De Leo November 2023 ONF

Telenursing Interventions
for Patients With Cancer

Receiving Chemotherapy:
A Scoping Review
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Aurora De Leo, MSN, RN, Gloria Liquori, MSN, RN, Sara Dionisi, PhD, RN, Fabrizio Petrone, MSN, RN,
Alessandro Spano, MSN, RN, Nicolò Panattoni, MSN, RN, Noemi Giannetta, PhD, RN,
Marco Di Muzio, PhD, RN, and Emanuele Di Simone, PhD, RN
T
PROBLEM IDENTIFICATION: To provide an overview he care pathway of patients with
of telenursing interventions, primary outcomes, cancer involves a strong integration
and tools used in patients with cancer receiving among healthcare organizations,
chemotherapy, a scoping review was conducted. healthcare professionals, patients,
family members, and caregivers
LITERATURE SEARCH: PubMed®, Embase®, and (World Health Organization, n.d.). Improvements
CINAHL® databases were searched using the in cancer-related treatment have led to an increase
following keywords: telenursing, adverse event, and in cancer survivors and a consequent increase in the
drug therapy. needs of patients with cancer. Patients receiving che-
motherapy or oral cancer treatments frequently ex-
DATA EVALUATION: From the screening process, 11 perience side effects or symptoms as a result of the
studies were identified. disease or its treatment (Chae et al., 2022; Zerillo et
al., 2018). Using oral chemotherapies poses numerous
SYNTHESIS: In patients with cancer receiving challenges in patients with cancer, including toxicity
chemotherapy, telenursing interventions were mainly management and therapeutic adherence. However,
used to monitor symptoms, particularly fatigue, these symptoms are often underestimated and under-
anxiety, and depression. The interventions used reported in health records by clinicians (Carrasco &
included outcome-specific, nonspecific, and validated Symes, 2018).
tools, or tools developed from reporting systems for In nursing care, telenursing—a branch of
adverse events. eHealth—is the application of electronic technology
to health (Scantlebury et al., 2017). Telenursing can
IMPLICATIONS FOR RESEARCH: Large-scale, well- improve data transmission and patients’ relationship
conducted randomized controlled trials, systematic with the care team, as well as increase access to and the
reviews, and meta-analyses are needed to test the quality of care (Barbosa et al., 2016). Patient-reported
results of this scoping review. outcomes have been used to improve symptom mon-
itoring, therapeutic adherence, and patients’ quality
of life (QOL), and to decrease costs related to health
care (Howell et al., 2017; Strasser et al., 2016). Patient-
reported outcomes can include treatments and
cancer-related symptoms (Kerrigan et al., 2020), and
they allow for closer symptom monitoring. For exam-
ple, the use of patient-reported outcomes can help to
avoid conducting a retrospective summary with the
KEYWORDS telenursing; chemotherapy; adverse care team (Baldwin et al., 2017). In addition, the use
events; oncology nursing; cancer of digital tools to collect patient-reported outcomes
ONF, 50(6), 767–782 for symptom monitoring positively affects data
DOI 10.1188/23.ONF.767-782 transmission, patient self-efficacy, and timeliness of
WWW.ONS.ORG/ONF NOVEMBER 2023, VOL. 50, NO. 6 ONCOLOGY NURSING FORUM 767
cancer treatment interventions (Warrington et al., laws of different countries by sharing responsibilities
2019), thus improving patient–provider communica- among stakeholders (Ministry of Health, 2022).
tion (Greenhalgh et al., 2018). The spread of eHealth,
and telenursing in particular, can create challenges for Purpose
nurses participating in different roles, such as thera- The use of a telenursing model in patients with cancer
peutic educational interventions, remote monitoring, receiving chemotherapy is a relatively new and broad
and new interactions with patients and the care team development area for nurses. Knowledge of this field
(Allen et al., 2015). has yet to be extensively explored or developed using
In particular, a meta-analysis suggested that tele- a broad study design to provide an overview of the
medicine (i.e., telehealth managed and delivered by topic (Harada et al., 2023). Therefore, the aim of the
physicians) and telenursing (i.e., telehealth managed scoping review was to explore telenursing interven-
and delivered by nurses) interventions had a positive tions, primary outcomes, and tools used in patients
impact on QOL and symptoms of anxiety and depres- with cancer receiving chemotherapy.
sion compared to usual care among patients with
lung cancer (Pang et al., 2020). On-the-job education Methods
and training of nurses in this area should be provided Design and Research Questions
by universities, scientific societies, and health orga- This scoping review was based on the methodologic
nizations (Nittari et al., 2020). At the same time, guidance from JBI (Peters et al., 2020) and followed
international laws can be used to inform the national PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines. In accor-
dance with the scoping review guidance proposed
FIGURE 1. PRISMA Flow Diagram in the JBI methodology (Peters et al., 2020; Tricco
et al., 2016, 2018), the study was not registered. For
Articles identified from Duplicate articles the construction of the research strategy, the acro-
databases (N = 1,106) removed before nym PCC (population: patients with cancer receiving
ɐ PubMed® (n = 556) screening (n = 140) chemotherapy; concept: telenursing intervention; and
ɐ Embase® (n = 395) context: hospital and home setting) was used. The
ɐ CINAHL® (n = 155) research questions were as follows:
ɐ What telenursing interventions are used to moni-
tor patients with cancer receiving chemotherapy?
Articles screened Articles excluded, with
ɐ What are the primary clinical outcomes?
(n = 966) reasons (N = 930)
ɐ What are the main tools?
ɐ Different patient
The first question investigated the primary inter-
population (n = 668)
national telenursing interventions used in patients
ɐ Study design (n =
196) with cancer. The second question examined the main
ɐ No nurse-led clinical outcomes used within telenursing inter-
intervention (n = 55) ventions in oncologic settings. The third question
ɐ Not written in English investigated the main quantitative tools used.
(n = 11)
Inclusion Criteria
Studies including patients aged 18 years or older in
Full-text articles retrieved Full-text articles the outpatient or homecare setting were eligible.
and assessed for excluded, with reasons All studies focused on telenursing interventions or
eligibility (n = 36) (N = 25) involved nurses in education, prevention, and the
ɐ Non-nursing treatment and management of patients receiving
intervention (n = 23) chemotherapy. The types of sources of evidence
ɐ Intervention unrelated included primary studies (observational and exper-
Studies included to chemotherapy imental, including randomized and nonrandomized
in review (N = 11) treatment (n = 2)
controlled trials), cohort studies, cross-sectional
studies, case-control studies, qualitative studies, and
PRISMA—Preferred Reporting Items for Systematic Reviews
and Meta-Analyses mixed-methods studies written in English. For com-
pleteness, the researchers screened the reference lists
768 ONCOLOGY NURSING FORUM NOVEMBER 2023, VOL. 50, NO. 6 WWW.ONS.ORG/ONF
of the excluded studies to find additional relevant (2009). Therefore, 11 studies were included in the
studies to include in this scoping review. No limita- final analysis.
tions were used.
Results
Exclusion Criteria Characteristics of the Studies
The exclusion criteria were patients aged younger In total, 2,189 outpatients or homecare patients with
than 18 years, interventions in which nurses were not solid or hematologic cancers of varying stages par-
included, and a hospital setting. Studies that were ticipated in the 11 studies reviewed (Absolom et al.,
published in a language other than English or stud- 2021; Aranda et al., 2012; Basch et al., 2016; Børøsund
ies focused on healthcare professional perspectives, et al., 2014; Coombs et al., 2020; Innominato et
literature reviews, gray literature, protocol papers, or al., 2016, 2018; Kearney et al., 2009; McCann et al.,
conference abstracts were also excluded. 2009; Mooney et al., 2017; Ream et al., 2015) (see
Table 1). Eight randomized controlled trials (RCTs)
Search Strategy (Absolom et al., 2021; Aranda et al., 2012; Basch et
The authors consulted the following databases al., 2016; Børøsund et al., 2014; Coombs et al., 2020;
from January 1 to February 28, 2022: PubMed®, Kearney et al., 2009; McCann et al., 2009; Mooney
Embase®, and CINAHL®. For the construction of the et al., 2017) compared an intervention group that
search string, the main terms of interest were ini- received the telenursing intervention to usual care
tially searched using free text. Based on the results or enhanced usual care (control group). The three
obtained, the keywords with the highest results in remaining studies were a pilot study (Innominato
each database were selected. MeSH (Medical Subject et al., 2018), an observational study (Innominato et
Headings) terms and free words for telenursing, al., 2016), and a mixed-methods study (Ream et al.,
adverse event, and drug therapy were identified and 2015).
combined with Boolean operators AND and OR. Two Telenursing interventions were mainly aimed
experienced librarians (F.S. and V.S.) adapted the at the prevention, management, and monitoring of
search strategy to the three databases. chemotherapy-related symptoms, with educational
purposes in the clinical pathway. Samples from indi-
Study Selection and Analysis vidual studies ranged from 11 to 766 patients with
Relevant studies were assessed. As stated in the scop- varying cancer types. Although some studies pro-
ing review guidelines (Peters et al., 2020; Tricco et al., vided only the average age of patients, the overall
2016, 2018), a critical appraisal of the individual stud- age range across all studies was 18–91 years. With
ies included in this scoping review was not performed. the exception of two studies (Kearney et al., 2009;
The classification of the data produced a narrative McCann et al., 2009), which reported results from
synthesis of the results arising from the research the same study, all the studies were published in
questions, which enabled the drafting of this study. 2012 or later.
The search led to the identification of 1,106 stud-
ies related to the use of telenursing interventions in Single Study Characteristics
patients with cancer receiving chemotherapy (see Innominato et al. (2016) assessed the acceptability
Figure 1). After excluding duplicates, the titles and of and adherence to a telemedicine platform for an
abstracts were screened by two researchers. During average of 58 days (range = 38–313) among a sample
the screening process, doubts were resolved with the of 31 patients with cancer. In the 30-day intervention
agreement of the two researchers or with the support interval, 95% of the sample transmitted their data at
of a third researcher who supervised the study. The least once through the platform (830 of 874 patient
full text of relevant studies was read and led to the days). The overall adherence rate was 59.7% (522
inclusion of nine studies (Absolom et al., 2021; Aranda of 874 patient days), and the predictivity for urgent
et al., 2012; Basch et al., 2016; Børøsund et al., 2014; hospitalizations during the next three days was 94%.
Innominato et al., 2016, 2018; Kearney et al., 2009; The worst outcome scores were regarding impacts on
— —
Mooney et al., 2017; Ream et al., 2015). Following work (X = 5.1) and activities of daily living (X = 4.9), as
—
a review of the reference lists of the included stud- well as fatigue, distress, and loss of appetite (X = 4.9,
ies, two relevant studies were found (Coombs et al., 4.2, and 3.6, respectively).
2020; McCann et al., 2009), which were secondary In the study by Mooney et al. (2017), 358
analyses of Mooney et al. (2017) and Kearney et al. patients with cancer receiving chemotherapy were
TABLE 1. Data Extraction of Selected Studies (N = 11)
Study Population, Timing, Tools,

