GRAPHICAL ABSTRACT

INTRODUCTION

Cancer is the second leading cause of death among non-communicable diseases. In 2020, an estimated 19.3 million new cases occurred, with 9.9 million deaths reported worldwide [1]. Recent evidence suggests that an epidemiological transition is underway, with cancer increasingly surpassing cardiovascular disease as the leading cause of death [2]. More than 50% of cancers require radiotherapy (RT) [3–5]. RT uses ionizing radiation to damage and inhibit the growth of cancer [6].

Patients diagnosed with cancer are particularly vulnerable to psychological distress due to the high morbidity associated with treatment [7]. Anxiety is a common psychological response prior to RT procedures [8–10]. Multiple factors influence anxiety levels, including physical condition, psychological well-being, and social support [11]. In addition, RT procedures can cause side effects that may increase the risk of anxiety. Elevated anxiety can impair a patient’s perception of treatment, hinder communication with healthcare providers, reduce adherence to RT schedules, and negatively affect quality of life and treatment outcomes [12,13]. From a patient-centered perspective, reducing anxiety is crucial for enhancing emotional comfort, self-efficacy, decision-making capacity, and long-term psychological resilience. Evidence shows that effective anxiety management improves treatment adherence, strengthens coping mechanisms, and reduces healthcare utilization [14,15]. Thus, addressing anxiety in RT patients is not merely a supportive measure but a clinical necessity that can influence overall treatment success.

Various patient education interventions have been developed to manage or reduce anxiety in RT patients. Patient education is expected to prevent or alleviate the emergence of various emotional responses, including anxiety. This systematic review aims to evaluate and synthesize existing evidence on patient education strategies and their effect on anxiety levels in cancer patients undergoing RT.

METHODS

Study Design

We conducted a systematic review to evaluate the effect of patient education on anxiety levels in cancer patients undergoing RT. Relevant articles were identified through searches of multiple scientific databases, with selection based on predefined inclusion criteria. The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart [16]. We developed a search strategy using the PICO (Patients, Interventions, Comparisons, Outcomes) framework (Table 1).

Search Strategy

Searches were conducted in PubMed, EBSCOhost, and Web of Science using the following main keywords: “education” OR “patient education” OR “treatment education” OR “education intervention” OR “educational methods” AND “anxiety” OR “anxious” OR “distress” OR “psychological symptoms” AND “cancer patient” OR “cancer” AND “radiotherapy” OR “radiation therapy” OR “radiation oncology.” The searches included all articles published from database inception through August 2024.

Inclusion and Exclusion Criteria

The inclusion criteria were as follows: (1) design: experimental studies including randomized (true experiments) and non-randomized (quasi-experiments); (2) patients: adult cancer patients undergoing RT; (3) intervention: patient education delivered before or during RT; (4) outcome: anxiety level. Studies were excluded if they were irrelevant, review articles, or not published in English.

Selection and Data Collection Process

The electronic database was uploaded into Mendeley software, and duplicates were automatically removed during the initial screening. FJH screened the titles and abstracts for relevance. FJH and RM then assessed the full texts of potentially eligible articles based on the inclusion criteria. Any disagreements were resolved by other reviewers (SG, DK, WAH, AE, F, and RS) in sequence. Articles that met the criteria, along with relevant references cited within them, were included for review.

Assessment of Study Quality

Study quality was assessed by FJH using the methods described by Hawker et al. [17]. This tool evaluates aspects of methodology, analysis, and reporting to determine validity, reliability, and relevance. It assesses 9 components, each scored from 1 to 4, resulting in a final quality score ranging from 9 points to 36 points [17].

Synthesis Methods

Data were analyzed using narrative synthesis, which integrates findings across studies, draws comprehensive conclusions, and offers recommendations based on the overall evidence.

Ethics Statement

This study is a systematic review of previously published literature and does not involve human or animal subjects. Therefore, ethical approval was not required.

RESULTS

Included Studies

Fifteen studies were included in this review, all of which demonstrated good methodological quality, with Hawker et al. [17] scores ranging from 30 to 35, making them eligible for analysis. Details of the quality assessments are provided in Supplemental Material 1. The studies were conducted across multiple countries: 4 in Asia, 5 in Australia, 3 in Europe, and 2 in the United States. In total, 1988 participants were enrolled between 2001 and 2023. The study designs included eleven randomized controlled trials (RCTs) and 4 quasi-experimental studies (pre- and post-test designs). Full details of documents identified, screened, included, and analyzed are presented in the PRISMA flow diagram (Figure 1). The PRISMA checklist is available in Supplemental Material 2. Study characteristics are summarized in Table 2 [18–32].

