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After going through chemotherapy I can’t see another needle
ARTICLE IN PRESS European Journal of Oncology Nursing (2007) 11, 43–48
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After going through chemotherapy I can’t see another needle Anna Clare Cox, Lesley J. Fallowfield Cancer Research UK Psychosocial Oncology Group, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9QG, UK
KEYWORDS Needle anxiety; Chemotherapy; Cancer patients
Summary Needle anxiety not only impacts on a patient’s quality of life but can delay or prevent future medical care. Our survey of women with breast cancer indicated that 78/208 women (37.5%) reported feeling anxious about injections. Patients who reported needle anxiety were significantly younger (tð206Þ ¼ 3:72; Po0:01), with a lower body mass index (BMI) (tð182Þ ¼ 2:16; Po0:05), experience of chemotherapy (w2 ð1Þ ¼ 8:29; Po0:01), a lower internal health locus of control (tð187Þ ¼ 2:28; Po0:05) and higher levels of state (tð197Þ ¼ 3:58; Po0:01) and trait anxiety (tð197Þ ¼ 2:30; Po0:05). Patients repeatedly highlighted the experience of chemotherapy as having caused their needle anxiety. Patient discourse suggests that chemotherapy related needle anxiety is a result of physical (e.g. finding a suitable vein) and environmental (e.g. the chemotherapy room) factors. Patients with cancer require psychosocial support during all stages of care, this should include the application of techniques to prevent or ameliorate the development of anxiety caused by certain aspects of cancer treatments, such as the development of chemotherapy-related needle anxiety. & 2006 Elsevier Ltd. All rights reserved. Zusammenfassung Angst vor Punktionen kann die Lebensqualita ¨t eines Patienten beeintra ¨chtigen und daru ¨ber hinaus zu einer Verzo ¨gerung oder sogar Verhinderung von medizinischen Maßnahmen fu ¨hren. Die Ergebnisse unseres Surveys bei Brustkrebspatientinnen zeigen, dass 78 von 208 befragten Frauen (37,5%) angaben, Angst vor Injektionen zu haben. Patienten mit Angst vor Punktionen zeigten folgende Merkmale: signifikant ju ¨ngeres Alter (t (206) ¼ 3,72; po0,01), niedrigerer Body Mass Index (BMI) (t (182) ¼ 2,16; po0,01), Zustand nach Chemotherapie (w2 (1) ¼ 8,29; po0,01), niedrigerer interner Health Locus of Control (t (187) ¼ 2,28; po0,05), ho ¨here Level of State (Zustandsebene) (t (197) ¼ 3,58; po0,01) sowie Trait Anxiety (Angst als Eigenschaft) (t (197) ¼ 2,30; po0,05). Die Patienten gaben wiederholt an, Ursache fu ¨r ihre Angst vor Punktionen sei die erhaltene Chemotherapie. Die ¨ußerungen der Patienten lassen vermuten, dass eine Chemotherapie-assoziierte Angst vor A Punktionen auf ko ¨rperlichen (z. B. Finden einer geeigneten Vene) und umfeldbedingten (z. B. Chemotherapie-Raum) Faktoren beruht. Krebspatienten beno ¨tigen in allen Phasen ihrer Behandlung eine psychosoziale Unterstu ¨tzung, einschließlich der Anwendung von Techniken,
Corresponding author. Tel.: +44 1273 873015; fax: +44 1273 873022.
E-mail address: [email protected] (L.J. Fallowfield). 1462-3889/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2006.04.035
ARTICLE IN PRESS 44
A.C. Cox, L.J. Fallowfield ¨ngste vor bestimmten onkologischen Behandlungen (z. B. eine Chemothermit denen sich A apie-assoziierte Angst vor Punktionen) verhindern oder verringern lassen. & 2006 Elsevier Ltd. All rights reserved.
Introduction Needle phobia, defined as ‘an intense and persistent fear of injections’ (Deacon and Abramowitz, 2006), affects a small minority (1.6%) of individuals in the general population (Bienvenu and Eaton, 1998). Increasing attention is now being given to a less severe fear of injections, known as needle anxiety. Most studies addressing the prevalence of and factors associated with needle anxiety have been conducted in phlebotomy (Deacon and Abramowitz, 2006), diabetes (Mollema et al., 2001), dentistry (Enkling et al., 2006) and the general population (Noyes et al., 2000). Cancer patients experience increased exposure to needles during assessment procedures and treatment regimens and their attitude to needles should be assessed as the development of needle anxiety may cause delay or avoidance of appropriate medical care in the future (Noyes et al., 2000). A commonly used theory for explaining the aetiology of anxiety is the behavioural theory (Skinner, 1984). Behavioural theory suggests that anxiety is a conditioned response to a specific stimuli following a bad experience. In a review of blood-injury phobia, Marks (1988) reports that needle phobia is usually traced back to an adverse experience with needles in a health-care setting. A bad experience can then lead to a generalised learned response to needle procedures and related objects. Historically, literature concerned with the response of cancer patients to needle exposure has focused on the physical side effects of chemotherapy. Over the past 20 years, significant advances have been made in reducing both the incidence and severity of physical side effects associated with chemotherapy. It is claimed that chemotherapy associated emesis can now be prevented in 60–90% of patients (Gralla, 2002). These improvements are reflected in patient perceptions of the side effects of chemotherapy. A survey in 1983 revealed that patients ranked vomiting as the most severe side effect of chemotherapy (Coates et al., 1983). A repeat of this survey in 1993 (Griffin et al., 1996), reported a reduction in the perceived severity of vomiting which now ranked in 5th place. The overall ranking for ‘thought of having treatment’ and ‘having a needle’ also decreased between 1983 and 1993 and the authors conclude ‘the entire experience of chemotherapy is less dreaded today’ (p. 194). However, it is important to note that 55 and 39% of patients still reported experiencing these side effects in 1993. Affective disturbance in terms of anxiety and depression were more apparent in the 1993 sample, supporting claims that the psychological impact of chemotherapy has increased (Carelle et al., 2002). Patient preference for oral chemotherapies could be due in part to apprehensions concerning intravenous (IV) regimens. Preference for route of administration was assessed in a population of incurable cancer patients who were
expected to receive chemotherapy in the future (Liu et al., 1997), 89% stated they would rather receive an oral than IV chemotherapy regimen. Reasons given for this preference include ‘problems with IV lines’ (66%), ‘control of chemotherapy environment’ (61%) and ‘previous IV chemotherapy problems’ (34%). Preference for oral chemotherapy is supported by a more recent study which asked patients with metastatic breast cancer to decide between two equally effective and tolerable treatments, 63% preferred oral chemotherapy, 29% preferred IV chemotherapy and 8% were neutral (Paley et al., 2005). During interviews conducted as part of a survey of patient preferences for different routes of administration of endocrine treatments by intramuscular (IM) injection or tablets, many patients made reference to their experience of chemotherapy when discussing their current attitude to needles. This paper reports factors associated with needle anxiety and explores quantitative and qualitative data on the association between experience of chemotherapy and needle anxiety. A full exploration of variables associated with patient preference for route of administration of breast cancer treatments have been published in a separate paper (Fallowfield et al., 2006).
