Patient Experience of an ¹⁸F-FDG-PET/CT Examination: Need for Improvements in Patient Care

Highlights

• Patient knowledge about the fluoro-deoxy-glucose positron emission tomography (PET)/computed tomography (CT) examination was low.

• Patient satisfaction was high but communication needs to be improved.

• Lower patient satisfaction correlates to a worse health-related quality of life.

• The time spent in the PET/CT camera may be strenuous for the patient.

Abstract

The aims of this study were to investigate the patients' knowledge about and experience of an ¹⁸F-fluoro-deoxy-glucose (FDG)-positron emission tomography (PET)/computed tomography (CT) examination and to investigate the self-reported feelings of stress, level of physical activity, and health-related quality of life (HRQoL) and to find out if this was related to how they experienced the examination. A cross-sectional survey was used to collect information on 198 patients with known or suspected malignancy. As many as 32% to 63% were satisfied with the nursing staff, the communication, and the professional skills. Most patients did not know beforehand what an FDG-PET/CT examination was. The HRQoL, level of perceived stress, and physical activity were relatively low. A better HRQoL, lower level of perceived stress, and a higher level of physical activity were correlated to a more positive experience and higher education to more knowledge about the examination (p < .01–.05). The information before the examination needs to be improved. The results may be used to improve patient care and optimize imaging procedures.

Introduction

Molecular imaging in oncology has developed significantly in recent years. New hybrid imaging techniques are increasingly used whereby anatomical and functional imaging is combined in the same session. Positron emission tomography (PET) combined with computed tomography (CT), with the radioactively labeled glucose analog ¹⁸F-fluoro-deoxy-glucose (FDG), constitutes a standardized examination tool in clinical routine, especially used in cancer imaging for tumor staging, diagnosis of recurrent disease, monitoring of treatment response, and radiation therapy planning (Saif, Tzannou, Makrilia, & Syrigos, 2010).

The PET/CT examinations require planning and preparation on the part of both patients and nursing staff. Thus, it is important that patients are well informed and that the nursing staff is well trained. There are many studies on the imaging field of FDG-PET/CT for many types of cancer, but little is known about the patients' experiences in connection with a PET/CT examination. The patients' level of satisfaction may be an indicator of quality of care (Aiken et al., 2012, Charalambous, 2013). To our knowledge, so far, no studies have been published on this topic.

Patient satisfaction is a widely accepted dimension of quality care for several reasons: it may improve compliance to treatment regimens, it is an important outcome measure, and it has been described as a factor associated to improved health status (Aharony and Strasser, 1993, Fitzpatrick et al., 1998, Hall and Dornan, 1988). A meta-analysis of the concept of patient satisfaction showed several aspects, such as availability, overall quality, humaneness, professional skills, sufficient information, good facilities, and the staff's interest in psychosocial problems (Hall & Dornan, 1990).

The patient professional interaction is a necessity for patient satisfaction. It consists of several elements of which the patient's goals are important. Good communication should enable the care provider to meet the patient's expectations and culminate in a care relationship (Feldman-Stewart, Brundage, & Tishelman, 2005).

A number of studies have investigated patients' expectations and satisfaction in relation to other types of diagnostic examinations than PET/CT (Nightingale et al., 2012, Törnqvist et al., 2006). Törnqvist et al. (2006) concluded that patients needed to have confidence in the staff to feel secure during a magnetic resonance imaging (MRI) examination. Nightingale et al. (2012) found that written information before the examination was helpful, and on-going repeated explanations and reassurance were important to reduce patients' anxiety and distress during the examination procedure. Still, each individual patient has specific needs, and the nursing staff should be aware of their interaction with the patient and how it affects his/her ability to deal with the examination.

