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Patients undergoing prostate radiation therapy were observed to have elevated blood pressures in clinic. Therefore, we sought to further characterise this phenomenon.
The charts of 76 patients who received radiotherapy for prostate cancer between 2014 and 2017 were examined. Blood pressure (BP) readings were obtained at initial consultation, on treatment visits, and subsequent follow-up appointments. To describe this effect, we defined radiation-associated hypertension (RAH) as an increase ≥15 mmHg systolic BP, 10 mmHg diastolic BP, or 5 mmHg mean arterial pressure.
Within this cohort, 36 patients developed RAH, with 75% developing RAH while on treatment, and 25% developing RAH at post-treatment visits. Two-thirds of patients remained hypertensive during post-treatment visits, and 27% were prescribed additional anti-hypertensives. There was no association between neoadjuvant/concurrent androgen deprivation therapy and RAH.
A significant number of patients undergoing prostate radiotherapy developed RAH, necessitating additional medication in some.
Overweight and obesity may increase risk of disease progression in men with prostate cancer, but there have been few studies of weight loss interventions in this patient group. In this study overweight or obese men treated for prostate cancer were randomised to a self-help diet and activity intervention with telephone-based dietitian support or a wait-list mini-intervention group. The intervention group had an initial group meeting, a supporting letter from their urological consultant, three telephone dietitian consultations at 4-week intervals, a pedometer and access to web-based diet and physical activity resources. At 12 weeks, men in both groups were given digital scales for providing follow-up weight measurements, and the wait-list group received a mini-intervention of the supporting letter, a pedometer and access to the web-based resources. Sixty-two men were randomised; fifty-four completed baseline and 12-week measurements, and fifty-one and twenty-seven provided measurements at 6 and 12 months, respectively. In a repeated-measures model, mean difference in weight change between groups (wait-list mini-intervention minus intervention) at 12 weeks was −2·13 (95 % CI −3·44, −0·82) kg (P = 0·002). At 12 months the corresponding value was −2·43 (95 % CI −4·50, −0·37) kg (P = 0·022). Mean difference in global quality of life score change between groups at 12 weeks was 12·3 (95 % CI 4·93, 19·7) (P = 0·002); at 12 months there were no significant differences between groups. Results suggest the potential of self-help diet and physical activity intervention with trained support for modest but sustained weight loss in this patient group.
To evaluate changes of accumulated doses from an initial plan in each fraction by deformable image registration (DIR) with daily megavoltage computed tomography (MVCT) images from helical tomotherapy for prostate cancer patients.
Materials and methods:
The MVCT images of five prostate cancer patients were acquired by using a helical tomotherapy unit before the daily treatment fraction began. All images data were exported to DIR procedures by MIM software, in which the planned kilovoltage computed tomography (kVCT) images were acting as the source images with the daily MVCT acquired as the target images for registration. The automatic deformed structure was used to access the volume variation and daily dose accumulation to each structure. All dose-volume parameters were compared to the initial planned dose.
The actual median doses of the planning target volume (PTV) received 70 Gy and 50.4 Gy were decreased at the end of the treatment with an average 1·0 ± 0·67% and 2·1 ± 1·54%, respectively. As regards organs at risk (OARs), the bladder and rectum dose-volume parameters tended to increase from the initial plan. The high-dose regions of the bladder and rectum, however, were decreased from the initial plan at the end of the treatment.
The daily actual dose differs from the initial planned dose. The accumulated dose of target tends to be lower than the initial plan, but tends to be higher than the initial plan for the OARs. Therefore, inter-fractional anatomic changes should be considered by the DIR methods, which would be useful as clinically informative and beneficial for adaptive treatment strategies.
To quantify the relationship between the planning target volume (PTV) dose homogeneity and organs at risk (OARs) sparing in correlation with anatomical parameters in prostate intensity-modulated radiotherapy (IMRT).
Materials and methods
Nine IMRT plans with various target dose constraints’ priorities were created for 15 prostate cancer patients. Selected PTV and OARs parameters were calculated for the patients. A trade-off was assessed between homogeneity index (HI) and OAR sparing. Several anatomical parameters were evaluated to investigate their effects on the OAR sparing and HI.
