – 40	Poor
41 – 60	Average
61 – 80	Good
81 – 100	Very good

Table 6: Data analysis strategies

Specific Objective	Related questions	Variable	Scale of measurement	Statistics
To assess the awareness of radiotherapy among cancer patients admitted for radiotherapy	Section B: Q7 –Q12	Awareness	Nominal	Descriptive
To assess the awareness of side effects among cancer patients admitted for radiotherapy	Section C: Q13 –Q19	Awareness	Nominal	Descriptive
To analyze the relationship between awareness and different social demographic factors	Section A: Q1 –Q6	Awareness	Nominal	Chi- square
		Socio- democratic factors	Ordinal
To identify sources of information about radiotherapy and its side effects	Section D: Q20 –Q23	Awareness	Nominal	Descriptive

Ethical considerations

Ethical clearance of this study was obtained from the Ethical Review Committee (ERC), Faculty of Health-Care Sciences (FHCS), Eastern University, Sri Lanka

The permission for collecting data was obtained from the director of Teaching Hospital Batticaloa.

Respondents were explained thoroughly about the study through an information sheet and written informed consent was obtained before data collection. The participants were informed clearly about their right to withdraw at any stage of the study without penalty.

All study subjects were identified by a serial number instead of using their names to ensure the anonymity of the study subject. The anonymity and confidentiality of the participants were maintained throughout the study. All collected data were handled with confidentiality. Collected data were processed and saved with a password on a personal computer. The handling and analysis were carried out only by investigators and only for the above study.

RESULTS

Socio-demographic details of the participants

Table 7: Socio-demographic characteristics of the population

Variable (n=74)	n		%
Age group
21-30	2		2.7
31-40	9		12.2
41-50	13		17.6
51-60	25		33.8
61-70	25		33.8
Gender
Male	31		41.9
Female	43		58.1
Place of living
Urban	40		54.1
Rural	34		45.9
Educational Level
Never been to school	5		6.8
Primary	20		27
Junior Secondary	14		18.9
Senior Secondary	25		33.8
Graduated	10		13.5
Occupation
Self-employment		5	6.8
Government		11	14.9
Retired		3	4.1
Non-government		16	21.6
Unemployment		39	52.7

Variable (n=74)	n	%
Type of cancer
Anal cancer	1	1.4
Bladder cancer	5	6.8
Brain cancer	5	6.8
Breast cancer	13	17.6
Cervical cancer	2	2.7
Colon cancer	8	10.8
Laryngeal cancer	5	6.8
Lung cancer	4	5.4
Oral cancer	10	13.5
Pancreas cancer	1	1.4
Pharyngeal cancer	1	1.4
Testicular cancer	1	1.4
Thyroid cancer	1	1.4
Uterus cancer	17	23

Type of Cancer

Figure 1: Type of cancer

A total of 74 Cancer patients were included in the study. Where 41.9% of the patients were male and 58.1% were female. More than half of the patients were from urban areas 40(54.1%). Among them, the highest number of cancer patients 25(33.8%) were found under the 51-60 and 61-70 years’ age group, and the lowest number 2(2.7%) were aged 21-30 years. Highest number of patients 25(33.8%) had completed senior secondary education. Around 39(52.7%) individuals were unemployed. Common cancer type for this population was uterus cancer 17(23%).

Awareness of Radiotherapy

Table 8: Responses for awareness of radiotherapy

Awareness of Radiotherapy (n=74)	Yes			No		Don’t Know
	n	%	n		%	n	%
Do you know that there are treatments available for cancer?	50	67.6	12		16.2	12	16.2
Did you hear the word radiotherapy before treatment starts?	60	81.1	14		18.9
Do you know that radiotherapy can be used to treat cancer?	50	67.6	10		13.5	14	18.9
Do you know the importance of radiotherapy?	17	23	57		77
Do you know, which part of your body is being treated?	71	95.9	3		4.1
Do you know, how many times you had radiotherapy?	69	93.2	5		6.8

Overall, 50(67.6 %) of the respondents were aware of the treatment availability of the cancer. Most 60(81.1 %) of the respondents heard the word radiotherapy. More than half 50(67.6%) of the respondents know that radiotherapy can be used to treat the cancer. Only 17(23%) respondents know about the importance of radiotherapy. Majority of the respondents 71(95.9%) know their treated body parts. The majority of the respondents 69(93.2%) know about how many times they had radiotherapy.

