Audiologists’ perceived value of ototoxicity management and barriers to implementation for at-risk cancer patients in VA: the OtoMIC survey

Purpose
 Platinum-based chemotherapies used to treat many types of cancers are ototoxic. Ototoxicity management (OtoM) to mitigate the ototoxic outcomes of cancer survivors is recommended practice yet it is not a standard part of oncologic care. Although more than 10,000 patients each year are treated with platinum-based chemotherapies at the US Veterans Health Administration (VA), the current state of OtoM in VA is not well-defined. This study reports on a national survey of VA audiologists’ perceptions regarding OtoM in cancer patients. Methods A 26-item online survey was administered to VA audiologists and service chiefs across the VA’s 18 regional systems of care. Descriptive statistics and deductive thematic analysis were used to analyze the data. Results The 61 respondents included at least one from each VA region. All reported they felt some form of OtoM was necessary for at-risk cancer patients. A pre-treatment baseline, the ability to detect ototoxicity early, and management of ototoxic effects both during and after treatment were considered high value objectives of OtoM by respondents. Roughly half reported routinely providing these services for patients receiving cisplatin and carboplatin. Respondents disagreed regarding appropriate hearing testing schedules and how to co-manage OtoM responsibilities with oncology. They identified barriers to care that conformed to three themes: care and referral coordination with oncology, audiology workload, and lack of protocols. Conclusions Although VA audiologists value providing OtoM for cancer patients, only about half perform OtoM for highly ototoxic treatment regimens. The OtoMIC survey provides clinician perspectives to benchmark and address OtoM care gaps. Implications for cancer survivors Collaboration between oncology and audiology is needed to improve current OtoM processes, so that cancer survivors can have more control over their long term hearing health. Supplementary Information The online version contains supplementary material available at 10.1007/s11764-022-01316-7.


