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Aim: To assess the relationship between psychological distress and quality of life (QoL), cancer-related fatigue (CRF), and chemotherapy efficacy in advanced gastric cancer patients. Methods: Advanced gastric cancer patients (39 with psychological distress and 35 without psychological distress) completed the Distress Thermometer (DT), QoL, and CRF test before receiving chemotherapy and assessed the efficacy after completing 2 courses of chemotherapy. Results: Psychological distress was a significant factor in the efficacy of chemotherapy in advanced gastric cancer patients (χ2 = 6.324; p = 0.042). Compared to advanced gastric cancer patients with no psychological distress, advanced gastric cancer patients with psychological distress had a poorer QoL (50.41 ± 6.17 vs. 60.01 ± 7.94, t = − 5.882, p < 0.01) and more pronounced CRF (5.75 ± 1.16 vs. 3.22 ± 0.75, t = 11.231, p < 0.01) while receiving chemotherapy. FACT-G (p = 0.0035, r = − 0.4568), as well as PFS (p < 0.0001, r = 0.6599), correlated significantly with efficacy for patients in the psychological distress group. The FACT-G (p = 0.0134, r = − 0.4139) of patients in the no psychological distress group correlated significantly with efficacy. Conclusion: Psychological distress has a negative impact on QoL, CRF, and efficacy and may be a potential risk for the efficacy of palliative chemotherapy in advanced gastric cancer patients. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study was to assess the suffering of patients on oncologic treatment and of those no longer on treatment. Preliminarily, we aimed to confirm the psychometric properties of Edmonton Symptom Assessment System–Total Care (ESAS-TC) in different stages of the disease. The ESAS-TC screens physical and psychological symptoms, but also spiritual pain, discomfort deriving from financial problems associated with illness, and suffering related to social isolation. Methods: A sample of consecutive advanced cancer patients on oncologic therapies treated at the Internistic and Geriatric Supportive Care Unit (IGSCU) of Istituto Nazionale dei Tumori, Milano, and of terminal patients no longer on treatment and cared for by the Fondazione ANT palliative home care team were asked to fill the ESAS-TC. In order to strengthen the previous validation study of the ESAS-TC, 3-ULS (to assess social isolation), JSWBS (to assess spiritual well-being), COST-IT (to assess financial distress), and KPS (to assess functional status) were administered too. Results: The questionnaires were self-reported by 108 patients on treatment (52% >60 years old, female 53%, and 61% with KPS 90–100) and by 94 home care patients (71% >60 years old, female 51%, and 68% with KPS 10–50). The sound psychometric characteristics of ESAS-TC were confirmed. Patients on treatment showed lower total ESAS-TC score (19.3 vs 52.7, p<.001) after controlling for age and functional status, and lower financial distress (p.<001). Financial distress, spiritual suffering, and social isolation, after controlling for age, showed a significantly higher score in home care patients. Conclusions: Only through an adequate routine assessment with validated tools is it possible to detect total suffering, the “Total pain” of patients, and treat it through a multidisciplinary approach. The study confirms the reliability and validity of the Italian version of ESAS-TC and the importance of supportive and early palliative care fully integrated with oncological treatment. [ABSTRACT FROM AUTHOR]

Purpose: This study was designed to investigate the effectiveness and safety of massage therapy in cancer-related fatigue (CRF) and to provide a reference for the future management of CRF. Methods: Eight databases (PubMed, Embase, Cochrane Library, CINAHL, Sinomed, Chinese Scientific Journal database (VIP), Wanfang, and China National Knowledge Infrastructure (CNKI)) were systematically reviewed from inception to May 2022 for randomized controlled trials. Two reviewers critically and independently assessed the risk of bias using Cochrane Collaboration criteria and extracted correlated data using the designed form. The meta-analysis was performed using RevMan 5.3 to calculate the pooled effect sizes and 95% confidence intervals (CIs). Sensitivity analysis was performed to find the source of the heterogeneity. Publication bias was assessed via funnel plot analysis and the Egger test. Result: A total of 11 qualified studies that included 789 patients (massage therapy group: 389; control group: 400) were included in the meta-analysis. Massage therapy had a marked effect on fatigue in cancer patients [standardized mean difference (SMD) = − 1.69, 95% CI (− 2.46, − 0.93), P < 0.01], especially in breast cancer [SMD = − 1.62, 