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Web-Based Symptom Monitoring With Patient-Reported Outcomes During Definitive Radiation Therapy With Chemotherapy (SYMPATHY): A Prospective Single-Center Phase 1 Study
We evaluated the feasibility of patient symptom self-reporting using a web-based interface (WBI), with automated message alerts for severe and/or worsening symptoms, in patients undergoing definitive chemoradiation therapy (CRT).
Methods and Materials
Patients receiving definitive CRT for gastrointestinal, lung, and head and neck cancers with access to a computer and/or mobile device were eligible. Symptom self-reporting was conducted via a WBI through surveys adapted from the patient-reported outcomes version of the Common Terminology Criteria for Adverse Events: 2 per week during CRT and 1 per week for 3 months after CRT. Nurses were alerted whenever a patient's symptom worsened by ≥2 points or reached a score of ≥3. Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were conducted at baseline, end of CRT, and 3 months after CRT. Patients also completed exit surveys 3 months after CRT.
Results
Nineteen patients were enrolled with a median of 30 fractions (range, 28-33). The median survey completion rate was 26% (range, 0%-100%) during CRT and 33% (range, 0%-100%) during the first 3 months after CRT. Five (26%) had acute hospital encounters during CRT or within 3 months of CRT completion. Two patients (11%) experienced CRT treatment interruptions. During CRT, 70 of 81 surveys (86%) were flagged and 61 of 70 (87%) were acted upon by a nurse or physician within 4 days; during the first 3 months after CRT, 47 of 85 (55%) were flagged and 28 of 47 (60%) were acted upon within 7 days. Ninety-two percent of patients found it always easy to access the survey while 58% found the surveys too long or too frequent. None of the PROMIS domains had statistically significant changes during any time points.
Conclusions
Symptom self-reporting via a WBI is feasible during definitive chemoradiation with high patient satisfaction. Survey fatigue is common and may be mitigated by improving the WBI to make it more patient-centered and allowing patients to choose which symptoms to report.
Introduction
Patients undergoing concurrent chemoradiation therapy (CRT) for definitive treatment of cancer often experience substantial symptom burden as a result of treatment-related side effects.
Standardized surveys to collect patient-reported outcomes have been shown to improve symptom control, facilitate communication between patients and providers and promote patient satisfaction.
A randomized trial of symptom self-reporting versus usual care in patients receiving palliative chemotherapy showed improvement in health-related quality of life (HR-QOL), fewer emergency room (ER) visits and hospitalizations, and even increased overall survival among those in the self-reporting arm.
This striking 5-month increase in overall survival was attributed to early responsiveness to patients’ symptoms, preventing adverse consequences of serious toxicities, and better ability to tolerate chemotherapy, resulting in increased time on chemotherapy in the intervention arm.
Similarly, a multicenter randomized clinical trial comparing web-based monitoring versus standard scheduled imaging to detect symptomatic recurrence in patients with lung cancer following initial treatment also detected an improvement of overall survival by 8 months with web-based monitoring.
However, the effects of symptom self-reporting are not well established in the setting of definitive concurrent CRT. Whether the benefits of implementing systems that collect radiation oncology patient self-reported symptoms outweigh their cost and administrative burden is an unanswered question.
A systematic review of the impact of routine collection of patient-reported outcome measures on patients, providers and health organisations in an oncologic setting.
The primary goal of the present study was to assess the feasibility of patient symptom self-reporting using a WBI in patients undergoing definitive CRT for cancer.
Methods and Materials
Study design and participants
Patients initiating definitive CRT at the Department of Radiation Oncology at University of California, Los Angeles (UCLA) for gastrointestinal, lung, and head and neck cancers from December 2018 to December 2020 were eligible to be enrolled in a prospective single-arm study of web-based self-reporting of symptoms. The aforementioned histologies were chosen as they are among the disease sites associated with the greatest number of radiation-related acute encounters
Using treatment interruptions to palliate the toxicity from concurrent chemoradiation for limited small cell lung cancer decreases survival and disease control.
The study protocol was approved by the UCLA institutional review board (IRB# 18-001634).
To be eligible, patients had to have access to a computer, mobile device, or tablet at home and had to read and understand English. Patients were ineligible if they were participating in another clinical trial, as such studies stipulate structured symptom reporting. Participants remained on the study until 3 months after completion of RT, voluntary withdrawal, or death. Enrollment occurred before the start of RT.
