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Cancer survivorship care for post-treatment cancer survivors in Japan: A secondary analysis of a multinational study across Asia–Pacific countries

Open AccessPublished:July 31, 2022DOI:https://doi.org/10.1016/j.apjon.2022.100121

      Abstract

      Objective

      The global understanding of cancer survivorship care leads to optimal care delivery for cancer survivors. This study aimed to assess the perceptions of Japanese oncology nurses regarding cancer survivorship care and explore the factors influencing the provision of survivorship care.

      Methods

      A questionnaire survey of oncology nurses was conducted as part of a multinational, cross-sectional survey. A 29-item measurement scale with four subscales regarding survivorship care was used to assess nurses’ perceptions regarding responsibility, confidence, and frequency of practice for cancer survivors. Additionally, we investigated a list of 16 factors influencing the provision of survivorship care.

      Results

      Among 181 oncology nurses, the mean adjusted scores for survivorship care items were 65.6–84.7, 16.8–44.7, and 29.2–47.2 for responsibility, confidence, and frequency, respectively. Significant correlations were observed in the subscales for frequency of care with responsibility (r ​= ​0.315–0.385, P ​< ​0.001) and confidence (r ​= ​0.428–0.572, P ​< ​0.001). Participants with > 10 years of experience in cancer care reported more frequent performance on surveillance than those with ≤ 5 years of experience (P ​= ​0.03). The major barriers for providing survivorship care by oncology nurses were lack of knowledge and skills (87.8%), lack of time (81.8%), and not seeing the value of survivorship care (79.6%).

      Conclusions

      Oncology nurses face many challenges regarding survivorship care, even though they recognize their responsibility. Educational support for oncology nurses is warranted to overcome impeding factors and improve confidence.

      Keywords

      Introduction

      Asia accounts for 49% of the total cancer cases globally in 2020.
      • Sung H.
      • Ferlay J.
      • Siegel R.L.
      • et al.
      Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
      The burden of cancer also applies to Japan. In 2018, there were 980,856 new cancer cases in Japan suggesting that 50% of women and 65% of men would be diagnosed with cancer in their lifetime.

      Cancer Information Service, National Cancer Center, Japan (National Cancer Registry, Ministry of Health, Labour and Welfare). Cancer statistics. Accessed 26 January, 2022. https://ganjoho.jp/reg_stat/statistics/stat/summary.html.

      Despite being a life-threatening disease, there has been a steady improvement in the survival rate in Japan. According to the population-based registry, the 5-year relative survival rate of patients diagnosed with cancer between 2009 and 2011 was > 60%.
      Center for Cancer Control and Information Services, National Cancer Center
      Monitoring of Cancer Incidence in Japan - Survival 2009-2011 Report.
      ,
      • Matsuda T.
      • Ajiki W.
      • Marugame T.
      • Ioka A.
      • Tsukuma H.
      • Sobue T.
      Population-based survival of cancer patients diagnosed between 1993 and 1999 in Japan: a chronological and international comparative study.
      Additionally, the population-based registry described the 10-year relative survival rates of patients who were followed for ≥ 5 years after diagnosis. The 10-year relative survival rate of patients with cancer who were followed-up from 2002 to 2006 reached 95% for patients having a good prognosis.
      • Ito Y.
      • Miyashiro I.
      • Ito H.
      • et al.
      Long-term survival and conditional survival of cancer patients in Japan using population-based cancer registry data.
      These findings demonstrate the increasing population of cancer survivors, highlighting the importance of cancer survivorship care.
      Increasing interest in cancer survivorship care led to the development of cancer survivorship guidelines in Japan.
      • Matsuoka Y.J.
      • Okubo R.
      • Shimizu Y.
      • et al.
      Developing the structure of Japan's cancer survivorship guidelines using an expert panel and modified Delphi method.
      Additionally, the Japanese version of the Cancer Survivors' Unmet Needs scale was developed to evaluate the unmet needs of cancer survivors.
      • Komatsu H.
      • Yagasaki K.
      • Sato Y.
      • Arao H.
      • Yamamoto S.
      • Hayashida T.
      Evaluation of the Japanese version of the cancer survivors' unmet needs scale.
      However, the delivery of optimal survivorship care remains a significant issue. An international service-mapping study on Survivorship care for patients with cancer after TrEatment completion in the Asia–Pacific Region (ie., the STEP study) was carried out on patients and cancer health professionals from 10 Asia–Pacific countries.
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      The STEP study's survey on healthcare professionals had the following aims: (1) to establish their perceptions of responsibility, confidence, and frequencies of survivorship care practices in relation to the post-treatment survivorship care of patients with cancer and (2) to examine their perspectives on factors that influence the provision of survivorship care. The study revealed different survivorship care practices among the participating countries and across the professional disciplines. Notably, compared to practitioners from other countries, Japanese oncology practitioners reported a lower frequency of survivorship care practice.
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      Moreover, with respect to survivorship care, nurses were more likely to report lower confidence levels in delivering care and lower frequencies of intervention than physicians.
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      Although oncology nurses significantly contribute to all survivorship aspects,
      • Ferrell B.R.
      • Virani R.
      • Smith S.
      • Juarez G.
      The role of oncology nursing to ensure quality care for cancer survivors: a report commissioned by the National Cancer Policy Board and Institute of Medicine.
      they could face challenges related to survivorship care practice.
      Accordingly, we conducted a secondary analysis of data derived from the Japanese oncology nurses who participated in the STEP study. The aim of this study aimed to (1) assess the perceptions of Japanese oncology nurses regarding their responsibility, confidence level, and frequency of practice regarding cancer survivorship care; (2) identify demographic and professional characteristics related to the frequency of survivorship care practice; and (3) to examine the factors limiting the provision of survivorship care. Elucidating the current patterns and practice-related elements among Japanese oncology nurses can help provide further insight to improve comprehensive provisions of survivorship patient care among Asia–Pacific region. This will ensure quality survivorship care in the context of the Japanese culture and health system.