Methods Patients Women with early or advanced stage breast cancer at least 2-year post-diagnosis and currently in remission or with stable disease were invited to participate in this study. Two hundred and seventy women expressed an interest in participating, 35 women later refused, and 27 proved to be ineligible or unavailable. This paper reports the results of 208 women.
Procedure Women attending routine follow-up appointments at one of six oncology outpatient clinics in the UK were invited to participate in a study investigating patient preference for breast cancer treatments. Patients were given written information and those who expressed an interest were followed up with a telephone call. Those who agreed to participate were interviewed at home by a trained Cancer Research UK researcher. Patients gave written informed consent prior to the interview, which included permission for the interview to be audiotaped. The study had approval from Multi-centre and Local Research Ethics Committees.
Interview The semi-structured interview included details of the patient’s socio-demographic variables, treatment, medica-
ARTICLE IN PRESS After going through chemotherapy I can’t see another needle tion (both past and present), and preference for route of administration of medication. Patient experience of and attitude towards injections were also elicited, specifically whether they had ever had IV, IM, subcutaneous (SC) or other types of injections (O), whether they felt anxious about injections or had ever suffered from needle phobia, and whether they would avoid injections in the future. Finally, participants completed two short standardised measures, the State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983) and the Multidimensional Health Locus of Control Scale (MHLOC) (Wallston et al., 1976). The STAI provides a measure of state and trait anxiety (range 20–80, a higher score indicating a greater level of anxiety). The MHLOC is comprised of three dimensions; internal control (e.g. ‘If I get sick it is my own behaviour, which determines how soon I get well again’), external control/powerful others (e.g. ‘When I don’t feel well I should consult my doctor’) and external control/chance (e.g. ‘Good health is largely a matter of good luck’). Audiotaped interviews were coded against a predetermined checklist as to whether or not patients had been treated with i.v. chemotherapy, i.e. yes, no or unsure. What they felt about that experience, if volunteered by the patient was noted verbatim, Sections of discourse regarding chemotherapy were transcribed and checked by an independent researcher prior to analysis. If it was not clear from the audiotape, the patient’s medical notes were reviewed to determine whether or not a patient had been given i.v. chemotherapy.
Statistics and analysis All quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) v11.5. The t-test was used to examine differences between group means and the w2 test to examine differences in proportions. Any free responses to open ended questions were listed and grouped into broad thematic categories.
Results The mean age of participants was 60 years (SD ¼ 11.5), the majority (64%) were married/living with partner and just over half of the sample (53%) had completed their education by 16 years of age. Full patient demographics and scores for the STAI and MHLOC are given in Table 1. Approximately, a third of patients (78/208, 37.5%) reported feeling anxious about injections and 13.5% of patients (28/208) had experienced a needle phobia. Fortyone per cent of patients (32/78) who reported needle anxiety said the way they felt about injections would cause them to avoid having one in the future.
Factors associated with needle anxiety An exploratory analysis was performed to determine which factors affected needle anxiety. Patients who reported needle anxiety were significantly younger (tð206Þ ¼ 3:72; Po0:01), with a lower body mass index (BMI) (tð182Þ ¼ 2:16; Po0:05), experience of chemotherapy (w2 ð1Þ ¼ 8:29; Po0:01), a lower internal health locus of control
45 (tð187Þ ¼ 2:28; Po0:05) and higher levels of state (tð197Þ ¼ 3:58; Po0:01) and trait anxiety (tð197Þ ¼ 2:30; Po0:05). Socioeconomic status, education, marital status and broad experience of any of the injection groups (IV/IM/SC/O) were not significantly associated with needle anxiety.
