Abstract
Introduction:
Older adults are often prescribed oral anticancer agents (OAAs). Technology-based interventions may offer medication and symptom support. We aimed to evaluate technology ownership, use, and preferred design features of a supportive web-based program using a multimethod design utilizing surveys and semi-structured interviews.
Materials and Methods:
Patients were recruited from a National Cancer Institute-designated Comprehensive Cancer Center. Eligibility included those: (1) ≥65 years of age; (2) prescribed a Food and Drug Administration-approved OAA; (3) English speaking; (4) able/willing to complete telephone interviews. Interviews were audio-recorded and transcribed verbatim. Cohen’s Kappa was used to evaluate inter-rater reliability and calculated at 0.87.
Results:
Participants (N = 30) were predominantly female (70 %), White (83.3 %), with metastatic disease (90 %). The mean age was 74.9 years. Ninety percent owned a smartphone, 66.7 % owned a tablet, and 90 % owned a computer. Nearly 57 % reported using smartphones frequently for cancer-related purposes. Four themes with corresponding subthemes were identified: (1) comfort with technology; (2) reasons for technology use for health-related purposes (research of cancer, cancer treatment, and related symptoms/side effects; using the portal to manage health; and appointment and medication reminders); (3) recommended design features for a web-based program (OAA medication-specific information; calendars & medication alarms/reminders; symptom management & symptom trackers; and tutorials and testimonials); and (4) adaptations for older adults (simple navigation; larger font; use of layperson’s terms; use of pictures, graphics, and color coding; and voice activation).
Discussion:
Older adults use technology for health-related purposes. Specific web-design features and adaptations are needed to enhance usability among older adults.
Keywords: Oral oncolytic agents, Older adults, cancer, Technology, Self-management
1. Background
Oral anticancer agents (OAAs) are increasingly prescribed and account for nearly half of the new cancer treatments approved by the Food and Drug Administration (FDA) [1,2]. Older adults aged ≥60 years have the highest incidence of solid tumor cancers and are often prescribed OAAs [3]. Despite the speculated convenience of OAAs, patients are often met with numerous challenges with these medications, including complex dosing schedules, adherence, and symptom/side-effect management [1,4–9]. Self-efficacy is required to monitor and report drug toxicities and potential drug-drug or food-drug interactions, which are often coupled with polypharmacy in the older adult [4,6,8,9].
As oncology care shifts from oncology clinics to the home environment, opportunities exist to find innovative and technologically driven ways to deliver information about OAAs to patients, given the decreased frequency of face-to-face contact [10]. Currently, an estimated 80 % of adults in the United States aged ≥65 years own a cellphone, over 40 % own a smartphone, 67 % use the internet, and 32 % own a tablet [11]. High internet use and moderate digital literacy among older adults have also been reported [12]. Web-based programs offer a potential solution to increase communication and generate new ways to support self-medication and symptom management in response to a changing cancer care model.
Currently, there is limited research specific to OAAs and web-based programs, with most studies focusing on smartphone mobile health (mHealth) specific applications that can typically only be opened on one device. Although evidence has supported acceptability, usability, feasibility, and engagement in technology-based interventions for younger individuals [4,13–15], older adults are underrepresented. This is important given that older adults have unique needs for decreased cognitive function, physical impairments (e.g., vision changes, dexterity), and digital/health literacy. Previous work involving mobile health apps specific to OAAs included patient involvement during the development phase, resulting in positive perceived benefits in managing medications [4,13–15]. However, because these studies included a younger cohort, it is unknown how older adults perceive such interventions.
1.1. Aim
This study aimed to evaluate technology use and perceptions of web-based program design features to assist older adults manage OAAs.
2. Methods
This multi-method study was approved by the University of South Florida Institutional Review Board (#000264) and the Scientific Review Committee at Moffitt Cancer Center (#20727). Informed consent was obtained prior to data collection. Patients were recruited from a National Cancer Institute-designated Comprehensive Cancer Center. Eligibility criteria included those: (1) ≥65 years; (2) prescribed a Food and Drug Administration-approved OAA; (3) able to speak English; and (4) able/willing to complete audio-recorded interviews via telephone. Data collection occurred between June 2021 and February 2024. A one-time individual interview was completed by the principal investigator (Table 1). All interviews were audio-recorded with the participant’s permission and transcribed verbatim. Interviews lasted between 40 and 60 min. Participants received a $40 Publix gift card as compensation for their time.
