Introduction
Breast cancer is the most common cancer in the UK. 1 Advances in UK breast cancer radiotherapy have improved patient outcomes, Reference Probst, Rosbottom, Crank, Stanton and Reed2 with conformal techniques reducing cardiac risks. Reference Currey, Bergom, Kelly and Wilson3 There is a linear relationship between mean heart dose and the risk of cardiac events, with pre-existing cardiac risk factors further compounding the risk. Reference Darby, Ewertz, McGale, Bennet, Blom-Goldman and Brønnum4 Voluntary breath hold reduces mean heart dose. Reference Bartlett, Donovan, McNair, Corsini, Colgan and Evans5 26 Gy in 5 fractions over 1 week 6 has been adopted as a new standard of care for patients with operable breast cancer requiring adjuvant radiotherapy. Surface guided radiotherapy (SGRT) is positively impacting breast cancer patients, Reference Freislederer, Kügele, Öllers, Swinnen, Sauer and Bert7 and investigations continue to find alternative treatment techniques to reduce late effect cardiac toxicity, with the PARABLE trial comparing proton beam therapy to photon therapy. Reference Kirby, Holt, Taylor, Haviland, MacKenzie and Coles8
The publication of postoperative radiotherapy for breast cancer: UK consensus statements, 9 states that all UK radiotherapy departments should have a breathhold technique available. The National Institute for Health and Care Excellence (NICE) 10 now recommends using a technique that minimises the dose to the lung and heart and using a deep inspiration breath hold (DIBH) technique for left-sided breast cancer radiotherapy to reduce cardiac toxicity. DIBH is the established standard of care; however, it is unclear how many radiotherapy departments in England use the technique. Patient selection is on a clinical basis, Reference Bergom, Currey, Desai, Tai and Strauss11,Reference Anastasi, Bertholet, Poulsen, Roggen, Garibaldi and Tilly12 but there is limited evidence of patients with a hearing impairment or other language barriers being treated with this technique.
DIBH improves radiotherapy accuracy by reducing organ motion and is feasible on most treatment systems. Reference Anastasi, Bertholet, Poulsen, Roggen, Garibaldi and Tilly12 Systems vary between commercial products and may have some in-house-designed equipment as an add-on. Giap Reference Giap13 designed a virtual reality (VR) interactive 3D game to assist patients with breathing depth feedback. Ku et al.’s Reference Ku, Ng, Yu, Kong, Kwok and Mui14 homemade self-held respiration monitoring device gives a green light signal with an alarm to guide patients during respiratory motion. The primary object of these two studies was improving reproducibility during DIBH but would have visual references that would be of great benefit to patients with a hearing impairment or other language barrier.
An increased number of radiotherapy departments using DIBH could provide equitable access geographically. However, this study considers whether diverse patient groups in each department are included for DIBH. The UK has approximately 70,000 individuals who are deaf (British Sign Language users) and many more who are hard of hearing (deaf with a lower-case d). 15 These two groups will be inclusively referred to as D/deaf. With an ageing population and older age being the main risk factor for cancer, 16 about one in seven people will be experiencing some kind of hearing loss. 15 Additionally, 9% of England’s population have a primary language other than English, 17 posing communication challenges during radiotherapy for breast cancer.
Hearing and understanding of vocal commands are listed consistently on inclusion criteria for studies of DIBH. Reference Li, Zhan, Jia, Xiong, Lin and Li18–Reference Pembroke24 A study by Jahraus et al. Reference Jahraus, Sokolosky, Thurston and Guo25 to assess the effectiveness of education programmes for patients with breast cancer undergoing radiotherapy also has fluent English as an inclusion criterion. Visual aids such as scans or plan diagrams may have been used to aid communication in a study by Schnitzler et al.; Reference Schnitzler, Smith, Shepherd, Shaw, Dong and Carpenter26 however, there is no mention of translation or use of text on a screen. These studies may have helped to ascertain what patients might want to know and have highlighted differing patient information needs, yet have not provided any evidence base for patients with a hearing impairment or other language barrier undergoing radiotherapy for breast cancer.
