Abstract
Penile cancer is a relatively rare cancer globally. The cancer itself and its surgical excision can have detrimental physical and psychosocial implications on patients. Patients can share assessments of their health and quality of life using patient-reported outcome measures. These questionnaires are associated with more dynamic, patient-centred clinical decision-making, better patient symptom control and reduced need for hospitalisation. There is a drive for increased implementation and digitalisation of patient-reported outcome measures, especially in surgical settings, to allow real-time monitoring and adjustment of patient management. Consequently, this narrative review provides a contemporary exploration of the usage of patient-reported outcome measures in patients with penile cancer.
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Introduction
Penile cancer (PeCa) is a rare genitourinary malignancy that accounts for less than 1% of male cancers in the United States of America (USA) and the United Kingdom (UK) [1]. However, PeCa is more common in lower-income regions and countries such as South America and South Africa [2, 3]. The most common type of PeCa is squamous cell carcinoma and it is often diagnosed in men over 50 years old. Most risk factors for PeCa are acquired and include phimosis, poor genital hygiene, immunosuppression, smoking, human papillomavirus (HPV), chronic genital inflammation, and absence of childhood circumcision [4]. PeCa is generally treated with surgery. Varying degrees of excisions are used to remove the cancer and hopefully improve a patient’s prognosis [5, 6]. PeCa that has spread to inguinal lymph nodes (ILN), as is characteristic, or has distant metastasis may be treated with additional inguinal lymph node dissections (ILND), chemotherapy, and radiotherapy [7,8,9]. While treatment for PeCa is often associated with good oncological outcomes, it can leave patients with profound functional and psychosocial sequelae [10,11,12]. For this reason, organ-sparing surgery (OSS), where the aim is to remove as much cancer as possible whilst preserving as much penis as possible, has become increasingly popular however it is not appropriate for every patient and their cancer [13].
Patient-reported outcome measures (PROMs) are assessments of a patient’s health status provided directly by the patient without clinician involvement [14]. PROMs are employed to screen and track symptoms, enabling timely patient triage and facilitating collaborative decision-making among clinicians from different specialities [14]. Hence, they are prevalent in oncology and rising in prominence in other medical and surgical specialities [15, 16]. The correct usage of PROMs is associated with enhanced patient self-advocacy, stable symptom management, increased long-term survival, and reduced hospitalizations [17,18,19,20].
It is vital to understand and encourage PROM usage in PeCa due to this cancer’s distinct physical and psychosocial effects on patients [21]. However, there is a lack of PROM usage, research, and education in PeCa compared to other conditions and diseases [16]. Consequently, this article aims to provide a narrative review of PROMs in patients with PeCa. To do this, a search of premier electronic databases was carried out and relevant articles have been reported and discussed. Collating this literature will hopefully lead to more clinical, academic, educational, and governance interest in PROM usage in PeCa.
Methods
A narrative literature review was performed by searching premier electronic databases - PubMed, Web of Science Core Collection and Cochrane Database of Systematic Reviews. The search strategy employed predefined terms relating to PeCa and PROMs including paper and electronic forms. The MeSH terms used were “penile cancer”, “patient-reported outcome measures”, and “outcome assessment, health care”. The scope of this narrative literature review aimed to provide a contemporary overview of PROMs in PeCa rather than answer a specific question related to existing literature. Therefore, strictly following the preferred reporting items for systematic reviews and meta-analyses was not within this study’s scope [22]. The inclusion criteria of screened studies included primary research articles that discussed PROMs in patients with PeCa, regardless of the setting or the PROM questionnaire used. Eligibility was not affected by the date of publication or language. Reference lists and citations were examined for further eligible articles. Reviews and other secondary research were excluded during the screening for primary research and original however secondary research was cited and discussed where appropriate. The included original articles are deductively grouped, reported, and discussed in this manuscript.
Results
Patient-reported outcome measures in penile cancer
Fifteen original studies utilised PROMs in PeCa (Table 1) [11, 12, 23,24,25,26,27,28,29,30,31,32,33,34,35]. The median cohort size of these articles was 36 (range: six to 141). These articles were published in 12 journals from 1994 to 2024. Ten articles used known questionnaires alone and the other five articles used a novel questionnaire alongside known questionnaire(s). Only one of these articles used ePROMs. Eight articles utilised a questionnaire(s) that targeted the holistic management of PeCa. Six articles used questionnaires aimed at the functional complications of PeCa. A single article used questionnaires only aimed at psychosocial concerns. Reviews, short commentaries, and letters discussing PROMs in PeCa were cited and discussed in this review.