An RCT by Behboudifar et al. [18] included 66 adult head and neck cancer patients (33 control vs. 33 intervention). Anxiety levels were measured using the State-Trait Anxiety Inventory (STAI) before RT and 2 weeks after treatment initiation. Both groups received a 20-minute face-to-face session with a caregiver who briefly explained the disease and treatment. The intervention group additionally received multimedia education, while the control group was provided with written material. Both groups had moderate anxiety levels prior to RT. Anxiety decreased in both groups, but the control group showed a greater reduction.

Antoni et al. [19] evaluated 126 breast cancer patients (61 control vs. 65 intervention). Both groups received an information booklet covering treatment procedures, side effects, and advice during the first consultation with the radiation oncologist. The intervention group also received a 30-minute procedure announcement from radiation therapists, explaining the treatment process, positioning, dosimetry, and what to expect during RT. Anxiety was measured before the procedure announcement using the STAI Y-A and STAI Y-B. All patients completed the STAI Y-A again before the first and second RT sessions and once more at the end of RT. Anxiety decreased significantly over time in both groups; however, no significant between-group differences were observed.

An RCT by Cartledge Hoff and Haaga [20] included 51 cancer patients (22 control vs. 29 intervention). In the intervention group, patients and their family members participated in an orientation program that included a clinic tour, detailed information about RT, and a question-and-answer session with an oncology counselor. The control group received usual care, consisting of standard verbal and written information about RT without a clinic tour or additional support. Anxiety was assessed using the STAI before and after RT. No significant reduction in anxiety was observed in either patients or family members following the intervention.

A quasi-experimental study by Kadhim Al-Zaidy and Al-Fayyadh [21] included 128 cancer patients (64 control vs. 64 intervention). The intervention group received nursing counseling through direct face-to-face sessions lasting approximately 30–45 minutes, 3 times per week. After 3 weeks, all patients completed a post-test. The control group received standard patient education. Anxiety was assessed using the Depression, Anxiety, and Stress Scale (DASS). The intervention group showed a significant reduction in anxiety from pre-test to post-test.

An RCT by Siekkinen et al. [22] included 115 breast cancer patients (58 control vs. 57 intervention). Standard patient education was available to all participants, including face-to-face education with the radiation therapist, radiation oncologist, and oncology nurse. The intervention group additionally received e-feedback on RT knowledge (e-Re-Know), a program developed with 6 hospital professionals to support female’s empowerment through enhanced expertise. Anxiety was measured with the STAI before the first RT procedure, after the final RT sessions, and 3 months post-treatment. Slight but significant differences in anxiety were observed between groups during follow-up, indicating that the e-Re-Know program was effective in reducing anxiety over a longer period.

A multiple-baseline study by Halkett et al. [23] included 408 breast cancer patients (218 control vs. 190 intervention). The intervention group received face-to-face consultation with radiation therapists, delivered in a classroom-style format for approximately 30–45 minutes, 3 times per week, prior to planning and treatment. The control group did not receive these consultations. The intervention group reported significantly lower anxiety levels on the first day of treatment and at treatment completion compared with the control group.

A quasi-experimental study by Zaheer et al. [24] included 61 breast cancer patients (30 control vs. 31 intervention). The intervention group received a face-to-face educational session (approximately 40–60 minutes) with a nurse. Patients were also provided with a booklet containing explanatory information about RT, and the nurse’s phone number was given to patients and caregivers for further assistance. The control group received only the information booklet. In the intervention group, the overall average anxiety decreased significantly from pre-test to post-test.

An RCT by Halkett et al. [25] included 112 cancer patients (51 control vs. 61 intervention). The control group received usual care, including standard written and verbal information about RT during their first consultation with the radiation oncologist. The intervention group received 2 face-to-face consultations with a trained radiation therapist, who provided sensory and procedural information about RT. Anxiety levels were measured using the Hospital Anxiety and Depression Scale (HADS) at baseline, before planning, and on the first day of treatment. The intervention group showed reduced anxiety after the first consultation; however, no significant differences between groups were observed at follow-up 2 (the first treatment day).

An RCT conducted by Li et al. [26] involved 279 breast cancer patients (144 control vs. 135 intervention). All patients were offered a 15-minute educational session on basic breast cancer and RT knowledge on the day of admission. The intervention group additionally received comprehensive group-based education, including courses covering the basics of breast cancer with emphasis on psychiatry and psychological management. Anxiety levels were measured using the HADS at the first and last RT sessions. Compared with the control group, the intervention focusing on breast cancer and stress management did not reduce anxiety during RT. Changes in anxiety from baseline to post-RT did not differ significantly between groups.