Intervention
Self-reporting was conducted via a WBI similar to what has previously been reported to be a feasible strategy for chemotherapy toxicity symptom monitoring at Memorial Sloan Kettering Cancer Center.
UCLA has rebranded Epic System's myChart, the online patient portal, as myUCLAHealth. Patients can access the portal via the website https://my.uclahealth.org/. As part of the study, patients were required to sign up for a myUCLAHealth account so that they could self-report their symptoms on the website or using the Questionnaires tab of the free myChart mobile application.
The WBI included questions adapted from the patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). While all questionnaires included a set of core items (ie, radiation skin reaction, skin darkening, general pain, and fatigue), questionnaires also contained questions specific to each disease site.
Content validity of anatomic site-specific Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) item sets for assessment of acute symptomatic toxicities in radiation oncology.
National Cancer Institute. Patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Available at: https://healthcaredelivery.cancer.gov/pro-ctcae/. Accessed March 1, 2022.
For example, questions for patients with gastrointestinal cancers of the lower abdomen (ie, rectum and anus) pertained to decreased appetite, nausea, vomiting, gas, bloating, constipation, diarrhea, abdominal pain, fecal incontinence, frequent urination, and painful urination. These symptoms were graded on a 5-point Likert scale from 0 (not present) to 4 (disabling) based on clinical criteria. The recall period was “the past 7 days.” PRO-CTCAE has demonstrated strong content validity as a measure of symptomatic toxicities in patients receiving radiation.
Content validity of anatomic site-specific Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) item sets for assessment of acute symptomatic toxicities in radiation oncology.
At the time of enrollment, study staff trained participants to use the WBI and facilitated completion of a baseline self-report. At each radiation oncology visit (weekly on-treatment visit [OTV] and follow-up visits), e-mail reminders were sent to participants to self-report using the my.uclahealth.org website or the MyChart mobile application. During treatment, biweekly e-mail reminders were sent every 3 to 4 days such that participants had the chance to report their symptoms halfway between the scheduled weekly OTVs. The e-mail reminder continued to be sent out on a weekly basis after the completion of RT for a 3-month period, after which it was sent out monthly for 3 additional months. Only the most recent questionnaire was available to be accessed if the patient had multiple outstanding questionnaires. Of note, upon auditing at the end of the study, 7 patients (37%) had surveys sent at incorrect frequencies (higher or lower than expected) due to a technical anomaly.
The WBI automatically sent an e-mail alert to nurses (not directly to physicians) whenever a patient-reported symptom worsens by ≥2 points or reaches a score of ≥3. Nurses used a standardized form (Appendix E1) to record if and what clinical actions were taken in response to e-mail alerts. A report tracking participants’ symptoms was given to the treating radiation oncologist at each visit. Clinicians were not provided with specific guidance about what actions to take in response to alerts or the symptom reports.
Outcome measures
The primary objective of this study was to assess the feasibility of patient symptom self-reporting using a WBI in patients undergoing definitive CRT for cancer. Feasibility was determined based on patient adherence to the WBI self-reporting system by measuring how often each user completed their assigned questionnaires. The frequency that clinicians initiated clinical actions in response to e-mail alerts for worsening or severe symptoms was also measured, and patient and clinician assessment of the usefulness of the WBI was determined. We calculated the rate of acute hospital encounters and the number of RT breaks (defined as 2 or more missed consecutive treatments) based on the medical record. Patient HR-QOL at baseline, completion of radiation, and 3 months after completion of radiation was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS),
The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
A higher T-score denotes more of the concept being measured; for instance, a higher PROMIS score on physical function points to better functioning, whereas a higher score on depression identifies more severe depressive symptoms. Patient assessment of the usefulness of the WBI was measured via an exit survey (Appendix E2). Patients were asked to score each statement on a scale of 1 to 7, 1 being never and 7 being always, except for the questions regarding proficiency of personal computer (PC) and/or mobile applications, 1 being never used and 7 being a regular/expert user.
