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Supportive care in head and neck cancer patients Jansen, F.

2018

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Jansen, F. (2018). Supportive care in head and neck cancer patients: Patient-reported needs and costs.

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Femke Jansen Birgit I Witte

Cornelia F van Uden-Kraan Anna M Braspenning C René Leemans

Irma M Verdonck-de Leeuw

Supportive Care in Cancer (2016) 24:4639-4649

This study was funded by the Dutch Cancer Society/Alpe d’HuZes Foundation (VU 2015-5930).

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INTRODUCTION

,ĞĂĚĂŶĚŶĞĐŬĐĂŶĐĞƌ;,EͿƉĂƟĞŶƚƐŽŌĞŶĞdžƉĞƌŝĞŶĐĞŐĞŶĞƌŝĐĐĂŶĐĞƌͲƌĞůĂƚĞĚƉƌŽďůĞŵƐ͕ ƐƵĐŚĂƐƉĂŝŶ͕ĨĂƟŐƵĞϭ_{͕ĂŶdžŝĞƚLJ}Ϯ _{and depression}ϯ_{ĂƐǁĞůůĂƐ,EͲƐƉĞĐŝĮĐƉƌŽďůĞŵƐƐƵĐŚĂƐ}

ĚLJƐƉŚĂŐŝĂϰ_{͕ŽƌƉƌŽďůĞŵƐǁŝƚŚƐƉĞĞĐŚ}ϱ_{͕ŶƵƚƌŝƟŽŶ}ϲ_{ĂŶĚŚĞĂƌŝŶŐ}ϳ_{ŝŶŇƵĞŶĐŝŶŐƚŚĞŝƌƋƵĂůŝƚLJŽĨ}

lifeϭ͕ϲ_{͘^ƵƉƉŽƌƟǀĞĐĂƌĞ͕ĚĞĮŶĞĚĂƐƚŚĞƉƌĞǀĞŶƟŽŶĂŶĚŵĂŶĂŐĞŵĞŶƚŽĨĂĚǀĞƌƐĞĞīĞĐƚƐŽĨ}

cancer and its treatmentϴ_{͕ĐĂŶŚĞůƉƚŽŝŵƉƌŽǀĞƚŚĞƐĞƉƌŽďůĞŵƐ͘}

ϰϴ

ϱϬ ƌĞƐĞĂƌĐŚĞƌǁŚŽǁĂƐƉƌĞƐĞŶƚĚƵƌŝŶŐƚŚĞŶƵƌƐŝŶŐĐŽŶƐƵůƚĂƟŽŶĨŽůůŽǁŝŶŐKŶĐŽYƵĞƐƚ͘dŚŝƐ ƌĞƉŽƌƚĨŽƌŵŝŶĐůƵĚĞĚŝŶĨŽƌŵĂƟŽŶŽŶƚŽƉŝĐƐ͕ŝŶĨŽƌŵĂƟŽŶĂŶĚƐƵƉƉŽƌƟǀĞĐĂƌĞŽƉƟŽŶƐ ĚŝƐĐƵƐƐĞĚĚƵƌŝŶŐƚŚĞŶƵƌƐŝŶŐĐŽŶƐƵůƚĂƟŽŶ͘ &ŝŶĂůůLJ͕ƐŽĐŝŽͲĚĞŵŽŐƌĂƉŚŝĐĐŚĂƌĂĐƚĞƌŝƐƟĐƐǁĞƌĞƉĂƟĞŶƚͲƌĞƉŽƌƚĞĚĂŶĚĐůŝŶŝĐĂůĐŚĂƌĂĐƚĞƌŝƐƟĐƐ ǁĞƌĞƌĞƚƌŝĞǀĞĚĨƌŽŵƉĂƟĞŶƚƐ͛ŵĞĚŝĐĂůƌĞĐŽƌĚƐ͘ Data analyses ŽŶƚĞŶƚ ǀĂůŝĚŝƚLJ ŽĨ ƚŚĞ ^E^Ͳ,E ǁĂƐ ĂŶĂůLJnjĞĚ ďLJ ĞdžĂŵŝŶŝŶŐ ƌĞĚƵŶĚĂŶĐLJ ĂŶĚ ĐŽŵƉůĞƚĞŶĞƐƐ ŽĨ ŝƚĞŵƐ͘ /ƚĞŵƐ ǁĞƌĞ ĐŽŶƐŝĚĞƌĞĚ ƌĞĚƵŶĚĂŶƚ ŝĨ ф ϭϬй ŽĨ ƚŚĞ ƉĂƟĞŶƚƐ ƌĞƉŽƌƚĞĚĂŶĞĞĚ;ŽƌŝŶĐĂƐĞŽĨ^E^Ͳ,EŝƚĞŵϲфϭϬйŽĨƉĂƟĞŶƚƐƚƌĞĂƚĞĚǁŝƚŚƚŽƚĂů ůĂƌLJŶŐĞĐƚŽŵLJͿ͘ŽŵƉůĞƚĞŶĞƐƐŽĨƚŚĞ^E^Ͳ,EǁĂƐĞdžĂŵŝŶĞĚďLJĂŶĂůLJnjŝŶŐƐƵƉƉŽƌƟǀĞ ĐĂƌĞŶĞĞĚƐƌĞƉŽƌƚĞĚŽŶƚŚĞĨƌĞĞͲƚĞdžƚŝƚĞŵŽĨƚŚĞ^E^Ͳ,EĂŶĚĂŶĂůLJnjŝŶŐŶĞĞĚƐĚŝƐĐƵƐƐĞĚ ĚƵƌŝŶŐƚŚĞŶƵƌƐŝŶŐĐŽŶƐƵůƚĂƟŽŶĂƐĂƐƐĞƐƐĞĚŝŶƚŚĞƐƚƵĚLJͲƐƉĞĐŝĮĐƌĞƉŽƌƚĨŽƌŵ͘/ĨшϱйŽĨ ƉĂƟĞŶƚƐƌĞƉŽƌƚĞĚŽƌĚŝƐĐƵƐƐĞĚĂŶĂĚĚŝƟŽŶĂůƐƵƉƉŽƌƟǀĞĐĂƌĞŶĞĞĚ͕ĂĚĚŝŶŐƚŚŝƐƐƉĞĐŝĮĐ ŶĞĞĚƚŽƚŚĞ^E^Ͳ,EƐŚŽƵůĚďĞĐŽŶƐŝĚĞƌĞĚ͘ ŽŶĮƌŵĂƚŽƌLJ ĨĂĐƚŽƌ ĂŶĂůLJƐŝƐ ǁĂƐ ƵƐĞĚ ƚŽ ĂŶĂůLJnjĞ ǁŚĞƚŚĞƌ ƚŚĞ ŽƌŝŐŝŶĂů ϱͲĨĂĐƚŽƌϵ _or ĂůƚĞƌŶĂƟǀĞ ϰͲĨĂĐƚŽƌ ƐƚƌƵĐƚƵƌĞϭϲ_{ ŽĨ ƚŚĞ ^E^Ͳ^&ϯϰ ĐŽƵůĚ ďĞ ƌĞƉůŝĐĂƚĞĚ͕ ĂƐ ƉƌŽƉŽƐĞĚ} ďLJdĞƌǁĞĞĞƚĂů͘ϯϯ_{͘ƌŝƚĞƌŝĂĨŽƌĂŶĂĐĐĞƉƚĂďůĞĮƚǁĞƌĞ͗ϭͿZŽŽƚDĞĂŶ^ƋƵĂƌĞƌƌŽƌŽĨ} ƉƉƌŽdžŝŵĂƟŽŶ;ZD^ͿфϬ͘ϬϲĂŶĚŽŵƉĂƌĂƟǀĞ&ŝƚ/ŶĚĞdž;&/ͿĂŶĚdƵĐŬĞƌͲ>ĞǁŝƐ/ŶĚĞdžͲ EŽŶͲEŽƌŵĞĚ&ŝƚ/ŶĚĞdžшϬ͘ϵ͘WƌŝŶĐŝƉĂůĐŽŵƉŽŶĞŶƚĂŶĂůLJƐŝƐǁŝƚŚǀĂƌŝŵĂdžƌŽƚĂƟŽŶŽĨ ĨĂĐƚŽƌƐǁŝƚŚĞŝŐĞŶǀĂůƵĞƐхϭ͘ϬǁĂƐƵƐĞĚƚŽĂŶĂůLJnjĞƚŚĞĨĂĐƚŽƌƐƚƌƵĐƚƵƌĞŽĨƚŚĞ^E^Ͳ,E͘ ƉƉƌŽƉƌŝĂƚĞŶĞƐƐŽĨƉƌŝŶĐŝƉĂůĐŽŵƉŽŶĞŶƚĂŶĂůLJƐŝƐǁĂƐĞdžĂŵŝŶĞĚƵƐŝŶŐĂƌƚůĞƩ͛ƐƚĞƐƚŽĨ ƐƉŚĞƌŝĐŝƚLJ;ƉфϬ͘ϬϱͿĂŶĚƚŚĞ<ĂŝƐĞƌ͕DĞLJĞƌKůŬŝŶŝŶĚĞdžŽĨƐĂŵƉůŝŶŐĂĚĞƋƵĂĐLJ;<DKшϬ͘ϲϬͿ͘ /ŶƚĞƌŶĂůĐŽŶƐŝƐƚĞŶĐLJǁĂƐĂƐƐĞƐƐĞĚƵƐŝŶŐƌŽŶďĂĐŚ͛ƐĂůƉŚĂĐŽĞĸĐŝĞŶƚ͖ĂǀĂůƵĞďĞƚǁĞĞŶ Ϭ͘ϳϬĂŶĚϬ͘ϵϱŝƐĐŽŶƐŝĚĞƌĞĚŐŽŽĚϯϯ_͘ dŽĂŶĂůLJnjĞĐŽŶƐƚƌƵĐƚǀĂůŝĚŝƚLJ͕ĂƉƌŝŽƌŝŚLJƉŽƚŚĞƐĞƐǁĞƌĞĨŽƌŵƵůĂƚĞĚƌĞŐĂƌĚŝŶŐƚŚĞĐŽƌƌĞůĂƟŽŶ ďĞƚǁĞĞŶƚŚĞ^E^Ͳ^&ϯϰ;ϯϭŚLJƉŽƚŚĞƐĞƐͿŽƌ^E^Ͳ,E;ϵŚLJƉŽƚŚĞƐĞƐͿĂŶĚŽƚŚĞƌWZKDƐ ;KZdY>YͲϯϬ͕KZdY>YͲ,ΘEϯϱ͕,^͕^,/ĂŶĚ^t>ͲYK>Ϳ;ƉƌĞƐĞŶƚĞĚŝŶdĂďůĞϭͿ͕ ĂŶĚĞdžƉĞĐƚĞĚĚŝīĞƌĞŶĐĞƐďĞƚǁĞĞŶŐƌŽƵƉƐŽĨ,EƉĂƟĞŶƚƐ;ϭϯŚLJƉŽƚŚĞƐĞƐͿ͘,LJƉŽƚŚĞƐĞƐ were based on previous studiesϵ͕ϭϭͲϭϯ͕ϭϲ͕ϭϴ͕ϯϰͲϯϲ_{ĂŶĚƌĞƐĞĂƌĐŚĞƌƐ͛ĞdžƉĞĐƚĂƟŽŶƐ͘ZĞŐĂƌĚŝŶŐ}

