Peer Review

The Timing of Breast Cancer Patient

Education: Its Influence on Satisfaction
Jill Sutherland, MHS, BSc, R.T.(T)
Lauren McLaughlan, R.T.(T), CTIC
Purpose To explore whether the timing of patient education sessions influences levels of satisfaction in
women treated for breast cancer.
Methods Two groups of participants, 350 women total, were surveyed retrospectively via a postal question-
naire. Participants from group 1 received a patient education session following their first radiation therapy
treatment. Group 2 received a patient education session on the same day as their computed tomography
(CT) simulation appointment. Data were analyzed using descriptive and inferential statistics.
Results No significant difference in the levels of satisfaction was found between the 2 groups. Satisfaction
levels were high in both groups across all measures; however, satisfaction levels were lowest when partici-
pants were asked how satisfied they were with the information provided about support services.
Discussion The timing of patient education did not significantly influence the level of patient satisfaction
among the study participants. When given a choice, the majority of patients stated they preferred to receive
a patient education session on the same day as their CT simulation vs other time points.
Conclusion Patient preference for the timing of education sessions should be accommodated whenever
possible; however, it also is reasonable to consider the operation requirements of the department when
scheduling education sessions.

P
atient satisfaction is an important measure of
the quality of health services.1,2 Patient satisfac-
tion takes into account patient experience and
can be defined as the extent to which the servic-
es and care patients experience match their expecta-
tions.3 Patient satisfaction data informs health care pro-
viders about patient concerns and needs and provides
valuable guidance for program evaluation, resource
management, and quality improvement. 4 Factors such
as health status, personal expectations, personal charac-
teristics, and the health care environment can influence
patient satisfaction, making it a complex phenomenon
to measure and evaluate. 4,5 Health care providers are in
a position to influence some of these factors positively. 5
Cancer patients actively seek information about their
treatment, and a number of studies have found that
patient satisfaction is positively influenced by infor-
mation from health care providers. 6-8 Patients whose
information needs are met report higher levels of patient
satisfaction,5,9,10 have reduced anxiety, anger, and depres-
sion, and feel a greater sense of control. These benefits
better prepare them for treatment and increase their
understanding and recall of information.11-14
The information needs and preferences of cancer
patients vary with respect to the content, amount, and
timing of information.11,15-17 One study found that women
with breast cancer had the highest need for information
during their first consult with the radiation oncologist
and at the time of treatment planning.15 A survey of 123
women with breast cancer found that they had the great-
est need for information before treatment planning and
before starting treatment. The study and survey findings
indicate that more emphasis on patient education should
be given prior to treatment planning and treatment to
reduce patient psychological distress.16 Interestingly,
another study concluded that women with breast cancer

