Preparedness to Implement Physical Activity and Rehabilitation Guidelines in Routine Primary Care Cancer Rehabilitation: Focus Group Interviews Exploring Rehabilitation Professionals' Perceptions.

To explore primary care professionals' perceptions of physical activity and other cancer rehabilitation practice in cancer survivors, investigating the preparedness to implement guidelines regarding cancer rehabilitation. We collected qualitative data through seven semi-structured focus group interviews with 48 rehabilitation professionals, with mean 9 years of experience in primary care rehabilitation (32 physiotherapists, 15 occupational therapists, and 1 rehabilitation assistant) in a primary care setting. Data was analyzed using content analysis. Primary care rehabilitation professionals expressed limited experience of cancer survivors, experienced lack of knowledge of cancer-related disability, and had doubts concerning how to treat cancer survivors. They also experienced uncertainty about where to find collaboration and support in the healthcare system outside their own rehabilitation clinic. There is a need to combine different implementation strategies to tackle multiple barriers for effective cancer survivor rehabilitation in primary care, to boost individual rehabilitation professionals' knowledge and self-efficacy, to clarify roles and responsibilities for cancer rehabilitation across levels of care, and to develop and strengthen organizational bridges to provide adequate access to rehabilitation for cancer survivors.

The nonpenetrating telescopic sham needle may blind patients with different characteristics and experiences when treated by several therapists.

Background. Little is known which factors influence the blinding in acupuncture studies. Aim. To investigate if blinding varied between patients with different characteristics receiving verum or sham acupuncture. Methods. We randomised cancer patients to verum (n = 109) or sham acupuncture (n = 106) with a nonpenetrating telescopic sham needle for nausea. Level of blinding was compared between different sub-groups of patients using Bang's blinding index (BI) ranged -1 to 1 (-1 = all state the opposite treatment, 1 = all identify treatment). Results. Most patients in the verum (74 of 95; 78%, BI 0.72) and the sham (68 of 95; 72%, BI -0.60). acupuncture group believed they had received verum acupuncture. The probability for a patient to believe he/she received verum acupuncture was related to the received needling type (P = .003) and to the patient's belief in received treatment effects (P = .008). Hospital (P = .425), therapist (P = .434), previous acupuncture experience (P = .578), occurrence of nausea (P = .157), gender (P = .760), and age (P = .357) did not affect blinding. Conclusions. Blinding was successfully achieved irrespective of age, gender, acupuncture experience, treatment effect, or in which hospital or by which therapist the patient received treatment. Patients with higher belief in the effect of the treatment were more likely to believe they had received verum acupuncture.

Methodology Aspects of Nausea Measuring During Pelvic Radiotherapy: Daily Nausea Measuring Is Successful to Identify Patients Experiencing Nausea.

BACKGROUND: Nausea seems underreported during pelvic radiotherapy. OBJECTIVE: The aims of this study were to investigate if a 5-week recall measure of nausea covering the entire radiotherapy period was comparable with accumulated daily nausea measurements and to investigate if the measuring method affected potential difference in quality of life (QoL) between nauseated patients and patients free from nausea. METHODS: This longitudinal methodology study covered 200 patients (mean age, 64 years; 84% women; 69% had gynecological cancer). The patients graded QoL (Functional Assessment of Cancer Therapy-General). They registered nausea daily and at a 5-week recall at the end of radiotherapy. RESULTS: The nausea-intensity category scale and visual analog scale correlated well (Spearman correlation coefficient = 0.622). According to the 5-week recall, 57 of 157 answering patients (36%) experienced nausea during the radiotherapy period. Using the daily nausea measurements, 94 of 157 patients (60%) experienced nausea (relative risk, 1.65; 95% confidence interval, 1.29-2.10). Of these 94 nauseated patients, 39 (42%) did not report nausea using the 5-week recall. The nauseated patients experienced worse QoL (physical/functional subscores) than patients free from nausea whether nausea was registered daily or at the 5-week recall. CONCLUSIONS: Almost half, 42%, of the patients who experienced nausea according to daily nausea measurements did not report having had nausea according to the 5-week recall. Nauseated patients graded worse QoL than patients who were free from nausea. IMPLICATIONS FOR PRACTICE: Nursing professionals should measure nausea repeatedly to identify patients at risk of nausea and worsened QoL, to be able to deliver evidence-based antiemetic treatment strategies.

