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n Feature Article
Patient Anxiety, Pain, and Satisfaction With
Image-Guided Needle Biopsy
Casey Jo Humbyrd, MD; Emily K. Miller, BA; Richard L. Skolasky, PhD; Laura M. Fayad, MD;
Frank J. Frassica, MD; Kristy L. Weber, MD
abstract
Image-guided percutaneous needle biopsy has become the preferred diagnostic modality for bone and soft tissue tumors. However, to the authors’
knowledge, the levels of patient anxiety, pain, and satisfaction before and
after the procedure have not been studied. Sixty-five patients undergoing
image-guided needle biopsy of a possible bone or soft tissue tumor were
prospectively surveyed to quantify preprocedure and postprocedure levels
of anxiety and pain and to determine demographic and clinical correlates of
anxiety, pain, and satisfaction. Anxiety was measured with the Spielberger
State-Trait Anxiety Inventory, pain was measured with a visual analog scale,
and satisfaction was measured by patient willingness to repeat the procedure
if necessary. Statistical analysis was performed with Student’s t test, Fisher’s
exact test, and linear regression analysis. Compared with preprocedure values, trait anxiety (defined as the underlying level of anxiety, P<.0011), state
anxiety (defined as the current level of situational anxiety, P<.001), and pain
(P<.05) decreased significantly postprocedure. The relationship between
changes in pain and state anxiety was significant (r=0.31, P=.014), whereas
no relationship was seen between changes in pain and trait anxiety (r=0.13,
P=.28). Patients who were somewhat satisfied with the procedure reported
higher levels of postprocedure pain than those who were completely satisfied (5.24±2.19 cm vs 1.70±2.08 cm, respectively; P<.001). In other words,
lower levels of experienced pain correlated with patient satisfaction. Older
age was inversely correlated with postprocedure pain (r=0.41, P=.001), and
there was a trend toward increasing dissatisfaction among younger patients.
[Orthopedics. 2016; 39(2):e219-e224.]
D
uring the past 20 years, imageguided percutaneous needle biopsy has replaced open biopsy
as the diagnostic standard of care for bone
MARCH/APRIL 2016 | Volume 39 • Number 2
and soft tissue tumors at most major US
cancer centers.1-3 Percutaneous biopsy is
often preferred to open biopsy because
of its lower cost, decreased scarring and
healing time, safer anesthesia, and decreased risk of tumor plane violation.2,4-6
Although previous studies determined
the diagnostic accuracy of percutaneous
needle biopsy for bone and soft tissue tumors,1-3 no studies have analyzed patients’
anxiety before biopsy, pain experienced
during the procedure, and willingness to
undergo the procedure again.
The goal of the current study was to
quantify the degree of anxiety and pain
immediately before and after percutaneous biopsy in patients with musculoskeletal tumors to improve counseling for patients who are choosing between open and
percutaneous biopsy. Similar studies of
patients in other disciplines after biopsy
and surgical procedures showed a postprocedure decrease in anxiety and less
The authors are from the Department of Orthopaedic Surgery and the Russell H. Morgan
Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore,
Maryland.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to:
Casey Jo Humbyrd, MD, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical
Center, 4940 Eastern Ave, 6th Fl, A Building, Baltimore, MD 21224 ([email protected]).
Received: May 20, 2015; Accepted: July 8,
2015.
doi: 10.3928/01477447-20160119-01
e219
n Feature Article
Table 1
Correlation Between Preprocedure and Postprocedure Anxiety
and Pain Scores
r (P)
Parameter
Anticipated Pain
Experienced Pain
Preprocedure
0.19 (.11)
0.10 (.42)
Postprocedure
0.16 (.20)
0.30 (.02)
Trait anxiety
State anxiety
Preprocedure
0.36 (.004)
0.16 (.19)
Postprocedure
0.29 (.02)
0.38 (.002)
pain than expected.7-12 The study also investigated the increasing body of knowledge about the relationship between preoperative anxiety and experienced pain.12
Finally, survey data were compared with
demographic and clinical characteristics
to determine whether certain subsets of
patients are more likely to experience
greater pain or anxiety with percutaneous
biopsy.
The authors expected to find that state
anxiety would be higher preprocedure
than postprocedure, trait anxiety would be
the same preprocedure and postprocedure,
and anticipated pain and patient anxiety
would correlate. They also expected to
find an association between experienced
pain and patient satisfaction.