(Country) Design, Setting, and Aim and Outcomes Intervention and Nursing Implications
Absolom A randomized controlled trial comparing ɐ Population: 508 patients with colorec- Weekly or as needed based on severity
et al., 2021 the effects of adding eRAPID (elec- tal, breast, or gynecologic cancer (age of symptoms, patients in the inter-
(United tronic patient self-Reporting of Adverse range = 18–86 years) vention group completed an online
Kingdom) events: Patient Information and aDvice) ɐ Timing: 6, 12, and 18 weeks symptom reporting tool for 18 weeks.
to usual care versus usual care alone ɐ Tools and outcomes: FACT-PWB (lack Patients received weekly reminders to
on symptom control, processes of care of energy, pain, nausea, bothersome report symptoms and were given advice
(admissions or chemotherapy delivery), side effects, feeling ill, spending time in based on the severity of their symptoms.
patient self-efficacy, and global quality bed, not meeting family needs); EQ-5D, Nurses monitored daily symptoms and
of life among outpatients in home care EQ Visual Analog Scale, and EORTC alerts sent via messaging or email.
QLQ-C30 scores; brief Cancer Behavior
Inventory; Self-Efficacy Scale; and the
Patient Activation Measure
Aranda A randomized controlled trial of outpa- ɐ Population: 192 patients with nonmet- Nurses led a prechemotherapy educa-
et al., 2012 tients to evaluate psychological distress astatic breast, gastrointestinal, or hema- tional intervention. Patients received
—
(Australia) and secondary outcomes, including tologic cancer (X age = 52.4 years) self-care information, educational
chemotherapy-related information, ɐ Timing: at baseline and precycles 1 and 3 counseling 24 hours or more before the
support needs, and symptom burden ɐ Tools and outcomes: Eastern first treatment, telephone follow-up 48
because of nausea, vomiting, infection, Cooperative Oncology Group hours after the first treatment, and a
mucositis, fatigue, and hair loss Performance Status Scale, HADS, face-to-face intervention immediately
Cancer Treatment Survey (nausea, before the second treatment.
vomiting, infection, mucositis, fatigue,
and hair loss), and the Chemotherapy
Symptom Assessment Scale
Basch A randomized controlled trial comparing ɐ Population: 766 patients with metastatic Weekly symptom reports were requested
et al., 2016 web-based self-reporting of symptoms breast, genitourinary, gynecologic, or lung by email and uploaded to Symptom
(United versus usual care to enhanced symp- cancer (age range = 26–91 years) Tracking and Reporting. Nurses received
States) tom monitoring for cancer treatment ɐ Timing: at baseline and 6 months alerts about severe or worsening symp-
through patient-reported outcomes ɐ Tools and outcomes: EQ-5D (mobil- toms and carried out interventions as
and assessing emergency department ity, self-care, usual activities, pain needed. Clinicians monitored symptoms
visits, hospitalizations, and survival and discomfort, and anxiety and during visits.
among outpatients depression); 1-year survival; and the
5-point Symptom Tracking and Reporting
scale based on the CTCAE (appetite loss,
constipation, cough, diarrhea, dyspnea,
dysuria, fatigue, hot flashes, nausea,
pain, neuropathy, and vomiting)
Børøsund A randomized controlled trial com- ɐ Population: 167 patients with breast IPPCs supported patients in sending and
et al., 2014 paring IPPCs, WebChoices, and usual cancer (age range = 31–79 years) receiving messages, and WebChoices
(Norway) care to assess the efficacy and effects ɐ Timing: at baseline and 2, 4, and 6 supported symptom monitoring and
of digital support added to usual care months included information about containing
on symptom discomfort, anxiety, ɐ Tools and outcomes: baseline question- and self-managing toxicities, a diary,
depression, and self-efficacy among naires, SCQ-19, Memorial Symptom and communication with other patients.
outpatients Assessment Scale, HADS, and Cancer Nurses identified eligible patients,
Behavior Inventory; primary outcomes provided information, managed IPPCs,
were distress, anxiety, and depression; responded with suggestions, and
the secondary outcome was self-efficacy. involved physicians only when necessary.
Continued on the next page
TABLE 1. Data Extraction of Selected Studies (N = 11) (Continued)