Statistical analysis
The initial accrual goal was 36 patients. Descriptor statistics were obtained to describe baseline patient characteristics, patient adherence to WBI, treatment interruptions, and provider's response rate to e-mail alerts. The Spearman correlation test was performed to evaluate whether pretreatment Eastern Cooperative Oncology Group (ECOG) performance status, age, and prior experience with PC/mobile applications were associated with survey response rate. Mann-Whitney U test was performed to evaluate whether treatment interruptions or acute hospital encounters were associated with survey response rate. Paired t tests were performed to assess whether there was a statistically significant change in the domain scores of the PROMIS survey compared with baseline. All tests were 2-sided and statistical significance was set at 0.05.
Results
Between December 2018 and December 2020, 19 eligible patients were enrolled. The median age was 59 (range, 40-80). The predominant site of malignancy was gastrointestinal (84%), followed by lung (11%), and head and neck (5%). The median number of RT fraction was 30 (range, 28-33). Overall, 42%, 53%, and 5% of patients had a pretreatment ECOG score of 0, 1, and 2, respectively. Baseline patient characteristics are shown in Table 1.
Table 1Patient baseline characteristics and treatment parameters (n = 19)
The median duration of RT was 42 days (range, 37-53 days). All patients completed all planned fractions. A median of 12 surveys were sent to each patient during treatment (range, 3-21), and a median of 3 surveys were completed, yielding a survey completion rate of 26% (range, 0%-100%). The survey completion rate was 25% (range, 0%-86%) when excluding patients who received on-treatment surveys at incorrect intervals. During the first 3 months after treatment completion, a median of 12 follow-up surveys were sent to each patient, and a median of 4 surveys were completed, yielding a survey completion rate of 33% (range, 0%-100%) (Table 2). The survey completion rate was 40% when excluding patients who received follow-up surveys at incorrect frequencies. During treatment, among 81 completed surveys, 70 (86%) met the prespecified criteria and triggered an automatic alert to the nursing staff. Among these 70 on-treatment survey responses, nurses directly responded to 37 (53%), and the most common courses of action were providing reassurance (49%) and notifying the treating radiation oncologist (49%). Most (50 of 70, 71%) of the alerted survey responses were addressed by a medical doctor either immediately after survey or during OTV within 4 days of the completion of the survey. Among these, 23 (46%) resulted in a change in the treatment plan. Overall, 61 out of 70 (87%) alerted on-treatment survey responses were addressed by either nurses or physicians within 4 days of completing the survey. The flow diagram of on-treatment survey responses is shown in Fig. 1. There was no significant association between survey response rate during treatment and ECOG status (P = .95), age (P = .31), acute hospital encounters (P = .52), or prior experience with PC/mobile applications (P = .28).
Table 2Patient adherence to the web-based interface self-reporting system and treatment interruptions
Variable
Value
During treatment
Treatment duration (d), median (range)
42 (37-53)
Number of patients who completed all planned fractions
19 (100%)
Number of surveys sent per patient during CRT, median (range)
From the start of RT to 30 days after completion of RT. Treatment interruption was defined as 2 or more missed consecutive treatments (excluding weekends and holidays).
5 (26%)
Number of acute hospital encounters
7
Emergency room
5 (63%)
Inpatient admission
3 (37%)
Acute hospital encounters related to treatment toxicity
5 (63%)
During follow-up (first 3 mo after completion of RT)
Number of surveys sent per patient during follow-up, median (range)
Based on actual number of surveys sent to each patient.
† From the start of RT to 30 days after completion of RT. Treatment interruption was defined as 2 or more missed consecutive treatments (excluding weekends and holidays).
Figure 1Flowchart of providers’ response to on-treatment symptom surveys. Surveys were flagged and an automatic alert message was sent to the nursing staff whenever a patient's symptom worsened by ≥2 points or reached a score of ≥3 on the patient-reported outcomes version of the Common Terminology Criteria for Adverse Events survey. Abbreviations: ER = emergency room; MD = medical doctor; RN = registered nurse; RT = radiation therapy; Rx = prescription; OTV = on-treatment visit.
During the first 3 months of treatment completion, among 85 completed surveys, 47 (55%) met the prespecified criteria and triggered an automatic alert to the nursing staff. Among these 47 follow-up survey responses, nurses directly responded to 25 (53%), and the most common courses of action were notifying the treating radiation oncologist (64%) and providing reassurance (28%). A minority of the alerted survey responses (8 of 47, 17%) were addressed by a medical doctor either immediately after survey or during follow-up visits within 1 week of the completion of the survey. Among these, 3 (38%) resulted in a change in the treatment plan. Overall, 28 out of 47 (60%) alerted follow-up survey responses were addressed by either nurses or physicians within 1 week of completing the survey. The flow diagram of follow-up survey responses is shown in Fig. 2. There was no significant association between survey response rate during treatment and ECOG status (P = .31), age (P = .73), acute hospital encounters (P = .39), or prior experience with PC/mobile applications (P = .06).