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3

dĂďůĞϮ͘ŽŶƟŶƵĞĚ ŚĂƌĂĐƚĞƌŝƐƟĐƐ &ĂĐƚŽƌĂŶĂůLJƐĞƐ ĂŶĚĐŽŶƐƚƌƵĐƚ validity ŶсϮϬϭ dĞƐƚͲƌĞƚĞƐƚ reliability ŶсϭϭϬ Content validity ;ƐƚƵĚLJƐƉĞĐŝĮĐ ƌĞƉŽƌƚĨŽƌŵͿ Ŷсϲϵ й й й Tumor site Ͳ KƌĂůĐĂǀŝƚLJ ϯϭ͘ϯй ϯϯ͘ϲй ϯϬ͘ϰй Ͳ WŚĂƌLJŶdž ϯϲ͘ϴй ϯϱ͘ϱй ϯϲ͘Ϯй Ͳ >ĂƌLJŶdž ϭϵ͘ϵй ϮϬ͘ϵй ϭϳ͘ϰй Ͳ EĂƐĂůĐĂǀŝƚLJ ϲ͘Ϭй ϰ͘ϱй ϴ͘ϳй Ͳ DĂũŽƌƐĂůŝǀĂƌLJŐůĂŶĚƐ ϲ͘Ϭй ϱ͘ϱй ϳ͘Ϯй ŝƐĞĂƐĞƐƚĂŐĞ;h/Ϳ Ͳ ^ƚĂŐĞ/ Ϯϳ͘ϵй ϯϬ͘ϵй Ϯϯ͘Ϯй Ͳ ^ƚĂŐĞ// ϭϯ͘ϰй ϭϬ͘Ϭй Ϯϭ͘ϳй Ͳ ^ƚĂŐĞ/// ϭϲ͘ϰй ϭϲ͘ϰй ϭϴ͘ϴй Ͳ ^ƚĂŐĞ/s ϯϲ͘ϴй ϯϰ͘ϱй ϯϰ͘ϴй Ͳ hŶŬŶŽǁŶ ϱ͘ϱй ϴ͘Ϯй ϭ͘ϰй Type of treatment Ͳ ^ƵƌŐĞƌLJ Ϯϱ͘ϰй Ϯϱ͘ϱй Ϯϳ͘ϱй Ͳ ZĂĚŝŽƚŚĞƌĂƉLJ ϮϬ͘ϰй Ϯϭ͘ϴй Ϯϯ͘Ϯй Ͳ ^ƵƌŐĞƌLJĂŶĚĐŚĞŵŽƌĂĚŝĂƟŽŶ ϴ͘ϱй ϳ͘ϯй ϱ͘ϴй Ͳ ^ƵƌŐĞƌLJĂŶĚƌĂĚŝĂƟŽŶ ϮϮ͘ϰй ϮϮ͘ϳй Ϯϯ͘Ϯй Ͳ ŚĞŵŽƌĂĚŝĂƟŽŶ Ϯϯ͘ϰй ϮϮ͘ϳй ϮϬ͘ϯй

