Communicating the Gynecologic Brachytherapy Experience (CoGBE): Clinician perceived benefits of a graphic narrative discussion guide

Published:January 19, 2023DOI:



      Many current radiotherapy patient education materials are not patient-centered. An interprofessional team developed Communicating the Gynecologic Brachytherapy Experience (CoGBE), a graphic narrative discussion guide for cylinder, intracavitary, and interstitial high-dose-rate (HDR) gynecologic brachytherapy. This study assesses perceived clinical benefits, usability, and anxiety-reduction of CoGBE.


      An electronic survey was sent to members of the American Brachytherapy Society. Participants were assigned to assess one of the three modality-specific CoGBE versions using a modified Systems Usability Scale (SUS), modified state-trait anxiety index (mSTAI), and Likert-type questions. Free response data was analyzed using modified grounded theory.


      Median modified SUS score was 76.3 (interquartile range [IQR], 71.3−82.5) and there were no significant differences between guide types. Median mSTAI was 40 (IQR, 40−43.3) for all guides collectively. The cylinder guide had a significantly higher median mSTAI than the intracavitary and interstitial guides (41.6 vs. 40.0 and 40.0; p = 0.04) suggesting the cylinder guide may have less impact on reducing anxiety. Most respondents reported that CoGBE was helpful (72%), would improve patient understanding (77%) and consultation memorability (82%), and was at least moderately likely to be incorporated into their practice (80%). Qualitative analysis themes included personalization and relatability (positive); generalizability (negative); illustrations (both).


      Clinicians rate CoGBE as usable with potential to reduce patient anxiety, especially with more invasive treatment modalities including intracavitary or interstitial high-dose-rate. CoGBE has the potential to improve patient-clinician communication for a wider range of patients due to its accessible, adaptable, and patient-centered design.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Brachytherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Matsuyama RK
        • Lyckholm LJ
        • Molisani A
        • Moghanaki D.
        The value of an educational video before consultation with a radiation oncologist.
        J Cancer Educ. 2013; 28: 306-313
        • Humphrey P
        • Bennett C
        • Cramp F.
        The experiences of women receiving brachytherapy for cervical cancer: A systematic literature review.
        Radiography (Lond). 2018; 24: 396-403
        • Kirchheiner K
        • Czajka-Pepl A
        • Ponocny-Seliger E
        • et al.
        Posttraumatic stress disorder after high-dose-rate brachytherapy for cervical cancer with 2 fractions in 1 application under spinal/epidural anesthesia: incidence and risk factors.
        Int J Radiat Oncol Biol Phys. 2014; 89: 260-267
        • Paulsson A
        • Braunstein SE.
        Patient communication prior to initial consultation for palliative radiotherapy.
        JCO. 2016; 34 (30–): 30
        • Long D
        • Friedrich-Nel HS
        • Joubert G.
        Patients’ informational needs while undergoing brachytherapy for cervical cancer.
        Int J Qual Health Care. 2016; 28: 200-208
        • Rainey LC.
        Effects of preparatory patient education for radiation oncology patients.
        Cancer. 1985; 56: 1056-1061
        • Canil T
        • Cashell A
        • Papadakos J
        • Abdelmutti N
        • Friedman AJ.
        Evaluation of the effects of pre-treatment education on self-efficacy and anxiety in patients receiving radiation therapy: a pilot study.
        J Med Imaging and Radiation Sci. 2012; 43: 221-227
        • Wynia MK
        • Osborn CY.
        Health literacy and communication quality in health care organizations.
        J Health Commun. 2010; 15: 102-115
        • Nielsen-Bohlman L
        • Panzer AM
        • Kindig DA
        Institute of Medicine (U.S.), Committee on Health Literacy.
        Health Literacy, Washington, D.C.2004
        • Berkman ND
        • Sheridan SL
        • Donahue KE
        • Halpern DJ
        • Crotty K.
        Low health literacy and health outcomes: an updated systematic review.
        Ann Intern Med. 2011; 155: 97-107
        • Yee LM
        • Silver R
        • Haas DM
        • et al.
        Association of health literacy among nulliparous individuals and maternal and neonatal outcomes.
        JAMA Network Open. 2021; 4e2122576
        • Stewart MA.
        Effective physician-patient communication and health outcomes: a review.
        CMAJ. 1995; 152: 1423-1433
        • Arnold J
        • Goodacre S
        • Bath P
        • Price J.
        Information sheets for patients with acute chest pain: randomised controlled trial.
        BMJ. 2009; 338: 541
      1. Radiology (ACR) RS of NA (RSNA) and AC of. brachytherapy. Available at Accessed November 16, 2022.