Coombs A randomized controlled trial secondary ɐ Population: 126 patients (n = 90 female Patients reported daily symptoms and
et al., 2020 analysis of Symptom Care at Home (N = and n = 36 male) aged 60 years or older their severity to Symptom Care at Home
(United 59) versus usual care (N = 67) among with any cancer type every day. For moderate and/or severe
States) outpatients in home care to identify ɐ Timing: daily for 6 months symptoms, patients in the intervention
whether a remote symptom monitoring ɐ Tools and outcomes: demographic char- group were contacted by oncology
intervention resulted in improved adher- acteristics and type and stage of cancer nurses who suggested symptom control
ence and benefits regardless of age collected at baseline; patient-reported strategies, whereas patients in the
symptoms (pain, fatigue, nausea and control group were asked to contact
vomiting, fever, diarrhea, constipation, their oncologist.
sleep disturbance, sore mouth, anxiety,
and depressed mood) and severity using
a symptom severity scale (1–10); and a
decision support system
Innominato An observational study of outpatients ɐ Population: 17 male and 14 female Nurses monitored patients’ daily
et al., 2016 in home care to assess patients’ patients with any cancer type receiving symptoms to prevent severe toxicities.
(France) adherence to and the acceptability and multichemotherapy (age range = 35–91 A touchscreen computer equipped with
clinical feasibility of a daily telemonitor- years) SARA software was connected to a body
ing intervention ɐ Timing: daily for 30 days and 30 addi- weight scale for obtaining weight and
tional days postintervention a wrist accelerometer for monitoring
ɐ Tools and outcomes: MDASI for daily 24-hour heart rate, allowing patients to
self-assessment of 13 symptoms (pain, self-complete the MDASI questionnaire
fatigue, nausea, sleep disturbance, every morning. In cases of lack of data
distress, shortness of breath, memory for more than 24 hours, nurses called
problems, lack of appetite, drowsiness, patients to evaluate the necessary
dry mouth, sadness, vomiting, numb- intervention (e.g., information, visit,
ness or tingling) and 6 items to assess hospitalization). Patient satisfaction
impact on ADLs; inCASA platform, was evaluated using the Service User
connected with a body weight scale and Technology Acceptability Questionnaire
a wrist accelerometer (rest–activity); at study completion.
WHO-PS score at baseline; Service User
Technology Acceptability Questionnaire
for patient satisfaction; and unstruc-
tured narrative interviews for nurses
Innominato A pilot study of outpatients in home care ɐ Population: 11 homecare patients (age Nurses monitored patients’ daily
et al., 2018 to assess the effects of chemotherapy range = 48–72 years) with advanced or symptoms to prevent severe toxicity and
(France) on patients’ physiology, behavior, and metastatic colorectal (n = 5) or pancre- provide remote support. Nurses checked
symptoms (e.g., sleep–wake rhythm, atic (n = 6) cancer the dashboard daily for patient data on
patient-reported outcomes, weight ɐ Timing: daily for 30 days body weight and rest–activity rhythm,
change) and to compare continuous ɐ Tools and outcomes: MDASI for daily calling the patient in case of inactivity
and repeated measurement of the most self-assessment of 13 symptoms and 6 for more than 24 hours or severe signs
frequent symptoms items to measure interference with ADLs and symptoms. Nurses implemented
(fatigue, insomnia, anorexia, pain, and the most appropriate intervention (e.g.,
interference with activity, work, or rela- educational intervention, reassurance,
tionships and enjoyment of life); WHO-PS; urgent visit, hospitalization).
rest–activity; inCASA platform with SARA
software integrated with wrist scale,
accelerometer, and a body weight scale
TABLE 1. Data Extraction of Selected Studies (N = 11) (Continued)

