Identifying the unmet supportive care needs of individuals affected by testicular cancer: a systematic review

Purpose To critically appraise studies to identify experiences of unmet supportive care needs of individuals affected by testicular cancer. Methods A registered priori systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CINAHL, PsycINFO, and MEDLINE were searched for quantitative, qualitative, and mixed methods studies using a wide range of search terms. All articles were double screened according to a pre-determined eligibility criterion. Reference lists of the final included studies were checked for further eligible studies. The review process was managed using Covidence systematic review software. Data from the studies were extracted, methodological quality appraisal conducted, and a narrative synthesis conducted. Results Of the 72 papers identified, 36 studies were included. In descending order of frequency of need, psychological needs were identified in 26/36, physical needs 18/36, interpersonal/intimacy needs 19/36, health system/information needs 11/36, cognitive needs 9/36, social needs 7/36, and of equal frequencies counts of 4/36 for family, practical, and patient-clinician information needs. Only one study explored spiritual needs and no daily living needs were identified. Conclusions The experience of needs varied in terms of frequency and distress which were commonly influenced by the age of the individual across the cancer care continuum persisting after 1-year post-treatment. Implications for Cancer Survivors When caring for individuals affected by testicular cancer, clinicians are encouraged to take a holistic lens to cancer care, particularly to explore issue or concerns that young men affected by testicular cancer might be embarrassed or reticent to discuss. Supplementary Information The online version contains supplementary material available at 10.1007/s11764-022-01219-7.


Introduction
Testicular cancer is the 26th most commonly diagnosed cancer worldwide [1].Evidence has underscored that testicular cancer is the most prevalent type of cancer diagnosed among young men aged 15-35 years [2] with 74,458 cases diagnosed globally in 2020 [3].Testicular cancer is highly curable with survival rates estimated above 90% largely attributed to the introduction of platinum-based chemotherapies [4] resulting in an increased number of survivors.Treatments include orchiectomy, retroperitoneal lymph node dissection, chemotherapy, and radiotherapy, [5] all of which are associated to their own unique profile of concerns with implications for rehabilitation and supportive care [6].
Supportive care is defined as a holistic term used to describe a person-centred approach to the delivery of oncology services for individuals diagnosed with cancer to meet their informational, spiritual, psychological, social, or physical needs across the cancer care continuum [7].Healthcare professionals and researchers have a growing awareness of the importance to identify gaps in supportive care experiences for people affected by cancer.Though the timely identification of unmet needs, planning and delivery of cancer services can be targeted to improve patients' overall health-related quality of life and recovery [7].To date, a growing number of systematic reviews have examined the unmet needs in various cancer populations such as prostate [8], bladder [9], gynaecological [10], kidney [11], penile [12], breast [13], and colorectal [14], including older populations affected by cancer [13].However, none of these existing evidence synthesis studies provides any clinical insight into the unique needs of young men affected by testicular cancer [6,15,16].The life expectancy among men diagnosed with testicular cancer is about 30-50 years after treatment.Due to high survival rates, minimising the adverse effects of treatment is a major issue and of central importance.Unmet supportive care needs are associated with quality-of-life outcomes in people with cancer, and therefore, supportive care is considered a modifiable factor for research and service provision [17].
Evidence has demonstrated that men affected by testicular cancer commonly report at least one unmet supportive care need despite routine clinical follow-up [15,16,18].Moreover, unmet supportive care needs have been reported to persist up to 1 year after treatment and correlate with anxiety and depression [19].These young men may have enduring physical and psychological needs related to diagnosis and treatments comparative to their youth.Existing studies have reported enduring and longlasting effects from treatment which include problems related to infertility, altered neurological and respiratory function, problems in securing life insurance and employment, psychological distress (such as fear of cancer recurrence), altered masculinity/ body image, concerns related to chemotherapy-induced alopecia, and challenges with intimacy and relationships [6,7,15,16,19].Physical needs are prevalent in testicular cancer survivors, who on average may experience 4.5 physical symptoms (SD = 4.4; range, 1-28) [20].Existing studies have identified that the physical needs among testicular cancer survivors are associated with unemployment, age, low socioeconomic status, and anxiety and depression [20,21].Furthermore, the psychological/ emotional needs of individuals affected by testicular cancer were also found to be high with on average 1.4 psychological unmet needs [20].Emotional needs are related to emotional functioning, depression [22], hopeless coping style [23], and cancerrelated masculinity threat [24].Several studies [6,8,16,18,19] have been conducted to explore the unmet supportive care needs of men affected by testicular cancer.To date, there has not been a systematic review to critically appraise the existing evidence to identify the classification of supportive care needs among men affected by testicular cancer to inform the planning and development of cancer services.