Introduction
Platinum-based chemotherapeutics, such as cisplatin and carboplatin, are highly effective at treating a variety of common cancers including those of the bladder, bone, cervix, colon, endometrium, esophagus, head and neck, lung, ovaries, testes, pancreas, rectum, and stomach [1]. Unfortunately, platinumbased drugs are also highly ototoxic [2][3][4][5][6][7]. According to the 2018 Ototoxicity Working Group of Pharmaceutical Interventions for Hearing Loss, ototoxicity is defined as "…damage to the inner ear, targeting cochlear and vestibular structures and sensory function, due to exposure to certain pharmaceuticals, chemicals, and/or ionizing radiation" [8]. In a recent meta-analysis of data from over 5077 patients receiving cisplatin and/or carboplatin, hearing loss occurred in 38-49% of patients pooled across age and tumor type [9]. Cisplatin, the most ototoxic of these drugs, causes some combination of ototoxic hearing loss (prevalence 50-80% [10,11]), tinnitus (prevalence 11-40%; [10,12]), and/or balance problems (prevalence 0% to 50%; [7]) in the majority of those who receive it. The impact of ototoxicity on patient quality of life (QoL) is of increasing concern as cancer survivors are living longer and the number of people diagnosed with cancer each year continues to grow [13]. A recent review by Pearson et al. [14] found that QoL was lower in cancer patients with documented hearing loss and/or tinnitus following cisplatin chemotherapy than in patients who did not report these symptoms or who received another course of care. The one study (of the six identified and reviewed) that found no impact of chemotherapy exposure on QoL and hearing outcomes evaluated only self-reported hearing status [15]. Notably, a recent study of 1410 patients with testicular cancer treated with cisplatin-based chemotherapy showed that patients consistently underestimated the degree of their treatment-related hearing loss compared with contemporaneous audiometric observations [16]. Falchook and colleagues [17] found that oncologists also tend to underestimate the rate and severity of their patient's chemotherapy side effects. This incongruence is most pronounced for non-visible symptoms like tinnitus. In the sample of 43 head and neck cancer patients receiving cisplatin-based chemotherapy, the oncology providers identified only seven of their patients as having ototoxicity-related tinnitus (16%) and considered all but one case to be mild. In contrast, 31 of the 43 patients (72%) self-reported developing tinnitus that they rated as mild, moderate, or severe using the National Cancer Institute Common Terminology for Cancer Adverse Events Patient-Reported Outcomes (CTCAE-PRO) [17]. Cancer survivors' QoL should be considered in relation to ototoxicity especially as it pertains to the wellestablished correlations observed in the general population between uncorrected hearing loss and depression, isolation, social withdrawal, and cognitive decline [18][19][20][21][22]. Hearing loss also needs to be considered in relation to the provision of effective oncologic care, as hearing loss in older adults is associated with reduced levels of health literacy and increased patient-clinician miscommunication [23,24]. In addition to the burden hearing loss places on the patient, there is also an associated economic burden. For adults living in the USA, it has been estimated that each new onset of hearing loss, tinnitus, or vestibular effects has a socioeconomic cost of over $350,000 [25]. To mitigate these impacts and ensure rapid intervention when indicated, a hearing health management approach through an ototoxicity management (OtoM) program is warranted [26].
Ototoxicity monitoring guidelines were put in place by the American Speech-Language-Hearing Association (ASHA) nearly three decades ago [27]. As shown in Table 1, other medical associations and public health entities have subsequently advocated not just for ototoxicity symptom surveillance but for programmatic OtoM. These guidelines advocate for including education and counseling, and ototoxicity assessments that take place before, during, and after treatment, and for the use of these data to promote timely provision of aural rehabilitation and chemotherapy dosage adjustments as indicated [28][29][30][31][32]. Unfortunately, ototoxic medications are commonly administered without the involvement of a hearing health provider on the care team.
In 2021, Konrad-Martin and colleagues evaluated the premise that OtoM should be the recommended standard of care for patients receiving cisplatin-based chemotherapy, using a randomized control trial conducted in the VA. The trial compared the efficacy of OtoM provided as a dedicated program using automated protocols that enabled patients to screen their own hearing in the oncology infusion unit, against a referral system for "usual care" ototoxicity monitoring administered through the audiology clinic. Although the research team made referrals to audiology for each participant in the usual care group, only one patient completed a monitoring visit prior to each cisplatin dose, the protocol recommended by US audiology governing bodies for patients receiving cisplatin [27,28]. In contrast, most (83%) participants in the automated screening group completed the recommended screening. The two groups saw similar incidence of hearing shifts and self-reported hearing handicap and no significant difference in the estimated 2-year survival risk. Similarly, there was no difference across groups in the number of patients who adopted recommended hearing loss intervention (46% vs. 50% in the automated versus usual care groups, respectively) or who received a dose modification based upon the findings of audiological monitoring (1 patient in each group). Notably, this study included research visits to collect and identify ototoxicity outcomes for participants in both arms for comparison, and these outcomes were shared with the patient and their oncology teams for ethical reasons. Participants being informed of their hearing loss coupled with the low cost of audiological services in VA [33], may explain why so many participants actively followed up with audiology to obtain hearing aid services. The striking difference in uptake of recommended monitoring across groups indicates that OtoM as currently recommended  [34]. A similar lack of effective OtoM delivery was also observed in a recent chart review of 379 patients who received cisplatin at UC Davis Medical Center. Although 24% of patients had hearing complaints documented in their medical record, only 4.5% received an audiometric evaluation during cisplatin treatment [35]. Many interventions shown to be effective in research studies fail to be successfully implemented in real-world healthcare settings. Barriers to successful implementation exist at multiple levels of healthcare delivery that must be understood and considered [36]. The Consolidated Framework for Implementation Research (CFIR) is a useful conceptual framework to guide the assessment of diverse implementation contexts, to inform the design of health care interventions, and to identify barriers and facilitators associated with the implementation of health care interventions [37]. Due to the inherent complexity of health care contexts and health care interventions, the CFIR framework describes intersecting factors that guide implementation across disparate contexts [38]. According to CFIR, intervention context and the implementation process are factors that can affect an intervention's success [36]. Investigating clinical service gaps also is vital to understanding how clinical practices can be adapted to overcome current barriers and allow recommended care to become standard of care for at-risk patients. Research and federal healthcare system guidance shows that successful implementation of evidence-based interventions that impact patient outcomes require a common understanding of the problem as well as the alignment of goals among the key partners including provider groups, hospital leadership, and patients [39,40]. Thoughtful consideration of audiologists' and oncologists' views on ototoxicity and its management in patients receiving cancer treatment is, therefore, important for the successful implementation of an OtoM program.
This report documents the development of the "Ototoxicity Management Through Interdisciplinary Care (OtoMIC) Survey" (provided in Appendix A of the online supplementary materials) and its use to gain VA audiologists' perspectives that can be used to improve OtoM practices and protocols in VA. The VA is the largest integrated healthcare system in the USA [41]. In 2018, the most recent year with complete VA Cancer Registry data prior to the COVID-19 pandemic, 10,421 patients were treated with platinum-based chemotherapies (cisplatin 2443, carboplatin 5621, oxaliplatin 2357). The VA provides audiology services as high-priority, direct access care because tinnitus and hearing loss are the number one and number three most prevalent service-connected disabilities, respectively [42]. However, the current state of OtoM in VA is not well-defined. We hypothesized that evidence of OtoM service gaps similar to those identified in the usual care arm of our clinical trial [34] would be found throughout the VA.
We further expected to find that provider perspectives would yield important insights on barriers in specific VA contexts, and how to overcome them.