Kearney A randomized controlled trial com- ɐ Population: 112 patients with lung, Nurses trained patients in the use of
—
et al., 2009 paring ASyMS versus usual care in breast, or colorectal cancer (X age = 56 ASyMS. Patients received automated
(United outpatients to assess the effect of years) information after entering a symptom
Kingdom) ASyMS on the incidence, severity, and ɐ Timing: at baseline and precycles 2–5 into the system. Clinicians received
distress of 6 chemotherapy-related (days 1–14 and any time they felt unwell) alerts for clinically relevant symptoms
symptoms (nausea, vomiting, fatigue, ɐ Tools and outcomes: CTCAE-based and contacted patients as needed.
mucositis, hand–foot syndrome, and questionnaire (nausea, vomiting,

diarrhea) fatigue, mucositis, hand–foot syndrome,
and diarrhea); Chemotherapy Symptom
Assessment Scale
McCann A randomized controlled trial to ɐ Population: 112 patients with lung, Nurses trained patients in the use of
—
et al., 2009 evaluate perceptions of ASyMS versus breast, or colorectal cancer (X age = 56 ASyMS. Information entered by patients
(United usual care on cancer treatment–related years) for the assessment of treatment-related
Kingdom) adverse events among outpatients in ɐ Timing: baseline and precycles 2–5 symptoms generated real-time alerts
home care ɐ Tools and outcomes: pre–/postinterven- at 2 levels. For moderate symptoms,
tion perception questionnaires (n = 56 patients received indications to alleviate
patients) and semistructured interviews symptoms, and for severe symptoms,
(n = 12 patients) health professionals contacted patients.
—
Mooney A randomized controlled trial com- ɐ Population: 358 patients (X age = 55.8 All participants called the automated
et al., 2017 paring Symptom Care at Home versus years) with breast or lung cancer system and reported their experience
(United usual care to assess the effectiveness ɐ Timing: at baseline and daily for 6 months with 11 symptoms following a reminder
States) of an electronic cancer treatment– ɐ Tools and outcomes: the severity of 11 call. Only reports of severe symptoms
related symptom control system among symptoms (fatigue, trouble sleeping, for patients in the Symptom Care at
outpatients and symptom severity, as nausea and vomiting, pain, numb- Home group alerted the nurses, who
well as the number of severe, moderate, ness or tingling, feeling blue or down, subsequently contacted the patients to
mild, and symptom-free days feeling nervous or anxious, distress over suggest the appropriate intervention.
appearance, diarrhea, sore mouth, and
trouble thinking or concentrating) on a
symptom severity scale; and a decision
support system
Ream A mixed-methods exploratory study to ɐ Population: 44 patients with breast or Semistructured interviews conducted
et al., 2015 evaluate reductions in fatigue intensity, colorectal cancer or lymphoma, with a by nurses trained in motivational
(United and related suffering, self-efficacy, anx- mean age of 53.3 years (range = 47–64) interviewing were used to investigate the
Kingdom) iety, and depression among outpatients ɐ Timing: at baseline and the completion usefulness of the intervention, its contri-
using an adaptation of the Brief Fatigue of chemotherapy bution to fatigue management, patient
Inventory for telephone delivery ɐ Tools and outcomes: Brief Fatigue satisfaction, time spent, and the number
Inventory, Fatigue Distress Scale, HADS, of and intervals between calls.
and brief health-specific self-efficacy
scales (fatigue intensity, distress, and
self-efficacy; anxiety and depression);
motivational interviewing with semi-
structured interviews
ADLs—activities of daily living; ASyMS—Advanced Symptom Management System; CTCAE—Common Terminology Criteria for Adverse Events; EORTC
QLQ-C30—European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire–Core 30; EQ—Euro Quality of Life; FACT-
PWB—Functional Assessment of Cancer Therapy–Physical Well-Being subscale; HADS—Hospital Anxiety and Depression Scale; inCASA—Integrated
Network for Completely Assisted Senior Citizen’s Autonomy; IPPCs—internet-based patient–provider communication services; MDASI—MD Anderson
Symptom Inventory; SARA—Simulation Assisted Reliability Assessment; SCQ—Social Communication Questionnaire; WHO-PS—World Health Orga-
nization Performance Status
randomized to enhanced usual care (N = 178) or issues. Semistructured interviews from 12 patients
Symptom Care at Home (SCH) (N = 180). Patients in globally confirmed the positive experience detected
the SCH group provided daily reports on the severity by the study questionnaires (McCann et al., 2009).
of 11 symptoms and received evidence-based sugges- Absolom et al. (2021) included 508 patients with
tions from nurses to reduce their daily symptom cancer in their RCT, which compared the effects of
burden. Patients receiving usual care called SCH usual care (n = 252) and eRAPID (electronic patient
without subsequently receiving nursing support self-Reporting of Adverse events: Patient Information
or alerts. The SCH group reported lower symptom and aDvice) added to usual care (n = 256) on symptom
severity (p < 0.001) across all ages (p < 0.001), with control, self-efficacy, system usability, and QOL at 6,
high adherence in both groups (p = 0.8). Compared 12, and 18 weeks. For the primary outcome of physical
to usual care, SCH significantly reduced days well-being, patients in the intervention group reported
—
with severe (p < 0.001) and moderate symptoms significantly better physical well-being at 6 weeks (X
(p = 0.001) and improved mild (p = 0.016) and no difference = 1.08, 95% CI [0.12, 2.05], p = 0.028) and
—
symptom days (p = 0.006). In addition, except for 12 weeks (X difference = 1.01, 95% CI [0.05, 1.98], p =
diarrhea, SCH significantly reduced all symptom 0.039) compared to patients in the usual care group.
scores (p < 0.05). In addition, compared to usual care, the eRAPID arm
In the secondary analysis by Coombs et al. (2020), reported better outcomes at 6 and 12 weeks, maintain-
126 patients aged 60 years or older were random- ing more extended physical well-being (39% versus
ized to the SCH (n = 59) or usual care (n = 67) group. 32%, respectively). Significant differences in QOL were
Regardless of age, all patients in the SCH group had reported between the eRAPID and usual care groups
—
better symptom control than those in the usual care at 12 (X difference = 3.5, 95% CI [0.35, 6.66], p = 0.03)
—
group (p < 0.001). Older adult patients in the SCH and 18 weeks (X difference = 4.48, 95% CI [1.11, 7.86],
—
group experienced fewer severe and moderate symp- p = 0.009) but not at 6 weeks (X difference = 1.36, 95%
toms than older adults in the usual care group (p = CI [1.66, 4.49], p = 0.377). Self-efficacy improved at 18
—
0.03 and 0.004, respectively), and no differences were weeks in the eRAPID arm (X difference = 0.48, 95%
observed in mild and asymptomatic patients (p = 0.38 CI [0.13, 0.83], p = 0.007). There were no differences
and 0.21, respectively). in healthcare resource usage or the Patient Activation
Kearney et al. (2009) performed a two-group RCT Measure and brief Cancer Behavior Inventory scores.
using the Advanced Symptom Management System In the eRAPID arm, EuroQOL Visual Analog Scale
—
(ASyMS) at five time points (baseline, precycle 2, pre- scores improved at 12 and 18 weeks (X difference = 3.5,
—
cycle 3, precycle 4, and precycle 5) with 112 patients 95% CI [0.35, 6.66], p = 0.03, and X difference = 4.48,
