The Effect of Dietary Intervention Along with Nutritional Education on Reducing the Gastrointestinal Side Effects Caused by Chemotherapy Among Women with Breast Cancer

Non-pharmacological interventions for chemotherapy-induced diarrhoea and constipation management: A scoping review

PURPOSE

Chemotherapy-induced diarrhoea (CID) and constipation (CIC) are among the most common and severe gastrointestinal symptoms related to chemotherapy. This review aimed to identify and describe the evidence for non-pharmacological interventions for the management of CID and CIC.

METHODS

The scoping review was based on the Joanna Briggs Institute methodology and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Evidence from five databases were included: CINAHL, MEDLINE, Embase, PubMed, and APA PsycInfo. Data were systematically identified, screened, extracted and synthesised narratively to describe the evidence for non-pharmacological interventions and their effects on CID and CIC.

RESULTS

We included 33 studies, of which 18 investigated non-pharmacological interventions for CID management, six for CIC management, and nine for both CID and CIC management. Interventions were categorized into five groups, including (1) digital health interventions, (2) physical therapies, (3) diet and nutrition therapies, (4) education, and (5) multimodal. Diet and nutrition therapies were the most common to report potential effectiveness for CID and CIC outcomes. Most of the interventions were implemented in hospitals under the supervision of healthcare professionals and were investigated in randomised control trials.

CONCLUSIONS

The characteristics of non-pharmacological interventions were diverse, and the outcomes were inconsistent among the same type of interventions. Diet and nutritional interventions show promise but further research is needed to better understand their role and to contribute to the evidence base. Nurses are well placed to assess and monitor for CIC and CID, and also deliver effective non-pharmacological interventions.

Effects of food-based interventions in the management of chemoradiotherapy-induced nausea and vomiting: a systematic review

BACKGROUND

Cancer treatment-related nausea and vomiting continue to be common and distressing symptoms for patients, despite improvements in antiemetics. Dietary modifications could potentially improve this symptom experience. Clinicians frequently provide dietary advice to patients, although the evidence base of such suggestions or recommendations is not clear.

PURPOSE

This systematic review aimed to examine the current literature on food interventions associated with improvements in cancer treatment-related nausea and vomiting.

METHODS

Eight electronic databases were searched with a specific search term strategy covering trials without time or language limitations. Eligible studies focused on a food substance, defined as any nutritious substance that people eat or drink to maintain life and well-being. Trials in children and adults during chemotherapy or radiotherapy were included. Cochrane risk of bias tool was used to assess trial quality and GRADE was used to assess the certainty in the effect of each outcome.

RESULTS

Seventeen trials were included, 3 focusing on children and 14 on adults. Two trials included patients receiving radiation. Ten out of 17 trials (59%) had a high risk of bias. Strongest evidence with highest certainty was found for dietary counseling to meet macronutrient requirements in reducing incidence of radiotherapy-related nausea and vomiting in adults (n=2 studies; n=124 participants; GRADE level: moderate). There was also moderate certainty in the beneficial effect of protein supplementation on nausea and vomiting incidence in adults during radiotherapy (n=2 studies; n=124 participants; GRADE level: moderate). A significant positive effect on CINV incidence and/or severity in adults was also found for dietary counseling to meet macronutrient requirements during chemotherapy, a peppermint drink, scaly wood mushroom, chamomile, protein with ginger, and a colorless odorless diet (GRADE level: low to very low).

CONCLUSIONS

The review identified food-based approaches that could improve the nausea and vomiting experience in patients with cancer and provide guidance to clinicians. However, confidence in these findings was low and studies were heterogeneous and mostly of low quality, requiring further investigation before stronger recommendations can be made. Future research is needed to confirm efficacy and safety.

TRIAL REGISTRATION

PROSPERO CRD42022341154.