In addition to having available technology, effective DIBH requires patient compliance, Reference Anastasi, Bertholet, Poulsen, Roggen, Garibaldi and Tilly12 influenced by coaching and preparatory education. Patient preparation for DIBH is delivered in many forms and can vary significantly between centres. Reference Kron, Bressel, Lonski, Hill, Mercieca-Bebber and Ahern27 Studies like Berman et al. Reference Berman, Jo, Cumberland, Booth, Wolfson and Stern28 of 68 D/deaf breast cancer survivors highlighted gaps in their knowledge about their cancer and treatment, potentially due to a reliance on lip reading and insufficient adaptations in communication by healthcare professionals. Shukla et al. Reference Shukla, Sueyoshi, Diamond, Chowdhury, Stambaugh and Wazer29 concluded that there were disparities in the application of DIBH between English-speaking versus non-English-speaking patients. Hill et al. Reference Hill, Deville, Alcorn, Kiess, Viswanathan and Page30 literature search like this study did not reveal any data on whether D/deaf patients are getting treatment that adheres to national guidelines. Yamauchi, Reference Yamauchi, Mizuno, Itazawa, Masuda, Akiyama and Kawamori31 demonstrated improved reproducibility of DIBH by testing a visual feedback system in a clinical setting.
Improved communication may equally boost patient engagement. Patients have reported that holding their breath made them feel like they were contributing to their treatment. Reference Kron, Bressel, Lonski, Hill, Mercieca-Bebber and Ahern27 Patients’ engagement during treatment can be an additional safety barrier. Reference Pernet, Mollo, Bibault and Giraud32 Without engagement and compliance, patients could be the source of errors, unknowingly threatening their own safety. Reference Pernet, Mollo, Bibault and Giraud32 Raising an alarm and identifying an error during patient setup and treatment, in addition to better knowledge of their own disease and treatment options, and being able to advocate for themselves more and self-manage toxicities better.
Existing resources, such as Respire training tools 33 and Cancer Research UK videos 16 with BSL interpretation, are available to radiotherapy departments to help support patient education. Virtual reality education has also shown improved patient understanding and reduced anxiety. Reference Grilo, Almeida, Rodrigues, Isabel Gomes and Caetano34
This study explores DIBH implementation in NHS radiotherapy departments in England and investigates technology in use with a particular interest in the use of non-verbal communication. This survey enquires whether patients are coached in the DIBH technique and what adaptations are in place in radiotherapy departments for patients with a hearing impairment and other language barriers. Findings will inform best practice, ensuring equitable access to optimal breast cancer radiotherapy.
Methods
This cross-sectional mixed-methods study used a Society of Radiographers (SOR) contact list 35 (last updated 2021) of 56 NHS Radiotherapy department managers in England. These were contacted via email with a link to a questionnaire (Appendix A). The other home nations and private practice were excluded due to potential differences in funding, adding to an already lengthy list of potential variables between radiotherapy departments. Of the 56 departments contacted, delivery failed to 4, and 22 responded.
Data collection was carried out over a 2-week period from 13 December 2023 to 5 January 2024, following ethical approval to proceed from a UK university reference SREC 23003 (Appendix B). The email invite provided details of the survey, and participants were informed that submission of a questionnaire would be an acknowledgement of consent (Appendix C).
A pilot study of 8 questionnaires, distributed at two radiotherapy departments, helped with the clarity of the questions and the completeness of the multiple-choice answers. Reference Hicks36 Microsoft Forms 37 was used to design the questionnaire. Respondents were allocated unique reference numbers to maintain the anonymity of the responding radiotherapy centres (‘respondents’ hereafter).
Microsoft Forms data was exported to Excel, and descriptive statistical analysis was used to present graphical data and tables. Researchers identified qualitative themes independently prior to reviewing together to improve the validity of the data.
Results
All respondents (n = 22) indicated that their departments practised DIBH for breast cancer radiotherapy techniques. Just over half (n = 12) stated that the decision of whether the patient is for DIBH or not is made when radiotherapy is decided as a course of treatment, 32% (n = 7) stated at the pre-treatment planning scan and 14% (n = 3) responded in terms of the clinical requirement of the target being treated. When asked what may make a patient unsuitable for DIBH, respondents answered as in Figure 1 and Table 1 below.
Figure 1. Reasons for DIBH unsuitability.
Table 1. ‘Other’ reasons given for DIBH unsuitability
All left breast cancer treatments were considered for DIBH by 91% (n = 20) of respondents. One respondent was more inclusive with all breast cancer treatments, and one respondent did not select either all breast or all left breast as options but answered ‘Internal mammary chain (IMC) treatments; Left breast lower quadrant tumours; Bilateral breast, High cardiac risk or on Herceptin (CCO discretion) Dosimetry replan for high cardiac dose, Inner half (LIQ, UIQ)’.
Table 2 details the responses to the question what aspects of DIBH do you find challenging with 14% (n = 3) experiencing no challenges with the treatment technique.
77% (n = 17) of respondents use the same equipment for DIBH at the pre-treatment computer tomography (CT) scan and for treatment delivery.