Research questions
This systematic review set out to address the following research questions: 1. What are the unmet supportive care needs of individuals affected by testicular cancer?2. What are the most frequently reported individual domains of unmet need in individuals affected by testicular cancer?

Design
This integrative systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [25,26] (see supplementary Table 1).This review also followed a registered priori systematic review protocol available from: PROSPERO: https:// www.crd.york.ac.uk/ prosp ero/ displ ay_ record.php?Recor dID= 292072.

Types of studies
Inclusion: • All qualitative, quantitative, and mixed methods studies irrespective of research design.• All studies published in the English language within the last 10 years. Exclusion: • Commentaries, editorials, and studies where unmet supportive care needs are not reported were excluded.

Types of participants
Inclusion: • Participants diagnosed with testicular cancer, irrespective of cancer stage or treatment.• Studies conducted with patients in mixed cancer groups, except where separate subgroup analyses of only testicular cancer participants were reported.

Inclusion:
The primary outcome of this review was non-oncological outcomes related to unmet supportive care needs.The Supportive Care Needs Framework [27] guided the classification of supportive care needs.Outcomes specifically are related to the measurement of unmet supportive care needs (e.g. the Supportive Care Needs Survey [28]) and qualitative experiences, informed by the definition of supportive care (see Table 1 for classification).

Literature search
The APA PsycINFO, CINAHL, and MEDLINE databases were searched in November 2021 for relevant studies published from 2002 onwards.To capture as many studies as possible, the database search architecture utilised a wide range of keywords and subject headings.Limiters were placed on all searches for peer-review and English language.A full record of the database searches is included in Supplementary Table 2.The reference lists of all the articles included were searched to locate additional relevant studies.Citations were managed with Endnote 20 and imported into Covidence systematic review software to facilitate the study selection process.

Selection of studies
Following de-duplication, titles and abstracts were double screened independently by reviewers for eligibility, and any disagreements were resolved by discussion.Full texts were then retrieved, double screened by reviewers, and linked multiple records of the same study together.Any

Physical needs
Experience of symptoms such as faƟgue, pain, etc.

CogniƟve needs
Individual experience of cogniƟve impairment or decline, memory problems, etc.

PaƟent-clinician communicaƟon needs
Quality of communicaƟon and co-ordinaƟon between paƟents and health care professionals, shared decision making, etc.
Health system/informaƟon needs InformaƟon needs, uncertainty of follow-up, lack of informaƟon about diagnosis and treatment, etc.

Spiritual needs
Fear of death and dying, fears regarding the aŌerlife, etc.

Daily living needs
Experience of restricƟons to daily living, exercise, housekeeping, etc Interpersonal/inƟmacy needs Experience of difficulƟes with body image, masculinity, sexual dysfuncƟon, compromised inƟmacy with partner, etc.

PracƟcal needs
Related to daily task restrictions, employment, accessing benefits, life insurance, etc.

Family related needs
Experience of fears/concerns of the family, dysfuncƟonal relaƟonships, etc

Social needs
Experience of reduced social support, social isolaƟon, loneliness, lack of peer support, etc disagreements were resolved by discussion.The process of the selection of studies was conducted in Covidence systematic review software.

Data extraction and management
Data extraction was performed on the retained full-text studies meeting the inclusion criteria.

Assessment of risk of bias in included studies
The final retrained full-text studies all underwent a methodological quality assessment.None of the studies was excluded based upon their methodological quality score to enable a comprehensive overview of the current state of the evidence.The methodological quality assessment was conducted using the Mixed Methods Assessment Tool (MMAT) [29].The MMAT tool was selected because it enables a plethora of study designs to methodological appraised given the integrative review design.This assessment tool enables critical appraisal of all qualitative, quantitative, and mixed methods studies.Each domain of assessment is rated against, "no", "yes", and "unclear".Methodological quality assessment was performed by one reviewer and quality checked by a second reviewer.