Figure 2: Awareness of radiotherapy

Table 9: Awareness level of Radiotherapy

Awareness level	n	%
Very poor	3	4.1
Poor	8	10.8
Average	9	12.2
Good	12	16.2
Very good	42	56.8

The minimum awareness score was 0/6 and the score for maximum awareness was 6/6 among participants. Mean awareness of Radiotherapy was 4.28. While analyzing the overall awareness of radiotherapy, more than half of the patient 56.8% had a very good awareness level of radiotherapy, and only 4.1% of the respondents had a very poor level of awareness.

Figure 3: Awareness Level of Radiotherapy

Awareness of Side effects

Table 10: Responses for Awareness of Side effects of Radiotherapy

Awareness of side effects (n=74)	Yes		No		Don’t Know
	n	%	n	%	n	%
Do you know that there are associated side effects of radiotherapy	34	45.9	9	12.2	31	41.9
Fatigue	25	33.8	12	16.2	37	50
Hair loss	26	33.8	18	24.3	31	41.9
Weight loss	19	25.7	14	18.9	41	55.4
Nausea   & vomiting	22	29.7	12	16.2	40	54.1
Loss of appetite	16	21.6	17	23	41	55.4
Difficulty in swallowing	14	18.9	18	24.3	42	56.8
Diarrhea	5	6.8	24	32.4	45	60.8
Taste changes	16	21.6	17	23	41	55.4
tiff joint and muscle	8	10.8	15	20.3	51	68.9
S Infertility	3	4.1	11	14.9	60	81.1
Subfertility	1	1.4	15	20.3	58	78.4
Skin changes	22	29.7	12	16.2	40	54.1
Do you believe that side effects after radiotherapy?	30	40.5	7	9.5	37	50
Did you see patients with side effects after radiotherapy?	28	37.8	46	62.2
Do you believe that repeating radiotherapy increases the side effects?	14	18.9	18	24.3	42	56.8
Do you know that the side effects of radiotherapy can’t be avoidable?	18	24.3	15	20.3	41	5.4
Do you know that the side effects of radiotherapy can be overcome?	14	18.9	15	20.3	45	60.8

Of those 34(45.9%) respondents were aware of the associated side effects of radiotherapy and 30(40.5%) of respondents believed that there are associated side effects of radiotherapy. Only 28(37.8%) of the participants saw patients with side effects after radiotherapy. Only 14(18.9%) of the respondents believed that repeating radiotherapy increases the side effects, 18(24.3%) of the participants know that side effects of radiotherapy can’t be avoidable and 14(18.9%) of the participants know that side effects of radiotherapy can be overcome.

Less than half 25(33.8%) respondents were aware of Fatigue and hair loss. Only one (1.4%) respondent was aware that radiotherapy can cause subfertility.

Table 11: Awareness level of side effects

Level of awareness	n	%
Very poor	42	56.8
Poor	8	10.8
Average	14	18.9
Good	9	12.2
Very good	1	1.4

The minimum awareness score was 0/18 and the score for maximum awareness was 15/18 among participants. The mean awareness of Radiotherapy was 4.24. While analyzing the overall awareness of side effects of radiotherapy majority 56.8% of the respondents had a very poor level of awareness of side effects and only 1.4% of the respondents had very good level of awareness regarding side effects.

Awareness level of Side effects of radiotherapy

Figure 4: Awareness level of side effects of radiotherapy

Association between socio-demographic factors and the awareness level of radiotherapy

Among socio-demographic factors, only educational level (p=0.001) was found to have significant associations with an awareness level of radiotherapy (Cramer’s V- 0.377). Other socio-demographic factors such as age (p=0.187), gender (p=0.777), place of living (p=0.305), occupation (p=0.249) and type of cancer (p=0.768) did not show a significant association with awareness level.

Table 12: Association between education and the level of awareness of Radiotherapy

			Level of awareness
Education	Very  poor	Poor	Average	Good	Very good	df	Likelihoo d ratio	P  value
Never been to school	2(40%)	1(20%)	1(20%)	0(0%)	1(20%)
Primary Junior Secondary Senior Secondary	1(5%) 0(0%) 0(0%)	4(20%) 2(14.3%) 1(4%)	4(20%) 4(28.6%) 0(0%)	4(20%) 2(14.3%) 6(24%)	7(35%) 6(42.9%) 18(72%)	16	40.203	0.001
Graduated	0(0%)	0(0%)	0(0%)	0(0%)	10(100%)

Our study examines the relationship between respondent’s educational level and awareness level of radiotherapy. Of the respondents 100% (10 respondents) who were graduated, they had a very good level of awareness of radiotherapy and those who had senior secondary education 72% (18 respondents) also had a very good level of awareness of radiotherapy.

