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Zhang J, Zhan Y, Chen J, Kang D, Xiang R, Zhang R, Zhang Y, Pu Y, Zhang J, Zhang L, Huang Y, Gong R, Su X, Nie Y, Shi Q. Development of a Patient-Reported Symptom Item Bank for Patients with Hepatobiliary or Pancreatic Malignancies: A Systematic Review. Patient Prefer Adherence 2023; 17:199-207. [PMID: 36698859 PMCID: PMC9869794 DOI: 10.2147/ppa.s398666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/12/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Patients with hepatobiliary or pancreatic cancers often experience severe symptoms, resulting in a sharp decline in functioning, poor quality of life, and increased mortality risk. Early and effective management of symptoms allows a better quality of life and reduced mortality, depending on the selection of appropriate assessment of specific symptoms for a defined purpose. We aimed to develop a symptom measurement item bank for hepatobiliary or pancreatic cancers. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was applied to organize this systematic review. The articles validated patient-reported outcome measures (PROMs) for hepatobiliary or pancreatic cancer and published before December 2021 were retrieved from the Web of Science, PubMed, Embase databases and Cochrane Library. Items from the existing PROMs were selected and classified into different patient-reported symptoms based on the concepts and specific underlying constructs of the objects measured. RESULTS Sixteen unique PROMs were identified across the 29 eligible studies included in our analysis. Items from the literature review (14 PROMs with 421 items for which information was obtained) were selected and classified. As a result of this study, we developed a symptom item bank with 40 patient-reported symptoms and 229 assessment items for hepatobiliary or pancreatic cancer, and fatigue, pain and nausea were the most common symptom items. CONCLUSION We developed an item bank to assess the patient-reported symptoms of hepatobiliary or pancreatic cancer. This item bank could allow researchers to select appropriate measures of symptom and provide a basis for the development of a single-item symptom-measurement system.
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Affiliation(s)
- Jingyu Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yinxia Zhan
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jiaojiao Chen
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Dan Kang
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Rumei Xiang
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Ruoyi Zhang
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yubo Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yang Pu
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Jiayuan Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Lijun Zhang
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yanyan Huang
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Ruoyan Gong
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xueyao Su
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Yuxian Nie
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Qiuling Shi
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, People’s Republic of China
- School of Public Health, Chongqing Medical University, Chongqing, People’s Republic of China
- Correspondence: Qiuling Shi, State Key Laboratory of Ultrasound in Medicine and Engineering, Chongqing Medical University, No. 1, Medical College Road, Yuzhong District, Chongqing, 400016, People’s Republic of China, Tel +86-18290585397, Email
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Zou H, Li M, Lei Q, Luo Z, Xue Y, Yao D, Lai Y, Ung COL, Hu H. Economic Burden and Quality of Life of Hepatocellular Carcinoma in Greater China: A Systematic Review. Front Public Health 2022; 10:801981. [PMID: 35530735 PMCID: PMC9068962 DOI: 10.3389/fpubh.2022.801981] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/11/2022] [Indexed: 12/12/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) accounts for more than 85%-90% of primary liver cancer globally, and approximately 45% of deaths from HCC occur in greater China. This disease poses a significant economic burden for patients, payers and society and significantly affects patients' quality of life (QoL). However, such impact of HCC in greater China has not been well characterized. This review was conducted to analyze the current evidence about the economic and humanistic impact of HCC in greater China for informing national disease management and identifying clinical gaps yet to be resolved. Methods A systematic search literature using seven databases (Web of Science, PubMed, Medline, Cochrane Central, China National Knowledge Infrastructure, Wanfang, and Weipu) was performed to identify interventional and observational studies that reported the impact of HCC on cost or QoL