Sexual function
A key consideration of managing PeCa is the functional outcome of patients who undergo surgery [36]. PROMs are an excellent tool for recording baselines and monitoring symptom changes over time [18]. One of the most common questionnaires used in studies to assess sexual function was The International Index of Erectile Function (IIEF) [37]. The IIEF is a validated and globally used PROM that measures male sexual function, with a focus on erectile and orgasmic function, sexual desire intercourse satisfaction and overall satisfaction [37, 38]. There is a shortened form of the questionnaire, the IIEF-5, and the full form, the IIEF-15 [39]. Notably, the IIEF is not specific to or validated for PeCa. Various conditions and different aetiologies, including psychological causes, may alter male sexual function and their effects may be measured by the IIEF [40]. van Kollenburg et al. [41] validated electronic versions of the IIEF questionnaires however electronic IIEF questionnaires were not identified in the studies included in this narrative review [41].
Many of the included studies utilised the IIEF to measure post-operate sexual function in PeCa [11, 25, 26, 29,30,31, 33,34,35]. A prospective study by Croghan et al. [26] showed that patients who underwent radical glansectomy (n = 14), where all the glans tissue is removed, had similar postoperative IIEF-5 scores (15.8 vs 14.9) compared to patients who had partial glansectomy, where only some of the glans tissue is excised (n = 11) [26]. This suggested that erectile function between both treatment groups was similar post-operatively. A multicentre study by Pérez et al. (2020) also reported that patients (n = 12) who underwent partial penectomy, the removal of a portion of the entire penis, had similar post-operative IIEF-5 scores compared to patients who underwent OSS (n = 20) [30]. In Croghan et al.’s study [26], the mean overall score of radical glansectomy patients was lower (4.4 vs 6.33) than partial glansectomy patients [26]. Moreover, the mean overall change in overall satisfaction pre- and post-operatively was more statistically significant in radical glansectomy patients compared to partial glansectomy patients (3.57 vs 2.08). Pérez et al.’s study [30] found no significant difference in the health-related quality of life between the partial penectomy and OSS groups [30]. Hence, the findings of the aforementioned studies suggest that more radical penile excisions may have a more negative impact on sexual satisfaction but the overall sexual function and quality of life of patients may be similar [26, 30].
Zimmermann et al. [35] utilised a novel, non-validated 14-item visual analogue questionnaire to compare pre and post-operative sexual and urinary function in patients with PeCa [35]. The questionnaire items were demographical and clinical. Most of the clinical questions were on sexual function, particularly erection quality and sexual satisfaction. There were only two non-specific questions on urinary function, limiting the questionnaire’s ability to measure urinary function. Patients were given the novel questionnaire post-operatively therefore like other PROMs and questionnaire studies it was prone to recall bias [42]. Patients who underwent partial penectomy (n = 18) and underwent glansectomy (n = 8) reported a mean decrease in both erectile function and sexual satisfaction post-operatively on the novel questionnaire [35]. In partial penectomy patients alone, this decrease in erectile function and sexual satisfaction was statistically significant which suggested that these outcomes were more clinically relevant in partial penectomy patients compared to glansectomy patients. Zimmermann et al.’s novel questionnaire [35] was not validated by psychometric or other known means [35]. However, the study further investigated post-operative sexual function in this patient cohort through the validated IIEF tool although the version wasn’t reported. Post-operative scores of IIEF were measured and collated then compared across the treatment groups. Partial penectomy patients (with or without the following reconstruction) had the lowest IIEF score (13.7). This was significantly lower than the glansectomy group (19.4, p < 0.05). Overall, Zimmermann et al.’s study [35] suggested that the OSS preservers sexual function compared to more radical surgical options [35].