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Peer Review
Breast Cancer Patient Education
have high information needs throughout the course of
radiation therapy, indicating a need for ongoing educa-
tion.18 From these studies, several important time points
for patient education have emerged:
The initial visit with the radiation oncologist.
The treatment planning appointment.
The first day of treatment.
The end of treatment.
The radiation therapists role is to assess the educa-
tional needs of patients and ensure those needs are met.
Some research reports that the timing of patient
education has significant effects on patient satisfac-
tion10; however, variation exists within the literature
as to when women with breast cancer have the great-
est need for information and what the optimal timing
of radiation therapy patient education should be.19 As
such, radiation therapy departments vary as to when
patient education is provided, and further exploration
is needed.19
The purpose of this study was to explore whether
the timing of patient education influences patient sat-
isfaction with the education experience and to test the
following hypothesis: Patients who receive a patient
education session on the same day as their computed
tomography (CT) simulation appointment will be
significantly more satisfied than patients who receive a
patient education session on their first day of radiation
therapy treatment.
Historically, radiation therapy patient education
sessions at the cancer center in this study were pro-
vided after the first radiation treatment had been
delivered. Treatment unit radiation therapists provide
patient education on an individual patient basis. The
education session lasts approximately 20 minutes and
includes information about the radiation therapy treat-
ment procedure, the scheduling of treatment appoint-
ments and physician visits, site-specific adverse
effects, management of adverse effects, site-specific
written information, and support services available at
the cancer center.
In June 2010, a process change was implemented in
response to staff scheduling modifications, and patient
education sessions are now provided the day of the
patients CT simulation appointment, approximately
2 weeks prior to the first day of radiation treatments.
Before this study, patient levels of satisfaction with the
132
timing of patient education sessions had not been col-
lected or analyzed at this cancer center.
Methods
A quantitative research design was used to retrospec-
tively survey 2 groups of participants via a postal ques-
tionnaire. The study was approved by the university
Health Research Ethics Board and the cancer centers
Research Resource Impact Committee.
Participant Population
Participants were identified from the cancer centers
cancer registry database. The sample group was lim-
ited to female patients older than 18 years of age who
received radiation therapy for breast carcinoma in 2010.
Selection criteria were set to exclude patients who had
received previous radiation therapy, patients who were
deceased, and patients on the do not contact list.
Participants were divided into 2 groups. The first
group of participants (group 1) received a radiation
therapy patient education session following the indi-
viduals first radiation treatment. Group 1 received
radiation therapy treatments between January 1 and
June 18, 2010. The second group (group 2) received a
radiation therapy patient education session following
participants CT simulation, which was approximately
2 weeks prior to their first radiation treatment. Group 2
received radiation therapy treatments between June 21
and December 31, 2010.
Sampling and Participation
Sample size was determined in consultation with
the centers department of epidemiology. Based on
the selection criteria, 531 patients were identified
(222 participants in group 1 and 309 in group 2).
An introductory letter, the survey, and a prepaid
return-addressed envelope were mailed to partici-
pants in April 2011. The centers cancer registry
department processed the outgoing mailing to
ensure participant confidentiality, and surveys were
returned anonymously between May and July 2011.
The response rate from group 1 was 59% (132 surveys
returned), while the response rate from group 2 was
71% (218 surveys returned). The overall response
rate was 65%, bringing the number of study partici-
pants to 350.
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Sutherland, McLaughlan

Measures Table 1
A self-administered survey tool was developed spe- Survey Questions: Median Response and
cifically for this study. Questions were derived from P-Value of Questionnaire
the Survey of Manitobans Treated for Rectal Cancer How satisfied are you with Median P
and not formally validated. The survey included brief
How clear the information was about how 0.953
instructions followed by 13 questions. The first 12
many radiation treatments you would get?
questions employed a 5-point Likert scale in which
Group 1 (n = 132) 5
participants responded to questions with 1 of 5 choices
(very dissatisfied, somewhat dissatisfied, cannot decide, Group 2 (n = 218) 5
somewhat satisfied, and very satisfied). The series of How clear the information was about your 0.314
questions addressed patient satisfaction in reference to radiation treatment appointments?
the information provided them about scheduling and Group 1 (n = 132) 5
appointments, adverse effects and management, quality Group 2 (n = 217) 5
and amount of information provided, preparedness for
The information you got about the side 0.723
radiation therapy treatment, and preference regarding
effects you might get from radiation
the timing of their education session. therapy?
The last question was a multiple-choice question
Group 1 (n = 132) 5
in which participants selected their preference for the
timing of a radiation therapy patient education session Group 2 (n = 216) 5
(the same day as CT simulation, the same day as the The information you got about how you 0.877
first radiation treatment, the day after the first radiation should cope with side effects from radiation
treatment, and other). therapy?
Group 1 (n = 131) 5
Data Analysis Group 2 (n = 218) 5
The cancer centers department of epidemiology
The information you got about what your 0.987
conducted the data analysis, gathering descriptive radiation treatments would be like (such as
statistics for all questions and determining median how long the treatment would last, what
response and frequency of responses for each of the you would feel while the machine was on)?
questions. Given the ordinal nature of the data, non-
Group 1 (n = 132) 5
parametric statistical analysis was employed using the
Wilcoxon rank-sum test; a P value less than .05 was Group 2 (n = 216) 5
considered significant, and all tests were 2-tailed. Data The information you got about support 0.609
were analyzed using SAS software version 9.2 (SAS services (such as counseling, patient
Institute Inc, Cary, North Carolina). resources, and supports)?
Group 1 (n = 131) 5
Results Group 2 (n = 215) 5
A Wilcoxon rank-sum test indicated no significant
difference in the levels of satisfaction on any question
between the 2 groups, P > .05 (see Table 1). The results
from both groups were positive. The median response for Scheduling and Appointments
each question was 5, which corresponds to very satisfied. Participants from both groups were largely very
This was true of both groups. The percentage of responses satisfied with the information given about the number
received for somewhat satisfied and very satisfied of radiation treatments they would receive as well as
ranged from 9.85% to 83.33%. The percentage of respons- information given pertaining to the scheduling of radia-
es received for very dissatisfied and somewhat dissatis- tion appointments (83.33% and 81.06% vs 83.03% and
fied across all questions ranged from 0.76% to 9.3%. 76.04%, respectively).

