Cancer Patients Undergoing Radiotherapy Treatment Research Articles

Impact of declared wildfire disasters on survival of lung cancer patients undergoing radiation treatment.

302 Background: In recent years, the frequency and severity of climate-driven disasters, including wildfires, have posed significant challenges to the delivery of oncology care. Among various treatment modalities, radiotherapy stands is particularly vulnerable due to its reliance on consistent electrical power and daily treatment sessions. For patients receiving radiation treatment for locally advanced non-small cell lung cancer (NSCLC), even minor disruptions in treatment continuity have been shown to have a detrimental impact on overall survival. Methods: Patients undergoing definitive radiotherapy for nonoperative locally advanced NSCLC between 2004 and 2019 were selected from the hospital-based National Cancer Database, which captures approximately 70% of all cases in the United States. Disaster declarations were identified from the Federal Emergency Management Agency from 2004 to 2019. Exposed patients (n = 1,419) were defined as those who had a wildfire disaster declared in the county of the treatment facility during the exposure window (within 12 weeks of radiotherapy start date), while unexposed patients (n = 226,719) had no disasters declared within the same timeframe. Overall survival was defined as age when radiation therapy started and age of death, last contact, or study end. Cox proportional hazards was used for estimating hazard ratios (HRs) adjusted for sex, region, health insurance, comorbidities, facility type, lymph node involvement and concomitant chemotherapy. Survival estimates were weighted by the inverse of the probability of remaining uncensored at the end of the exposure window. Results: A total of 228,138 individuals were included in the study. Our preliminary data shows that exposed individuals were more likely to receive treatment in facilities located in western states, have no comorbidities, and have private health insurance coverage. Individuals whose facility had a wildfire disaster declared within 12 weeks of the radiation start date had worse overall survival (HR = 1.03; 95% Confidence Interval = 1.01, 1.06) compared to unexposed individuals with sensitivity analyses pending. Conclusions: Our study highlights the vulnerability of individuals undergoing radiotherapy for NSCLC to the hazards posed by wildfires. These findings underscore the urgent need for oncology institutions to prioritize the climate adaptation efforts aimed at safeguarding the needs of this vulnerable population.

Fibrin hydrogels fortified with FGF-7/10 and laminin-1 peptides promote regeneration of irradiated salivary glands

Ionizing radiation, commonly used for head and neck cancer treatment, typically damages the salivary glands, resulting in hyposalivation. The development of treatments to restore this lost function is crucial for improving the quality of life for patients suffering from this condition. To address this clinical need, we have developed an innovative hydrogel by chemically conjugating laminin-1 peptides (A99 and YIGSR) and growth factors, FGF-7 and FGF-10, to fibrin hydrogels. Our results demonstrate that FGF-7/10 and laminin-1 peptides fortified fibrin hydrogel [enhanced laminin-1 peptides fibrin hydrogel (Ep-FH)] promotes salivary gland regeneration and functionality by improving epithelial tissue organization, establishing a healthy network of blood vessels and nerves, while reducing fibrosis in a head and neck irradiated mouse model. These results indicate that fibrin hydrogel-based implantable scaffolds containing pro-regenerative signals promote sustained secretory function of irradiated salivary glands, offering a potential alternative treatment for hyposalivation in head and neck cancer patients undergoing radiation treatment. These unique findings emphasize the potential of fibrin hydrogel-based implantable scaffolds enriched with pro-regenerative signals in sustaining the secretory function of irradiated salivary glands and offer a promising alternative treatment for addressing hyposalivation in head and neck cancer patients undergoing radiation therapy. Statement of significanceRadiation therapies used to treat head and neck cancers often result in damaged salivary gland, leading to severe dryness of the oral cavity. In this study, we engineered FGF-7 and FGF-10 and immobilized them into L1p-FH. The resulting hydrogel, Ep-FH, restored irradiated salivary gland functionality by enhancing epithelial tissue organization, promoting the development of a healthy network of blood vessels and nerves as well as reduction of fibrosis.

Circulating cell-free methylated DNA reveals tissue-specific, cellular damage from radiation treatment.