Frequent Stools Were Related to Reduced Quality of Life and Capacity in Daily Activities: Weekly Observations During and After Pelvic or Abdominal Radiotherapy.

BACKGROUND: Greater knowledge regarding stool frequency and infrequency during pelvic and abdominal irradiation is needed to accurately identify patients at risk of either. OBJECTIVE: To describe occurrence of frequent and infrequent stools during pelvic-abdominal radiotherapy, and to compare quality of life (QoL) and activities of daily living (ADLs) of those patients experiencing frequent stools with those of patients experiencing infrequent stools. METHODS: Longitudinally during radiotherapy, 193 patients (64% had gynecological tumors) documented stool frequency, medications, and QoL using the Functional Assessment of Cancer Therapy-General. RESULTS: Fifty (26%) experienced frequent stools (≥28 stools a week), and 17 (9%) experienced infrequent stools (<3 stools a week). The frequency of stools and the consumption of medication for diarrhea were highest the last week of the radiotherapy period (50% had ≥49 stools a week, and 50% could not even define the number of stools). Thirty-seven of the patients experiencing frequent stools used antidiarrhea medications. Patients with frequent stools experienced lower QoL (P = .035) and capacity in ADLs (P = .023) compared with patients not experiencing frequent stools. CONCLUSIONS: A fourth of patients irradiated over pelvic or abdominal fields experienced frequent stools, defined as moderate to severe diarrhea, and those patients experienced lower QoL and capacity in ADLs compared with patients who did not experience frequent stools. Infrequent stools were rarely experienced. IMPLICATIONS FOR PRACTICE: Cancer nursing professionals should deliver evidence-based strategies to prevent frequent stools and treat frequent stools as an approach to lower the risk of impaired capacity in daily living and worsened QoL.

Can individuals identify if needling was performed with an acupuncture needle or a non-penetrating sham needle?

UNLABELLED: A control treatment in acupuncture research must be credible, regardless if the needling is performed by one or by several therapists. OBJECTIVE: To investigate if individuals could identify whether needling had been given with an acupuncture needle or a sham needle and if the therapist influenced this ability. DESIGN: Eighty individuals were randomized to one single needling given by one of four physiotherapists using either an invasive needle or a non-penetrating telescopic sham needle. RESULTS: An equal proportion of individuals, 27 (68%), in the acupuncture group and the sham group answered incorrectly or was not sure at all regarding needling type but the proportion varied between the therapists from 55 to 80% (ns). Bang's blinding index was 0.20 (95% CI 0.03-0.36) in the acupuncture group and 0.10 (95% CI 0.09-0.29) in the sham group (interpretation: 20 and 10% identified needling type beyond statistical chance). Acupuncture was on a four-grade scale rated as median "mildly painful" and sham as "not painful" (ns). Pain ratings varied from median "not" to "mildly painful" in the therapists (p = 0.01). CONCLUSIONS: Two thirds of individuals needled by acupuncture as well as sham could not identify needling type and only 10-20% of the individuals were unblinded beyond chance. The therapists, not the needling type, influenced how painful the needling was perceived. IMPLICATIONS: To achieve blinding success in acupuncture efficacy studies using the sham needle, the needling procedure must be strictly standardized in order to minimize differences between the therapists.

Understanding rationales for acupuncture treated individuals' beliefs in acupuncture effects, to be able to maximize therapeutic results: A qualitative analysis.

OBJECTIVE: To investigate how individuals expressed rationales for their beliefs regarding efficacy of acupuncture. METHODS: Qualitative data from participants of two different randomized sham-controlled trials, of relaxing (non-cancer volunteers of the general population) or antiemetic (patients with cancer undergoing radiotherapy) effects of acupuncture was analyzed. Participants (n = 441) received genuine (n = 120 and n = 100) or sham (n = 121 and n = 100) (telescopic blunt sham-needle) relaxing or antiemetic acupuncture. The participants (n = 428; 97% response rate) expressed their belief regarding the efficacy of acupuncture, and n = 264 delivered qualitative rationales for their belief, analyzed using qualitative content analysis. RESULTS: Of the 428 participants, 35 (8%) believed entirely that the acupuncture was effective, 209 (49%) believed much, 136 (32%) believed moderately, 39 (9%) believed a little, and 9 (2%) did not believe that the acupuncture was effective. Five categories and seven subcategories represented the meaning units of the central message of the rationales for the treatment belief. Participants with positive beliefs (believed entirely/much, n = 244) presented rationales related to: "Experienced positive effects", "Knowledge regarding effect-mechanisms of acupuncture", and "General trustworthiness of acupuncture". Participants with more negative beliefs (believed a little or not, n = 48) presented rationales related to: "Lack of feasibility of the acupuncture", "Varying effects", and "The effect is individual, not available for everybody". CONCLUSION: In order to strengthen acupuncture treated patients' beliefs in the efficacy of acupuncture during clinical practice or research, acupuncture therapists may consider emphasizing these aspects in the therapeutic situation.