Other original studies that were included in this current review agreed with Zimmermann et al.’s conclusions [35]. Preto et al. [31] displayed that after total glans resurfacing (OSS) over 80% of patients with PeCa (n = 21) reported maintained glans sensitivity and an improvement in quality of life [31]. Moreover, there was no statistically significant decrease in sexual function as measured by the IIEF (version not specified) [31]. Scarberry et al. [34] performed a retrospective study that investigated the functional outcomes of PeCa patients who underwent OSS. Sexual outcomes were measured by the IIEF-15 [34]. The sample size was small (n = 6) and three patients reported erections with normal rigidity [34]. The other three patients reported moderately to severely reduced erectile rigidity and no sexual desire. Of note, the patients with reduced erectile rigidity were much older. Interestingly, five of the six patients claimed that their sexual symptoms did not interfere with their daily lives. All patients reported being satisfied with their operation. Chaubey et al. [25] carried out a retrospective observational study which showed that patients who underwent partial penectomy (n = 32) had significantly decreased erectile function, orgasm, and overall satisfaction post-operatively as measured by the IIEF-15 [25]. In Kieffer et al.’s questionnaire study, partial penectomy patients reported more problems with orgasm than patients undergoing OSS also measured by the IIEF-15 [29]. Cakir et al. [24] described a novel coronal-sparing glans resurfacing technique in PeCa patients (n = 8). The median post-operative IIEF-5 score was 20, the cutoff for normal erectile function, again suggesting OSS, including atypical approaches, are associated with better sexual function [24]. The collective consensus of these studies suggests that PeCa patients have better outcomes of sexual function following OSS compared to more radical surgery.
The IIEF was not the only tool used to measure sexual function. Other known and novel questionnaires were employed to assess sexual function in PeCa patients. A cross-sectional study by Harju et al. [27] investigated the treatment-related quality of life in Finnish PeCa patients (n = 107) compared to the general population [27]. To measure the sexual function of PeCa patients, Harju et al. [27] employed the Overall Sexual Functioning Questionnaire, the Erection Hardness Score (EHS), and self-reported changes in sexual functioning [27]. The Overall Sexual Functioning Score is a non-validated questionnaire that measures sexual interest, activity, and relationships. The EHS is used to measure erection hardness and is validated for post-radical prostatectomy following prostate cancer. The EHS and Overall Sexual Functioning Score have not yet been validated for patients with PeCa to the best of the authors’ knowledge.
Harju et al.’s [27] cross-sectional study showed that lower scores and decline in overall sexual function and low scores in erectile function were associated with health-related quality of life (HRQoL) and age [27]. The HRQoL of Finnish PeCa patients was statistically significantly lower than the general Finnish population used in Harju et al.’s study [27], probably due to the psychosocial complications associated with PeCa and its treatment [21, 27]. Previous studies concluded that patients with PeCa who undergo more radical surgery, like partial or total penectomies, are more likely to have a lower quality of life due to poor sexual function [33, 43, 44]. Together the literature suggests that patients undergoing radical surgery for PeCa should be informed of the associated sexual outcomes and be offered psychosocial support. IIEF and other PROMs may be used to track and manage symptoms over time however they are not specific to PeCa.
Urinary function
Urinary function is another key element of management in patients with PeCa. The International Prostate Symptom Score (IPSS) is a widely used 7-item PROM that measures lower urinary tract symptoms (LUTS), for instance, urinary frequency and urgency, and quality of life [45]. The anatomical position of the prostate means that the disease processes of this organ lead to LUTS [46]. The IPSS is primarily validated in patients with benign prostate hyperplasia (BPH) however the PROM is also utilised to measure urinary function in other prostatic diseases such as prostatitis and prostate cancer [47, 48]. The IPSS has not been validated for patients with PeCa.
Studies have displayed that, as expected, OSS for PeCa does not appear to significantly impact urinary function [26, 29, 31]. Preto et al. [31] observed no deterioration in urinary function measured by the IPSS and a 5-item “ad hoc” telephone questionnaire in PeCa patients [31]. Croghan et al. [26] revealed that PeCa patients who underwent partial (n = 15) and radical glansectomy (n = 18) had similar pre- and post-operation urinary voiding satisfaction, as measured by a novel urinary questionnaire that used a Likert Scale [26]. However, partial penectomy patients (n = 2) had a significant decrease in urinary voiding satisfaction post-operatively, despite reporting excellent satisfaction pre-operatively [26]. Kieffer et al. [29] used a novel questionnaire to compare urinary function in PeCa patients who underwent partial penectomy or OSS [29]. The findings of Kieffer et al.’s [29] study displayed poorer urinary function and life interference in PeCa patients who underwent partial penectomy compared to patients who received OSS [29].