Time since last treatment

ϱϲ

Factor analysis and internal consistency

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3

ĂŚŝŐŚĞƌŶĞĞĚŽŶƚŚĞƉŚLJƐŝĐĂůΘĚĂŝůLJůŝǀŝŶŐ;ƉсϬ͘ϬϭϱͿĂŶĚƉƐLJĐŚŽůŽŐŝĐĂůĚŽŵĂŝŶ;Ɖс Ϭ͘ϬϬϵͿ͕ǁŚŝůĞŶŽĚŝīĞƌĞŶĐĞǁĂƐĨŽƵŶĚĨŽƌŚĞĂůƚŚƐLJƐƚĞŵ͕ŝŶĨŽƌŵĂƟŽŶΘƉĂƟĞŶƚƐƵƉƉŽƌƚ ;Ɖ с Ϭ͘ϬϳϬͿ͘ WĂƟĞŶƚƐ ůŽŶŐĞƌ ĂŌĞƌ ƚƌĞĂƚŵĞŶƚ ƌĞƉŽƌƚĞĚ ůĞƐƐ ŶĞĞĚ ĨŽƌ ŚĞĂůƚŚ ƐLJƐƚĞŵ͕ ŝŶĨŽƌŵĂƟŽŶΘƉĂƟĞŶƚƐƵƉƉŽƌƚƚŚĂŶƉĂƟĞŶƚƐƐŚŽƌƚĞƌĂŌĞƌƚƌĞĂƚŵĞŶƚ;ƉсϬ͘ϬϭϱͿ͘EŽ ƐŝŐŶŝĮĐĂŶƚĚŝīĞƌĞŶĐĞƐǁĞƌĞĨŽƵŶĚƌĞŐĂƌĚŝŶŐŐĞŶĚĞƌŽƌĂŐĞ͘ KĨƚŚĞ^E^Ͳ,E͕ϴŽĨƚŚĞϵ;ϴϵйͿŚLJƉŽƚŚĞƐŝnjĞĚĐŽƌƌĞůĂƟŽŶƐǁĞƌĞĨŽƵŶĚ;dĂďůĞϭͿ͘^ŝdž ĐŽƌƌĞůĂƟŽŶƐ;ϲϳйͿĂůƐŽƐƵƉƉŽƌƚĞĚƚŚĞĂƉƌŝŽƌŝŚLJƉŽƚŚĞƐŝnjĞĚŵĂŐŶŝƚƵĚĞŽĨĐŽƌƌĞůĂƟŽŶ͘ dĞƐƚͲƌĞƚĞƐƚƌĞůŝĂďŝůŝƚLJ dĞƐƚͲƌĞƚĞƐƚƌĞůŝĂďŝůŝƚLJŽĨƚŚĞ^E^Ͳ^&ϯϰĚŽŵĂŝŶƐǁĂƐŐŽŽĚ;/ƌĂŶŐĞĚĨƌŽŵϬ͘ϳϰ;ƐĞdžƵĂůŝƚLJͿ ƚŽϬ͘ϴϯ;ƉŚLJƐŝĐĂůΘĚĂŝůLJůŝǀŝŶŐͿͿ͘dĞƐƚͲƌĞƚĞƐƚƌĞůŝĂďŝůŝƚLJĨŽƌ,EͲƐƉĞĐŝĮĐĨƵŶĐƟŽŶŝŶŐǁĂƐĂůƐŽ ŐŽŽĚ;/сϬ͘ϴϯͿ͕ǁŚŝůĞŝƚǁĂƐƐůŝŐŚƚůLJůŽǁĞƌƚŚĂŶϬ͘ϳϬĨŽƌƚŚĞůŝĨĞƐƚLJůĞĚŽŵĂŝŶ;/сϬ͘ϲϳͿ͘ WƌĞƐĞŶĐĞŽĨŇŽŽƌĂŶĚͬŽƌĐĞŝůŝŶŐĞīĞĐƚƐ KŶĂůů^E^Ͳ^&ϯϰĂŶĚ^E^Ͳ,EĚŽŵĂŝŶƐŇŽŽƌĞīĞĐƚƐǁĞƌĞƉƌĞƐĞŶƚ;dĂďůĞϱĂŶĚϲͿ͘ &ůŽŽƌĞīĞĐƚƐ;ŶŽŶĞĞĚĨŽƌĐĂƌĞͿƌĂŶŐĞĚĨƌŽŵϮϭ͘ϭй;ŚĞĂůƚŚƐLJƐƚĞŵ͕ŝŶĨŽƌŵĂƟŽŶΘƉĂƟĞŶƚ ƐƵƉƉŽƌƚͿƚŽϳϬ͘ϵй;ůŝĨĞƐƚLJůĞͿ͘EŽĐĞŝůŝŶŐĞīĞĐƚƐǁĞƌĞƉƌĞƐĞŶƚ͘ dĂďůĞϯ͗'ŽŽĚŶĞƐƐͲŽĨͲĮƚŝŶĚŝĐĞƐĨŽƌƚŚĞ^ƵƉƉŽƌƟǀĞĂƌĞEĞĞĚƐ^ƵƌǀĞLJ^ŚŽƌƚͲ&Žƌŵϯϰ;^E^Ͳ ^&ϯϰͿƵƐŝŶŐĐŽŶĮƌŵĂƚŽƌLJĨĂĐƚŽƌĂŶĂůLJƐŝƐ;ŶсϮϬϭͿ Model ʖ2