Patients' and physiotherapists' belief in and use of acupuncture for cancer-related symptoms.

BACKGROUND: It is important to investigate attitudes to acupuncture, because therapists' and patients' expectations may affect the treatment outcome. AIM: To explore the use of and belief in acupuncture among oncological physiotherapists and to explore patients' interest in receiving acupuncture during cancer therapy and their belief in its effectiveness. METHODS: 522 patients (80% female, mean age 67 years) reported on their interest in receiving acupuncture for nausea during radiotherapy treatment; a subgroup (n=198) additionally disclosed their belief in the effectiveness of acupuncture. 117 Swedish oncological physiotherapists (96% female, mean age 48 years) answered a questionnaire regarding their use of and belief in acupuncture. RESULTS: Of the patients initiating cancer therapy, 359 (69%) were interested in receiving acupuncture. The patients believed acupuncture to be effective for pain (79%), nausea (79%) and vasomotor symptoms (48%). Of the 117 physiotherapists, 66 (56%) practised acupuncture. Physiotherapists generally believed in the effectiveness of acupuncture. For pain, 89% believed that acupuncture was effective and 42% of them practised it. Similar responses were noted for chemotherapy-induced nausea (86% and 38%, respectively) and vasomotor symptoms (80% and 28%, respectively). Younger physiotherapists and patients were more likely to believe in the effectiveness of acupuncture compared with older ones. CONCLUSIONS: More than two thirds of patients with cancer were interested in receiving acupuncture during therapy. Patients and oncological physiotherapists believed that acupuncture was effective for cancer pain, nausea and vasomotor symptoms. Further studies of acupuncture for cancer-related symptoms and of the effect of patients' and clinicians' therapeutic relationships, including treatment expectations, would be welcome.

Type and frequency of side effects during PC6 acupuncture: observations from therapists and patients participating in clinical efficacy trials of acupuncture.

BACKGROUND: Many therapists practise PC6 acupuncture for emesis (nausea and vomiting) during pregnancy, different cancer therapies, palliative care, after surgery, or to induce relaxing effects in general. Knowledge of side effects is central to shared decision-making. AIM: To describe the type and frequency of side effects and the level of needle-induced pain during PC6 acupuncture. METHODS: We included 1298 PC6 acupuncture treatments, delivered to 221 participants (77% women, mean age 52.5, range 18-91 years). The subjects had received genuine PC6 acupuncture, in one of two previous randomised controlled trials, aimed at inducing antiemetic (n=100, with 100 providing data on side effects and 94 on needle-induced pain, respectively) or relaxing (n=121, with 120 providing data) effects. Side effects during and after the acupuncture treatments were registered in structured treatment protocols and study diaries. RESULTS: No serious complications occurred. Side effects during the acupuncture sessions included minor bleeding in 5.0%, tiredness in 4.9%, numbness in 4.5% and dizziness in 1.4% of the 1298 treatments. After treatment, the mean proportions of participants reporting side effects each week were: tiredness 25.8%; feeling cold 17.8%; dizziness 9.7%; sweating 9.3%; haematoma 8.8%; and soreness at the needling sites 4.3%. Participants perceived the needling to be not painful (47.4% of participants), or mildly (39.1%), moderately (11.6%) or very painful (1.4%). CONCLUSIONS: Few side effects occurred and those that did were mild. Nearly 90% found PC6 acupuncture to be not painful or only mildly painful. Healthcare professionals may consider the observed levels of side effects when informing patients about side effects of PC6 acupuncture.

Emesis in patients receiving acupuncture, sham acupuncture or standard care during chemo-radiation: A randomized controlled study.