with breast, colorectal, or lung cancer. Patients in 95% CI [1.11, 7.86], p = 0.009, respectively) but not in
the intervention group used an interactive voice the short term, with an average patient adherence rate
response tool to receive tips on symptom manage- of about 65%.
ment after completing their symptom assessment In a two-phase exploratory, mixed-methods study,
questionnaires. The results suggested no significant Ream et al. (2015) described the effects of telephone
differences in both groups for monitoring symptoms, motivational interviews delivered by oncology nurses
except for fatigue, which was higher in the control on cancer-related fatigue and proactive behavior
group (odds ratio = 2.29, 95% confidence interval (CI) changes in complex situations. An in-depth fatigue
[1.04, 5.05], p = 0.04), and hand–foot syndrome, which assessment was conducted with 23 patients with
was lower in the control group (odds ratio = 0.39, 95% cancer, 9 of whom participated in motivational inter-
CI [0.17, 0.92], p = 0.031). views. For the 21 patients in the control group (usual
McCann et al. (2009) conducted a secondary care), no thorough screening for fatigue was per-
analysis of the experience and perceptions of 56 formed. Except for anxiety, all variables improved in
patients in the intervention group of the Kearney et the intervention arm and worsened in the control arm,
al. (2009) study. The patients’ expectations of using albeit with minor effect size. Seven of nine patients
ASyMS were globally positive regarding improv- found benefit from the motivational interview, similar
ing communication with the care team (87%), to the face-to-face intervention.
management of treatment-related symptoms (79%), An RCT by Basch et al. (2016) randomized 766
and reassurance regarding toxicity alerts. One patient patients into two groups: 539 computer-experienced
reported issues using ASyMS every day, whereas 36% patients and 227 computer-inexperienced patients.
of the sample reported rarely experiencing some Both groups were subsequently randomized into
the intervention (use of Symptom Tracking and educational intervention on the day of the first che-
Reporting) or control group (usual care). The primary motherapy cycle. Prechemotherapy education did not
outcome was health-related QOL, which was assessed significantly reduce distress but improved personal
at baseline and six months using the EuroQOL-5D. and treatment-related concerns and vomiting at all
Secondary outcomes were related to hospitalizations, time points (p = 0.027, p = 0.03, and p = 0.001, respec-
emergency department visits, and one-year survival. tively). In addition, among both patient groups with
In the intervention group compared to the control high distress at time 1, a significant reduction was
group, health-related QOL improved in more patients observed at time 2.
(34% versus 18%), worsened in fewer patients (38%
versus 53%, p < 0.001), and decreased less overall (1.4 Main Outcomes and Tools
versus 7.1, p < 0.001). In addition, in the intervention Table 2 summarizes the primary outcomes and
group compared to the control group, one-year sur- tools highlighted in this scoping review. Fatigue
vival (75% versus 69%, p = 0.05) and quality-adjusted was assessed in 9 of 11 studies and was measured
—
survival (X = 8.7 versus 8 months, p = 0.004) improved, using specific tools, such as the Fatigue Distress
—
and duration of chemotherapy (X = 6.3 versus 8.2 Scale (Holley, 2000) and the Brief Fatigue Inventory
months, p = 0.002), one-year emergency department (Mendoza et al., 1999), and nonspecific tools.
access (34% versus 41%, p = 0.02), and hospitalizations Psychological distress and symptoms of anxiety
(45% versus 49%, p = 0.08) decreased. In 77% of cases and depression were assessed in nine studies using
followed by nurse counseling, 63% of patients in the nonspecific and specific tools, such as the Hospital
intervention group experienced major grade 3 symp- Anxiety and Depression Scale (Zigmond & Snaith,
toms. Computer-inexperienced patients obtained the 1983). Symptom burden was assessed in 10 studies.
most significant benefits from Symptom Tracking and The main symptoms assessed in the studies were
Reporting. pain, nausea and vomiting, diarrhea, sleep distur-
Børøsund et al. (2014) used an RCT to compare bance, insomnia, loss of appetite, dizziness and
three arms of patients with breast cancer: usual care tingling, hair loss, hand–foot syndrome, and muco-
(control group), an internet-based patient–provider sitis. Different outcomes were used to describe
communication service (IPPC), and a WebChoices patients’ health status (e.g., performance status);
intervention added to an IPPC on depression, anxi- the impact of care on patients’ physical, psycholog-
ety, and symptom distress (primary end points) and ical, and social well-being; burdens on the health
self-efficacy (secondary end point), at two, four, and system (e.g., hospitalizations, visits, emergency
six months. IPPCs enable the exchange of informa- department use); and how decision-making, alerts,
tion, questions, and experiences between patients and interventions affected the care process. The
and nurses. Clinicians are notified by nurses as main outcomes investigated were self-efficacy, QOL,
needed. Improvements in scores for depression (p = performance status, perceived physical and psycho-
0.03), anxiety (p = 0.03), symptom distress over time logical well-being and treatment-related distress, and
(p = 0.001), and self-efficacy (p = 0.08) were best for activities of daily living, among others. Four studies
WebChoices versus usual care, with no significant dif- (Innominato et al., 2016, 2018; McCann et al., 2009;
ferences reported in the IPPC group. The IPPC group Ream et al., 2015) also investigated the usability of
had better scores than usual care for depression (p = and/or patient satisfaction with the intervention.
0.03), with no significant differences for anxiety and Tools were mainly administered at baseline, during
distress. the studies, and at the completion of the studies using
Aranda et al. (2012) addressed the effects of an validated tools, which patients accessed through
educational intervention using prechemotherapy web-based platforms, software, or telephone deliv-
education on distress, information and support ery. Specific tools used to measure symptom burden
needs, and symptom burden among 192 patients included the Memorial Symptom Assessment Scale
with cancer prior to and while receiving chemother- (Portenoy et al., 1994), the MD Anderson Symptom
apy. The intervention group received an educational Inventory (Cleeland et al., 2000), the Chemotherapy
intervention from nurses to fill information needs, Symptom Assessment Scale (Brown et al., 2001), the
provide support for treatment-related fears and Cancer Treatment Survey (Schofield et al., 2012), and
concerns, and promote self-efficacy before start- generic tools based on the Common Terminology
ing chemotherapy and subsequently before cycles 1 Criteria for Adverse Events. Table 3 describes the
and 3. Patients in the usual care group received the remote management systems used.
TABLE 2. Tools Used to Evaluate Primary Outcomes in Selected Studies
Tool Study
Anxiety and depression
EQ-5D Basch et al., 2016
FACT-G and FACT-PWB Absolom et al., 2021
Hospital Anxiety and Depression Scale Aranda et al., 2012; Børøsund et al., 2014; Ream et al., 2015
Symptom severity scale Coombs et al., 2020; Mooney et al., 2017

