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This clinical study aims to evaluate whether short-term personalized nutritional support, when combined with structured health education, can improve nutritional status, quality of life, and clinical outcomes in patients who have undergone surgery for colorectal cancer (CRC). Colorectal cancer is one of the most common cancers worldwide, and many patients experience malnutrition and poor physical condition during treatment, which can negatively affect recovery and long-term survival.
In this multicenter, randomized, controlled clinical trial, approximately 360 postoperative CRC patients will be enrolled and randomly assigned to one of four groups: (A) nutritional enhancement combined with health education, (B) health education alone, (C) nutritional enhancement alone, or (D) standard care (control group). Nutritional support will include individualized diet counseling and oral nutritional supplements tailored to each patient's needs. Health education will be delivered using an "Internet Plus" approach, including weekly educational videos and expert consultations focusing on nutrition, physical activity, and mental health.
The primary objectives are to determine whether these interventions can improve patients' short-term nutritional status and quality of life. Secondary outcomes include the impact of interventions on long-term survival, treatment-related side effects, patient adherence to nutrition recommendations, and psychological well-being.
This study will also investigate the biological mechanisms underlying the clinical effects by analyzing changes in the gut microbiome, blood-based metabolic profiles, and immune responses. Blood, stool, and tumor tissue samples will be collected and analyzed using advanced techniques, including untargeted metabolomics, metagenomics, and single-cell sequencing.
This trial is designed to provide evidence for the integration of nutritional strategies into routine cancer care, and to guide the development of more personalized, effective nutrition-based therapies for colorectal cancer patients. Participants will be followed for up to annually up to 5 years to evaluate both clinical outcomes and biological markers of response.
This is a prospective, multicenter, open-label, randomized controlled clinical trial designed to assess the effects and underlying mechanisms of short-term nutritional enhancement combined with health education on clinical outcomes in patients undergoing surgery for non-metastatic colorectal cancer (stages IIa, IIb, IIIa). The rationale is based on the high prevalence of malnutrition among CRC patients, which significantly impacts treatment tolerance, quality of life, and long-term prognosis.
Eligible participants will be randomized into four parallel arms: (1) individualized nutritional enhancement plus structured health education; (2) structured health education alone; (3) individualized nutritional enhancement alone; and (4) standard care without additional intervention. Personalized nutrition plans will be developed based on energy and protein needs, supported by dietary counseling and the provision of oral nutritional supplements. Health education will be delivered through a digital platform, featuring weekly videos and interactive content on nutrition, exercise, and psychological well-being.
The study includes a 14-day intervention phase and a 12-month follow-up period. Outcomes will be assessed at baseline, and at 1, 2, 3, 6, and 12 months, and annually up to 5 years to evaluate both clinical outcomes and biological markers of response.post-intervention. Key endpoints include improvements in nutritional status, patient-reported quality of life, and overall survival metrics.
To investigate mechanisms, the study incorporates biological sampling and multi-omics analysis. Non-targeted serum metabolomics, gut microbiota metagenomics, and single-cell RNA sequencing of tumor and adjacent normal tissues will be used to characterize metabolic and immune changes associated with the interventions. The study also evaluates the role of inflammatory markers and immune cell profiles in mediating clinical effects.
