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Journal of Medical Imaging and Radiation Sciences
Journal of Medical Imaging and Radiation Sciences 43 (2012) 221-227
Journal de l’imagerie médicaleet des sciences de la radiation
www.elsevier.com/locate/jmir
Evaluation of the Effects of Pre-Treatment Education on Self-Efficacy andAnxiety in Patients Receiving Radiation Therapy: A Pilot Study
Thomas Canil, BSca, Angela Cashell, MRTT, AC(T), MScbc*,Janet Papadakos, MEdd, Nazek Abdelmutti, MScd and Audrey Jusko Friedman, MSWd
a Faculty of Medicine, University of Toronto, Toronto, Ontario, CanadabRadiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, CanadacDepartment of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
dPatient Education & Survivorship Program, Princess Margaret Hospital, Toronto, Ontario, Canada
ABSTRACT
Introduction: Patients receiving radiation therapy for cancer
treatment have been reported to experience increased anxietybefore starting therapy and often have diminished feelings ofcontrol. An evaluation was done to measure the impact of aneducational class that was designed to lower patient and family
anxiety and to help them know what to expect before startingradiation therapy.
Methods: A single-centre, cross-sectional study was conducted fromJanuary to March 2011 at an ambulatory radiation therapy clinic.The study used the Cancer Behavior Inventory Brief (CBI-B) and
State-Trait Anxiety Inventory-State (STAI-S) to investigate the effectof the class on the participant’s perceived self-efficacy and anxiety,respectively. Participant demographics and an evaluation of the
course content and the teaching skills of the facilitators werecollected.
Results: Twenty-four responses were analyzed. Although the coursewas designed for those starting treatment, 11 participants had alreadybegun. The majority of participants were non-immigrant patients
with high socioeconomic status. Patient self-efficacy scores increasedsignificantly P � .001 and anxiety scores decreased significantlyP � .001 after completion of the pre-treatment class. Overall, partic-
ipants rated the content and delivery of the class highly.
Conclusion: This study has shown that pre-treatment education may
reduce anxiety and increase self-efficacy in patients starting and thosealready receiving radiation therapy. This information may providesupport for the delivery of pre-treatment patient education in ambu-latory radiotherapy clinics.
* Corresponding author: Angela Cashell, MRTT, AC(T), MSc, Clinical Educator
University of Toronto, Rm 2B 619, Princess Margaret Hospital, 610 University Avenu
E-mail address: [email protected] (A. Cashell).
1939-8654/$ - see front matter � 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jmir.2012.05.002
R�ESUM�E
Introduction: L’exp�erience d�emontre que les patients qui recoivent
de la radioth�erapie pour le traitement d’un cancer font �etat d’uneaugmentation du niveau d’anxi�et�e avant le d�ebut du traitement etont souvent un sentiment de perte de controle.
On a effectu�e une �evaluation pour mesurer les effets d’une s�eanced’�education concue pour diminuer l’anxi�et�e du patient et de la fa-
mille et les aider �a savoir �a quoi s’attendre avant le d�ebut de laradioth�erapie.
M�ethodes: Une �etude transversale dans un seul centre a �et�e r�ealis�eeentre janvier et mars 2011 dans une clinique de radioth�erapie ambu-latoire. L’�etude a fait appel aux instruments de mesure CBI-B (Can-cer Behavior Inventory Brief) et STAI-S (State-Trait Anxiety
Inventory-State) pour examiner les effets de la s�eance surl’autoefficacit�e et l’anxi�et�e percues par le patient, respectivement.Les donn�ees d�emographiques des patients et une �evaluation du con-
tenu du cours et des comp�etences d’enseignement des animateurs ontaussi �et�e recueillies.
R�esultats: On a effectu�e une analyse de 24 r�eponses. Bien que lecours ait �et�e concu pour les patients en d�ebut de traitement, 11 pa-tients avaient d�ej�a commenc�e le leur. La majorit�e des participants
�etaient des patients non immigrants avec un statut socio�economique�elev�e. Les notes d’autoefficacit�e des patients ont augment�e de faconmarqu�ee p¼<0,001 alors que les notes d’anxi�et�e diminuaient de fa-
con marqu�ee p¼<0,001 au terme de la s�eance men�ee avant le d�ebutdu traitement. Globalement, les patients ont accord�e une excellentenote �a la s�eance.