Comorbidity
Self-Administered Comorbidity Questionnaire Børøsund et al., 2014
Distress
MD Anderson Symptom Inventory Innominato et al., 2018
Fatigue
Brief Fatigue Inventory Ream et al., 2015
Cancer Treatment Survey Aranda et al., 2012
CTCAE-based scale Basch et al., 2016; Kearney et al., 2009
FACT-PWB Absolom et al., 2021
Fatigue Distress Scale Ream et al., 2015
MD Anderson Symptom Inventory Innominato et al., 2016, 2018
Symptom severity scale Coombs et al., 2020; Mooney et al., 2017
Multisymptom patient-reported outcomes
Chemotherapy Symptom Assessment Scale Absolom et al., 2021; Aranda et al., 2012; Kearney et al., 2009
CTCAE-based scale Basch et al., 2016; Kearney et al., 2009
MD Anderson Symptom Inventory Innominato et al., 2016, 2018
Memorial Symptom Assessment Scale Børøsund et al., 2014
Symptom severity scale Absolom et al., 2021; Coombs et al., 2020; McCann et al., 2009;
Mooney et al., 2017; Ream et al., 2015
1-year survival
Social Security Death Index Basch et al., 2016
Performance status
ECOG Performance Status Scale Aranda et al., 2012
World Health Organization Performance Status Innominato et al., 2016, 2018
Quality of life
EORTC QLQ-C30 Absolom et al., 2021
EQ-5D and EQ Visual Analog Scale Absolom et al., 2021; Basch et al., 2016
TABLE 2. Tools Used to Evaluate Primary Outcomes in Selected Studies (Continued)
Tool Study
Satisfaction
Semistructured interviews Innominato et al., 2016, 2018; McCann et al., 2009; Ream et al.,
2015
Self-efficacy
Brief health-specific self-efficacy scales Ream et al., 2015

CBI and brief CBI Børøsund et al., 2014
Self-Efficacy Scale Absolom et al., 2021
System usability
Perception questionnaires McCann et al., 2009
SUTAQ Innominato et al., 2016
Well-being
Cancer Treatment Survey Aranda et al., 2012
FACT-G and FACT-PWB Absolom et al., 2021
Patient Activation Measure Absolom et al., 2021
Rest–activity Innominato et al., 2016, 2018
CBI—Cancer Behavior Inventory; CTCAE—Common Terminology Criteria for Adverse Events; ECOG—Eastern Cooperative On-
cology Group; EORTC QLQ-C30—European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire–
Core 30; EQ—Euro Quality of Life; FACT-G—Functional Assessment of Cancer Therapy–General; FACT-PWB—Functional
Assessment of Cancer Therapy–Physical Well-Being subscale; SUTAQ—Service User Technology Acceptability Questionnaire
Discussion al., 2016; Denis et al., 2019), no significant improve-