Inverse exponential relationships were found between the OAR sparing and HI (average R2 of 0·983 and 0·994 for bladder and rectum, respectively). Decreasing the priority led to more OARs sparing (normal tissue complication probability reduction: 97·6 and 74·5%; mean dose reduction: 16·3 and 11·3% for bladder and rectum, respectively) and worsening of the HI (0·095–0·322) but with no significant effect on tumour control probability. Furthermore, OARs volumes, distances between OARs and PTV and their joint volumes had stronger correlations with OARs’ mean doses.
Enforcement of target dose constraints was more effective on the improvement of HIs for the patients with initial high HI values at low dose constraints’ priorities. Reducing the priority had more effects on the OARs sparing compared to HI, especially for the patients with high OAR doses in high priority plans. This can be attributed to smaller distances or greater joint volumes between the OARs and PTV.
Radiotherapy clinical trials are at the forefront of modern-day prostate cancer patient management. Patients are reviewed during treatment by clinical oncologists or competent on-treatment review radiographers to minimise treatment toxicities. Clinical Research Radiographers (CRRs) routinely monitor and gather research data from patients participating in clinical trials.
The aim of this article is to evaluate the effectiveness of the CRR undertaking the on-treatment review of clinical trial patients.
An experienced CRR within the Northern Ireland Cancer Trials Network was supervised by a clinical oncologist to undertake the role of the on-treatment review of patients receiving radiotherapy for prostate cancer. The CRR explored published literature and compiled this written evaluation as part of their advanced practice learning.
The supervising clinical oncologist verified, following the planned period of supervised practice and academic study, that the CRR was competent to fulfil the role. Evidence of the beneficial synergistic impact of co-joining the roles was experienced at first hand during the undertaking of supervised practice.
Co-joining the roles and responsibilities of the CRR and the on-treatment review radiographer enhanced the quality of care offered to the patients participating in clinical trials.
The focus of this study is to find the optimal clinical tumour volume (CTV) to planning tumour volume (PTV) margins for precise radiotherapy treatment of prostate cancer. The geometrical shape of the target volume posses challenges in accurately identifying the CTV to PTV margins, especially when the organ affected by cancer demonstrates anatomical variations and the surrounding organs have high radio-sensitivity, in comparison to the organ of origin of the cancer.
Materials and methods
The geometrical margins of CTV to PTV are investigated using portal imaging, in three directions. This study is carried out on 20 patients treated by the external photon beam radiotherapy of prostate cancer using standard accelerator without stereotaxic and without prostate markers.
Results and discussion
Based on previous studies and the findings of our work, we propose CTV to PTV margin of 5·84 mm in the lateral direction, of 5·1 mm in the cranio-spinal direction and of 7·3 mm in the antero-posterior direction for external photon beam radiotherapy of prostate cancer.
The proposed CTV to PTV margins ensure high radiotherapy treatment precision of prostate cancer.
Radiation therapy (RT) remains a common and effective treatment modality for patients with locally advanced prostate cancer. Technological advancements over the past decade have resulted in the introduction of intensity-modulated radiation therapy (IMRT) planning and delivery techniques that maximise the dose of radiation delivered to the prostate while sparing organs at risk (OAR). A more recent and evolving IMRT technique, called volumetric-modulated arc therapy (VMAT), involves a continuous irradiation at a constant or variable dose rate when the gantry rotates around the prostate using one or more arcs.
Materials and methods
This paper reports on a dosimetric evaluation of our implementation of VMAT technique for prostate cancer treatment. A retrospective analysis of VMAT plans was performed for 300 prostate cancer patients treated during the period of January 2013 to December 2014. Two prescription cohorts of patients treated to a dose of 78 Gy in 39 fractions as the primary radiation therapy treatment (XRT) and 66 Gy in 33 fractions as a post-op or salvage XRT were considered.
The mean and maximal doses, dose inhomogeneities and conformity indexes for the planning target volumes were evaluated for each prescription cohort of patients. Similarly, the doses to OAR such as rectum, bladder and femoral heads were also assessed for various dose levels.
This study shows that highly conformal radiation dose distribution for the treatment of prostate cancer is achievable with the VMAT technique. It provides evidence to support the adoption of such conformal technology in many disease sites such as the prostate. We believe that our experience reported here could help form the foundation for individual institutions to evaluate and develop the most suitable planning criteria tailored to their own needs and priority. This endeavour hopefully will provide further improvement in the planning process and, therefore, help achieve an effective and efficient delivery of radiotherapy for prostate cancer.