This trial is expected to generate high-quality evidence supporting the integration of nutrition and health education strategies into standard postoperative care for CRC patients. It may also identify novel metabolic or microbial biomarkers associated with treatment response and prognosis, contributing to the development of precision nutrition approaches in oncology.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Nutritional Enhancement Plus Health Education | Experimental | Participants in this arm will receive individualized nutritional enhancement along with structured health education. Nutritional intervention includes personalized dietary plans and oral nutritional supplements based on energy and protein requirements. Health education is delivered via an "Internet Plus" platform and includes weekly videos and interactive content focusing on nutrition, physical activity, and psychological support. The intervention lasts for 14 days and is followed by a 12-month, and annually up to 5 years to evaluate both clinical outcomes and biological markers of response. follow-up period. |
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| Health Education Only | Experimental | Participants in this arm will receive structured health education without additional nutritional supplementation. The education is delivered via an "Internet Plus" platform, including weekly videos and interactive content focused on nutrition knowledge, physical activity guidance, and psychological support. This intervention is administered for 14 days, followed by a 12-month follow-up and annually up to 5 years. |
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| Nutritional Enhancement Only | Experimental | Participants in this arm will receive individualized nutritional enhancement based on personalized dietary assessment and calculated energy and protein needs. Interventions include oral nutritional supplements and tailored dietary counseling provided by a clinical nutrition team. No additional health education is provided. The intervention phase lasts for 14 days, with scheduled follow-up for 12 months and annually up to 5 years. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Personalized Oral Nutritional Supplementation | Dietary Supplement | Participants receive individualized oral nutritional supplementation based on energy and protein requirements, calculated using the Harris-Benedict equation and body weight (1.2-1.5 g protein/kg/day). The supplement may include complete nutrition powder, whey protein powder, and compound multivitamins. The intervention is prescribed and monitored by a clinical nutrition team and adjusted every 3 days during the 14-day intervention phase. The goal is to ensure both energy and protein intake targets are met. Supplements are administered in addition to standard meals. |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Nutritional Status Assessed by Modified Patient-Generated Subjective Global Assessment (mPG-SGA) | Longitudinal assessment of nutritional status using the mPG-SGA, a validated tool composed of five sections (weight loss history, dietary intake, symptoms, function/activity, and age). Total scores range from 0 to ≥7 points, with higher scores indicating worse nutritional status. Patients will be classified as: 0-2 = Normal 3-6 = Mild malnutrition ≥7 = Moderate to severe malnutrition. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Change in Global Health Status Score on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) | Assessment of patients' perceived overall health status using the global health subscale of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Scores range from 0 to 100, with higher scores indicating better global quality of life. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Change in Symptom Scores on the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) | Assessment of symptom burden including fatigue, pain, nausea/vomiting, appetite loss, sleep disturbance, constipation, diarrhea, and financial difficulty using symptom subscales of the EORTC QLQ-C30. Each symptom is scored separately from 0 to 100, with higher scores indicating worse symptom severity. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Overall Survival (OS) in Cancer Patients | Overall survival is defined as the time from the date of enrollment to the date of death from any cause. Patients still alive at the last follow-up will be censored. Kaplan-Meier survival analysis and Cox proportional hazards regression will be used to estimate survival and explore associations with baseline and longitudinal nutritional status. |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Nutritional Risk Assessed by Nutritional Risk Screening 2002 (NRS-2002) | Longitudinal evaluation of nutritional risk using the NRS-2002, which considers disease severity, nutritional impairment, and age. Total score ranges from 0 to ≥7 points. A score of ≥3 indicates nutritional risk and warrants intervention; <3 indicates no immediate risk. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Measure | Description | Time Frame |
|---|---|---|
| Predictive Value of Baseline Nutritional Indicators for 30-Day Clinical Events | Evaluation of whether baseline nutritional indicators-including mPG-SGA scores and laboratory biomarkers such as albumin, prealbumin, and CRP-predict 30-day clinical outcomes, including mortality, ICU admission, and significant unintentional weight loss (>5%). Logistic regression will be used for model construction and discrimination. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Xiaoqin Luo, Ph.D | Contact | +8618802932796 | luoxiaoqin2012@xjtu.edu.cn | |
| Hexiang Yang, Ph.D | Contact | +8617791547192 | clyeah@hotmail.com |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Xi 'an Jiaotong University | Recruiting | Xi'an | Shaanxi | 710000 | China |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 33446996 | Background | Yang Y, Han Z, Li X, Huang A, Shi J, Gu J. Epidemiology and risk factors of colorectal cancer in China. Chin J Cancer Res. 2020 Dec 31;32(6):729-741. doi: 10.21147/j.issn.1000-9604.2020.06.06. | |
| 34843383 | Background | Bennell KL, Lawford BJ, Keating C, Brown C, Kasza J, Mackenzie D, Metcalf B, Kimp AJ, Egerton T, Spiers L, Proietto J, Sumithran P, Harris A, Quicke JG, Hinman RS. Comparing Video-Based, Telehealth-Delivered Exercise and Weight Loss Programs With Online Education on Outcomes of Knee Osteoarthritis : A Randomized Trial. Ann Intern Med. 2022 Feb;175(2):198-209. doi: 10.7326/M21-2388. Epub 2021 Nov 30. |
| Label | URL |
|---|---|
| World Health Organization. Cancer\[EB/OL\]. Cancer\[2023-05-12\]. | View source |
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The study intends to share IPD with other researchers for advancing scientific understanding and improving patient care. The shared data will include anonymized participant information, such as demographic details, clinical outcomes, and treatment responses. The data will be stripped of any identifiers to ensure participant confidentiality.