Data synthesis
This integrative review used a narrative synthesis [30].The steps in the narrative synthesis involved (1) data reduction by tabulation, (2) data comparison between studies, and finally, (3) drawing conclusions.This process involved reading the full papers multiple times, linking together similarities and differences between the studies, and quality checking with the primary sources.The data reduction involved delineation of the classification by domain of unmet need within the tabulated data.The data comparison phase involved the reviewers' identifying patterns and themes through counting and clustering and making comparisons and contrasting the study findings.Finally, the drawing of conclusions and verification involved a subgroup analysis to inform a comprehensive understanding of the topic, which was verified with the primary sources data for accuracy throughout the process.The data synthesis was conducted by two reviewers and consulted with a third reviewer.The reviewers were multidisciplinary healthcare professionals in cancer care.

Results
The initial search yields 2383 results (see Fig. 1).A total of 72 full-text articles were assessed, and 36 articles were excluded with reasons (see Fig. 1).A total of 36 studies fully met the inclusion criteria of which there were five qualitative [21,[31][32][33][34], 30 quantitative [15,18,20,[22][23][24], and one mixed methods [59] which underscores that this is a developing evidence base (see Table 2).Studies were conducted in the UK (5), the USA (5), Canada (4), Germany (4), Norway (4), Australia (3), Denmark (2), Italy (2), the Netherlands (2), Turkey (2), Greece (1), Lebanon (1), Serbia (1), and Sweden (1).The sample sizes of the included studies varied widely; 16 studies had < 100 participants, 17 studies had ≥ 100 participants, two studies had > 500 participants, and one failed to report how many participants were included [33].The average age of study participants varied from 25.1 to 44.4 years, and most of the participants had localised disease compared to metastatic disease.Treatments also varied, but most participants were treated by either orchiectomy or orchiectomy and chemotherapy.Although some underwent surveillance, radiotherapy, and/or retroperitoneal lymph node dissection (RPLND) were reported, most of the participants were married, were in full-time employment, and had at least secondary education or higher.Therefore, the participants in this review are not representative of other minority groups (see Table 3 for the results of the methodological quality assessment).Most of the studies were cross-sectional in design and therefore provide little information about how supportive care needs change over time.The studies had small sample sizes and used convenience sampling approaches.
Other less commonly experience symptoms but still caused distress among testicular cancer survivors included itching, cough, sweats, shortness of breath, dizziness, skin changes, mucositis, numbness and tingling, feeling bloated, changed taste, urination difficulties, diarrhoea, and constipation [20].Additionally, there were problems with fertility [23,38,41,58], hypogonadism [43,45,46], higher white matter hyperintensities and radial kurtosis [52], and low testosterone [38] were reported.Chemotherapy-induced consequences such as obesity, peripheral sensory neuropathy, renal disease, tinnitus, hearing loss, Raynaud phenomenon, and autonomic neuropathy were frequently experienced.However, long-term conditions such as hypertension, thromboembolism, hypocholesteraemia, peripheral artery disease, diabetes, thyroid disease, coronary artery disease, transient ischaemic attack, and stroke were identified less frequently in this young population [43].Testicular cancer survivors were found to have lower mean vitality, physical functioning, physical role functioning, and general health when compared to the general healthy population [23].Men had physical concerns related to having one testicle which was intertwined with psychological consequences and intimacy concerns [38].Noteworthy, 20% of the participants who received a prothesis were unhappy with the aesthetic result [18].

Interpersonal/intimacy needs
Individuals affected by testicular cancer reported needing help with their sex life [18,37] because they were embarrassed to discuss this with healthcare professionals [38].Only 14% of testicular cancer survivors reported having "none/a little" issues in their sex life [41].Some men reported a decreased level of sexual function post-treatment and long-lasting into survivorship [39].The most commonly experienced issues for these young men included erectile dysfunction [39,43,46,47,53], reduced erectile rigidity [58], and inability to maintain an erection during intercourse due to chronic pain [47].Other concerns were reduced sexual interest [20,23,59], lack of sexual desire [39,46,47], and in frequent of sexual activity [22,47,58].Disorders of ejaculation were prevalent [39,42,47] with loss of antegrade ejaculation [42].Decreased sexual satisfaction [47], enjoyment of intercourse [42], intercourse satisfaction [46], reduced pleasure [58], decreased orgasm frequency [42], and decreased orgasm intensity [47] were also reported.Problems within intimate relationships also surfaced because some participants felt they could not speak to their partner about sexual issues [23], which reported decreased general satisfaction [46] or decreased satisfaction with their sexual life and relationship [42].For other young men, they reported concerns about finding a future partner [38] and did not know how to communicate to discuss this sensitive issue with partners or healthcare professionals [22].Treatments including chemotherapy and extended lymph node dissection were associated with poor sexual functioning [42,43]."Sexual questions for example, which might have come up during the doctors' rounds … This might be easier to ask about in an e-mail to a person that you don't know than when the doctor asks: "What about your … (sexual function)?"Then you answer: "Oh, that's OK" or "That's normal" or whatever …" (page 4) [34].

