Developing a supportive care pathway for sarcopenia prevention in nasopharyngeal carcinoma: a context-sensitive and implementation-oriented approach

Abstract

Purpose

Patients with nasopharyngeal carcinoma (NPC) undergoing definitive treatment commonly experience muscle loss, nutritional deterioration, symptom burden, and functional decline, increasing sarcopenia risk. This study aimed to develop a context-sensitive supportive care pathway integrating multidisciplinary care strategies for sarcopenia prevention across the NPC treatment trajectory.

Methods

A multidisciplinary team (MDT) developed the pathway iteratively, guided by the updated Medical Research Council framework for complex interventions. Development integrated evidence synthesis, semi-structured interviews with healthcare professionals, programme theory, economic and resource considerations, contextual analysis, and informal consultations with patients and family caregivers. These inputs informed implementation requirements, professional roles, longitudinal care procedures, and core supportive care domains.

Results

Evidence was most extensive for nutritional interventions; evidence for exercise and probiotic approaches was more limited and heterogeneous. Interviews with 21 healthcare professionals generated three themes comprising 11 subthemes, synthesised into four implementation requirements: recognition and professional competency; care organisation and MDT coordination; longitudinal monitoring and continuity of care; and patient self-management and family-supported care. Patient and caregiver consultations informed refinements to education, home-based self-management, and family involvement. The final pathway specified MDT roles, six longitudinal care procedures, and five integrated domains: nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support.

Conclusion

The resulting pathway provides a context-sensitive, implementation-informed structure for coordinating multidisciplinary sarcopenia prevention across the NPC treatment trajectory. It incorporates clinical workflow, resource considerations, and continuity of care, but its feasibility, implementation, and effectiveness require prospective evaluation.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s00520-026-11242-4.

Introduction

Sarcopenia is increasingly recognised as a clinically significant complication in oncology and represents an important supportive care concern for patients with nasopharyngeal carcinoma (NPC) during treatment. Throughout the treatment trajectory, patients commonly experience treatment-related xerostomia, nausea, taste alterations, mucositis, dysphagia, fatigue, and reduced physical activity, all of which may impair dietary intake, accelerate muscle loss, and compromise functional capacity [1–3]. In a cohort of 394 patients with non-metastatic NPC, the prevalence of sarcopenia increased from 33.0% before treatment to 61.2% after chemoradiotherapy [4]. Sarcopenia has been associated with increased treatment toxicity, reduced response to chemotherapy, and poorer clinical outcomes [5]. These consequences highlight the importance of incorporating sarcopenia prevention into proactive supportive care throughout the NPC treatment trajectory [6].

The development of sarcopenia during cancer treatment is multifactorial, reflecting interacting nutritional, inflammatory, metabolic, immune, behavioural, and functional disturbances [7, 8]. In NPC, treatment-related toxicities, particularly those affecting oral intake, swallowing, and salivary function during radiotherapy, may compound these processes and contribute to progressive deterioration in nutritional status, physical activity, and daily functioning [9–11]. Consequently, sarcopenia risk and supportive care needs may change across the treatment trajectory, creating a need for preventive strategies that can respond to patients’ evolving clinical and functional status.

Current approaches to sarcopenia prevention and management in cancer care remain limited and are often delivered as isolated interventions targeting a single aspect of care [12]. Nutritional supplementation is the most common strategy and plays an essential role in maintaining energy and protein intake [13]. However, sarcopenia during cancer treatment arises from the interaction of nutritional compromise, symptom burden, reduced physical activity, treatment-related toxicities, psychological distress, and behavioural challenges [11, 12, 14]. Consequently, interventions focused on nutrition alone may be insufficient to address the complex and evolving factors contributing to muscle loss during definitive treatment. This complexity highlights the need to consider a broader range of supportive care strategies that address the multiple factors influencing muscle health during treatment. Despite this, such integrative approaches remain underdeveloped in NPC care, particularly within real-world clinical settings.

The multidimensional nature of sarcopenia creates challenges not only for identifying effective intervention components, but also for integrating and sustaining supportive care throughout treatment [15]. In many oncology settings, the prevention and management of cancer-related sarcopenia remain fragmented across disciplines and care encounters [16]. Challenges include limited awareness, unclear professional responsibilities, insufficient multidisciplinary coordination, inadequate support for patients and families, and the absence of structured mechanisms to integrate nutritional, physical, behavioural, and symptom-management interventions into routine care [17, 18]. Despite growing recognition of sarcopenia as an important clinical concern, challenges remain in its early identification and management, multidisciplinary care, and recognition among patients and healthcare professionals [19–21].

A structured approach is therefore needed to support the development of a complex, context-sensitive supportive care pathway for sarcopenia prevention. The updated Medical Research Council (MRC) framework for developing and evaluating complex interventions provides a robust methodological basis for integrating evidence, theory, stakeholder perspectives, contextual understanding, economic considerations, and iterative refinement throughout the intervention development process [22]. Given the multifactorial nature of sarcopenia and the complexity of care during definitive treatment, the framework is well suited to guide pathway development within routine NPC oncology practice.

Guided by the updated MRC framework, this study aimed to develop a supportive care pathway for sarcopenia prevention in patients with NPC undergoing definitive treatment. Specifically, the study sought to systematically identify and organise evidence-informed supportive-care components and care processes within a coordinated multidisciplinary framework designed to align with routine oncology practice and support subsequent feasibility and implementation testing. The resulting pathway is intended to support the delivery of longitudinal, patient-centred, and family-supported preventive care that is responsive to both patient needs and real-world clinical contexts.

Methods

Study design

This study focused on the development of a complex intervention and aimed to develop a context-sensitive supportive care pathway for sarcopenia prevention in adults with NPC undergoing definitive treatment. Guided by the updated MRC framework [22], the study did not seek to evaluate effectiveness. Instead, it aimed to transparently describe the processes through which multiple sources of evidence and contextual information were used to develop a pathway prototype for subsequent feasibility testing.

Target population

The preventive supportive care pathway was developed for adults with NPC undergoing definitive treatment who did not have sarcopenia at pathway entry. Patients with established sarcopenia at baseline were outside the preventive scope of the pathway and were directed to multidisciplinary team (MDT)-led assessment and intensified, individualised therapeutic management according to their clinical needs, while clinically indicated supportive care continued.