and published before April 6, 2021. The focus population included adult patients with HCC in greater China. This review excluded any studies that focused on any specific treatment. Study quality was assessed using the Effective Public Health Practice Project tool. Results Of 39,930 studies retrieved, 27 were deemed eligible for inclusion. The methodologies, perspectives and data sources used in studies were heterogeneous. In greater China, while few studies reported the health expenditures of HCC patients and investigations about economic burden at national level was lacking, the significant economic impact of HCC on patients and their families had been reported. Health-related costs increased as the disease deteriorated. Additionally, HCC also has a negative impact on the QoL of patients, mostly in terms of physical, cognitive, social functioning and severe symptoms. Conclusions HCC has brought significant economic and QoL burden to patients in greater China. Both physical and psychological factors predicted QoL in patients with HCC in greater China. Future studies should explore the disease-related economic effects on Chinese patients and their families, the effects of physical and psychological factors on QoL and the relationships of physical and psychological factors in the region. Systematic Review Registration:www.crd.york.ac.uk/prospero/display_record.php?RecordID=278421, PROSPERO: CRD42021278421
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Affiliation(s)
- Huimin Zou
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Meng Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Qing Lei
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Zejun Luo
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Yan Xue
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Dongning Yao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China
| | - Yunfeng Lai
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China.,School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Carolina Oi Lam Ung
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, Macao SAR, China
| | - Hao Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, Macao SAR, China.,Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, Macao SAR, China
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Psychometric validation of the EORTC QLQ-HCC18 in patients with previously treated unresectable hepatocellular carcinoma. Qual Life Res 2021; 31:937-950. [PMID: 34518988 PMCID: PMC8921023 DOI: 10.1007/s11136-021-02992-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2021] [Indexed: 11/06/2022]
Abstract
To demonstrate the measurement properties of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Hepatocellular Carcinoma 18-question module (EORTC QLQ-HCC18) within a previously treated, unresectable hepatocellular carcinoma (HCC) clinical trial population that was distinct from the published QLQ-HCC18 validation population. Analyses were conducted using data from BGB-A317-208, an open label, international, clinical trial assessing efficacy and safety of the monoclonal antibody tislelizumab in adult HCC patients. The EORTC Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and QLQ-HCC18 instruments were assessed at baseline and weeks 3 and 9 follow-up visits. Per US Food and Drug Administration guidance, psychometric validation of the QLQ-HCC18 included reliability (internal consistency and test–retest), construct validity (convergent and discriminant validity and known-groups validity), ability to detect change, and meaningful within-patient change (MWPC). Known-groups validity and MWPC analyses were also stratified on several pre-defined subgroups. A total of 248 patients were included. Only the QLQ-HCC18 fatigue, nutrition, and index domains demonstrated acceptable internal consistency; acceptable test–retest reliability was found for fatigue, body image, nutrition, pain, sexual interest, and index domains. The QLQ-HCC18 fatigue domain achieved the pre-specified criterion defining acceptable convergent and discriminant validity for 13 of 16 correlations, whereas the index domain achieved the pre-specified criterion for 14 of 16 correlations. Clear differentiation of the QLQ-HCC18 change scores between improvement and maintenance anchor groups were observed for body image, fatigue, pain, and index domains, whereas differentiation between deterioration and maintenance anchor groups were observed for fever and fatigue domains. MWPC point estimates defining improvement for the QLQ-HCC18 fatigue and index domains were −7.18 and −4.07, respectively; MWPC point estimates defining deterioration were 5.34 and 3.16, respectively. The EORTC QLQ-HCC18 fatigue and index domains consistently demonstrated robust psychometric properties, supporting the use of these domains as suitable patient-reported endpoints within a previously treated, unresectable HCC patient population.
