Abstract
Malnutrition is a common condition in cancer patients which is usually associated with functional limitations, as well as increased morbidity and mortality. Based on the support of the young sections of Italian Association of Medical Oncology (AIOM), Italian Association of Radiotherapy and Clinical Oncology (AIRO) and Italian Society of Surgical Oncology (SICO) merged into the NutriOnc Research Group, we performed a multidisciplinary national survey with the aim to define the awareness of nutritional issues among healthcare professionals delivering anticancer care. The questionnaire was organized in four sections, as follows: Knowledge and practices regarding Nutritional Management of cancer patients; Timing of screening and assessment of Nutritional Status; Nutritional Treatment and prescription criteria; Immunonutrition and educational topics. The modules focused on esophagogastric, hepato-bilio-pancreatic and colorectal malignancies. Overall, 215 physicians completed the survey. As regards the management of Nutritional Status of cancer patients, many responders adopted the ERAS program (49.3%), while a consistent number of professionals did not follow a specific validated nutritional care protocol (41.8%), mainly due to lack of educational courses (14.5%) and financial support (15.3%). Nearly all the included institutions had a multidisciplinary team (92%) to finalize the treatment decision-making. Cancer patients routinely underwent nutritional screening according to 57.2% of interviewed physicians. The timing of nutritional assessment was at diagnosis (37.8%), before surgery (25.9%), after surgery (16.7%), before radiochemotherapy (13.5%) and after radiochemotherapy (7%). Most of the responders reported that nutritional status was assessed throughout the duration of cancer treatments (55.6%). An important gap between current delivery and need of nutritional assessment persists. The development of specific and defined care protocols and the adherence to these tools may be the key to improving nutritional support management in clinical practice.
Keywords: clinical nutrition, cancer, malnutrition, nutritional assessment, survey
Acknowledgments
The authors thank Barbara Borlotti Amico (Nestlè Health Science) and Iside Morabito (Isi Events) for support, Mariateresa Cirillo for graphic design. The authors affiliated to the IRCCS Istituto Tumori “Giovanni Paolo II” in Bari are responsible for the views expressed in this article, which do not necessarily represent the Institute.
Contributor Information
NutriOnc Research Group:
Silvia Sofia, Marco Milone, Benedetto Ielpo, Maria Teresa Mita, Silvia Ministrini, Mario Giuffrida, Roberta Tutino, Caterina Baldi, Giampaolo Perri, Anna Stella Lippolis, Chiara Marafante, Giusy Giannandrea, Marco Vito Marino, Letizia Laface, Salomone Di Saverio, Luca Aldrighetti, Nicola de’Angelis, Nick Salimian, Marco Caricato, Gianluca Pellino, Sara Vertaldi, Federica Cipriani, Gabriella Teresa Capolupo, Antonio Costanzo, Letizia Santandrea, Gaetano Gallo, Andrea Belli, Laura Mastrangelo, Fausto Rosa, Nicolò Pecorelli, Graziella Marino, Alessio Giordano, Nicola Cillara, Maria Lemma, Francesco Pata, Federico Cammillini, Gianmario Edoardo Poto, Giulia Grassi, Donato Francesco Altomare, Arcangelo