This is a retrospective study to evaluate the efficacy and safety of routine use of electronic portal imaging device (EPID) in intensity-modulated radiation therapy for localised prostate cancer.
Materials and methods
Data from 20 patients with localised prostate cancer treated by radical radiotherapy using intensity-modulated technique in Habib Bourguiba Hospital were analysed to define the action levels for pretreatment planer dose distribution of 100 treatment fields and the set-up errors of 418 portal imaging. Pretreatment planar dose distribution was measured with the EPID. The additional dose from repeated portal imaging was determined with treatment planning system.
For all 100 fields, the predicted and the measured planar dose distribution agrees well with mean±standard deviation value for γmax=2·31±0·57, γavg=0·36±0·07 and γ%≤1=98·94%±0·71%, respectively. For the evaluation of set-up errors, the mean total errors with 1 SD in the lateral, longitudinal and vertical directions were 0·11±0·44 cm; 0·02±0·37 cm and −0·02±0·21 cm, respectively. The imaging additional dose was evaluated as 1 cGy per monitor unit.
EPID is a useful tool to verify pretreatment dose distribution and to assess the correct field position without a significant increase in the absorbed dose due to the repetition of portal imaging.
Current literature suggests the information and support needs of oncology patients undergoing radical radiotherapy to the prostate often remain unmet and can impact quality of life. We aimed to explore the effectiveness of delivery and opportunities for service improvement, including a group-based treatment review.
A total of 60 prostate patients completing radical radiotherapy (mean age 70, range 47–79) in a UK cancer-centre completed a self-designed questionnaire assessing information and support. To explore views on a group-based treatment review, 11% took part in a semi-structured interview. Descriptive data were computed and interviews transcribed and analysed thematically.
In all, 87% were satisfied with information and support when delivered by radiographers. However, 26% were only ‘sometimes’ able to complete bladder-filling, suggesting information regarding treatment delays would improve this. In total, 49% preferred both Doctor and Urology nurse reviews whereas 26% preferred nurse only; 70% stated their ‘concerns were always addressed’ by a nurse and 49% by a Doctor. Interviews revealed that a group review was generally acceptable with peer support an influencing factor.
Overall patients felt their needs were being met. Suggestions for improvement (more information on preparation, side effects and delays) will be implemented locally. Future work will explore the feasibility of group reviews in patients undergoing radical radiotherapy to the prostate.
Although manual adjustment of automatic cone beam computed tomography (CBCT) matching may improve the target coverage in certain points of interest, concerns exist that this may lead to dosimetric uncertainties which would negate the theoretical benefit of this approach. The objective of this study is to evaluate the dosimetric impact of manual adjustments made after automatic bony registration on CBCT in prostate patients.
A total of 50 CBCT datasets of ten high-risk prostate cancer patients were randomly chosen. Each CBCT dataset was registered three times. Method (A): Automatic registration, Method (M1): Manual adjustment carried out by two experienced radiation therapists, Method (M2): Manual adjustment carried out by different radiation therapists with varying levels of experience. The clinical target volume (CTV), planning target volume (PTV), the bladder and the rectum were subsequently contoured on each CBCT dataset by a radiation oncologist blinded to the registration methods. The absolute difference of various dosimetric parameters were then analysed and compared with the original planning doses. A comparison of the three matching methods employed was also carried out.
There was a statistically significant difference in the magnitude of move taken in the inferior superior direction between M1 and M2 method. There were no significant differences observed in any of the dosimetric parameters examined in relation to the rectum, bladder or CTV. The only significant difference observed was the volume of PTV covered by the prescription isodose (95%) which was statistically significant lower in method A compared with both M1 and M2. There was no difference observed between M1 and M2 methods. The mean duration of the automated registration and subsequent analysis was 64 seconds compared with 91 seconds for automated registrations which included the additional manual adjustment.
CBCT-based manual adjustments of automated bony-based registrations during the image-guided radiotherapy verification of prostate cancer patients can improve PTV coverage without impacting negatively on the doses received by the organs at risk. This strategy is associated with a small increase in overall treatment time.