Operational definition of sarcopenia and pathway risk stratification

Sarcopenia was assessed according to the 2019 Asian Working Group for Sarcopenia (AWGS 2019) criteria [23]. Low muscle mass was defined as a bioelectrical impedance analysis (BIA)–derived appendicular skeletal muscle mass index (ASMI) < 7.0 kg/m² in men and < 5.7 kg/m² in women, low muscle strength as handgrip strength < 28 kg in men and < 18 kg in women, and low physical performance as usual 6-m gait speed <1.0 m/s. Sarcopenia was diagnosed when low muscle mass was accompanied by low muscle strength and/or low physical performance. The same assessment methods and cut-offs were applied at all prespecified assessment time points.

Low muscle mass with preserved strength and physical performance was treated as a pathway-level early-warning state; this operational state corresponds conceptually to the earlier European Working Group on Sarcopenia in Older People (EWGSOP) “pre-sarcopenia” construct but was not treated as an AWGS diagnostic category [24]. Sarcopenia risk also included early deterioration suggesting progression towards sarcopenia, such as a newly abnormal muscle mass, muscle strength, or physical performance measure, or ≥ 2.5% body-weight loss from T0 baseline. These findings triggered MDT review and consideration of intensified supportive care. More substantial deterioration, including ≥ 5% body-weight loss from T0 (baseline), prompted further escalation of nutritional, exercise, and symptom-management support. The ≥ 2.5% and ≥ 5% body-weight-loss thresholds were pragmatic, MDT-agreed pathway triggers for early review and further escalation, respectively; they were not AWGS diagnostic thresholds and should not be interpreted as universally validated sarcopenia cut-offs. If an assessment was temporarily infeasible, the unavailable measure was recorded as missing and repeated when clinically appropriate; sarcopenia status remained unclassifiable until sufficient data were available. Patients who met AWGS 2019 criteria for incident sarcopenia during follow-up underwent prompt MDT reassessment and transitioned from preventive to intensified, individualised therapeutic management, while clinically indicated supportive care components and scheduled outcome assessments continued where feasible.

Ethical considerations

The pathway-development study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University (Approval No. KYLL-2024-0645; March 2024). Healthcare professionals who participated in the qualitative interviews received verbal and written information about the study and provided written informed consent before participation, including consent for the use of anonymised quotations in publications. Patients and family caregivers who participated in the consultation activities received a brief, plain-language explanation of the purpose and nature of the consultation and provided oral informed consent before participation.

Formation of the multidisciplinary team

A multidisciplinary team (MDT) was established to support pathway development, with representation sought from oncology, nursing, dietetics, pharmacy, physiotherapy, and psychology/mental health. Members were purposively selected based on expertise in NPC care, sarcopenia prevention, supportive oncology, or multidisciplinary service delivery. Eligibility criteria included ≥ 15 years of professional experience, a bachelor’s degree or higher, and an associate senior or senior professional rank within their respective discipline.

The MDT served as the core decision-making body throughout pathway development, providing expert input on the selection, adaptation, and refinement of pathway components and supporting the interpretation and application of evidence within the local care context. The principal investigator coordinated MDT activities and facilitated communication across disciplines. Formal participation was confirmed through signed MDT participation agreements.

Foundational evidence identification

Guided by the MDT, foundational evidence identification involved five complementary activities: evidence synthesis, healthcare professional involvement, economic and resource considerations, programme theory development, and contextual analysis. Together, these activities provided the evidentiary, theoretical, and contextual foundation for pathway development and informed the selection, refinement, and implementation planning of pathway components.

Evidence synthesis

To identify relevant evidence for pathway development, we conducted a systematic review of non-pharmacological interventions in patients with NPC undergoing chemoradiotherapy. The review protocol had been published previously [25]. The review was used to identify candidate pathway components, evidence gaps and methodological considerations for sarcopenia prevention during definitive treatment. Literature searches were conducted in major English and Chinese databases, and eligible studies were randomised controlled trials published between November 2014 and November 2024. The search strategy was developed and peer-reviewed by an experienced medical librarian at St. Luke’s International University, Tokyo.

Healthcare professional involvement

An interpretive qualitative study was conducted at the General Hospital of Ningxia Medical University, China, to explore healthcare professionals’ perspectives on sarcopenia prevention and supportive care delivery for patients with NPC undergoing definitive treatment. Purposive sampling was used to recruit healthcare professionals directly involved in NPC care who had at least 6 years of oncology experience. Recruitment was facilitated through departmental meetings and information distributed by unit heads. Participation was voluntary, and unit heads were not informed of individuals’ decisions regarding participation. The healthcare professionals who participated in the qualitative interviews were not members of the MDT responsible for pathway construction and refinement.

Semi-structured face-to-face interviews were conducted between January and February 2025 by a female registered nurse and researcher with oncology experience and training in qualitative methods. Although some participants were professionally acquainted with the interviewer through routine clinical work, no supervisory, evaluative, or managerial relationship existed. Interviews were conducted in a private setting, lasted approximately 35–45 min, and were audio-recorded with participants’ permission and transcribed verbatim. Field notes were taken to document contextual information, non-verbal cues, and immediate reflections.

The interview guide was informed by the literature, expert input, and the Theoretical Domains Framework (TDF) [26, 27]. A common set of questions explored current practices, professional roles, barriers and facilitators, and recommendations for sarcopenia intervention, supplemented by discipline-specific probes. The guide was pilot-tested with three healthcare professionals from different disciplines and subsequently reviewed by two clinical experts for clarity and relevance.

Data were analysed in Chinese using inductive reflexive thematic analysis following Braun and Clarke [28, 29], with the TDF used as a sensitising framework rather than a predefined coding structure. Three researchers (LJX, SL, and SJC) familiarised themselves with the transcripts and generated initial codes. Differences in interpretation were explored through reflexive discussion rather than inter-coder reliability testing, and themes were iteratively developed and refined through research-team discussions. ATLAS.ti version 23.2.1 was used for data management, and coding and theme-development decisions were documented to maintain an audit trail. Reflexivity was addressed through ongoing discussion of the researchers’ professional backgrounds and assumptions throughout data collection and analysis.

Recruitment continued until the research team considered the dataset sufficiently rich to address the study objectives, with later interviews yielding no substantively new insights. All interviews and primary analyses were conducted in Chinese to preserve contextual meaning. Representative quotations selected for reporting were subsequently translated into English and independently cross-checked by a second bilingual researcher, with discrepancies resolved through discussion. For the present pathway-development study, the interview findings were used as one of several developmental inputs and were synthesised to identify implementation requirements and inform pathway design. Online Resource 1 (Supplementary Table S1) presents representative quotations supporting the pathway-relevant findings and maps these findings to corresponding implementation requirements and pathway features. Reporting of the qualitative component was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) [30].