Health system/information needs
Some studies identified that men wanted improved communication in the healthcare system to address problems with co-ordination of their care [23,37].However, participants also needed informational support to provide reassurance that they were receiving the best care [23,37] and that their complaints were being addressed in a timely manner.Informational supports within the healthcare system were, at times, inadequate for patients [15,59] and their partners [59] and omitted recovery expectation post-treatment [15,59] to inform rehabilitation care plans.
"There was no discussion that I remember that was any, you know, 'if you're feeling like this, then come and talk to us,' or, you know, 'there's counselling available,' or anything like that.I don't recall anything like that for the psychological side of any concerns, really."(page 16) [59].
It was important that men received understandable and up-to-date information to support decision-making [37] at diagnosis and treatment phases [51].Fundamental gaps in information provision were observed for knowledge and understanding of which treatments men received, and associated risks of treatments, lifestyle advice to support selfmanagement within the multidisciplinary team, and timely access to results, and how to self-report concerning symptoms to healthcare professionals [59].Patients also identified that websites were critical for accessing information [41] but raised questions about the quality of information which is being accessed by men.
Men reported informational needs related to deciding on which prothesis to proceed with [15], and 44% of patients did not receive any information related to the option of a prothesis [58].Men also wanted information in relation to how to access to complementary or alternative therapies [15] and information in relation to sexual recovery [38].Noteworthy, 50% of testicular cancer survivors did not know what information supports were available to them [59].

Cognitive needs
Testicular cancer survivors frequently experienced cognitive impairment [20, 35, 36, 48-50, 52, 56, 57] or cognitive decline over time [48,56] post-treatment and into survivorship.Participants self-reported cognitive difficulties [20,50,52], but were not always reflected in objective neuropsychological testing used to evaluate cognitive decline [49].One study [20] found that of the 32% of participants who reported difficulty concentrating, 8% of the participants found it highly distressing.None of the participants across these studies reported receiving timely intervention or support for their difficulties with cognition.Evidence identified that as many as 58% of testicular cancer survivors can experience cognitive impairment [35,36] which is significant given this young cohort of men who could be either studying or working in paid employment.One study [49] found that self-reported cognitive impairment was associated with psychological distress.
'It just feels kind of like you're incomplete.Just as a person you feel like you're missing something you're supposed to have.I guess it's just the fact that it doesn't have any real effect but there's still something missing.So it's just that weird dichotomy' (Participant 9)" (page 742) [31].

Social needs
Men diagnosed with testicular cancer reported the need to talk to other survivors [15,23,37].Other social needs included how to navigate sensitive conversations of their cancer diagnosis in the work environment [15,37].Testicular cancer survivors and their caregivers indicated that cancer made their social relationships difficult [41] and they wanted help and advice in how to create new relationships with intimate partners [37].Testicular cancer survivors needed help knowing how to deal with this impact on relationships [37] and were found to have lower social functioning than healthy populations [23].
"'I just think it just helped just reassure me, like I wasn't a nutter, or some weirdo, and you're not the only person, you won't ever be the only person who's gone through it' (P20, T1, 22 years., single, surgery and chemotherapy)" (page 199) [32].

Family-related needs
Young men expressed needs in knowing how to support their partners or families [37], how to communicate with their young children [38], and concerns about being unable to have children due to fertility issues [38].It was common for men to experience issues within their existing relationships which caused emotional strain [41,51].
"An infertile man … the way people perceive him makes him want to beat himself … I suffered … a man is about sex and kids to a certain extent."(page 206) [33].

Practical needs
Practical unmet needs included a lack of assistance to access government benefits [15,23], guidance on life insurance, and accessible parking at the hospital [23].Testicular cancer survivors reported having difficulties with their work or study [41], experienced higher unemployment than general populations [43], with an increased risk of loss of employment [44].One study [52] highlighted that upon testicular cancer survivors return to work, some required changes to their workplace to return to work, and others did not return to their previous role because of cognitive impairment [52]."I don't know what to look for, I don't know what to expect."(page e16) [59].