Volumetric-modulated arc therapy (VMAT) has emerged as one of the most favourable techniques for radiotherapy treatment in recent years because of its conformal dose distribution to the planning target volume (PTV), lower doses to adjacent normal organs at risk (OARs) and faster and easier dose delivery. A typical conventional VMAT protocol for low-intermediate risk prostate cancer uses a flattened 6 MV photon beam to deliver 78 Gy in 39 fractions, however, a recent Radiation Therapy Oncology Group study investigated prostate cancer radiotherapy with a hypofractionated dose scheme of 36·25 Gy in 5 fractions. One advantage of flattening filter-free (FFF) beams in radiotherapy is the higher doses in the central region on the dose profile and much higher dose delivery rates.
Methods and materials
This paper reports the investigation of preclinical studies for implementing FFF beams in hypofractionated VMAT for prostate cancer radiotherapy. All treatment planning were accomplished using Varian EclipseTM treatment planning system version 11 and delivered on Varian Truebeam linear accelerators. The studies compared the biological-effective dose–volume histograms and dose–volume histograms of PTV and OARs for 20 patients using conventional and hypofractionated dose schemes. The study also evaluated the 6 and 10 MV FFF by comparing 6 and 10 MV VMAT plans with the FFF beams. The treatment time was investigated using plans with 6 MV beams and doses of 2, 4, 5, 6, 7·25 Gy/fraction and plans with 10 MV FFF with a dose of 7·25 Gy/fraction. We also investigated an angular monitor unit (MU) quantity (MU/deg) and its threshold value for RapidArcTM plans, beyond which FFF beams can be considered superior to flattened beams in terms of treatment time increased caused by higher dose per fraction.
The results show that the hypofractionated plans resulted in greater biological equivalent doses to PTV and lower doses to OARs. The 10 MV FFF plans have statistically lower mean doses to all the OARs, whereas PTV homogeneity index remains the same compared with other beam energies. The mean body integral dose for the 20 patients is 8·7% lower using 10 MV FFF compared with 6 MV FFF mainly because of the higher energy and less required MUs with the 10 MV FFF beam. The hypofractionated scheme with 10 MV FFF plan has the same treatment time as that of the 6 MV plan at 2 Gy/fraction, as the higher dose delivery rates at 10 MV FFF can compensate for the higher prescribed dose per fraction without the need of extra treatment time.
In this study, we observed that the 10 MV FFF beam is better for hypofractionated prostate cancer VMAT plan delivery. The threshold value of MU/deg is found to be 2·083 MU/deg based on our machine configurations.
Due to the increased degree of modulation and complexity of volumetric-modulated arc therapy (VMAT) plans, it is necessary to have a pre-treatment patient-specific quality assurance (QA) programme. The gamma index is commonly used to quantitatively compare two dose distributions. In this study we investigated the sensitivity of single- and multi-gamma criteria techniques to detect multileaf collimator (MLC) positioning errors using the Varian TrueBeam Electronic Portal Imaging DeviceTM (EPID) dosimetry and the ArcCHECKTM device.
Materials and methods
All active MLC positions of seven intact prostate patients VMAT plans were randomly changed with a mean value of 0.25, 0.5, 1 and 2 mm and a standard deviation of 0.1 mm on 25, 50, 75 and 100% of the control points. The change in gamma passing rates of six gamma criteria of 3%/3 mm, 3%/2 mm, 3%/1 mm, 2%/2 mm, 2%/1 mm and 1%/1 mm were analysed individually (single-gamma criterion) and as a group (multi-gamma criteria) as a function of the simulated errors. We used the improved and global gamma calculation algorithms with a low dose threshold of 10% in the EPID and ArcCHECK software, respectively. The changes in the planning target volume dose distributions and the organs at risk due to the MLC positioning errors were also studied.
When 25, 50, 75 and 100% of the control points were modified by the introduction of the simulated errors, the smallest detectable errors with the EPID were 2, 1, 0.5 and 0.5 mm, respectively, using the multi-gamma criteria technique. Similarly for the single-gamma criteria technique errors as small as 2, 1, 1 and 1 mm applied to 25, 50, 75 and 100% of the control points, respectively, were detectable using a 2%/2 mm criterion. However, the smallest detectable errors with the ArcCHECK when using the multi-gamma criteria technique were 2, 2 and 1 mm when MLC errors were applied on 50, 75 and 100% of the control points. When only 25% of the control points were affected the ArcCHECK were unable to detect any of the errors applied. No noticeable difference was observed in the sensitivity using the single- or the multi-gamma criteria techniques with the ArcCHECK.