Economic and resource considerations

Economic and resource considerations were incorporated to inform pathway design and enhance its alignment with real-world service constraints. The assessment focused on the affordability, resource implications, and scalability of candidate pathway components rather than on formal economic evaluation.

Using evidence synthesis findings and information on local service capacity, the MDT examined whether components not routinely delivered in standard care, such as vitamin D supplementation and probiotics, could be realistically incorporated into the pathway. The potential value and feasibility of biomarker testing were also considered, particularly where resource-intensive investigations might limit routine implementation. These considerations informed the selection, adaptation, and prioritisation of pathway components for future testing and implementation.

Development of programme theory

Programme theory development was undertaken to identify behavioural mechanisms relevant to patient engagement and self-management during definitive treatment. Evidence synthesis and healthcare professional interviews were reviewed to explore factors that could influence participation in supportive care and adherence to recommended behaviours.

The theory of planned behaviour (TPB) [31] was selected as the theoretical framework to inform the development of the programme theory. The three TPB constructs, namely attitudes, subjective norms, and perceived behavioural control, were used to examine potential influences on patient behaviour and to inform the development of pathway components. The resulting programme theory provided a framework for linking supportive care activities with anticipated behavioural processes during treatment.

Contextual analysis

Contextual analysis was undertaken to inform the development of a pathway responsive to the conditions of routine supportive oncology and suitable for subsequent feasibility and implementation testing. Context was considered broadly to include organisational, health system, clinical, and patient-related factors that could influence pathway delivery and uptake.

The analysis focused on clinical workflow, resource availability, interdisciplinary coordination, follow-up capacity, and patient-specific factors that might affect the acceptability, feasibility, and delivery of the pathway. Particular attention was given to factors that could influence continuity of care across the treatment trajectory and the integration of multidisciplinary supportive care activities.

These findings informed pathway content, delivery procedures, and professional responsibilities, helping to align the pathway with real-world clinical conditions and prepare it for subsequent feasibility and implementation testing.

Pathway development, multidisciplinary review, and finalisation

Candidate intervention components were initially derived from the systematic review of non-pharmacological interventions for patients with NPC undergoing definitive treatment, which served as the primary evidence source for candidate component generation. Findings from healthcare professional interviews, programme theory, contextual analysis, and resource considerations were subsequently used to assess the clinical relevance, implementation requirements, contextual fit, and necessary adaptation of these evidence-derived components.

Two formal MDT meetings were conducted during pathway development, in February and March 2025. Both meetings were conducted face-to-face, lasted approximately 120 min, and were facilitated by the principal investigator. The first meeting aimed to appraise the candidate components identified through the systematic review and determine their suitability for inclusion and adaptation within the local clinical pathway. Components were considered in relation to clinical relevance, safety, anticipated patient burden, compatibility with the definitive treatment trajectory, resource requirements, local availability, and feasibility of delivery within routine care. Based on this appraisal, components were retained, modified, integrated with other components, not carried forward in their original form, or identified for further consideration. Proposed delivery time points and professional responsibilities were also discussed.

Following the first meeting, the preliminary pathway structure was revised. Evidence from healthcare professional interviews, programme theory, contextual analysis, and resource considerations was used to refine the delivery, coordination, adaptation, and implementation support required for the retained components within the local clinical context. Issues that remained unresolved or required further clarification were documented and carried forward to the second MDT meeting.

The second meeting aimed to resolve outstanding issues and finalise the operational structure of the pathway. The MDT reviewed the revised pathway structure, re-examined components requiring further consideration, and agreed on the final selection and operationalisation of pathway components, including their delivery time points, professional responsibilities, and multidisciplinary coordination procedures.

Agreement was reached through multidisciplinary discussion rather than through a formal consensus method such as the Delphi technique, nominal group technique, or formal voting. For the purposes of pathway development, agreement was considered to have been reached when participating MDT members supported the proposed decision and no substantive objection remained unresolved. When differing views arose, the MDT revisited the relevant evidence together with the clinical rationale, safety considerations, anticipated patient burden, resource implications, and local feasibility. Components were modified and re-discussed where necessary, and issues that could not be resolved at the first meeting were carried forward for reconsideration at the second meeting. No unresolved substantive disagreements remained following the second meeting.

A pathway development matrix was used throughout this process to systematically document the progression of each candidate component from initial identification through multidisciplinary team appraisal, refinement, and final operationalisation. The matrix recorded the evidence source and rationale, intended function, feasibility and contextual considerations, proposed timing and responsible professional groups, modifications arising from multidisciplinary team review, and final operational form within the pathway. Decisions and modifications arising from the MDT discussions were documented in the matrix following each meeting. The completed matrix is provided in Online Resource 2 (Supplementary Table S2).

Specification of MDT roles and responsibilities

Discipline-specific roles and responsibilities were specified within the supportive care pathway according to professional expertise and care needs across the treatment trajectory. The allocation clarified responsibility for pathway delivery at different stages of treatment and established referral and communication processes to support timely coordination between disciplines. These role specifications were incorporated into the final pathway framework to promote coordinated and consistent multidisciplinary team supportive care.

Specification of longitudinal care procedures

The MDT translated the proposed pathway into a structured set of longitudinal care procedures that defined how supportive care would be initiated, monitored, escalated, reassessed, and reviewed across the treatment trajectory. The procedures were organised sequentially to support continuity of care and were linked to relevant professional responsibilities, referral processes, and multidisciplinary team communication.

Specifically, the longitudinal pathway incorporated assessment and individualised planning, one-to-one education, weekly monitoring, trigger-based MDT consultation for complex or escalating supportive care needs, scheduled MDT reassessment at key treatment time points, and end-of-treatment MDT review and care summary. Together, these procedures established the operational framework within which supportive care needs could be identified, reviewed, and addressed over time.

Specification of supportive care strategies

Once the longitudinal care procedures had been established, the MDT appraised and organised candidate supportive care strategies for integration within this framework. Drawing on the available evidence, stakeholder input, and contextual considerations, candidate components were considered according to the nutritional risks, treatment-related symptoms and adverse effects, functional decline, and behavioural barriers they were intended to address across the treatment trajectory.