Conclusion: Cette �etude a d�emontr�e que l’�education pr�eparatoire autraitement pouvait diminuer l’anxi�et�e et augmenter l’autoefficacit�echez les patients qui entreprennent un traitement de radioth�erapie
, Radiation Medicine Program, Instructor, Department of Radiation Oncology,
e, Toronto, Ontario, M5G 2M9.
autant que chez ceux qui ont d�ej�a commenc�e �a recevoir des traite-ments. Cette information pourrait venir appuyer la prestation de
222 T. Canil et al./Journal of Medical Imaging and
services d’�education pr�ealables au traitement dans les cliniques ambu-latoires de radioth�erapie.
Keywords: anxiety; neoplasm; patient education; radiation therapy; radiotherapy; self-efficacy
Introduction
Preparing for radiation therapy can be a stressful experiencefor both patients and their caregivers. In addition to the prac-tical and existential concerns that often accompany a cancerdiagnosis, it involves a wide range of new experiences andconcerns about treatment that can cause significant amountsof stress and anxiety [1]. This can further be aggravated bypoor communication of information and knowledge concern-ing treatment. More specifically, a lack of information aboutradiation therapy can lead to misperceptions about side effectseverity [2], whereas poor timing for information can dimin-ish patient satisfaction with the treatment itself [3].
A review of literature on the importance of patienteducation in radiation therapy concluded that informationcan augment self-efficacy, reduce anxiety, and aid in symptommanagement [4]. However, research investigating the infor-mation needs of patients receiving radiation therapy indicatedthat many patients are not totally satisfied with the informa-tion given before receiving treatment [5]. Effective patient ed-ucation has been shown to increase feelings of control and tolower anxiety [6]. Feelings of control or perceived self-efficacyis an individual’s confidence that he/she can carry out a healthbehavior [7]. Self-efficacy is associated with improved emo-tional well-being, effective stress management and lower anx-iety [8, 9], adoption of self-management behaviors [10], andultimately better health outcomes.
To address the importance of information provision in can-cer care, the ‘‘Radiation Therapy: Answering Your Questions’’class is offered to all patients starting radiation therapy at Prin-cess Margaret Hospital (PMH) in Toronto, Canada. The classconsists of a standardized scripted didactic presentation deliv-ered by radiation therapist clinical educators. The curriculumincludes an overview of the process and procedures, scheduling,and side effects that are expected with radiation therapy. Smallmodels of an external beam radiation apparatus are present forparticipants to examine. Participants are encouraged to askquestions throughout the class. After the conclusion of the di-dactic portion of the class, individual participants are directedto any additional informational resources they may need asrevealed through their questions and discussion. The objectiveof the hour-long class is to lower anxiety and increase feelings ofcontrol and preparedness by educating patients and caregiverson what to expect during radiation treatment, how to manageside effects, and what practical and psychosocial support re-sources are available to them. The class has been offered regu-larly for more than five years, and anecdotal evidence suggeststhat patients and families benefit from participating.
Research evaluating the use of preparatory educationalprograms has yielded mixed results. Some studies have dis-played no significant improvement in anxiety, perceived
self-efficacy, or increased knowledge of radiation therapy[11, 12], whereas others displayed improvements in patientanxiety, knowledge, and overall satisfaction in care with pre-paratory education [13–15]. The techniques used within eachstudy vary in terms of the timing of the education, the mediaused, and the degree of contact with a healthcare professional.No one technique has been shown to be consistently superior,and a patient-focused didactic approach has been found to beboth successful [15] and unsuccessful [11] in separate studies.Overall, the current body of literature was inconclusive on theeffectiveness of preparatory educational programs as well asthe most effective means of communicating information.This pilot study aimed to investigate whether the current classhad any effect on patient anxiety and self-efficacy and to de-termine how the patients and caregiver rated the currentmethod of delivery and overall teaching. The results fromthe study will be used to determine if the class will be offeredas a standard of care for all patients who are about to startradiation therapy.
Methods
Participants
A single-centre cross-sectional study was conducted.Between January andMarch 2011, patients whowere scheduledto receive radiation therapy at PMH were sent an invitation toattend the pre-treatment class and an invitation to participate inthe study. The classes are not mandatory but are offered to allpatients. After informed consent was obtained, study partici-pants were asked to complete questionnaires before the startof the class and again at the conclusion. Questionnaires admin-istered pre-class included two validated scales and a demo-graphic survey. Post-class, the same scales were completedand a class evaluation. Completion of both the pre- and post-session questionnaires provided an opportunity to detect anypotential changes in patient anxiety and perceived self-efficacyafter completion of the class.