Other validated questionnaires for urinary function, such as the visual prostate symptom score, were rarely used in PeCa literature [30, 49, 50]. Pérez et al. [30], however, conducted a multicentre study that utilised the International Consultation on Incontinence Modular Questionnaire for Male Lower Urinary Tract Symptoms (ICIQ-MLUTS) to measure urinary function in PeCa patients (n = 32) [30]. PeCa patients who had undergone glans resurfacing (n = 14), glansectomy (n = 6) or partial penectomy (n = 12) reported a mild change in urinary symptoms, as measured by the ICIQ-MLUTS. Moreover, there was no statistically significant difference in the urinary function between glans resurfacing, glansectomy, or partial penectomy patients.
Overall, studies that used urinary function PROMs in PeCa patients suggest that patients who undergo more radical surgeries, such as penectomies, may suffer more urinary complications however more studies with a larger sample of penectomy patients are needed to explore and confirm this observation.
A limitation of the IPSS and other validated or novel questionnaires urged patients to report voiding and irritable symptoms, among other LUTS however these PROM questionnaires rarely sought information about additional urinary symptoms that could indicate other postoperative complications. For example, changes in urine colour or dysuria may suggest postoperative bleeding or urinary tract infection [51]. It is important to understand post-operative urinary complications in PeCa patients to appropriately guide patients and clinicians during the decision making process.
Adegboye et al. [23] published an article that reported on the development and feasibility of a novel to-be-validated electronic patient-reported outcome measure (ePROM) questionnaire that included questions on sexual and urinary function, as well as the quality of life [23]. This novel ePROM included questionnaire items such as blood in urine and urinary colour, symptoms which may be overlooked. The key findings displayed that ePROMs, when utilised correctly, can improve patient outcomes, foster patient-clinician partnerships and offer real-time tracking of patients’ symptoms. Importantly, Adegboye et al. [23] identified that while ePROMs may be viable in patients with PeCa, elderly patients are less likely to adhere to using electronic interfaces therefore patient education is needed in addition to further validation and research.
Psychosocial impact and quality of life
Adegboye et al.’s [23] ePROM questionnaire used the EuroQoL EQ-5D-5L (EQ-5D) tool to measure the quality of life in patients with PeCa [23]. The EQ-5D is a descriptive measurement of a patient’s quality of life in the 5 domains of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [52]. The EQ-5D has been used in several cancer groups but few studies concerning PeCa [30, 53]. Adegboye et al. [23] displayed that patients who underwent total penectomy (n = 10) reported greater issues with their mobility, usual activities, and pain/discomfort compared to patients who underwent partial penectomy (n = 103) and circumcision (n = 23) as measured by the EQ-5D [23, 52]. Moreover, the results showed a positive correlation between worse quality of life within the EuroQoL domains and increased symptom occurrence, displaying that the physical and psychosocial burden of PeCa patients is interconnected. Adegboye et al’s [23] ePROM also employed a visual analogue scale measured from 0 (worse health) to 100 (best health). This revealed that total penectomy patients reported a worse median quality of life scale, 68.50 (8–99), compared to partial penectomy patients, 76.0 (10–99), and circumcised patients, 72.0 (37–94) [23]. Pérez et al. [30] utilised the EuroQoL EQ-5D-3L (5D-3L) tool, which is less sensitive than the EQ-5D, to explore HRQoL in PeCa patients (n = 32) [30, 54]. Their results displayed that there was no statistically significant difference in HRQoL of life between PeCa patients who underwent glansectomy (n = 6), glans resurfacing (n = 14), or partial penectomy (n = 12) [30]. Kieffer et al. [29], akin to Pérez et al. [30], found few differences between HRQoL in PeCa patients (n = 90) who had undergone partial penectomy or OSS, as measured by the 36-item short-form (SF-36) [29, 30, 55]. Of note, neither of these two studies included PeCa patients who had undergone total penectomy. Altogether, the literature suggests that PeCa patients who undergo total penectomy have a poorer quality of life however further studies with a larger cohort of these patients are needed to understand their psychosocial burden.