Rather than treating these strategies as isolated interventions, the MDT considered how individual components could be coordinated within a multimodal supportive care approach. For each candidate component, its intended function, target clinical or supportive care need, delivery requirements, responsible discipline(s), feasibility, and need for contextual adaptation were considered. This process informed whether components were retained, modified, integrated, or restricted, and how they were operationalised within the final pathway.

Patient and caregiver consultation

During the early stage of pathway development, informal consultations were conducted with six patients with NPC who were undergoing or had recently completed definitive treatment, together with six family caregivers, at the General Hospital of Ningxia Medical University. Participants were approached by nursing staff and provided with a brief, plain-language explanation of sarcopenia, its relevance during cancer treatment, and the purpose of the proposed preventive pathway. As these consultations were intended to provide contextual and practical input rather than to constitute a formal qualitative study, detailed demographic characteristics beyond participant role and treatment status were not systematically collected.

The consultations focused on participants’ experiences during treatment, supportive-care needs, difficulties related to nutrition and physical activity, home-based self-management, and the role of family members in providing support. Discussions were documented using field notes. Most participants were initially unfamiliar with the term sarcopenia and, following explanation by nursing staff, tended to relate it to the more familiar concept of malnutrition. Their feedback therefore centred primarily on practical supportive-care needs, particularly nutritional support, physical activity, home-based self-management, and family involvement.

The documented feedback was reviewed by the research team as contextual input to pathway development rather than subjected to formal qualitative analysis. It informed selected refinements to the pathway, particularly the content and delivery of one-to-one education, supportive care for home-based self-management, and the involvement of family caregivers.

These activities were classified as informal patient and caregiver consultation rather than formal patient and public involvement or co-development. This classification reflected the nature and extent of participants’ involvement: patients and caregivers provided experiential and contextual input but were not continuing members of the development team, did not participate in iterative pathway decision-making, and did not share responsibility for final pathway decisions.

Overview of the pathway development process

The overall development process is summarised in Fig. 1. Guided by the updated MRC framework, evidence synthesis, healthcare professional perspectives, programme theory, contextual analysis, and economic and resource considerations were integrated through multidisciplinary team appraisal and iterative refinement. The resulting pathway comprised defined multidisciplinary team roles, longitudinal care procedures, and integrated supportive care strategies.

Fig. 1.

Overview of the development process of the supportive care pathway guided by the updated Medical Research Council framework. Note. The figure illustrates how evidence synthesis, healthcare professional involvement, programme theory development, contextual analysis, and economic/resource considerations were integrated through multidisciplinary team review and refinement to develop the final supportive care pathway

Results

Overview of development outputs and final supportive care pathway

The supportive care pathway for sarcopenia prevention in patients with NPC undergoing definitive treatment was developed through an iterative multidisciplinary team process. The final pathway comprised coordinated multidisciplinary team roles, longitudinal care procedures, and integrated supportive care strategies across the treatment trajectory. The overall structure of the final pathway is presented in Fig. 2.

Fig. 2.

Final supportive care pathway for sarcopenia prevention during definitive treatment for nasopharyngeal carcinoma. Note. The pathway integrates longitudinal care procedures across treatment-linked milestones and five supportive care domains: nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support. T0–T8 illustrate the local reference operationalisation of these treatment-linked milestones and may require adaptation to local treatment sequencing and clinical workflow. T0, baseline; T1, 12 ± 2 days after completion of induction chemotherapy; T2, first radiotherapy session; T3, seventh radiotherapy session; T4, 14th radiotherapy session; T5, 21st radiotherapy session; T6, 28th radiotherapy session; T7, end of definitive treatment; T8, 4 weeks post-treatment. MDT, multidisciplinary team; H&N, head and neck; GI, gastrointestinal

The final pathway was organised across treatment-linked milestones from baseline assessment to post-definitive treatment follow-up. It comprised six longitudinal care procedures: assessment and planning, one-to-one education, weekly monitoring, MDT consultation for complex or escalating needs, MDT reassessment at key treatment time points, and end-of-treatment MDT review and care summary. These procedures were embedded within five supportive care domains: nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support.

The pathway was further informed by constructs from the TPB, including attitudes, subjective norms, and perceived behavioural control, which guided the design of patient education, goal setting, feedback, and self-management supportive care strategies during treatment [32].

MDT composition and involvement in pathway development

The MDT comprised 13 healthcare professionals: four physicians, four nurses, two dietitians, one physiotherapist, one clinical pharmacist, and one psychologist. Twelve members attended the first formal pathway-development meeting and 11 attended the second, with all six professional disciplines represented at both meetings. The MDT appraised and refined pathway components using the evidence, stakeholder, theoretical, resource, and contextual inputs described above.

Foundational evidence identification

Evidence-derived priorities for pathway development

The systematic review included 21 studies reported in 22 publications, all conducted in China. Evidence was most extensive for nutritional interventions. Oral nutritional supplementation was associated with attenuation of weight loss and BMI decline and reduced severe oral mucositis, although effects on serum nutritional biomarkers were inconsistent [33–36]. Multicomponent nutritional interventions incorporating nutritional assessment or screening, dietary counselling, individualised intake targets, and symptom management showed broader benefits across nutritional and clinical outcomes [37–43].

Evidence for non-nutritional components was more limited. Probiotic interventions showed potential benefits for selected immune-related outcomes and oral mucositis but were supported by few studies and did not consistently improve body weight or serum nutritional markers [44, 45]. Exercise interventions showed potential benefits for physical fitness, muscle preservation, and fatigue, although the evidence base was small and heterogeneous [46, 47]. Evidence for body-composition and sarcopenia-specific outcomes remained limited.

As most studies evaluated discrete rather than integrated interventions, the evidence supported retaining nutritional management as a core component while incorporating exercise and symptom management and treating less-established components, including probiotic and immune-related approaches, as context-sensitive elements requiring clinical and resource appraisal. These priorities were subsequently integrated with healthcare professional perspectives, programme theory, contextual analysis, and resource considerations during pathway construction.

Healthcare professional stakeholder involvement

Of the 26 healthcare professionals invited, 21 participated in semi-structured interviews, including five physicians, seven nurses, three dietitians, two physiotherapists, two clinical pharmacists, and two psychologists. Reflexive thematic analysis of the healthcare professional interviews generated three overarching themes comprising 11 subthemes: knowledge and competency gaps, structural and implementation barriers, and key intervention suggestions. For pathway-development purposes, these same qualitative findings were subsequently synthesised into four cross-cutting implementation requirements: recognition and professional competency, care organisation and multidisciplinary team coordination, longitudinal monitoring and continuity of care, and patient self-management and family-supported care.