Figure 2Flowchart of providers’ response to follow-up symptom surveys during the first 3 months after treatment completion. Surveys were flagged and an automatic alert message was sent to the nursing staff whenever a patient's symptom worsened by ≥2 points or reached a score of ≥3 on the patient-reported outcomes version of the Common Terminology Criteria for Adverse Events survey. Abbreviations: ER = emergency room; MD = medical doctor; pt = patient; RN = registered nurse; RT = radiation therapy; Rx = prescription; f/u = follow-up; w/i = within.
Two patients (11%) experienced RT treatment interruptions with the mean duration of treatment interruption of 4 days. Five patients (26%) had acute hospital encounters with 5 ER visits and 3 inpatient admissions in total. The result of patient-reported HR-QOL at baseline, completion of RT, and at 3 months after CRT as assessed by the PROMIS survey is shown in Fig. 3. There was no statistically significant change in the scores at any time points compared with baseline, at any domains, including physical function, anxiety, depression, fatigue, sleep disturbance, social roles and activities, and pain interference.
Figure 3Patient health-related quality of life at baseline, completion of radiation, and 3 months after completion of chemoradiation as assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). A higher T-score denotes more of the concept being measured in that domain. For example, a higher score on physical function points to better functioning, whereas a higher score on depression identifies more severe depressive symptoms. Orange lines connect mean score at each time point, and the error bars denote 95% confidence intervals. Individual patient's response was plotted in gray lines. Abbreviation: CRT = chemoradiation.
Twelve patients (63%) completed the exit survey at the 3-month post treatment visit (Fig. 4). Among these, 5 (42%) used a PC, 5 (42%) used mobile applications, and 1 (8%) used tablet applications to access the symptom surveys. Patients reported a median score of 6.5 for familiarity with PC (1 being never used and 7 being a regular/expert user) and 5.5 for familiarity with mobile applications. Patients reported it was always easy to log onto myUCLAHealth (1 being never and 7 being always; median score, 7), easy to locate the questionnaires (median score, 7), easy to enter answers (median score, 7), easy to understand the questions (median score, 6.5), and that the care team always read the answers (median score, 7) with a good understanding of the symptoms (median score, 7). When asked about whether answering the questions made the patient feel more involved in his or her care, helped keep track of symptoms, and helped what questions to ask the physician during the next clinical visit, the patients reported a median score of 6, 5, and 6, respectively. However, 6 patients (55%) indicated that the surveys were too long or sent too frequently. Overall, 64% of patients (7 of 11) affirmed that their care was improved by completing the symptom surveys and 36% (4 of 11) reported that their care was somewhat improved. When asked what they liked most about the symptom survey, 6 patients noted they felt connected to the care team while 2 patients pointed to the ease of use of the platform (Table E1).
Figure 4Patient exit survey at 3 months after treatment. Patients were asked to score each statement on a scale of 1 to 7. The red lines denote median response scores, and the orange bars denote interquartile ranges.
In the current prospective phase 1 study of patients receiving definitive concurrent CRT at a large academic cancer center, web-based symptom self-reporting is feasible with high patient satisfaction. All surveyed patients reported that their care was improved or somewhat improved as a result. This intervention was also associated with low rates of treatment interruptions and acute hospital encounters. There was no statistically significant decline in patient-reported outcomes in any domains at the end of treatment or at 3 months post CRT. To the best of our knowledge, the current study is the first assessing the feasibility of a web-based, symptom self-reporting system specifically in patients undergoing definitive CRT.
Most of the previous studies of oncology symptom self-reporting systems centered on patients receiving systemic therapy or surgery.
SYMptom monitoring with Patient-Reported Outcomes using a web application among patients with lung cancer in the Netherlands (SYMPRO-Lung): Study protocol for a stepped-wedge randomised controlled trial.
Use of mobile device technology to continuously collect patient-reported symptoms during radiation therapy for head and neck cancer: A prospective feasibility study.