Those who had never been to school 40% (2 respondents) had a very poor level of awareness.

Association between Level of awareness and educational level

Figure 5: Association between level of awareness and educational level

Association between socio-demographic factors and the awareness level of side effects of radiotherapy

Among socio-demographic factors, Age (p=0.021, Cramer’s V=0.321) and educational level (p=0.044, Cramer’s V=0.288) were found to have significant associations with awareness level of side effects. Other sociodemographic factors such as gender (p=0.249), place of living (p=0.772), occupation (p=0.365) and type of cancer (p=0.980) did not show any significant association with awareness level.

Table13:  Association between age and the awareness of side effects of RT

				Awareness level
Age	Very poor	Poor	Average	Good	Very good	df	Likelihood ratio	P value
21-30	1(50%)	1(50%)	0(0%)	0(0%)	0(0%)
31-40 41-50	2(22.2%) 5(38.5%)	0(0%) 0(0%)	4(44.4%) 5(38.5%)	3(33.3%) 2(15.4%)	0(0%) 1(7.6%)	16	29.386	0.021
51-60	14(56%)	5(20%)	3(12%)	3(12%)	0(0%)
61-70	20(80%)	2(8%)	2(8%)	1(4%)	0(0%)

In our study, we found a relationship between respondent’s age and awareness level of side-effects of radiotherapy. Only 7.6% (1 respondent) had a very good level of awareness in the age group of 41-50. And 33.3% (3 respondents) had a good level of awareness in the age group of 31-40. 80% (20 respondents) had a very poor level of awareness of side effects in the age group of 61-70. Of those 50% (1 respondent) have a poor awareness level of the side effects of radiotherapy.

Association between Awareness level and Age

Figure 6: Association between awareness level and age

Table 14: Association between awareness of radiotherapy and educational level

			Level of awareness
Education	Very poor	Poor	Average	Good	Very  good	df	Likeliho od ratio	P  value
Never been to school	5(100%)	0(0%)	0(0%)	0(0%)	0(0%)
Primary Junior Secondary Senior Secondary	14(70%) 10(71.4%) 11(44%)	4(20%) 1(7.1%) 3(12%)	1(5%) 2(14.3%) 6(24%)	1(5%) 1(7.1%) 4(16%)	0(0%) 0(0%) 1(4%)	16	26.808	0.044
Graduated	2(20%)	0(0%)	5(50%)	3(30%)	0(0%)

We found to have a relationship between respondents’ educational level and awareness level of the side effects of radiotherapy. Of those who had senior secondary education, only 4%(1respondent) had a very good awareness level of side effects. and those who were graduated 30%(3 respondents) had a good awareness level. 50% (5 respondents) of the graduated respondents had average awareness levels. Those who had never been to school 100% (5 respondents), primary education 70% (14 respondents), and junior secondary education 71.4% (10 respondents) had a very poor awareness level of the side effects of radiotherapy.

Awareness level and Education

Figure 7: Association between awareness level and education

Prior information about Radiotherapy Source of information about radiotherapy

Figure 8: Source of information about radiotherapy

In this study population, more than half 45(60.8%) of the respondents received prior information about radiotherapy. Most of the respondents who received information about radiotherapy, receive information from the doctors 31(68.89%). Only 2(4.44%) got the information from the media.

Prior information about Side effects

Source of information about side effects

   

Figure 9: Source of information about side effects

In this study population, more than half of the respondents 47(63.5%) didn’t receive prior information about side effects. And only 27(36.5%) of the respondents received prior information about side effects. Of those who received information about side effects, 16(59.26%) received the information from the doctors and only 5(18.5%) got the information from the media.

Association between awareness of radiotherapy and source of information

Among sources of information, doctors (p=0.036, Cramer’s V=0.342) and nurses (p=0.043, Cramer’s V=0.314) were found to have a significant association with the awareness level of radiotherapy. Other sources of information such as radiotherapists (p= 0.136), family and relatives (p=0.331), cancer patients (p=0.392), and media (p=0.679) did not show a significant association with awareness level.