Participants described limited recognition of sarcopenia and practical confidence in its assessment and management, alongside unclear professional responsibilities and fragmented multidisciplinary team care. They emphasised the need for structured longitudinal monitoring across inpatient, outpatient, and home-based periods, with timely referral and care adjustment when deterioration occurred. They also highlighted the importance of ongoing behavioural reinforcement, individualised feedback, and family involvement in supporting nutrition, exercise, and symptom-management behaviours. Table 1 summarises these implementation requirements and resulting pathway design responses; Online Resource 1 (Supplementary Table S1) provides the complete theme- and subtheme-level findings, illustrative quotations, and their translation into pathway features.

Table 1.

Healthcare professional–identified implementation requirements and resulting pathway design responses

Implementation domain	Key healthcare professional–identified requirements	Resulting pathway design response
Recognition and professional competency	Improve recognition of sarcopenia as a clinically important complication during NPC treatment and strengthen practical competency in its assessment, monitoring, and management	Integration of sarcopenia prevention into routine supportive care; sarcopenia-focused HCP education; standardised assessment and monitoring procedures; practical tools and role-specific guidance.
Care organisation and multidisciplinary coordination	Establish standardised care processes, clarify professional responsibilities, and strengthen multidisciplinary coordination and decision-making	Defined MDT roles and responsibilities; nurse-led coordination; structured assessment, referral and care-adjustment procedures; trigger-based MDT consultation for complex or escalating needs; scheduled MDT reassessment at key treatment time points
Longitudinal monitoring and continuity of care	Maintain monitoring and supportive care across inpatient, outpatient, and home-based treatment periods, with timely feedback, referral, and individualised adjustment when problems emerge	Baseline assessment and individualised planning; weekly monitoring; reassessment at key treatment time points; longitudinal follow-up; monitoring of nutritional status, physical function, symptoms, adherence, and treatment-related adverse effects
Patient self-management and family-supported care	Strengthen patient education, behavioural reinforcement, and family involvement to support sustained nutrition, exercise, and symptom-management behaviours outside hospital-based encounters	One-to-one education; MDT-reviewed educational materials; theory of planned behaviour–informed behavioural support; tailored feedback; family participation in education and care; home-based guidance for nutrition, exercise, and symptom management

HCP healthcare professional(s), MDT multidisciplinary team, NPC nasopharyngeal carcinoma

Resource- and feasibility-informed pathway decisions

The MDT made several pragmatic decisions to balance clinical relevance with affordability, local availability and scalability, particularly for vitamin D supplementation, probiotic support, and immune and nutritional status monitoring.

For vitamin D supplementation, routine supplementation was not adopted; it was restricted to patients with documented vitamin D deficiency, with classification, dosing, and monitoring following locally approved laboratory and clinical procedures. This context-sensitive decision considered available evidence, safety, cost, and local feasibility, together with emerging evidence on the clinical relevance of vitamin D status in head and neck cancer and NPC [48, 49].

Probiotic support was retained as a context-adaptable rather than universally fixed pathway component because the formulations evaluated in NPC trials were not fully matched by locally available products and similar products had limited routine affordability [44, 45]. Product selection therefore depended on local formulary availability, affordability, clinical appropriateness, gastrointestinal tolerance and patient preference; detailed operational specifications are provided in Online Resource 3 (Supplementary Table S3).

For immune and nutritional status monitoring, repeated specialised immunological testing was considered too resource-intensive for routine longitudinal care. The MDT therefore selected global immune-nutrition-inflammation index (GINI), hemoglobin, albumin, lymphocyte, and platelet (HALP) score, and prognostic nutritional index (PNI) as pragmatic supplementary monitoring measures derived from routinely collected clinical parameters. These indices were not used as standalone diagnostic or intervention thresholds; their trends were interpreted alongside body weight, oral intake, nutritional status, sarcopenia-related measures, symptoms, and treatment tolerance to inform reassessment and MDT consideration of supportive care modification or intensification.

Programme theory for patient engagement and self-management

Programme theory development identified patient engagement and self-management as important considerations for pathway delivery. Evidence synthesis and healthcare professional interviews indicated that treatment-related symptoms, psychological distress, and reduced confidence could affect participation in supportive care during definitive treatment [50–52].

The TPB was used to organise these findings into three behavioural domains: attitudes, subjective norms, and perceived behavioural control. This analysis highlighted the importance of strengthening patients’ understanding of sarcopenia prevention, fostering support from family members and healthcare professionals, and enhancing confidence in managing treatment-related challenges. These insights informed the specification of behaviourally oriented pathway components and patient engagement strategies across the treatment trajectory [53].

These constructs were operationalised through one-to-one education, goal setting, family and healthcare professional reinforcement, tailored feedback, and psycho-behavioural support. Improved understanding and positive beliefs were expected to strengthen attitudes towards preventive behaviours; family and professional reinforcement was intended to strengthen supportive subjective norms; and individualised guidance, goal setting, and feedback were intended to enhance perceived behavioural control. Together, these mechanisms were hypothesised to strengthen engagement and adherence to nutritional, exercise, symptom-management, and self-management recommendations. Improved adherence was, in turn, expected to support nutritional intake, physical activity, and functional maintenance during definitive treatment, thereby reducing deterioration in muscle mass, muscle strength, and physical performance and ultimately lowering the risk of sarcopenia. These relationships represent hypothesised mechanisms of action and require empirical evaluation.

Contextual considerations shaping implementation fit

Contextual analysis highlighted the need for clearly defined professional roles and coordination because supportive care responsibilities were distributed across multiple disciplines. The prolonged and dynamic treatment trajectory also required longitudinal rather than episodic care, with reassessment and adaptation as patients’ needs changed. In addition, preventive recommendations needed to be translated into practical actions that patients and families could sustain despite symptom burden, treatment fatigue, and competing care demands. Family involvement was therefore considered important for supportive care delivery beyond the clinical setting. Together, these considerations informed the pathway’s emphasis on multidisciplinary team coordination, longitudinal management, and patient- and family-supported care.