ϱϴ dĂďůĞϰ͗&ŝƌƐƚĨĂĐƚŽƌƐƚƌƵĐƚƵƌĞŐĞŶĞƌĂƚĞĚĨŽƌƚŚĞ^E^Ͳ^&ϯϰŝŶŚĞĂĚĂŶĚŶĞĐŬĐĂŶĐĞƌƉĂƟĞŶƚƐ ƵƐŝŶŐƉƌŝŶĐŝƉĂůĐŽŵƉŽŶĞŶƚĂŶĂůLJƐŝƐ;ŶсϮϬϭͿ &ĂĐƚŽƌ>ŽĂĚŝŶŐƐ1 Item 1 2 3 4 5 ϭ͘WĂŝŶ Ϭ͘ϯϴ Ϭ͘ϯϵ Ϭ͘ϰϴ Ϯ͘>ĂĐŬŽĨĞŶĞƌŐLJͬƟƌĞĚŶĞƐƐ Ϭ͘ϯϬ Ϭ͘ϱϮ Ϭ͘ϱϴ ϯ͘&ĞĞůŝŶŐƐƵŶǁĞůůĂůŽƚŽĨƚŚĞƟŵĞ Ϭ͘ϱϱ Ϭ͘ϲϱ ϰ͘tŽƌŬĂƌŽƵŶĚƚŚĞŚŽŵĞ Ϭ͘ϳϱ ϱ͘EŽƚďĞŝŶŐĂďůĞƚŽĚŽƚŚĞƚŚŝŶŐƐLJŽƵƵƐĞĚƚŽĚŽ Ϭ͘ϯϴ Ϭ͘ϰϭ Ϭ͘ϲϵ ϲ͘ŶdžŝĞƚLJ Ϭ͘ϳϵ Ϭ͘ϯϬ ϳ͘&ĞĞůŝŶŐĚŽǁŶŽƌĚĞƉƌĞƐƐĞĚ Ϭ͘ϯϬ Ϭ͘ϳϴ ϴ͘&ĞĞůŝŶŐƐŽĨƐĂĚŶĞƐƐ Ϭ͘ϴϭ ϵ͘&ĞĂƌƐĂďŽƵƚƚŚĞĐĂŶĐĞƌƐƉƌĞĂĚŝŶŐ Ϭ͘ϴϰ ϭϬ͘tŽƌƌLJƚŚĂƚƚŚĞƌĞƐƵůƚƐ ŽĨ ƚƌĞĂƚŵĞŶƚĂƌĞďĞͲ

yond your control Ϭ͘ϳϯ

ϭϭ͘hŶĐĞƌƚĂŝŶƚLJĂďŽƵƚƚŚĞĨƵƚƵƌĞ Ϭ͘ϴϮ ϭϮ͘>ĞĂƌŶŝŶŐƚŽĨĞĞůŝŶĐŽŶƚƌŽůŽĨLJŽƵƌƐŝƚƵĂƟŽŶ Ϭ͘ϯϭ Ϭ͘ϲϴ Ϭ͘ϯϵ ϭϯ͘<ĞĞƉŝŶŐĂƉŽƐŝƟǀĞůŽŽŬ Ϭ͘ϱϮ Ϭ͘ϰϭ ϭϰ͘&ĞĞůŝŶŐƐĂďŽƵƚĚĞĂƚŚĂŶĚĚLJŝŶŐ Ϭ͘ϳϴ ϭϱ͘ŚĂŶŐĞƐŝŶƐĞdžƵĂůĨĞĞůŝŶŐƐ Ϭ͘ϰϳ Ϭ͘ϳϯ ϭϲ͘ŚĂŶŐĞƐŝŶLJŽƵƌƐĞdžƵĂůƌĞůĂƟŽŶƐŚŝƉƐ Ϭ͘ϯϱ Ϭ͘ϴϯ ϭϳ͘ŽŶĐĞƌŶƐĂďŽƵƚƚŚĞǁŽƌƌŝĞƐŽĨƚŚŽƐĞĐůŽƐĞƚŽ you Ϭ͘ϯϳ Ϭ͘ϱϭ ϭϴ͘ DŽƌĞ ĐŚŽŝĐĞ ĂďŽƵƚ ǁŚŝĐŚ ĐĂŶĐĞƌ ƐƉĞĐŝĂůŝƐƚƐ you see Ϭ͘ϯϰ Ϭ͘ϳϯ ϭϵ͘DŽƌĞĐŚŽŝĐĞĂďŽƵƚǁŚŝĐŚŚŽƐƉŝƚĂůLJŽƵĂƩĞŶĚ Ϭ͘ϳϰ ϮϬ͘ZĞĂƐƐƵƌĂŶĐĞďLJŵĞĚŝĐĂůƐƚĂīƚŚĂƚƚŚĞǁĂLJLJŽƵ feel is normal Ϭ͘ϱϱ Ϭ͘ϯϮ Ϭ͘ϯϱ Ϯϭ͘ ,ŽƐƉŝƚĂů ƐƚĂī ĂƩĞŶĚŝŶŐ ƉƌŽŵƉƚůLJ ƚŽ LJŽƵƌ physical needs Ϭ͘ϲϯ Ϭ͘ϰϰ ϮϮ͘ ,ŽƐƉŝƚĂů ƐƚĂī ĂĐŬŶŽǁůĞĚŐŝŶŐ͕ ĂŶĚ ƐŚŽǁŝŶŐ ƐĞŶƐŝƟǀŝƚLJƚŽ͕LJŽƵƌĨĞĞůŝŶŐƐĂŶĚĞŵŽƟŽŶĂůŶĞĞĚƐ Ϭ͘ϲϴ Ϭ͘ϯϱ Ϯϯ͘ĞŝŶŐŐŝǀĞŶǁƌŝƩĞŶŝŶĨŽƌŵĂƟŽŶĂďŽƵƚƚŚĞŝŵͲ

portant aspects of you care Ϭ͘ϲϰ Ϭ͘ϱϬ

Ϯϰ͘ ĞŝŶŐ ŐŝǀĞŶ ŝŶĨŽƌŵĂƟŽŶ ;ǁƌŝƩĞŶ͕ ĚŝĂŐƌĂŵƐ͕ ĚƌĂǁŝŶŐƐͿĂďŽƵƚĂƐƉĞĐƚƐŽĨŵĂŶĂŐŝŶŐLJŽƵƌŝůůŶĞƐƐ ĂŶĚƐŝĚĞͲĞīĞĐƚƐĂƚŚŽŵĞ

ϱϵ

3

dĂďůĞϰ͗ŽŶƟŶƵĞĚ͘ &ĂĐƚŽƌ>ŽĂĚŝŶŐƐ1 Item 1 2 3 4 5 Ϯϱ͘ ĞŝŶŐ ŐŝǀĞŶ ĞdžƉůĂŶĂƟŽŶƐ ŽĨ ƚŚŽƐĞ ƚĞƐƚƐ ĨŽƌ ǁŚŝĐŚLJŽƵǁŽƵůĚůŝŬĞĞdžƉůĂŶĂƟŽŶƐ Ϭ͘ϲϳ Ϭ͘ϯϭ Ϭ͘ϯϭ Ϯϲ͘ ĞŝŶŐ ĂĚĞƋƵĂƚĞůLJ ŝŶĨŽƌŵĞĚ ĂďŽƵƚ ƚŚĞ ďĞŶͲ ĞĮƚƐ ĂŶĚ ƐŝĚĞͲĞīĞĐƚƐ ŽĨ ƚƌĞĂƚŵĞŶƚƐ ďĞĨŽƌĞ LJŽƵ choose to have them