OBJECTIVE: To study nausea, vomiting and need for rescue antiemetics in patients receiving antiemetic acupuncture, sham acupuncture or standard care during concomitant chemotherapy during pelvic radiotherapy. METHODS: In total, 68 patients participated (75% women, mean age 56 years, 53% had gynecological, 43% colorectal, and 4% other cancer types). Fifty-seven of them were blinded randomized to verum (n=28) or sham (n=29) acupuncture, median 10 sessions. During the study period of four weeks, the patients daily registered their nausea, vomiting and consumption of antiemetics. They were compared to a reference group (n=11) receiving standard care only, who delivered these data once (after receiving mean 27Gy radiotherapy dose). RESULTS: More patients in the sham acupuncture group (17 of 20; 85%, p=0.019, RR 1.81, CI 1.06-3.09) consumed antiemetics, compared to the verum acupuncture group (8 of 17; 47%). In the standard care group, 7 of 11 (63%) consumed antiemetics. The verum acupuncture treated patients experienced lower intensity of nausea than the other patients (p=0.049). There was a non-significant tendency that more patients receiving either sham acupuncture or standard care experienced nausea (21 of 31; 68%) than patients receiving verum acupuncture (9 of 17; 53%: p=0.074, RR 1.58, CI 0.91-2.74). CONCLUSION: Patients treated with verum acupuncture needed less antiemetics and experienced milder nausea than other patients. Our study was small and many analyses lacked statistical power to detect differences; we welcome further sham-controlled efficacy studies and studies regarding the role of non-specific treatment components for experiencing antiemetic effects of acupuncture.

Complementary and alternative medicine self-care strategies for nausea in patients undergoing abdominal or pelvic irradiation for cancer: A longitudinal observational study of implementation in routine care.

OBJECTIVE: To longitudinally describe practice of Complementary and Alternative Medicine (CAM) self-care strategies for nausea during radiotherapy. METHODS: Two hundred patients daily registered nausea and practice of CAM self-care strategies, beside conventional antiemetic medications, for nausea during abdominal/pelvic irradiation (median five weeks) for gynecological (69%) colorectal (27%) or other tumors (4%). RESULTS: During radiotherapy, 131 (66%) experienced nausea, and 50 (25%) practiced self-care for nausea at least once, for a mean (m) of 15.9days. The six of 50 patients who stayed free from nausea practiced self-care more frequent (m=25.8days) than the 44 patients experiencing nausea (m=14.5) (p=0.013). The CAM self-care strategies were: modifying eating (80% of all self-care practicing patients, 80% of the nauseous patients versus 83% of the patients free from nausea; ns) or drinking habits (38%, 41% vs 17%; ns), taking rests (18%, 20% vs 0%; ns), physical exercising (6%, 2% vs 33%; p=0.035), acupressure (4%, 5% vs 0%; ns) and self-induced vomiting (2%, 2% vs 0%; ns). CONCLUSION: A fourth of patients undergoing emetogenic radiotherapy practiced CAM self-care for nausea, mostly by modifying eating or drinking habits. The CAM self-care practicing patients who did not become nauseous practiced self-care more frequent than the nauseous patients did. To make such self-care evidence based, we need studies evaluating its efficacy.

Reduced Need for Rescue Antiemetics and Improved Capacity to Eat in Patients Receiving Acupuncture Compared to Patients Receiving Sham Acupuncture or Standard Care during Radiotherapy.

Objective. To evaluate if consumption of emesis-related care and eating capacity differed between patients receiving verum acupuncture, sham acupuncture, or standard care only during radiotherapy. Methods. Patients were randomized to verum (n = 100) or sham (n = 100) acupuncture (telescopic blunt sham needle) (median 12 sessions) and registered daily their consumption of antiemetics and eating capacity. A standard care group (n = 62) received standard care only and delivered these data once. Results. More patients in the verum (n = 73 of 89 patients still undergoing radiotherapy; 82%, Relative Risk (RR) 1.23, 95% Confidence Interval (CI) 1.01-1.50) and the sham acupuncture group (n = 79 of 95; 83%, RR 1.24, CI 1.03-1.52) did not need any antiemetic medications, as compared to the standard care group (n = 42 out of 63; 67%) after receiving 27 Gray dose of radiotherapy. More patients in the verum (n = 50 of 89; 56%, RR 1.78, CI 1.31-2.42) and the sham acupuncture group (n = 58 of 94 answering patients; 62%, RR 1.83, CI 1.20-2.80) were capable of eating as usual, compared to the standard care group (n = 20 of 63; 39%). Conclusion. Patients receiving acupuncture had lower consumption of antiemetics and better eating capacity than patients receiving standard antiemetic care, plausible by nonspecific effects of the extra care during acupuncture.