Table 1.
Sample Semi-structured Interview Questions.
| 1. Describe your comfort level of using all of the following: smartphone/tablet/personal computer. |
| 2. How often do you use a smartphone/tablet, personal computer for health-related reasons (e.g., setting alarms to remember to take medication, set calendars for doctor visits, search the internet for health-related information)? |
| 3. Describe your thoughts regarding design features that may help you manage your oral anticancer medication using a web health application that could be used on a smartphone, tablet, or personal computer. |
| 4. What type of consideration do you think web health application designs should have for older adults receiving oral anticancer medication? |
Descriptive statistics were used to describe the sample and survey results. Three PhD research team members (V.K.M, M.C., and T.M.) trained in qualitative methods reviewed transcripts independently to become familiar with the data. A codebook, including both a priori and emergent themes, was developed. A thematic analysis was employed by each reviewer who then met to share individual analyses, justify coding and thematic analyses, and discuss any discrepancies until a consensus was met [16]. Inter-rater reliability was assessed with Cohen’s Kappa coefficients at 0.87. All analytic decisions made during the study were documented to ensure the findings’ consistency, accuracy, and credibility [16].
3. Results
3.1. Quantitative
The mean age of participants (N = 30) was 74.9 years (Table 2). Participants were predominantly female (70 %) and White (83.3 %) with metastatic disease (90 %). Participants reported a considerably high use of technology, including technology utilization specific to cancer care (Table 3).
Table 2.
Patient demographics.
| Sample Characteristics | n | % | M | SD |
|---|---|---|---|---|
| Sex | ||||
| Female | 21 | 70 | ||
| Male | 9 | 30 | ||
| Age | 74.9 | 5.99 | ||
| Hispanic/Latino | ||||
| No | 30 | 100 | ||
| Race | ||||
| White | 25 | 83.3 | ||
| Black/African American | 5 | 16.7 | ||
| Highest Level of Education | ||||
| Some High School | 2 | 6.7 | ||
| Diploma Program | 1 | 3.3 | ||
| High School Diploma | 5 | 16.7 | ||
| Graduate/Professional | 1 | 3.3 | ||
| Some College | 3 | 10 | ||
| Associate degree | 1 | 3.3 | ||
| Bachelor’s degree | 7 | 23.3 | ||
| Master’s degree | 8 | 26.7 | ||
| Doctorate | 1 | 3.3 | ||
| Missing | 1 | 3.3 | ||
| Marital Status | ||||
| Never Married | 1 | 3.3 | ||
| Married | 21 | 70 | ||
| Divorced | 2 | 6.7 | ||
| Separated | – | 0 | ||
| Widowed | 6 | 20 | ||
| Living Together | – | 0 | ||
| Income | ||||
| Less than $24,999 | 3 | 10 | ||
| $25,000 to $49,999 | 4 | 13.3 | ||
| $50,000 to $99,999 | 10 | 33.3 | ||
| $100,000 to $149,999 | 5 | 16.7 | ||
| $150,000 and above | 2 | 6.7 | ||
| Missing | 6 | 20 | ||
| Living Arrangements | ||||
| Living with spouse/partner/family | 21 | 70 | ||
| Living alone | 9 | 30 | ||
| Currently Employed | 1 | 3.3 | ||
| Employed at Time of Cancer Diagnosis | 4 | 13.3 | ||
| Currently Retired | 27 | 90 | ||
| Oral Chemotherapy Agent | ||||
| Pomalyst (pomalidomide) | 1 | 3.3 | ||
| Calquence (acalabrutinib) | 1 | 3.3 | ||
| Lenvimo (lenvatinib) | 1 | 3.3 | ||
| Lynparza (olaparib) | 1 | 3.3 | ||
| Verzenio (abemaciclib) | 4 | 13.3 | ||
| Keytruda (pembrolizumab) | 1 | 3.3 | ||
| Lonsurf (trifluridine/tipiracil) | 1 | 3.3 | ||
| Afinitor (everolimus) | 3 | 10 | ||
| Xtandi (enzalutamide) | 3 | 10 | ||
| Xeloda (capecitabine) | 7 | 23.3 | ||
| Zytiga (abiraterone acetate) | 2 | 6.7 | ||
| Ibrance (palbociclib) | 5 | 16.7 | ||
| Concurrent Chemotherapy | ||||
| Yes | 15 | 50 | ||
| No | 15 | 50 | ||
| Cancer Type | ||||
| Breast | 17 | 56.7 | ||
| Colon | 3 | 10 | ||
| Prostate | 5 | 16.7 | ||
| Renal Cell Carcinoma | 2 | 6.7 | ||
| Anal | 1 | 3.3 | ||
| Chronic Lymphocytic Leukemia | 1 | 3.3 | ||
| Multiple Myeloma | 1 | 3.3 | ||
| Metastases Present | 27 | 90 |
Note. N = 30.
