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Brachytherapy (BT) is an important component of the curative treatment for locally advanced cervical cancer. It consists of several steps, but the impact of these steps on patient experience in terms of pain and anxiety is still scarcely reported. The step durations can potentially influence patient experience, but this is also not well described. The aims of this study are to perform a time-action analysis and to determine the patient experience during each step of the workflow.

Patients treated with EBRT and 3 or 4 fractions of HDR BT with an intracavitary/interstitial applicator were included in a prospective study. For the time-action analysis, the involved staff reported the time needed for each step on a standardised form which included start and end time of each step. For the patient experience analysis, an EQ-5D questionnaire was used to calculate the health state index (0= equivalent to dead, 1= full health), and EQ VAS score (0= worst imaginable health, 1= best imaginable health) at the beginning of the day to establish a base line health status. Pain, anxiety and duration experience for each treatment step were assessed with a numeric rating scale questionnaire (0= the perfect situation, 10= worst possible situation). The median and interquartile range was provided for all parameters. 

A total of 30 patients (69 fractions) were included for the time-action analysis of which 13 patients (28 fractions) were also included for the analysis of the patient experience. The total procedure time, expressed in hours:minutes, from arrival at BT department till discharge was 8:55 (8:00-9:25). For the separate steps, the durations are shown in Figure 1. The target & OAR delineation and applicator reconstruction are done concurrently while the patient is waiting before treatment.

A health state index score of 0.82 (0.67-1.00) was calculated from individual health profiles of the EQ-5D using a specific value set of the Netherlands. The EQ VAS score was 0.80 (0.63-0.88). During 20 of the 28 fractions, patients had no to slight pain at the beginning of the day, and during 18 of the 28 fractions, patients had no to slight anxiety. During treatment, patients had the highest pain score during waiting before treatment (3 (1-7)), the highest anxiety score during applicator removal (2.5 (0-8)), and the highest duration score for waiting before treatment (6 (0-7.5)). Figure 2 gives an overview of scores in different steps. The large variations in scores points at inter- and intra-patient variations.

This time-action analysis highlights the importance of logistics between different steps during cervical cancer brachytherapy. Pain, and anxiety scores were found to be highest during waiting time before treatment and applicator removal with large inter- and intra-patient variations. In the future, the time-action and patient experience analysis can be used to optimise different steps of the brachytherapy treatment.