This secondary analysis of a large multicenter cross-sectional study demonstrated high satisfaction with radiotherapy care among cancer patients treated in Germany. Determinants of patient satisfaction included higher global health status/quality of life, treating center, and tumor entity.

Overall satisfaction with radiotherapy was reported by 85% of the patients in our cohort using a dichotomized analysis of a 10-point Likert scaled question. Various measures of patient satisfaction have been used in different settings, making a comparison across studies challenging. Gomez-Cano and colleagues reported results of the English Cancer Patient Experience Survey from the UK [22]. The study surveyed a diverse cohort of cancer patients after treatment and used a similar question on overall satisfaction with care as our study. Based on their results, we hypothesized a right-skewed distribution of patient satisfaction towards greater satisfaction. Interestingly, Gomez-Cano and colleagues reported nearly the same rate of patient satisfaction at 86%. Few studies focused more on cancer patients treated with radiotherapy and these studies used various patient satisfaction measures. Shabason and colleagues conducted a cross-sectional study of 305 patients treated with radiotherapy in the US [27]. At the last week of radiotherapy, 76% of the patients were considered satisfied with radiotherapy care reporting the highest score of patient satisfaction on a 5-point Likert scaled question. Further, a Canadian study included 220 patients within 6 months after treatment [28]. Using the Ambulatory Oncology Patient Satisfaction Survey questionnaire, this study reported an overall satisfaction rate of 88%. Concerning satisfaction with radiotherapy of cancer patients treated in Germany, to our knowledge only two studies reported results across various tumor entities. Geinitz and colleagues surveyed 273 patients in two tertiary cancer centers in Munich at the start of a course of radiotherapy in 2005 [29]. Overall satisfaction as measured by the “Questions on Satisfaction Questionnaire (ZUF-8)” was high ranging from 95 to 99%. Finally, Becker-Schiebe and colleagues conducted a cross-sectional study at a single center surveying 1710 patients from 2012 to 2014 [16]. The study employed a 4-point Likert scaled question on overall patient satisfaction. A score of 1 represented highest and a score of 4 lowest satisfaction. The reported mean value was 1.4 suggesting a high level of patient satisfaction with radiotherapy at this single center. Taken together, generic and radiotherapy-specific studies reported high levels of patient satisfaction over time per year of the survey, in different settings, and using various measures. Geinitz and colleagues reported exceptionally high rates of patient satisfaction as mentioned above, possibly owing to the timing of the survey at the start of radiotherapy or to the selected measure [29]. Overall, however, high rates of patient satisfaction with radiotherapy care as found in our multicenter cohort are reassuring and fit well into the diverse international and national literature.

Determinants of patient satisfaction in our cohort included global health status/quality of life, treating center, and tumor entity according to a multivariable model. Various determinants of patient satisfaction have been investigated before. First, sociodemographic factors such as age, gender or education have been reported to be relevant by some, but not all studies [16, 30, 31]. Accordingly, a systematic review of patient satisfaction reported that the influence of sociodemographic factors is equivocal [32]. This is in line with the findings of our study as sociodemographic factors were not associated with patient satisfaction in our analysis. Second, results on general health-related quality of life as determinant of patient satisfaction have been reported previously. Versteeg and colleagues, for example, conducted a longitudinal cohort study of patients treated with surgery and/or radiotherapy for spinal metastases [33]. General health-related quality of life was measured using the EuroQol 5‑Dimension (EQ-5D-3L) questionnaire and was not associated with overall patient satisfaction before or after radiotherapy in this study. In contrast, a nationwide Danish cross-sectional study surveyed a variety of different cancer patients three to five months after diagnosis and reported a significant association of patient satisfaction with better health-related quality of life [3]. The latter study used the same measure for general health-related quality of life (EORTC QLQ-C30) as our study. Therefore, the association of patient satisfaction with general health-related quality of life found in our study appears plausible. Third, treating radiotherapy center has, to our knowledge, not been reported previously to be associated with patient satisfaction. The study of Geinitz and colleagues, for example, did not find a difference in patient satisfaction between two participating centers [29]. Differences in patient satisfaction between centers are plausible and might support recent regulatory efforts as outlined in the introduction. Yet a note of caution is warranted for such comparisons when patient satisfaction is used as quality indicator as various possible biases have been reported including the appearance of office interiors [34, 35]. Fourth, the role of tumor entity in patient satisfaction is controversial. The study of Geinitz and colleagues did not find any associations of patient satisfaction with tumor entity, whereas Becker-Schiebe and colleagues reported lower patient satisfaction among head and neck cancer patients [16, 29]. Yet Rühle and colleagues found high rates of patient satisfaction across elderly head and neck cancer patients treated with radiotherapy [36]. Further, the Danish study by Heerdegen and colleagues reported lower patient satisfaction in patients with gastrointestinal or colon cancer, whereas Al-Rashdan and colleagues found higher patient satisfaction in patients with gastrointestinal cancer [3, 28]. Therefore, the result of our study that rectal cancer patients had lower patient satisfaction remains difficult to interpret. Most likely, the conflicting results are related to differences in the timing and methods of measurement of patient satisfaction. Fifth, various further areas of patient experience with healthcare have been found to correlate with patient satisfaction as reported by studies dedicated to its assessment. These areas are not limited to but include shared decision-making, patient-provider relation, waiting times or received information [3, 14, 27, 29,30,31]. Multi-item questionnaires have been developed such as the EORTC PATSAT-C33 and aim to cover such determinants of patient satisfaction [37,38,39]. Taken together, determinants of patient satisfaction are manifold and treating center is newly described in cancer patients treated with radiotherapy in Germany.

Although we report data of a large multicenter cohort, there are limitations to our analyses. This was a secondary post hoc analysis and the study was not primarily designed to capture all aspects of patient satisfaction. Further, we used an unvalidated single-item question on overall patient satisfaction with radiotherapy care at the end of radiotherapy. Although a dedicated questionnaire could have offered more detail and although single-item questions are prone to ceiling effects, single-item questions of overall patient satisfaction are still an area of active research [40, 41]. It is also possible that the timepoint may influence patient satisfaction. Future studies should therefore include longitudinal analysis of patient satisfaction. In addition, effect sizes of associations of covariables with patient satisfaction were small or modest overall. Finally, all study data were patient-reported and collected anonymously. Medical variables such as tumor entity should therefore be interpreted cautiously in our data set.

In conclusion, we have found high rates of overall satisfaction with radiotherapy care across 11 centers in Germany. Although exploratory, determinants of patient satisfaction included general health-related quality of life, treating center, and tumor entity. This data may inform other treating centers and future research concerning patient satisfaction with radiotherapy care.