Investigating the Impact of Tailored Reports on Anxiety Amongst Cancer Patients and Their Confidants
Investigating the Impact of Tailored Reports on Anxiety Amongst Cancer Patients and Their Confidants
Objective: To explore the hypothesis that different methods of selecting and printing
 information for cancer patients could improve emotional support by affecting interaction with
 others, and so lead to improved psychological wellbeing.

 Design: Randomised trial with 8 groups (three factors, 2X2X2). Data collected at recruitment
 and three month follow-up.

 Participants: 400 patients starting radiotherapy and their 'confidant' (the person in who
 they confide).

 Interventions: Printed booklets.

 1. Half had 'general' CancerBACUP information for that cancer; half had 'personal'
 information from the medical record plus selected general information;

 2. Half chose information by 'interacting' with the computer; half had a larger volume of
 material in booklets that were produced 'automatically'.

 3. Half had additional 'anxiety management advice'.

 Outcomes: Patients' views; use of booklet with others; change in reported social support;
 change in anxiety and depression.
Aim:

 -  Based on a randomised trial the researchers aimed to model use of leaflets in the home
 as a function of three factors:

 1. whether patients chose the information themselves or if it was chosen for them;

 2. whether it included personal information from their own medical record or not;

 3. whether it included anxiety management advice or not.

 -  The researchers aimed to model patient and confidant's anxiety at three months as a
 function of these three factors and patients' use of leaflets in the home.

 Patient Population: Beatson Oncology Centre (BOC). Patients thought to be eligible were to be
 identified from outpatient appointment diaries over fifteen months. Medical records were to
 be checked for all those initially identified to ensure that patients have breast,
 gynaecological, prostate or bladder or testicular, or selected cancers of the head or neck.
 Patients excluded were to be those:

 -  receiving palliative treatment,

 -  with no knowledge or understanding of their diagnosis (very few),

 -  with visual or mental handicap,

 -  with severe pain or symptoms causing distress,

 -  medical or nursing students,

 -  taking part in other trials with possibly confounding interventions, and

 -  those not giving informed consent.

 Sample size: The researchers aimed to recruit 400 patients. This was to give 80% power to
 find a difference between 40% and 27% who have improved anxiety between (eg) 200 in
 personalised group and 200 in general group.

 Recruitment: Eligible patients were to be sent a letter explaining the study and advising
 them that a researcher will approach them in a visit to the BOC soon after, to seek
 participation in the study. Patients were not to be recruited at their bad news consultation
 but as soon as possible thereafter and at any point in their course of contact and treatment
 at the Beatson. At recruitment the researcher was to further explain the study and seek
 written consent. If the patient consented the researcher was to arrange a time for the
 intervention and give the patient a questionnaire to take home to complete themselves and a
 questionnaire for their 'confidant'.

 Baseline data: Patients were to be asked to bring the completed questionnaire with them to
 the intervention consultation about one week later. The questionnaire included the following
 sections:

 1. previous computer and information use, perceived knowledge, significant others in
 providing emotional support, family and living arrangements,

 2. a Hospital Anxiety and Depression Scale (HADS),

 3. a Miller Coping Style questionnaire,

 4. Helgeson's measures of social support and negative interactions.

 Completion of this questionnaire should have taken about half an hour at home.

 Confidants: The researchers aimed to recruit 400 'confidants', one for each patient (but
 estimated that it were more likely to recruit (say) 60% of 400. Patients were to be asked if
 they were prepared to pass on the baseline questionnaire to a person selected by them as the
 person they are most likely to use to seek emotional support. This may be a husband, wife,
 partner, but may also be a daughter, son, or friend. The confidant questionnaire has
 sections:

 1. demographics and relationship to patient, newspaper read, frequency of discussion with
 patient, perceived knowledge

 2. HADS,

 3. Miller coping style.

 The researchers did not know what proportion of patients would be prepared to pass on the
 questionnaire or what response rate would be received from confidants. Rees in her work with
 daughters of women with breast cancer found that 93% of patients passed the questionnaires on
 and 77% of daughters responded. If we got an overall 60% response (ie 240 before and after
 questionnaires) this would give us 80% power to find a difference between 40% and 23% who had
 improved anxiety between (eg) 120 in personalised group vs 120 in general group. The
 confidant population would be less than the patient population. Patients will not be excluded
 if there is no corresponding 'confidant'.