Patients were included if they had a confirmed diagnosis ofcancer, they were registered to attend the introduction to ra-diation therapy class, older than 18 years of age, and couldread and write in English. Approval for the study was ob-tained from the Research Ethics Board at PMH/UniversityHealth Network, Toronto, Canada.
Measurement Instruments
Nonvalidated Questionnaires
Participants completed a demographic questionnaire thatincluded both demographic information and health informa-tion. Demographic information included; race, age, languagesspoken, marital status, number of persons in the household,
Radiation Sciences 43 (2012) 221-227
employment, and education level. Health information in-cluded: the patient’s health condition, diagnosis, stage incancer journey, and treatments received. In addition to thedemographic questionnaire, participants were asked to com-plete a brief survey at the end of the class to evaluate instruc-tor skills and course content. Using Likert scales, theparticipants were asked to rate from 1 to 5 how stronglythey agreed with seven statements about the delivery of theclass content and the content itself. A score of 1 indicatedstrong disagreement with a statement and a score of 5 indi-cated strong agreement. The questionnaire included twoopen-ended questions that sought feedback for potentialimprovements to the class. These questions were selected bythe authors to highlight any opportunities for revision tocourse material.
Validated Questionnaires
Participants completed two validated scales: the CancerBehavior Inventory Brief (CBI-B) [16] and State-Trait Anxi-ety Inventory-State (STAI-S) [17]. The STAI-S and CBI-Bare validated tools that have been used in cancer patient pop-ulations and also in similar evaluations of patient educationinterventions, including materials and curricula [4, 18, 19].
CBI-B measures perceived self-efficacy for cancer copingand is a 14-item questionnaire. The 14 items are tasks oremotional states that reflect a degree of patient self-efficacyneeded to fulfill each item. Participants were asked to ratefrom 1 to 9 how confident they are that they can accomplishthe items listed. A rating of 1 indicated that they are not at allconfident, whereas a rating of nine indicated that they are to-tally confident that they could accomplish the item. An aver-age score can be produced from the 14 items. The averagescores range between 1 and 9 with higher scores indicatinghigher self-efficacy.
The STAI-S may be used as a measure of patient anxiety.In this study, only the state portion of the STAI was used, asthis assesses a participant’s anxiety as a cross-section in time,as opposed to the trait portion of the STAI, the STAI-T,which assesses personality characteristics that make individualsmore or less susceptible to suffering from anxiety. The STAI-Sis a 20-point questionnaire. Participants were asked to ratefrom 1 to 4 in the STAI-S how strongly they think the feel-ings expressed in the questions apply to them currently. A rat-ing of 1 indicated ‘‘does not at all apply,’’ whereas a rating of4 indicated that the item ‘‘very much so’’ applies to theircurrent emotional state. An average score can be producedfor the complete survey. The average score ranges between1 and 4, with a higher average score indicating a current stateof heightened anxiety.
Statistical Analysis
Summary statistics for both anxiety and self-efficacy werecalculated for the population pre- and post-session. A two-tailed Wilcoxon signed-rank test was used to evaluatewhether there was a statistically significant change in patient
T. Canil et al./Journal of Medical Imaging and
self-efficacy and anxiety after attending the class. A Wilcoxonsigned-rank test will be more reliable for this sample as we areunable to assume that scores for self-efficacy and anxietyfollow a normal distribution in this population. However,the use of this statistical test acted as a limitation in the studyas it can be difficult to communicate the results of this anal-ysis, because values such as standard deviation and confidenceintervals, which are obtained using a standard t-test, were notavailable for this type of analysis. A descriptive analysis wasperformed to determine the level of course satisfaction ob-served through the satisfaction questionnaire and also to inter-pret the demographic data collected.
Results
Participation and Demographics
Fourteen sessions of the class were conducted during the pe-riod of data collection (January and March 2011). We wereable to recruit some participants from each of the 14 sessionswhich in total hosted 100 patients. With an n of 24, we obtaineda 24.0%participation rate. Initially we had planned to analyze pa-tients and family members/friends separately, but because onlythree study participants were family members/friends, we re-stricted the evaluation to data supplied by the patient participants.