Picciariello, Lorenzo Petagna, Luca Ippolito, Elio Treppiedi, Daniele Delogu, Abdallah Moukachar, Stefano Granieri, Giuseppe Cuticone, Osvaldo Carpineto Samorani, Daniela Rega, Leonardo Solaini, Stefano de Pascale, Francesca Ascari, Michele Manigrasso, Simona Badalucco, Salvatore Paiella, Sara Coppola, Roberta Iadarola, Giovanna Di Meo, Isacco Montroni, Fabio Vistoli, Valentina Ferraro, Edoardo Saladino, Federico Fazio, Roberta Rota, Francesco Orlando, Simone Famularo, Cinzia Bizzoca, Giorgio Dalmonte, Marco Inama, Luigi Verre, Leandro Siragusa, Casoni Pattacini Gianmaria, Michele Benedetti, Nicolò Tamini, Cristian Conti, Giorgio Ammerata, Serena Mantova, Vito Leonardo Pinto, Arianna Corvasce, Giorgio Micheletti, Teresa Perra, Marco Pellicciaro, Marco Materazzo, Michele Zuolo, Emanuele Doria, Antonio Brillantino, Luca Del Prete, Andrea Muratore, Claudio Luciani, Giulia Turri, Fabio Casciani, Giuliani Giuseppe, Graziana Barile, Oldrà Gaia, Valeria Restaino, Simona Deidda, Michele Ammendola, Andrea Fares Bucci, Patrizia Marsanic, Dario Cassetti, Luca Resca, Daniele Fusario, Eleonora Andreucci, Anna Michelotti, Brunella Amoruso, Isabella Franco, Laura Noto, Andrea Spallanzani, Raimondo Calogero Scalia, Teresa Del Giudice, Valeria Merz, Gianmarco Motta, Alessandro Parisi, Mikol Modesti, Antonella Argentiero, Debora Basile, Gianmarco Vannini, Carlotta Ottanelli, Salvatore Corallo, Eufemia Stefania Lutrino, Daniele Rossini, Federica Morano, Luigia Stefania Stucci, Costanza Winchler, Martina Catalano, Andrea Marini, Giuseppe Brisinda, Enrico Sammarco, Martina Carullo, Giandomenico Roviello, Mirko Barone, Maria Grazia Rodriquenz, Giuseppe Tirino, Alessia Amoruso, Anna Russo, Veronica Conca, Laura Orgiano, Sveva Macrini, Giulia Nazzicone, Maria Bensi, Martina Montesano, Emanuela Dell’Aquila, Andrea Sbrana, Beatrice Borelli, Lorenzo Fornaro, Lucrezia Raimondi, Valeria Zurlo, Mattia Garutti, Elena Ongaro, Arianna Pellegrino, Andrea lanese, Laura Bernardini, Alessandra Boccaccino, Patrizia Farina, Federica Buzzacchino, Angelica Petrillo, Ada Taravella, Vittorio Studiale, Paolo Ciracì, Giovanna Lovino, Dora Di Cosmo, Sabrina Montrone, Fabiana Gregucci, Luca Dominici, Alba Fiorentino, Filippo Carannante, Giambattista Siepe, Giampaolo Montesi, Manuele Roghi, Michele Aquilano, Andrea Romei, Ilaria Bonaparte, Roberta Grassi, Emma D’Ippolito, Giulio Frosini, Giuseppina De Marco, Gennaro Giovine, Chiara Mattioli, Ilaria Morelli, Victoria Lorenzetti, Matteo Mariotti, Carolina Orsatti, Vincenzo Troncone, Lorenzo Livi, Antonio Angrisani, Marco Banini, Teresa Di Pietro, Giuseppe Carlo Iorio, Iacopo Cavallo, Cecilia Cerbai, Valerio Nardone, Francesca De Felice, Consuelo Rosa, Giulia Stocchi, Sara Lucidi, Michele Ganovelli, Damiano Dei, Chiara Cascone, Anna Peru, Luisa Caprara, Lucia Angelini, Luca Visani, Giulio Francolini, Beatrice Bettazzi, Francesco Belia, Virginia Boccardi, Simone Serafini, Vincenzo Bottino, Luca Ferrario, Giuseppe Frazzetta, Felice Pirozzi, Gennaro Martines, Francesco Antonio Ciarleglio, Daniele Indiani, Giuliano Barugola, Luca Mazza, and Chiara Guarini
References