Table 3.
Technology Ownership and Use (N = 30).
| Owns a Smartphone | N(%) |
|---|---|
| Yes | 27 (90) |
| No | 3 (10) |
| Type of Smartphone | |
| Android | 14 (51.9) |
| Apple | 13 (48.1) |
| How often do you use your smartphone for everyday use? | |
| Never | 1 (3.7) |
| Rarely | 1 (3.7) |
| Frequently | 3 (11.1) |
| All the Time | 22 (81.5) |
| How often do you use your smartphone for health-related purposes? | |
| Never | 3 (11.1) |
| Rarely | 7 (25.9) |
| Frequently | 9 (33.3) |
| All the Time | 8 (29.6) |
| Owns a Tablet | |
| Yes | 20 (66.7) |
| No | 10 (33.3) |
| How often do you use your tablet for everyday use? | |
| Never | 0 (0) |
| Rarely | 6 (30) |
| Frequently | 9 (45) |
| All the Time | 5 (25) |
| How often do you use your tablet for health-related purposes? | |
| Never | 4 (20) |
| Rarely | 10(50) |
| Frequently | 5 (25) |
| All the Time | 1 (5) |
| Owns a Computer | |
| Yes | 27 (90) |
| No | 3 (10) |
| How often do you use your computer for everyday use? | |
| Never | 3 (11.1) |
| Rarely | 7 (25.9) |
| Frequently | 9 (33.3) |
| All the Time | 8 (29.6) |
| How often do you use your computer for health-related purposes? | |
| Never | 7 (25.9) |
| Rarely | 10 (37) |
| Frequently | 7 (25.9) |
| All the Time | 3 (11.1) |
3.2. Qualitative
Four themes were identified in the qualitative analysis, with some having corresponding subthemes. Each is described below with supporting quotes.
3.2.1. Comfort with technology
Comfort levels with technology varied among participants. Some noted they were not comfortable using technology due to age-related factors. Participant 1, an 81-year-old female, noted: “Because I had cataract surgery. I do not use a computer or smartphone. I have a phone, but it’s a flip phone. I am not [comfortable] because of [my] eyes. It’s not difficult [to use technologies]. I choose not to because of the glare.” Other participants were uncomfortable with technology because of the design and complexity. Participant 11, a 77-year-old female, shared: “If I lose something, I have no idea how to find it. Like sometimes something will slip off the screen. I have to start all over again, because I have no idea where it is. Yeah, I’m not comfortable with it. Texting doesn’t interest me on the phone and I don’t text. Everybody has to call me.”
In contrast, there were participants who expressed being very comfortable using technology, despite their age. Participant 4, a 76-year-old female, verbalized: “I’m comfortable with it. It’s just a way of life nowadays. Even the age thing, though, is fine with me. I just don’t have any of the problems. I know that some people my age are just still not gonna conform to a smartphone, and yet that’s what I do every day.” Participant 9, a 71-year-old male, echoed, “I’m a big user of technology. I’m an early adopter, so, despite my age, I’m certainly not the worst at navigating through things.” One participant noted technology being a part of his occupation, “I’m very comfortable. I’m very technology-oriented. My background’s in technology. I worked in the industry a significant amount of my career… I mean, I understand it more than the average person.” Participant 13, a 65-year-old male
3.2.2. Reasons for technology use for health-related purposes
Technology use was evident in our sample for a variety of purposes explicitly related to cancer care. The following subthemes were revealed: (1) research of cancer, cancer treatment, and related symptoms and side effects; (2) using the portal to manage health; and (3) appointment and medication reminders.
3.2.2.1. Research of cancer, cancer treatment, and related symptoms and side effects.
Most notably, participants were using technology to learn more about their cancer diagnosis, OAA medication, and related symptoms and side effects. Participant 23, a 75-year-old female, shared: “I use my computer to look up side effects and what exactly the medicine’s supposed to [do]. I always look for my specific problem like the metastatic breast cancer that’s gone to the liver. I do a lot of searching for information and anything that might help me overcome this.” Participant 4, a 76-year-old female, expressed similar reasons for technology use: “I would say I’ve used technology more for….medications-just ‘cause I wanna know side-effects, etcetera.”