77% of respondents (n = 17) used multiple methods to provide information about DIBH to the patient prior to the pre-treatment (CT) appointment. 91% (n = 20) use face-to-face either on its own or in combination with other methods, as shown in Table 3 below.
Table 2. Challenging aspects of DIBH
Table 3. Information methods used with patients
In response to who provides the patient with the information prior to the pre-treatment (CT) appointment, this list provides a breakdown: oncologist n = 15, consultant radiographer n = 6, advanced practitioner n = 3 and radiographer n = 7. 46% of respondents (n = 10) expanded their response by listing additional options provided in the ‘Other’ option, and these have been included in the figures.
50% (n = 11) of respondents do not offer DIBH coaching prior to a patient’s pre-treatment CT scan. Of those that do, 6 offer coaching in person and 5 online.
86% (n = 19) of respondents offer breath-hold coaching on treatment, of which 45% (n = 10) use verbal instruction only, with 18% (n = 4) using visual aids or references and 23% (n = 5) using a combination of both verbal and visual. Figure 2 displays these data visually.
Figure 2. Delivery of breath hold coaching treatment.
Patients with a hearing impairment are offered DIBH by 73% (n = 16) of respondents. Table 4 shows how this is achieved.
55% (n = 12) are investigating or implimenting changes to enable equitable access for patients with a hearing impairment. These developments can be seen in Table 5.
Table 4. Adaptations made for patients with a hearing impairment
Table 5. Awareness of new approaches or equipment departments will be introducing to be more accessible for patients with a hearing impairment
Of the respondents who do not currently offer DIBH for hearing-impaired patients (27%, n = 6), five of these suggested visual aids, screens and coaching would be required to do so. N = 1 responded that the use of red and green lights, prior coaching with a BSL interpreter and hearing aids, would be necessary.
All respondents (n = 22) reported offering DIBH to non-English speakers and provided multiple adaptations which are grouped together in themes in Table 6.
Table 6. Adaptations made for non-English speakers
Of the five respondents in Table 6 who reported using screens or other visual aids for DIBH delivery, two use surface guide radiotherapy (SGRT), one uses Varian real-time position management (RPM), one uses SGRT Varian and an in-house system, and one uses a screen with instructions on breathing appearing in text.
In response to Are you aware of any new approaches or equipment departments will be introducing to be more accessible for non-English speaking patients?, 55% (n = 12) answered ‘no’. Three did not provide an answer, and one responded that the question was not applicable. Of the remaining six respondents, one is looking at possible future upgrade options available on Respiratory Gating for Scanners (RGSC) in different languages, one is investigating light prompts, one is currently auditing visual and verbal techniques following the implementation of coloured lights, one has recently implemented a screen with breathing instruction appearing as text, one answered ‘breath hold lights’ and one answered ‘visual aids’.
Discussion
It is encouraging that 100% of respondents, representing 39% of the NHS radiotherapy departments in England, use DIBH for breast cancer radiotherapy. According to a European Organisation for Research and Treatment of Cancer (EORTC) survey with a 47% response rate, 19% of institutions used breathhold techniques. Reference van der Laan, Hurkmans, Kuten and Westenberg38 This is also much increased from the 4% reported in the audit mentioned within Bartlett et al.; Reference Bartlett, Colgan, Carr, Donovan, McNair and Locke39 however, the details of this are unpublished, and the sample size, methods and full results are therefore not able to be further interrogated. This suggests England is moving towards more equitable access to the breathhold technique as per the expectations of both the UK consensus statements 9 and the NICE (2018) recommendations. 10 All (n = 22) responses to the questionnaire indicated that this was the case.
What is of concern, however, is that only 73% (n = 16) of respondents reported that they offer DIBH to patients with a hearing impairment. The term hearing impairment encompasses a range of hearing abilities and may be open to interpretation; had the questionnaire specified D/deaf, that percentage may have been considerably lower. Information provided in response to what adaptations had been made to deliver DIBH to patients with a hearing impairment highlights that 56% (n = 9) used verbal instruction, making it less likely that patients with very limited hearing or those reliant on lip reading would have been treated with DIBH at these sites. This view is supported by the following two quotes.
‘Depends on hearing impairment level. We have not had a patient who is deaf and unable to hear commands, this would likely prevent us being able to offer DIBH however we would try to adapt if possible, especially as our treatment is gated’. (Respondent 21)
‘Depends on level of impairment - visual display screen can be used to assist but still need to be able to hear breathe in command’. (Respondent 12)
Although Table 5 highlights positive changes that are being implemented, 32% (n = 7) of respondents were not aware of any new initiatives to increase accessibilty to DIBH for patients with a hearing impairment.