Core and adaptable pathway elements

The MDT distinguished between core pathway functions and context-adaptable operational elements. Core functions were those considered necessary to preserve the intended logic of the pathway, including structured assessment and risk identification, individualised nutritional management, exercise management, symptom management, psycho-behavioural support, longitudinal monitoring, and multidisciplinary team coordination and escalation. In contrast, specific products, supplementation regimens, probiotic formulations, nutritional and immune-status monitoring measures, professional task allocation, and alignment with local treatment workflows were considered adaptable according to local resources and service structures, provided that the underlying function and safety requirements were maintained.

Construction of the multimodal supportive care pathway

Following two rounds of MDT review and refinement, candidate components were adapted and operationalised for the local clinical context; their development sources, appraisal, modifications, and final operational forms are documented in Online Resource 2 (Supplementary Table S2). The final pathway comprised three interconnected structural elements: MDT roles and workflows, six longitudinal care procedures, and five supportive care domains, integrated across the treatment trajectory to address nutritional, functional, symptom-related, and psycho-behavioural contributors to sarcopenia risk.

The pathway-development process preceded the subsequently published pilot randomised controlled trial protocol [54]. The pilot protocol operationalised the same underlying pathway for feasibility testing and therefore shares its MDT structure, longitudinal procedures, and principal supportive care components. The present study instead reports how these elements were generated, appraised, and refined. Online Resource 3 (Supplementary Table S3) provides component-level operational specifications and distinguishes core pathway requirements, context-adaptable elements, and pilot-reference parameters. Pilot-specific doses, schedules, frequencies, and treatment-phase parameters are presented for reproducibility rather than as universally fixed pathway requirements [54]. Psycho-behavioural support is presented explicitly as a domain in this developmental report to clarify its programme-theory function, rather than as a substantive change to the underlying intervention.

Defined MDT roles and coordinated workflow

The final pathway assigned discipline-specific responsibilities within a coordinated MDT workflow. Physicians oversaw clinical assessment and diagnosis, medical and supportive interventions, management of treatment-related symptoms and comorbidities, and rehabilitation-related clinical oversight. Nurses conducted comprehensive assessment and patient education, monitored nutritional status and treatment-related complications, supported pathway implementation, and coordinated MDT communication. Dietitians developed and adjusted individualised nutritional management plans according to patients’ evolving needs. Physiotherapists assessed functional capacity, designed and modified individualised rehabilitation, guided safe physical activity, and conducted initial screening for swallowing-related problems. This screening supported early identification and did not replace comprehensive specialist swallowing assessment; further assessment or management was referred to an appropriately qualified professional. Where swallowing screening or assessment is undertaken by speech and language therapists or other professionals, responsibility may be reassigned according to local scope of practice. Psychologists assessed and managed psychological distress and supported behavioural adaptation across treatment. Clinical pharmacists supported management of treatment-related adverse effects and pharmacological and nutrition-related symptom management.

Longitudinal care procedures and timeline

The pathway comprised six core longitudinal care procedures: assessment and planning, one-to-one education, weekly monitoring, MDT consultation for complex or escalating needs, MDT reassessment at key treatment time points, and end-of-treatment MDT review and care summary. Their purposes and key operational criteria are summarised in Table 2. In the subsequent pilot reference implementation, the pathway spanned approximately 120–140 days, including 3–4 cycles of induction chemotherapy followed by 31–33 radiotherapy sessions with at least two cycles of concurrent chemotherapy [54].

Table 2.

Core longitudinal procedures and implementation criteria of the developed supportive care pathway

Procedure	Purpose within the pathway	Key operational elements and implementation criteria
Assessment and planning	Identify baseline risks and establish an individualised supportive care plan	MDT-led baseline assessment at T0, including sarcopenia status, nutritional status, symptoms, functional capacity, and psychosocial risks. Findings are used to stratify risk and develop an individualised care plan
One-to-one education	Enhance patient understanding, engagement, and self-management capacity	Nurse-led education with MDT support begins at pathway entry and is reinforced throughout treatment according to individual needs. Education covers sarcopenia prevention, nutrition, exercise, symptom management, and home-based self-management. Family involvement is encouraged and incorporated where appropriate and with the patient’s agreement
Weekly monitoring	Identify early deterioration and enable timely supportive-care adjustment	Nurses conduct weekly monitoring of body weight, oral intake, nutritional status, functional changes, symptoms, exercise adherence, treatment tolerance, and patient concerns. Findings are reviewed against predefined escalation criteria, including ≥ 2.5% body weight loss from T0 baseline, inadequate nutritional intake, worsening symptoms, functional decline, or poor adherence, with referral to relevant MDT members when required
MDT consultation for complex or escalating needs	Provide coordinated multidisciplinary decision-making when supportive-care needs become complex or clinically significant deterioration occurs	Trigger-based MDT consultation is initiated for clinically meaningful deterioration or complex supportive-care needs, including ≥ 2.5% body weight loss from T0 baseline, emerging sarcopenia risk, persistent or severe symptoms, nutritional or functional decline, exercise intolerance, high fall risk, or other concerns requiring multidisciplinary input. The MDT reviews contributing factors and modifies or intensifies the care plan as appropriate
MDT reassessment at key treatment time points	Evaluate treatment-related changes and adjust supportive-care intensity at key treatment milestones	Scheduled MDT reassessment is conducted at predefined treatment milestones. The MDT reviews changes in nutritional and functional status, symptoms, adherence, treatment tolerance and safety, and adjusts supportive-care strategies according to the patient’s current risk status
End-of-treatment MDT review and care summary	Review pathway delivery, consolidate care outcomes, and identify ongoing supportive-care needs	At completion of definitive treatment, the MDT and nurse coordinator conduct an end-of-treatment review and prepare a concise care summary covering clinical changes, interventions provided, adherence, referrals, safety events, and unresolved supportive care needs. Patients requiring continued support are referred for appropriate follow-up management

MDT multidisciplinary team, T0 baseline; safety-related temporary-suspension, resumption, and permanent-discontinuation criteria are described in the main text. The complete prespecified safety framework is reported in the published pilot randomised controlled trial protocol [54]

The local reference schedule included assessments and reviews at baseline (T0), 12 ± 2 days after induction chemotherapy (T1), the first radiotherapy session (T2), the 7th, 14th, 21 st, and 28th radiotherapy sessions (T3–T6), the end of definitive treatment (T7), and 4 weeks post-treatment (T8). These time points were selected based on clinical experience to capture treatment-related changes across the treatment trajectory, with particular consideration given to the evolution of radiation-induced oral mucositis during head and neck radiotherapy [55]. The specific T0–T8 schedule represents the local reference operationalisation of the pathway and may be adapted to local treatment sequencing and clinical workflow while preserving the underlying functions of longitudinal monitoring and reassessment.