95% CI (− 2.18, − 1.05), P < 0.01]. Reflexology [SMD = − 2.71, 95% CI (− 4.65, − 0.77), P < 0.01] and Chinese massage [SMD = − 1.14, 95% CI (− 1.95, − 0.33), P < 0.01] can have a more significant effect on fatigue. Massage time is 20 to 40 min [SMD = − 2.39, 95% CI (− 4.13, − 0.66), P < 0.01], twice a week [SMD = − 3.46, 95% CI (− 5.47, − 1.45), P < 0.01] for 3–5 weeks [SMD = − 2.36, 95% CI (− 3.53, − 1.19), P < 0.01], which is more effective in relieving fatigue in cancer patients. Five studies described the occurrence of adverse events and only two studies had adverse events. Conclusion: Massage therapy can be effective in relieving fatigue in cancer patients. Current evidence suggests that reflexology is the most effective approach to relieve fatigue, particularly in the breast cancer patients. The optimal intervention frequency and cycle for massage therapy is twice a week for 3–5 weeks, and the optimal duration is 20–40 min. [ABSTRACT FROM AUTHOR]

Purpose: Head and neck cancer (HNCa) presents numerous challenges secondary to treatment. While there is substantial clinical awareness to the range of challenges demonstrated in this population, information on the impact of post-treatment fatigue is limited. This study investigated the degree of perceived fatigue in those treated for HNCa. Methods: The study was a cross-sectional, self-report, survey design. Adult participants (n = 47) completed a series of three questionnaires; two validated fatigue measures – the Fatigue Screening Inventory (FSI) and the Multidimensional Fatigue Inventory (MFI-20) and a general health-related quality of life measure the European Organisation of Research on the Treatment of Cancer – Quality of Life Questionnaire (EORTC-QLQC30) and the head and neck site specific module (QLQ - H&N 35) were administered. Results: Of the 47 participants, more than half (55%) were identified as having clinically significant self-reported levels of fatigue. Correlational analysis revealed an inverse relationship between fatigue and overall health-related quality of life (HRQOL) implying that as fatigue increases, one’s perceived HRQOL decreases. Conclusions: These data suggest that efforts to proactively screen for and index fatigue and seek anticipatory interventions may benefit both short- and long-term HRQOL outcomes in those diagnosed with HNCa. Level of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: To explore psycho-oncologists’ knowledge of cancer-related fatigue and their self-efficacy to intervene for fatigue. We further aimed to examine the role of fatigue in psycho-oncological training and derive specific suggestions for improvements. Methods: For this cross-sectional survey study, psycho-oncologists working in Germany were systematically recruited via an address directory or invited by training institutes or colleagues. The online survey encompassed questions on knowledge of fatigue guidelines and interventions, self-efficacy, counseling, and fatigue in professional training. Data were analyzed descriptively and using Mann-Whitney U tests. A logistic regression analysis was performed to identify variables linked to fatigue guideline knowledge. Results: Seventy two percent of the 144 surveyed psycho-oncologists stated not knowing any fatigue-specific guidelines. Those unaware of guidelines reported a lower self-efficacy to intervene for fatigue. However, despite low knowledge of the guidelines, more than 80% of the participants felt well informed about fatigue and reported high self-efficacy. Most participants were aware of the empirical evidence for psychotherapeutic interventions (95%); everyday physical activity, e.g., taking a walk (98%); yoga (82%); and mindfulness-based interventions (82%). Knowledge gaps existed concerning the evidence of resistance/endurance training for treating fatigue. Knowing that resistance/endurance training is an effective treatment was related to an increased frequency to recommend it to patients. Suggestions to improve training for psycho-oncologists included raising awareness earlier in the career path and offering multidisciplinary trainings for fatigue. Conclusion: To improve fatigue-related guideline knowledge among psycho-oncologists and enhance implementation into clinical practice multidisciplinary trainings are needed. Psycho-oncologists should play an important role in fatigue management. Trial registration: , identifier: NCT04921644. Registered in June 2021. [ABSTRACT FROM AUTHOR]

