This study aimed to evaluate patient satisfaction among patients with head and neck cancer that are undergoing VMAT Radiation Therapy The research focused on patient satisfaction of medical, nursing, and radiation technologist services. Moreover, correlations between patient satisfaction and quality of life (QoL) were explored, providing a more comprehensive understanding of patient experiences, including psychological factors under the scope of psycho- oncology.

Patient Demographics
The demographics of the participants revealed a predominance of male patients (73.3%) compared to females (26.7%). The majority of patients were over 62 years of age (51%) and had completed either primary (40%) or secondary (45.3%) education. Most participants were married or cohabiting (72%), and a large proportion (56%) were retired. These findings align with typical patient demographics for head and neck cancer, where advanced age and retirement are common due to the median onset age of the disease and the significant role that treatment can have on patients’ physical and cognitive functions.

Service Satisfaction
Patient satisfaction with medical services was overwhelmingly positive. High levels of satisfaction were reported regarding the behavior of the medical staff (98.6% rated as good or very good), information provided about disease progression (96%), and the guidance on treatment and lifestyle (94.7% and 96%, respectively). This high satisfaction level is crucial, as effective communication and support from medical professionals can significantly impact patient outcomes and adherence to treatment regimens.

Satisfaction with nursing services was similarly high. Participants reported excellent behavior (100%), service speed (100%), and communication (100%) from nursing staff. The support provided by nurses in addressing patient problems was highly appreciated, with 69.3% reporting extreme satisfaction. This suggests that nursing staff plays a critical role in patient care, providing not only medical but also emotional support, which is vital for patients undergoing challenging treatments for head and neck cancers.

Radiation therapists received uniformly positive evaluations across all measured dimensions. All participants reported good or very good behavior, service speed, communication, and interest from technologists (100%). This highlights the critical role of technologists in ensuring the smooth operation of diagnostic and therapeutic procedures, contributing to the overall patient experience.

The notable levels of trust (98.7%) and the desire to continue medical visits (98.7%) highlight the importance of fostering strong, supportive doctor-patient relationships, which are essential for effective care and patient compliance.

Trust in nursing and radiation therapists staff was also very high (98.6% and 100% respectively), further underlining their importance in the healthcare team and indicate their significant impact on patient comfort and confidence in the treatment process.

Psychosocial Factors and Psychological Well-being
The data derived from the EORTC QLQ-C30 questionnaire, specifically from questions 21 to 24, provide insight into the emotional responses of patients with head and neck cancer across three different time points: before treatment, at the end of treatment, and three months post-treatment. These questions focus on four key emotional domains: tension, worry, irritability, and depression.

Emotional Responses Over Time
The results indicate a notable trend in the patients' emotional responses. Before treatment, a significant majority of patients reported low levels of emotional distress, with over 83.3% indicating they were "not at all" tense, irritable, or depressed, and slightly fewer (54.8%) reporting no worry. This suggests a relatively mild emotional burden before treatment. However, immediately after treatment, there was a noticeable increase in emotional distress, with fewer patients reporting no distress across all emotional domains. For instance, the percentage of patients who reported "not at all" tense decreased from 70% to 52%, and those reporting "not at all" worried dropped from 46% to 32%. This increase in distress is expected as patients face the physical and psychological challenges of cancer treatment. Three months after treatment, patients' emotional states showed improvement, with many returning to similar levels as before treatment. Although the number of patients reporting "not at all" tense, irritable, or depressed approached pre-treatment levels, there was a slight increase in mild worry, indicating some ongoing emotional burden post-treatment.

Despite the overall trend of increased emotional distress before and immediately after treatment, the emotional responses of these patients remain predominantly mild across all time points. Even at the peak of distress (right after treatment), the majority of patients report only mild or moderate levels of tension, worry, irritability, and depression. This consistent reporting of mild emotional distress, even in the face of a life-threatening disease, raises important questions regarding the accuracy and authenticity of these self-reported outcomes.

One potential explanation for these findings is that patients may be reluctant to acknowledge or express severe emotional distress, possibly due to the social stigma associated with mental health issues or a desire to appear resilient [23,24]. This reluctance might stem from an internal need to believe that they are coping well, as a part of psychological defense mechanism—a form of illness denial [25]. This phenomenon aligns with the psychological concept of defense mechanisms and the stages of grief described by Elisabeth Kübler-Ross. According to Kübler-Ross's model, denial is a common initial reaction to a life-threatening diagnosis, which might be reflected in these patients' reluctance to report severe emotional distress.

Moreover, this tendency to underreport emotional distress might be linked to the Theory of Cognitive Dissonance [26]. Patients may experience cognitive dissonance when their actual emotional state (which may be one of significant distress) conflicts with their desire to be perceived (by themselves and others) as strong and coping well [27,28]. To resolve this dissonance, they might downplay their emotional struggles, reporting them as less severe than they actually are [29].