Therapeutic Fasting in Reducing Chemotherapy Side Effects in Cancer Patients: A Systematic Review and Meta-Analysis

The aim of this study was to assess the available evidence regarding the effect of a variety of fasting-like regimens on preventing chemotherapy-related side effects. PubMed, Scopus and Embase were used to select the studies for this review, which concluded on 24 November 2022. All types of clinical trials and case series reporting chemotherapy toxicity associated with fasting regimens and any comparison were considered. A total of 283 records were identified, of which 274 were excluded, leaving only nine studies that met the inclusion criteria. Five of these trials were randomized. Overall, moderate to high-quality evidence showed that several fasting regimens did not provide benefits compared to a conventional diet or other comparators in reducing the risk of adverse events. The overall pooled estimate for a variety of fasting regime when compared to non-fasting, indicated no significant difference in the side effects (RR = 1.10; 95% CI: 0.77-1.59; I² = 10%, p = 0.60), including neutropenia alone (RR = 1.33; 95% CI: 0.90-1.97; I² = 0%, p = 0.15). A sensitivity analysis confirmed these results. Based on our systematic review and meta-analysis, there is currently no evidence supporting the superiority of therapeutic fasting over non-fasting in preventing chemotherapy toxicity. The development of cancer treatment that do not entail toxicities remains imperative.

Interaction between carbon dots from folic acid and their cellular receptor: a qualitative physicochemical approach

According to the World Health Organization, the number of cancers (all cancers, both sexes, all ages and worldwide) in 2020 reached a total of 19 292 789 new cases leading to 9 958 133 deaths during the same period. Many cancers could be cured if detected early. Preventing cancer and detecting it early are two essential strategies for controlling this pathology. For this purpose, several strategies have been described for imaging cancer cells. One of them is based on the use of carbon nanoparticles called carbon dots, tools of physical chemistry. The literature describes that cancer cells can be imaged using carbon dots obtained from folic acid and that the in cellulo observed photoluminescence probably results from the interaction of these nanoparticles with the folic acid-receptor, a cell surface protein overexpressed in many malignant cells. However, this interaction has never been directly demonstrated yet. We investigated it, for the first time, using (i) freshly synthesized and fully characterized carbon dots, (ii) folate binding protein, a folic acid-receptor model protein and (iii) fluorescence spectroscopy and isothermal titration calorimetry, two powerful methods for detecting molecular interactions. Our results even highlight a selective interaction between these carbon made nano-objects and their biological target.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Assessing Impact of Nutrition Care by Registered Dietitian Nutritionists on Patient Medical and Treatment Outcomes in Outpatient Cancer Clinics: A Cohort Feasibility Study

More information is needed about the impact of outpatient nutrition care from a registered dietitian nutritionist (RDN) on patient outcomes. This study aimed to assess the feasibility of a cohort study design to evaluate impact of RDN nutrition care on patient outcomes, describe clinic malnutrition screening practices, and estimate statistical parameters for a larger study. Seventy-seven patients with lung, esophageal, colon, rectal, or pancreatic cancer from six facilities were included (41 received RDN care and 36 did not). RDN nutrition care was prospectively documented for six months and documented emergency room visits, unplanned hospitalizations and treatment changes were retrospectively abstracted from medical records. Most facilities used the Malnutrition Screening Tool (MST) to determine malnutrition risk. Patients receiving RDN care had, on average, five, half hour visits and had more severe disease and higher initial malnutrition risk, although this varied across sites. Documented medical and treatment outcomes were relatively rare and similar between groups. Estimated sample size requirements varied from 113 to 5856, depending on tumor type and outcome, and intracluster correlation coefficients (ICCs) ranged from 0 to 0.47. Overall, the methods used in this study are feasible but an interventional or implementation design might be advantageous for a larger study.