Purpose: Cancer-related fatigue (CRF) is the most common symptom in cancer patients and may interfere with patients’ daily activities and decrease survival rate. However, the etiology of CRF has not been identified. Diagnosing CRF is challenging. Thus, our study aimed to develop a CRF prediction model in cancer patients, using data that healthcare professionals routinely obtained from electronic health records (EHRs) based on the 3P model and externally validate this model in an independent dataset collected from another hospital. Methods: Between April 2022 and September 2022, a cross-sectional study was conducted on adult cancer patients at two first-class tertiary hospitals in China. Data that healthcare professionals routinely obtained from electronic health records (EHRs) based on the 3P model were collected. The outcome measure was according to ICD-10 diagnostic criteria for CRF. Data from one hospital (n = 305) were used for model development and internal validation. An independent data set from another hospital (n = 260) was utilized for external validation. logistic regression, random forest (RF), Naive Bayes (NB), and extreme gradient boosting (XGBoost) were constructed and compared. The model performance was evaluated in terms of both discrimination and calibration. Results: The prevalence of CRF in the two centers was 57.9% and 56.1%, respectively. The Random Forest model achieved the highest AUC of 0.86 among the four types of classifiers in the internal validation. The AUC of RF and NB were above 0.7 in the external validation, suggesting that the models also have an acceptable generalization ability. Conclusions: The incidence of CRF remains high and deserves more attention. The fatigue prediction model based on the 3P theory can accurately predict the risk of CRF. Nonlinear algorithms such as Random Forest and Naive Bayes are more suitable for diagnosing and evaluating symptoms. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of physical therapy on cancer-related fatigue (CRF) during cytotoxic anticancer treatment. Methods: Systematic review with meta-analysis of randomized clinical trials published from 2010 to 2021 (EMBASE, MEDLINE, PEDro; SciELO, and LILACS). Studies assessing the effect of supervised physical therapy (IG) for the management of CRF on adults undergoing anticancer treatment compared with a control group (CG) covering usual care or any uncontrolled practice, such as recommendations about exercise and health education, were included in this review. Results: A total of 22 studies were included in the SR and 21 in the meta-analysis, resulting in 1.992 individuals (CG = 973 and IG = 1.019). There was a reduction in general fatigue [SMD = − 0.69; 95%CI (− 1.15, − 0.22) p < 0.01; I2 = 87%; NNT = 3], with greater weight attributed to combined exercise (44%). Physical fatigue also reduced [SMD = − 0.76; 95%CI (− 1.13, − 0.39) p < 0.01; I2 = 90%; NNT = 2], with greater weight for resistance exercise (50%) and greater effect with combined exercise [SMD = − 1.90; 95%CI (− 3.04, − 0.76) p < 0.01; I2 = 96%]. There was reduction in general fatigue with moderate intensity (74%) [SMD = − 0.89; 95%CI (− 1.61, − 0.17) p < 0.02; I2 = 90%] and physical fatigue [SMD = − 1.00; 95%CI (− 1.54, − 0.46) p < 0.01; I2 = 92%], while high intensity reduced only general fatigue [SMD = − 0.35; 95%CI (− 0.51, − 0.20) p < 0.01; I2 = 0%]. The number of overall and weekly sessions has been shown to contribute to the reduction of CRF. Conclusion: Physical rehabilitation with moderate intensity promoted greater relief of general and physical fatigue. Even after controlling for high heterogeneity, the quality of evidence, summarized in GRADE, was considered moderate for general fatigue and low for physical fatigue. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the patients' perspective on feasibility of using a fatigue diary and its benefits on self-management.Methods: This longitudinal study enrolled 50 cancer patients in routine care. Following baseline (t0) assessment, patients were asked to complete a 7-day fatigue diary and subsequently obtained written diary evaluation. Feasibility, benefits, and fatigue-related attitudes were assessed via self-report 1 (t1) and 4 months (t2) after distributing the diary. Data were analyzed descriptively and using Wilcoxon signed-rank tests.Results: Most patients (94%) completed the diary for 7 days and rated feasibility as high. After diary completion and receiving the evaluation, fewer patients felt helpless in the face of fatigue (t1: 21% vs. t0: 53%). Additionally, more patients addressed fatigue with their general practitioner (t2: 49% vs. t0: 36%) and pro-actively searched for information and help (t2: 59% vs. t0: 38%). The diary enabled a majority of patients to be aware of their fatigue patterns, to plan daily routines accordingly and to take adequate actions against fatigue.Conclusion: The study showed that symptom monitoring via a fatigue diary was considered feasible and enhanced self-management in cancer patients. Thus, fatigue diaries might be a useful measure contributing to an improved fatigue management. The results reinforce guideline recommendations for routine application of fatigue diaries in clinical care. Healthcare professionals should encourage patients to fatigue diary use and provide individually tailored counseling based on diary entries. [ABSTRACT FROM AUTHOR]

