PATIENT COMFORT SURVEY ON THE USE OF TERMOPLASTIC MASK

IMMOBILIZATION EQUIPMENT IN THE HOSPITAL RADIOTHERAPY

DEPARTMENT MRCCC SILOAM SEMANGGI

, Arif Jauhari1) Nursama Heru Apriantoro2) Hafiz Rahadiyan3) Agus Budiyanto4),

1 Teknik Radiodiagnostik dan Radioterapi, Politeknik Kesehatan Kemenkes Jakarta II

Jl Hang Jebat II/F3, South Jakarta, Indonesia

Email : aagusbudiyanto@gmail.com

ABSTRACT
Immobilization is one of the first technical steps that conducted in providing radiation treatment and the good
treatment quality is highly dependent in this step. Patient comfort is also very important when choosing
immobilization techniques for radiation therapy. The more relaxed and comfortable the patients are, the more
possibility they will not moving their limbs in the thermoplastic mask immobilization tool, the actions that could
harm the outcome of radiation therapy.
This research aims to know the patient's comfort level on the use of thermoplastic mask immobilization at
Radiotherapy Department of MRCCC Siloam Semanggi Hospital seen from 3 aspects, position, movement, and
suitability. This research method uses descriptive quantitative research type with Cross-Sectional approach,
where data related to independent variable and dependent variable will be collected in the same time. The
population in this study were all cancer outpatient and inpatient medical patients who were treated in the
Radiotherapy Department of MRCCC Siloam Semanggi Hospital.
The result of the research from 67 respondents got 3 aspect comfort of the use of thermoplastic mask with
mostly in comfortable category; 97% Position, 100% Movement, and 98% Suitability.
The conclusion of patient comfort level on the use of thermoplastic mask immobilization tool at Radiotherapy
Department of MRCCC Siloam Semanggi Hospital is 89% comfortable and 11% enough.

Keywords : Immobilization Tool, Patient Comfort, Thermoplastic Mask

INTRODUCTION
Immobilization is one of the first technical steps taken in providing radiation
treatment and the quality of good treatment is very dependent on this step [1].
Immobilization of patients and accurate positioning of targets has long been
recognized critically as an important aspect of the quality of radiotherapy[2].
And it is recognized that patient movements can be reduced by the use of
immobilizationdevices[3].
Good immobilization is not only done to reduce movement during radiation treatment,
but also to provide patient regulation that can be reproduced day by day, comfortable
forpatients,
easy to use in the simulation process and must not interfere with the radiation dose
distribution [1,4,5].
The development of immobilization with new materials and methods has made
it possible to resist the movement of almost all areas of the patient's cooperative body to
a range of 3 mm - 5 mm unless target movement occurs with immobilization of problem
patients[2,6].
It is generally recognized that the immobilization of patients during radiotherapy
increases the accuracy of radiation, thereby ensuring the delivery of the right dose to the
tumor and can protect adjacent normal tissue [2,7–9].
This is important even in the imaging imaging era, because some regulatory errors
cannot be corrected by image imaging alone. Immobilization can also be used to
increase the minimum dose received in normal tissue. Various immobilization
technologies, namely, thermoplastic masks, bite blocks, wing boards, and breast boards
for breast cancer patients [1].
Patient comfort is also very important when choosing an immobilization
technique for radiation therapy. The more patients can relax and feel comfortable, the
more likely they are not to move their limbs in thermoplastic masks, actions that can
endanger the results of radiation therapy [8].
Patient comfort problems can also be very important, especially for elderly patients, if
treatment time is long, as is treatment with the IMRT technique [3]. And in some
patients, the use of masks is problematic, because of the feeling of claustrophobia [8].
 The discomfort of the mask may get worse if a longer thermoplastic mask
such as a head and shoulder mask (HSM) is used [8]. Patients who are uncomfortable
will tend to move to try to find a more comfortable position [1], actions that can
endanger the results of radiation therapy. This can cause severe pain and discomfort in
patients, and in the worst cases, treatment disorders [8]
Verification before radiation irradiation is done to determine whether the
patient's position when he wants to be shined is the same as during the simulation.
Radiation verification can be done using the On Board Imager (OBI). Treatment
verification is an important component of radiotherapy. Its role in radiotherapy is to
detect treatment delivery errors, evaluate whether or not the planning of boundaries
around clinical volume targets in the radiotherapy process [10].
This verification is carried out before irradiation and has two objectives,
namely to confirm that the patient is properly regulated and ensure that the normal area
or organ is protected as planned or during planning and to record the patient's position
as a reference position for the future. In treatment verification, tolerance will be a range
that allows set-up errors from the reference point. Tolerance used in practice will
consider several factors, including how to immobilize, set-up, and also move internal
organs[11].
Based on preliminary observations January 18, 2018, the hospital's
radiotherapy department MRCCC Siloam Semanggi has a variety of thermoplastic
masks that are used on patients such as head, head and neck, breast, and abdominal
thermoplastic masks. Thermoplastic masks are also accurate and efficient
immobilization devices that can be used for radiation treatment. This is the reason the
researchers want to know "What is the patient's comfort level for the use of
thermoplastic mask immobilization tools in the hospital's radiotherapy department
MRCCC Siloam Semanggi ".
RESEARCH METHODS