There is notable bias toward non-immigrant, higher socio-economic status within the study population, with Englishacting as the primary language of all participants and approx-imately two-thirds having an annual income greater than$75,000. Table 1 shows the complete demographic informa-tion that was obtained for the study participants.
CBI-B and STAI-S
In evaluating the radiation therapy class, our two maintools for assessment were the CBI-B and STAI-S, whichwere used to measure patient self-efficacy and anxiety, respec-tively, before and after completion of the education session.
The medians and ranges for the results of the CBI-B arefound in Table 2. The median pre-test score over the 24 partic-ipants was 6.96, whereas the post-test median score was 7.82.This represents an increase of 0.86 points (12.4%) on the9-point scale after completion of the course. Only three partic-ipants showed no change in their CBI-B score after the course;no participants had a negative change in score post-course. Therange in score values decreased in the post-test results. A two-tailedWilcoxon signed-rank test was performed to see if the in-dividual patient changes in self-efficacy scores on the CBI-Bwere significant. The two-sided P value was less than .001.
A similar process of analysis was done for the STAI-S withthe 20 questions scored appropriately and an average valueproduced for the entire survey. The median and ranges fortest results of the STAI-S can be found in Table 2. The me-dian pre-test score over the 24 participants was 2.00, whereasthe post-test median score was 1.46. This represents a decreaseof 0.54 points (27%) on the 4-point scale after completion ofthe course. One participant showed no change in their
Radiation Sciences 43 (2012) 221-227 223
Table 1
Demographic information for patient participants
Variable Study group
Sex n (% of respondents)
Male 7 (30.4)
Female 16 (69.6)
Age
18–29 1 (4.2)
30–39 2 (8.3)
40–49 8 (33.3)
50–59 3 (12.5)
60–69 8 (33.3)
70þ 2 (8.3)
Education Level
Grade school 0 (0)
Some high school 0 (0)
High school 0 (0)
Some college/university 3 (12.5)
College/university 14 (58.3)
Graduate School (ie, MA, PhD) 7 (29.2)
Language Spoken
English 24 (100)
Other 0 (0)
Number of Individuals in Household
1 6 (25)
2 11 (45.8)
3 3 (12.5)
4 4 (16.7)
5 0 (0)
6 0 (0)
7 or more 0 (0)
Annual Income of Household
Less than 25,000 4 (17.4)
25,000–49,999 3 (13)
50,000–74,999 0 (0)
75,000–99,000 6 (26.1)
100,000 or More 10 (43.5)
Point in Treatment
Just diagnosed 0 (0)
About to start 13 (54.2)
In treatment 11 (45.8)
Type of Cancer
Brain 1 (5.3)
Breast 9 (47.4)
Rectal 2 (10.5)
Uterine 1 (5.3)
Head and neck 3 (15.8)
Prostate 2 (10.5)
Liver/bile duct 1 (5.3)
Table 2
Median and range values for CBI-B and STAI-S
STAI-S score after the course, whereas three participants sawan increase in their score after the course. The range in scorevalues again decreased in the post-test results. A two-tailedWilcoxon signed-rank test was performed to see if there wasa change in the level of anxiety experienced by the partici-pants. The two-sided P value was less than .001.
Pre-test Post-test Overall
Median Range Median Range Median Range
Post-Class QuestionnaireCBI-B 6.96 4.98 7.82 3.77 7.57 5.29
STAI-S 2.00 2.05 1.46 1.60 1.78 2.05
CBI-B, Cancer Behavior Inventory Brief; STAI-S, State-Trait Anxiety
Inventory-State.
To evaluate instructor skills and course content, and tohighlight any opportunities to revise course materials, a sup-plementary questionnaire was used. All responses from the24 participants for the class evaluation component were taken
224 T. Canil et al./Journal of Medical Imaging and
together to produce an average response for each statement.All of the questions received greater than a 4.50 rating, indi-cating that these patients were in agreement with all sevenstatements concerning instructor communication and contentwithin the course. The results are shown in Table 3. The post-class questionnaire, also posed two short answer questions.The first was whether the class had changed their thoughtsand feelings about radiation therapy. The responses indicatedeither reduced concerns about the treatment or simply a con-firmation of expectations (16 of 23 responses). Three patientscited an increase in anxiety following the class. The secondquestion asked about suggested changes to the course to im-prove its delivery. The most popular comment was that thecourse required no changes (eight respondents). Severalpatients noted that perhaps classes targeted towards specificcancers (eg, breast or prostate) might be more effective. Thecommon themes and their frequencies are presented inTable 4.