RADIATION THERAPIST, Fall 2013, Volume 22, Number 2 133

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Breast Cancer Patient Education
Table 1 (continued)
Survey Questions: Median Response and
P-Value of Questionnaire
How satisfied are you with
The radiation therapists ability to answer
any questions you had about your radiation
treatments?
Group 1 (n = 132)
Group 2 (n = 218)
The amount of information provided during
your patient education session?
Group 1 (n = 130)
Group 2 (n = 214)
The quality of information provided during
your patient education session?
Group 1 (n = 129)
Group 2 (n = 213)
The amount of time spent with you during
your patient education session?
Group 1 (n = 130)
Group 2 (n = 214)
The chance to talk and ask questions during
your patient education session?
Group 1 (n = 130)
Group 2 (n = 214)
How your patient education session
prepared you for your radiation treatments?
Group 1 (n = 130)
Group 2 (n = 214)
Note: Numbers do not total 350 for each question because some
participants did not respond to every question. Participant response
of 5 indicates very satisfied.
Adverse Effects and Management
When participants were asked how satisfied they
were with the information provided about the pos-
sible adverse effects of radiation therapy, 59.85% of
group 1 responded that they were very satisfied,
compared to 62.96% of group 2. The frequency of
participants who were somewhat satisfied was equal
between the 2 groups (4.6%), while more participants
134
in group 2 (5.09%) were very dissatisfied, compared
to those in group 1 (3.03%).
The proportion of participants who were very satisfied
Median P
with the information provided about the management of
radiation therapyrelated adverse effects was 57.25% in
0.280
group 1 and 58.26% in group 2. The second most frequent
response was somewhat satisfied, with 29.77% of
group 1 selecting this response, compared to 25.69% of
5 group 2. Participants who responded very dissatisfied or
5 somewhat dissatisfied were 2.29% and 4.58% in group 1
0.815 and 4.59% and 6.88% in group 2, respectively.
Support Services
5
Satisfaction levels were lowest when participants
5 reported on the information provided about support
0.898 services such as counseling and patient resources. Of
group 1 participants, 54.2% responded that they were
5 very satisfied, while 7.64% responded that they were
either very dissatisfied or somewhat dissatisfied. In
5
group 2, 57.21% responded that they were very satis-
0.734 fied, while 13.5% responded that they were either very
dissatisfied or somewhat dissatisfied.
5
5 Quality and Amount of Information
0.848
Table 2 shows the number and percentage of patient
responses when satisfaction levels were assessed with
respect to the amount and quality of information provided
5 as well as the time spent and opportunity to ask questions
5 during the patient education session. Overall, more than
0.719 60% of participants in both groups responded that they
were very satisfied with these elements of the patient
education session, while fewer than 5% responded that they
5
were either very dissatisfied or somewhat dissatisfied.
5
Preparedness for Radiation Therapy Treatment
A Wilcoxon rank-sum test indicated no significant
difference between the 2 groups in how satisfied they
were with how well their education session had prepared
them for their radiation treatments (W [n1 = 130, n2 =
214] = 22149.5, P = .719, 2-tailed). For both groups, more
than 60% of participants were very satisfied, believing
that the patient education session had prepared them for
radiation treatments. In each group, fewer than 8% of
participants responded that they were very dissatisfied
or somewhat dissatisfied with how well the education
session prepared them for radiation treatments.
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Table 2
Satisfaction With the Amount and Quality of Information Provided During Patient Education Session
How satisfied are you with Very dissatisfied Somewhat dissatisfied Cannot decide Somewhat satisfied Very satisfied
Amount of information provided.
Group 1 3.85% 1.54% 6.15% 26.15% 62.31%
Group 2 4.21% 3.27% 4.21% 24.3% 64.02%
Quality of information provided.
Group 1 3.88% 0.78% 4.65% 23.26% 67.44%
Group 2 4.69% 2.82% 3.76% 19.72% 69.01%
Amount of time spent with you.
Group 1 3.08% 3.85% 4.62% 23.08% 65.38%
Group 2 3.74% 3.74% 6.07% 22.43% 64.02%
Chance to talk and ask questions.
Group 1 2.31% 4.62% 3.08% 20.0% 70.0%
Group 2 2.8% 3.27% 5.61% 16.82% 71.5%