Ϭ͘ϳϰ Ϭ͘ϯϬ Ϯϳ͘ ĞŝŶŐ ŝŶĨŽƌŵĞĚ ĂďŽƵƚ LJŽƵƌ ƚĞƐƚ ƌĞƐƵůƚƐ ĂƐ soon as feasible Ϭ͘ϳϲ Ϭ͘ϯϭ Ϯϴ͘ĞŝŶŐŝŶĨŽƌŵĞĚĂďŽƵƚĐĂŶĐĞƌǁŚŝĐŚŝƐƵŶĚĞƌ ĐŽŶƚƌŽůŽƌĚŝŵŝŶŝƐŚŝŶŐ;ƚŚĂƚŝƐ͕ƌĞŵŝƐƐŝŽŶͿ Ϭ͘ϳϴ Ϭ͘ϯϲ Ϯϵ͘ ĞŝŶŐ ŝŶĨŽƌŵĞĚ ĂďŽƵƚ ƚŚŝŶŐƐ LJŽƵ ĐĂŶ ĚŽ ƚŽ ŚĞůƉLJŽƵƌƐĞůĨƚŽŐĞƚǁĞůů Ϭ͘ϳϰ ϯϬ͘ ,ĂǀŝŶŐ ĂĐĐĞƐƐ ƚŽ ƉƌŽĨĞƐƐŝŽŶĂů ĐŽƵŶƐĞůůŝŶŐ ;Ğ͘Ő͕͘ ƉƐLJĐŚŽůŽŐŝƐƚ͕ ƐŽĐŝĂů ǁŽƌŬĞƌ͕ ĐŽƵŶƐĞůůŽƌ͕ ŶƵƌƐĞƐƉĞĐŝĂůŝƐƚͿŝĨLJŽƵ͕ĨĂŵŝůLJŽƌĨƌŝĞŶĚƐŶĞĞĚŝƚ Ϭ͘ϲϱ Ϭ͘ϯϰ ϯϭ͘dŽďĞŐŝǀĞŶŝŶĨŽƌŵĂƟŽŶĂďŽƵƚƐĞdžƵĂůƌĞůĂƟŽŶͲ ships Ϭ͘ϳϳ ϯϮ͘ĞŝŶŐƚƌĞĂƚĞĚůŝŬĞĂƉĞƌƐŽŶŶŽƚũƵƐƚĂŶŽƚŚĞƌ case Ϭ͘ϴϮ ϯϯ͘ĞŝŶŐƚƌĞĂƚĞĚŝŶĂŚŽƐƉŝƚĂůŽƌĐůŝŶŝĐƚŚĂƚŝƐĂƐ physically pleasant as possible Ϭ͘ϳϰ ϯϰ͘ ,ĂǀŝŶŐ ŽŶĞ ŵĞŵďĞƌ ŽĨ ŚŽƐƉŝƚĂů ƐƚĂī ǁŝƚŚ whom you can talk to about all aspects of you ĐŽŶĚŝƟŽŶ͕ƚƌĞĂƚŵĞŶƚĂŶĚĨŽůůŽǁͲƵƉ

Ϭ͘ϳϳ Ϭ͘ϯϭ

ϲϬ dĂďůĞϱ͘&ůŽŽƌĂŶĚĐĞŝůŝŶŐĞīĞĐƚƐŽĨƚŚĞ^E^Ͳ^&ϯϰĂŶĚƐƵŐŐĞƐƚĞĚĨĂĐƚŽƌƐƚƌƵĐƚƵƌĞŝŶŚĞĂĚĂŶĚ ŶĞĐŬĐĂŶĐĞƌƉĂƟĞŶƚƐ;ŶсϮϬϭͿ &ĂĐƚŽƌ>ŽĂĚŝŶŐƐ1 Item й>ŽǁĞƐƚ ƐĐŽƌĞ й,ŝŐŚĞƐƚƐĐŽƌĞ 1 2 3 4

Physical & daily living 38.8% 0%

ϭ͘WĂŝŶ ϳϬ͘ϵй Ϯ͘ϱй Ϭ͘ϯϵ Ϭ͘ϱϰ Ϯ͘>ĂĐŬŽĨĞŶĞƌŐLJͬƟƌĞĚŶĞƐƐ ϱϭ͘Ϭй ϰ͘ϱй Ϭ͘ϯϯ Ϭ͘ϱϭ Ϭ͘ϲϬ ϯ͘&ĞĞůŝŶŐƐƵŶǁĞůůĂůŽƚŽĨƚŚĞƟŵĞ ϳϰ͘ϲй ϭ͘Ϭй Ϭ͘ϱϯ Ϭ͘ϲϳ ϰ͘tŽƌŬĂƌŽƵŶĚƚŚĞŚŽŵĞ ϱϴ͘ϰй ϯ͘Ϭй Ϭ͘ϳϲ ϱ͘EŽƚďĞŝŶŐĂďůĞƚŽĚŽƚŚĞƚŚŝŶŐƐLJŽƵ used to do ϱϳ͘ϳй ϳ͘ϱй Ϭ͘ϯϵ Ϭ͘ϯϵ Ϭ͘ϲϵ Psychological 29.7% 0% ϲ͘ŶdžŝĞƚLJ ϲϴ͘Ϭй Ϯ͘ϱй Ϭ͘ϳϴ Ϭ͘ϯϭ ϳ͘&ĞĞůŝŶŐĚŽǁŶŽƌĚĞƉƌĞƐƐĞĚ ϲϳ͘ϳй ϭ͘Ϭй Ϭ͘ϯϮ Ϭ͘ϳϴ ϴ͘&ĞĞůŝŶŐƐŽĨƐĂĚŶĞƐƐ ϲϲ͘ϳй Ϯ͘Ϭй Ϭ͘ϴϭ ϵ͘&ĞĂƌƐĂďŽƵƚƚŚĞĐĂŶĐĞƌƐƉƌĞĂĚŝŶŐ ϱϭ͘ϱй ϴ͘ϱй Ϭ͘ϴϱ ϭϬ͘tŽƌƌLJƚŚĂƚƚŚĞƌĞƐƵůƚƐŽĨƚƌĞĂƚŵĞŶƚ