Chemotherapy and needle anxiety Of the 113 women who had experienced chemotherapy, 52 women (46%) reported feeling anxious about injections and 18 women (16%) had experienced a needle phobia. Twenty per cent of patients (22/113) who had experienced chemotherapy said the way they felt about injections would cause them to avoid having one in the future. Table 2 gives full patient details by chemotherapy experience including attitudes towards injections and preference for route of administration of future treatments. Women who had experienced chemotherapy tended to be younger (tð205Þ ¼ 8:63; Po0:01) with higher levels of state anxiety (tð196Þ ¼ 2:15; Po0:05). The difference in the state anxiety of women who had experienced chemotherapy and reported a needle anxiety (mean state anxiety ¼ 39) and those who had experienced chemotherapy but did not report needle anxiety (mean state anxiety ¼ 41) was not significant (tð107Þ ¼ 1:36; P ¼ 0:18). Patients repeatedly highlighted the experience of chemotherapy as having caused their needle anxiety ‘I would say with the chemotherapy I got very anxious’ [ID:02017], ‘very anxious and I have to say that’s since the chemoyit’s totally connected to the chemotherapy, I had no problem before’ [ID:03007], ‘It never used to bother me, I think once you start having chemo, that’s when it changes’ [ID:01055] and ‘after going through chemotherapy I can’t see another needle’ [ID:03009]. Patient discourse offers insight into the cause of chemotherapy related needle anxiety. Many patients focused on the pain and anxiety of finding a vein ‘they ran out of veins and it was getting more and more difficult so it was getting very painful’ [ID:02013], ‘they can’t always find the vein you know, it is quite painful’ [ID:03007], ‘they can’t find my veins and they keep poking and pushing inside and it is very, very painful since the chemotherapy’ [ID:03059] and ‘its the whole thing of trying to find a vein and one vein collapsing, it’s just the whole, the whole thing of that, it really gets to me, I actually ran out one day where they were having that much trouble’ [ID:04001]. Support and environment issues were also highlighted as causing chemotherapy-related anxiety ‘there wasn’t much reassurance or advice given to me’ [ID:01003], ‘it’s just that room, I remember one lady was taken into another room and I said to her why has she gone into this other little room and she says she can’t enter this room. I said I know the feeling, it’s horribleyit’s got a certain smell, I think that’s really powerful isn’t it’ [ID:03060]. There was a significant difference in the preference for route of administration of future treatments between women who had experienced chemotherapy and those who had not (w2 ð2Þ ¼ 12:86; Po0:01). When asked their preference for route of administration of future breast cancer treatments, assuming the treatments were equally effective
ARTICLE IN PRESS 46
A.C. Cox, L.J. Fallowfield
Table 1
Patient characteristics and needle anxiety.
Characteristic
All patients (n ¼ 208)
No needle anxiety (n ¼ 130)
Needle anxiety (n ¼ 78)
Age mean years [SD (range)] BMIa mean kg/m2 [SD (range)] Educationa n (%) Secondary Further/higher Socioeconomic statusb (Carstairs quintiles) n (%) 1 (most affluent) 2 3 4 5 (most deprived) Partnership status n (%) Single Married/living with partner Separated/divorced Widowed Experience of injections n (%) Intravenous (IV) Intramuscular (IM) Subcutaneous (SC) Other types of injections (O) Experience of chemotherapyb n (%) State-Trait Anxiety Inventory Trait anxietyc mean [SD (range)] State anxietyc mean [SD (range)] Multidimensional Health Locus of Control Scale Internal controlc mean [SD (range)] External control/chance meand [SD (range)] External control/powerful othersc mean [SD (range)]
60 [11.5 (32–88)] 26 [5.0 (17–42)]
62 [10.9 (32–86)] 27 [5.3 (19–42)]
56 [11.6 (34–88)] 26 [4.5 (17–41)]
111 (53.4) 95 (45.7)
74 (57.8) 54 (42.2)
37 (47.4) 41 (52.6)
27 38 46 46 50
14 22 32 35 27
(10.8) (16.9) (24.6) (26.9) (20.8)
13 16 14 11 23
24 (11.5) 134 (64.4) 24 (11.5) 26 (12.5)
17 81 17 15
(13.1) (62.3) (13.1) (11.5)
7 (9.0) 53 (67.9) 7 (9.0) 11 (14.1)
155 (74.5) 120 (57.7) 58 (27.9) 207 (99.5) 113 (54.3)
91 (70.0) 80 (61.5) 35 (26.9) 129 (99.2) 61 (46.9)
64 40 23 78 52
38 [10.5 (20–72)] 38 [9.9 (20–72)]
36 [10.1 (20–72)] 37 [9.6 (20–72)]
40 [10.8 (21–72)] 42 [9.7 (20–69)]
24 [5.1 (11–34)] 18 [5.3 (8–34)] 19 [6.2 (6–36)]
24 [5.1 (11–34)] 18 [5.3 (8–30)] 20 [6.7 (6–36)]
23 [5.1 (11–32)] 19 [5.2 (9–34)] 18 [5.2 (7–32)]
(13.0) (18.4) (22.2) (22.2) (24.2)
(16.9) (20.8) (18.2) (14.3) (29.9)
(82.1) (51.3) (29.5) (100.0) (67.5)
a
Data missing for 2 patients. Data missing for 1 patient. c Data missing for 9 patients. d Data missing for 8 patients. b
and similar in terms of side effects, 37/113 women (33%) with experience of chemotherapy stated they would prefer to receive future breast cancer treatments in the form of a monthly IM injection, compared to 14/94 women (15%) who had not experienced chemotherapy. It is interesting to note that a small minority of women, who had experienced chemotherapy, reported needle anxiety and needle avoidance but still stated a preference for a monthly IM injection over a daily tablet (5/113, 4%). It appears that patients are able to differentiate between the type of injection which causes them anxiety. Chemotherapy seems to lead to anxiety for future IV injections but not generalise to other types of injection (e.g. IM) ‘if it’s just one in the arm then you know that would be fine, I wouldn’t have any problems with that at all but if it was again into a vein then I would have a problem with that.’ [ID:01047], ‘an injection for typhoid or something like that would be fine, it’s intravenous I would say that’s the problem’ [ID: 01055], ‘if it was intravenous yes I suppose I would be anxious because my veins are pretty poor....intramuscular I’d be
fine with’ [ID:2001], ‘With the chemotherapy very anxious, if it’s just an ordinary injection finey’ [ID:04001].
Discussion This study highlights patient anxiety for IV injections following chemotherapy and suggests that chemotherapy-related needle anxiety is a result of physical (e.g. finding a suitable vein) and environmental (e.g. the chemotherapy room) factors. State anxiety levels of chemotherapy patients were higher than the published mean for this age group of women (Spielberger et al., 1983), however, there was no significant difference in state anxiety between chemotherapy patients who had/had not reported needle anxiety, suggesting that chemotherapy related needle anxiety is not merely a reflection of increased general anxiety but a reaction to elements of the chemotherapy experience.