Health-related quality of life and musculoskeletal function in patients with musculoskeletal disorders: after compared to before short-term group-based aqua-exercises.

This study assessed health-related quality of life (HRQoL) and musculoskeletal function in patients with musculoskeletal disorders after participation in group-based aqua-exercising, compared to before participation. Physiotherapists instructed group-based aqua-exercising for 30 min twice a week for 8 weeks in 39 patients (81% women, mean age 55 ± 12 years), with musculoskeletal disorders located in the back (28%), neck (17%), general myalgia (21%), lower extremities (9%), shoulder (7%) and multiple/other regions (18%). Before and after the aqua-exercising, physiotherapists assessed patients' musculoskeletal function categorized using Goal Attainment Scaling, and HRQoL was measured using EuroQol 5 Dimensions (EQ-5D). The median EQ-5D score was 0.36 (25th-75th percentiles 0.09-0.69) at the start, and after the intervention improved to 0.62 (0.09-0.73) (p = 0.038). The EQ-5D score and musculoskeletal function improved in 49% (EQ-5D) and 34% (physiotherapist assessment), were stable in 33% and 63%, and worsened in 18% and 7% of patients, respectively. In conclusion, comparable with improvements previously seen after more time-consuming exercise periods, patients with musculoskeletal disorders had improved HRQoL after 8 weeks of aqua-exercising compared to before exercising. This uncontrolled feasibility study does not reveal whether this was the result of aqua-exercising. The effects and costs need to be evaluated in randomized controlled studies.

The Effects of Positive or Neutral Communication during Acupuncture for Relaxing Effects: A Sham-Controlled Randomized Trial.

Introduction. The link between patient-clinician communication and its effect on clinical outcomes is an important clinical issue that is yet to be elucidated. Objective. Investigating if communication type (positive or neutral) about the expected treatment outcome affected (i) participants' expectations and (ii) short-term relaxation effects in response to genuine or sham acupuncture and investigating if expectations were related to outcome. Methods. Healthy volunteers (n = 243, mean age of 42) were randomized to one treatment with genuine or sham acupuncture. Within groups, participants were randomized to positive or neutral communication, regarding expected treatment effects. Visual Analogue Scales (0-100 millimeters) were used to measure treatment expectations and relaxation, directly before and after treatment. Results. Participants in the positive communication group reported higher treatment expectancy, compared to the neutral communication group (md 12 versus 6 mm, p = 0.002). There was no difference in relaxation effects between acupuncture groups or between communication groups. Participants with high baseline expectancy perceived greater improvement in relaxation, compared to participants with low baseline levels (md 27 versus 15 mm, p = 0.022). Conclusion. Our data highlights the importance of expectations for treatment outcome and demonstrates that expectations can be effectively manipulated using a standardized protocol that in future research may be implemented in clinical trials.

Pilot testing of methods for evaluation of acupuncture for emesis during radiotherapy: a randomised single subject experimental design.

BACKGROUND: Many acupuncture studies are of weak methodological quality, possibly due to lack of pilot testing. This pilot study tested design features, including test of feasibility, compliance to treatment and data collection, level of blinding success and the patients' potential perceived effects of the treatment, in preparation for an efficacy study. METHOD: A modified single subject experimental design was conducted. 10 cancer patients were randomised to verum penetrating acupuncture or non-penetrating sham needles for 30 min 2-3 times/week during radiotherapy over abdomen/pelvis. They answered test-retested emesis questions (r=0.527-1.0) covering nausea, vomiting, use of antiemetics, wellbeing and activities of daily living. RESULTS: Overall, the patients completed 98% of the 345 emesis-questionnaire days and 101 of the 115 offered treatments. All patients believed they received verum acupuncture. 10 patients experienced antiemetic effects, seven relaxation, five pain-reduction and five experienced sleep improvement. Two types of nausea questions showed absolute concordance (r=1.0) (n of observations=456). Nausea was experienced by one of five verum acupuncture treated patients (duration median 0% of the radiotherapy-days) and four of five sham acupuncture treated patients (duration median 24% of the radiotherapy-days). Patients experiencing nausea rated decreased wellbeing and performance of daily activities compared to patients free from nausea. CONCLUSIONS: All patients were blinded, complied with verum/sham treatments and data-collection, and believed they had effects of the received treatment. The methods for verum/sham treatment and data collection may thus be used in an adequately powered randomised controlled study of the effect of acupuncture for radiotherapy-induced emesis.