Methods
Requests for participation by VA audiology service chiefs/ leads and one other audiologist per department were emailed to 128 individuals across the VA's 18 integrated service networks (VISNs). Follow-up emails to service chiefs/leads were sent to VISNs that lacked responses following the initial request for participation. Respondents were surveyed between November and December of 2020 using a VAapproved secure web-based application called Qualtrics, and the survey took approximately 15 min to complete. Sixty-one respondents completed survey questions, and 57/61 respondents provided their VISN or specific VA location (shown in Appendix B). Two additional respondents provided information on barriers to OtoM through emailed responses bringing the total N for the qualitative analysis to 63. These two respondents indicated they did not fill out the survey itself.

Survey development
We developed a survey to inform OtoM implementation in multidisciplinary healthcare contexts. Survey objectives and questions were informed by three constructs from CFIR [36] (1) inner setting (e.g., structural characteristics of the healthcare system/facility), (2) outer setting (e.g., patients' needs and resources committed by the organization to address these needs), and (3) individuals involved (e.g., provider experience, knowledge and beliefs, and other personal characteristics). The survey objectives were to identify: (a) demographic characteristics of the respondent (who could conceivably be any type of provider closely involved in the healthcare of patients receiving an ototoxic medical treatment); (b) number of patients receiving specific ototoxic medications; (c) knowledge of ototoxicity (e.g., prevalence, patient risk factors, symptoms); (d) current OtoM processes and protocols; (e) perspectives on the value and prioritization of OtoM; (f) OtoM implementation climate; and (g) barriers and facilitators associated with OtoM. Figure 1 is a schematic depicting the survey purpose and how it maps onto CFIR constructs in order to achieve our survey objectives and address our longer term goal of developing OtoM implementation recommendations and an associated toolkit specific for VA. The 26-item survey included multiple-choice, multiple-selection, rating-scale, ranking, and open-ended questions.

Survey validation
The face validity of the survey was established by two different review panels. The first review panel consisted of a VA Audiology Chief, an Oregon Health & Science University Audiologist, a VA Oncology Chief, a VA Oncologist, and a VA Oncology Nurse Practitioner to ensure that the questions captured the salient dimensions of OtoM. This prompted revisions to the response options for a few of the multiple-choice questions, in addition to other minor edits. The second review was conducted by an Implementation Science/Health Service Delivery expert to assess question clarity and fit to the conceptual framework. The final version of the OtoMIC survey 1 (Appendix A) can be used or adapted for use with permission from the authors.