are beyond your control ϱϵ͘ϳй ϯ͘ϱй Ϭ͘ϯϰ Ϭ͘ϳϰ

ϭϭ͘hŶĐĞƌƚĂŝŶƚLJĂďŽƵƚƚŚĞĨƵƚƵƌĞ ϱϬ͘Ϭй ϱ͘ϱй Ϭ͘ϯϯ Ϭ͘ϴϮ ϭϮ͘>ĞĂƌŶŝŶŐƚŽĨĞĞůŝŶĐŽŶƚƌŽůŽĨLJŽƵƌ ƐŝƚƵĂƟŽŶ ϱϴ͘Ϭй ϭ͘ϱй Ϭ͘ϯϱ Ϭ͘ϲϴ Ϭ͘ϰϭ ϭϯ͘<ĞĞƉŝŶŐĂƉŽƐŝƟǀĞůŽŽŬ ϱϰ͘Ϯй ϯ͘ϱй Ϭ͘ϯϭ Ϭ͘ϱϮ Ϭ͘ϰϮ ϭϰ͘&ĞĞůŝŶŐƐĂďŽƵƚĚĞĂƚŚĂŶĚĚLJŝŶŐ ϲϱ͘Ϭй ϰ͘ϱй Ϭ͘ϳϵ ϭϳ͘ŽŶĐĞƌŶƐĂďŽƵƚƚŚĞǁŽƌƌŝĞƐŽĨƚŚŽƐĞ close to you ϲϬ͘ϱй Ϯ͘ϱй Ϭ͘ϯϴ Ϭ͘ϰϮ Ϭ͘ϯϬ Sexuality 69.9% 0.5% ϭϱ͘ŚĂŶŐĞƐŝŶƐĞdžƵĂůĨĞĞůŝŶŐƐ ϳϱ͘ϯй ϯ͘Ϭй Ϭ͘ϰϴ Ϭ͘ϳϰ ϭϲ͘ŚĂŶŐĞƐŝŶLJŽƵƌƐĞdžƵĂůƌĞůĂƟŽŶƐŚŝƉƐ ϳϳ͘ϴй Ϯ͘ϱй Ϭ͘ϯϲ Ϭ͘ϴϰ ϯϭ͘dŽďĞŐŝǀĞŶŝŶĨŽƌŵĂƟŽŶĂďŽƵƚƐĞdžƵͲ ĂůƌĞůĂƟŽŶƐŚŝƉƐ ϴϱ͘ϰй Ϭ͘ϱй Ϭ͘ϳϲ ,ĞĂůƚŚƐLJƐƚĞŵ͕ŝŶĨŽƌŵĂƟŽŶΘƉĂƟĞŶƚ support 21.1% 0% ϭϴ͘DŽƌĞĐŚŽŝĐĞĂďŽƵƚǁŚŝĐŚĐĂŶĐĞƌ

specialists you see ϲϳ͘ϱй ϭ͘ϱй Ϭ͘ϰϳ Ϭ͘ϰϭ

ϮϬ͘ZĞĂƐƐƵƌĂŶĐĞďLJŵĞĚŝĐĂůƐƚĂīƚŚĂƚ

the way you feel is normal ϰϯ͘ϱй Ϯ͘ϱй Ϭ͘ϲϮ Ϭ͘ϯϰ Ϭ͘ϯϭ

Ϯϭ͘,ŽƐƉŝƚĂůƐƚĂīĂƩĞŶĚŝŶŐƉƌŽŵƉƚůLJƚŽ

ϲϭ

3

dĂďůĞϱ͘ŽŶƟŶƵĞĚ &ĂĐƚŽƌ>ŽĂĚŝŶŐƐ1 Item й>ŽǁĞƐƚ ƐĐŽƌĞ й,ŝŐŚĞƐƚƐĐŽƌĞ 1 2 3 4 ϮϮ͘,ŽƐƉŝƚĂůƐƚĂīĂĐŬŶŽǁůĞĚŐŝŶŐ͕ĂŶĚ ƐŚŽǁŝŶŐƐĞŶƐŝƟǀŝƚLJƚŽ͕LJŽƵƌĨĞĞůŝŶŐƐĂŶĚ ĞŵŽƟŽŶĂůŶĞĞĚƐ ϱϱ͘Ϭй ϭ͘ϱй Ϭ͘ϳϱ Ϯϯ͘ĞŝŶŐŐŝǀĞŶǁƌŝƩĞŶŝŶĨŽƌŵĂƟŽŶ

about the important aspects of you care ϱϴ͘Ϭй Ϯ͘Ϭй Ϭ͘ϳϱ

Ϯϰ͘ĞŝŶŐŐŝǀĞŶŝŶĨŽƌŵĂƟŽŶ;ǁƌŝƩĞŶ͕ ĚŝĂŐƌĂŵƐ͕ĚƌĂǁŝŶŐƐͿĂďŽƵƚĂƐƉĞĐƚƐŽĨ ŵĂŶĂŐŝŶŐLJŽƵƌŝůůŶĞƐƐĂŶĚƐŝĚĞͲĞīĞĐƚƐ at home ϲϭ͘ϱй ϰ͘Ϭй Ϭ͘ϲϱ Ϭ͘ϯϬ Ϯϱ͘ĞŝŶŐŐŝǀĞŶĞdžƉůĂŶĂƟŽŶƐŽĨƚŚŽƐĞ ƚĞƐƚƐĨŽƌǁŚŝĐŚLJŽƵǁŽƵůĚůŝŬĞĞdžƉůĂŶĂͲ ƟŽŶƐ ϰϲ͘Ϯй Ϯ͘ϱй Ϭ͘ϳϮ Ϭ͘ϯϭ Ϯϲ͘ĞŝŶŐĂĚĞƋƵĂƚĞůLJŝŶĨŽƌŵĞĚĂďŽƵƚ ƚŚĞďĞŶĞĮƚƐĂŶĚƐŝĚĞͲĞīĞĐƚƐŽĨƚƌĞĂƚͲ ments before you choose to have them

ϰϳ͘Ϯй ϰ͘ϱй Ϭ͘ϳϵ

Ϯϳ͘ĞŝŶŐŝŶĨŽƌŵĞĚĂďŽƵƚLJŽƵƌƚĞƐƚ

results as soon as feasible ϰϯ͘ϯй ϭϭ͘ϵй Ϭ͘ϳϰ Ϭ͘ϯϭ

Ϯϴ͘ĞŝŶŐŝŶĨŽƌŵĞĚĂďŽƵƚĐĂŶĐĞƌǁŚŝĐŚ ŝƐƵŶĚĞƌĐŽŶƚƌŽůŽƌĚŝŵŝŶŝƐŚŝŶŐ;ƚŚĂƚŝƐ͕ ƌĞŵŝƐƐŝŽŶͿ ϯϴ͘ϯй ϭϬ͘ϰй Ϭ͘ϳϳ Ϭ͘ϯϳ Ϯϵ͘ĞŝŶŐŝŶĨŽƌŵĞĚĂďŽƵƚƚŚŝŶŐƐLJŽƵ ĐĂŶĚŽƚŽŚĞůƉLJŽƵƌƐĞůĨƚŽŐĞƚǁĞůů ϱϬ͘Ϯй ϴ͘ϱй Ϭ͘ϳϴ Ϭ͘ϯϬ ϯϬ͘,ĂǀŝŶŐĂĐĐĞƐƐƚŽƉƌŽĨĞƐƐŝŽŶĂůĐŽƵŶͲ ƐĞůůŝŶŐ;Ğ͘Ő͕͘ƉƐLJĐŚŽůŽŐŝƐƚ͕ƐŽĐŝĂůǁŽƌŬĞƌ͕ ĐŽƵŶƐĞůůŽƌ͕ŶƵƌƐĞƐƉĞĐŝĂůŝƐƚͿŝĨLJŽƵ͕ĨĂŵŝͲ ly or friends need it ϲϲ͘ϳй ϰ͘ϱй Ϭ͘ϲϳ Ϭ͘ϯϱ ϯϮ͘ĞŝŶŐƚƌĞĂƚĞĚůŝŬĞĂƉĞƌƐŽŶŶŽƚũƵƐƚ another case ϱϯ͘Ϯй ϵ͘ϱй Ϭ͘ϳϵ ϯϯ͘ĞŝŶŐƚƌĞĂƚĞĚŝŶĂŚŽƐƉŝƚĂůŽƌĐůŝŶŝĐ