Preferred Timing of Radiation Therapy Patient Discussion

Education Sessions
Participants were asked to select their preference for
the timing of radiation therapy patient education sessions.
The majority of participants in both groups indicated
the same day as my CT simulation as their preference
(73.55% and 80.3%; see Figure).
Scheduling and Appointments
Overall, patients were very satisfied with informa-
tion provided to them about the number of radiation
treatments they would receive and the scheduling of
radiation appointments. This suggests that the number
of treatments and their scheduling does not change

100
90
80
70
Percentage

60
Group 1
50 (First day education session)
40 Group 2
30 (After CT simulation education session)
20
10
0
The same The same A day after Other
day as my CT day as my first my first radiation
simulation radiation treatment
treatment

Figure. Participant preference for timing of radiation therapy patient education session.

RADIATION THERAPIST, Fall 2013, Volume 22, Number 2 135

Peer Review
Breast Cancer Patient Education
between patients simulation appointments and their
first day of treatment and that the timing of patient edu-
cation sessions does not influence radiation therapists
ability to give patients accurate information about the
scheduling of their radiation appointments.
Information Provided and Preparedness for
Radiation Therapy Treatments
Although the timing of patient education was not
shown to affect patient satisfaction significantly, areas
for further exploration were identified in the study
results. In comparison to other measured parameters,
participants in both groups were less satisfied with
the information they received about both the pos-
sible adverse effects of radiation treatment and how
to cope with adverse effects. This may be explained
by findings that suggested informational needs vary
among patients, with those patients whose needs
are met reporting higher levels of satisfaction.5,9-11,15,16
Patient variables that can affect satisfaction include
the readability of the information provided, as well as
the patients education level, age, gender, psychosocial
status, information preference style, and information-
seeking behavior.10,15
The radiation therapist is responsible for assessing
patient needs, providing accurate information to the
patient, ensuring the patient comprehends the informa-
tion given, and addressing the patients questions or con-
cerns. The radiation therapists perception of the patients
needs and ability to tailor the education session specifi-
cally to the patient can alter patient satisfaction with the
education experience.15 Radiation therapists are qualified
to provide patient education; however, the education and
knowledge, teaching style, and personal characteristics
of the radiation therapist are variables that can affect the
patients experience. Patients have different education
needs than those identified by radiation therapists, indi-
cating that the patients information needs are not always
met.20 Ways the content of patient education sessions
might be tailored to meet individual patient needs should
be explored.
Satisfaction levels were lowest when patients
reported on the information they received about sup-
port services such as counseling and patient resources,
suggesting that patients are interested in accessing
these services. One study obtained data from 5907
136
cancer outpatients treated in 23 hospitals across the
United States as a part of analyses for quality improve-
ment. The results indicated that meeting patients
emotional needs was among the highest priorities for
quality improvement.21
In this study, timing did not significantly affect
satisfaction rates of participants with respect to the
quality and amount of information provided during
their education sessions. Participants in both groups
felt they were prepared adequately for their radiation
therapy treatments, with the vast majority of partici-
pants being satisfied with the radiation therapists
ability to answer questions during the education ses-
sion. This finding suggests that at the time of the CT
simulation, the radiation therapist had the required
information to provide a patient education session,
and did not increase patient satisfaction by providing
information on the patients first day of treatment.
Preferred Timing of Radiation Therapy Patient
Education Sessions
The majority of patients preferred to have a
patient education session on the same day as their
CT simulation appointment. This finding is reflec-
tive of other study results, supporting patients pref-
erence to receive information prior to starting radia-
tion therapy treatments. 9,11,15
Limitations
This study had limitations that should be acknowl-
edged. The self-administered survey tool used in the
study was derived from an existing survey tool (Survey
of Manitobans Treated for Rectal Cancer) and has not
undergone formal reliability and validity testing. Content
validity of the survey was assessed by epidemiologists
experienced in survey design, radiation therapists, and
laypeople. The survey underwent several revisions to
enhance its readability and to correct ambiguity.
Patient satisfaction is dependent upon the patient, the
health care provider, and the health care organization.
Given the complexity and subjective nature of patient sat-
isfaction, it is difficult to control variables such as person-
ality, previous experience, patient expectations, physical
facilities, health care providers competence and appear-
ance, access to facilities, and communication.4,22 The
study did not control for patients exposed to external
RADIATION THERAPIST, Fall 2013, Volume 22, Number 2