Quantitative analysis
The quantitative data obtained from the survey were analyzed using descriptive statistics. Quantitative responses from the survey are reported as absolute frequency (number of respondents that selected each option), relative frequency (percentage of all responses to a question that included a given response option), or the median response (non-parametric estimates of central tendency). All data were securely stored in compliance with VA policy.

Qualitative analysis
A directed, deductive thematic analysis [43] was used to identify barriers and facilitators associated with OtoM. Two members of the project team (KC and RP) reviewed the data by reading and re-reading participant responses, which were downloaded directly from Qualtrics as a spreadsheet. During this immersive phase of reading the data, the analysts collaboratively developed a codebook to tag text related to OtoM barriers and facilitators. They then independently coded a subset of the responses using the codebook and met to compare Fig. 1 Objectives of the Ototoxicity Management Through Interdisciplinary Care (OtoMIC) survey. Flow chart shows relationships between the survey objectives, the CFIR constructs used to develop the survey, and the project goals any differences in coding. Next, to assess the reliability of our coding, the study PI (DK-M) reviewed the codebook, raw data, and coded output. Based on that review, two codes were collapsed into other codes, and the team determined that no further modifications were required. The lead analyst (KC) independently coded the remaining responses and connected the codes thematically, periodically checking in with the project team to discuss the meanings and revisions to the codebook. Atlas.ti software was used for all qualitative analyses.

Demographics
Sixty-one respondents answered the demographic questions in the survey: VA name and geographic location, clinic type (VA Medical Center [VAMC], Community Based Outreach Center [CBOC]), and position (service chief/lead or staff member); of these, some chose not to provide specific location information. Forty-eight percent of the responses were from audiologists and the remaining 52% were from Speech Pathology and Audiology Service Chiefs, which corresponded with the expected response from one audiologist and one service chief or lead from each facility. Seventy-nine percent of respondents worked primarily at a VAMC only, and the other 21% worked at both a CBOC and a VAMC. Seventy-seven percent of the respondents had been practicing in their field for over 10 years and 15% of respondents had been practicing for 7-10 years. The geographical distribution of the 57 respondents who provided this information is shown in Appendix B. These 57 respondents included at least one from each of the VA's 18 regional systems of care called Veterans' Integrated Service Networks (VISNs). Four of the 61 respondents chose not to disclose their service location.

Outer setting: patients' OtoM needs
Questions related to the outer setting CFIR construct included those asking about Veterans OtoM needs and resources. Audiologists were asked approximately how many patients in their monthly caseload were receiving a platinum-based chemotherapy and/or radiotherapy. Appendix C shows the relative frequency distribution for this question. Over 70% of respondents reported that they saw fewer than 5 patients a month receiving cisplatin or carboplatin, and more than half also saw fewer than 5 patients a month receiving oxaliplatin or radiation.
Respondents were also asked what percentage of their patients experienced new or increased hearing loss, tinnitus, balance changes, or decreased quality of life because of an ototoxic agent. The reported presentation and impact of ototoxicity symptoms varied substantially. Despite a large range in responses, respondents indicated similar median incidence of new or increased tinnitus (20%), balance problems (17%), and hearing loss (18%) in their OtoM caseloads. Finally, the respondents reported that 29% of their OtoM patients experienced reduced quality of life due to the ototoxic impacts of their cancer treatment. These estimates can be seen in greater detail in Appendix D. When asked about their knowledge regarding the expected prevalence of ototoxicity, estimates for cisplatin were as low as 5%. On average, respondents indicated a lower ototoxicity symptom prevalence for cisplatin and carboplatin than reported in a large meta-analyses of treated patient cohorts [9].