Radiation therapy is an effective cancer treatment although damages to healthy tissues are common. Here we analyzed cell-free, methylated DNA released from dying cells into the circulation to evaluate radiation-induced cellular damages in different tissues. To map the circulating DNA fragments to human and mouse tissues, we established sequencing-based, cell-type specific reference DNA methylation atlases. We found that cell-type specific DNA blocks were mostly hypomethylated and located within signature genes of cellular identity. Cell-free DNA fragments were captured from serum samples by hybridization to CpG-rich DNA panels and mapped to the DNA methylation atlases. In a mouse model, thoracic radiation-induced tissue damages were reflected by dose-dependent increases in lung endothelial and cardiomyocyte methylated DNA in serum. The analysis of serum samples from breast cancer patients undergoing radiation treatment revealed distinct dose-dependent and tissue-specific epithelial and endothelial responses to radiation across multiple organs. Strikingly, patients treated for right-sided breast cancers also showed increased hepatocyte and liver endothelial DNA in the circulation indicating the impact on liver tissues. Thus, changes in cell-free methylated DNA can uncover cell-type specific effects of radiation and provide a readout of the biologically effective radiation dose received by healthy tissues.

Investigation of the radioprotective properties of Zingerone, Ibuprofen, and Sulfasalazine against neutron radiation damage

Nuclear radiation (neutron, gamma X rays, etc.) is widely used in power generation, industry, medicine, research, and agriculture. Exposure to ionizing or indirect ionizing radiation can cause mutagenetic cell death depending on the dose and duration. It is important to reduce the carcinogenesis of cancer patients undergoing radiotherapy treatment and people working in radiation fields. Neutrons have wide applications in neutron activation analysis (NAA), neutron capture therapy (NCT), neutron radiography (NR), neutron capture, neutron conversion doping (NTD) sample irradiation, and neutron diffraction (ND). In these applications, protective substances are needed to stop the neutrons from entering the body and to reduce their effects. In this work, the use of zingerone, ibuprofen, and sulfasalazine compounds as active ingredients in a neutron protective drug was investigated. Some important neutron attenuation parameters such as an effective removal cross section, mean free path, half-value layer, and transmission number were theoretically calculated with the Monte Carlo simulation GEANT4 code for fast and epithermal neutrons.The 241Am-Be fast neutron source and a BF3 gaseous detector were used to determine the neutron absorption ability of all of the samples. All of the results were compared with paraffin, which has a good shielding capacity. According to the results, it was found that every examined sample had a fast and epithermal neutron absorption capacity. It reported that the dose amount from the source was absorbed by the samples at rates of 33.37% (DAI1), 34.85% (DAI2), and 34.21% (DAI3). It was determined that the DAI2 sample in particular had a high absorption ability ratio compared to other samples. Because this sample have high hydrogen content than others samples. So, it was shown that these compounds can be used as active substances to make a radioprotective drug.

An 8-week exercise study to improve cancer treatment related fatigue and QOL among African American breast cancer patients undergoing radiation treatment: A pilot randomized clinical trial

Cancer treatment related fatigue (CTRF) is one of the most debilitating side effects of adjuvant radiation therapy (RT). Several studies have found that physical activity (PA) may be an effective intervention to decrease fatigue and enhance QOL in cancer survivors. The primary objective of the PEDLAR study is to test the feasibility of an easily administered 8-week structured moderate-intensity PA intervention, delivered concurrently with RT, in reducing CTRF and improving health-related QOL among African-American breast cancer patients. This study is also designed to provide pilot data on the acceptability and adherence of PA interventions in African-American women with breast cancer. It is a prospective, 2-arm, 8-week feasibility trial. Participants are randomized to either a structured, moderate-intensity aerobic training exercise regimen concurrent with radiotherapy or a control group. Participants in intervention group reported high satisfaction with exercise and adherence was >75% for exercise sessions. African-American breast cancer patients in a moderate-intensity 75 min/wk aerobic exercise intervention had marginally lower fatigue at 8-wk follow-up compared to baseline. The control group participants had marginally higher fatigue at 8-wk follow-up compared to baseline. Participants in the intervention group reported slightly better quality of life at 8-wk follow-up compared to baseline (P = 0.06).