Table 15: Association between awareness level of radiotherapy and source of information

Very Poor	Poor	Average	Good	Very good	df	Likelihood	ratio	P value
Doctors	0(0%)	1(3.2%)	2(6.5%)	6(19.4%)	22(71.0%)	4	10.304	0.036
Nurses	0(0%)	0(0%)	2(11.8%)	1(5.9%)	14(82.4%)	4	9.879	0.043

P<0.05 is considered as significant

Of those 71% (22 respondents) of respondents who received information from the doctors and 82.4% (14 respondents) who received information from the nurses had a very good awareness level of radiotherapy.

Association between awareness of side effects and source of information

Among sources of information, doctors (p=0.00, Cramer’s V=0.583), nurses (p=0.001, Cramer’s V=0.473), family and relatives (p=0.013, Cramer’s V=0.409), cancer patients (p=0.00, Cramer’s V=0.626) and media (p=0.007, Cramer’s V=0.537) were found to have a significant association with the awareness level of radiotherapy. Other sources of information such as radiotherapists (p=0.057) did not show a significant association with awareness level.

Table 16: Association between awareness level of Side effects and source of information

Very Poor	Average	Good	Very df	Like liho	P value	poor good	od	ratio
Doctors	2(12.5%)	1(6.3%)	7(43.8%)	6(37.5%)	0(0%)	4	24.292	0.000
Nurses	0(0%)	2(20%)	5(50%)	3(30%)	0(0%)	4	19.909	0.001
Family             and relatives	0(0%)	1(16.7%)	2(33.3%)	3(50%)	0(0%)	4	12.679	0.013
Cancer patients	0(0%)	1(11.1%)	2(22.2%)	5(55.5%)	1(11.1%)	4	24.904	0.000
Media	0(0%)	2(40%)	1(20%)	1(20%)	1(20%)	4	14.119	0.007

P<0.05 is considered as significant

Of those 43.8% (7 respondents) of respondents who received information from the doctors and 50% (5 respondents) who received information from the nurses had an average level of awareness. 55.5% (5 respondents) who received information from cancer patients and 37.5% (6 respondents) who received information from doctors had a good awareness level of the side effects of radiotherapy.

Figure 11: Association between awareness level of side effects and source of information

Association between Awareness level of Side effects and source of information

DISCUSSION

This study aimed to assess the awareness of radiotherapy and its side effects among cancer patients admitted at the Oncology Unit Teaching Hospital Batticaloa. The awareness level of the participants regarding radiotherapy and its side effects according to their socio-demographic factors and the source of information they received.

According to our objectives we analyzed these things and described them in this study

Awareness on Radiotherapy

Even though Radiotherapy continues to be an important modality in cancer management. It’s public awareness and images remain negative. According to our study, overall awareness of Radiotherapy is higher than 42(56.8%) 3(4.1%), and 8(10.8%) had very poor and poor awareness. In contrast to that (Soko et al., 2019) study results review that 33.9% of respondents had a low level of awareness about Radiotherapy, whereas 42.8% and 23.2% had medium & and high levels of awareness. The cause of this difference between these 2 studies may be because of population difference (629) and more than 50% of respondents acquired a diploma or degree (Soko et al., 2019).

When we analyzed awareness of Radiotherapy, we got to know the most commonest treated site was the breast (18%) (Hammick et al., 1998) Despite our study, we found it was uterus 23% (17 patients).

The majority of patients (69) used the word “Cancer” to describe the diagnosis that they are being treated and only 05 participants used the word “Tumor” to describe why they are being treated. These results tied well with previous studies done in Georgia to describe the reason for being treated. (Mitchell, 1977)

Knowledge and awareness of cancer are extremely important to effectively detect and treat the disease (Samat et al., 2014). Only 17(23%) participants know the importance of Radiotherapy and some of them describe the importance of destroying the cancer cells and removing cancer cells. Same as our study 19 study revealed that

87% of the participants employed words similar to those used to describe the understanding of the word “Radiotherapy” as “destroy cancer cells”, “completely kill cancer”, “get rid of /eliminate, attack cancer, “shrink the tumor”, “burn off”. A similar study revealed that the most staggering finding of their study was that a large number (69%) compared to only 18% of the respondents do not know the importance of radiology for diagnosis (Almatared et al., 2017). These results are proved by (Soko et al., 2019) studies also.