Background and Objectives: The purpose of this study is to determine the risk of constipation and to identify the significant risk factors for constipation in patients with gastrointestinal cancer using the Chinese version of the constipation risk assessment scale (CRAS-C), as well as to explore the complementary constipation risk factors in patients with gastrointestinal cancer, to improve the specificity of the CRAS-C in this population, and finally to provide a theoretical basis for constipation prevention.Research Design and Methods: A cross-sectional study involving multiple centers was conducted. A total of 190 patients with gastrointestinal cancer completed surveys that included demographic information, defecation habits, and the CRAS-C. The mean, SD, median, maximum, minimum, frequency, and percentage were used as indicators for the constipation risk and significant risk factors. The t test and Chi-square tests were used to analyze constipation indicators in patients with gastrointestinal cancer.Results: The mean (SD) age of the 190 participants was 61.68 (12.35) years. The total CRAS-C mean (SD) score was 13.22 (4.69). Fifty-one patients (26.8%) scored lower than 11, who were at the low-risk level of constipation. One hundred thirty-nine patients (73.2%) scored 11 or above, who were at the high-risk level of constipation. The top 10 factors were insufficient liquid intake (81.1%), failure to consume bran products daily (78.9%), insufficient fiber intake (77.9%), antiemetics (74.7%), cytotoxic chemotherapy (52.6%), colorectal/abdominal diseases (42.6%), female (35.3%), opioid analgesics(26.8%), calcium channel blockers (16.3%), and endocrine disorders (14.2%). Chi-square test showed that constipating for most of the past 3 months, ascites and ECOG score were complementary constipation risk factors in gastrointestinal cancer patients.Conclusion: The findings indicate that most gastrointestinal cancer patients were at a high risk of constipation. There are also several complementary constipation risk factors, and CRAS-C can be further revised in future studies to make it more specific in gastrointestinal cancer patients. Integrating CRAS into the pathway of constipation management, carrying out constipation risk screening for hospitalized cancer patients, and building systematic constipation prevention plan based on risk assessment are important to reduce the incidence of constipation in patients with gastrointestinal cancer and improve the quality of life. [ABSTRACT FROM AUTHOR]

Purpose: To identify risk factors for opioid-induced constipation (OIC).Methods: This study retrospectively analyzed 175 advanced cancer patients who were receiving pain treatment with opioids and were newly prescribed laxatives for OIC at Seirei Hamamatsu General Hospital between November 2016 and June 2021. For the regression analysis of factors associated with OIC, variables were extracted manually from clinical records. The effect of newly prescribed laxatives for OIC was evaluated as "effective" in cases where the number of spontaneous bowel movements increased at least once in the first 3 days. The OIC was defined based on Rome IV diagnostic criteria. Multivariate logistic regression analysis was performed to identify risk factors for OIC. Optimal cutoff thresholds were determined using receiver operating characteristic analysis. Values of P < 0.05 (two-tailed) were considered significant.Results: Significant factors identified included body mass index (BMI) (odds ratio [OR] = 0.141, 95% confidence interval [CI] = 0.027-0.733; P = 0.020), chemotherapy with taxane within 1 month of evaluation of laxative effect (OR = 0.255, 95% CI = 0.068-0.958; P = 0.043), use of naldemedine (OR = 2.791, 95% CI = 1.220-6.385; P = 0.015), and addition or switching due to insufficient prior laxatives (OR = 0.339, 95% CI = 0.143-0.800; P = 0.014).Conclusion: High BMI, chemotherapy including a taxane within 1 month of evaluation of laxative effect, no use of naldemedine, and addition or switching due to insufficient prior laxatives were identified as risk factors for OIC in advanced cancer patients with cancer pain. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the effects of exercise training on cancer-related fatigue (CRF) in colorectal cancer survivors. Methods: Randomized controlled trials published between 1 January 2010 and 19 October 2020, selected through online search conducted in PubMed, Scopus, Web of Science, SPORTDiscus and PEDro databases, were included. Eligible trials compared the effect of exercise training interventions, versus non-exercise controls on CRF, in colorectal cancer survivors, during or after treatment. The methodological quality of individual studies was analysed using the Physiotherapy Evidence Database (PEDro) scale. Standardized mean differences (SMD) that were pooled using random-effects models were included as the effect size. In addition, 95% prediction intervals (PI) were calculated. Results: Six trials involving 330 colorectal cancer patients met the inclusion criteria and presented reasonable to good methodological quality. An overall small-to-moderate effect of exercise training on CRF was found (SMD = − 0.29: 95% CI: [− 0.53; − 0.06]; p = 0.01; PI: [− 0.63; 0.04]; low-quality evidence). Subgroup analysis revealed moderate effects of exercise interventions performed during chemotherapy (SMD = − 0.63; 95% CI: [− 1.06; − 0.21]; p = 0.003) and small, non-significant effects, when exercise training was performed after cancer treatment (SMD = − 0.14; 95% CI: [− 0.43; 0.14]; p = 0.32). Steady improvements were achieved when a combination of aerobic plus resistance exercise was used, in interventions lasting 12 to 24 weeks. Conclusion: Exercise training could be regarded as a supportive therapy for the clinical management of CRF in colorectal cancer patients undergoing chemotherapy, but further studies are necessary to clarify the effects of exercise interventions on CRF after cancer treatment. [ABSTRACT FROM AUTHOR]

Purpose: To investigate cancer patients' knowledge and attitudes regarding fatigue and the potential benefits and acceptability of a brief information booklet. Methods: The CARPE DIEM study assessed knowledge and attitudes regarding fatigue in a diverse group of 50 cancer patients before (T0) and about one (T1) and four months (T2) after reading the booklet. At T1, participants additionally rated its usefulness. Results: At baseline, 37.5% of respondents did not know the term "fatigue" or what it meant. Those who already knew something about fatigue mainly had obtained their information from booklets, books, or articles (63.3%) and/or the internet (46.7%). Overall, knowledge gaps existed, particularly about potential fatigue treatment options and whether fatigue is an indicator of cancer progression. Furthermore, 56.4% felt poorly informed, and 46.1% reported feeling helpless in the face of fatigue. Lower knowledge at baseline was significantly associated with lower education and older age. At T1 and T2, there were significant improvements in several knowledge questions and attitudes. Patient-reported benefits included getting new information about fatigue (91.1%), awareness of not being alone with their problems (89.7%), taking appropriate actions (72.9%), and encouragement to talk about their fatigue with family/friends (55.3%) or with a health professional (52.7%). Conclusions: Specific gaps were identified in the provision of information and education for cancer patients about fatigue. A low-cost intervention asking to read a brief information booklet was associated with improved knowledge. This could be considered as a first step offered as part of a bundle of further efforts to improve knowledge and care of fatigue. [ABSTRACT FROM AUTHOR]

Background: Physical exercise in women with breast cancer has shown benefits in reducing fatigue levels during adjuvant radiotherapy and chemotherapy. However, it is not well understood which type of exercise is more effective. Objective: Assess the impact of different types of physical exercises on fatigue and which is the most effective in reducing this adverse effect during adjuvant treatment in breast cancer. Methods: The inclusion criteria were randomized clinical trials of physical exercise in women diagnosed with breast cancer in stages I to IV, above 18 years, evaluating fatigue using validated questionnaires. The meta-analysis pooled results by standardized mean difference (SMD). Results: A total of 20 randomized clinical trials involving 1793 participants revealed that the practice of physical exercise was statistically effective in reducing fatigue (SMD = − 0.46; 95% CI: − 0.66, − 0.27). Our analysis of subgroups suggests that the supervised combination of resistance training (RT) with aerobic training (AT) is the most effective physical exercise to reduce fatigue (SMD = − 1.13; 95% CI: − 2.09, − 0.17). The supervised RT was more effective (SMD = − 0.30; 95% CI: − 0.46, − 0.15) than supervised AT or mind–body techniques. It was observed that only during chemotherapy, women with breast cancer in the intervention groups showed a significant reduction in fatigue (SMD = − 0.38; 95% CI: − 0.55 to − 0.20). Conclusion: Physical exercise during adjuvant chemotherapy and/or radiotherapy in women with breast cancer can be considered beneficial in reducing fatigue, especially for women undergoing chemotherapy and for supervised training of resistance or combined RT and AT. [ABSTRACT FROM AUTHOR]