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Wohlleber K, Heger P, Probst P, Engel C, Diener MK, Mihaljevic AL. Health-related quality of life in primary hepatic cancer: a systematic review assessing the methodological properties of instruments and a meta-analysis comparing treatment strategies. Qual Life Res 2021; 30:2429-2466. [PMID: 34283381 PMCID: PMC8405513 DOI: 10.1007/s11136-021-02810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Patient-reported outcomes including health-related quality of life (HRQoL) are important oncological outcome measures. The validation of HRQoL instruments for patients with hepatocellular and cholangiocellular carcinoma is lacking. Furthermore, studies comparing different treatment options in respect to HRQoL are sparse. The objective of the systematic review and meta-analysis was, therefore, to identify all available HRQoL tools regarding primary liver cancer, to assess the methodological quality of these HRQoL instruments and to compare surgical, interventional and medical treatments with regard to HRQoL. METHODS A systematic literature search was conducted in MEDLINE, the Cochrane library, PsycINFO, CINAHL and EMBASE. The methodological quality of all identified HRQoL instruments was performed according to the COnsensus-based Standards for the selection of health status Measurements INstruments (COSMIN) standard. Consequently, the quality of reporting of HRQoL data was assessed. Finally, wherever possible HRQoL data were extracted and quantitative analyses were performed. RESULTS A total of 124 studies using 29 different HRQoL instruments were identified. After the methodological assessment, only 10 instruments fulfilled the psychometric criteria and could be included in subsequent analyses. However, quality of reporting of HRQoL data was insufficient, precluding meta-analyses for 9 instruments. CONCLUSION Using a standardized methodological assessment, specific HRQoL instruments are recommended for use in patients with hepatocellular and cholangiocellular carcinoma. HRQoL data of patients undergoing treatment of primary liver cancers are sparse and reporting falls short of published standards. Meaningful comparison of established treatment options with regard to HRQoL was impossible indicating the need for future research.
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Affiliation(s)
- Kerstin Wohlleber
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Patrick Heger
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
- The Study Centre of the German Surgical Society (SDGC), University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Patel N, Lie X, Gwaltney C, Rokutanda N, Barzi A, Melisi D, Macarulla T, Ueno M, Kim ST, Meyers O, Workman C, Bachini M, Cohen G. Understanding Patient Experience in Biliary Tract Cancer: A Qualitative Patient Interview Study. Oncol Ther 2021; 9:557-573. [PMID: 34244955 PMCID: PMC8594245 DOI: 10.1007/s40487-021-00159-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Patients living with biliary tract cancer (BTC) experience a decline in health-related quality of life (HRQoL). This study aimed to obtain a comprehensive understanding of the patient experience of BTC-related signs/symptoms and the impacts of these on daily functioning and HRQoL. Methods Patients with BTC participated in qualitative semi-structured concept elicitation interviews. Signs/symptoms and impacts of BTC were initially explored by targeted literature searches and interviews with five clinicians. Patient interviews were transcribed and coded using qualitative research software. Concept saturation was assessed over five interview waves. A sign/symptom or impact was defined as “salient” if mentioned by ≥ 50% of patients, with a mean disturbance rating of ≥ 5 (0–10 scale). A conceptual model of the patient experience of BTC-related signs/symptoms and impacts was produced. Results Twenty-three patients from the USA (78% women; median age: 54 years), diagnosed as having early (n = 3), locally advanced (n = 11) or metastatic (n = 9) disease, were interviewed. Sixty-six signs/symptoms and 12 impacts were identified. Of these, 46 signs/symptoms and 8 impacts were not identified from the targeted literature or clinician interviews. Concept saturation was reached by the fourth of five interview waves. Fourteen disease-related signs/symptoms (including fatigue/lack of energy, abdominal pain, lack of appetite, insomnia and diarrhoea) and three impacts (physical, emotional and cognitive impacts) were deemed “salient”. The conceptual model included 50 signs/symptoms and 12 impacts. Conclusion Patients with BTC reported a range of signs/symptoms and impacts that negatively affect daily functioning and HRQoL. Supplementary Information The online version contains supplementary material available at 10.1007/s40487-021-00159-z.