Technology-supported remote interventions can ments were observed in patients with advanced
improve the well-being of patients with cancer and disease (Absolom et al., 2021), but the small sample
alleviate the burden of treatment (da Silva et al., 2022; size and observation period may have underpowered
Kwok et al., 2022). This is particularly important the effects.
given the increased use of telemedicine and telenurs- Following broad studies (Al Maqbali et al., 2021;
ing following the COVID-19 pandemic (Doraiswamy Fabi et al., 2020; Frick et al., 2017; Ma et al., 2020),
et al., 2020; Grasselli et al., 2020). the current study’s findings confirmed the impact of
The purpose of this scoping review was to inves- chemotherapy on fatigue, highlighting the frequency
tigate the use of telenursing interventions in the and importance of this symptom. The results for the
management of patients with cancer receiving che- burden of fatigue in the primary study using ASyMS
motherapy. The findings suggest that telenursing (Kearney et al., 2009) could be because of the sim-
interventions were carried out using different study plified and more accurate reporting from remote
designs, objectives, outcomes, and tools. Eleven stud- monitoring of this high-burden symptom, which has
ies met the inclusion criteria, but the scoping review been commonly underscreened and underreported in
design and the studies’ evident heterogeneity did clinical practice (Carrasco & Symes, 2018).
not allow for a meta-analysis. In accordance with the Within the limits of its exploratory nature, the
literature (da Silva et al., 2022; Kwok et al., 2022), real- study by Ream et al. (2015) assessed the effectiveness
time monitoring can improve symptom management of a telephone version of the Brief Fatigue Inventory
in the early phases of chemotherapy and disease stage and motivational interviews compared to face-to-face
(Absolom et al., 2021). Unlike other studies (Basch et delivery in managing fatigue. The findings suggest that
nurses’ skills, qualifications, and empathetic qualities
play a key role in such interventions, influencing their KNOWLEDGE TRANSLATION
success in managing cancer-related fatigue. However, ɐ Telenursing interventions can play a strategic role in the complex
the findings should consider the study’s limitations care pathways of patients with cancer by preventing and effective-
and be tested through a powered RCT. Based on this ly managing symptoms, particularly fatigue, anxiety, and depres-
review, the literature suggests that psychological dis- sion, and reducing patient burden.
tress, particularly anxiety and depression, has a high ɐ Patient-tailored prevention strategies, such as primary telenursing
prevalence among patients with cancer, which can interventions, can help patients to manage fatigue, anxiety, and
negatively affect QOL and survival (Absolom et al., depression using specific, generic, and validated tools.
2021; Aranda et al., 2012; Basch et al., 2016; Børøsund ɐ Remote telenursing interventions can engage patients in a pro-
et al., 2014; Coombs et al., 2020; Innominato et al., active approach to symptom management, increasing the quality
2016, 2018; Mooney et al., 2017; Ream et al., 2015; and safety of care.
Setyowibowo et al., 2022). The reported high prev-
alence of telenursing interventions for symptom
assessment and monitoring during the care process
emphasizes the importance of tailored interventions (Yun & Sim, 2021). Many studies have found improve-
in decision-making to improve patient outcomes. ment in clinical outcomes and control of symptoms
In their secondary analysis, Coombs et al. (2020) with the use of patient self-reporting, shared decision-
compared differences between the use of SCH versus making between patients and clinicians (Kotronoulas
usual care. Unlike some previous studies (Gordon & et al., 2014; Kroenke et al., 2014), and nurse-led coun-
Hornbrook, 2018; Vaportzis et al., 2017), no statisti- seling (Fieux et al., 2020).
cally significant differences were observed when using Despite initial concerns, patients found
digital technologies with older adults. These findings ASyMS helpful and straightforward in managing
underscore the need for more effortless access to chemotherapy-related toxicities and improving cli-
digital resources and the use of simple and inclusive nicians’ communication (McCann et al., 2009). Poor
tools for older adults with cancer, a large population communication between the care team and patients
among patients with cancer (Siegel et al., 2019). represents one of the primary concerns of patients
Børøsund et al. (2014) found that web-based with cancer and is a cause of medication errors,
support systems positively affected the severity of particularly in transitional care (Dionisi et al., 2022;
symptoms of anxiety and depression (Leis et al., Liquori et al., 2022). Digital tools (Aapro et al., 2020)
2022) and symptom burden (Maguire et al., 2021; and telenursing interventions (Johnson et al., 2018)
Ruland et al., 2013) among patients with cancer. can improve communication, not only in the oncol-
The WebChoices intervention and IPPCs positively ogy setting but also in overall health care (Dionisi et
influenced the psychological well-being of patients al., 2021). However, some patients with cancer are not
with cancer, particularly by improving symptoms of receptive to this type of care delivery (Wintheiser et
anxiety and depression. Based on the high burden of al., 2022). The RCT by Basch et al. (2016) showed a
depression in patients with cancer (Leis et al., 2022), reduction in emergency department visits and hos-
these findings are promising and demonstrate cost- pitalizations and an improvement in treatment
effectiveness. In addition, these findings show how duration, one-year survival, and quality-adjusted
technology can offer nurses many support systems survival, which are promising findings for nursing
and strategies in cancer care. Telephone support contributions in cancer care.
systems can be helpful and sufficient. However, a Finally, this review suggests significant hetero-
web-based platform promoting more continuous geneity regarding the tools used to measure clinical
monitoring and virtual meetings through video outcomes. The most used tools to detect the impact
calls and messaging can improve the patient care of multisymptoms were a symptom severity scale
experience and be an effective alternative to face-to- (Absolom et al., 2021; Coombs et al., 2020; McCann
face meetings, with low interference with the team et al., 2009; Mooney et al., 2017; Ream et al., 2015)
workflow. and the Chemotherapy Symptom Assessment Scale
The attention to self-efficacy underlines its impor- (Absolom et al., 2021; Aranda et al., 2012; Kearney et
tance in self-care and proactivity of patients with al., 2009). Several validated tools were used to eval-
cancer, improving their coping strategies, well-being, uate the effects of telenursing interventions on the
and QOL, as in other diseases and chronic conditions study outcomes, strengthening the findings of the
TABLE 3. Remote Management Systems Used populations, and some studies took place at only a
by Selected Studies single institution.
System Study
Implications for Nursing
ASyMS McCann et al., 2009 Preventing and managing chemotherapy toxicities
is an important nursing focus (De Leo et al., 2021).
Decision support system Coombs et al., 2020; Mooney et al., 2017
Nurses can help to prevent and manage adverse
eRAPID Absolom et al., 2021 events among patients with cancer receiving chemo-
therapy, particularly cancer-related fatigue, anxiety,
inCASA Innominato et al., 2016, 2018
and depression. Remote telenursing interventions and
IPPCs Børøsund et al., 2014 electronic patient-reported outcomes for treatment-