Inner setting: healthcare system/facility structural characteristics
The inner setting domain includes questions on the tasks that providers perform related to OtoM and the prioritization of ototoxicity monitoring. Table 2 shows a summary of what aspects of ototoxicity monitoring respondents routinely perform including baseline evaluation, monitoring hearing during treatment, and performing a follow-up exam after cessation of treatment. About half (39-64%) of respondents indicated "yes" to routinely performing all aspects of OtoM for cisplatin and carboplatin and "sometimes" or "no" for oxaliplatin and radiation. Responses to this question also displayed some differences between the responses of audiology chiefs/leads and the responses of their staff. Most audiology chiefs reported no implementation of key OtoM services for oxaliplatin and radiation, whereas audiologists' responses varied more and indicated partial or full implementation for some services. Table 2 also shows respondent's self-assessment regarding whether they routinely screen for tinnitus, and vestibular changes. As compared with hearing and tinnitus testing, balance testing was less often fully implemented.
Several questions asked about team member responsibilities for aspects of OtoM. As shown in Fig. 2, the distribution of responses to question 17 reveals that many audiologists consider it part of their scope of practice to inform patients about the risks of ototoxicity, but only in a supporting role and look to oncologist to take the lead in these discussions. There was also a lack of alignment regarding who should communicate results of ototoxicity monitoring to the patient and be responsible for monitoring patientreported ototoxicity symptoms. In a separate question about how patients access OtoM in a respondent's facility, 89% of respondents indicated that the oncology team provides the referral (Appendix G).

Individuals involved: providers' experience, knowledge, and beliefs about OtoM
Survey respondents ranked hearing loss and balance dysfunction as the most and second most important non-lethal cancer treatment side effects to manage, respectively (Appendix F). These symptoms ranked higher than the ototoxic symptom of tinnitus and toxicities related to other body systems, though this may reflect a bias related to the survey audience. Respondents were asked to rate the importance of various factors for OtoM scheduling including cost, feasibility, patient health status, patient preference, and the ability of tests to impact rehabilitation or treatment. Responses are shown as stacked relative frequencies (percentages) in Fig. 3. The relevance of test results to rehabilitation and to the cancer treatment plan, and patient's current health status were all rated as important or very important by about 80% of respondents. In contrast, cost was rated as not important or neutral by nearly 90% of respondents. Notably, audiologists rated feasibility as less important than all factors other than cost.
Respondents were asked to indicate the appropriate monitoring schedule for ototoxic medications based on drug type. Figure 4 shows that all respondents believed that some form of monitoring was needed for each ototoxic treatment except radiation. In addition, respondents were asked to rate the usefulness of different aspects of OtoM. Figure 5 displays stacked relative frequencies for each aspect of this question. Performing a baseline evaluation was rated as very useful to extremely useful by 100% of respondents, and approximately 97% of respondents rated the early detection of ototoxic effects as very useful to extremely useful. The only element that was rated as extremely useful by less than half of participants was at-home ototoxicity screening.

Barriers associated with OtoM
When asked about the main barriers associated with OtoM implementation, respondents cited several including factors related to interdisciplinary communication (e.g., lack of collaboration between audiology and oncology), identifying patients (e.g., limited strategies to identify at-risk patients that should be included in their caseload), resources, and the Table 2 Level of implementation of OtoM clinical objectives. For each clinical objective, the possible responses, "Yes," "Sometimes," and "No," were interpreted as "Fully implemented," "Partially implemented" and "Not implemented" for the purposes of estimating the level of implementation for a given audiologist or audiology service. Responses were elicited by ototoxic exposure type. Numbers and percentages of respondents are tabulated separately for clinicians versus service chiefs/leads absence of national protocols. Table 3 shows select quotations related to each of these themes.