ARTICLE IN PRESS After going through chemotherapy I can’t see another needle
Table 2
47
Patient characteristics by experience of chemotherapy.
Characteristic
Chemotherapy (n ¼ 113)
No chemotherapy (n ¼ 94)
Age mean years [SD (range)] BMIa mean kg/m2 [SD (range)] Educationa n (%) Secondary Further/higher
54 [9.8 (32–80)] 26 [5.1 (19–42)]
66 [9.8 (43–88)] 26 [5.1 (17–42)]
55 (49.5) 56 (50.5)
55 (58.5) 39 (41.5)
Socioeconomic statusb (Carstairs quintiles) n (%) 1 (most affluent) 2 3 4 5 (most deprived)
15 23 21 20 34
12 15 25 25 16
Partnership status n (%) Single Married/living with partner Separated/divorced Widowed
15 (13.3) 77 (68.1) 13 (11.5) 8 (7.1)
9 (9.6) 57 (60.6) 11 (11.7) 17 (18.1)
State-Trait Anxiety Inventory Trait anxietyc mean [SD (range)] State anxietyc mean [SD (range)]
39 [10.2 (20–72)] 40 [9.2 (20–72)]
36 [10.7 (20–72)] 37 [10.6 (20–69)]
24 [5.1 (11–34)] 19 [5.4 (9–34)] 19 [5.9 (7–33)]
24 [5.1 (11–34)] 18 [5.2 (8–32)] 19 [6.6 (6–36)]
52 (46.0) 18 (15.9) 22 (19.5)
25 (26.6) 9 (9.6) 14 (14.9)
37 (32.7) 68 (60.2) 8 (7.1)
14 (14.9) 62 (66.0) 18 (19.1)
Multidimensional Health Locus of Control Scale Internal controlc mean [SD (range)] External control/chanced mean [SD (range)] External control/powerfulc others mean [SD (range)] Attitude towards injections Self-reported needle anxiety n (%) Self-reported needle phobia n (%) Self-reported needle avoidance n (%) Preference for route of administration of future treatment Monthly IM injection Daily tablet No preference
(13.3) (20.4) (18.6) (17.7) (30.1)
(12.9) (16.1) (26.9) (26.9) (17.2)
a
Data missing for 2 patients. Data missing for 1 patient. c Data missing for 9 patients. d Data missing for 8 patients. b
Consistent with previous reports we found a lower prevalence of needle anxiety in older patients (Bienvenu and Eaton, 1998; Deacon and Abramowitz, 2006; Mollema et al., 2001; Nir et al., 2003) and an association between higher levels of state and trait anxiety and needle anxiety (Mollema et al., 2001). In addition, the data suggests that patients with a lower BMI and a lower internal health locus of control were more likely to report needle anxiety. Consideration of techniques to prevent and ameliorate needle anxiety is mainly confined to paediatrics (Duff, 2003; Franck and Jones, 2003; Willemsen et al., 2002). A summary of psychological approaches to prevent anxiety in paediatric venepuncture include taking a brief assessment of previous experiences and coping strategies, presenting sensory and procedural information in leaflet form, and stocking as wide a range of distraction materials in the clinic area as possible (Duff, 2003). Once needle anxiety is established in children, suggested techniques for relieving anxiety include medical
approaches (e.g. use of topical anaesthesia) and cognitive behavioural approaches (e.g. education, distraction, and relaxation exercises) (Willemsen et al., 2002). More research is needed on the benefit of these approaches in an oncology setting in order to inform the practice of health care professionals administering chemotherapy and subsequently improve the experience of cancer patients who receive IV therapies. It would seem quite reasonable however for specialist nurses to consider some fairly simple things such as varying the actual room, bed or chair that a woman sat in when being treated and distracting her attention away from the sight of the cannula. These strategies might help prevent the powerful conditioned responses to needles from developing and then generalising to all needles. Considering that simply stating feelings of anxiety prior to a consultation has been shown to reduce state anxiety in patients with dental anxiety (Dailey et al., 2002), providing
ARTICLE IN PRESS 48 cancer patients with an opportunity to discuss needle anxiety prior to chemotherapy could affect the performance of health care professionals and/or patient expectancy and subsequently improve the perceived experience of chemotherapy. Contrary to Liu et al. (1997), our results suggest that experience of chemotherapy is associated with patient preference for route of administration of future treatment. It is crucial that chemotherapy regimens are monitored not only in terms of their therapeutic benefit but also in terms of their effect on a patient’s psychosocial well-being, particularly if this affects future treatment decisions. A further study specifically designed to explore the relationship between chemotherapy and needle anxiety is required in a broader sample of cancer patients. The current study is confined to women with breast cancer, previous studies report a higher prevalence of needle anxiety in female patients compared to their male counterparts (Bienvenu and Eaton, 1998; Coates et al., 1983; Deacon and Abramowitz, 2006; Griffin et al., 1996; Liu et al., 1997). Psychosocial support should be provided to all cancer patients during all aspects of their treatment and care, this should include the application of techniques to prevent or ameliorate the development of anxiety caused by certain aspects of cancer treatments, such as the development of chemotherapy-related needle anxiety.
Acknowledgements We thank all the women who took part in this study and the following clinicians for allowing recruitment to take place in their clinics; Dr. Peter Barrett-Lee, Dr. Andrew Wardley, Professor Charles Coombes, Dr. George Deutsch and Dr. Sankha Suvra Mitra. Interviews were conducted by Louise Atkins, Dr. Sue Catt, Anna Cox, Dr. Trudi Edginton, Rhona McGurk, Belinda Moore, Robbie Morris and Miranda Price. We would also like to thank Dr. Val Jenkins and Carolyn Langridge for their helpful comments in the preparation of this manuscript. The study was funded via an unrestricted educational grant from AstraZeneca. Anna Cox and Professor Lesley Fallowfield are funded by Cancer Research UK.