This type of research is quantitative descriptive. Samples were inpatient and

outpatient cancer patients using thermoplastic masks taken accidentally during March -
April 2018.
The preparation stage until the implementation of January - April 2018 uses a
questionnaire that has tested the validity and reliability test at MRCCC Siloam
Semanggi Hospital. The final stage of data processing in May 2018 uses the SPSS
application (Statistical Product and Service Solutions), namely univariate analysis
through frequency distribution [12].

RESULTS AND DISCUSSION

1. Patient Description
The results of univariate analysis of patient characteristics based on age groups are
presented in the distribution table (f) as follows:
Table 1
Patient description based on age group
No Age F %
Teenager – Adult
1 17 25,4
(20 – 40)
Adult – Elderly
2 23 34,3
(41 – 50)
Elderly – Old human
3 27 42,3
(51 – 77)
Amount 67 100

Based on Table 1, most of the patients were in the elderly - elderly group of
42.3%. This shows that this age group is the stage where a person experiences various
decreases in endurance and various psychological stresses.
 The results of the descriptive univariate analysis of patients based on Gender,
Education Level, Immobilization Tools, and Administration are presented in the
frequency distribution table (f) as follows:
Table 2
Patient Descriptions based on Gender, Education Level, Immobilization Equipment
Type, and Administration.
Description f %
Gender
1 Male 12 17,9
2 Female 55 82,1
Level of education
1 No school 2 3
2 Senior high school 22 32,7
3 Diploma 7 10,5
4 Bachelor 36 53,8
Types of
immobilization
equipment
1 Head Mask 5 7,5
Head and Neck
2 10 14,9
Mask
3 Breast Mask 32 47,8
4 Abdomen Mask 20 29,9
Administration
1 Independent 13 19,4
2 BPJS 54 80,6
Amount 67 100

Based on Table 2, the sex of cancer patients in the radiotherapy department of

the MRCCC Siloam Semanggi hospital who used thermoplastic masks was dominated
by female gender at 80.6%. More than half of cancer patients who use thermoplastic
masks have undergraduate education levels of 53.8%.
Most types of immobilized cancer patients use breast masks, 47.8%. And most of the
patients in the MRCCC Siloam Semanggi hospital's radiotherapy department with BPJS
administration were 80.6%.

2. Patient Comfort in Using Thermoplastic Masks in the Radiotherapy

Department of MRCCC Hospital Siloam Semanggi.
The results of univariate analysis based on patient comfort in aspects of the
patient's position are presented in the frequency distribution table (f) as follows:
Table 3
Patient Frequency Distribution based on Patient Comfort in the Patient Position aspect
Comfort rate f %
Very comfortable 16 23,9
Comfortable 40 59,7
Enough 9 13,4
Not Convenient 1 1,5
Very Uncomfortable 1 1,5
Amount 67 100

Based on Table 3, the data shows that the patient's comfort level in the aspect of
the patient's position belongs to the Comfortable category, which is 97%.
But there are 3% that are classified as uncomfortable. According to the
researchers' observations, this can be affected by the condition of patients undergoing
treatment as in the case of head cancer treatment whose cancer cells have pressed into
the brain tissue so that the head will feel pain, especially if thermoplastic masks are
used to add a little pressure to the head of course patients will feel uncomfortable.
However, this only occurs in the condition of patients who are already classified as bad
/ advanced stage so special attention is needed by always paying attention to the
position of the installation of the mask slowly to handle it, especially when installing
thermoplastic masks.
Then in the case of breast cancer treatment there can be discomfort in the
position when thermoplastic masks are installed because this type of treatment requires
a quite complicated position for the patient, namely by lifting both hands over the head
so that the chest is exposed as a radiation field and thermoplastic masks can be used.
This position will be very uncomfortable when the patient has a history of lymph nodes
that have enlarged so that it will limit the movement of the patient's hand so that it will
feel stiff and sick.
The results of univariate analysis based on patient comfort in aspects of patient
movements are presented in the frequency distribution table (f) as follows:
Table 4
Patient Frequency Distribution based on Patient Comfort in Patient Movement aspects
Comfort rate f %
Very Easy 12 17,9
Easy 50 74,6
Enough 5 7,5
Not Easy - -
Very not easy - -
Amount 67 100