An early interactive human coaching via a mobile application to improve quality of life in patients who underwent gastrectomy for gastric cancer: Design and protocol of a randomized controlled trial

BACKGROUND

After gastrectomy, patients may experience the postgastrectomy syndrome and face difficulties adapting to everyday diet. Recently, human health coaching via a mobile application (app) has been used for obese patients or patients with chronic diseases, with significant improvements in clinical outcomes. The aim of this study is to evaluate and compare the effects of human health coaching via a mobile app and conventional face-to-face counseling in patients who underwent gastrectomy for gastric cancers.

METHODS

This study is a single-institution, prospective randomized controlled trial comparing the mobile health and face-to-face counselling groups. After randomization, participants assigned to the mobile health coaching group will receive health coaching via a mobile app for 3 months after discharge, and the assigned coaches will provide personalized advice based on the self-recorded health data. Participants in the face-to-face group will have 1- and 3-months postoperative dietary consultations with a clinical dietitian. The primary endpoint is the food restriction score on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-STO22, and secondary endpoints included all other quality of life scale scores and nutritional parameters. The calculated sample size is 180, and the outcomes will be measured until 1-year post-surgery.

SIGNIFICANCE

This study will show the efficacy of human health coaching via a mobile app on dietary adaptation in patients who underwent gastrectomy. A relational approach based on personal data and timely intervention using a mobile platform could reduce patients' trial and error and improve quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04394585, Registered 19 May, 2020 -Retrospectively registered, http://clinicaltrials.gov/ct2/show/NCT040394585.

Dietary strategies for chemotherapy-induced nausea and vomiting: A systematic review

BACKGROUND & AIMS

Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing cancer treatment side effects, affecting 20-70% of patients despite routine antiemetic prescription. Although dietary modifications are routinely recommended in clinical practice, there is lack of data synthesis to determine which dietary strategies for managing CINV are supported by quality evidence. This systematic review was conducted to examine the effect of dietary strategies on incidence and severity of CINV in adults compared with no intervention, usual care, or alternative strategies.

METHODS

Five electronic databases were searched from inception to 15th July 2021 for original research studies of interventional or observational design assessing dietary strategies for CINV. The quality of evidence was appraised, data were synthesized narratively, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment of the certainty of the evidence was applied.

RESULTS

Twenty-one studies were included, 10 (48%) interventional studies and 11 (52%) observational studies. Most interventional and observational studies had a high or neutral risk of bias (70% and 72%, respectively). Of the interventions studied, strongest evidence with highest certainty was found for the very large positive effect of CINV-specific education and support with a personalized meal plan from a dietician, implemented in person or in writing, for reducing the severity of nausea and overall CINV (effect size: very large; GRADE: high). A statistically significant very large positive effect of ginger tea consumption was also found on overall CINV severity; however, certainty in this effect was very low. Although confidence in the findings from observational studies was very low to low, a statistically significant positive association was also found between a moderate intake of alcohol and incidence of nausea, vomiting, or overall CINV as well as nausea severity; the Mediterranean diet and nausea incidence and severity; and adequate intake of energy, protein, fat, or carbohydrate and nausea or vomiting incidence.

CONCLUSION

Improved CINV was associated with CINV-specific nutrition education and support from health professionals. Non-restrictive dietary patterns that include adequate energy and macronutrient intakes, particularly protein, and include ginger, and Mediterranean diet concepts may benefit CINV; however, the confidence in the body of evidence to inform these conclusions is mostly very low to moderate. Future rigorous trials with adequate sample sizes, clearly defined dietary strategies, and valid outcome measures are warranted prior to dietary strategies being routinely prescribed alongside antiemetic regimens.