The Varian TrueBeam EPID dosimetry shows a higher sensitivity in detecting MLC positioning errors compared with the ArcCHECK regardless of using the single- or the multi-gamma criteria techniques. Higher sensitivity was observed using the multi-gamma criteria technique compared with the single-criterion technique when using the EPID.
Androgen deprivation therapy (ADT) is used widely as part of a combined modality for the treatment of prostate cancer. However, ADT has also been associated with the development of cardiometabolic complications that can increase mortality from cardiovascular events. There is emerging evidence to suggest that ADT-related cardiometabolic risk can be mitigated by diet and lifestyle modification. While the clinical focus for a nutritional approach for achieving this effect is unclear, it may depend upon the timely assessment and targeting of dietary changes to the specific risk phenotype of the patient. The present review aims to address the metabolic origins of ADT-related cardiometabolic risk, existing evidence for the effects of dietary intervention in modifying this risk, and the priorities for future dietary strategies.
This retrospective study aimed to report clinical outcomes of high-dose rate brachytherapy (HDR-BT) and whole pelvic radiation therapy (WPRT) in intermediate- to high-risk localised prostate cancer and to gain a better understanding of how behavioural variability of patients from various ethnic origins affects clinical practice.
Materials and methods
In total, 116 localised intermediate- to high-risk prostate cancer patients who were treated during 2004–12 were enroled into the study. WPRT was delivered to the full pelvis (50 Gy per conventional fractionation) and two fractions (15 Gy per fraction) of high-dose rate brachytherapy were designed for all patients to the peripheral zone of McNeal. The reported results were biochemical control rate, toxicity profiles and behavioural variations of patients.
The median follow-up time was 51 months. The 4-year biochemical control rates, according to the American Society for Therapeutic Radiology and Oncology was 93·1%. T stage was the prognostic factor for biochemical control. No significant differences in biochemical control could be identified across ethnic groups (p>0·05). Five patients developed grade 3–4 gastrointestinal toxicity. Prior knowledge was commonly found among Caucasian patients and urinary functions seemed to be more concerned among Caucasian and Middle East patients than those from other ethnic origins.
Clinical outcomes of intermediate- to high-risk prostate cancer patients from various ethnic origins were comparable with that of the Caucasian-only population reported previously. A number of detected ethnic-related factors might be beneficial for treatment decision-making for patients with different cultural background and could be utilised to better personalise/optimise cancer care and aftercare.
Black men are known to have a higher risk for prostate cancer (PC). Carotenoids and retinol, linked to PC, have not been compared in different black populations at risk. We examined serum carotenoid and retinol levels between PC-free African-Caribbean (AC) Tobagonian men with a high PC risk (high-grade prostatic intraepithelial neoplasia, atypical foci or repeated abnormal PC screenings) and African-American (AA) men with elevated serum prostate-specific antigen (PSA) levels (≥4 ng/ml). AC men who participated in the 2003 lycopene clinical trial and AA men who participated in the 2001–2006 National Health and Nutrition Examination Survey were compared. Serum specimens were analysed for carotenoid (β-carotene, α-carotene, β-cryptoxanthin, lutein/zeaxanthin and lycopene) and retinol levels by isocratic HPLC. Quantile regression was used to examine the association between serum carotenoid and retinol levels and black ethnicity, overall and among men with elevated serum PSA. There were sixty-nine AC men and sixty-five AA men, aged 41–79 years, included. AC men were associated with lower serum lycopene and retinol levels, and higher serum α- and β-carotenes and lutein/zeaxanthin levels compared with AA men, after adjusting for age, BMI, ever smoked cigarettes, education and hypertension (P≤0·03). Among men with elevated PSA, serum retinol was no longer statistically significant with ethnicity (P=0·06). Possible differences may be attributed to dietary intake, genetics and/or factors that influence bioavailability of these micronutrients. Prospective studies are warranted that investigate whether these differences in micronutrients between AC Tobagonian and AA men influence PC risk.
To evaluate and develop an image-guided radiotherapy (IGRT) protocol for the effective treatment of prostate and pelvic lymph nodes.