Utilization of patient-reported outcomes to guide symptom management during stereotactic body radiation therapy for clinically localized prostate cancer.
The experience for patients undergoing definitive CRT differs from patients with metastatic disease undergoing chemotherapy in several ways. First, patients undergoing definitive CRT experience the combined side effects from both chemotherapy and RT, although they may have a more limited disease burden. Second, RT is associated with a different toxicity profile compared with chemotherapy for metastatic cancer. Third, patients who undergo definitive RT come to the department daily (Monday-Friday) for RT, where they are seen by radiation therapists who can alert the clinician should a patient express concerns or appear ill. Finally, patients undergoing definitive RT are seen at least once every 5 treatments by their radiation oncologist as part of weekly treatment management. Therefore, it is important to study the role of symptom self-reporting specifically in this patient population.
Basch et al reported that patients randomized to symptom monitoring during outpatient chemotherapy were less frequently admitted to the ER (34%) than their counterparts receiving usual care (41%).
A recent retrospective analysis from a quaternary-care center showed that ER visits and inpatient admissions during and within 30 days of the completion of definitive RT occurred in 36% of radiation courses.
Patients undergoing concurrent chemotherapy had an elevated risk of at least 1 acute encounter with an odds ratio of 6.38. The acute encounter rate was approximately 19% for radiation courses without concurrent chemotherapy compared with 60% for those with concurrent chemotherapy. In the present study, only 26% of patients had acute hospital encounters, with primary cancer types among the ones identified to be associated with the highest rate of acute encounters,
A few areas of improvement can be identified for design of future studies. The median response rate of biweekly symptom survey while on treatment was 26% (range, 0%-100%) and that of weekly symptom survey during the first 3 months of follow-up was 33% (range, 0%-100%). Some patients were very motivated with 100% completion rate while some did not any at all (0%), contributing to a lower median response rate. Over half of patients (58%) indicated that the surveys were too long or sent too frequently. Survey fatigue may be a major contributing factor of the low response rate. Excessive burden has shown to reduce survey response rates and data accuracy.
Utilization of patient-reported outcomes to guide symptom management during stereotactic body radiation therapy for clinically localized prostate cancer.
Use of mobile device technology to continuously collect patient-reported symptoms during radiation therapy for head and neck cancer: A prospective feasibility study.
Content validity of anatomic site-specific Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) item sets for assessment of acute symptomatic toxicities in radiation oncology.
As comprehensive as it is in capturing major side effects, it is lengthy and requires substantial time and concentration to complete each survey. For example, the version for patients undergoing gastrointestinal treatment contained questions about 18 symptoms (some with multiple items asking about severity and interference). One possible mitigation strategy is to shorten the number of required questions or to use computer-adaptive testing that caters the questions to the patient's symptoms. One could also consider redesigning the interface so patients can selectively input the symptoms of the greatest concern instead of going through a screening approach that canvasses all possible side effects. The interface can be further enhanced by including multimedia in addition to texts, such as pictures and diagrams showing different grades of skin reaction on different skin tones and pictures of disease-specific anatomy where patient can conveniently indicate the location of pain by clicking on the picture. Another consideration is to decrease the frequency of symptom surveys or to let patients decide when and how often they would like to symptom self-report. An automated symptom self-reporting and triage system may enhance efficiency and selectively alert the physicians and staff on symptoms that are more severe or require immediate attention. Radiation oncology is unique that patients typically meet with their radiation oncologist weekly at OTVs to manage ongoing symptoms. Web-based symptom surveys may be placed strategically halfway between OTVs to decrease the survey burden while allowing maximal capture of symptoms on a continuous basis.
Another area of improvement is the low response rate of providers to flagged symptom surveys during follow-up. Just over half (60%) of flagged follow-up survey responses were addressed by either nurses or physicians within 1 week of completing the survey. Based on the criteria that automatically generate alerts to the nursing staff (symptom worsened by ≥2 points or reached a score of ≥3), it was impossible to distinguish between surveys that were flagged due to a continuation of symptoms at the end of treatment or gradually improving symptoms yet to be below the threshold of alert (generally not clinically actionable) and those with new symptoms or worsening of existing symptoms (generally clinically actionable). This likely resulted in excessive alerts to the providers during the follow-up period and contributed to the provider alert fatigue as well. Similarly, a redesigned interface that prioritizes patients’ input of most concerning symptoms and the ability to automatically graph the severity of symptoms over time in a report may help reduce false positive survey alerts during follow-up. A feature to “silence” alerts for symptoms that providers are aware of or actively managing will be another welcoming addition. A phase 2 study with a redesigned mobile application-based symptom self-reporting system is currently under development.