Adipose tissue-to-breast cancer crosstalk: Comprehensive insights

The review focuses on mechanistic evidence for the link between obesity and breast cancer. According to the IARC study, there is sufficient evidence that obesity is closely related to a variety of cancers. Among them, breast cancer is particularly disturbed by adipose tissue due to the unique histological structure of the breast. The review introduces the relationship between obesity and breast cancer from two aspects, including factors that promote tumorigenesis or metastasis. We summarize alterations in adipokines and metabolic pathways that contribute to breast cancer development. Breast cancer metastasis is closely related to obesity-induced pro-inflammatory microenvironment, adipose stem cells, and miRNAs. Based on the mechanism by which obesity causes breast cancer, we list possible therapeutic directions, including reducing the risk of breast cancer and inhibiting the progression of breast cancer. We also discussed the risk of autologous breast remodeling and fat transplantation. Finally, the causes of the obesity paradox and the function of enhancing immunity are discussed. Evaluating the balance between obesity-induced inflammation and enhanced immunity warrants further study.

Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline

PURPOSE

To provide guidance on exercise, diet, and weight management during active cancer treatment in adults.

METHODS

A systematic review of the literature identified systematic reviews and randomized controlled trials evaluating the impact of aerobic and resistance exercise, specific diets and foods, and intentional weight loss and avoidance of weight gain in adults during cancer treatment, on quality of life, treatment toxicity, and cancer control. PubMed and the Cochrane Library were searched from January 2000 to May 2021. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

The evidence base consisted of 52 systematic reviews (42 for exercise, nine for diet, and one for weight management), and an additional 23 randomized controlled trials. The most commonly studied types of cancer were breast, prostate, lung, and colorectal. Exercise during cancer treatment led to improvements in cardiorespiratory fitness, strength, fatigue, and other patient-reported outcomes. Preoperative exercise in patients with lung cancer led to a reduction in postoperative length of hospital stay and complications. Neutropenic diets did not decrease risk of infection during cancer treatment.

RECOMMENDATIONS

Oncology providers should recommend regular aerobic and resistance exercise during active treatment with curative intent and may recommend preoperative exercise for patients undergoing surgery for lung cancer. Neutropenic diets are not recommended to prevent infection in patients with cancer during active treatment. Evidence for other dietary and weight loss interventions during cancer treatment was very limited. The guideline discusses special considerations, such as exercise in individuals with advanced cancer, and highlights the critical need for more research in this area, particularly regarding diet and weight loss interventions during cancer treatment.Additional information is available at www.asco.org/supportive-care-guidelines.

Evaluation of Implementation Effect of Cervical Cancer Comprehensive Treatment Patients With Whole-Course High-Quality Care Combined With Network Continuation Care

Purpose

Discuss the implementation effect of cervical cancer comprehensive treatment patients applying whole-course high-quality care combined with network continuation care.

Methods

From August 2020 to August 2021, 120 patients who met the inclusion criteria for comprehensive treatment of cervical cancer were divided into the regular group (n = 60) who received conventional care and the joint group (n = 60) who received whole-course high-quality care combined with network continuation care, according to the method of care. The comprehensive treatment cognition level, comprehensive treatment compliance, adverse reaction rate, quality of life questionnaire (QLQ-C30) score, self-rating anxiety/depression scale (SAS/SDS) score, and nursing satisfaction were compared between the two groups.

Results

After care, the comprehensive treatment cognition score and comprehensive treatment compliance score were higher in the joint group than in the regular group (P < 0.05). After care, the incidence of radiation cystitis and radiation proctitis was lower in the joint group than that in the regular group (P < 0.05). After care, QLQ-C30 scores on symptom domains, functional domains, and single questions were higher in both groups than before care, and were higher in the joint group than in the regular group (P < 0.05). After care, SAS and SDS scores were lower in both groups than before care, and were lower in the joint group than in the regular group (P < 0.05). After care, the joint group was more satisfied with care than the regular group (P < 0.05).

Conclusion

The implementation of cervical cancer comprehensive treatment patients with whole-course high-quality care combined with network continuation care has an ideal implementation effect, which can significantly increase the patient's cognition and compliance with treatment, the incidence of adverse reactions is less, the quality of life and emotional state have also improved significantly, and care satisfaction has also increased accordingly.

Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults

BACKGROUND

Disease-related malnutrition has been reported in 10% to 55% of people in hospital and the community and is associated with significant health and social-care costs. Dietary advice (DA) encouraging consumption of energy- and nutrient-rich foods rather than oral nutritional supplements (ONS) may be an initial treatment.

OBJECTIVES

To examine evidence that DA with/without ONS in adults with disease-related malnutrition improves survival, weight, anthropometry and quality of life (QoL).

SEARCH METHODS

We identified relevant publications from comprehensive electronic database searches and handsearching. Last search: 01 March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of DA with/without ONS in adults with disease-related malnutrition in any healthcare setting compared with no advice, ONS or DA alone.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, extracted data and graded evidence.

MAIN RESULTS

We included 94, mostly parallel, RCTs (102 comparisons; 10,284 adults) across many conditions possibly explaining the high heterogeneity.  Participants were mostly older people in hospital, residential care and the community, with limited reporting on their sex. Studies lasted from one month to 6.5 years.  DA versus no advice - 24 RCTs (3523 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.87 (95% confidence interval (CI) 0.26 to 2.96), or at later time points. We had no three-month data, but advice may make little or no difference to hospitalisations, or days in hospital after four to six months and up to 12 months. A similar effect was seen for complications at up to three months, MD 0.00 (95% CI -0.32 to 0.32) and between four and six months. Advice may improve weight after three months, MD 0.97 kg (95% CI 0.06 to 1.87) continuing at four to six months and up to 12 months; and may result in a greater gain in fat-free mass (FFM) after 12 months, but not earlier. It may also improve global QoL at up to three months, MD 3.30 (95% CI 1.47 to 5.13), but not later. DA versus ONS - 12 RCTs (852 participants) All outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.66 (95% CI 0.34 to 1.26), or at later time points. Either intervention may make little or no difference to hospitalisations at three months, RR 0.36 (95% CI 0.04 to 3.24), but ONS may reduce hospitalisations up to six months. There was little or no difference between groups in weight change at three months, MD -0.14 kg (95% CI -2.01 to 1.74), or between four to six months. Advice (one study) may lead to better global QoL scores but only after 12 months. No study reported days in hospital, complications or FFM. DA versus DA plus ONS - 22 RCTs (1286 participants) Most outcomes had low-certainty evidence. There may be little or no effect on mortality after three months, RR 0.92 (95% CI 0.47 to 1.80) or at later time points. At three months advice may lead to fewer hospitalisations, RR 1.70 (95% CI 1.04 to 2.77), but not at up to six months. There may be little or no effect on length of hospital stay at up to three months, MD -1.07 (95% CI -4.10 to 1.97). At three months DA plus ONS may lead to fewer complications, RR 0.75 (95% CI o.56 to 0.99); greater weight gain, MD 1.15 kg (95% CI 0.42 to 1.87); and better global QoL scores, MD 0.33 (95% CI 0.09 to 0.57), but this was not seen at other time points. There was no effect on FFM at three months. DA plus ONS if required versus no advice or ONS - 31 RCTs (3308 participants) Evidence was moderate- to low-certainty. There may be little or no effect on mortality at three months, RR 0.82 (95% CI 0.58 to 1.16) or at later time points. Similarly, little or no effect on hospitalisations at three months, RR 0.83 (95% CI 0.59 to 1.15), at four to six months and up to 12 months; on days in hospital at three months, MD -0.12 (95% CI -2.48 to 2.25) or for complications at any time point. At three months, advice plus ONS probably improve weight, MD 1.25 kg (95% CI 0.73 to 1.76) and may improve FFM, 0.82 (95% CI 0.35 to 1.29), but these effects were not seen later. There may be little or no effect of either intervention on global QoL scores at three months, but advice plus ONS may improve scores at up to 12 months. DA plus ONS versus no advice or ONS - 13 RCTs (1315 participants) Evidence was low- to very low-certainty. There may be little or no effect on mortality after three months, RR 0.91 (95% CI 0.55 to 1.52) or at later time points. No study reported hospitalisations and there may be little or no effect on days in hospital after three months, MD -1.81 (95% CI -3.65 to 0.04) or six months. Advice plus ONS may lead to fewer complications up to three months, MD 0.42 (95% CI 0.20 to 0.89) (one study). Interventions may make little or no difference to weight at three months, MD 1.08 kg (95% CI -0.17 to 2.33); however, advice plus ONS may improve weight at four to six months and up to 12 months. Interventions may make little or no difference in FFM or global QoL scores at any time point.