An RCT by Dunn et al. [27] evaluated a video-based educational intervention delivered before RT in addition to usual patient information and support. Patients were instructed to view the video at home before attending the planning session. Anxiety levels were measured with the Psychosocial Adjustment to Illness Scale Self-Report (PAIS-SR) at 3 time points: the first consultation, before treatment planning, and after treatment. No significant differences in outcomes were found between groups.

An RCT by Harrison et al. [28] included 274 cancer patients (133 control vs. 141 intervention). All patients received a booklet about planning and treatment, a question-and-answer section addressing common problems, and a tumor-specific brochure on side effects. The intervention group also received video recordings containing information about planning and treatment, interviews with patients discussing their experiences, and interviews with doctors about side effects. Anxiety scores were measured using the HADS. This study found that anxiety levels decreased by the last day of treatment; however, the decrease was not significant in either group.

An RCT by Koth et al. [29] included 78 head and neck cancer patients (39 control vs. 39 intervention). All patients received face-to-face consultations and printed materials, while the intervention group additionally received video-based education after standard education. Anxiety scores were measured using the STAI before and after the educational session. No significant difference in overall anxiety scores was observed between groups. However, the intervention group reported less worry and greater emotional stability than the control group. Subgroups including non-smokers, married patients, females, and those with longer times to consultation showed greater reductions in anxiety.

An RCT by Gao et al. [30] included 60 cancer patients (30 control vs. 30 intervention). Anxiety levels were measured using the STAI. The control group received standard nursing care, while the intervention group additionally received a detailed introduction to RT positions, procedures, treatments, and related information through virtual reality education. Both groups had high anxiety levels before the intervention. After the intervention, anxiety scores in the intervention group decreased significantly compared with the control group.

A quasi-experimental study by Jimenez et al. [31] included 37 cancer patients (19 control vs. 18 intervention). Both groups received standard breast cancer education through written and verbal information during the initial clinic consultation (before and during RT consent) with the radiation oncologist, at the simulation appointment with radiation therapists, and again on the first day of treatment. The intervention group additionally attended a Virtual Environment for Radiotherapy Training (VERT)-based educational session providing detailed information on RT immobilization, planning, and treatment. Anxiety was highest at the first consultation and declined over time in both groups, with no significant differences between them.

An RCT by Zissiadis et al. [32] included 194 cancer patients (92 control vs. 102 intervention). The intervention group received intensive education about RT procedures through a booklet, as well as a specially designed booklet addressing lifestyle issues such as diet, exercise, natural therapies, and practical matters such as costs and parking. Nurses contacted these patients by telephone one week after their consultation. In contrast, the control group received an information package consisting only of a general RT booklet. Results showed no significant changes in anxiety scores for the intervention group compared with controls.

Summary of Interventions

To clarify intervention effectiveness, we grouped the included studies according to the intensity and complexity of the educational methods used, as shown in Table 3. Interventions were categorized as follows: (1) Low-intensity interventions: Passive methods (e.g., booklets or videos only, with no interactive or personalized components); (2) Moderate-intensity interventions: Multimedia tools or structured verbal explanation sessions, but with limited personalization or interactivity; (3) High-intensity interventions: Personalized and/or multimodal interventions, such as nurse-led or therapist-led face-to-face consultations, immersive virtual reality education, or multiple session-based formats.

Most studies employing high-intensity educational interventions (5 of 7) reported significant reductions in anxiety compared with controls. Only 1 of 3 studies in the moderate-intensity group showed significant effects, while none of the 5 low-intensity studies did. These findings suggest that higher-intensity, professionally delivered interventions are more effective in reducing anxiety among RT patients.

DISCUSSION

At baseline, cancer patients scheduled for RT experienced anxiety ranging from 2.9% to 88.2%. Eight studies [18–20,22, 29–32] reported moderate STAI scores. In all studies using STAI, anxiety decreased in both intervention and control groups during and after RT. In 7 studies [18–20,22,29,31,32], control groups received standard oral and/or written education, while one study did not specify what the control group received [30]. Four studies used HADS, with one reporting that 2.8% of patients had abnormal HADS-A scores [26], while 3 studies did not provide prevalence data [23,25,28]. Other tools used included the AKUADS, PAIS-SR, and DASS-21 [21,24,27]. One study using DASS-21 found that 88.2% of patients had mild to severe anxiety at the initiation of RT [21]. These findings underscore the importance of routine anxiety screening and interventions to reduce anxiety in RT patients.

The results of this systematic review were mixed; 6 of 15 studies reported significantly lower anxiety in the intervention group at follow-up. High-intensity, personalized education—such as face-to-face counseling, interactive 2-way communication, or virtual reality combined with verbal support—was most effective [21–25,30]. In contrast, low-intensity approaches, such as booklets or passive video materials, were largely ineffective. However, most studies found that the intervention was not more effective than standard education. Both intervention and control groups showed reductions in anxiety at follow-up, suggesting that providing patient education before or during RT remains essential for managing treatment-related anxiety.

