G. Lee1,2, T. Rosewall1,2, C. Robertson1, X. Y. Ye1, A. Liu1, H. Mohseni1, Y. M. Tsang1,2, and J. M. Croke1,2; 1Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada, 2Department Radiation Oncology, University of Toronto, Toronto, ON, Canada
Purpose/Objective(s): The use of medical tattoos in radiation therapy (RT) is traditional practice to ensure daily treatment setup and positioning accuracy. Past studies have shown the negative psychosocial impact of tattoos on patients with breast cancer. However, in the current era of tattoo culture where it is also viewed as body art and self-expression, we examined patient and provider perceptions of medical tattooing in breast cancer RT. Materials/
Methods: Consecutive English-speaking patients undergoing whole breast RT using tattoos were asked to complete surveys after CT simulation (S1) and 2 weeks post-treatment completion (S2). S1 included social/demographic questions, and questions pertaining to stress, pain, anxiety, tattoo visibility, and satisfaction with RT tattoos (0 none-10 highest). S2 included similar visibility and satisfaction questions, the patient’s perceptions on tattoos, and their preference for alternative non-permanent marks. Provider surveys assessed CT simulation radiation therapists (CT-RTT) and treatment therapists (Tx-RTT) satisfaction and perceptions on tattoos. All surveys allowed free text comments about tattoos. Descriptive statistics and thematic analysis were performed. Results: From Nov 2023 - Mar 2024, 32 patients were approached, 30 completed S1 (94%) and 24 (75%) completed both. Median age was 60 years (range 39-82).During tattooing, patients commonly experienced pain (66%), stress (41%) and anxiety (34%). At pre-RT, 38% of respondents focused on getting through treatment and perceived tattoos as necessary for accurate RT. Tattoos were small and insignificant to 33% of patients. Post-RT, 13% saw tattoos as reminders of cancer. Those with adverse cosmesis from surgery or baseline freckles/brown spots (29%) felt less bothered by tattoos. While patients were satisfied with tattoos (median 9; IQR:8-10), if given alternative non-permanent options, only one patient (with existing body art) “definitively” would choose tattoos, and 25% felt tattoos were imposed on them with no alternative option presented. One patient with body art saw medical tattoos as a need for RT, not their choice, “I have tattoos, but those tattoos are my choice”. All Tx-RTTs (n=25) felt satisfied using tattoos for setup, but 8% noted difficulty distinguishing them on freckled skin. 94% (30/32) of CT-RTT responses indicate satisfaction with the tattooing process; 6% disliked needles and did not enjoy tattooing patients. Conclusion: Patients treated with breast RT perceived tattoos as a necessity for accurate daily setup, but most would prefer non-permanent options if given a choice. Medical tattoos should not be presumed acceptable in patients with existing body art. Providers were generally satisfied with tattoos for treatment. Work is ongoing to explore alternative non-permanent marks to facilitate shared decision-making in marking options used for RT treatment.