EFFECTIVENESS OF STRUCTURED EXERCISE PROTOCOL IN BREAST CANCER PATIENTS – PRE AND POST TEST DESIGN

Title : “EFFECTIVENESS OF STRUCTURED EXERCISE PROTOCOL IN BREAST CANCER PATIENTS – PRE AND POST TEST DESIGN.”
 Background: Post-operative breast cancer patients undergoing radiotherapy treatment shows complications like reduced shoulder ROM, and reduced function of upper extremity. Physiotherapy plays an important role in prevention and treatment of such complications.
 Methodology: Interventional study was done on 20 Breast cancer women undergoing Radiotherapy treatment in Dr. Vikhe Patil Memorial Hospital, Ahmednagar. Convenient sampling method was used. The Self Confidence was assessed using Rosen Berg Self Esteem Scale, ROM (Goniometer) and pectorals tightness (Plastic transparent right angle scale).
 Result: When shoulder Joint ROM was compared between 1st day with 3rd week for Flexion (p= 0.002), For Extension, Internal and External rotation (p?0.0001), Abduction (p=0.0003) showed significant improvement in extensibility. Similarly, for pectoral tightness (p?0.0001) showed significant improvement in extensibility. For Self-Confidence (p?0.0001) showed extreme improvement.
 Conclusion: This study concludes that, there’s an effect of structured exercise protocol in improving ROM of shoulder joint, extensibility of pectoral muscle and Self-Confidence.
 Key Words: Breast Cancer, Self Confidence, Exercise Therapy.

Radiographers’ perception on the provision of psychosocial support for cancer patients

Abstract Introduction: Therapeutic radiographers are the first point of contact for cancer patients undergoing radiotherapy treatment and therefore have an important role in providing both physical and psychosocial support to these patients. This study aimed to evaluate therapeutic radiographers’ perception about their role in identifying and providing psychosocial support for patients receiving RT treatment. Method: The study used a cross-sectional, prospective research design. A self-designed questionnaire was distributed to all therapeutic radiographers (n = 26) working at a radiotherapy department in Malta. Results: A total of 21 therapeutic radiographers completed the questionnaire. All participants felt that the provision of psychological care was an important part of their role as therapeutic radiographers. The majority of the participants reported having the most confidence in giving treatment-related symptoms advice rather than psychological support. The most common barrier to providing psychological support was lack of training (95·2%), followed by the lack of an appropriate screening tool (85·7%), availability of private space to talk to patients (76·2%) and a lack of knowledge (61·9%). Conclusion: While most therapeutic radiographers believed that providing psychosocial support was an important aspect of their role, several barriers prevented them from fulfilling this role. Training, the introduction of a psychosocial screening tool and clear referral processes are recommended to improve radiotherapy service.

Current Status of Radiotherapy Services in Kenya

Purpose: Owing to the missing recent data regarding cancer case volumes in Kenyan hospitals since 2012, the aim of the study was to fill the gap by providing data for two hospitals in Nairobi, the post year 2012. The general situation of radiation oncology and recommendation for improvement of radiotherapy services in the country were also highlighted. Further assessment was to investigate and determine the relationship between age, different types of cancer, and gender for cancer patients undergoing radiotherapy treatment. Materials and Methods: A data compilation, analysis, and evaluation process were conducted at two cancer treatment centers in Kenya followed by an assessment of radiotherapy cancer treatment facilities in the country. The number of the patients treated for cervical, breast prostate, esophagus, rectum, and lung cancer against their ages and gender were also compiled for assessment. Results: The number of cancer patients treated by radiotherapy continuously increased annually and he trends of the graphs in both centers were similar. Cervical cancer was the most common cancer treated by radiotherapy at the two centers, followed by breast and prostate cancer. Different types of cancer assessed were dependent on age and that cancer appeared at younger ages in female cervical and breast cancer patients as opposed to the male prostate cancer. Conclusion: The results indicate a continuous annual increase in cancer patients treated by radiotherapy in Kenya radiotherapy centers. The increase may be attributed to the rising population, limited access to cancer awareness, and the growing adoption of unhealthy lifestyles, among other factors. Female cervical and breast cancer patients contracted the disease at younger ages (46 - 50 years) compared to the male prostate cancer patients with a mean age of 61 - 65 years. Socio-economic factors, the organization of healthcare systems, and a limited workforce have been identified as some of the barriers to the provision of proper radiotherapy services in the country.

A feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment

A feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment

A feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment

ObjectiveWe conducted a feasibility trial of acupuncture in cancer patients undergoing radiotherapy treatment. The trial included training radiographers to deliver acupuncture within patients’ routine NHS care. MethodsMixed methods pragmatic randomized parallel-group exploratory feasibility trial comparing standard care to standard care plus acupuncture. ResultsMost aspects of the research design and acupuncture intervention were acceptable to the 101 participants. Participants’ valued the opportunity to receive acupuncture within their NHS care, perceived the treatment as eliciting a number of beneficial effects, and had a positive impact on their NHS cancer treatment. However, quantitative analysis of outcome measure data revealed no consistent significant differences between those receiving standard care and those receiving standard care plus acupuncture. ConclusionIt is feasible to implement acupuncture in a busy radiotherapy unit provided by specially trained radiographers. The methodology employed appears acceptable for the evaluation of acupuncture for radiotherapy patients.

Psychiatric comorbidities and quality of life in breast cancer patients undergoing radiation treatment: Risk and protective factors.

The primary goal was to evaluate the prevalence of psychiatric comorbidities and changes in psychological distress levels among breast cancer patients receiving radiotherapy (RT). The secondary goal was to determine risk and protective factors for psychiatric comorbidities of these patients. From June 2018 to November 2019, patients were recruited from the hospital, Department of Psychiatry. Patients completed baseline surveys after seeing their radiation oncologist and prior to the first treatment, which was scheduled to take place within 7 days (visit 1, baseline); visit 2 occurred within 7 days after RT completion, and visit 3 occurred at 6 weeks after RT completion. A total of 99 patients participated in the study at visit 1; 56 patients completed the study through visit 3. Although changes in psychiatric comorbidities and overall quality of life were observed in patients with breast cancer prior to, during, and after RT, the differences were not significant among visits. Patients diagnosed with psychiatric comorbidities after RT had exhibited risk factors at previous visits, including preexisting psychiatric comorbidities, functional deterioration, and more severe symptoms related to breast cancer. Based on the results, the psychological characteristics of optimism and resilience can be considered as protective factors for psychiatric comorbidities. The results suggest that early detection and follow-up of psychological distress and poor quality of life at the onset of RT are of paramount importance, and that psychosocial interventions to enhance protective factors (optimism and resilience) may be helpful.

Factors affecting anxiety and depression in young breast cancer survivors undergoing radiotherapy.

This study examined anxiety and depression, and their relationship with symptom assessment, uncertainty, social support, and stress in young breast cancer patients receiving radiotherapy. This is a descriptive quantitative study. The participants were 126 patients under 50 years of age with breast cancer undergoing radiotherapy. The anxiety and depression levels were higher among those who were married (t=-2.318, p=.022), non-religious (t=4.510, p=.005), and had a higher monthly income (F=2.840, p=.041). The hierarchical regression analysis model included symptom assessment, uncertainty, social support, and stress, and accounted for about 49% of the variance in anxiety and depression (F=7.688, p<.001). Additionally, uncertainty (β=0.304, p=.001) and stress (β=0.308, p=.001) were significant predictors of anxiety and depression. Based on the results of this study, nursing interventions are needed to reduce uncertainty and stress in order to reduce anxiety and depression in young breast cancer patients undergoing radiation treatment.

Modeling Dose-Function Response and Toxicity Pathways in Non-Small Cell Lung Cancer Patients Undergoing Radiation Treatment

Modeling Dose-Function Response and Toxicity Pathways in Non-Small Cell Lung Cancer Patients Undergoing Radiation Treatment

Effects of exercise therapy in cancer patients undergoing radiotherapy treatment: a narrative review.

Despite its beneficial effects, radiotherapy still results in a range of side effects that negatively impact quality of life of patients. Exercise has been shown to counteract the side effects induced by cancer treatment. This narrative review aims to provide an up-to-date review of the effects of an exercise intervention in cancer patients during radiotherapy. A literature search was performed on PubMed to identify original articles that evaluated the effects of an exercise programme to alleviate treatment-related side effects in cancer patients undergoing radiotherapy with or without other cancer treatments. Benefits related to exercise training have been shown in breast, prostate, rectal, lung, head and neck cancer patients undergoing radiotherapy. Therefore, exercise should be considered as a concurrent treatment alongside radiotherapy to alleviate treatment-related side effects and facilitate effective recovery. Due to the onset and progress of treatment-related side effects throughout radiotherapy, a regular clinical evaluation seems strongly advisable in order to continuously adapt the exercise programme depending on symptoms and side effects. An exercise professional is needed to personalize exercise training based on the medical condition and tailor it throughout the intervention according to progress and the patient’s medical status. Future studies are needed to confirm the potential benefits of exercises observed on treatment-related side effects. Furthermore, because of the narrative design of this study, a systematic review is required to evaluate the strength of the evidence reported.