Getting the grip on nonspecific treatment effects: emesis in patients randomized to acupuncture or sham compared to patients receiving standard care.

BACKGROUND: It is not known whether or not delivering acupuncture triggers mechanisms cited as placebo and if acupuncture or sham reduces radiotherapy-induced emesis more than standard care. METHODOLOGY/PRINCIPAL FINDINGS: Cancer patients receiving radiotherapy over abdominal/pelvic regions were randomized to verum (penetrating) acupuncture (n = 109; 99 provided data) in the alleged antiemetic acupuncture point PC6 or sham acupuncture (n = 106; 101 provided data) performed with a telescopic non-penetrating needle at a sham point 2-3 times/week during the whole radiotherapy period. The acupuncture cohort was compared to a reference cohort receiving standard care (n = 62; 62 provided data). The occurrence of emesis in each group was compared after a mean dose of 27 Gray. Nausea and vomiting were experienced during the preceding week by 37 and 8% in the verum acupuncture group, 38 and 7% in the sham acupuncture group and 63 and 15% in the standard care group, respectively. The lower occurrence of nausea in the acupuncture cohort (verum and sham) compared to patients receiving standard care (37% versus 63%, relative risk (RR) 0.6, 95 % confidence interval (CI) 0.5-0.8) was also true after adjustment for potential confounding factors for nausea (RR 0.8, CI 0.6 to 0.9). Nausea intensity was lower in the acupuncture cohort (78% no nausea, 13% a little, 8% moderate, 1% much) compared to the standard care cohort (52% no nausea, 32% a little, 15% moderate, 2% much) (p = 0.002). The acupuncture cohort expected antiemetic effects from their treatment (95%). Patients who expected nausea had increased risk for nausea compared to patients who expected low risk for nausea (RR 1.6; Cl 1.2-2.4). CONCLUSIONS/SIGNIFICANCE: Patients treated with verum or sham acupuncture experienced less nausea and vomiting compared to patients receiving standard care, possibly through a general care effect or due to the high level of patient expectancy. TRIAL REGISTRATION: ClinicalTrials.gov NCT00621660.

One third of patients with radiotherapy-induced nausea consider their antiemetic treatment insufficient.

OBJECTIVE: To describe the prevalence of nausea and vomiting during radiotherapy and to compare quality of life, psychological and functional status in patients experiencing or not experiencing nausea. MATERIALS AND METHODS: A cross-sectional selection of 368 cancer patients treated with radiotherapy answered a questionnaire (=93% answering rate) regarding nausea, vomiting, actual use of and interest in antiemetic treatment, quality of life and psychological and functional status during the preceding week of radiotherapy. Mean age was 60 years and 66% were women. MAIN RESULTS: Nausea was experienced by 39% (145) and vomiting by 7% (28) of patients in general, by 63% in abdominal or pelvic fields and by 48% in head/neck/brain fields. Abdominal/pelvic field (Relative risk (RR) 2.0), age < or = 40 years (RR 1.9) and previous nausea in other situations (RR 1.8) implied an increased risk for nausea. Antiemetics were used by 17% and 78% were interested in or wanted more information about acupuncture treatment against nausea. Of the 145 nauseous patients only 25% felt that antiemetics had helped them and 34% would have liked additional treatment, although the nausea intensity was mild in 72%. The nauseous patients reported lower well-being and quality of life, lower satisfaction with aspects of daily living and more frequent anxiety and depressed mood than the patients without nausea. CONCLUSIONS: Of all patients undergoing radiotherapy, 39% experienced nausea and one third of them would have liked more treatment against the nausea. This study stresses the importance to identify and adequately treat patients with increased risk for nausea related to radiotherapy.