Discussion
This survey study was conducted to characterize OtoM service gaps and barriers to care across the VA healthcare system from the audiologist's perspective, with a focus on care provision for patients prescribed platinum-based chemotherapies and/or radiation for the treatment of cancer. The provision of OtoM is generally not standard practice for cancer patients despite the high rates of ototoxicity associated with platinum-based chemotherapy, the known adverse effects of ototoxicity on QoL, and the existence of position statements from medical professional organizations advocating OtoM [e.g., 26,44]. The OtoMIC survey provided in Appendix A delivered useful information that, when combined with perspectives of VA oncology teams and patients, will facilitate our long-term goal to provide OtoM as a standard of care in the VA health care system. The aggregated survey results indicate that audiology providers in the VA believe certain aspects of OtoM are "extremely useful" or "very useful" for patient's receiving platinum-based drugs, and that some form of monitoring is necessary for this population. However, only about half of respondents reported having fully implemented these valued OtoM services for highly ototoxic, cisplatin, and carboplatin-containing chemotherapies. The most frequently reported barriers to implementing OtoM were a lack of integrated interdisciplinary care, referral issues, no standardized protocol to guide care, and insufficient resources. Lastly, there were inconsistencies in the respondents' knowledge  regarding ototoxicity symptoms, and differing opinions about the responsibilities of audiologists and oncologists for OtoM care. Audiologists were primarily deemed responsible for monitoring hearing during treatment and providing patients with hearing aids and rehabilitation, but the oncology team was considered the main source for informing patients about the risks of ototoxicity, monitoring patientreported symptoms, counseling patients who develop ototoxicity, as well as referring patients for OtoM services.
The CFIR constructs used to guide each stage of this research were those that Damschroder et al. [36] determined through a meta-analysis to be most valuable for informing successful healthcare interventions. The CFIR outer setting indicates that implementing a clinical intervention requires an established patient need and prioritization among the clinical providers and organizational partners. This consensus is typically determined by rigorous evidence-based research; efficacy, and especially effectiveness data for the intervention program are particularly useful for influencing policies and budget decisions [45]. To date, such data are limited for OtoM [34,44], highlighting a crucial need for future research in this area. The CFIR inner setting stipulates Fig. 4 When to monitor for ototoxic hearing loss by ototoxic exposure type (columns). The numbers and color gradation in each panel indicate the percentage of respondents that selected a given symptom surveillance option (rows). N = 47

Fig. 5
Baseline hearing evaluation, ototoxicity early detection, and management of ototoxic effects after treatment were considered the most useful aspects of ototoxicity management. This plot illustrates by shading type, the relative importance of various OtoM objectives (rows). N = 46 that the perspectives of healthcare providers are important to understand and consider when developing and implementing a clinical intervention because of the context these insights provide for why a protocol works or does not work. Additionally, provider perspectives can identify implementation characteristics of low or high value [37]. The findings of this study add to the available literature on healthcare providers' perspectives on ototoxicity and its management. The CFIR characteristics of individuals revealed audiologists' limited knowledge about the prevalence of ototoxicity, which highlights the need for additional education in this area.
The variation in the audiologists' perspectives on when ototoxicity should be monitored may reflect the need to expand and refine existing guidance on OtoM protocols [26,32]. Patient narratives [46] and data from a small clinical trial [34] indicate that patients value being able to access hearing healthcare during treatment with an ototoxic therapy and will follow-up to obtain new hearing aids or hearing aid adjustments. However, the clinical trial results revealed significant barriers to patients accessing OtoM in VA and suggest that a screening approach may help overcome some of these barriers [34]. In the general population, providing a hearing screen that demonstrates what sounds an individual cannot hear, is crucial for motivating a person with hearing loss to address their hearing healthcare needs [33,47,48]. The audiologists surveyed did not perceive hearing screening as a highly valued aspect of OtoM, indicating that probing to obtain further information about this perspective is needed to inform OtoM delivery methods. Additional outcome data in support of specific OtoM protocols and delivery methods will be crucial for refining and standardizing OtoM.
Survey results further indicate that barriers such as unclear referral pathways are exacerbated by a lack of confidence that oncology teams would value and utilize information about ototoxicity in their patients. Audiologists also point to the need for alignment across audiology and oncology care providers regarding their responsibilities for OtoM. While results indicated a small number of "unsure" responses, more respondents indicated that no provider was specifically assigned to key tasks or that multiple providers were. This underscores the need for interdisciplinary discussion, and perhaps formalized agreements, between care teams to clarify roles for different elements of OtoM. This could ensure that patients do not miss key opportunities to improve their long-term hearing, tinnitus, and balance outcomes.
Approximately 14 studies from five of the six global regions defined by WHO have collected patient data or surveyed health care providers on aspects of OtoM implementation in cancer patients. A list of these publications can be found in Appendix H with descriptions of methods and brief summaries of OtoM program prevalence and service gaps. Results of the present study are generally consistent with the results of these studies which collectively indicate that across the globe, ototoxicity is not consistently monitored or addressed, and that the burden is often placed on the patient to self-advocate for the recommended hearing healthcare. Barriers noted in these studies include a lack of communication and collaboration between audiology and oncology or primary care departments, oncology or primary care not prioritizing or referring patients for OtoM, lack of oncology provider knowledge of ototoxicity and its adverse effects, and a paucity of accepted protocols and trainings pertaining to OtoM. Themes related to facilitators also emerge from these studies including models of care that provide OtoM at the convenience of the patient (e.g., flexible scheduling of audiology appointments [44], hearing screening in the hospital infusion unit [34]).
Understanding how OtoM fits into the VA can inform integration into other healthcare systems and structures; however, applying similar analyses will be necessary to identify locally available resources and barriers to care in the many other contexts in which patients are treated with ototoxic drugs. The VA survey respondents may have been biased toward those who prioritize OtoM, in which case actual care gaps could be greater than indicated in this report. The current report also is limited to the VA audiology community. Ongoing work for this project includes surveying VA oncology teams (oncologists, oncology nurses, pharmacists, and patient coordinators). A better understanding of what purpose OtoM serves for the oncology team will be crucial for better integrating OtoM into oncology care. This report does not provide any data on the perspectives of patients receiving OtoM, a necessary element to ensure the care is relevant and valuable for the patient and to increase buy-in from a multidisciplinary team of providers as well as organizational leadership.