Materials and Methods
Institutional review board approval
was obtained in August 2009 and renewed
annually. Patients were recruited from October 2009 through December 2012. All
adult patients of the musculoskeletal oncology division at the authors’ institution
who were referred for computed tomography–guided needle biopsy were invited
to participate. Excluded from the study
were minors, pregnant women, vulnerable
populations (ie, prisoners), non–Englishspeaking individuals, and those who had
undergone a previous percutaneous needle biopsy. All patients who agreed to take
e220
the survey provided informed consent to
participate in the study.
Biopsies were performed by 1 of 3 attending radiologists (all with more than 10
years of experience performing biopsies),
with assistance from a musculoskeletal
radiology fellow. Patients had local analgesia with 1% lidocaine, and intravenous
access was created for all patients preprocedure. When provided, systemic analgesia consisted of intravenous fentanyl and
midazolam given in standard doses and
titrated as needed.
The 65 eligible patients who participated completed the preprocedure survey
immediately before the biopsy and then
completed the postprocedure survey before discharge from the recovery unit.
Patient anxiety was evaluated with the
Spielberger State-Trait Anxiety Inventory.13 State anxiety was measured by responses to 20 statements that reflect current anxiety about a specific situation, and
trait anxiety was measured by responses
to 20 statements that reflect general disposition to anxiety. Responses were scored
on a scale of 1 to 4 points, and a composite score of between 20 and 80 points was
calculated for state and trait anxiety separately, with higher scores reflecting higher
anxiety. A visual analog scale was used to
assess anticipated and experienced pain.
This tool has been used extensively for
patients undergoing biopsy.7,9,10,14,15 Fi-
nally, patient satisfaction was determined
postprocedure in terms of willingness to
undergo another needle biopsy if it were
medically necessary, a technique used in
similar studies.7,10,14,16 The response options in the survey were: (1) “Yes, unconditionally,” which was designated as completely satisfied; (2) “Yes, but only with
more pain medication/anesthesia,” which
was designated as somewhat satisfied; and
(3) “No,” which was designated as not satisfied.
The following prospectively collected
patient information was obtained from
the institution’s musculoskeletal oncology database: demographic data (ie, age,
sex); clinical factors (ie, history of previous cancer or musculoskeletal lesion, preprocedure use of narcotics for any reason,
intravenous analgesia during the procedure); and final diagnosis (Table 1). This
information was analyzed to identify relationships between the data and the survey
results.
One patient did not return for followup after an inconclusive biopsy that was
suspicious but not definitive for lymphoma. This patient was lost to follow-up and
was excluded from analysis of the effect
of diagnosis. Only 1 patient was dissatisfied; exclusion of this patient’s data from
the analysis of pain and anxiety did not
change the results, and therefore the data
were excluded only from the analysis of
satisfaction. Five patients (2 completely
satisfied, 2 somewhat satisfied, and 1
dissatisfied) had unknown analgesia and
were excluded from the intravenous pain
medication category.
Statistical Analysis
An a priori power analysis was performed to determine the minimum number of completed surveys required. The
mean clinically significant difference in
visual analog scale pain score between
ratings separated by 30 minutes is 1.3
cm.17 Therefore, the study was powered
to detect as significant a difference as 1.3
cm between preprocedure pain anticipa-
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n Feature Article
tion and postprocedure pain assessment.
Assuming a standard deviation of 3 cm,
the study needed to include 56 completed
surveys to achieve 80% power to detect
this difference.
A matched-pairs Student’s t test was
used to compare visual analog scale and
Spielberger State-Trait Anxiety Inventory
scores before and after biopsy to determine whether pain expectations and state
anxiety changed significantly. Linear regression modeling was used to examine
the relationship between anxiety and pain
scores. A Spearman correlation coefficient was used to describe the strength of
the association between variables.
The change in anxiety and pain from
preprocedure to postprocedure was calculated by subtracting preprocedure values
from postprocedure values. A negative
value represented a decrease in anxiety.
Spearman correlation coefficients were
calculated to (1) compare the change in
anxiety with the change in pain, (2) compare the relationship between preprocedure and postprocedure anxiety and preprocedure and postprocedure pain, and
(3) evaluate whether there was a relationship between patient age and anxiety and
pain.
Fisher’s exact test was used to explore
the relationship between discrete variables (eg, the number of men and women)
and patient satisfaction by constructing a
2×2 contingency table. Significance was
set at P<.05 for all analyses.