By contrast, 100% (n = 22) of respondents offer DIBH to non-English-speaking patients. 50% (n = 11) adapt by using more succinct instruction. The patient learns the commands ‘breathe in’ and ‘breathe out’ in English. 68% (n = 15) of respondents mentioned using an interpreter; however, it is unknown exactly when interpreters were present, and this figure includes using digital translation. With a reliance on predominantly verbal feedback and translation, the risk for both is that expediting patient treatment may be prioritised over patient comprehension, Reference Berman, Jo, Cumberland, Booth, Wolfson and Stern28,Reference Shukla, Sueyoshi, Diamond, Chowdhury, Stambaugh and Wazer29 most likely due to time constraints.
By comparison, in the Shukla et al. Reference Berman, Jo, Cumberland, Booth, Wolfson and Stern28 study, 51% had an interpreter present for 76%–100% of the time at CT, 31% at the first fraction and 11% at subsequent fractions. Respondents from both studies mention using radiographers or other staff who speak the patient’s language. The following response demonstrates how workarounds can be found to deliver patient-centred treatment.
‘DIBH instructions are recorded into the CT scanner using Google Translate on an iPod. Standard phrases for CT & trt are verified by a staff member/interpreter and stored on an iPod prior to CT. These are then used through the intercom on treatment’. (Respondent 11).
Communication challenges were frequently cited (n = 8), yet hearing impairment and language barriers were rarely mentioned, likely due to limited exposure to these specific patient groups. Additionally, consistent breath hold, patient compliance, consistency of setup and no visual cues or aids were mentioned (n = 12, see Table 2), and these may also relate to aspects of communication, which, if more patients with a hearing impairment or other language barrier were to be treated with DIBH, would most likely make treatment delivery more challenging. Verbal and visual feedback had improved reproducibility compared to just verbal feedback in Kron et al.’s Reference Kron, Bressel, Lonski, Hill, Mercieca-Bebber and Ahern27 multi-centre feasibility study of DIBH. Poor communication may result in patients not tolerating a breathhold technique. Reference Aznar, Fez, Corradini, Mast, McNair and Meattini21 These data illustrate multiple challenges associated with the delivery of DIBH and the inconsistencies across departments and differing resources. Kron et al. Reference Kron, Bressel, Lonski, Hill, Mercieca-Bebber and Ahern27 have commented on these inconsistencies too. Although this study focuses on the inclusion of D/deaf and non-English-speaking patients, these findings raise concerns about the potential number of hearing English speakers who may also be excluded due to inadequate communication and the lack of person-centred care.
Although face-to-face communication may be preferable for some and used by 91% (n = 20) of respondents, being able to use technology such as Microsoft Teams for video calls 40 could be of benefit for those who are hearing impaired or have other language barriers due to the subtitle and translation features. Table 3 details the multiple combinations of communication methods across departments. In the Pembroke Reference Pembroke24 study, although patients received both written and spoken information, 6 of the 17 participants recommended implementing video education.
Communication challenges may be further compounded by a lack of coaching; 50% (n = 11) of respondents stated that DIBH coaching is not offered prior to a patient’s pre-treatment CT scan. Prior to pre-treatment (CT) was identified as a time when patient need was highest. Reference Halkett, Merchant, Smith, O’Connor, Jefford and Aranda41 Without adequate preparation, hearing-impaired patients may struggle, as lip reading and sign language become impractical during treatment. Of the 86% (n = 19) that offer DIBH coaching during treatment delivery, 79% (n = 15) use either some or only verbal instruction, whilst only 18% (n = 4) use visual aids. Therefore, whilst 100% offer DIBH, only 18% could realistically deliver DIBH to a patient with no hearing at all.
Further to the lack of coaching discussion, there could be increased challenges with patient compliance and patient experience. Reference Aznar, Fez, Corradini, Mast, McNair and Meattini21 A study exploring anxiety in the radiotherapy department by Gimson et al. Reference Gimson, Greca Dottori, Clunie, Yan Zheng, Wiseman and Joyce23 found personal, effective and timely communication was essential in mitigating anxiety for their participants. A study by Anastasi et al. Reference Anastasi, Bertholet, Poulsen, Roggen, Garibaldi and Tilly12 reported over half of respondents treating breast cancer provided a dedicated coaching session. Duration ranged from 15 minutes to an hour; however, it is not known at which stage of treatment that coaching session took place. It does, however, indicate the requirement for suitably qualified staff and time.