Although they know the importance of radiotherapy. 12(16.2%) participants answered that they don’t know the context, we asked “Do you know that there are treatments available for cancer”. Even if they are being treated with radiotherapy they haven’t heard the word radiotherapy. Only 60(81.1%) participants heard the word

Radiotherapy. Other participants describe the word radiotherapy as “current” and also “light”. The reason for the unfamiliarity with the word “Radiotherapy” might be because of the disparity in the health literacy of the study populations.

Awareness of Side Effects

40(54.1%) participants responded that they don’t know there are associated side effects of radiotherapy. These results have been supported by a similar study done in Turkey (Güleser et al., 2012). Saudi Arabia (Almatared et al., 2017) and the United Kingdom (Hammick et al., 1998). A small number of patient (n=5) focused their concerns on the reactions to the treatment. The patient spoke, often at length, about the problem of treatment reactions either side effects on the bowel or skin. This poor awareness might be related to the low dose of radiation received by the patients who are being treated with radiotherapy.

The results of most studies confirm that patients with cancer receiving radiotherapy reported multiple symptoms. Similar results have been reported in the (Güleser et al., 2012),(Jensen et al., 1994), (Almatared et al., 2017) studies as well as (Soko et al., 2019).

The most common complaint during radiotherapy was fatigue (86%), other than that same study revealed that patients experienced nausea and vomiting (59.9%), lack of appetite (50.9%), swallowing difficulties (48%), skin reactions, weight loss, diarrhea, constipation (Güleser et al., 2012). (Soko et al., 2019) study results show that patients agreed with the terms that radiotherapy causes erectile dysfunction and infertility in women. 253 (40.2%), radiotherapy burns my skin 197 (31.3%), radiotherapy will cause me to lose my hair 195(31.0%) and radiotherapy will cause nausea and vomiting 201(31.9%). According to (Jensen et al., 1994) article, xerostomia (44%), tiredness (37%), and taste change (33%) were frequently mentioned as early major side effects. Other than that skin problems 10(23%), weight loss 8(9%), problem with swallowing 5(12%), vomiting 3(2%) also mentioned.

Surprisingly we also noticed that the same results have been shown in our study. Only half of the population know that there are associated side effects of radiotherapy out of 34, 25 patients agreed that they are aware about fatigue (70.6%), hair loss 25(55.9%), Nausea and vomiting 21(61.8%), weight loss 19(55.9%), taste changes 16(47.1%) and skin reactions 22(64.7%).

In our study we found that 30(40.5%) patients believe that, side effects can be experienced after radiotherapy. These results have been supported by similar studies done in Tanzania and Saudi Arabia (Soko et al., 2019), (Almatared et al., 2017). (Soko et al., 2019) have described that radiotherapy kills body cells and 25.1% of participants agreed that they feel radiology tests cause hazards and side effects (Almatared et al., 2017).

According to our findings, participants said that they have seen patients with side effects 28(37.8%) after radiotherapy and 14(18.9%) believe that repeating radiotherapy increases the side effects. Meanwhile (Almatared et al., 2017) Study reported that (25.9%) equal number of participants either believed that repeating the radiological tests within 6 months could cause harm to the body or were neutral about it.

Our study found that overall awareness of the side effects of radiotherapy was very poor among cancer patients. 42(56.8%) and only 1(1.4%) had a very good level of awareness compared to our results. (Güleser et al., 2012) article conducted in 2012, 54.5% had good knowledge about the side effects of radiotherapy. The cause for this knowledge gap might be due to variations in population.  Our study had only 1/5th of their population.

Association between Awareness & socio demographic Factors

In our study educational level (p=0.001) is the only factor we found to have significant association with awareness of radiotherapy. This result has been supported by a similar study done in Tanzania (Soko et al., 2019). Other than that, they found an association for place of living (p<0.001), age (p<0.003), marital status (p<0.001), level of education (p<0.001) and occupation (p<0.001).

Source of information about Radiotherapy and Side Effects

In our study, we found that 45(60.8%) patients receive information about radiotherapy and most of the respondents who receive information about radiotherapy got information from doctors 31(68.89%) and 17(37.78%) got from nurses. This was closely similar with the results reported fin Turkey (Güleser et al., 2012).

And higher than results reported from United Kingdom (Hammick et al., 1998).