The current study has several limitations. First, it was conducted at a single, urban comprehensive cancer center, limiting its generalizability. Second, the sample size was small and less than the recruitment target of 36 patients. This was partially due to the COVID-19 pandemic, when study recruitment was disrupted. However, the information regarding feasibility was sufficient with current enrollment. Third, most of the patients on the study had high self-reported computer/mobile device literacy, which may not be representative of the diverse cancer population in the United States. Care must be taken to streamline the WBI and provide patients with adequate resources and training so as to not widen the health care disparity due to digital literacy. Fourth, the study included only English speakers; future WBI should include additional languages and nontext interfaces, such as interactive voice response. Fifth, the single-arm design precludes the direct comparison with a control group in terms of acute hospital encounter rate and change in HR-QOL. However, the primary objective of this study was to assess the feasibility of a WBI-based patient symptom self-reporting system and a comparator arm will be included in an upcoming phase 2 study. Sixth, ER and inpatient admissions were tracked based on the institution's electronic medical record system and interinstitutional electronic medical record exchange system (CareEverywhere) and some admissions to outside facilities may not have been recorded. Finally, a formal cost-utility analysis was not performed. However, resource use was relatively modest and included WBI development and time spent by patients and providers to report and review symptoms and to respond when clinically indicated.
Conclusion
Symptom self-reporting via a WBI is feasible with high patient satisfaction and low rates of acute hospital encounters and treatment interruptions in a cohort of patients undergoing definitive concurrent chemoradiation. Future work to refine WBIs and survey strategies to optimize both patients and provider engagement is needed to provide the best electronic patient-reported symptom monitoring as a part of high-quality cancer care.
A systematic review of the impact of routine collection of patient-reported outcome measures on patients, providers and health organisations in an oncologic setting.
Using treatment interruptions to palliate the toxicity from concurrent chemoradiation for limited small cell lung cancer decreases survival and disease control.
Content validity of anatomic site-specific Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) item sets for assessment of acute symptomatic toxicities in radiation oncology.
National Cancer Institute. Patient-reported outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Available at: https://healthcaredelivery.cancer.gov/pro-ctcae/. Accessed March 1, 2022.
The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008.
SYMptom monitoring with Patient-Reported Outcomes using a web application among patients with lung cancer in the Netherlands (SYMPRO-Lung): Study protocol for a stepped-wedge randomised controlled trial.
Use of mobile device technology to continuously collect patient-reported symptoms during radiation therapy for head and neck cancer: A prospective feasibility study.
Utilization of patient-reported outcomes to guide symptom management during stereotactic body radiation therapy for clinically localized prostate cancer.
Sources of support: The UCLA Jonsson Comprehensive Cancer Center Seed Grant provided funding support.
Disclosures: Dr Raldow reports consulting work for Intelligent Automation, Inc, ViewRay, Inc, Clarity, Inc, and Varian Medical Systems; honoraria from Varian Medical Systems and Clarity PSO/RO-ILS RO-HAC; research grants from ViewRay, Inc; rectal cancer panel membership in the Veteran's Health Administration Radiation Oncology Quality Surveillance Program Services; and nonfinancial support from the United States Department of Veterans Affairs, all outside the present work. Dr. Kishan reports stock from ViewRay Inc., honoraria from Varian Medical Systems and ViewRay Inc., consulting for Janssen and research funding from ViewRay Inc.; additional funding support from grant P50CA09213 from the Prostate Cancer National Institutes of Health Specialized Programs of Research Excellence, grant RSD1836 from the Radiological Society of North America, the STOP Cancer organization, the Jonsson Comprehensive Cancer Center, and the Prostate Cancer Foundation, all outside the present work. Dr Lee reports personal fees from ViewRay, Inc, grants and personal fees from AstraZeneca, personal fees and nonfinancial support from Varian Medical Systems, and personal fees from Genentech, Inc, all outside the present work. No other disclosures were reported.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Based on actual number of surveys sent to each patient.
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