Discussion
CBI-B and STAI-S
In evaluating the results of the CBI-B, a modest, but sta-tistically significant increase in self-efficacy was seen in the pa-tient group. Those who attended the class demonstrateda 12.4% increase in their median score on the CBI-B. Thisresult provides evidence that the class does impact perceivedself-efficacy and improves patient outlook and motivation. Al-though the increase in self-efficacy after the course is modest,this appears to be secondary to patients already scoring highlyfor self-efficacy on the pre-test component of the CBI-B leav-ing a limited window for improvement. This could be viewedas a testament to the ongoing educating and counseling ofthese patients by their healthcare team at PMH immediatelyafter a cancer diagnosis. Looking at the questions on theCBI-B individually, there were two questions that on averagefeatured an increase of greater than 1.00 on the CBI-B scaleafter completion of the class. These were ‘‘Remaining relaxedthroughout treatments and not allowing scary thoughts to up-set me’’ and ‘‘Managing nausea and vomiting.’’ The class cur-riculum dedicates a significant amount of time to addressingthe treatment process and some of the expected side effects.This might explain the large increase on the CBI-B scale forboth these questions after completion of the class. The resultsof the STAI-S survey showed that the class significantly re-duced patient anxiety scores by a factor of 27%. The most
Radiation Sciences 43 (2012) 221-227
Table 3
Survey responses for post-class questionnaire
Survey questions Average
response
The educator spoke clearly and was easy to understand 5.00
The slides were clear and helped in making the class
easier to understand
4.91
I felt comfortable asking questions in the class 4.92
The educator answered my questions clearly 4.87
The class improved my understanding of radiation therapy 4.88
The class addressed my concern(s) about radiation therapy 4.71
Overall the class was helpful for me 4.92
significant change after the course was seen in questions 4, 8,and 15 of the STAI-S where there was an average decreasegreater than 0.65 points in anxiety scores. Question 4 askedpatients if they felt strained, question 8 if they felt currentlysatisfied, whereas question 15 asked if they felt relaxed.Here it is possible the large change in anxiety score in thesecategories reflects the emphasis of the class on the ease of ra-diation therapy and the large degree of control patients havein the process of receiving this form of therapy. In work byCartledge et al, when comparing randomized control trials in-volving preparatory patient education, no significant reduc-tion in STAI-S scores were noted; however, post-class datacame as late as eight weeks after the initial class [11]. In eval-uating the study done by Poroch, who used both a preparatoryorientation session as well as a secondary educational sessionafter treatment had been initiated, results showed a significantreduction in patient anxiety before treatment, and this wasmaintained throughout their treatment course [15]. However,it was apparent that the initial preparatory orientation sessionbefore treatment initiation had the largest impact on patientanxiety [15]. These results might suggest that the effects ofearly orientation on mood could be transitory or that the ini-tial intervention is only effective during the early stages oftreatment. Therefore it might be advantageous to plan formultiple events of patient education and teaching throughout
Table 4
Short answer response questions: themes, representative quotes, and their associated
Now that you have attended the class, have your thoughts and feelings about radiation
Themes Representative qu
No change ‘‘Not much.’’
Confirmation of expectations ‘‘This class reinfor
the literature I
Feel comfort/reduced concern with more information ‘‘I feel better prep
Still concerns remaining/some anxiety from conversation ‘‘I’m still very con
Share any comments you have. concerning the quality of the course and/or potential im
Themes Representative qu
No need to change/great experience ‘‘No need to chan
Cancer-specific class/specific information on audience
cancer
‘‘I think it is good
we were all bre
Increased room size ‘‘Larger space nee
Therapy complete prior to class ‘‘Timing of the se
an emergency’’
Information on side effects ‘‘I would apprecia
T. Canil et al./Journal of Medical Imaging and
the course of treatment in order to maintain a reduction inpatient anxiety. As noted in the demographic data reported,11 participants had already initiated radiation therapy beforecompleting the study. This factor may have influenced the re-sults of both the CBI-B and STAI-S survey with those whomhad already initiated treatment showing reduced impact inself-efficacy and anxiety with the education program com-pared to those patients who had not yet started treatment.This is likely due to the increased familiarity with the treat-ment process and a sense of achievement gained by complet-ing the early stages of treatment.