Based on Table 4, the data shows that the patient's comfort level in the aspect of
the patient's movement is in the category of Very Easy, Easy, and Enough that is 100%
andclassifiedasComfortable.
Patient movement is an important concern in the field of radiotherapy. When the
patient feels uncomfortable consciously or unconsciously the patient will move his body
to be able to find a comfortable position, of course this is very risky when irradiation
takes place. As the main function of the thermoplastic mask immobilization device,
which is to hold back the movement of the patient during irradiation, it will certainly be
an important aspect when viewed from the comfort side of the thermoplastic mask.
To be able to produce comfort from restraining these movements, of course the
role of radiotherapy officers is needed that interacts directly with patients when using
thermoplastic masks, with correct positioning that always pays attention to whether the
patient feels comfortable or not and effective communication by always asking whether
the mask used is appropriate patient's comfort or not so that the patient will find a
comfortable position before and after using a thermoplastic mask and the patient will
withstand movement easily.
 The results of univariate analysis based on patient comfort in aspects of patient
suitability are presented in the frequency distribution table (f) as follows:
Table 5
Patient Frequency Distribution based on Patient Comfort in the aspect of Patient
Conformity
Comfort rate f %
Very Easy 11 16,4
Easy 47 70,1
Enough 8 11,9
Not Easy 1 1,5
Very Not easy - -
Amount 67 100

Based on Table 5, the data shows that the patient's comfort level in the aspect of
patient suitability is in the category of Very Easy, Easy, and Enough that is 98.5% and
classified as Comfortable.
The ease of the patient for the suitability of his limbs to be installed with a
thermoplastic mask will affect the patient's comfort when using a thermoplastic mask
during irradiation. Narrow thermoplastic masks will affect the comfort of the patient by
receiving excessive pressure so that the patient will feel pain, on the contrary if a loose
thermoplastic mask will affect the patient's mobility so that it can endanger the results
of therapy. The control of the loose thermoplastic nasal can be simulated again by re-
mapping the location of the tumor, making a mask of temroplastik, and planning for the
accuracy of radiation irradiation.
This can occur in certain cases that can be caused by 2 factors, namely patient
factors and thermoplastic mask factors.
Patient factors can occur if patients who are undergoing treatment using
thermoplastic masks have enlarged parts of their bodies due to tumor growth or the
body of patients who are getting fat so that their body parts are getting bigger, this is
more likely in cancer cases of the abdomen so that thermoplastic masks are used
become narrower.
 The thermoplastic mask factor can also occur if the manufacturing process is not
in accordance with existing procedures, such as the process of printing thermoplastic
masks on the body of patients who have to wait 20-30 minutes so that the thermoplastic
mask becomes stiff after being softened in the waterbath. This can affect the shape of
thermoplastic masks that are inconsistent if not in accordance with the procedure
performed.
So as to better ensure the suitability of masks to patients apart from properly
fitting masks, verification can be done using OBI (On Board Imager) so that the number
of shifts that occur.
The results of univariate analysis based on patient comfort in aspects of patient
suitability are presented in the frequency distribution table (f) as follows:
Table 6
Patient Frequency Distribution based on Patient Comfort in the Radiotherapy
Department of MRCCC Hospital Siloam Semanggi

Comfort rate f %
Comforable 60 89,6
Enough 7 10,4
Amount 67 100

Based on Table 6, the data shows that the patient's comfort level for the use of
thermoplastic mask immobilization tools in the Radiotherapy Department of MRCCC
Hospital Siloam Semanggi is in the category of Comfort, which is 89.6%.
This can be shown based on the respondent's responses from each aspect,
namely the patient's position, the patient's movement, and the patient's suitability which
is classified as a comfortable category.
Although there are some patients who give an uncomfortable response in one
aspect of the patient's comfort, it can be overcome by effective and efficient
communication by always asking what the patient feels when installing thermoplastic
masks before and after radiation irradiation so that it fits the patient's comfort needs and
does not forget also according to therapeutic needs. Thermoplastic masks also need to
be considered the manufacturing process so that it is in accordance with existing
procedures. According to the researchers' analysis, it was seen from the patient's
comfort towards the use of thermoplastic masks, the Department of Radiotherapy at the
MRCCC Hospital, Siloam Semanggi, to meet the patient's needs and the need for
thermoplastic masks by giving the best attention so that they could influence the quality
of good therapy.