Table 1 shows only one participant gave anxiety as the reason a patient may not be suitable for DIBH; however, it is worthy of note that this is perceived anxiety by the respondent. The literature suggests that anxiety is commonly experienced by patients. Difficulty identifying anxious patients due to stoicism could lead to an underestimation of anxiety by radiographers. Reference Gimson, Greca Dottori, Clunie, Yan Zheng, Wiseman and Joyce23 As cancer patients undergoing radiotherapy, it is likely that those with a hearing impairment or other language barrier will experience similar levels of anxiety as a minimum and quite likely to a higher degree should communication be less effective.
Kron et al. Reference Kron, Bressel, Lonski, Hill, Mercieca-Bebber and Ahern27 compared anxiety, as a secondary objective, in patients undergoing DIBH for left breast radiotherapy to patients free breathing during radiotherapy to the right breast and concluded that anxiety levels between the two groups were on a parr. This emphasises the need for improved communication for all patient groups, as it is known from other studies that this anxiety can be substantial. Reference Gimson, Greca Dottori, Clunie, Yan Zheng, Wiseman and Joyce23
Whilst there are alternative cardiac sparing techniques such as heart shielding, according to Bartlett et al., Reference Bartlett, Yarnold, Donovan, Evans, Locke and Kirby42 dose coverage is not as good. Proton beam therapy is less robust to changes in the treatment volume; breast size and contour can change with seroma. Reference Bergom, Currey, Desai, Tai and Strauss11 Even if the outcome of the PARABLE trial favours proton beam therapy and robustness proves not to be an issue, the capacity is limited with just two proton centres in the UK. Reference Kirby, Holt, Taylor, Haviland, MacKenzie and Coles8 The alternative of treating the patient in the prone position may also not be suitable, as the heart position can still be variable. Reference Bergom, Currey, Desai, Tai and Strauss11 DIBH is effective in sparing heart tissue and is reproducible and feasible in a multicentre setting. Reference Bartlett, Donovan, McNair, Corsini, Colgan and Evans5 For patients not currently being offered DIBH due to a hearing impairment or language barrier, any awareness of this disparity of treatment may further increase anxiety.
The results show that patients could receive information from different healthcare professionals prior to the pre-treatment (CT) appointment. The answers refer to radiotherapy professions specifically; however, oncology nurses have a patient education role too. Reference Jahraus, Sokolosky, Thurston and Guo25 What is unknown is who delivers what information. The regular attendance in radiotherapy departments for fractionated treatments lends itself well to delivering and reinforcing quality information, Reference Schnitzler, Smith, Shepherd, Shaw, Dong and Carpenter26 so it is disappointing that shortfalls exist in communication and quality of patient care in radiotherapy departments across England today.
With only 22 responses out of 56 NHS radiotherapy departments, generalisation of findings is not possible. Additionally, the overall data analysis could be strengthened via the application of an appropriate theoretical framework. The role or experience of the respondent is not known so the reliability of these data cannot be confirmed. In addition, the variable size and location of departments could result in different levels of experience with non-English-speaking patients or hearing-impaired patients as well as account for the variable resources across departments. The short data collection period, compounded by the dates falling over the Christmas period, may have affected the number of responses received. A university dissertation submission deadline following ethics approval left a small window for data collection.
Questionnaire design limited data obtained regarding the equipment used for DIBH. Clarification of in-house equipment or SGRT was not sought, leaving the only manufacturer specified as Varian. 43 Technological disparities across departments affect inclusivity, with advanced systems like SGRT and Varian Respiratory Gating for Scanners (RGSC) facilitating DIBH for patients with a hearing impairment or language barrier more easily with fewer adaptations required. Further research is needed to standardise adaptations, and collaboration with professional groups such as the SOR Breast Radiotherapy Interest Group (BRIG) could promote best practices. Improved patient data collection on communication needs would also help radiographers tailor support.
Conclusion
With 100% of the respondents, representing 39% of all NHS radiotherapy departments in England, using a DIBH technique for patients with breast cancer, it can be concluded that equitable access for breast cancer patients to DIBH has greatly increased. The indications are that the figures are lower for D/deaf and non-English speakers; however, more specific enquiry is needed to determine their inclusion more accurately. Without published figures for the number of breast cancer patients with a hearing impairment or language barrier, quantifying equitable access is not possible. An alternative measurement in this study is the critical evaluation of adaptations in place for these patient groups. Although some of the more recent implementations of advanced technologies have made the use of digital and visual feedback mechanisms for D/deaf and non-English speakers easier to implement, the study has shown that it is feasible to implement adaptations for these patient groups on existing treatment delivery systems. On that basis, until all departments have made some reasonable adjustments along the radiotherapy treatment pathway for DIBH, access by those with a hearing impairment or other language barrier cannot be deemed to be equitable.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1460396925100216.
Acknowledgements
None.
Competing interests
The authors declare none.
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