3.2.2.2. Using the portal to manage health.
Many participants mentioned using the healthcare portal to review and learn more about their diagnostic test results. Participant 3, a 72-year-old female, noted: “If I get my PET scan, and I’m checking results from the portal, and I’m trying to read what it says, and if I don’t understand it, then I’ll look up the words, and figure out what it means.” Participant 7, a 75-year-old female, echoed: “I’m on a portal. So I can do MyChart and check my results and my tests and everything.”
Participants also used technology to manage and track medical visits to their oncologists, mentioning the convenience of accessing their information anytime they needed it. Participant 13, a 65-year-old female, shared,
“I use the portal because I’ve found it to be more efficient, and it helps with my memory. I can go back and see, ‘Oh. This is what they said’, when I get the information through the portal. I find that the phone calls are hard to connect with. People are busy and they have different schedules, things change. Portal, you know, written, it’s there and it’s available at any time.”
3.2.2.3. Appointment and medication reminders.
Participants stated that they used features such as alarms and calendars to stay organized with medication schedules and health-related appointments. Participant 18 revealed, “I keep a calendar of my appointments, be it oncology or cardiology or whatever. Participant 22 echoed: “Definitely for scheduling. Because that’s the only way I remember exactly where I need to be at the—if I have enough now between dental and oncology and the various other things and so forth. I definitely need to use a calendar. I’ve gotten so used to doing it.” Participant 24 noted using alarms to remember to take their medication,
“It’s usually on my phone. There’s an app where your medications, and what time you take them. There’s usually an alarm. Which, I usually take it a few minutes before the alarm anyway because I’m so used to it now. If I’m out and about, and I have it in my pocket, the alarm will alert me, and I’m like, ‘Oh, okay. I gotta take it.’”
3.2.3. Recommended design features for a web-based program
Older adults provided several recommendations for specific design features that would be helpful to them as they managed cancer care in the home environment. These recommendations included: (1) OAA medication-specific information; (2) calendars & medication alarms/reminders; (3) symptom management & symptom trackers; and (4) tutorials and testimonials.
3.2.3.1. OAA medication-specific information.
Participants noted the importance of having information regarding their OOA medication, including name, dose, and potential interactions with food or other medications. This was especially important given that many participants were taking multiple medications for comorbid conditions. Participant 24 shared, “When I go into my app, the medications for that day are all up there at the different times, and across the bottom is—if I can look for interactions. Mostly interaction with other medications.” Others echoed wanting to have a place to go to find more information on their specific OAA medication: “Have that particular medicine, Verzenio, listed by its generic name as well as the brand name and just be able to, if I’m reading somethin’, to be able to click on a link that will take me into another screen for further explanations.” (Participant 18, a 72-year-old female.)
3.2.3.2. Calendars & medication alarms/reminders.
Participants shared recommendations for features that could help support OAA medication management, symptoms, and side effects. Tracking medication schedules, including OAA cycling, was often mentioned. Participant 9, a 71-year-old male, shared:
“There could be a calendar format that could be populated for the specific individual so that they’re certain when and how much of that medication they take and over what period and when to take a break. There are times when I just worry if I’m doing things right, and I want to go back and check. Having it on the calendar helps a lot.”
Similarly, Participant 13, a 65-year-old female, noted: “I think the tracking because frankly I was very overwhelmed when I had two medications added to my list, and then the alternate days that I’m taking the Verzenio…If I was able to log on somewhere and, ‘Here is a spreadsheet…,’ then I could enter my medication into that. Then maybe, say, ‘I wanna take this medication between 7:00 and 9:00 a.m., and if I haven’t entered something by 9:00 a.m., maybe there’d be a notification…Don’t forget. You didn’t take your medication this morning.’”