Implementation of a Protocol to Increase Gastrostomy Tube Placement for Head and Neck Cancer Patients Undergoing Radiation Treatment

Implementation of a Protocol to Increase Gastrostomy Tube Placement for Head and Neck Cancer Patients Undergoing Radiation Treatment

Assessment of psychological distress among cancer patients undergoing radiotherapy in Saudi Arabia.

BackgroundCancer patients under psychological distress have reduced compliance with treatment and prolonged hospitalizations. Identifying cancer patients who may be more likely to suffer from psychological distress over the disease trajectory is essential to targeting the proper interventions and providing the best care. In this descriptive cross-sectional study, we aim to assess the levels of emotional and physical distress, depressive symptoms, and social concerns of cancer patients undergoing radiotherapy treatment in Saudi Arabia.MethodsA total of 148 cancer patients undergoing radiotherapy from five different public tertiary-level hospitals in Saudi Arabia participated in this study. The survey was conducted by a trained researcher from November 2015 through April 2016. The Psycho-Oncology Screening Tool was used to identify levels of distress of cancer patients undergoing radiotherapy. Emotional and physical distress, depressive symptoms, and social concerns in receiving psychosocial services were assessed.ResultsThe findings show above average levels of physical and emotional distress was (342.07±78.9) and social concerns was (7.27±1.68). Age was a significant predictor of psychological distress and in social concerns (P<0.05). Marital status and employment status emerged as significant predictors of depressive symptoms and social concerns (<0.05), (P<0.001), respectively. The patients’ type of cancer was significantly associated with the level of physical distress, emotional distress, and depressive symptoms (P<0.05).ConclusionCancer patients undergoing radiotherapy displayed above-average levels of distress. This may have significant implications on their adherence for treatment and patient outcomes. Routine screening and support services or psychosocial care for patients are warranted among cancer patients undergoing radiotherapy.

Patch-based lung ventilation estimation using multi-layer supervoxels

Patch-based approaches have received substantial attention over the recent years in medical imaging. One of their potential applications may be to provide more anatomically consistent ventilation maps estimated on dynamic lung CT. An assessment of regional lung function may act as a guide for radiotherapy, ensuring a more accurate treatment plan. This in turn, could spare well-functioning parts of the lungs. We present a novel method for lung ventilation estimation from dynamic lung CT imaging, combining a supervoxel-based image representation with deformations estimated during deformable image registration, performed between peak breathing phases. For this we propose a method that tracks changes of the intensity of previously extracted supervoxels. For the evaluation of the method we calculate correlation of the estimated ventilation maps with static ventilation images acquired from hyperpolarized Xenon129 MRI. We also investigate the influence of different image registration methods used to estimate deformations between the peak breathing phases in the dynamic CT imaging. We show that our method performs favorably to other ventilation estimation methods commonly used in the field, independently of the image registration method applied to dynamic CT. Due to the patch-based approach of our method, it may be physiologically more consistent with lung anatomy than previous methods relying on voxel-wise relationships. In our method the ventilation is estimated for supervoxels, which tend to group spatially close voxels with similar intensity values. The proposed method was evaluated on a dataset consisting of three lung cancer patients undergoing radiotherapy treatment, and this resulted in a correlation of 0.485 with XeMRI ventilation images, compared with 0.393 for the intensity-based approach, 0.231 for the Jacobian-based method and 0.386 for the Hounsfield units averaging method, on average. Within the limitation of the small number of cases analyzed, results suggest that the presented technique may be advantageous for CT-based ventilation estimation. The results showing higher values of correlation of the proposed method demonstrate the potential of our method to more accurately mimic the lung physiology.

Engaging patients with radiation related skin discomfort in self-care.