For deterioration in oral intake, functional decline, and exercise intolerance, no universal numerical cut-offs were prespecified because these changes were interpreted in relation to symptom burden, treatment tolerance, baseline functional status, and the patient’s overall clinical condition. Nevertheless, clinically meaningful deterioration in any of these areas was treated as a predefined trigger for supportive care reassessment, modification or intensification, and/or MDT review.

Safety-related pathway principles and pilot reference criteria

At pathway level, clinical deterioration that could make continued participation in a supportive care component unsafe prompted clinical reassessment and appropriate modification or temporary withholding of that component, without interruption of clinically necessary symptom management, hydration, nutritional support, or medical treatment. In the subsequent pilot reference implementation, this safety principle was operationalised using protocol-defined criteria for urgent reassessment, temporary suspension, resumption, and discontinuation [54]. These pilot-specific numerical thresholds and procedures are summarised in Online Resource 3 (Supplementary Table S3) and the published pilot protocol and were not intended as universally fixed pathway requirements.

Strategic domains of the pathway

The final pathway comprised five strategic domains: nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support. The intended purpose and rationale for inclusion of each domain are presented in Table 3. These domains were selected to address modifiable contributors to sarcopenia risk during definitive treatment, including nutritional deterioration, reduced physical activity, treatment-related symptom burden, and behavioural barriers to sustained self-management.

Table 3.

Strategic domains of the developed supportive care pathway

Strategic domain	Intended purpose	Rationale for inclusion
Nutritional and immune management	To support adequate nutritional intake and nutritional status during definitive treatment, with supplementary monitoring of immune-nutritional and inflammatory status	Nutritional deterioration contributes to sarcopenia risk and may compromise treatment tolerance. Nutritional support is therefore integrated with symptom-responsive care. GINI, HALP, and PNI provide supplementary longitudinal information on nutritional, immune, and inflammatory status to inform reassessment and MDT decision-making; they are not used as standalone diagnostic criteria or independent intervention thresholds.
Exercise management	To help preserve muscle mass, physical function, and activity tolerance during treatment	Reduced physical activity and treatment-related deconditioning were identified as modifiable contributors to sarcopenia risk. Exercise guidance needed to be tailored to treatment stage, symptoms, and functional capacity.
Head and neck symptom cluster management	To reduce local treatment-related barriers to eating, swallowing, communication, and daily functioning	Patients receiving treatment for NPC commonly experience oral, swallowing, taste, and radiation-related symptoms. These symptoms may compromise nutritional intake, adherence to supportive care, and quality of life.
Gastrointestinal symptom cluster management	To manage gastrointestinal symptoms that may interfere with intake, hydration, and treatment tolerance	Gastrointestinal symptoms may aggravate nutritional deterioration, reduce adherence to nutritional and exercise recommendations, and increase the risk of treatment-related decline.
Psycho-behavioural support	To strengthen self-efficacy, perceived control, adherence, and sustained engagement in self-management	By targeting attitudes, subjective norms, and perceived behavioural control, psycho-behavioural support is expected to improve adherence to nutritional, exercise, and self-management recommendations, thereby supporting nutritional intake, physical activity, and functional maintenance relevant to sarcopenia prevention.

GINI global immune-nutrition-inflammation index, HALP hemoglobin, albumin, lymphocyte, and platelet, MDT multidisciplinary team, NPC nasopharyngeal carcinoma, PNI prognostic nutritional index

Patient education materials

A patient education booklet, Staying Strong: A Guide to Preventing Sarcopenia in NPC Patients, was adapted from existing institutional materials to standardise one-to-one education and support patient and family engagement. It covered sarcopenia and NPC, psychological preparation, chemotherapy and radiotherapy, treatment-related adverse effects and their management, dietary guidance, and exercise guidance. Following multidisciplinary review, the booklet was refined to clarify sarcopenia-related concepts, strengthen guidance on treatment-related adverse effects and infection prevention, and include potential long-term radiotherapy complications. These revisions aligned the material with the pathway domains and implementation needs identified during development.

Discussion

Principal interpretation and contribution

The principal contribution of this study lies not in demonstrating clinical effectiveness, which remains to be evaluated, but in providing a transparent and theoretically informed approach to pathway development. The findings support conceptualising sarcopenia prevention during NPC treatment as a coordinated supportive care process rather than a series of isolated interventions. The developed pathway therefore links nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support through longitudinal assessment, monitoring, multidisciplinary team referral, and care adjustment across the treatment trajectory.

The evidence base supporting these components was uneven. Nutritional interventions were comparatively better supported, and multicomponent nutritional approaches that combined assessment, dietary counselling, intake targets, and symptom management were associated with broader nutritional and clinical benefits [37–43]. In contrast, evidence for probiotic and exercise approaches was more limited, with heterogeneous protocols and uncertain effects on sarcopenia-specific, nutritional, and immune outcomes [44–47]. The pathway should therefore not be interpreted as an evidence-proven multimodal intervention. Rather, evidence-informed components were integrated with healthcare professional perspectives, programme theory, contextual analysis, and economic and resource considerations through multidisciplinary appraisal. This is consistent with contemporary complex-intervention guidance, which emphasises the integration of evidence, theory, context, stakeholder perspectives, and implementation considerations during development [22].

A key feature of the pathway is its preventive and adaptive orientation. Nutritional intake, treatment-related symptoms, physical function, treatment tolerance, and self-management capacity may change substantially across treatment, making a fixed intervention package unlikely to remain appropriate throughout the trajectory. Repeated assessment and predefined escalation processes therefore function not only as monitoring activities but also as mechanisms for adapting care to emerging risk and patient tolerance. This is particularly relevant because sarcopenia and nutritional deterioration are associated with adverse treatment and clinical outcomes, while head and neck cancer care involves changing nutritional and symptom-related needs across treatment [56]. The pathway consequently conceptualises prevention as dynamic risk management, shifting supportive care from episodic management of established problems towards earlier, coordinated, and proactive care.