Results
Anxiety, Pain, and Satisfaction
Compared with preprocedure values, trait anxiety, state anxiety, and pain
decreased significantly postprocedure
(34.02±8.48 vs 31.51±8.18, P<.0011;
37.95±12.95 vs 31.82±10.29, P<.001;
3.97±2.71 vs 2.21±2.45, P<.001, respectively). The relationship between the
change in state anxiety and the change in
pain was statistically significant (r=0.31,
P=.014). No significant relationship was
found between the change in trait anxiety
MARCH/APRIL 2016 | Volume 39 • Number 2
Figure: Correlation between the change in state anxiety and the change in pain (r=0.31, P=.014).
and the change in pain (r=0.13, P=.28)
(Figure). Preprocedure trait anxiety in patients who were diagnosed with a malignancy was significantly higher than that in
patients diagnosed with a benign process
(36.26±9.08 vs 31.67±7.20, respectively;
P=.03).
Significant correlations were found between preprocedure state anxiety and anticipated pain and between postprocedure
state and trait anxiety and experienced
pain (Table 1).
Of the patients, 54 (83.1%) were completely satisfied with the procedure and 10
(15.4%) were somewhat satisfied (Table
2). When the anxiety and pain scores of
the 2 subsets of satisfied patients were
compared, postprocedure pain was the
only significant variable between those
who were completely satisfied and those
who were somewhat satisfied (1.70±2.08
vs 5.24±2.19, respectively; P<.001).
Preprocedure and postprocedure anxiety
scores for somewhat satisfied patients
were higher than those for patients who
were completely satisfied, but this increase was not statistically significant
(Table 2).
Demographic and Clinical Variables
Half of the participants were women
(31 of 65, 47.7%), and mean age was
53.34±16.77 years. One third of patients
(21 of 65, 32.3%) were taking narcot-
ics before the procedure, and most of
the patients had no history of tumor (37
of 65, 56.9%). More bone biopsies than
soft tissue biopsies were performed (37
vs 28). Of the biopsies, 17 (26.1%) were
performed with local analgesia only, 43
(66.2%) were performed with local and
systemic analgesia, and in 5 cases the use
or nonuse of systemic sedation was not recorded. The final pathology report showed
30 benign tumors (46.2%), 34 malignant
tumors (52.3%), and 1 unknown tumor
(1.5%).
No statistically significant differences
were found between women and men in
trait anxiety, state anxiety, pain score, or
satisfaction before and after the procedure
(Table 3). Patient age was inversely correlated with experienced pain (r=-0.41,
P=.001) (Table 3). Patients who were
somewhat satisfied tended to be younger
than those who were completely satisfied,
but the difference was not statistically significant (P=.065) (Table 2).
Patients who took narcotic pain medication preprocedure for any reason had
higher preprocedure trait anxiety than
patients who did not (32.59±7.77 vs
37.00±9.30, respectively; P=.049) (Table
4). They were also less satisfied with the
procedure (somewhat satisfied, 60%;
completely satisfied, 29.6%), but this difference was not statistically significant
(P=.08) (Table 2).
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Table 2
Comparison of Anxiety, Pain, and Demographic and Clinical
Characteristicsa in Completely Satisfied and Somewhat Satisfied
Patientsb
Completely Satisfied
Patients (n=54)
Somewhat Satisfied
Patients (n=10)
P
Preprocedure
33.46 (8.30)
36.90 (9.69)
.25
Postprocedure
30.78 (7.66)
35.90 (10.16)
.07
Preprocedure
37.59 (13.42)
40.30 (11.07)
.55
Postprocedure
30.94 (10.49)
37.10 (8.10)
.08
Preprocedure
3.85 (2.79)
4.53 (2.44)
.48
Postprocedure
1.70 (2.08)
5.24 (2.19)
<.001
Men/women, No.
30/24
4/6
.49
Age, mean±SD, y
Parameter
Trait anxiety, mean (SD)
State anxiety, mean (SD)
Pain, mean (SD)
Characteristic
54.91±16.36
44.20±17.61
.06
Taking/not taking preprocedure
narcotics, No.
16/38
6/4
.08
With benign/malignant final
diagnosis,c No.
26/28
4/6
.74
Using local only/intravenous
pain medication,d No.
14/38
3/5
.68
Undergoing bone/soft tissue
biopsy, No.
30/24
6/4
1.0
a
Discrete variables were analyzed with Fisher’s exact test with a 2×2 contingency table. The
continuous variable (age) was analyzed with an unpaired Student’s t test. The 1 dissatisfied
patient (would refuse a second biopsy) was excluded from the analysis. Satisfied patients were
those who stated that they would undergo the needle biopsy procedure again unconditionally;
somewhat satisfied patients were those who stated that they would undergo the needle biopsy
procedure again only with additional pain medication or anesthesia.
b
Completely satisfied patients were those who stated that they would undergo the needle biopsy
procedure again unconditionally; somewhat satisfied patients were those who stated that they
would undergo the needle biopsy procedure again only with additional pain medication or
anesthesia.
c
One completely satisfied patient had no ultimate diagnosis made and was excluded from the
final diagnosis row.
d
Five patients (2 completely satisfied, 2 somewhat satisfied, and 1 dissatisfied) had unknown
analgesia and were excluded from the intravenous pain medication row.