The data will become available after the publication of the main study results, anticipated to be by the end of 2030. The data will be accessible for a period of five years following this date.
Researchers interested in accessing the data will be required to submit a proposal outlining their intended use of the data, which will be reviewed by the study's principal investigator. Access will be granted based on the scientific merit and ethical considerations of the proposal.
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Oct 10, 2024 |
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This is a prospective, multicenter, open-label, parallel-group randomized controlled trial involving four intervention arms. Participants are assigned in a 1:1:1:1 ratio to one of the following: (A) short-term nutritional enhancement combined with health education, (B) health education alone, (C) nutritional enhancement alone, or (D) standard care. Stratified randomization is performed based on baseline nutritional status and cancer stage to ensure group balance.
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Laboratory personnel conducting metabolomic, microbiome, and single-cell analyses will remain blinded to group allocation to reduce bias during data generation and interpretation.
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| Standard Care (Control) | No Intervention | Participants in this arm will receive standard inpatient care without structured nutritional intervention or health education. Patients eat according to personal ability and appetite but do not receive individualized nutrition counseling or supplemental nutrition support. This group serves as the control group for comparison. Routine clinical follow-up will be conducted for 12 months and annually up to 5 years. |
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| Personalized Parenteral Nutritional Supplementation | Drug | For participants unable to meet nutritional goals through oral intake, parenteral nutrition is administered intravenously. The formulation includes amino acids, glucose, lipids, electrolytes, trace elements, and vitamins. Dosages are aligned with those of the enteral nutrition group, ensuring a consistent intake of energy and protein (1.2-1.5 g/kg/day protein). Formulation and administration follow standardized hospital protocols and are supervised by the nutrition support team. |
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| Structured Nutrition-Focused Health Education | Behavioral | Participants receive structured health education focused on nutrition, physical activity, and psychological well-being. The education is delivered over 14 days using a digital "Internet Plus" platform, featuring weekly videos, interactive Q&A sessions, and guidance from a multidisciplinary nutrition support team. Educational content covers dietary recommendations, exercise safety, stress management, and post-treatment recovery strategies. Materials are updated weekly, and participants may access them remotely via smartphone or tablet. This intervention aims to improve nutrition knowledge, adherence, and health behavior change. |
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| From date of enrollment until death or last follow-up (up to 5 years) |
| Progression-Free Survival (PFS) in Cancer Patients | Progression-free survival is defined as the time from enrollment to the first documented disease progression or death from any cause, whichever occurs first. Patients without progression at the time of last follow-up will be censored. PFS will be analyzed using Kaplan-Meier estimates and Cox regression models, stratified by nutritional status. | From date of enrollment until death or last follow-up (up to 5 years) |
| Serum Total Protein | Serum total protein concentration (g/L), used to evaluate protein-energy nutritional status. Measured using standard biochemical assays. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Serum Albumin | Serum albumin concentration (g/L), used to assess visceral protein status and systemic inflammation. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Serum Prealbumin | Serum prealbumin level (mg/L), an indicator of short-term changes in protein-energy nutritional status. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Serum Transferrin | Serum transferrin concentration (g/L), a marker of protein status and iron metabolism. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| C-Reactive Protein (CRP) | Serum CRP (mg/L), a marker of systemic inflammation and acute-phase response. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Blood Glucose | Fasting blood glucose (mmol/L), measured to assess metabolic function and risk of hyperglycemia. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Aspartate Aminotransferase (AST) | AST concentration (U/L), used as a liver function test and hepatotoxicity marker. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Alanine Aminotransferase (ALT) | ALT level (U/L), a liver enzyme measured to monitor hepatic injury. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Interleukin-1 (IL-1) | IL-1 concentration (pg/mL), a pro-inflammatory cytokine indicative of immune and inflammatory activity. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Tumor Necrosis Factor-alpha (TNF-α) | Tumor Necrosis Factor-alpha (TNF-α) level (pg/mL) measured to assess systemic inflammation and cancer-related cachexia. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Serum Creatinine | Serum creatinine (μmol/L), measured to evaluate kidney function and treatment-related nephrotoxicity. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Blood Urea Nitrogen | Blood urea nitrogen (umol/L), used to monitor renal function and protein catabolism. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Total Bilirubin | Blood urea nitrogen (umol/L), used to monitor renal function and protein catabolism. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Total Cholesterol | Total cholesterol level (mmol/L), measured to assess lipid metabolism and nutritional status. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Triglycerides | Serum triglyceride level (mmol/L), used to evaluate energy reserves and lipid metabolism. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| High-Density Lipoprotein Cholesterol (HDL-C) | HDL-C (mmol/L), assessed as a marker of cardiovascular health and lipid status. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Low-Density Lipoprotein Cholesterol (LDL-C) | LDL-C (mmol/L), measured as a risk factor for cardiovascular disease and lipid status. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Interleukin-6 (IL-6) | IL-6 level (pg/mL), a pro-inflammatory cytokine measured to monitor systemic inflammation and cachexia. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Hemoglobin | Hemoglobin concentration (*10⁹/L), used to assess anemia and oxygen-carrying capacity. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| White Blood Cell Count (Leukocytes) | Total white blood cell count (*10⁹/L), measured to monitor immune status and detect infection or myelosuppression. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Neutrophil Count | Absolute neutrophil count (*10⁹/L), used to assess infection risk and bone marrow suppression. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Lymphocyte Count | Lymphocyte count (*10⁹/L), measured to evaluate immune competence. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Red Blood Cell Count | Red blood cell count (*10¹²/L), used to assess erythropoiesis and anemia. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Platelet Count | Platelet count (*10⁹/L), measured to evaluate coagulation status and myelosuppression. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Height | Standing height (cm) measured using a stadiometer with 0.5 cm precision. Values adjusted for presence of ascites, edema, or large tumors.ascites, systemic edema, and huge tumors. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Body Weight | Body weight (kg) measured using a calibrated scale with 0.2 kg precision. Values adjusted if ascites or edema are present. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Body Mass Index (BMI) | BMI calculated as weight (kg) divided by height squared (m²), recorded to one decimal place. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Change in Anxiety Symptoms Assessed by Hospital Anxiety and Depression Scale (HADS-A) | Assessment of anxiety using the HADS-A subscale of the Hospital Anxiety and Depression Scale. Scores range from 0 to 21, with higher scores indicating more severe anxiety symptoms. Results will be analyzed in relation to nutritional status (normal, mild, moderate malnutrition). | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Change in Depression Symptoms Assessed by Hospital Anxiety and Depression Scale (HADS-D) | Assessment of depressive symptoms using the HADS-D subscale of the Hospital Anxiety and Depression Scale. Scores range from 0 to 21, with higher scores indicating more severe depression. Results will be analyzed in relation to nutritional status (normal, mild, moderate malnutrition). | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Functional Performance Measured by Karnofsky Performance Status (KPS) | Functional performance will be evaluated using the Karnofsky Performance Status (KPS) scale, which ranges from 0 to 100. Higher scores indicate better functional ability and independence in daily activities. Longitudinal KPS changes will be assessed in relation to changes in nutritional status over time. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Changes in Sleep Quality Assessed by Pittsburgh Sleep Quality Index (PSQI) | Sleep quality and disturbances will be evaluated using the Pittsburgh Sleep Quality Index (PSQI), a standardized questionnaire assessing seven components of sleep. Total scores range from 0 to 21, with higher scores indicating poorer sleep quality. PSQI scores will be analyzed in relation to nutritional risk categories and treatment phases. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Changes in Physical Activity Level During Cancer Treatment | Assessment of leisure-time physical activity levels (mild, moderate, vigorous) and their relationship with nutritional status and cancer treatment response. | Baseline, after the intervention, 1, 2, 3, 6, and 12 months after intervention; annually up to 5 years |
| Changes in Nutrition-Related Knowledge, Attitudes, and Practices (KAP) | Patients' dietary knowledge, attitudes, and practices will be assessed using a validated Nutrition KAP (Knowledge, Attitude, and Practice) questionnaire. The total score ranges from 0 to 104, with higher scores indicating better nutritional knowledge, more positive attitudes, and healthier dietary behaviors. Longitudinal changes in KAP scores will be evaluated in relation to treatment outcomes. | Baseline, after the intervention, 6 months after intervention; annually up to 5 years |
| Healthcare Utilization and Cost of Nutrition-Related Care | Evaluation of healthcare utilization related to nutritional care, including total number of hospitalization days, number of ICU admissions, and direct costs associated with enteral and parenteral nutrition support. Metrics will be analyzed in relation to malnutrition risk at baseline and during treatment. | From admission through 30-day post-discharge and annually for 5 years |
| Incidence of Serious Adverse Events Related to Nutrition or Treatment | Tracking of serious adverse events potentially related to nutritional support or treatment, including infections, allergic reactions, gastrointestinal distress, and metabolic complications. | Continuously from enrollment through end of study follow-up (up to 5 years) |
| Baseline to 30 days post-admission |
| Nutritional Trajectory Typing and Clustering | Identification of distinct nutritional change trajectories over time using latent class growth analysis (LCGA) and hierarchical clustering based on serial measurements of mPG-SGA and anthropometric data. Trajectories will be used to classify patients into nutritional risk subgroups. | From baseline to 12-month follow-up |
| Agreement Between Nutritional Screening Tools (mPG-SGA vs. NRS-2002) | Assessment of the diagnostic agreement, sensitivity, and specificity of two nutritional screening tools-modified Patient-Generated Subjective Global Assessment (mPG-SGA) and Nutritional Risk Screening 2002 (NRS-2002)-in detecting malnutrition risk. Agreement will be evaluated using Cohen's kappa and ROC curve analysis. | Baseline and each scheduled follow-up (up to 5 years) |
| Sociodemographic Determinants of Malnutrition | Analysis of sociodemographic factors-including income level, education, employment status, and rural vs. urban residence-in predicting baseline malnutrition and nutritional deterioration over time. Multivariable models will be used to explore independent associations. | From baseline throughout study follow-up (up to 5 years) |
| Patient Adherence to Out-of-Hospital Nutritional Support | Evaluation of patient-reported adherence to prescribed oral nutritional supplements or enteral/parenteral support regimens after hospital discharge. Adherence data will be collected via structured interviews and compared with clinical outcomes and readmission rates. | Baseline to 12 months post-treatment initiation |
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| World Health Organization. Colorectal Cancer Awareness Month 2022 | View source |
| Jul 18, 2025 |
| Prot_SAP_000.pdf |
| ID | Term |
|---|---|
| D015179 | Colorectal Neoplasms |
| D004194 | Disease |
| D044342 | Malnutrition |
| D006266 | Health Education |
| ID | Term |
|---|---|
| D007414 | Intestinal Neoplasms |
| D005770 | Gastrointestinal Neoplasms |
| D004067 | Digestive System Neoplasms |
| D009371 | Neoplasms by Site |
| D009369 | Neoplasms |
| D004066 | Digestive System Diseases |
| D005767 | Gastrointestinal Diseases |
| D003108 | Colonic Diseases |
| D007410 | Intestinal Diseases |
| D012002 | Rectal Diseases |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D009748 | Nutrition Disorders |
| D009750 | Nutritional and Metabolic Diseases |
| D000099060 | Adherence Interventions |
| D055118 | Medication Adherence |
| D010349 | Patient Compliance |
| D010342 | Patient Acceptance of Health Care |
| D000074822 | Treatment Adherence and Compliance |
| D015438 | Health Behavior |
| D001519 | Behavior |
Not provided
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