CONCLUSION
From the results of the study concluded that in general, the three aspects
namely patient position, patient movement, and patient suitability in determining patient
comfort for the use of thermoplastic mask immobilization equipment in the MRCCC
Hospital's Radiotherapy Department, Siloam Semanggi were considered good and
comfortable for patients namely 97%, 100 %, and 98.5%.
In terms of patient comfort in the use of thermoplastic mask immobilization
tools in the Department of Radiotherapy at MRCCC Siloam Semanggi Hospital, we can
conclude the patient's comfort level
the use of thermoplastic mask immobilization devices based on patient comfort index
was 89.6%. This figure shows that overall the radiotherapy patients of MRCCC
Hospital Siloam Semanggi who use thermoplastic masks during their treatment are in
the category of Comfortable use of thermoplastic masks.
It is expected that the radiotherapy officers will further enhance their insight
and communication regarding the comfort of patients with the use of thermoplastic
mask immobilization tools, and must be monitored, pay attention to and improve the
quality of thermoplastic mask immobilization devices that will be used for cancer
patients, especially on how to make thermoplastic masks according to procedures and
how to use thermoplastic masks for cancer patients with different types of treatment
cases so that patients are not agitated when using thermoplastic masks during treatment
so that the treatment can be optimized and achieved properly.
BIBLIOGRAPHY
1. Dieterich S, Ford E, Pavord D, Jing Z. Practical Radiation Oncology Physics.
Philadelphia: Elsevier Ltd; 2015. 87-94 p.
2. LynnJ. Verhey. Immobilizing and Positioning Patients for Radiotherapy. Radiat
Oncol. 1995;5:100–14.
3. Kim S, C H, Akpati, G J, Liu CR, Amdur RJ, et al. An Immobilization System
for Claustrophobic Patients in Head-and-Neck Intesity Modulated Radiation
Therapy. Int J Radiat Oncol Biol Phys. 2004;59:1531–9.
4. Sexton T, Rodrigues G, Bauman G, Harriman-Duke J, Kron T, Yartsev S. A
randomized crossover study evaluating two immobilization devices for prostate
cancer treatment. J Radiother Pract. 2008;7:141–9.
5. Laing RW, Thompson V, Warrington AP, Brada M. Feasibility of patient
immobilization for conventional cranial irradiation with a relocatable stereotactic
frame 1. Br J Radiol. 1993;66:1020–4.
6. B C, Yakoob R, A C, P T, M K. Immobilization Devices for Intesity Modulated
Radiation Therapy (IMRT). Med Dosim. 2001;26:71–7.
7. Marks JE, Gerber RL. Thermal Plastics for Immobilization Patients During
Radiotherapy. Int J Radiat Oncol Biol Phys. 1982;8:1461–2.
8. Howlin C, O’Shea E, Dunne M, Mullaney L, McGarry M, Clayton-Lea A, et al.
A randomized controlled trial comparing customized versus standard headrests
for head and neck radiotherapy immobilization in terms of set-up errors, patient
comfort and staff satisfaction. Radiography. 2015;21:74–83.
9. Sharp L, Lewin F, Johansson H, Payne D, Gerhardsson A, Rutqvist LE.
Randomized trial on two types of thermoplastic masks for patient immobilization
during radiation therapy for head-and-neck cancer. Int J Radiat Oncol Biol Phys.
2005;61:250–6.
10. The Royal College of Radiologist. Ensuring Geometric Accuracy in
Radiotherapy. 2008. 76 p.
11. Djordjevic M. Evaluation of Geometric Accuracy and Image Quality of an On-
Board Imager (OBI). Med Radiat Phys. 2007;66.
12. Hastono, Sutanto Priyo. Analisis Data Kesehatan. Universitas Indonesia. 2007. 1-
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