Methods and materials
This study comprised of nine patients receiving radiotherapy for node negative prostate cancer, who had a pair of planar kV images taken for 37 treatment fractions. The positioning accuracy for both implanted fiducial markers and pelvic bony anatomy (surrogate for pelvic node position) was calculated using random and systematic errors. Appropriate margins were also determined. All patients followed a strict bladder and bowel protocol before computed tomography planning and treatment.
In total, 292 sets of images were used for fiducial marker and pelvic bone registration. A discrepancy of >5 mm between the fiducial markers and the anatomical pelvic bone was seen in 4% of treatment sessions. The maximum displacement observed between the fiducial match and the bone match was 7, 10 and 4 mm in the A/P (anterior/posterior), S/I (superior/inferior) and R/L (right/left) directions, respectively.
The margins used in combination with an online IGRT strategy ensure both the fiducial match and the bone match correlate within 5 mm thus allows good coverage of both prostate and nodal target volumes. It is essential that this is combined with a strict bladder and rectal preparation protocol to ensure accuracy and reproducibility.
The aim of this study is to develop predictive models to predict organ at risk (OAR) complication level, classification of OAR dose-volume and combination of this function with our in-house developed treatment decision support system.
Materials and methods
We analysed the support vector machine and decision tree algorithm for predicting OAR complication level and toxicity in order to integrate this function into our in-house radiation treatment planning decision support system. A total of 12 TomoTherapyTM treatment plans for prostate cancer were established, and a hundred modelled plans were generated to analyse the toxicity prediction for bladder and rectum.
The toxicity prediction algorithm analysis showed 91·0% accuracy in the training process. A scatter plot for bladder and rectum was obtained by 100 modelled plans and classification result derived. OAR complication level was analysed and risk factor for 25% bladder and 50% rectum was detected by decision tree. Therefore, it was shown that complication prediction of patients using big data-based clinical information is possible.
We verified the accuracy of the tested algorithm using prostate cancer cases. Side effects can be minimised by applying this predictive modelling algorithm with the planning decision support system for patient-specific radiotherapy planning.
Recent evidence suggests that a pro-inflammatory diet could be associated with prostate cancer (PC) risk. To evaluate the association between dietary inflammatory index (DII) and PC risk as well as aggressiveness, we conducted a case–control study in Mexico City. Cases were 394 individuals with incident, histologically confirmed PC, who were matched by age (±5 years) with 794 population controls. Dietary information was obtained through a semi-quantitative FFQ with a 3-year frame of reference before diagnosis, for cases, or interview, for controls. On the basis of twenty-eight food parameters, we estimated the energy-adjusted DII (E-DII). According to the Gleason score at diagnosis, PC cases were categorised as high (≥8), moderate (=7) and low (≤6) PC risk. Independent, unconditional logistic regression models adjusted for potential confounders were used to estimate PC risk and PC aggressiveness. There were no significant associations between overall PC risk and E-DII (OR3rd v. 1st tertile 1·18; 95 % CI 0·85, 1·63; P=0·33) or among men with high-risk PC (Gleason≥8) (OR 1·46; 95 % CI 0·88, 2·42; P=0·14). These results do not support the hypothesis that a pro-inflammatory diet is related to PC risk and PC aggressiveness. However, further studies with larger sample sizes, with sufficient statistical power and of varying designs should be conducted to address this hypothesis.
The aim of this study was to ascertain prostate cancer patients’ perceptions of the quality of physical and emotional support they receive as standard during their course of radiotherapy treatment.
Semi-structured interviews were conducted on 13 patients undergoing radical radiotherapy treatment for prostate cancer. Interviews were conducted between fractions 32 and 37 and data were analysed using the Giorgi method.
A number of themes emerged from the data including, interestingly, the value of patients’ place on the ‘waiting room support’ with 46% finding this to be a positive aspect of their experience. On the whole, patients felt well supported during their treatment by both radiographers and fellow patients. However, the results highlighted areas for further improvements, particularly around bowel and bladder preparation.
This small single-centre study has highlighted the importance of good quality, timely information provision. Although patients were, for the most part very happy with the services they were being provided with, areas in need of development where also highlighted. If a more structured review process is to be further investigated then the role of the ‘review radiographer’ should be considered as part of this. The potential benefits of patient peer support is also worthy of further exploration.