that is as physically pleasant as possible ϰϰ͘ϯй ϲ͘ϱй Ϭ͘ϳϮ

ϲϯ

3

dĂ ďůĞϳ͘ŝī Ğƌ ĞŶĐĞƐŝŶ^E^Ͳ^&ϯϰĚŽŵĂŝŶƐĐ Žƌ ĞƐďĞ ƚǁ ĞĞŶĚŝī Ğƌ ĞŶ ƚƉĂ ƟĞŶ ƚŐƌ ŽƵƉ Ɛ SCNS domain WŚLJƐ ŝĐ ĂůΘĚĂŝůLJůŝǀŝŶŐ Ŷсϭϵϲ WƐ LJĐ ŚŽůŽŐŝĐ Ăů Ŷсϭϵϱ ^Ğ džƵ ĂůŝƚLJ Ŷсϭϵϲ ,ĞĂůƚŚƐ LJƐ ƚĞ ŵ͕ ŝŶ ĨŽ ƌŵĂ ƟŽŶΘƉĂ ƟĞŶ ƚƐƵƉƉŽƌƚ Ŷсϭϵϵ ŚĂƌ ĂĐƚ ĞƌŝƐ ƟĐƐ E D ĞĚŝĂŶ ΀ƌ ĂŶŐ Ğ΁ p DĞĚŝĂŶ ΀ƌĂŶŐ Ğ΁ p DĞĚŝĂŶ ΀ƌĂŶŐ Ğ΁ p DĞĚŝĂŶ ΀ƌĂŶŐ Ğ΁ p Ő Ğ Ϭ͘ϲϳ Ϭ͘ϯϭ Ϭ͘ϳϮ ϭϴͲϲϬLJ ĞĂƌ Ɛ ϲϯ ϳ͘ϱ΀ϬͲϵϮ͘ϱ΁ Ϭ΀ϬͲϳϱ͘Ϭ΁ ϭϯ͘ϯ΀ϬͲϴϯ͘ϯ΁ хϲϬLJ ĞĂƌ Ɛ ϭϯϴ ϭϬ͘Ϭ΀ϬͲϴϱ͘Ϭ΁ Ϭ΀ϬͲϭϬϬ͘Ϭ΁ ϭϱ͘Ϭ΀ϬͲϵϭ͘ϳ΁ 'ĞŶĚĞƌ Ϭ͘ϭϭ Ϭ͘ϲϳ Ϭ͘ϱϱ DĂůĞ ϭϯϰ ϭϬ͘Ϭ΀ϬͲϵϱ͘Ϭ΁ ϭϬ͘Ϭ΀ϬͲϵϮ͘ϱ΁ Ϭ΀ϬͲϭϬϬ͘Ϭ΁ Fe m al e ϲϳ ϭϮ͘ϱ΀ϬͲϵϱ͘Ϭ΁ ϭϬ͘Ϭ΀ϬͲϴϱ͘Ϭ΁ Ϭ΀ϬͲϲϲ͘ϳ΁ Tr ea tmen t pr ocedur e Ϭ͘ϬϮ Ϭ͘Ϭϭ Ϭ͘Ϭϳ ^ŝŶŐůĞ trea tmen t ϵϮ ϱ͘Ϭ΀ϬͲϵϱ͘Ϭ΁ ϱ͘Ϭ΀ϬͲϴϱ͘Ϭ΁ ϭϭ͘ϳ΀ϬͲϴϱ͘Ϭ΁ DƵůƟŵŽĚĂůŝƚLJ trea tmen t ϭϬϵ ϭϬ͘Ϭ΀ϬͲϵϱ͘Ϭ΁ ϭϱ͘Ϭ΀ϬͲϵϮ͘ϱ΁ ϭϴ͘ϯ΀ϬͲϵϭ͘ϳ΁