related toxicities can promote a preventive and
PRISMS Kearney et al., 2009
proactive approach in patients with cancer, increas-
Risk modela Kearney et al., 2009; McCann et al., 2009 ing the safety and quality of care and reducing
burdens on patients, caregivers, and health systems
SARA software Innominato et al., 2016, 2018
(Ebrahimabadi et al., 2021; Sato, 2020; Shohani et al.,
STAR Basch et al., 2016 2018).
The use of telenursing interventions by oncol-
Symptom Care at Home Coombs et al., 2020; Mooney et al., 2017
ogy nurses with the proper skills, qualifications,
a
For any concerning symptom reported and empathetic abilities can play a strategic role in
ASyMS—Advanced Symptom Management System; eRAPID—electronic the complex therapeutic pathways of patients with
patient self-Reporting of Adverse events: Patient Information and cancer and improve clinical and organizational out-
aDvice; inCASA—Integrated Network for Completely Assisted Senior
Citizen’s Autonomy; IPPCs—internet-based patient–provider commu- comes. In addition, patients without transportation,
nication services; PRISMS—Patient Remote Intervention and Symptom those living in remote areas, or those with disabili-
Management System; SARA—Simulation Assisted Reliability Assess- ties or little social support could benefit more from
ment; STAR—Symptom Tracking and Reporting a wider availability of telenursing interventions and
services. Support from healthcare organizations and
best-practice strategies are needed to implement
individual studies. Patient satisfaction and system more meaningful telenursing interventions and
usability were assessed in only four studies using evenly distribute the increase in care-related costs
interviews and validated tools (Innominato et al., that this approach may entail.
2016, 2018; McCann et al., 2009; Ream et al., 2015).
This may represent a lack of important feedback to Conclusion
overcome patients’ and healthcare professionals’ bar- Cancer and its treatments have a significant impact
riers to the use of these tools in cancer care. on patients’ QOL and on healthcare organizations
overall (World Health Organization, n.d.). Patient
Limitations self-efficacy and prevention and management of
This scoping review has some limitations. First, a cancer-related toxicities and treatments are needed
scoping review does not have the methodologic rigor to ensure the well-being of patients and sustainabil-
of a systematic review. Only studies in English, which ity of health systems (Howell et al., 2017). The use of
is considered the common language used by the inter- patient-reported outcomes, eHealth, and telenurs-
national scientific community, were included in this ing interventions can provide a more objective and
review because a lack of fluency in other languages systematic approach to monitoring toxicities and
limited the authors’ ability to review additional stud- symptom distress (Harada et al., 2023) and increase
ies. However, this may have excluded eligible studies early clinical interventions for their reduction.
written in languages other than English. Given the This review suggests the importance of tailored
lack of quality assessment of the included studies, the patient prevention strategies and healthcare pro-
implications for clinical practice and generalizations fessionals’ involvement and support in managing
must consider this gap. In addition, many studies treatment-related toxicities to promote patient
included small samples, partial data loss affecting adherence and QOL (Absolom et al., 2021). An inter-
the results, high dropout rates, the use of nonspecific professional approach to symptom management,
symptom detection tools, and heterogeneous cancer including the contribution of oncology nurses and
proactive patient involvement, can improve the pre- Ospitalieri; Noemi Giannetta, PhD, RN, is an assistant professor
vention, identification, assessment, and management of nursing science in the School of Nursing at UniCamillus-Saint
of symptoms (De Leo et al., 2021). In addition to Camillus International University of Health and Medical Sciences in
managing, preventing, and monitoring fatigue, exam- Rome; and Marco Di Muzio, PhD, RN, is an assistant professor of
ining psychological distress, anxiety, and depression nursing and Emanuele Di Simone, PhD, RN, is a research fellow in
using specific and nonspecific tools may represent nursing sciences, both in the Department of Clinical and Molecular
a critical element in the clinical pathway of patients Medicine at Sapienza University of Rome, all in Italy. De Leo can be
with cancer. Implementing telenursing interventions reached at [email protected], with copy to ONFEditor@
based on the experiences and satisfaction of patients ons.org. (Submitted May 2023. Accepted August 17, 2023.)
and nurses can help to overcome stakeholder barriers
to using these tools. The authors gratefully acknowledge the librarians of the digital
The implementation of telenursing interventions library, Knowledge Center “Riccardo Maceratini” and Patient Library;
should consider the organizational, professional, and the Regina Elena National Cancer Institute in Rome; and Francesca
instrumental resources available; digital health lit- Servoli, PhD, and Virginia Scarinci, PhD, for their invaluable support
eracy; and the involvement of the interprofessional in the implementation phase of the research strategy.
team, patients, and caregivers (Ferrua et al., 2020).
The current review identified 11 studies focused on No financial relationships to disclose.
outpatients and patients in homecare settings; future
studies on the use of telenursing interventions are De Leo, Petrone, and Di Simone contributed to the conceptualization
needed to evaluate their effectiveness in acute or and design. Liquori and Giannetta completed the data collection.
primary care. It may be useful to investigate whether Panattoni provided statistical support. De Leo and Dionisi provided
personalized baseline educational prechemotherapy the analysis. De Leo, Spano, Panattoni, Di Muzio, and Di Simone
telenursing interventions produce better outcomes contributed to the manuscript preparation.
based on patients’ needs. More significant support,
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Telenursing Interventions

for Patients With Cancer

Study Population, Timing, Tools,

Continued on the next page

Study Population, Timing, Tools,

Continued on the next page

Study Population, Timing, Tools,

mucositis, hand–foot syndrome, and questionnaire (nausea, vomiting,

Anxiety and depression

EQ-5D Basch et al., 2016

FACT-G and FACT-PWB Absolom et al., 2021

Symptom severity scale Coombs et al., 2020; Mooney et al., 2017

Self-Administered Comorbidity Questionnaire Børøsund et al., 2014

MD Anderson Symptom Inventory Innominato et al., 2018

Brief Fatigue Inventory Ream et al., 2015

Cancer Treatment Survey Aranda et al., 2012

CTCAE-based scale Basch et al., 2016; Kearney et al., 2009

FACT-PWB Absolom et al., 2021

Fatigue Distress Scale Ream et al., 2015

MD Anderson Symptom Inventory Innominato et al., 2016, 2018

Symptom severity scale Coombs et al., 2020; Mooney et al., 2017

Multisymptom patient-reported outcomes

CTCAE-based scale Basch et al., 2016; Kearney et al., 2009

MD Anderson Symptom Inventory Innominato et al., 2016, 2018

Memorial Symptom Assessment Scale Børøsund et al., 2014

Social Security Death Index Basch et al., 2016

ECOG Performance Status Scale Aranda et al., 2012

World Health Organization Performance Status Innominato et al., 2016, 2018

EORTC QLQ-C30 Absolom et al., 2021

Continued on the next page

Brief health-specific self-efficacy scales Ream et al., 2015

CBI and brief CBI Børøsund et al., 2014

Self-Efficacy Scale Absolom et al., 2021

Perception questionnaires McCann et al., 2009

SUTAQ Innominato et al., 2016

Cancer Treatment Survey Aranda et al., 2012

FACT-G and FACT-PWB Absolom et al., 2021

Patient Activation Measure Absolom et al., 2021

Rest–activity Innominato et al., 2016, 2018

Discussion al., 2016; Denis et al., 2019), no significant improve-

IPPCs Børøsund et al., 2014 electronic patient-reported outcomes for treatment-

557–565. https://doi.org/10.1200/jco.2015.63.0830 & Giannetta, N. (2022). Medication errors’ causes analysis in

20(2), e12516. https://doi.org/10.1111/jjns.12516 7119–7132. https://doi.org/10.1007/s00520-022-07052-z

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