- 1.De Maria MR, Di Sante G, Piro G, Carbone C, Tortora G, Boldrini L, et al. Translational research in the era of precision medicine: where we are and where we will go. J Pers Med. (2021) 11:216. doi: 10.3390/jpm11030216, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Zhang X, Tang M, Zhang Q, Zhang K-P, Guo Z-Q, Xu H-X, et al. The GLIM criteria as an effective tool for nutrition assessment and survival prediction in older adult cancer patients. Clin Nutr. (2021) 40:1224–32. doi: 10.1016/j.clnu.2020.08.004, PMID: [DOI] [PubMed] [Google Scholar]
- 3.Qin L, Tian Q, Zhu W, Wu B. The validity of the GLIM criteria for malnutrition in hospitalized patients with gastric cancer. Nutr Cancer. (2021) 73:2732–9. doi: 10.1080/01635581.2020.1856894, PMID: [DOI] [PubMed] [Google Scholar]
- 4.Baracos VE. Cancer-associated malnutrition. Eur J Clin Nutr. (2018) 72:1255–9. doi: 10.1038/s41430-018-0245-4 [DOI] [PubMed] [Google Scholar]
- 5.Garla P, Waitzberg DL, Tesser A. Nutritional therapy in gastrointestinal cancers. Gastroenterol Clin N Am. (2018) 47:231–42. doi: 10.1016/j.gtc.2017.09.009 [DOI] [PubMed] [Google Scholar]
- 6.Virizuela JA, Camblor-Álvarez M, Luengo-Pérez LM, Grande E, Álvarez-Hernández J, Sendrós-Madroño MJ, et al. Nutritional support and parenteral nutrition in cancer patients: an expert consensus report. Clin Transl Oncol. (2018) 20:619–29. doi: 10.1007/s12094-017-1757-4, PMID: [DOI] [PubMed] [Google Scholar]
- 7.Castillo-Martínez L, Castro-Eguiluz D, Copca-Mendoza ET, Pérez-Camargo DA, Reyes-Torres CA, Damasco-Ávila EA, et al. Nutritional assessment tools for the identification of malnutrition and nutritional risk associated with cancer treatment. Rev Investig Clin. (2018) 70:121–5. doi: 10.24875/RIC.18002524 [DOI] [PubMed] [Google Scholar]
- 8.Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. (2012) 31:345–50. doi: 10.1016/j.clnu.2011.11.001, PMID: [DOI] [PubMed] [Google Scholar]
- 9.Contreras-Bolívar S-T, Ruiz-Vico G-A, Barrios P, Alba O. GLIM criteria using hand grip strength adequately predict six-month mortality in cancer inpatients. Nutrients. (2019) 11:2043. doi: 10.3390/nu11092043, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kim J-Y, Wie G-A, Cho Y-A, Kim S-Y, Kim S-M, Son K-H, et al. Development and validation of a nutrition screening tool for hospitalized cancer patients. Clin Nutr. (2011) 30:724–9. doi: 10.1016/j.clnu.2011.06.001 [DOI] [PubMed] [Google Scholar]
- 11.Muscaritoli M, Lucia S, Farcomeni A, Lorusso V, Saracino V, Barone C, et al. Prevalence of malnutrition in patients at first medical oncology visit: the PreMiO study. Oncotarget. (2017) 8:79884–96. doi: 10.18632/oncotarget.20168, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Beirer A. Malnutrition and cancer, diagnosis and treatment. Eur Soc Med Oncol. (2021) 14:168–73. doi: 10.1007/s12254-020-00672-3 [DOI] [Google Scholar]
- 13.Song C, Cao J, Zhang F, Wang C, Guo Z, Lin Y, et al. Nutritional risk assessment by scored patient-generated subjective global assessment associated with demographic characteristics in 23,904 common malignant Tumors patients. Nutr Cancer. (2019) 71:50–60. doi: 10.1080/01635581.2019.1566478, PMID: [DOI] [PubMed] [Google Scholar]