 Randomisation for the three factors: After recruitment the RA was to randomise for each of
 the three binary factors (2X2X2 factorial design):

 A. Interactive v Automatic;

 B. Medical Record v General;

 C. Anxiety reducing advice v no advice.

 Patients were to randomised to the eight sub-groups in blocks of 32 and separately by breast
 vs rest. The eight (2X2X2) subgroups, each receive different styles of leaflet. These are
 detailed further below.

 Baseline Data: Collected from case notes was to be severity, length of onset of cancer,
 treatments so far (surgery, radiotherapy, chemotherapy), date of birth, gender, address,
 deprivation category from postcode for all patients, and a problem and treatment list for
 patients in the 'medical record' groups.

 Intervention: The delay between recruitment and intervention was to allow patients time to
 think about their participation and withdraw if desired. At the intervention, patients were
 to produce a report about their cancer. Patients in the 'automatic group' would not need to
 use the computer.

 -  Interactive vs automatic. Those in the 'interactive' groups were to choose from menus,
 see information on the screen, and press an 'add to report' button on information
 screens for that information which they want to include in their report. Patients'
 choices were to be recorded by the computer.

 -  Those in the medical records group were to have personal information included based on
 their medical record. They were to either have information automatically selected and
 formatted by the computer, or to see it on screen and choose what they want to include.

 -  Lastly, half the patients were to have an additional section offering advice for the
 reduction of anxiety. This section was written based on previous work in cognitive
 behavioural therapy for anxiety.

 All reports were to include colour photos (for example of treatment rooms, staff), and
 diagrams (for example, anatomical) of good quality printing etc. The patient were to be given
 the report to take away.

 Three month follow-up: At three months patients were to be sent a follow-up questionnaire
 with the following sections:

 1. questions about their satisfaction with the information received, their use of their
 reports, their interactions with their family and friends, and the influence of the
 reports on these interactions, their perceived knowledge.

 2. HADS,

 3. Helgeson's social support questionnaires.

 Significant others will be sent a questionnaire which has sections on:

 1. questions about their satisfaction with the information they have received,

 2. HADS

 Measures of Outcome:

 -  Change in anxiety (for patient or confidant) between intervention and 3 month follow-up
 (HADS)

 -  Change in social support (for patient) between intervention and 3 months (Helgeson)

 -  Patient satisfaction with information score at 3 month follow-up

 -  Confidant satisfaction with information score at 3 month follow-up

 -  Whether patient had read report, shown it or discussed it with the named confidant,
 other family members or friends and whether the discussion was aided by use of the
 report.

 -  What patients liked and disliked about the reports.

 -  Amongst the interactive group, choices made between presentation styles and how well
 these would correspond to automatic computer choices.

 -  Patient and staff time, and hence costs, needed for routine delivery of each
 intervention will be modelled on a variety of assumptions.

 Analysis: The researchers were to produce a CONSORT patient flow diagram and compare losses
 to follow-up by the three interventions (A,B,C). Analysis of outcomes was to be for those
 patients completing both intervention and follow-up. The researchers will focus on the
 following:

 -  Comparison of outcomes 1-4 by interventions A, B, and C while controlling for age,
 gender, cancer site, time since diagnosis, severity, coping style, using analysis of
 variance (factorial design) and multiple logistic regression.

 -  Comparison of outcomes 5 and 6 by interventions A,B, and C (qualitative).

 -  Modelling of anxiety (outcomes 1-2) on use of report at home (outcome 4), perceived
 social support, and interventions A,B,C.

 -  Frequencies of choices (outcome 7) and comparison with automatic selection, both
 statistically and through qualitative description of the differences.

 -  Comparison of patient and NHS costs (outcome 8) will be made between the methods used in
 this trial and other methods of providing information.

 -  Comparison of anxiety change in patient and significant other.

 -  Analyses will be on those completing follow-up. No substitution of data will be carried
 out for those randomised but not completing follow-up. The researchers will thus be able
 to make provisional conclusions on how the different types of information provision
 influence interaction, anxiety and patient satisfaction, and on the correlation between
 the use of information with family, and anxiety; The researchers will have information
 on patient selection to inform the better development of automatic systems, and costs to
 inform practical deployment.
Inclusion Criteria:

 -  Patients starting outpatient radiotherapy treatment with breast, prostate, cervical or
 laryngeal cancer

 Exclusion Criteria:

 -  Receiving palliative care

 -  Severe pain or symptoms causing distress

 -  Having cancer at other sites

 -  Having no spoken English

 -  Receiving treatment for psychological or psychiatric problems

 -  Visual or mental handicap

 -  Having case notes not available or ambiguous or illegible.