One of the most striking findings of our study was, that 47(63.5%) didn’t get prior information regarding side effects and those who received information about side effects got 16(59.26%) from doctors and 10(37%) from nurses and 11(40%) from cancer patients. Similar positive results have been demonstrated in Turkey in 2012 (Güleser et al., 2012). Nearly half of the participants knew the side effects of radiotherapy on the patients 42.9% gained knowledge by self-experience. And only 31.9% from doctors and 1.5% from nurses.

Association between awareness and source of information

Even though, they got adequate information about radiotherapy, the relationship between awareness of radiotherapy and the source of information was only with doctors (p=0.036) and nurses (p=0.043). Respondents who got information from doctors and nurses have very good knowledge. This is strong evidence that they got adequate information regarding radiotherapy.

Even though they didn’t receive adequate information about side effects, they had average to good awareness regarding side effects. And also we found that there is a significant association between awareness of side effects and source of information. Participants who receive information from doctors and nurses receive adequate information about side effects.

Summary

In our study, even though the majority of cancer patients Radiotherapy awareness is high they don’t know the importance of the treatment. Even though they experienced the side effects from radiotherapy, overall awareness of the side effects of radiotherapy was very poor among them. We found that they got adequate information regarding Radiotherapy but not about side effects. So we believe that improving awareness of cancer patients is the responsibility of health care professionals including doctors, nurses as well and radiotherapists.

CONCLUSION

Our study found out very good level of awareness of radiotherapy (56.8%) and very poor level of awareness of side effects of radiotherapy (58.1%) among cancer patients admitted at the oncology unit Teaching Hospital Batticaloa. We found to have significant association between education and awareness level of radiotherapy and as well as side effects. We believed that education plays a major role in awareness of radiotherapy and its side effects. 59.5% of the respondents received prior information about radiotherapy and only 39.2% of the respondents received prior information about side effects of radiotherapy. Doctors had a major role in providing information to the patients.

According to our study only few respondents received information from the radiotherapists. So as health care professionals they have responsibility to provide adequate information regarding radiotherapy and especially about its side effects to the patients. Based on our findings following recommendations are suggested, providing specialized awareness programs on: importance of radiotherapy, effectiveness of radiotherapy for cancer treatment, side effects of radiotherapy, how to overcome those side effects and misconceptions regarding radiotherapy.

LIMITATIONS

Following limitations have been identified in our study:

An interviewer administered questionnaire may cause reactivity bias and answers of the respondents may not be 100% reliable.

A few drawbacks of the method which may have an effect on the results of the study, were identified. The sample size, duration of the data collection period was some of them at the same time this study was done only in the Oncology unit, Teaching Hospital Batticaloa.

The severity of the cancer is a major limitation in our study (most of the oral cancer patients refuse to participate in this study due to Dysarthria)

Even with the achievement of the study objective, a general assumption cannot be made until a larger representation of patients in Batticaloa is surveyed. Also, because the sample population is from a public healthcare institution, this may not take into account the attitude and knowledge of non-nationals who attend private health facilities. However, this preliminary study is one of its kind in the region. Therefore, a follow-up study is warranted to reveal the current situation.  

RECOMMENDATIONS

Based on the current finding, the following recommendations are suggested.

Providing specialized awareness programs on:

1. Importance of Radiotherapy
2. Effectiveness of radiotherapy for cancer treatment
3. Side effects of radiotherapy
4. How to overcome those side effects
5. Misconceptions regarding radiotherapy (myths and believes)

To intensify efforts at informing cancer patients who are attending radiotherapy; they need to have printed materials with simple message and local mass media can also be used to increase awareness of radiotherapy and its side effects among cancer patients. Elder patients who never been to school had low level of understanding so we suggested to have awareness programs with pictures, videos and understandable paper materials. Suggest to carryout workshops in Oncology unit through ministry of health to improve awareness of radiotherapy and its side effects.

Targeted awareness raising activities regarding radiotherapy and its side effects; can recommend among cancer patients.

Counselling the radiotherapy patients who had low knowledge level of awareness of radiotherapy and its side effects and to patients who believe myths and beliefs.

Efforts also needed to take to promote optimal use of resource person such as doctors, nurses and radiotherapists to receive adequate information regarding their treatment and the doubts to clarify. Oncology healthcare professionals should motivate more effective implementation of radiotherapy educational programs for cancer patients who take radiotherapy.

At the community level, the health professionals should continue promoting key messages about radiotherapy and its side effects before patient attending for radiotherapy at Oncology unit, during different contact points like “Cancer week” and at oncology clinics.

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