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After going through chemotherapy I can’t see another needle Anna Clare Cox, Lesley J. Fallowfield Cancer Research UK Psychosocial Oncology Group, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9QG, UK
KEYWORDS Needle anxiety; Chemotherapy; Cancer patients
Summary Needle anxiety not only impacts on a patient’s quality of life but can delay or prevent future medical care. Our survey of women with breast cancer indicated that 78/208 women (37.5%) reported feeling anxious about injections. Patients who reported needle anxiety were significantly younger (tð206Þ ¼ 3:72; Po0:01), with a lower body mass index (BMI) (tð182Þ ¼ 2:16; Po0:05), experience of chemotherapy (w2 ð1Þ ¼ 8:29; Po0:01), a lower internal health locus of control (tð187Þ ¼ 2:28; Po0:05) and higher levels of state (tð197Þ ¼ 3:58; Po0:01) and trait anxiety (tð197Þ ¼ 2:30; Po0:05). Patients repeatedly highlighted the experience of chemotherapy as having caused their needle anxiety. Patient discourse suggests that chemotherapy related needle anxiety is a result of physical (e.g. finding a suitable vein) and environmental (e.g. the chemotherapy room) factors. Patients with cancer require psychosocial support during all stages of care, this should include the application of techniques to prevent or ameliorate the development of anxiety caused by certain aspects of cancer treatments, such as the development of chemotherapy-related needle anxiety. & 2006 Elsevier Ltd. All rights reserved. Zusammenfassung Angst vor Punktionen kann die Lebensqualita ¨t eines Patienten beeintra ¨chtigen und daru ¨ber hinaus zu einer Verzo ¨gerung oder sogar Verhinderung von medizinischen Maßnahmen fu ¨hren. Die Ergebnisse unseres Surveys bei Brustkrebspatientinnen zeigen, dass 78 von 208 befragten Frauen (37,5%) angaben, Angst vor Injektionen zu haben. Patienten mit Angst vor Punktionen zeigten folgende Merkmale: signifikant ju ¨ngeres Alter (t (206) ¼ 3,72; po0,01), niedrigerer Body Mass Index (BMI) (t (182) ¼ 2,16; po0,01), Zustand nach Chemotherapie (w2 (1) ¼ 8,29; po0,01), niedrigerer interner Health Locus of Control (t (187) ¼ 2,28; po0,05), ho ¨here Level of State (Zustandsebene) (t (197) ¼ 3,58; po0,01) sowie Trait Anxiety (Angst als Eigenschaft) (t (197) ¼ 2,30; po0,05). Die Patienten gaben wiederholt an, Ursache fu ¨r ihre Angst vor Punktionen sei die erhaltene Chemotherapie. Die ¨ußerungen der Patienten lassen vermuten, dass eine Chemotherapie-assoziierte Angst vor A Punktionen auf ko ¨rperlichen (z. B. Finden einer geeigneten Vene) und umfeldbedingten (z. B. Chemotherapie-Raum) Faktoren beruht. Krebspatienten beno ¨tigen in allen Phasen ihrer Behandlung eine psychosoziale Unterstu ¨tzung, einschließlich der Anwendung von Techniken,
Corresponding author. Tel.: +44 1273 873015; fax: +44 1273 873022.
E-mail address: [email protected] (L.J. Fallowfield). 1462-3889/$ - see front matter & 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejon.2006.04.035
ARTICLE IN PRESS 44
A.C. Cox, L.J. Fallowfield ¨ngste vor bestimmten onkologischen Behandlungen (z. B. eine Chemothermit denen sich A apie-assoziierte Angst vor Punktionen) verhindern oder verringern lassen. & 2006 Elsevier Ltd. All rights reserved.
Introduction Needle phobia, defined as ‘an intense and persistent fear of injections’ (Deacon and Abramowitz, 2006), affects a small minority (1.6%) of individuals in the general population (Bienvenu and Eaton, 1998). Increasing attention is now being given to a less severe fear of injections, known as needle anxiety. Most studies addressing the prevalence of and factors associated with needle anxiety have been conducted in phlebotomy (Deacon and Abramowitz, 2006), diabetes (Mollema et al., 2001), dentistry (Enkling et al., 2006) and the general population (Noyes et al., 2000). Cancer patients experience increased exposure to needles during assessment procedures and treatment regimens and their attitude to needles should be assessed as the development of needle anxiety may cause delay or avoidance of appropriate medical care in the future (Noyes et al., 2000). A commonly used theory for explaining the aetiology of anxiety is the behavioural theory (Skinner, 1984). Behavioural theory suggests that anxiety is a conditioned response to a specific stimuli following a bad experience. In a review of blood-injury phobia, Marks (1988) reports that needle phobia is usually traced back to an adverse experience with needles in a health-care setting. A bad experience can then lead to a generalised learned response to needle procedures and related objects. Historically, literature concerned with the response of cancer patients to needle exposure has focused on the physical side effects of chemotherapy. Over the past 20 years, significant advances have been made in reducing both the incidence and severity of physical side effects associated with chemotherapy. It is claimed that chemotherapy associated emesis can now be prevented in 60–90% of patients (Gralla, 2002). These improvements are reflected in patient perceptions of the side effects of chemotherapy. A survey in 1983 revealed that patients ranked vomiting as the most severe side effect of chemotherapy (Coates et al., 1983). A repeat of this survey in 1993 (Griffin et al., 1996), reported a reduction in the perceived severity of vomiting which now ranked in 5th place. The overall ranking for ‘thought of having treatment’ and ‘having a needle’ also decreased between 1983 and 1993 and the authors conclude ‘the entire experience of chemotherapy is less dreaded today’ (p. 194). However, it is important to note that 55 and 39% of patients still reported experiencing these side effects in 1993. Affective disturbance in terms of anxiety and depression were more apparent in the 1993 sample, supporting claims that the psychological impact of chemotherapy has increased (Carelle et al., 2002). Patient preference for oral chemotherapies could be due in part to apprehensions concerning intravenous (IV) regimens. Preference for route of administration was assessed in a population of incurable cancer patients who were
expected to receive chemotherapy in the future (Liu et al., 1997), 89% stated they would rather receive an oral than IV chemotherapy regimen. Reasons given for this preference include ‘problems with IV lines’ (66%), ‘control of chemotherapy environment’ (61%) and ‘previous IV chemotherapy problems’ (34%). Preference for oral chemotherapy is supported by a more recent study which asked patients with metastatic breast cancer to decide between two equally effective and tolerable treatments, 63% preferred oral chemotherapy, 29% preferred IV chemotherapy and 8% were neutral (Paley et al., 2005). During interviews conducted as part of a survey of patient preferences for different routes of administration of endocrine treatments by intramuscular (IM) injection or tablets, many patients made reference to their experience of chemotherapy when discussing their current attitude to needles. This paper reports factors associated with needle anxiety and explores quantitative and qualitative data on the association between experience of chemotherapy and needle anxiety. A full exploration of variables associated with patient preference for route of administration of breast cancer treatments have been published in a separate paper (Fallowfield et al., 2006).