      2. Treatment Types - Gynecologic Cancers - RTAnswers. Available at Accessed November 16, 2022.

      3. What is Brachytherapy? American Brachytherapy Society, Reston, VA. Available at Accessed November 16, 2022.

      4. Cervical Cancer Radiation Therapy Cervical cancer radiation treatment. Available at Accessed November 16, 2022.

      5. Radiation Therapy for Endometrial Cancer. Available at Accessed November 16, 2022.

      6. Brachytherapy for cancer - NCI. Available at Accessed November 16, 2022.

      7. Brachytherapy for Cervix Cancer Treatment.
        Targeting Cancer. 2022; (Available at) (Accessed November 16)
      8. Patient Education - Brochures - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO). ASTRO. Available at Patient-Care-and-Research/Provider-Resources/Patient-Brochures. Accessed November 16, 2022.

        • Byun J
        • Golden DW.
        Readability of patient education materials from professional societies in radiation oncology: are we meeting the national standard?.
        Int J Radiat Oncol Biol Phys. 2015; 91: 1108-1109
        • Rooney MK
        • Sachdev S
        • Byun J
        • Jagsi R
        • Golden DW.
        Readability of patient education materials in radiation oncology-are we improving?.
        Pract Radiat Oncol. 2019; 9: 435-440
        • Samuel D
        • Vilardo N
        • Isani SS
        • Kuo DYS
        • Gressel GM.
        Readability assessment of online gynecologic oncology patient education materials from major governmental, non-profit and pharmaceutical organizations.
        Gynecol Oncol. 2019; 154: 616-621
        • Weiss BD
        Health Literacy: A Manual for Clinicians.
        Chicago, IL: American Medical Association Foundation. 2003: 31-35
      9. Clear & Simple. National Institutes of Health (NIH). Available at Accessed August 21, 2020.

      10. Arya R, Ichikawa T, Callender B, et al. Communicating the External Beam Radiation Experience (CEBRE): perceived benefits of a graphic narrative patient education tool. Pract Radiat Oncol 2019.

        • Perni S
        • Rooney MK
        • Horowitz DP
        • et al.
        Assessment of use, specificity, and readability of written clinical informed consent forms for patients with cancer undergoing radiotherapy.
        JAMA Oncol. 2019; e190260
        • Shoemaker SJ
        • Wolf MS
        • Brach C.
        Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
        Patient Educ Couns. 2014; 96: 395-403
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Harris PA
        • Taylor R
        • Minor BL
        • et al.
        The REDCap consortium: Building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208
        • Brooke J.
        SUS: a “quick and dirty”usability scale.
        in: Jordan P.W. Thomas B. Weerdmeester B.A. McClelland I.L. Usability Evaluation In Industry. CRC Press, Earley, United Kingdom1996: 189-194
        • Marteau TM
        • Bekker H.
        The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI).
        Br J Clin Psychol. 1992; 31: 301-306
        • Watling CJ
        • Lingard L.
        Grounded theory in medical education research: AMEE Guide No. 70.
        Med Teach. 2012; 34: 850-861
        • Houts PS
        • Bachrach R
        • Witmer JT
        • Tringali CA
        • Bucher JA
        • Localio RA.
        Using pictographs to enhance recall of spoken medical instructions.
        Patient Educ Couns. 1998; 35: 83-88
        • Houts PS
        • Witmer JT
        • Egeth HE
        • Loscalzo MJ
        • Zabora JR.
        Using pictographs to enhance recall of spoken medical instructions II.
        Patient Educ Couns. 2001; 43: 231-242
        • Houts PS
        • Doak CC
        • Doak LG
        • Loscalzo MJ.
        The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence.
        Patient Educ Couns. 2006; 61: 173-190
        • DeTora L
        • Cressman J
        Graphic Embodiments.
        (editors) Leuven University Press, Leuven2021
        • Williams I.
        Autography as auto-therapy: psychic pain and the graphic memoir.
        J Med Humanit. 2011; 32: 353-366
        • Sanders JC
        • Showalter TN
        • Ouhib Z
        • et al.
        Safety practices and opportunities for improvement in brachytherapy: a patient safety practices survey of the American Brachytherapy Society membership.
        Brachytherapy. 2020; 19: 762-766
        • Martell K
        • Doll C
        • Barnes EA
        • Phan T
        • Leung E
        • Taggar A.
        Radiotherapy practices in postoperative endometrial cancer: a survey of the ABS membership.
        Brachytherapy. 2019; 18: 741-746
        • Brand A
        • Crayen C
        • Hamann A
        • et al.
        Informed Consent before coronary angiography and percutaneous coronary intervention from the patient's perspective: a picture is worth a thousand words.
        Int J Cardiol Heart Vasc. 2022; 41101076
        • Durand M-A
        • Yen RW
        • O'Malley AJ
        • et al.
        What matters most: randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata.
        Cancer. 2021; 127: 422-436
        • Alkureishi MA
        • Johnson T
        • Nichols J
        • et al.
        Impact of an educational comic to enhance patient-physician-electronic health record engagement: prospective observational study.
        JMIR Hum Factors. 2021; 8: e25054
        • Mahantshetty U
        • Lavanya G
        • Grover S
        • Akinfenwa CA
        • Carvalho H
        • Incidence Amornwichet N.
        Treatment and outcomes of cervical cancer in low- and middle-income countries.
        Clin Oncol (R Coll Radiol). 2021; 33: e363-e371