- 14.Poulter S, Steer B, Baguley B, Edbrooke L, Kiss N. Comparison of the GLIM, ESPEN and ICD-10 criteria to diagnose malnutrition and predict 30-day outcomes: an observational study in an oncology population. Nutrients. (2021) 13:2602. doi: 10.3390/nu13082602, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Zhang Z, Wan Z, Zhu Y, Zhang L, Zhang L, Wan H. Prevalence of malnutrition comparing NRS2002, MUST, and PG-SGA with the GLIM criteria in adults with cancer: a multi-center study. Nutrition. (2021) 83:111072. doi: 10.1016/j.nut.2020.111072, PMID: [DOI] [PubMed] [Google Scholar]
- 16.Gascón-Ruiz M, Casas-Deza D, Torres-Ramón I, Zapata-García M, Alonso N, Sesma A, et al. GLIM vs ESPEN criteria for the diagnosis of early malnutrition in oncological outpatients. Clin Nutr. (2021) 40:3741–7. doi: 10.1016/j.clnu.2021.04.025, PMID: [DOI] [PubMed] [Google Scholar]
- 17.Hébuterne X, Lemarié E, Michallet M, de Montreuil CB, Schneider SM, Goldwasser F. Prevalence of malnutrition and current use of nutrition support in patients with cancer. J Parenter Enter Nutr. (2014) 38:196–204. doi: 10.1177/0148607113502674 [DOI] [PubMed] [Google Scholar]
- 18.Bozzetti F, SCRINIO Working Group . Screening the nutritional status in oncology: a preliminary report on 1,000 outpatients. Support Care Cancer. (2009) 17:279–84. doi: 10.1007/s00520-008-0476-3, PMID: [DOI] [PubMed] [Google Scholar]
- 19.Cederholm T, Jensen GL, Correia MITD, Gonzalez MC, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition–a consensus report from the global clinical nutrition community. Clin Nutr. (2019) 38:1–9. doi: 10.1016/j.clnu.2018.08.002, PMID: [DOI] [PubMed] [Google Scholar]
- 20.Hu W-H, Cajas-Monson LC, Eisenstein S, Parry L, Cosman B, Ramamoorthy S. Preoperative malnutrition assessments as predictors of postoperative mortality and morbidity in colorectal cancer: an analysis of ACS-NSQIP. Nutr J. (2015) 14:91. doi: 10.1186/s12937-015-0081-5, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Santos I, Mendes L, Mansinho H, Santos CA. Nutritional status and functional status of the pancreatic cancer patients and the impact of adjacent symptoms. Clin Nutr. (2021) 40:5486–93. doi: 10.1016/j.clnu.2021.09.019, PMID: [DOI] [PubMed] [Google Scholar]
- 22.Gianotti L, Fumagalli Romario U, De Pascale S, Weindelmayer J, Mengardo V, Sandini M, et al. Association between compliance to an enhanced recovery protocol and outcome after elective surgery for gastric cancer. Results from a Western population-based prospective Multicenter study. World J Surg. (2019) 43:2490–8. doi: 10.1007/s00268-019-05068-x, PMID: [DOI] [PubMed] [Google Scholar]
- 23.Schwegler I, von Holzen A, Gutzwiller J-P, Schlumpf R, Mühlebach S, Stanga Z. Nutritional risk is a clinical predictor of postoperative mortality and morbidity in surgery for colorectal cancer. Br J Surg. (2009) 97:92–7. doi: 10.1002/bjs.6805 [DOI] [PubMed] [Google Scholar]
- 24.Hopkinson JB, Wright DNM, McDonald JW, Corner JL. The prevalence of concern about weight loss and change in eating habits in people with advanced cancer. J Pain Symptom Manag. (2006) 32:322–31. doi: 10.1016/j.jpainsymman.2006.05.012, PMID: [DOI] [PubMed] [Google Scholar]
- 25.Sandrucci S, Beets G, Braga M, Dejong K, Demartines N. Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition). Eur J Surg Oncol. (2018) 44:509–14. doi: 10.1016/j.ejso.2017.12.010, PMID: [DOI] [PubMed] [Google Scholar]