AUTHORS' CONCLUSIONS

We found no evidence of an effect of any intervention on mortality. There may be weight gain with DA and with DA plus ONS in the short term, but the benefits of DA when compared with ONS are uncertain. The size and direction of effect and the length of intervention and follow-up required for benefits to emerge were inconsistent for all other outcomes.  There were too few data for many outcomes to allow meaningful conclusions. Studies focusing on both patient-centred and healthcare outcomes are needed to address the questions in this review.

Nutritional Intervention Contributes to the Improvement of Symptoms Related to Quality of Life in Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: A Randomized Clinical Trial

During breast cancer treatment, worsening quality of life (QoL) and the presence of toxicities are common, but healthy eating practices are associated with better clinical results. Thus, this study aims to evaluate the effect of a nutritional intervention on QoL and on gastrointestinal and hematological toxicities resulting from chemotherapy in women with breast cancer. A randomized clinical trial was performed at the beginning of neoadjuvant chemotherapy treatment for women with breast cancer. All participants received nutritional advice on healthy eating practices, but only the intervention group (IG) received an individualized diet plan. The study enrolled 34 women, 19 in the IG and 15 in the control group (CG). During the study, the CG significantly presented a reduction (from 21.6 ± 5.9 kg to 18.8 ± 4.0 kg, p = 0.009) in handgrip strength (HGS), while the IG did not present changes in this variable. Regarding QoL, the IG preserved the role function during treatment and presented better results for nausea/vomiting and loss of appetite compared to the CG. In gastrointestinal and hematological toxicities, the IG had lower frequencies of leukopenia and abdominal pain. The nutritional intervention preserved the role function of QoL and HGS, reduced the occurrence of nausea/vomiting, loss of appetite and the frequency of leukopenia and abdominal pain.

The development and initial evaluation of the Diarrhoea Management Diary (DMD) in patients with metastatic breast cancer

PURPOSE

Chemotherapy-induced diarrhoea (CID) is a common, but often underreported problem in patients with breast cancer that has a profound effect on quality of life. It is best measured from a patient's perspective, but tools are limited. The aim of this study was to develop and evaluate the Diarrhoea Management Diary (DMD), a self-report measure to assess CID, use of self-management strategies and treatment adherence.

METHODS

The DMD was constructed using an iterative process of instrument development: concept elicitation (literature review), item generation and reduction (cognitive debriefing), and pilot testing in the target population. After translation into eight languages, the DMD was used in an international randomised trial for women receiving lapatinib and capecitabine for metastatic breast cancer with or without prophylactic octreotide. Patterns of missing data and sensitivity to change were examined.

RESULTS

The understandability and completeness of the 8-item DMD was confirmed in cognitive interviews and pilot testing. Practicability of the DMD was evaluated in 62 women with metastatic breast cancer (median age 57). Up to 68% reported CID at any given time-point, and 19% had diarrhoea at each time-point. Patients also described efficacy of different strategies for diarrhoea management. Missing data were associated with study discontinuation. DMD missing item response was 0.9%. Sensitivity to change was good at most assessment points.

CONCLUSIONS

Although further psychometric testing is recommended, initial evaluation of the DMD showed good content validity and practicability in international research with cancer patients.