Patient-clinician communication needs
These were some important implications for patientclinician communication needs identified across four studies [18,37,41,59].Men expressed that they wanted to feel more supported in the self-management of their health in partnership with their healthcare team [23,37]."There was no discussion that I remember that was any, you know, 'if you're feeling like this, then come and talk to us,' or, you know, 'there's counselling available,' or anything like that.I don't recall anything like that for the psychological side of any concerns, really.The attitude seemed to be, if something bothers you, tell us and we'll deal with it.We're not going to tell you in advance what any of those things might be."(page e16) [59].
However, on the whole, men expressed satisfaction and confidence with their patient-clinician communication needs [59].

Spiritual needs
Only two studies [37,51] explored the spiritual needs in this patient group.One study [51] identified that faith and the meaning of life were rated as least concerning unmet needs [43] and testicular cancer survivors reported that they had no unmet spiritual needs [37] in this young patient group.

Daily living needs
Across all the studies, no information was reported in relation to daily living unmet needs of individuals affected by testicular cancer.

Discussion
This systematic review sets out to identify the unmet supportive care needs among young men diagnosed with testicular cancer.The included studies identified that needs varied in terms of distress and frequency across different domains of supportive care.The current review found emotional, intimacy, and physical needs to be the most frequently reported unmet domains of care.This is a similar outcome to reviews conducted in other cancer populations [7][8][9]12].However, cognitive needs of individuals affected by testicular cancer were problematic for these young men, compared to mainstay experiences of unmet needs in other cancer groups [7][8][9]12].Cognitive impacts were investigated at varying time points from immediately post-orchiectomy [35, 48-50, 56, 57] and into survivorship [20,35,52].Cognition was found to be negatively impacted by orchiectomy alone [35,57].However, evidence about the relationship with chemotherapy on cognitive function [49,52,56] or indeed lack of association [35,48] is conflicting.Amidi [35] found that cortisol levels were associated with impaired cognitive function, while increased C-reactive protein was associated with poor verbal fluency test outcomes.Furthermore, selfreported cognitive problems were correlated to Raynaud-like symptoms and fatigue [49], and cognitive decline was also associated with hearing loss [48].Self-reported measures of cognitive impairment have also been linked to emotional/ psychological needs [49,50].Therefore, it should be noted that self-reported cognitive issues, and objective measurable cognitive impairment in testicular cancer survivors is conflicting [49] which is consistent within the literature in other cancer populations [60].Furthermore, a meta-analysis [61] of the effects of chemotherapy on cognition in patients with cancer remains unclear.Given the findings from this current review, future studies should explore mechanism pathways for both objective, and subjective measures in relation to cognitive impairment in this patient group.Gaining this information will help to leverage the development of interventions for cognitive pre -and/or rehabilitation.
This review found hypogonadism to occur in testicular cancer survivors.Hypogonadism is known to result in low testosterone in the male sex [62].Low testosterone has been associated with worse sexual functioning [63].This review identified that hypogonadism was reported, and one study found that it was not related to sexual functioning [46].It is established that sexual dysfunction can be of psychogenic nature [63] and the findings of this review support that this may be true for some testicular cancer survivors.One study [58] found that in men who received a prothesis they reported no sexual dysfunction, whereas men who did not have a prothesis did self-report issues with sexual dysfunction.Body image concerns have been found to be associated with sexual dysfunction in testicular cancer survivors [64].Intimacy needs are high in patient populations where the cancer affects the reproductive organs or secondary sexual characteristics [65] which can negatively impact the sexuality of the affected person.However, it is unlikely all sexual dysfunction reported in this review is only attributed to a psychogenic nature given the consistently high rates of sexual dysfunction in the testicular cancer survivor populations [66].Other issues encountered by these men were a lack of opportunity to discuss these problems with their intimate partner or healthcare professions, often because of embarrassment.Therefore, healthcare professionals should be mindful of these concerns and tactfully and sensitively explore concerns to ensure that men receive timely intervention.
Health system/information needs were frequently unmet.Reasons for these gaps were not explored in the included studies but would be an important clinical focus for future research.The spiritual needs of testicular cancer survivors were rarely discussed, and one study [37] found that testicular cancer survivors did not report any unmet spiritual needs.It is unclear to determine the spiritual needs of individuals affected by testicular cancer because of the lack of data.It is also noteworthy that the men represented in this systematic review also did not express concerns with existential issues, or fear of death and dying, concerns commonly experienced in other cancer populations [7][8][9]12].It would be important to explore whether these were concealed concerns because of their age or reticence to disclose, but ultimately this remains unknown.Likewise, there were no identified daily living needs which might be explained in part because of the young age demographic, but men did share challenges about their practical needs.
Testicular cancer survivors were found to experience greater work loss and take more sick leave than the general population [44].Unemployment rates for testicular cancer survivors were also higher than the general population 1 3 [43].Furthermore, peripheral neuropathy was associated with unemployment and disability leave [43], and receiving four or more courses of chemotherapy was associated with work loss [44].There are practical needs which have also been identified in the wider cancer care literature [67,68].However, specific to this young population were concerns about work, school, and finances compared to older patients [51].This is logical as this population is still generally establishing a career and financial independence [69].Family-related needs were infrequently investigated in the literature.The family needs of individuals affected by testicular cancer should be a central focus for future research, particularly given the impact on intimacy and relationships.
Lastly, future directions for research should focus on developing a core outcome set (COS) for testicular cancer survivorship research.This review has identified significant heterogeneity of study outcomes and in particular patient reported outcomes measures (PROMs).There were a total of 57 different PROMs used across the studies in this systematic review and a range of diverse methods used.