Post-Class Questionnaire
The results seen in the post-class questionnaire lends fur-ther support to the effectiveness of the course. Of the six ques-tions asked, each of them had an average response of 4.71 orgreater, indicating that class participants somewhat agreed toor strongly agreed that the technical aspects of the class werehandled appropriately. Question six, which asked whether pa-tients felt the class had addressed their personal concernsabout radiation therapy, was the lowest response at an averageof 4.71. This may be due to the fact that the class did not ad-dress specific cancer diagnoses and instead addressed the um-brella topic of radiation therapy in general. In the qualitativeresponse section patients expressed further support for the ef-fectiveness of the course. When asked whether the class hadchanged their thoughts and feelings about radiation therapy,the most common theme was that the course improved com-fort and reduced concern over treatment (11 of 23 respon-dents). Five respondents stated it confirmed the previousexpectations they had for radiation therapy. One patientwrote, ‘‘This class reinforced everything I was told by theradiation oncologist and the literature I was given at my firstappointment.’’ Patients were also asked if they had any com-ments on how they would change the course as it is offeredtoday. From the responses provided (eight responses), patientsindicated that no change was required, and this is in line with
frequencies
therapy changed?
ote Frequency
4
ced everything I was told by the radiation oncologist and
was given at my first appointment.’’
5
ared to start treatment.’’ 11
cerned about skin side effects due to my fair skin.’’ 3
provements that you feel should be made for future classes
ote Frequency
ge.’’ 8
to have classes specific to different typesdnice that
ast cancers.’’
3
ded to accommodate the number of people attending.’’ 4
ssion was unfortunate for me because I got treatment as 1
te a section on skin care and lymphedema in the slide.’’ 2
Radiation Sciences 43 (2012) 221-227 225
the results of the first part of the post-class evaluation suggest-ing the course is delivered in an effective manner. Interest-ingly, three patients felt more cancer-specific informationwould be beneficial, either addressing the specific diagnosesthat the patients attending the class have, or by holdingcancer-specific classes dedicated to specific diagnoses such asan introduction to radiation therapy class for breast cancer pa-tients or prostate cancer. Participants expressed that they appre-ciated the ability to network and relate to other patients in theclass. In addition, they reported that questions asked by otherparticipants often became relevant to the entire group, andtherefore contributed to a feeling of being less isolated.
Limitations
With the potential to recruit 100 participants to thestudy, we were disappointed with a participation rate ofonly 24.0%. We suspect that this low number was due toour inability to reach all patients before the class, whichmeant that most patients arrived just before the start of classwhich left inadequate time for completion of pre-class ques-tionnaires. With the respondents that did participate, threefactors were noticed in the demographics, suggesting thatthe sample population may overrepresent a select subgroupof the patient population. English was the first language ofall 24 participants; all 24 had at least some university or col-lege training, and greater than 40% of participants had an-nual income in excess of $100,000. This may indicate thatour sample does not reflect the general patient populationat PMH. Disparities in both education and income levelhave been shown to affect the way cancer patients commu-nicate and receive information with healthcare professionals[20] and thus it is possible that patients with higher socio-economic status are more likely to attend patient educationclasses. If the introduction to radiation therapy class werestandard of care, we feel that it could reach those individualswho may otherwise not attend. Further research is needed todetermine whether this class would benefit patients with lowsocioeconomic status.
Another significant limitation in the study is a lack of long-term follow-up with these patients to see how they did overthe course of their treatment. By following the patients, wemight better understand fluctuations in anxiety and self-efficacy throughout the treatment process and therefore betterunderstand the long-term role of patient education. A furtherlimitation is that we did not have a control group to comparethe impact of the intervention. This pilot was conducted inadvance of a randomized control trial to determine prelimi-nary findings to improve the curriculum and or studyapproach.
Conclusion
The results of this pilot study suggest that pre-treatmenteducation may reduce patient anxiety and increase patientself-efficacy. This evidence may lend support for inclusionof this class in treatment schedules as a standard approach
226 T. Canil et al./Journal of Medical Imaging and
to educating patients preparing to start radiation therapy atPMH.
Acknowledgments
The authors would like to acknowledge Caroline Daveywho provided support for the project and was instrumentalin the class teaching sessions.
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