3.2.3.3. Symptom management & symptom trackers.
Older adults shared that a place that described commonly experienced symptoms while taking OAA medication, tracked symptoms, and when to call the oncology office would be helpful. Participant 13, a 65-year-old female, discussed her experience with an adverse event that she felt could have been prevented if she had been more informed. She also expressed the importance of having trusted online resources to refer to:“Verzenio has some percentage of causing blood clots. Here are some signs that you should be aware of and look for…,” and when to call the doctor… I’m relying on other resources, online resources. It would have been nice to have some cancer-related or Verzenio-related to read about blood clots.” The same patient also noted having diarrhea that went untreated for too long and caused additional health issues. She noted being uninformed, which caused dehydration. She shared: “I think one of the things that was a big problem with the diarrhea—I didn’t know this until it happened to me—is how dehydrating it is, and then how the dehydration affects your heart rate. I didn’t know those things… The whole diarrhea thing was ongoing for a long time. If I had known that I need to drink more, and I need to maybe drink some of these electrolyte drinks, and I need to be paying attention to dehydration because dehydration is dangerous, maybe even life-threatening because of what it does to your heart, those are things I just didn’t know.”
Participant 18, a 72-year-old female, wanted additional information on how to manage symptoms and when to call the oncology team: “To stress the antidotes for the symptoms or the side effects and to determine how long you should go before it presents itself as a problem.” Participant 3 added: “I think something that would track your symptoms. ‘Cause I know for a while my husband and I were taking my temperature every morning. We were tracking it.”
3.2.3.4. Tutorials & testimonials.
Tutorials and testimonials from patients taking OAA medication were mentioned as a helpful addition to a supportive web-based design. Participant 13, a 65-year-old female, noted, “Tutorials are huge. I think the tutorials that drill down on the feature that you’re in. If you’re doing time collection, how do you do that? What does this mean? Because some of the tutorials are real big on start-up, but they don’t help you as you work through things. I think people, to me, are very YouTube-oriented. You know, ‘Here’s a series of five YouTube videos on how to use this technology…’ It shows the screen. It shows what you’re doing. It gives you the ability to go in and look at a 2-minute video, not a 30-minute video… The tutorials, I think, are a real key to success of software.” Participants were interested in hearing from others who had similar cancers or were prescribed the same OAA medication as them. Testimonies from others were noted to help understand how others coped with their illness and treatment. Participant 29 shared: “Testimonials. I’d like to know how other people have experienced it. I would like to see some results of people who have probably experienced it, as well as maybe see some of the stories of how some people deal with it. Just try to see people that have similar backgrounds as you, and how they’re dealing with it. Participant 30, a 72-year-old female, echoed: “I’d probably want to see different people’s experiences with them, and especially if I was going to start a medication like Xeloda and to see what the different side effects that people have had and to what degree.”
3.2.4. Adaptations for the older adults
There was a consensus that specific adaptations are needed for older adults using technology. Although many were already using technology, participants expressed features that could enhance their experience. Most adaptations were specific to address age-related vision and cognitive changes. Subthemes included: (1) simple navigation; (2) larger font; (3) use of layperson’s terms; (4) use of pictures, graphics, and color coding; and (5) voice activation.
3.2.4.1. Simple navigation.
Simplicity of navigation and design was commonly recommended. Older adults mentioned having a very basic design with only the essential number of icons, screens, and menu tabs. Participant 13, a 65-year-old female, noted, “Just really simplistic navigation…Not having a bunch of icons where the screen is really busy.” Participant 7, a 75-year-old female, expressed: “Simple navigation through the system for me ‘cause I get so frustrated when I’m tryin’ to set up a new portal, and it wants all this information, and then I can’t go back.”
3.2.4.2. Larger font.
Incorporating a larger font was highly suggested. Participant 8, a 70-year-old male, shared: “Larger[font] to see it might be helpful.” Participant 14 echoed: “I think the size of the print…As we get older, we do have losses in those areas, and it is helpful when things are written larger and/or the things you push are larger instead of getting smaller.” Some mentioned that font size may be dependent on the specific device being used, as expressed by Participant 3, a 72-year-old female: “Oh, larger font would be nice. Of course, that depends on what device you’re on. If I look at my cell phone, it’s pretty small. If I go to the computer, it’s much bigger. I think that’s a little dependent on what you’re on.”
3.2.4.3. Use of layperson’s terms.
Additionally, recommendations included clear language without medical jargon so that content could be easily understood. Participant 5, a 74-year-old female shared, “I think discussions with less doctors speak and more practical explanations.” Participant 18 added: “Simple wording. Layman’s terms that could be understood or have a glossary where if there’s a word that you don’t understand that you can click on and get the definition for.”
3.2.4.4. Use of pictures, graphics, and color coding.
Other adaptations recommended included incorporating pictures, perhaps in place of or in addition to icon labels. Participant 18, a 72-year-old female, shared, “I am a visual learner. I like pictures.”