The European Organisation for Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) was the most utilised tool to measure the quality of life of patients with PeCa in the literature [12, 25, 26, 28, 32, 56, 57]. The EORTC QLQ-C30 is a 30-item PROM questionnaire that measures eight symptoms (fatigue, pain, nausea/vomiting, constipation, diarrhoea, insomnia, dyspnoea, appetite loss) and five functional domains (cognitive, emotional, physical, social, role) as well as financial impact and global overall health [58]. Sosnowski et al. [32] performed a retrospective study including PeCa patients treated by circumcision/wide local excision (WLE) (n = 13), partial penectomy (n = 27), and total penectomy (n = 11) [32]. The results of Sosnowski et al.’s [32] study suggested that global overall health and physical function, as measured by the EORTC QLQ-C30, were negatively correlated with the aggressiveness of surgery [32]. Total penectomy patients included in this study were found to have worse global overall health and physical function than partial penectomy patients, and partial penectomy patients had worse outcomes than circumcision/WLE patients [32]. Sosnowski et al. [32] study indicated the PeCa patients treated with total penectomy (n = 10) had a significant decline in sex life and overall quality of life, measured by the EORTC QLQ-C30 [12]. Sosnowski et al.’s [12, 32] results were similar results to Adegboye et al.’s [23] prospective study, which displayed that poorer quality of life and increased symptom occurrence (decreased sexual and urinary function) were more common in total penectomy patients compared to partial penectomy or circumcision patients [12, 23, 32].
A limitation of many PROMs and research studies involving patients with PeCa is the lack of questions regarding male genital/body image. Croghan et al. [26] was one of few original studies to include a validated questionnaire that measured the impact of male genital image in PeCa patients. [26] This was a version of the Index of Male Genital Image (IMGI), a 14-item questionnaire that measures male perception of their genitals [59] Other studies have discussed male genital image in the context of PeCa patients and its implications on masculinity and well-being [60,61,62] Male genital appearance is associated with self-esteem and sexual identity, which can influence quality of life [63]. The most widely used questionnaire to assess this impact is the Male Genital Self-Image Scale (MGSIS-5) [64]. The MGSIS-5 has been validated across a wide age range of adult males and in different cultures and languages [64, 65]. PeCa clinicians and researchers should consider developing and validating an appropriate, validated questionnaire for genital appearance in PeCa patients.
Adjunct and alternative therapies in penile cancer
Another limitation of PROMs, both known and novel, is not including and overlooking the significance of adjunct or alternative therapies used in the management of PeCa. Chemotherapy, radiotherapy, and groin surgery are the other commonly used management options in PeCa aside from surgical excision. The European Association of Urology recommend neoadjuvant chemotherapy (NAC) as the first-line treatment for PeCa with bulky nodal disease [6]. A pooled results of a recent meta-analysis showed that approximately 50% of patients with locally advanced PeCa respond to platinum-based NAC and about 16% of patients achieve full pathological response [66, 67]. NAC may potentially improve the prognosis and health of PeCa patients therefore affecting their PROM responses. On the other hand, there are side effects and complications associated with NAC that may affect PeCa patients’ health [68]. For instance, haematological toxicity, cardiotoxicity and alopecia [68]. Similarly, while radiotherapy is attended to shrink locally advanced PeCa and improve prognosis, radiotherapy can cause complications [69]. Complications may be local, such as skin irritation or urethral stenosis, or systemic, such as fatigue [70]. The associated benefits and complications of chemotherapy or radiotherapy may affect sexual and urinary function therefore it would be relevant for PROMs to understand the role of these therapies in PeCa patients’ management.
Involvement of ILN is the most important prognostic factor in PeCa – the greater the number of affected ILN, the worse the overall survival [71, 72]. Groin surgery or ILND intends to remove affected ILN and improve prognosis. ILND is usually preceded by sentinel lymph node biopsy (SLNB), a less invasive diagnostic technique that minimises morbidity, since ILND itself is associated with complications, arguably the most important being lymphoedema [73,74,75]. Lymphoedema, akin to PeCa, is associated with its unique challenges related to function, cosmesis and mental well-being [76, 77]. Significant life adjustments may be needed to treat lymphoedema including compression therapy and surgical intervention [78, 79]. Consequently, it is important for PROMs aimed at PeCa patients to categorise and explore ILND including associated benefits and complications.