- 26.Santarpia L, Contaldo F, Pasanisi F. Nutritional screening and early treatment of malnutrition in cancer patients. J Cachexia Sarcopenia Muscle. (2011) 2:27–35. doi: 10.1007/s13539-011-0022-x, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Zhang K-P, Tang M, Fu Z-M, Zhang Q, Zhang X, Guo Z-Q, et al. Global leadership initiative on malnutrition criteria as a nutrition assessment tool for patients with cancer. Nutrition. (2021) 91–92:111379. doi: 10.1016/j.nut.2021.111379, PMID: [DOI] [PubMed] [Google Scholar]
- 28.Lim H-S, Cho G-S, Park Y-H, Kim S-K. Comparison of quality of life and nutritional status in gastric cancer patients undergoing Gastrectomies. Clin Nutr Res. (2015) 4:153–9. doi: 10.7762/cnr.2015.4.3.153, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Andreyev HJN, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer. (1998) 34:503–9. doi: 10.1016/S0959-8049(97)10090-9, PMID: [DOI] [PubMed] [Google Scholar]
- 30.Seo SH, Kim S-E, Kang Y-K, Ryoo B-Y, Ryu M-H, Jeong JH, et al. Association of nutritional status-related indices and chemotherapy-induced adverse events in gastric cancer patients. BMC Cancer. (2016) 16:900. doi: 10.1186/s12885-016-2934-5, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Arends J, Baracos V, Bertz H, Bozzetti F, Calder PC, Deutz NEP, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr. (2017) 36:1187–96. doi: 10.1016/j.clnu.2017.06.017, PMID: [DOI] [PubMed] [Google Scholar]
- 32.Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. (2017) 36:49–64. doi: 10.1016/j.clnu.2016.09.004, PMID: [DOI] [PubMed] [Google Scholar]
- 33.Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: clinical nutrition in surgery. Clin Nutr. (2017) 36:623–50. doi: 10.1016/j.clnu.2017.02.013, PMID: [DOI] [PubMed] [Google Scholar]
- 34.Caccialanza R, Lobascio F, Cereda E, Aprile G, Farina G, Traclò F, et al. Cancer-related malnutrition management: a survey among Italian oncology units and patients’ associations. Curr Probl Cancer. (2020) 44:100554. doi: 10.1016/j.currproblcancer.2020.100554, PMID: [DOI] [PubMed] [Google Scholar]
- 35.Sonmez O, Tezcanli E, Bas D, Kazanci HB, Altinok A, Demir A, et al. Identifying knowledge and practices regarding cancer patient malnutrition: a survey study among oncologists. Nutr Cancer. (2022) 74:2392–9. doi: 10.1080/01635581.2021.2008987, PMID: [DOI] [PubMed] [Google Scholar]
- 36.Lorenzon L, Brandl A, Guiral DC, Hoogwater F, Lundon D, Marano L, et al. Nutritional assessment in surgical oncology: an ESSO-EYSAC global survey. Eur J Surg Oncol. (2020) 46:2074–82. doi: 10.1016/j.ejso.2020.08.028, PMID: [DOI] [PubMed] [Google Scholar]
- 37.Serón-Arbeloa C, Labarta-Monzón L, Puzo-Foncillas J, Mallor-Bonet T, Lafita-López A, Bueno-Vidales N, et al. Malnutrition screening and assessment. Nutrients. (2022) 14:2392. doi: 10.3390/nu14122392, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Sieber CC. Malnutrition and sarcopenia. Aging Clin Exp Res. (2019) 31:793–8. doi: 10.1007/s40520-019-01170-1 [DOI] [PubMed] [Google Scholar]
- 39.Reber E, Schönenberger KA, Vasiloglou MF, Stanga Z. Nutritional risk screening in cancer patients: the first step toward better clinical outcome. Front Nutr. (2021) 8:603936. doi: 10.3389/fnut.2021.603936, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Taylor SR, Falcone JN, Cantley LC, Goncalves MD. Developing dietary interventions as therapy for cancer. Nat Rev Cancer. (2022) 22:452–66. doi: 10.1038/s41568-022-00485-y [DOI] [PubMed] [Google Scholar]