Follow-up timing varied considerably across studies, which may have influenced comparability. The STAI is designed to assess short-term, situational anxiety, whereas the HADS-A is more suitable for capturing longer-term effects [33,34]. Studies with multiple or extended follow-up time points, such as Siekkinen et al. [22] and Halkett et al. [23], were more likely to capture durable changes in trait anxiety. Therefore, heterogeneity in both the tools and the timing of anxiety measurement presents a challenge for synthesis and interpretation. Future research should consider standardizing anxiety measurement —preferably using validated tools such as STAI or HADS-A—and implementing longitudinal follow-up to capture both immediate and lasting effects.

Different patient education methods showed varying effects, and the same approach could yield mixed results. Written instructions, such as pamphlets provided before RT, were more effective at reducing anxiety in head and neck cancer patients than multimedia presentations with photos, music, and videos [18]. Three studies using video education (2 comparing booklets vs. video education [27,28] and one comparing face-to-face vs. video education [29]) did not significantly improve overall anxiety measures. Similarly, education using VERT compared to standard written and verbal education did not show significant improvements in overall anxiety [31]. In breast cancer patients, PowerPoint-based education presenting information about RT equipment and procedures—including patient admission, treatment planning, and treatment sessions—was effective in reducing anxiety [19]. Face-to-face education involving families did not demonstrate greater benefits compared to patient-only education [29]. Notably, virtual reality education effectively reduced anxiety levels compared with standard methods [30].

The professional delivering education also had a significant impact on patient outcomes. Studies led by radiation therapists, oncology nurses, or multidisciplinary teams were more likely to show significant reductions in anxiety [21,23–25,30]. Their technical expertise and communication skills may have contributed to greater effectiveness. By contrast, interventions relying solely on passive multimedia or with poorly described educator roles [18,27–29,32] generally showed no effect, highlighting gaps in reporting. Future research should clearly define and standardize educator roles and involve professionals with psychosocial or counseling training.

Only one study reported that females showed a greater decrease in worry than males after video education [29]. This finding is noteworthy, as anxiety and depression are common in female cancer patients, and theoretical perspectives suggest that females are generally more open than males in expressing anxiety or depression [35,36]. Future interventions should routinely analyze and report whether male and female patients differ in baseline anxiety, response to educational strategies, and retention of coping skills, as sex differences may inform the design of more tailored interventions.

Clinical Practice Recommendation

Based on the patterns observed in this review, we recommend a pragmatic and clinically oriented approach in which health services transition from passive, one-time information delivery (e.g., booklets or standalone videos) toward comprehensive, high-intensity, and professionally delivered educational packages. Effective programs should combine procedural and sensory preparation by trained staff, brief evidence-based psychological strategies (e.g., relaxation, cognitive behavioral therapy-informed coping), and immersive tools such as virtual reality to reduce treatment-related uncertainty. These components should be implemented within a stepped-care framework: routine anxiety screening using validated instruments such as STAI or HADS, followed by low-intensity support for mild symptoms and targeted, high-intensity interventions for moderate-to-severe anxiety. Sessions should occur before simulation/planning and immediately prior to treatment, supported by staff training, fidelity monitoring, and longitudinal evaluation. Future research should compare multimodal interventions with standard care and incorporate cost-effectiveness analyses and subgroup evaluations based on factors such as sex, cancer site, and baseline anxiety.

CONCLUSION

This systematic review highlights that patient education remains an important approach for reducing anxiety among cancer patients undergoing RT. Although both intervention and control groups showed reductions in anxiety, more intensive, structured, and professionally delivered educational interventions were more likely to achieve significant improvements. These findings emphasize the importance of implementing structured, interactive, and tailored educational strategies in clinical practice, supported by routine anxiety screening and appropriate follow-up. Future studies should focus on standardizing intervention methods and evaluating their long-term effectiveness across diverse patient populations.

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

None.

Author Contributions

Conceptualization: Hanum FJ, Machmud R, Gondhowiardjo S, Khambri D, Harahap WA, Elliyanti A, Firdawati, Semiarty R. Data curation: Hanum FJ, Machmud R. Formal analysis: Hanum FJ, Machmud R. Funding acquisition: None. Methodology: Hanum FJ, Machmud R. Project administration: Hanum FJ. Visualization: Hanum FJ, Machmud R. Writing – original draft: Hanum FJ, Machmud R. Writing – review & editing: Gondhowiardjo S, Khambri D, Harahap WA, Elliyanti A, Firdawati, Semiarty R.

Figure 1

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.

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References

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