A final diagnosis of malignancy was
associated with increased preprocedure
trait anxiety (P=.03), preprocedure state
anxiety, and postprocedure state anxiety
(Table 4). No association was found between final diagnosis and pain or between
final diagnosis and satisfaction. No difference in pain, anxiety, or satisfaction was
found with the use of intravenous anal-
e222
gesia (vs local only) or with biopsy type
(bone vs soft tissue) (Table 2 and Table 4).
Discussion
This study analyzed patient anxiety,
pain, and satisfaction with computed
tomography–guided percutaneous needle
biopsy used to diagnose bone and soft tissue tumors. To the authors’ knowledge,
this is the first study of its kind, and the
results provide baseline measures that can
be used for clinical counseling and future
research.
The perceived pain experienced by
patients was usually mild, the perceived
pain associated with biopsy for bone tumors was similar to that for soft tissue
tumors, and the perceived pain associated with biopsy performed with local
analgesia alone was similar to that for
biopsy performed with light sedation.2
As predicted, state anxiety was significantly higher preprocedure than postprocedure. Multiple correlations were found
between anxiety and pain (Figure and
Table 1). Although there is a growing
body of knowledge about the relationship
between preoperative anxiety and postoperative pain,3,11,13,14,18 neither preprocedure trait anxiety nor preprocedure state
anxiety correlated with experienced pain
in the current study (Table 1). One reason
for this finding may be that, although the
procedure itself may be painful, minimal
pain occurs postprocedure. Therefore,
this procedure likely differs from surgical
procedures in which patients experience
postoperative pain.
Trait anxiety was expected to remain
unchanged, but it was found to be higher
preprocedure than postprocedure. The
trait anxiety score (an individual’s general
disposition to anxiety) is considered fixed,
whereas the state anxiety score represents
anxiety about the current situation.19
These data suggest that the process of
undergoing a biopsy that might diagnose
a life-threatening disease may be stressful enough to increase a patient’s trait
anxiety. Interestingly, preprocedure trait
anxiety in patients diagnosed with a malignancy was significantly higher than that
in patients diagnosed with a benign lesion.
Patients whose preprocedure evaluation
suggested a malignant process often have
been counseled about this possibility by
their physicians, and this may explain the
differential in baseline (preprocedure) but
not postprocedure trait anxiety.
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n Feature Article
The authors also hypothesized that
there would be an association between experienced pain and patient satisfaction.19
Patients who were completely satisfied
vs those who were somewhat satisfied
had average pain levels of 1.70±2.08 cm
and 5.24±2.19 cm, respectively (P<.001).
Less satisfied patients had higher anxiety
and anticipated pain scores, but only the
difference in experienced pain was statistically significant.
No association was found between
patient sex and anxiety, pain, or satisfaction. However, the study found a negative
correlation between age and postprocedure pain (r=-0.41, P=.001). Additionally, somewhat satisfied patients were an
average of 10 years younger than completely satisfied patients (44.20±17.61 vs
54.91±16.36, respectively), although this
difference was not statistically significant.