Methods Patients Women with early or advanced stage breast cancer at least 2-year post-diagnosis and currently in remission or with stable disease were invited to participate in this study. Two hundred and seventy women expressed an interest in participating, 35 women later refused, and 27 proved to be ineligible or unavailable. This paper reports the results of 208 women.
Procedure Women attending routine follow-up appointments at one of six oncology outpatient clinics in the UK were invited to participate in a study investigating patient preference for breast cancer treatments. Patients were given written information and those who expressed an interest were followed up with a telephone call. Those who agreed to participate were interviewed at home by a trained Cancer Research UK researcher. Patients gave written informed consent prior to the interview, which included permission for the interview to be audiotaped. The study had approval from Multi-centre and Local Research Ethics Committees.
Interview The semi-structured interview included details of the patient’s socio-demographic variables, treatment, medica-
ARTICLE IN PRESS After going through chemotherapy I can’t see another needle tion (both past and present), and preference for route of administration of medication. Patient experience of and attitude towards injections were also elicited, specifically whether they had ever had IV, IM, subcutaneous (SC) or other types of injections (O), whether they felt anxious about injections or had ever suffered from needle phobia, and whether they would avoid injections in the future. Finally, participants completed two short standardised measures, the State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983) and the Multidimensional Health Locus of Control Scale (MHLOC) (Wallston et al., 1976). The STAI provides a measure of state and trait anxiety (range 20–80, a higher score indicating a greater level of anxiety). The MHLOC is comprised of three dimensions; internal control (e.g. ‘If I get sick it is my own behaviour, which determines how soon I get well again’), external control/powerful others (e.g. ‘When I don’t feel well I should consult my doctor’) and external control/chance (e.g. ‘Good health is largely a matter of good luck’). Audiotaped interviews were coded against a predetermined checklist as to whether or not patients had been treated with i.v. chemotherapy, i.e. yes, no or unsure. What they felt about that experience, if volunteered by the patient was noted verbatim, Sections of discourse regarding chemotherapy were transcribed and checked by an independent researcher prior to analysis. If it was not clear from the audiotape, the patient’s medical notes were reviewed to determine whether or not a patient had been given i.v. chemotherapy.
Statistics and analysis All quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) v11.5. The t-test was used to examine differences between group means and the w2 test to examine differences in proportions. Any free responses to open ended questions were listed and grouped into broad thematic categories.
Results The mean age of participants was 60 years (SD ¼ 11.5), the majority (64%) were married/living with partner and just over half of the sample (53%) had completed their education by 16 years of age. Full patient demographics and scores for the STAI and MHLOC are given in Table 1. Approximately, a third of patients (78/208, 37.5%) reported feeling anxious about injections and 13.5% of patients (28/208) had experienced a needle phobia. Fortyone per cent of patients (32/78) who reported needle anxiety said the way they felt about injections would cause them to avoid having one in the future.
Factors associated with needle anxiety An exploratory analysis was performed to determine which factors affected needle anxiety. Patients who reported needle anxiety were significantly younger (tð206Þ ¼ 3:72; Po0:01), with a lower body mass index (BMI) (tð182Þ ¼ 2:16; Po0:05), experience of chemotherapy (w2 ð1Þ ¼ 8:29; Po0:01), a lower internal health locus of control
45 (tð187Þ ¼ 2:28; Po0:05) and higher levels of state (tð197Þ ¼ 3:58; Po0:01) and trait anxiety (tð197Þ ¼ 2:30; Po0:05). Socioeconomic status, education, marital status and broad experience of any of the injection groups (IV/IM/SC/O) were not significantly associated with needle anxiety.