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Affiliation(s)
- Nikunj Patel
- AstraZeneca, 1 Medimmune Way, Gaithersburg, MD, 20878, USA.
| | | | | | | | - Afsaneh Barzi
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Unit, Università degli Studi di Verona, Verona, Italy.,Experimental Cancer Medicine Unit, Azienda Ospedaliera Integrata di Verona, Verona, Italy
| | - Teresa Macarulla
- Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Makoto Ueno
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Seung Tae Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Kang D, Shim S, Cho J, Lim HK. Systematic Review of Studies Assessing the Health-Related Quality of Life of Hepatocellular Carcinoma Patients from 2009 to 2018. Korean J Radiol 2020; 21:633-646. [PMID: 32410403 PMCID: PMC7231617 DOI: 10.3348/kjr.2019.0808] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 02/07/2023] Open
Abstract
We reviewed all studies assessing the health-related quality of life (HRQoL) in patients with hepatocellular carcinoma (HCC) between 2009 and 2018 (n = 45). Most studies assessed HRQoL as an outcome, and evaluated or compared the HRQoL of HCC patients depending on the type of treatment or stage of disease. HCC patients had a worse HRQoL than the general population, including in those with early-stage HCC. Patients commonly experienced pain, fatigue, sleep disturbance, distress, and lack of appetite, and these symptoms remained problematic even a few years after treatment. TNM classification of malignant tumors stage, tumor stage, presence of cirrhosis, being Asian, being female, living alone, or being unemployed were associated with a poor HRQoL. While recent studies have included a more diverse patient population, various topics, and different study designs, there were limited studies on supportive interventions. Given the increase in HCC cases and HCC survivors, addressing the HRQoL of HCC patients requires more attention.
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Affiliation(s)
- Danbee Kang
- Department of Clinical Research Design and Evaluation, SAISHT, Sungkyunkwan University, Seoul, Korea.,Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sungkeun Shim
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Digital Health, SAISHT, Sungkyunkwan University, Seoul, Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, SAISHT, Sungkyunkwan University, Seoul, Korea.,Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Digital Health, SAISHT, Sungkyunkwan University, Seoul, Korea.,Department of Health Sciences and Technology, SAISHT, Sungkyunkwan University, Seoul, Korea
| | - Hyo Keun Lim
- Department of Health Sciences and Technology, SAISHT, Sungkyunkwan University, Seoul, Korea.,Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Chen RW, Yang SL, Xu ZY, Peng M, Chen MN, Wang QS, Chang J, Hu JL. Validation and Application of the Chinese Version of the M. D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI-C). J Pain Symptom Manage 2019; 57:820-827. [PMID: 30684634 DOI: 10.1016/j.jpainsymman.2019.01.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To validate and use the Chinese Version of the M. D. Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI-C) to assess the symptom burden of Chinese-speaking patients with gastrointestinal cancer. METHODS In total, 527 patients with postoperative or advanced digestive tract tumors were enrolled in the trial, who had definitive diagnoses and different treatments in our cancer center. MDASI-GI-C was administered to these patients between February and December 2017. The item-scale correlations and internal consistency were evaluated. Construct validity was established by factor analysis. Hierarchical cluster analysis was performed. RESULTS Cronbach's alpha of the symptom severity and interference subscales was 0.842 and 0.859, respectively. Construct validity revealed a four-factor structure. Known-group validity was established by comparing the MDASI-GI-C scores between patients having different Karnofsky Performance Status scores (≤70 or >70), which were observed to have significant differences. The overall mean subscale scores for the core and interference subscales were 1.63 ± 2.02 and 2.17 ± 2.34, respectively. Fatigue, disturbed sleep, and lack of appetite had the highest scores for most serious symptoms. No significant differences in age, working status, and educational level were found. CONCLUSIONS MDASI-GI-C is a reliable and valid tool for assessing cancer-related symptoms in Chinese-speaking patients with digestive tract tumors, facilitates the understanding of the common symptoms of patients with digestive tract tumors, and enables timely management of these symptoms. Cognitive debriefing demonstrated that the patients found MDASI-GI-C to be an easy-to-use and understandable instrument.
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Affiliation(s)
- Ren-Wang Chen
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng-Li Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhong-Yu Xu
- Department of Epidemiology and Biostatistics, Huazhong University of Science and Technology, Wuhan, China
| | - Miao Peng
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meng-Ni Chen
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiu-Shuang Wang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Chang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian-Li Hu
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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