Patients receiving radiation to the breast can suffer painful, moist desquamation of the axilla and inframammary fold. Intensity of skin reactions will vary with each individual and be dependent on the total dose of radiation, treatment volume, daily fraction size, energy and type of radiation, as well as other personal factors (Gosselin, 2010). Treatment-related skin reactions make it difficult for women to wear clothing and undergarments comfortably and to perform daily activities. InterDry AG is a textile dressing with an antimicrobial complex that wicks away excess moisture and reduces friction, itching, and burning. Despite showing highly beneficial properties, there is no current published evidence indicating the utility of InterDry Ag for radiation skin reactions. This project evaluated the potential utility of InterDry Ag dressing to relieve discomfort of skin reactions for breast cancer patients undergoing radiation treatment. A descriptive design was employed to better understand the effectiveness of InterDry Ag dressing in reducing side effects of radiation treatment of the breast for women. Twenty eligible participants consented to participate. A radiation oncology nurse evaluated its effect every five days, utilizing a skin assessment questionnaire developed by the nursing team from clinical observations. A personalized skin care regimen was developed with each patient's feedback. A trusting relationship was developed between the nurse and patient by building rapport that indicated nursing care support. Some women began sharing their emotional stressors with nurses, as well as the physical pain they were experiencing due to the skin reactions. This observation resulted in provision of additional resources for women and engaging them in self-care using a patient-centred approach.

Ensuring model validity in a feasibility study of acupuncture to improve quality of life in cancer patients undergoing radiotherapy treatment

IntroductionA feasibility study of acupuncture for quality of life in cancer patients is planned. The pragmatic randomised controlled trial will aim to assess the feasibility of training radiographers to administer acupuncture to their patients undergoing radiotherapy intended to cure their cancer. The preliminary phase covered in this paper aimed to develop the trial acupuncture intervention and ensure its model validity. MethodsA mixed methods approach will be adopted. Systematic review conducted examining the treatments administered in papers reporting acupuncture treatment for cancer patients. Subsequently, one-day workshop held with an acupuncture expert panel. Informed by the systematic review and their clinical expertise the expert panel devised and agreed the trial acupuncture intervention. ResultsThe acupuncture expert panel came to a consensus on the trial acupuncture intervention. Trial radiographers will treat patients for 30 min, with needles inserted for approximately 20 min of this time. The trial will employ a standard treatment protocol for constitutional symptoms (fatigue, hot flushes, mood problems, anxiety, depression, and sleep problems) consisting of non traditional ASAD (anxiety, sickness and dyspnoea) acupoints, LI4, LR3, SP6 and ST36. Additional acupoints can be utilised for nausea/vomiting and pain. Guidelines on safe practice were also agreed. ConclusionsFew clinical trials of acupuncture, and complementary medicine interventions generally, document details of the process by which they ensured the model validity of their trial intervention. It is recommended that researchers in acupuncture, and other forms of complementary medicine, adopt appropriate methodological approaches to ensure model validity.

Acupuncture for cancer patients undergoing radiotherapy: Protocol for a programme of research

IntroductionCancer patients experience a range of symptoms associated with their cancer and its treatment. Research suggests that acupuncture delivered under trial conditions may be an effective intervention for some such problems. This paper reports a protocol for a research programme to assess the feasibility of implementing and evaluating acupuncture embedded in the radiotherapy service of an academic medical centre.The aims of the study are to examine the feasibility of acupuncture being delivered within the radiotherapy department by specially trained therapy radiographers when patients attend for treatment. The programme will culminate in a feasibility randomised controlled trial: Acupuncture for cancer patients undergoing Radiotherapy Treatment (ART). MethodsThe programme will use multiple methods: a systematic review and quality evaluation of the literature; expert consensus on model validity of the acupuncture intervention; implementation of a customised training course in acupuncture for therapy radiographers. The programme will culminate in a feasibility randomised clinical trial.ART will investigate aspects of the feasibility of a possible definitive clinical trial of acupuncture. Aspects to be investigated include processes, resources, interventions, procedures, model validity and safety of the acupuncture intervention, and quantitative and qualitative patient outcomes, in the UCLH radiotherapy department. Discussion100 cancer patients will be recruited to the clinical trial. Quantitative outcomes include the EORTC QLQ-C30, Multidimensional Fatigue Inventory, Memorial Symptom Assessment Scale, and EQ-5D-5L. Qualitative telephone interviews will be conducted with patients and stakeholders until data saturation.