Trust in the Procedure and Psycho-oncology Considerations
The results also raise questions about the trustworthiness of self-reported emotional distress in this patient population. If patients are consistently underreporting their emotional struggles, this could indicate a gap in the effectiveness of the current patient care model in oncology [30,31]. This gap might be further exacerbated by the possibility of patients not fully trusting the questionnaire as a tool for capturing their emotional state or feeling that their emotional struggles are less valid or important than their physical symptoms [31,32].

These observations are supported by existing literature in psycho-oncology, which suggests that cancer patients often struggle with acknowledging and articulating their emotional distress [33]. Psycho-oncological research indicates that patients with head and neck cancer, in particular, may experience alexithymia, a condition characterized by difficulty in identifying and expressing emotions [34,35,36]. This could contribute to the tendency of these patients to report lower levels of emotional distress, even when they are experiencing significant psychological challenges [37].

Further research in psycho-oncology has shown that the emotional well-being of cancer patients is crucial for their overall quality of life and treatment outcomes [38]. Studies suggest that patients who are engaged in psychological interventions, such as cognitive-behavioral therapy (CBT) or psychosocial support groups, often report better emotional and physical outcomes [39,40]. This emphasizes the importance of integrating comprehensive psycho-oncological care into the treatment plans of head and neck cancer patients.

However, the observed tendency to report only mild distress, despite the severity of the situation, suggests that current methods of assessing emotional well-being might not be entirely effective [41]. It raises the question of whether patients are receiving adequate psychological support and whether healthcare providers are fully aware of their patients' emotional needs.

Internal Consistency and Factor Analysis
The internal consistency of the service evaluation survey was commendable, with Cronbach's alpha values ranging from 0.900 to 0.946 for different subcategories. This indicates that the questionnaire is a reliable tool for assessing patient satisfaction across various dimensions of healthcare services. The exploratory factor analysis revealed a clear factor structure for each category, explaining substantial variance in: medical services (71.5%), nursing services (70%), technologist services (70%), and doctor-patient relationship (82.1%). These findings suggest that each category of the questionnaire robustly captures distinct aspects of service quality, providing a detailed and nuanced understanding of patient experiences.

Correlation Analysis
The analysis revealed statistically significant correlations between physical activity and satisfaction with nursing services (r = 0.234, p = 0.043) and the doctor-patient relationship (r = 0.238, p = 0.040). This suggests that patients who maintain higher levels of physical activity might perceive more positively the care they receive from nurses and their relationship with doctors. Additionally, there were significant negative correlations between pain and satisfaction with medical services (r = -0.238, p = 0.040), and between appetite loss and the doctor-patient relationship (r = -0.246, p = 0.033). These findings highlight that higher levels of discomfort or adverse symptoms can negatively impact patient satisfaction, which underscores the importance of effective symptom management in enhancing patient experiences.

The remarkably high percentages of patient satisfaction observed across all categories in this study are noteworthy and warrant deeper consideration. While it is encouraging to see such positive feedback, these findings raise several important questions about the underlying factors contributing to this overwhelming satisfaction.

Firstly, one must consider the possibility of biased responses. Patients might feel compelled to provide favorable feedback due to the nature of their relationship with healthcare providers or because or due to the challenges of a potentially life-threatening condition [42,43]. This raises the question: Are patients genuinely satisfied, or are they being exceptionally polite and appreciative, perhaps as a coping mechanism in facing a serious illness?

Secondly, the psychological impact of confronting a cancer diagnosis could play a significant role in how patients perceive and report their satisfaction. The fear and uncertainty associated with cancer might lead patients to value any form of care highly, creating a predisposition towards positive evaluations [44]. On a psychological level, some patients may have reached a stage of acceptance, leading to a heightened sense of appreciation for their care team and the services provided, regardless of their actual quality [45].

Another dimension to consider is the patients' understanding of their condition and treatment. The complexity of medical information and treatment protocols in oncology might leave patients feeling disoriented or unable to fully grasp the details of their care [46,47]. Consequently, they might express satisfaction simply because they lack the clarity or knowledge to critically evaluate the services they receive.

These observations suggest that there might be a need for further investigation into the authenticity of patient satisfaction reports. To ensure that feedback accurately reflects patient experiences, more nuanced and context-sensitive approaches to patient satisfaction surveys should be implemented [48]. Additionally, both patients and medical staff could benefit from appropriate training. For patients, enhanced education on their condition and treatment options could empower them to provide more informed feedback [49]. For healthcare providers, training in psychological and ethical aspects of patient care could help them better understand and support their patients' emotional and cognitive states during treatment [50].

In conclusion, while the high satisfaction rates are promising, they also highlight the importance of critically examining and understanding the factors that contribute to such positive evaluations. Addressing these questions through further research and training could lead to more meaningful insights into patient experiences and ultimately enhance the quality of care provided in head and neck cancer.