Furthermore, receiving information has been shown to reduce patients' anxiety and promote a positive attitude before undergoing an examination at a nuclear medicine department. Thus, the patient care provided by the nursing staff is fundamental to promoting patient satisfaction (Lledo et al., 1995). Cancer patients' needs, expectations, and experiences may also vary during the different stages of cancer treatment and management, and may depend on other factors such as age, gender, and educational status (Mistry, Wilson, Priestman, Damery, & Haque, 2010). According to Ollivier et al. (2009), most patients were (91–98%) in a radiology imaging department were generally satisfied with the care provided during ultrasound, mammography, CT, or MRI. However, 71% of the patients in this study would have appreciated additional information about the examination and some patients felt worried before the examination, and the reason for this was in most cases anxiety about the results.

The ¹⁸F-FDG-PET/CT requires that the patient has followed the given instructions beforehand and also staff members' instructions after arriving to the department (Boellaard et al., 2010). FDG is a glucose analog that reflects the increased metabolism in neoplastic viable and inflammatory cells (glycolytic pathway). Because the examination provides both anatomical (CT) and functional information (PET), there are rigorous pre-examination requirements. Patients must have fasted for at least 6 hours but with the intake of noncarbohydrate fluids to ensure adequate hydration. The blood glucose level should be 8.0 mmol/L or lower, corresponding to 150 to 200 mg/dL; and in patients with diabetes, the disease needs to be well controlled. It is important that documentation regarding relevant details in the patient history (recent surgery, inflammatory conditions, and treatments such as chemo or radiation therapy) is available. The FDG is injected intravenously, and during the subsequent 60-min uptake phase, the patient should be kept warm and remain silent and relaxed. The patient is also asked to drink water during this period and empty the urinary bladder immediately before the PET/CT examination. The patient is shown into the examination room and is positioned supine on the couch of the PET/CT scanner with the arms elevated over his/her head. It is important that the patient remains in the same position during the entire examination procedure to avoid image artifacts. The total time from the patient's arrival at the nuclear medicine department to his/her departure is approximately 2-3 hours, including a 30-min PET/CT examination time (Boellaard et al., 2010).

According to Romero, Vivas-Consuelo, and Alvis-Guzman (2013), health-related quality of life (HRQoL) is a concept that has a wide variety of definitions. Still, there is an evidence-based perception that has its focus on the individual's well-being. The HRQoL is also a useful indicator to measure health and disease. The HRQoL relates to how disease affects patients' well-being or patients' perceived quality of life (QoL; Ashing-Giwa, 2005). Cancer diagnosis is a traumatic experience that may affect different aspects of the patients' life, such as physiological well-being and the ability to physical activity. Karabulu, Erci, Ozer, and Ozdemir (2010) studied the prevalence and severity of symptoms in patients with cancer and found that the most common symptoms were fatigue, difficulty to remember, sadness, loss of appetite, lack of enjoyment of life, pain, distress, difficulty to walk, and dry mouth. Rustad, David, and Currier (2012) found that cancer patients and survivors have an increased risk to develop posttraumatic stress disorder in comparison with the general population, which could negatively affect the outcome of the treatment. Physical activity has proven to have health benefits across many diseases, including cancer (Broderick, Ryan, O'Donnell, & Hussey, 2014). Mishra et al. (2012) found that physical activity or exercise interventions improves cancer patients' HRQoL when it is given at the same time as the patients undergo cancer treatment and also reduces anxiety with breast cancer patients.

Because the ¹⁸F-FDG-PET/CT examination is dependent on the patient's cooperation and the procedure may be experienced as cumbersome, it would be interesting to evaluate the patient experience of the PET/CT examination and also the characteristics of the population remitted to the examination, such as physical activity, level of perceived stress, and experienced HRQoL. The desirable consequences of this study should be high patient satisfaction and patient care in nuclear medicine departments. The aims of the study were to investigate the patients' knowledge about and experience of the ¹⁸F-FDG-PET/CT examination. An additional aim was to investigate the self-reported feelings of perceived stress, the level of physical activity, and the experienced HRQoL and to find out if this was related to how the patients experienced the examination.