The importance of colors, hues, and backgrounds included in the web-based program were also highlighted. Participant 22 stated, “Chartjunk is all the flashy stuff that they put in the background. Just make it simple. There has to be good contrast between whatever the information is, and the background that it’s displayed on. Black on white is the simplest and the easiest to understand. If the color has information or makes it easier to understand, in the sense that by adding some color, you can distinguish some things more regularly. Possibly banding color so that you distinguish Monday from Tuesday from Wednesday from Thursday [on a calendar]. Things like that to make it more understandable and definitely to make it more readable.”
3.2.4.5. Voice activation.
An option for voice activation was mentioned, especially by those who could not read well due to diminished eyesight. Participant 23, a 75-year-old female, noted: “Maybe we would have two different options, where you could either read it, or you could have it read to you if maybe your eyesight was bad as well? On my computer I have on-voice that I can click.” Participant 1, an 81-year-old female, who had expressed issues with vision shared: “If it was voice-activated, that’s fine ‘cause I’ll listen to the voice.”
4. Discussion
Our study found a high prevalence of technology ownership, which is higher than the reported averages in the literature [11,12,17]. Importantly, older adults were using technology to manage their cancer care and were open to supportive interventions, which has previously been reported [10,18].
Most participants were comfortable using technology, but notably, some individuals did not use technology either because of physical impairments (e.g., poor eyesight) or the lack of self-efficacy to navigate the internet or mobile applications. Similar barriers among older adults using technology have been reported [19,20]. Older adults used a variety of technologies to manage their cancer care. They expressed the convenience of having access to the internet to research their cancer diagnosis, prescribed OAA, and existing or potential symptoms and side effects related to their treatment. However, many participants commented on the need for trusted resources as they sometimes were unsure if the information they received online was accurate. Older adults used technology-based features such as alarms and calendars to stay organized with healthcare appointments and medication administration. Many used the portal to communicate with the oncology team and receive diagnostic and laboratory values. This aligns with published reports that older adults are open to communicating with their oncology care team via such technologies [17].
With an increasing aging population and a rise in cancer diagnoses requiring OAA treatment, it is important to enhance care and produce innovative ways to communicate, educate, and support patients’ medication and symptom management. Our participants noted several critical components needed to help them manage OAAs. Adaptations such as larger font, simple navigation, and voice activation of screens were mentioned to help overcome age-related barriers.
We did not find unequal access to technology ownership or internet services. This contradicts the literature on technology use and experiences among older adults [19], perhaps due to data collected solely in the United States. Our sample was also largely educated, which could have impacted the high use and accessibility to technology. Education has been reported to impact technology and internet use [21]. Another explanation could be the increased technology use for healthcare utilization among all age groups since the COVID-19 pandemic [22].
4.1. Strengths and Limitations
This study is one of the first to approach technology ownership and use related to cancer care, specifically targeting older adults prescribed OAAs. However, the study is not without limitations. Our sample size was small, although considering the qualitative aspect, it provided rich data to fuel the development of a web-based program targeted at older adults. Our qualitative results are not generalizable. Our sample was predominantly White, and non-Hispanic/Latino, thus the diversity of our sample was lacking.
5. Conclusion
Older adults are using various technology-based platforms for health-related purposes. Specific web-design features and adaptations for older adults using technology are needed to enhance usability.
Acknowledgments
This study was funded by the National Cancer Institute (1R03CA262908-01A1), Exploring the Use of a Web-Based Program for Older Adults Receiving Oral Anticancer Agents to Improve Communication and Self-Management.
Footnotes
Ethical Approval
This study was approved by the University of South Florida Institutional Review Board (#000264) and the Scientific Review Committee at Moffitt Cancer Center (#20727).
CRediT authorship contribution statement
Victoria K. Marshall: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft. Melody N. Chavez: Data curation, Formal analysis, Project administration, Software, Validation, Writing – review & editing. Tina M. Mason: Formal analysis, Writing – review & editing. Martine Extermann: Data curation, Funding acquisition, Project administration, Supervision, Writing – review & editing. Lanie A. Simon: Resources, Writing – review & editing. Jay Ligatti: Supervision, Writing – review & editing. Usha Menon: Conceptualization, Supervision, Writing – review & editing. Laura A. Szalacha: Conceptualization, Formal analysis, Methodology, Funding acquisition, Supervision, Writing – review & editing.
Declaration of Competing Interest
The authors have no disclosures to report.
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