Conclusion
The OtoMIC survey provides stakeholder perspectives to benchmark and address OtoM care gaps. The implications of this report add to the growing body of evidence that shows OtoM is not consistently provided for cancer patients across clinical settings, healthcare structures, and global regions. Perspectives from VA audiologists gained through this nationwide survey have clarified factors that are barriers to implementing OtoM in the largest organized healthcare system in the USA [41]. Collaboration between oncology and audiology is required to address shortcomings in current OtoM practices so that cancer survivors can have more control over their long term hearing health. OtoM can ideally provide education and counseling to bolster a patient's healthcare literacy regarding ototoxicity, symptom surveillance for early detection of ototoxicity to inform cancer treatment decision making, rehabilitation to mitigate the effects of any unavoidable ototoxicity on quality of life, and strategies to address every-day communication difficulties.
Acknowledgements The authors thank Jayden Sarabia for assistance reviewing literature and compiling tables; and the Department of Defense Hearing Center of Excellence, Pharmaceutical Interventions for Hearing Loss, Ototoxicity Committee for allowing us to use some questions from their unpublished survey. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Veterans Health Administration or the United States Government. Authors DK-M, RD, ST, AG, TM and KC are members of the International Ototoxicity Management Group (IOMG). This manuscript is intended to align with the IOMG mission and views regarding effective ototoxicity management (https:// www. ncrar. resea rch. va. gov/ Clini cianR esour ces/ IOMG. asp#: ~: text= Natio nal% 20Cen ter% 20for% 20Reh abili tative% 20Aud itory% 20Res earch ,% 28NCR AR% 29% 20Int ernat ional% 20Oto toxic ity% 20Man ageme nt% 20Gro up% 20% 28IOMG% 29).
Author contributions All authors substantially contributed to the conception and design of the study, data analysis, data interpretation and the drafting of the manuscript. All authors approved the final version of the manuscript. DKM is responsible for the overall content of the manuscript

Declarations
Competing interest Dawn Konrad-Martin is listed as a co-inventor on a patent for a portable hearing test and testing device. The other authors declare no potential conflicts of interest.
Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the VA Portland Healthcare System/Oregon Health and Sciences University joint institutional review board, IRB (01/22/2020).

Consent to participate
The IRB granted a waiver of informed consent for this study because the survey participation was considered minimal risk and anonymous.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.