Discussion
This narrative literature review provides a necessary up-to-date overview of the use of PROMs in patients with PeCa. PROM questionnaires have assessed the function and quality of life, including psychosocial impact, on PeCa patients. Importantly, this review has highlighted the deficit of PROMs to the aesthetic and adjunct aspects of PeCa management, the lack of PeCa-specific questionnaires, and the scarcity of electronic or digital PROMs in a technology-led era.
Understanding the distinctive burden placed on patients with PeCa is vital in improving care. Many PROMs reported in the literature were not specific to PeCa, and less so validated in PeCa patients. For this reason, few PROMs included questions on all aspects of PeCa management such as sexual and urinary function, appearance and self-image, and quality of life and psychosocial impact. There are clear advantages in broad-based PROMs such as the EuroQoL or EORTC questionnaires. They are cost-effective to use and are designed to be utilised in contexts that examine HRQoL [80]. However, there is an argument that PROM questionnaires which explore the functionality of PeCa patients ought to be disease-specific. Basch et al. (2012) recommended that PROMs focus on symptoms unique to specific patient populations [81]. Studies have shown that patients and clinicians are more likely to engage with PROMs when addressing pertinent issues faced by the patient cohort [82]. This may help shape patient-clinician relationships, patient-centred decision-making, and generally contribute to the care of PeCa patients [17].
Despite a global push for further digitalisation of medical care, including digital PROMs there have been few studies that report on ePROMs [83, 84]. To the best of our knowledge, Adegboye et al. [23] is the only study to report the usage of a novel ePROM designed for PeCa patients. [23] The safe and efficient integration of ePROMs in the routine care of patients is associated with significant improvement in symptom control, physical function, and health-related quality of life [83, 84]. The specific benefits of ePROMs, compared to PROMs, are that data can be directly uploaded to the electronic patient records, real-time alerts can be sent to patients and clinicians, and ePROMs be filled in remotely further aiding telemedicine where appropriate [85]. Medicine is advancing, and patients alongside it, and PROMs must mirror this to encourage patient and clinician engagement and adherence.
The authors of this contemporary narrative literature review would like to recommend initiatives that may benefit PROMs in PeCa. Firstly, there needs to be a drive for validating PROMs in PeCa patients. To accurately capture outcomes reported by patients, PROMs need to provide data relevant to this patient cohort which can show significant changes in relevant symptoms. PROMs need to assess the functional, psychosocial, and aesthetic aspects of PeCa management. Adjunct and alternative therapies, such as chemotherapy, radiotherapy, groin surgery, and so on need to be discussed and included in the ideal PROM for this patient cohort. Secondly, existing and new PROMs must endeavour to become digital or electronic. The benefits of implementing accessible and appropriate ePROMs to patients, clinicians, and services are likely significant. When implementing ePROMs, extra education and research are needed to update and renew the service. Cost-benefit and cost-utility analyses may also reveal additional benefits of ePROMs. Finally, PROMs should endeavour to safety net PeCa patients. Male patients may find the topic of PeCa distressing and embarrassing, but it is important to help break down stigma and offer help in case patients do not seek help immediately.
Conclusion
A PeCa diagnosis brings a unique set of physical and psychosocial challenges. To better understand these, a variety of PROMs have been reported in research. However, there is limited literature on the use and validation of PROMs in this specific patient group. Effective PROMs for patients with PeCa should aim to be disease-specific, electronic, educational for all involved, and safe and accessible for patients, clinicians, and healthcare services.
Data availability
Not applicable.
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The authors want to acknowledge the Christie NHS Foundation Trust urological cancer and ePROMs teams for their previous and ongoing work in this field.
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AP and VS led the design of this study. OA wrote the initial manuscript. AP and VS reviewed and supervised this manuscript. All authors approve the final version of the manuscript, including the authorship list and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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The authors recently published a study discussing PROM usage in patients with penile cancer.
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Adegboye, O., Parnham, A. & Sangar, V. Patient-reported outcome measures in penile cancer: a narrative review. Int J Impot Res 37, 751–758 (2025). https://doi.org/10.1038/s41443-025-01031-8
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DOI: https://doi.org/10.1038/s41443-025-01031-8