- 41.Marano L, Porfidia R, Pezzella M, Grassia M, Petrillo M, Esposito G, et al. Clinical and immunological impact of early postoperative enteral Immunonutrition after Total Gastrectomy in gastric cancer patients: a prospective randomized study. Ann Surg Oncol. (2013) 20:3912–8. doi: 10.1245/s10434-013-3088-1, PMID: [DOI] [PubMed] [Google Scholar]
- 42.Baracos VE, Martin L, Korc M, Guttridge DC, Fearon KCH. Cancer-associated cachexia. Nat Rev Dis Prim. (2018) 4:17105. doi: 10.1038/nrdp.2017.105 [DOI] [PubMed] [Google Scholar]
- 43.Sukkar SG. The impact of clinical nutrition on cancer therapy: a frequently underestimated perspective. A complementary approach to cancer patients. Med J Nutr Metab. (2012) 5:75–9. doi: 10.1007/s12349-012-0105-z, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Bozzetti F. Forcing the vicious circle: sarcopenia increases toxicity, decreases response to chemotherapy and worsens with chemotherapy. Ann Oncol. (2017) 28:2107–18. doi: 10.1093/annonc/mdx271, PMID: [DOI] [PubMed] [Google Scholar]
- 45.Prado CM, Purcell SA, Laviano A. Nutrition interventions to treat low muscle mass in cancer. J Cachexia Sarcopenia Muscle. (2020) 11:366–80. doi: 10.1002/jcsm.12525, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Bossi P, Delrio P, Mascheroni A, Zanetti M. The Spectrum of malnutrition/cachexia/sarcopenia in oncology according to different cancer types and settings: a narrative review. Nutrients. (2021) 13:1980. doi: 10.3390/nu13061980, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Weimann A. Is there a rationale for perioperative nutrition therapy in the times of ERAS? Innov Surg Sci. (2019) 4:152–7. doi: 10.1515/iss-2019-0012, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Bozzetti F, Gurizzan C, Lal S, Van Gossum A, Wanten G, Golusinski W, et al. A European survey on the practice of nutritional interventions in head–neck cancer patients undergoing curative treatment with radio(chemo)therapy. Eur Arch Otorhinolaryngol. (2022) 279:1499–508. doi: 10.1007/s00405-021-06920-4, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. Lancet. (2021) 397:1905–13. doi: 10.1016/S0140-6736(21)00768-6, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Hauner H, Kocsis A, Jaeckel B, Martignoni M, Hauner D, Holzapfel C. Häufigkeit eines risikos für mangelernährung bei patienten in onkologischen schwerpunktpraxen–eine querschnittserhebung. Dtsch Med Wochenschr. (2020) 145:e1–9. doi: 10.1055/a-1008-5702, PMID: [DOI] [PubMed] [Google Scholar]
- 51.Taberna M, Gil Moncayo F, Jané-Salas E, Antonio M, Arribas L, Vilajosana E, et al. The multidisciplinary team (MDT) approach and quality of care. Front Oncologia. (2020) 10:85. doi: 10.3389/fonc.2020.00085, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Lin J-X, Chen X-W, Chen Z-H, Huang X-Y, Yang J-J, Xing Y-F, et al. A multidisciplinary team approach for nutritional interventions conducted by specialist nurses in patients with advanced colorectal cancer undergoing chemotherapy. Medicine (Baltimore). (2017) 96:e7373. doi: 10.1097/MD.0000000000007373, PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]