Implementation mechanisms and context

Implementation considerations were incorporated during development rather than deferred until after pathway design. Component selection and operationalisation were considered in relation to staffing, resource availability, monitoring capacity, referral mechanisms, affordability, and existing clinical workflows. This was particularly important for context-sensitive elements such as specialised immune monitoring, vitamin D supplementation, and probiotic support, for which evidence, cost, availability, and routine-care feasibility varied. The resulting pathway therefore distinguishes core supportive care functions from operational forms that may require contextual adaptation, consistent with complex-intervention and integrated-care perspectives that emphasise functional integrity, responsiveness to context, and coordination across the care continuum [57, 58].

Psycho-behavioural support was expected to influence sarcopenia-related outcomes indirectly through patient engagement and adherence. Guided by the TPB [31, 32], education, goal setting, tailored feedback, family reinforcement, and supported self-management targeted attitudes, subjective norms, and perceived behavioural control to strengthen adherence to nutritional, exercise, and symptom-management recommendations. Improved adherence was expected to support nutritional intake, physical activity, and timely symptom management, thereby helping to preserve muscle mass, strength, and physical function. Self-management was conceptualised as a supported process involving patients, caregivers, and healthcare professionals rather than transferring responsibility to patients. As adherence and TPB constructs were not directly evaluated, these mechanisms remain theoretical and require empirical testing.

Multidisciplinary coordination represents a second implementation mechanism. Healthcare professional interviews identified unclear responsibilities, fragmented referral, and inconsistent follow-up as barriers to sarcopenia-related supportive care. The pathway therefore specifies professional responsibilities, communication and referral processes, weekly monitoring, MDT consultation for complex or escalating needs, and MDT reassessment at key treatment time points. These functions are intended to move care beyond the presence of multiple disciplines towards coordinated accountability, in which emerging risks are linked to a defined response and responsible professional. In the present setting, nurses were positioned to play an important coordinating role because of their regular patient contact; however, this function is context-sensitive and may be undertaken by other appropriately positioned professionals in different healthcare systems.

Implications, transferability, and future evaluation

The pathway should be viewed as an implementation-informed framework for organising sarcopenia-related supportive care rather than a novel standalone intervention. Because the evidence synthesis and pathway development were situated predominantly within the Chinese healthcare context, transferability should be understood at the level of core functions rather than identical operational forms. Professional roles, assessment and monitoring approaches, treatment-linked timing, intervention products, laboratory monitoring, and delivery schedules may require adaptation according to local scope of practice, staffing and rehabilitation resources, treatment workflows, product and formulary availability, affordability, and laboratory capacity, while preserving the intended function and safety logic of the pathway.

The subsequently published pilot randomised controlled trial protocol [54] operationalised the same underlying pathway for feasibility testing and should therefore be regarded as a reference implementation rather than evidence of established feasibility, implementation or effectiveness. Prospective evaluation should assess acceptability, fidelity, adoption, appropriateness, workflow integration, and sustainability before adequately powered studies evaluate sarcopenia-related and broader patient-centred outcomes. Future refinement should also incorporate more structured patient and caregiver involvement.

Limitations

Several limitations should be acknowledged. First, this study focused on pathway development and did not empirically evaluate feasibility, acceptability, fidelity, adoption, sustainability, or clinical effectiveness. The pathway should therefore be regarded as a theoretically and contextually informed framework requiring prospective evaluation before wider routine implementation.

Second, evidence supporting individual pathway components was uneven. Nutritional interventions were comparatively better supported, whereas evidence relating to exercise, immune-related approaches, body composition, and sarcopenia-specific outcomes remained limited or heterogeneous. Some pathway elements were therefore informed by a combination of emerging evidence, theoretical rationale, clinical relevance, multidisciplinary judgement, and contextual feasibility rather than equivalent levels of demonstrated effectiveness.

Third, the evidence synthesis and pathway development were situated predominantly within the Chinese healthcare context. Local staffing models, professional scopes of practice, treatment workflows, resource availability, and institutional capacity may limit direct transferability, and the feasibility of adapting core functions to other settings requires empirical evaluation.

Fourth, patient and family caregiver involvement was limited to informal consultation rather than formal and sustained co-development. Although these consultations informed selected pathway features, patients and caregivers were not continuing partners in iterative pathway decision-making. Future work should incorporate more structured involvement to better address treatment burden, acceptability, communication needs, and the feasibility of home-based supportive care.

Conclusion

This study developed a context-sensitive and implementation-informed supportive care pathway for sarcopenia prevention in patients with NPC undergoing definitive treatment. The pathway conceptualises prevention as a longitudinal, multidisciplinary process integrating nutritional and immune management, exercise management, head and neck symptom cluster management, gastrointestinal symptom cluster management, and psycho-behavioural support. By incorporating organisational, resource, and contextual considerations during development, it provides a structured framework for subsequent feasibility and implementation testing. Future research should evaluate its feasibility, acceptability, implementation, and effectiveness before wider integration into routine cancer care.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Lijuan Xia: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Project administration, Funding Acquisition. Sujuan Chen: Investigation, Data curation, Formal analysis. Jia Min: Investigation, Data curation, Formal analysis, Validation. Zhifang Ma: Investigation, Validation. Yuning Zhang: Investigation, Software, Data curation. Fengfei Zhang: Investigation, Data curation, Formal analysis. Sha Liu: Investigation, Data curation, Formal analysis, Validation. Bin Yan: Methodology, Data curation, Formal analysis. Naoko Hayashi: Supervision, Methodology, Project administration, Writing - Review & Editing.

Funding

This research was funded by the Ningxia Natural Science Foundation, China, grant number 2024AAC03617. The funders had no role in the design of this study; the collection, analysis, or interpretation of data; the writing of the manuscript; or the decision to publish the results.

Data availability

De-identified qualitative data supporting the findings of this study may be available from the corresponding author upon reasonable request, subject to ethical and confidentiality considerations.

Declarations

Ethics approval

This study was conducted in accordance with the Declaration of Helsinki. The pathway-development study was approved by the Ethics Committee of the General Hospital of Ningxia Medical University (Approval No. KYLL-2024-0645; March 2024). Healthcare professionals who participated in the qualitative interviews provided written informed consent before participation, including consent for the use of anonymised quotations in publications. Patients and family caregivers who participated in the consultation activities provided oral informed consent before participation.

Consent for publication

Healthcare professionals who participated in the qualitative interviews provided written informed consent for the use of anonymised quotations in publications. No identifiable participant information is reported.

Competing interests

The authors declare no competing interests.