Introduction: The routine use of patient-reported outcomes (PROs) in clinical practice improves quality of care, it helps in reducing the access to emergency services and unscheduled visits, and it can improve cancer patients' time survival. The Edmonton Symptom Assessment System (ESAS) is a PRO largely used in different care settings to monitor physical and psychological symptoms. Nonetheless, along with these symptoms, literature also highlighted the presence and effect of spiritual pain, financial distress, and social isolation on quality of care, treatment effectiveness, and survival.Aim: The aims of the current study were (a) to complete the Italian version of the ESAS validation process by adding the missing symptom "insomnia" and (b) to develop and validate the ESAS-Total Care (ESAS-TC) that is intended to evaluate and screen not only physical and psychological symptoms but also spiritual pain, discomfort deriving from financial problems associated with illness, and suffering related to social isolation.Methods: A sample of Italian native outpatients, who referred to the dedicated Supportive Care Unit of the Fondazione IRCCS, Istituto Nazionale deiTumori (INT), Milano, were asked to fill the ESAS-TC to assess item properties, factorial structure, internal consistency, test-retest reliability (patients were asked to retake the scale after 2-6 weeks), and external validity. Concerning the latter, other self-administered scales were employed to assess perceived stress (Perceived Stress Scale), unmet needs (using theNeed Evaluation Questionnaire that describes informative, assistance/care, relational, needs for psycho-emotional support, material needs), and perceived social support (administering the Multidimensional Scale of Perceived Social Support that evaluates perceived support of family, friends, and significant others in the wider social field).Results: The scales were administered to 243 patients with solid (90%) and hematologic (10%) cancers, mean age 62.6, female 76.5%. Analysis suggested that a single factor better represents the structure of the ESAS scales, their internal consistency and test-retest reliability were good, and evidence of construct and criterion validity were provided. Additionally, incremental validity of the ESAS-TC was proved showing that the added items offer a unique contribution in predicting the patient's stress. Finally, known groups validity was confirmed testing the differences in the ESAS scores due to the Karnofsky Performance Status.Conclusions: The current study allowed to complete the validation of the Italian version of the ESAS and to develop a psychometrically sound scale, the ESAS-Total Care, that potentially helps in moving cancer research toward personalized total cancer care. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to determine the financial toxicity (FT) level in cancer patients, identify the risk factors associated with this level, and reveal the effect of this level on patient outcomes (health-related quality of life (HRQoL) and treatment non-adherence). Methods: The data of 316 cancer patients, who were receiving inpatient treatment in an oncology hospital affiliated to a public university in Ankara, Turkey, were ≥ 18 years old, and were receiving chemotherapy for at least 3 months, were evaluated. The data were collected through a face-to-face interview. FT was measured with the COmprehensive Score for financial Toxicity (COST) Measure (v2), HRQoL was measured with the Functional Assessment of Cancer Therapy-General (FACT-G) Scale (v4), and treatment adherence was measured using a questionnaire created by conducting a literature review. Results: Patients were found to experience FT above the moderate level (mean ± SD, 21.85 ± 12.02; median value, 24.0). Younger age, being married, low education level, low monthly household income, and receiving social/economic support for treatment were revealed to be the determinants of high FT. Moreover, as the FT score decreased (as the FT level felt increased), the HRQoL was observed to decrease, and treatment non-adherence increased. Conclusion: The results indicate that FT problem is also valid for cancer patients in Turkey despite the system of general health insurance. The FT was found to result from socio-economic characteristics rather than the disease and treatment-related characteristics. The significant associations revealed between FT and patient outcomes emphasize the importance of reducing the FT in cancer patients. [ABSTRACT FROM AUTHOR]