Limitations
This systematic review has many strengths including the clear and specific methodology which followed a registered priori protocol.In addition, to the independent reviewer's contributions throughout the entirety of the systematic review process, the study provided insights across heterogenous study populations in terms experiences of unmet supportive care needs.One of the major challenges of this review was combining heterogeneous methodologies, and our findings are constrained due to the methodological limitations of the studies included.The review only included articles in the English language, and as such, it may limit our understanding of the area globally considering cultural and societal differences.The review also did not include any participants from low-to middleincome countries, and efforts/funding should be targeted to support cancer care in developing nations as a future priority.Lastly, this review only included studies published in the English language, and therefore by omission, valuable insights may have been missed.

Conclusion and implications for cancer survivors
The interrelated nature of the unmet supportive care needs experienced by individuals affected by testicular cancer emphasises the importance of holistic, person-centred approaches to care delivery.The contemporary evidence identified in this review highlights areas of clinical practice that require improvement to enhance the healthcare experiences of individuals affected by testicular cancer.

Fig. 1
Fig. 1 PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers, and other sources there clear research quesƟons, S2.Do the collected data allow to address the research quesƟons, 5.1.Is there an adequate raƟonale for using a mixed methods design to address the research quesƟon, 5.2.Are the different components of the study effecƟvely integrated to answer the research quesƟon, 5.3.Are the outputs of the integraƟon of qualitaƟve and quanƟtaƟve components adequately interpreted, 5.4.Are divergences and inconsistencies between quanƟtaƟve and qualitaƟve results adequately addressed, 5.5.Do the different components of the study adhere to the quality criteria of each tradition of the methods involved *Three levels of assessment quality scores Yes (Y) Unclear (U) No (N)

Table 1
Classification of supportive care needs The data was extracted by one reviewer and independently quality checked by a second reviewer.The data extraction tables were developed and tested on a small sample of studies and then further refined through discussion among the reviewers.The first table of data extraction included information on the purpose, setting, country, sample size, participant characteristics, sampling used, response rate, attrition, design, time points, and data collection tools.The second data extraction table related to the supportive care needs outcome data according to the classification of supportive care needs (see Table1

Table 2
Overview of the included studies

Table 3
S1. Are there clear research quesƟons, S2.Do the collected data allow to address the research quesƟons, 1.1.Is the qualitaƟve approach appropriate to answer the research quesƟon, 1.2.Are the qualitaƟve data collecƟon methods adequate to address the research quesƟon, 1.3.Are the findings adequately derived from the data, 1.4.Is the interpretaƟon of results sufficiently substanƟated by data, 1.5.Is there coherence between qualitaƟve data sources, collecƟon, analysis and interpretaƟon.Are there clear research quesƟons, S2.Do the collected data allow to address the research quesƟons, 4.1.Is the sampling strategy relevant to address the research quesƟon, 4.2.Is the sample representaƟve of the target populaƟon, 4.3.Are the measurements appropriate, 4.4.Is the risk of non-response bias low, 4.5.Is the staƟsƟcal analysis appropriate to answer the research quesƟon

Table 4
Frequency of unmet needs by domain