Chemotherapy and needle anxiety Of the 113 women who had experienced chemotherapy, 52 women (46%) reported feeling anxious about injections and 18 women (16%) had experienced a needle phobia. Twenty per cent of patients (22/113) who had experienced chemotherapy said the way they felt about injections would cause them to avoid having one in the future. Table 2 gives full patient details by chemotherapy experience including attitudes towards injections and preference for route of administration of future treatments. Women who had experienced chemotherapy tended to be younger (tð205Þ ¼ 8:63; Po0:01) with higher levels of state anxiety (tð196Þ ¼ 2:15; Po0:05). The difference in the state anxiety of women who had experienced chemotherapy and reported a needle anxiety (mean state anxiety ¼ 39) and those who had experienced chemotherapy but did not report needle anxiety (mean state anxiety ¼ 41) was not significant (tð107Þ ¼ 1:36; P ¼ 0:18). Patients repeatedly highlighted the experience of chemotherapy as having caused their needle anxiety ‘I would say with the chemotherapy I got very anxious’ [ID:02017], ‘very anxious and I have to say that’s since the chemoyit’s totally connected to the chemotherapy, I had no problem before’ [ID:03007], ‘It never used to bother me, I think once you start having chemo, that’s when it changes’ [ID:01055] and ‘after going through chemotherapy I can’t see another needle’ [ID:03009]. Patient discourse offers insight into the cause of chemotherapy related needle anxiety. Many patients focused on the pain and anxiety of finding a vein ‘they ran out of veins and it was getting more and more difficult so it was getting very painful’ [ID:02013], ‘they can’t always find the vein you know, it is quite painful’ [ID:03007], ‘they can’t find my veins and they keep poking and pushing inside and it is very, very painful since the chemotherapy’ [ID:03059] and ‘its the whole thing of trying to find a vein and one vein collapsing, it’s just the whole, the whole thing of that, it really gets to me, I actually ran out one day where they were having that much trouble’ [ID:04001]. Support and environment issues were also highlighted as causing chemotherapy-related anxiety ‘there wasn’t much reassurance or advice given to me’ [ID:01003], ‘it’s just that room, I remember one lady was taken into another room and I said to her why has she gone into this other little room and she says she can’t enter this room. I said I know the feeling, it’s horribleyit’s got a certain smell, I think that’s really powerful isn’t it’ [ID:03060]. There was a significant difference in the preference for route of administration of future treatments between women who had experienced chemotherapy and those who had not (w2 ð2Þ ¼ 12:86; Po0:01). When asked their preference for route of administration of future breast cancer treatments, assuming the treatments were equally effective
ARTICLE IN PRESS 46
A.C. Cox, L.J. Fallowfield
Table 1
Patient characteristics and needle anxiety.
Characteristic
All patients (n ¼ 208)
No needle anxiety (n ¼ 130)
Needle anxiety (n ¼ 78)
Age mean years [SD (range)] BMIa mean kg/m2 [SD (range)] Educationa n (%) Secondary Further/higher Socioeconomic statusb (Carstairs quintiles) n (%) 1 (most affluent) 2 3 4 5 (most deprived) Partnership status n (%) Single Married/living with partner Separated/divorced Widowed Experience of injections n (%) Intravenous (IV) Intramuscular (IM) Subcutaneous (SC) Other types of injections (O) Experience of chemotherapyb n (%) State-Trait Anxiety Inventory Trait anxietyc mean [SD (range)] State anxietyc mean [SD (range)] Multidimensional Health Locus of Control Scale Internal controlc mean [SD (range)] External control/chance meand [SD (range)] External control/powerful othersc mean [SD (range)]
60 [11.5 (32–88)] 26 [5.0 (17–42)]
62 [10.9 (32–86)] 27 [5.3 (19–42)]
56 [11.6 (34–88)] 26 [4.5 (17–41)]
111 (53.4) 95 (45.7)
74 (57.8) 54 (42.2)
37 (47.4) 41 (52.6)
27 38 46 46 50
14 22 32 35 27
(10.8) (16.9) (24.6) (26.9) (20.8)
13 16 14 11 23
24 (11.5) 134 (64.4) 24 (11.5) 26 (12.5)
17 81 17 15
(13.1) (62.3) (13.1) (11.5)
7 (9.0) 53 (67.9) 7 (9.0) 11 (14.1)
155 (74.5) 120 (57.7) 58 (27.9) 207 (99.5) 113 (54.3)
91 (70.0) 80 (61.5) 35 (26.9) 129 (99.2) 61 (46.9)
64 40 23 78 52
38 [10.5 (20–72)] 38 [9.9 (20–72)]
36 [10.1 (20–72)] 37 [9.6 (20–72)]
40 [10.8 (21–72)] 42 [9.7 (20–69)]
24 [5.1 (11–34)] 18 [5.3 (8–34)] 19 [6.2 (6–36)]
24 [5.1 (11–34)] 18 [5.3 (8–30)] 20 [6.7 (6–36)]
23 [5.1 (11–32)] 19 [5.2 (9–34)] 18 [5.2 (7–32)]
(13.0) (18.4) (22.2) (22.2) (24.2)
(16.9) (20.8) (18.2) (14.3) (29.9)
(82.1) (51.3) (29.5) (100.0) (67.5)
a
Data missing for 2 patients. Data missing for 1 patient. c Data missing for 9 patients. d Data missing for 8 patients. b
and similar in terms of side effects, 37/113 women (33%) with experience of chemotherapy stated they would prefer to receive future breast cancer treatments in the form of a monthly IM injection, compared to 14/94 women (15%) who had not experienced chemotherapy. It is interesting to note that a small minority of women, who had experienced chemotherapy, reported needle anxiety and needle avoidance but still stated a preference for a monthly IM injection over a daily tablet (5/113, 4%). It appears that patients are able to differentiate between the type of injection which causes them anxiety. Chemotherapy seems to lead to anxiety for future IV injections but not generalise to other types of injection (e.g. IM) ‘if it’s just one in the arm then you know that would be fine, I wouldn’t have any problems with that at all but if it was again into a vein then I would have a problem with that.’ [ID:01047], ‘an injection for typhoid or something like that would be fine, it’s intravenous I would say that’s the problem’ [ID: 01055], ‘if it was intravenous yes I suppose I would be anxious because my veins are pretty poor....intramuscular I’d be
fine with’ [ID:2001], ‘With the chemotherapy very anxious, if it’s just an ordinary injection finey’ [ID:04001].
Discussion This study highlights patient anxiety for IV injections following chemotherapy and suggests that chemotherapy-related needle anxiety is a result of physical (e.g. finding a suitable vein) and environmental (e.g. the chemotherapy room) factors. State anxiety levels of chemotherapy patients were higher than the published mean for this age group of women (Spielberger et al., 1983), however, there was no significant difference in state anxiety between chemotherapy patients who had/had not reported needle anxiety, suggesting that chemotherapy related needle anxiety is not merely a reflection of increased general anxiety but a reaction to elements of the chemotherapy experience.