The study was underpowered to evaluate this difference, and it is likely that a
larger sample would show a statistically
Table 3
Relationships of Demographic Variables to Anxiety and Pain
Sex
Age
Women (n=31)
Men (n=34)
P
r
P
Preprocedure
35 (8.61)
33.12 (8.38)
.38
-0.017
.88
Postprocedure
32.35 (8.73)
30.74 (7.69)
.43
-0.108
.38
Preprocedure
39.06 (12.65)
36.94 (13.31)
.51
-0.046
.71
Postprocedure
33.87 (10.94)
29.94 (9.44)
.13
0.001
.99
Preprocedure
4.57 (2.90)
3.42 (2.45)
.09
-0.21
.10
Postprocedure
2.08 (2.69)
2.34 (2.24)
.68
-0.41
.001
Parameter
Trait anxiety, mean (SD)
State anxiety, mean (SD)
Pain, mean (SD)
significant difference. The relationship
between increased patient satisfaction and
increased age has been well documented;
it is not unique to the needle biopsy procedure.19,20 A possible explanation is that
younger patients generally metabolize
medications at a faster rate and may require a dosing nomogram different from
the current standardized protocol, which
does not vary by age.6 Another explanation is that, as a cohort, young patients
have less exposure to medical and surgical
Table 4
Relationship of Clinical Characteristics to Anxiety and Pain
Trait Anxiety
Parameter
State Anxiety
Pain
Preprocedure
Postprocedure
Preprocedure
Postprocedure
Preprocedure
Postprocedure
Not taking (n=44), mean (SD)
32.59 (7.77)
30.61 (7.97)
36.64 (12.26)
31.05 (10.21)
4.02 (2.78)
2.48 (2.70)
Taking (n=21), mean (SD)
37.00 (9.30)
33.38 (8.48)
40.71 (14.18)
33.43 (10.52)
3.87 (2.64)
1.67 (1.74)
.04
.20
.24
.39
.84
.21
Benign (n=30), mean (SD)
31.67 (7.20)
29.97 (7.09)
34.70 (11.39)
29.23 (7.74)
3.84 (2.79)
2.35 (2.49)
Malignant (n=34), mean (SD)
36.26 (9.08)
33.21 (8.74)
41.06 (13.77)
34.44 (11.64)
4.17 (2.66)
2.16 (2.46)
.03
.11
.05
.04
.63
.77
Local only (n=17), mean (SD)
33.18 (7.70)
30.94 (8.05)
33.06 (12.83)
30.29 (10.87)
3.01 (2.52)
2.58 (2.98)
Intravenous (n=43), mean (SD)
34.14 (8.33)
31.51 (7.69)
39.65 (12.97)
32.28 (10.25)
4.07 (2.75)
2.00 (2.16)
.68
.80
.08
.51
.18
.41
Bone (n=37), mean (SD)
33.81 (8.74)
31.22 (8.01)
39.84 (13.18)
32.00 (10.36)
4.39 (2.59)
2.07 (2.21)
Soft tissue (n=28), mean (SD)
34.29 (8.28)
31.89 (8.53)
35.46 (12.42)
31.57 (10.39)
3.42 (2.82)
2.41 (2.76)
.83
.74
.18
.87
.16
.59
Preprocedure narcotics
P
Final diagnosis
P
Analgesia
P
Biopsy type
P
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n Feature Article
interventions and therefore are surprised
by the relative discomfort of the biopsy
procedure. Conversely, older patients are
more likely to have undergone invasive
procedures and therefore may grade their
pain experience relative to those procedures.
Patients who had been taking narcotics
preprocedure had higher anxiety scores
than those who had not been taking them,
but only the difference in preprocedure
trait anxiety was statistically significant.
Interestingly, anticipated and experienced
pain were lower in patients who were taking preprocedure narcotics, although the
difference was not statistically significant. Furthermore, patients taking narcotics preprocedure tended to be less satisfied with the biopsy experience, although
this trend was not statistically significant.
Orthopedic oncologists and radiologists
should be aware that patients taking narcotics preprocedure have higher anxiety
levels preprocedure, and they may wish to
modify their clinical approach to address
this increased anxiety and improve the patient experience. In addition, because of
potential tolerance, patients taking narcotic pain medication at baseline may require
a higher dose or an alternative dosing nomogram.
Potential limitations of the study are
the enrollment of patients from 3 different
attending orthopedic surgeons with slightly different preprocedure patient counseling who underwent biopsy with 3 different musculoskeletal radiologists. To limit
variability, the radiologists used a uniform
consent form for the procedure. Additionally, the analgesia given to the cohort of
patients varied. Intravenous analgesics
were given by the nursing staff according
to a standardized protocol based on reported and perceived patient discomfort as
necessary. Many patients also were taking
narcotic pain medication preprocedure,
which may have affected the amount of
analgesia given.
Future studies could repeat the Spielberger State-Trait Anxiety Inventory
e224
several days after the procedure to determine whether the downward trend in trait
anxiety continues or if it increases as the
patient switches the focus of anxiety from
the procedure to the results. Also, studies
could investigate whether patient anxiety,
pain, and satisfaction are affected by the
use of a preprocedure supplemental video,21 intraprocedure music,14 or intraprocedure patient-controlled or age-directed
analgesia dosing.
Conclusion
This study presents the first evaluation
of patient pain, anxiety, and satisfaction
with needle biopsy. Clinicians can now
counsel their patients about the relatively
mild discomfort of the procedure, which
may decrease preprocedure anxiety. Additionally, clinicians should consider individualized dosing regimens for younger
patients and those taking narcotic pain
medication.
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