resources and those conducting their own preparatory
education. These influences could affect the patients
satisfaction with the patient education experience.
The length of time between the radiation therapy
patient education session and survey completion also
could be a limitation. Satisfaction levels have been
shown to vary between the time care is received and
satisfaction measured, with increasing time being asso-
ciated with higher levels of satisfaction.2,4 The overall
response rate (65%) was high, but it is possible that non-
respondents may represent a portion of the population
less satisfied with the patient education session.2
Generalization of results to other disease site groups
cannot necessarily be made because the study included
only patients with a diagnosis of breast cancer. The
study also did not investigate differences in patient
characteristics such as age, geographic residence, lan-
guage, and ethnicity. Significant variations in patient
satisfaction levels have been reported dependent on
patient characteristics and disease sites.23,24
Conclusion
Within this study population, the timing of patient
education sessions did not affect patient satisfaction
with the education session provided. When given a
choice, however, most patients preferred to receive a
patient education session on the same day as their CT
simulation. Apart from timing, the study results also
indicate that patient satisfaction could be improved
with respect to the information provided about
anticipated adverse effects of radiation therapy, the
management of radiation-induced adverse effects, and
support services. Patient education sessions should
place an increased emphasis on these areas, with
particular attention given to assessing and meeting
the unique educational needs and preferences of indi-
vidual patients.
Whenever possible, patient preferences should be
accommodated. However, because the level of satis-
faction was not statistically different between the 2
groups, it would seem reasonable that the timing of
patient education sessions could be scheduled based
on the operational requirements of the radiation ther-
apy program. The data obtained in this study could
serve as a benchmark from which to compare subse-
quent studies within the radiation oncology program.
RADIATION THERAPIST, Fall 2013, Volume 22, Number 2 137
Peer Review
Sutherland, McLaughlan
The study results underscore several areas for
improvement: patient education on the potential
adverse effects of radiation, the management of these
adverse effects, and information about support services.
Given the limitations of the study and the lack
of agreement among this and other studies, further
study is warranted on the timing of radiation therapy
patient education sessions and patient satisfaction
with the education provided.
Jill Sutherland, MHS, BSc, R.T.(T), is radiation
therapy coordinator for educational programming at the
CancerCare Manitoba radiation therapy department in
Winnipeg, Canada.
Lauren McLaughlan, R.T.(T), CTIC, is a radiation
therapist for the CancerCare Manitoba radiation therapy
department in Winnipeg, Canada.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Communications Department,
15000 Central Ave SE, Albuquerque, NM 87123-3909, or
e-mailed to communications@asrt.org.
2013 American Society of Radiologic Technologists
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