ARTICLE IN PRESS After going through chemotherapy I can’t see another needle
Table 2
47
Patient characteristics by experience of chemotherapy.
Characteristic
Chemotherapy (n ¼ 113)
No chemotherapy (n ¼ 94)
Age mean years [SD (range)] BMIa mean kg/m2 [SD (range)] Educationa n (%) Secondary Further/higher
54 [9.8 (32–80)] 26 [5.1 (19–42)]
66 [9.8 (43–88)] 26 [5.1 (17–42)]
55 (49.5) 56 (50.5)
55 (58.5) 39 (41.5)
Socioeconomic statusb (Carstairs quintiles) n (%) 1 (most affluent) 2 3 4 5 (most deprived)
15 23 21 20 34
12 15 25 25 16
Partnership status n (%) Single Married/living with partner Separated/divorced Widowed
15 (13.3) 77 (68.1) 13 (11.5) 8 (7.1)
9 (9.6) 57 (60.6) 11 (11.7) 17 (18.1)
State-Trait Anxiety Inventory Trait anxietyc mean [SD (range)] State anxietyc mean [SD (range)]
39 [10.2 (20–72)] 40 [9.2 (20–72)]
36 [10.7 (20–72)] 37 [10.6 (20–69)]
24 [5.1 (11–34)] 19 [5.4 (9–34)] 19 [5.9 (7–33)]
24 [5.1 (11–34)] 18 [5.2 (8–32)] 19 [6.6 (6–36)]
52 (46.0) 18 (15.9) 22 (19.5)
25 (26.6) 9 (9.6) 14 (14.9)
37 (32.7) 68 (60.2) 8 (7.1)
14 (14.9) 62 (66.0) 18 (19.1)
Multidimensional Health Locus of Control Scale Internal controlc mean [SD (range)] External control/chanced mean [SD (range)] External control/powerfulc others mean [SD (range)] Attitude towards injections Self-reported needle anxiety n (%) Self-reported needle phobia n (%) Self-reported needle avoidance n (%) Preference for route of administration of future treatment Monthly IM injection Daily tablet No preference
(13.3) (20.4) (18.6) (17.7) (30.1)
(12.9) (16.1) (26.9) (26.9) (17.2)
a
Data missing for 2 patients. Data missing for 1 patient. c Data missing for 9 patients. d Data missing for 8 patients. b
Consistent with previous reports we found a lower prevalence of needle anxiety in older patients (Bienvenu and Eaton, 1998; Deacon and Abramowitz, 2006; Mollema et al., 2001; Nir et al., 2003) and an association between higher levels of state and trait anxiety and needle anxiety (Mollema et al., 2001). In addition, the data suggests that patients with a lower BMI and a lower internal health locus of control were more likely to report needle anxiety. Consideration of techniques to prevent and ameliorate needle anxiety is mainly confined to paediatrics (Duff, 2003; Franck and Jones, 2003; Willemsen et al., 2002). A summary of psychological approaches to prevent anxiety in paediatric venepuncture include taking a brief assessment of previous experiences and coping strategies, presenting sensory and procedural information in leaflet form, and stocking as wide a range of distraction materials in the clinic area as possible (Duff, 2003). Once needle anxiety is established in children, suggested techniques for relieving anxiety include medical
approaches (e.g. use of topical anaesthesia) and cognitive behavioural approaches (e.g. education, distraction, and relaxation exercises) (Willemsen et al., 2002). More research is needed on the benefit of these approaches in an oncology setting in order to inform the practice of health care professionals administering chemotherapy and subsequently improve the experience of cancer patients who receive IV therapies. It would seem quite reasonable however for specialist nurses to consider some fairly simple things such as varying the actual room, bed or chair that a woman sat in when being treated and distracting her attention away from the sight of the cannula. These strategies might help prevent the powerful conditioned responses to needles from developing and then generalising to all needles. Considering that simply stating feelings of anxiety prior to a consultation has been shown to reduce state anxiety in patients with dental anxiety (Dailey et al., 2002), providing
ARTICLE IN PRESS 48 cancer patients with an opportunity to discuss needle anxiety prior to chemotherapy could affect the performance of health care professionals and/or patient expectancy and subsequently improve the perceived experience of chemotherapy. Contrary to Liu et al. (1997), our results suggest that experience of chemotherapy is associated with patient preference for route of administration of future treatment. It is crucial that chemotherapy regimens are monitored not only in terms of their therapeutic benefit but also in terms of their effect on a patient’s psychosocial well-being, particularly if this affects future treatment decisions. A further study specifically designed to explore the relationship between chemotherapy and needle anxiety is required in a broader sample of cancer patients. The current study is confined to women with breast cancer, previous studies report a higher prevalence of needle anxiety in female patients compared to their male counterparts (Bienvenu and Eaton, 1998; Coates et al., 1983; Deacon and Abramowitz, 2006; Griffin et al., 1996; Liu et al., 1997). Psychosocial support should be provided to all cancer patients during all aspects of their treatment and care, this should include the application of techniques to prevent or ameliorate the development of anxiety caused by certain aspects of cancer treatments, such as the development of chemotherapy-related needle anxiety.
Acknowledgements We thank all the women who took part in this study and the following clinicians for allowing recruitment to take place in their clinics; Dr. Peter Barrett-Lee, Dr. Andrew Wardley, Professor Charles Coombes, Dr. George Deutsch and Dr. Sankha Suvra Mitra. Interviews were conducted by Louise Atkins, Dr. Sue Catt, Anna Cox, Dr. Trudi Edginton, Rhona McGurk, Belinda Moore, Robbie Morris and Miranda Price. We would also like to thank Dr. Val Jenkins and Carolyn Langridge for their helpful comments in the preparation of this manuscript. The study was funded via an unrestricted educational grant from AstraZeneca. Anna Cox and Professor Lesley Fallowfield are funded by Cancer Research UK.
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