Discussion

This study found that 44% (95% CI 29–59%) of people with HNC reported clinically meaningful state anxiety (≥41 on the STAI Y-6) immediately before their first thermoplastic mask fabrication and that the STAI Y-6 could be administered within a busy pre-treatment workflow. A recruitment rate of 93%, a questionnaire completion rate of 100% and a median completion time of under four minutes indicate that people with HNC are both willing and able to engage with brief anxiety screening at this point in the pathway and that the instrument adds little to appointment time. These indicators establish acceptability and feasibility of administration rather than clinical utility: they do not demonstrate that screening changes management, nor that services would have the capacity to respond to a positive result. Establishing that link is a necessary next step and requires a study in which screening is embedded within a defined care pathway.

Our prevalence estimate sits toward the upper end of published figures. In a cross-sectional study by Nixon et al. (2018), 26% of 77 people with HNC reported moderate-to-severe anxiety during mask fabrication when screened with a modified distress thermometer. ^{Reference Nixon, Cartmill and Turner4} A subsequent prospective study by Nixon et al. (2019) using the full 20-item STAI (Form Y-1) identified 36% with moderate-to-severe anxiety at simulation. ^{Reference Nixon, Brown and Pigott9} More recently, Burns et al. (2022) found that 43% met the threshold for clinically significant anxiety using the STAI Y-1 ≥40 across a multi-centre cohort. ^{Reference Burns, Campbell and French12} Because instruments (full STAI Y-1 vs. pro-rated STAI Y-6) and thresholds differ, direct numerical comparisons should be interpreted with caution; nonetheless, the consistency of elevated rates underscores the need for routine screening.

The timing of our assessment immediately before the first mask application likely captures a period of heightened anticipatory distress. Notably, the comparison study that measured anxiety during rather than before mask fabrication reported a somewhat lower rate, ^{Reference Nixon, Brown and Pigott9} raising the possibility that anticipatory ‘fear of the unknown’ peaks before the procedure begins and attenuates once patients experience the mask and find it tolerable; Burns et al. similarly described a declining anxiety trajectory across the treatment course. ^{Reference Burns, Campbell and French12} If anxiety is indeed highest in the anticipatory window, this strengthens the rationale for preparation delivered before the simulation appointment (VR rehearsal, video walkthroughs or structured verbal preparation) rather than reactive management once distress has already occurred. Because anxiety was measured at only a single time point, we cannot determine whether the level we observed represents a transient peak or a sustained elevation. Future studies should incorporate repeated assessments from referral through simulation to treatment completion.

The association between STAI Y-6 caseness and mask-specific anxiety (Q7; p = 0.025) may suggest that the STAI Y-6 captures anxiety that is at least partly linked to the mask experience, rather than solely to generalised treatment-related distress. This interpretation is supported by the absence of an association with broader treatment anxiety (Q8; p = 0.41). However, with 39 participants and several cells containing fewer than five observations, the comparison is underpowered, and the finding should be regarded as hypothesis-generating rather than established; replication in a larger sample is required before the STAI Y-6 could be relied upon as a proxy for mask-specific anxiety.

The association with interest in VR (Q9; p = 0.027) also warrants careful interpretation. Across the full sample, 41% expressed interest in a guided VR session, 41% declined and 18% were unsure. The proportion expressing interest was virtually identical (41%) across anxiety groups; the difference between groups was driven by uncertainty. Among those with elevated anxiety, 35% responded ‘not sure’ compared with only 5% below the threshold, while those below the threshold were more likely to decline outright (55% vs. 24%). This suggests that people with higher anxiety may be open to novel preparatory tools but lack sufficient information or confidence to commit. Targeted education about VR-based preparation could help bridge this gap, although with only one ‘not sure’ response in the lower-anxiety group, this pattern requires confirmation in a larger sample.

These VR-related questions were included specifically to gauge patient receptivity ahead of a planned (and subsequently completed) interventional study. The existing evidence base provides a rationale: Wang et al. (2022) demonstrated that a VR simulation of the linear accelerator environment improved patient knowledge and self-efficacy prior to RT, ^{Reference Wang, Casto, Luh and Wang22} while a systematic review of seven interventional studies involving 376 adults found that VR-based educational sessions consistently improved treatment knowledge, with more variable but generally favourable effects on anxiety. ^{Reference Grilo, Almeida and Rodrigues21} However, none of these studies focused specifically on mask-related anxiety in HNC. Our finding that 41% of participants expressed interest in VR, with a further 18% uncertain, suggests sufficient receptivity to justify a feasibility trial of VR-based mask familiarisation in this population.

Persistently elevated anxiety has been associated with malnutrition and cachexia, ^{Reference Gosak, Gradišar, Rotovnik Kozjek and Strojan30} greater psychiatric contribution to opioid prescribing after diagnosis, ^{Reference Henry, Alias and Frenkiel31} and disrupted treatment sessions, ^{Reference Clover, Oultram, Adams, Cross, Findlay and Ponman32} all of which can jeopardise loco-regional control. Beyond VR, a 2024 scoping review of publicly available patient education materials for immobilisation masks found that many resources were limited in scope and that materials produced by cancer foundations and organisations were the most likely to discuss coping strategies for mask anxiety. ^{Reference Wood, Holman and Nguyen33} A 2025 randomised controlled trial reported that a personalised open-face mask combined with styrofoam fixation improved patient comfort relative to a conventional perforated head, neck and shoulder mask without compromising set-up accuracy, although the accompanying reduction in anxiety was a non-significant trend only. ^{Reference Yang, Li and Li34}

Given the small sample size, we deliberately omitted formal inferential testing of associations between anxiety scores and demographic or clinical variables. Descriptively, some patterns are nonetheless worth noting. Participants meeting the ≥41 threshold were on average five years younger than those below it (62.2 vs. 67.4 years), were slightly more likely to be female (29% vs. 23%) and more often reported a history of psychological disorder (35% vs. 23%); all 17 were receiving radical-intent treatment, whereas all four participants treated with palliative intent scored below the threshold. The direction of these differences is broadly consistent with the wider literature, in which female sex and pre-existing psychological morbidity have been associated with higher anxiety and mask anxiety in HNC, ^{Reference Pelland, Lagadec-Gaulin and Bahig8,Reference Nixon, Brown and Pigott9} although reported relationships with age have been less consistent. With only 39 participants, however, subdividing the sample across multiple strata would render any tests underpowered and inflate the risk of spurious findings, and none of these differences should be read as evidence of an effect. Larger, multi-centre cohorts are required before demographic or clinical factors can be examined robustly; a recent 512-patient study has begun this work by deriving a brief mask anxiety screening measure from multivariable predictors. ^{Reference Pelland, Lagadec-Gaulin and Bahig8}