Time since las

ϲϰ

DISCUSSION

dŚŝƐƐƚƵĚLJŝƐƚŚĞĮƌƐƚƐƚƵĚLJƚŚĂƚŝŶǀĞƐƟŐĂƚĞĚƚŚĞƉƐLJĐŚŽŵĞƚƌŝĐƉƌŽƉĞƌƟĞƐŽĨƚŚĞƵƚĐŚ ǀĞƌƐŝŽŶ ŽĨ ƚŚĞ ^E^Ͳ^&ϯϰ ĂŶĚ ŶĞǁůLJ ĚĞǀĞůŽƉĞĚ ^E^Ͳ,E ĂŵŽŶŐ ,E ƉĂƟĞŶƚƐ͘ WƐLJĐŚŽŵĞƚƌŝĐ ƉƌŽƉĞƌƟĞƐ ĂƐƐĞƐƐĞĚ ǁĞƌĞ ĐŽŶƚĞŶƚ ǀĂůŝĚŝƚLJ͕ ĨĂĐƚŽƌ ƐƚƌƵĐƚƵƌĞ͕ ŝŶƚĞƌŶĂů ĐŽŶƐŝƐƚĞŶĐLJ͕ĐŽŶƐƚƌƵĐƚǀĂůŝĚŝƚLJĂŶĚƚĞƐƚͲƌĞƚĞƐƚƌĞůŝĂďŝůŝƚLJ͘ ŽŶƚĞŶƚǀĂůŝĚŝƚLJĂŶĂůLJƐĞƐŽĨƚŚĞ^E^Ͳ,EƐŚŽǁĞĚƚŚĂƚƚŚĞƌĞǁĞƌĞŶŽƌĞĚƵŶĚĂŶƚŝƚĞŵƐ͕ ďƵƚƚŚĂƚƐŽŵĞ,EŝƐƐƵĞƐŵĂLJŶĞĞĚƚŽďĞĂĚĚĞĚ͗ƚĂƐƚĞĂŶĚŽůĨĂĐƟŽŶ͕ĚŝĸĐƵůƚLJĞĂƟŶŐ͕ ĞĂƟŶŐŝŶĐŽŵƉĂŶLJĂŶĚĐŚĂŶŐĞƐŝŶĂƉƉĞƟƚĞ͕ĐŽƵŐŚŝŶŐĂŶĚďƌĞĂƚŚůĞƐƐŶĞƐƐ͕ĂŶĚŵŽďŝůŝƚLJ ŽĨƚŚĞƚŽŶŐƵĞ͘&ŽƌƐŽŵĞŽĨƚŚĞƐĞƉƌŽďůĞŵƐƚŚĞŶĞĞĚĨŽƌƐƵƉƉŽƌƟǀĞĐĂƌĞǁĂƐĂůƌĞĂĚLJ ĂĚĚƌĞƐƐĞĚŝŶĚŝƌĞĐƚůLJ͕Ğ͘Ő͕͘ƚŚĞƉƌŽďůĞŵƐŽŶĚŝĸĐƵůƚLJĞĂƟŶŐ͕ĞĂƟŶŐŝŶĐŽŵƉĂŶLJĂŶĚĐŚĂŶŐĞƐ ŝŶĂƉƉĞƟƚĞǁĞƌĞĂĚĚƌĞƐƐĞĚƉĂƌƚůLJďLJƚŚĞƋƵĞƐƟŽŶŽŶďĞŝŶŐŝŶĨŽƌŵĞĚĂďŽƵƚŶƵƚƌŝƟŽŶ͕ ĂŶĚƚŚĞƉƌŽďůĞŵƐŽŶŵŽďŝůŝƚLJŽĨƚŚĞƚŽŶŐƵĞŝƐĂĚĚƌĞƐƐĞĚďLJƚŚĞƋƵĞƐƟŽŶŽŶĐŚĞǁŝŶŐĂŶĚ ƐǁĂůůŽǁŝŶŐ͕ĂŶĚƐƉĞĞĐŚ͘&ŽƌƚŚĞŽƚŚĞƌƉƌŽďůĞŵƐͬŶĞĞĚƐ;ƚĂƐƚĞĂŶĚŽůĨĂĐƟŽŶ͕ĂŶĚĐŽƵŐŚŝŶŐ ĂŶĚďƌĞĂƚŚůĞƐƐŶĞƐƐͿ͕ŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJĚŝƐĐƵƐƐŝŽŶƐĂƌĞŶĞĞĚĞĚŽŶƚŚĞŶĞĐĞƐƐŝƚLJƚŽƵƉĚĂƚĞ ƚŚĞ^E^Ͳ,E͘/ŶƚŚĞƉƌĞƐĞŶƚƐƚƵĚLJǁĞĂŝŵĞĚƚŽŝŶĐůƵĚĞŽŶůLJƚŚŽƐĞƉƌŽďůĞŵƐͬŶĞĞĚƐĨŽƌ ǁŚŝĐŚƐƵƉƉŽƌƟǀĞĐĂƌĞŝƐĂǀĂŝůĂďůĞ͘,ŽǁĞǀĞƌ͕ǁĞƌĞĂůŝnjĞƚŚĂƚƚŚŝƐĂŝŵŝƐŶŽƚĐŽŶƐŝƐƚĞŶƚ ǁŝƚŚƚŚĞƚĞŶĞƚƐŽĨƐƵƉƉŽƌƟǀĞĐĂƌĞŶĞĞĚƐĂƐƐĞƐƐŵĞŶƚ͘KŶĞŽĨƚŚĞƉƵƌƉŽƐĞƐŝƐƚŽĂƐƐŝƐƚ ŝŶŝĚĞŶƟĨLJŝŶŐ͕ŐƵŝĚŝŶŐĂŶĚĚĞƐŝŐŶŝŶŐƚŚĞƌĂŶŐĞŽĨƐĞƌǀŝĐĞƐƚŚĂƚŽƵŐŚƚƚŽďĞĂǀĂŝůĂďůĞƚŽ ƉĂƟĞŶƚƐϯϵ_{͘ůƚŚŽƵŐŚĂŶŝƚĞŵŽŶƚĂƐƚĞĂŶĚŽůĨĂĐƟŽŶ͕ĂŶĚŽŶĐŽƵŐŚŝŶŐĂŶĚďƌĞĂƚŚůĞƐƐŶĞƐƐ} ŵĂLJďĞĂĚĚĞĚ͕ƚŚĞ^E^Ͳ,EŝƐĂĐŽŵƉƌĞŚĞŶƐŝǀĞWZKD͘ ƉƉƌŽƉƌŝĂƚĞŶĞƐƐ ŽĨ ƚŚĞ ^E^Ͳ,E ǁĂƐ ĨƵƌƚŚĞƌ ƐƵƉƉŽƌƚĞĚ ďLJ ƚŚĞ ŝĚĞŶƟĮĞĚ ϮͲĨĂĐƚŽƌ ƐƚƌƵĐƚƵƌĞ͗,EͲƐƉĞĐŝĮĐĨƵŶĐƟŽŶŝŶŐǁŚŝĐŚĐŽŵƉƌŝƐĞƐŽĨϴŝƚĞŵƐŽŶŶĞĞĚƐƌĞůĂƚĞĚƚŽ ,EͲƐƉĞĐŝĮĐĨƵŶĐƟŽŶŝŶŐĂŶĚƉƌŽďůĞŵƐ͕ĂŶĚĂůŝĨĞƐƚLJůĞĚŽŵĂŝŶǁŚŝĐŚĐŽŵƉƌŝƐĞƐŽĨϮ ŝƚĞŵƐƌĞůĂƚĞĚƚŽƋƵŝƫŶŐƐŵŽŬŝŶŐĂŶĚĚƌŝŶŬŝŶŐ͘/ŶƚĞƌŶĂůĐŽŶƐŝƐƚĞŶĐLJŽĨ,EͲƐƉĞĐŝĮĐ ĨƵŶĐƟŽŶŝŶŐǁĂƐŐŽŽĚ;ƌŽŶďĂĐŚ͛ƐĂůƉŚĂсϬ͘ϴϵͿ͕ǁŚŝůĞƐŽŵĞǁŚĂƚůŽǁĨŽƌƚŚĞůŝĨĞƐƚLJůĞ ĚŽŵĂŝŶ;ƌŽŶďĂĐŚ͛ƐĂůƉŚĂсϬ͘ϲϬͿ͕ǁŚŝĐŚĐĂŶďĞĞdžƉůĂŝŶĞĚďLJƚŚĞĨĂĐƚƚŚĂƚƚŚŝƐĚŽŵĂŝŶ ŝŶĐůƵĚĞƐŽŶůLJƚǁŽŝƚĞŵƐ͘tĞĂĐŬŶŽǁůĞĚŐĞƚŚĂƚĂĚŽŵĂŝŶǁŝƚŚƚǁŽŝƚĞŵƐŝƐŐĞŶĞƌĂůůLJ ƌĞĐŽŐŶŝnjĞĚĂƐůĞƐƐƐƚĂďůĞĂŶĚƚŚĞƌĞďLJůĞƐƐƌĞůŝĂďůĞĂŶĚůĞƐƐĐŽŶƐƚƌƵĐƚǀĂůŝĚƚŚĂŶĂĚŽŵĂŝŶ with more itemsϰϬ_͘

ZĞŐĂƌĚŝŶŐƚŚĞ^E^Ͳ^&ϯϰ͕ĐŽŶĮƌŵĂƚŽƌLJĨĂĐƚŽƌĂŶĂůLJƐĞƐƐŚŽǁĞĚƚŚĂƚƚŚĞϱͲĨĂĐƚŽƌƐƚƌƵĐƚƵƌĞ ŽĨŽLJĞƐĞƚĂů͘ϵ_{ĂŶĚƚŚĞϰͲĨĂĐƚŽƌƐƚƌƵĐƚƵƌĞŽĨƵĞƚĂů͘}ϭϲ _{could not be replicated in this}