      Methods

      Design

      We conducted a secondary analysis of Japanese oncology nurses who participated in the STEP study.
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      The STEP study involved a multinational, cross-sectional survey of oncology practitioners across 10 Asia–Pacific countries.

      Setting and sample

      Data on Japanese participants were collected from four hospitals that provide systemic anti-cancer therapy or radiation therapy in Osaka and Tokyo, Japan. The sampling frame of the STEP study comprised convenience samples of hospital-based oncology practitioners who provided care to patients with cancer. The inclusion criteria were age > 20 years and spending more than half of the work time providing care to patients with cancer.

      Procedure

      The STEP study in Japan was ethically approved by the institutional review boards of the Faculty of Nursing and Medical Care, Keio University (No. 239), Keio University School of Medicine (No. 20150219), and Osaka University Hospital (No. 15161). The research team or nominated clinical nurses invited potential participants via email or face-to-face interaction in clinical settings. For the email recruitment, interested individuals received questionnaires by post and directed to send back the completed questionnaires. For the face-to-face recruitment, questionnaires were distributed by hand, and upon completion, they were collected in a collection box. All participants received a participant information sheet. For this study, we extracted the data obtained from oncology nurses.

      Measures

      The STEP study collected data using a self-administered questionnaire, which comprised the following three major sections: (1) demographic and professional characteristics, (2) survivorship care components, and (3) factors limiting the optimal survivorship care. The scale's reliability has been confirmed previously.
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.

      Demographic and professional characteristics

      Demographic and professional characteristics were collected, including age, sex, highest education level, years of experience in cancer care, work status, primary work setting, primary patient setting, and geographical location of the workplace.

      Survivorship care items

      A 29-item measurement scale regarding survivorship care was developed for the STEP study based on the Institute of Medicine's seminal report (which provides an outline for survivorship care
      • Hewitt M.
      • Greenfield S.
      • Stovall E.
      From Cancer Patient to Cancer Survivor: Lost in Transition.
      ), a literature review on survivorship care practices, and two pilot studies on Australian oncology nurses.
      • Chan R.J.
      • Button E.
      • Thomas A.
      • Gates P.
      • Yates P.
      Nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment.
      ,
      • Wallace A.
      • Downs E.
      • Gates P.
      • Thomas A.
      • Yates P.
      • Chan R.J.
      Provision of survivorship care for patients with haematological malignancy at completion of treatment: a cancer nursing practice survey study.
      These items were used to assess the perceptions of healthcare professionals regarding responsibility (whether care provision is part of their role), confidence (their confidence in care delivery), and frequency of practice (how often they provide care).
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      Perceptions regarding responsibility were rated using a five-point Likert scale (1 ​= ​totally disagree, 2 ​= ​somewhat disagree, 3 ​= ​do not know, 4 ​= ​somewhat agree, and 5 ​= ​totally agree). Confidence levels were rated on a numeric analog scale from 0 (cannot do at all) to 10 (highly certain can do). The frequency of practice was assessed on a five-point Likert scale (1 ​= ​never, 2 ​= ​occasionally, 3 ​= ​often, 4 ​= ​very often, and 5 ​= ​all the time). The 29 items were divided into four subscales; namely, “prevention of recurrent and new cancers as well as other late effects” (prevention, two items); “interventions for the physical and psychosocial consequences of cancer and its treatment” (intervention, 14 items); “surveillance for cancer recurrence” (surveillance, four items); “coordination of care for ensuring that all the survivor's health needs are met” (coordination, nine items).

      Factors limiting the provision of optimal survivorship care

      A list of 16 factors that impeded the provision of survivorship care, including individual, organizational, and professional factors, was used for assessment.
      • Michie S.
      • Johnston M.
      • Abraham C.
      • Lawton R.
      • Parker D.
      • Walker A.
      Making psychological theory useful for implementing evidence based practice: a consensus approach.
      Here, the participants rated their agreement levels on a four-point Likert scale (1 ​= ​not at all, 2 ​= ​somewhat, 3 ​= ​quite a lot, and 4 ​= ​a great deal).

      Translation and content validity

      The translation procedure was standardized in the STEP study as according to the World Health Organization.
      • World Health Organization
      Process of translation and adaptation of instruments.
      Specifically, one professional translator independently translated the original scale from English into Japanese. Subsequently, a bilingual physician checked the initial Japanese version, followed by back translation by another professional translator. Next, an expert panel comprising six nursing researchers and one physician identified and resolved discrepancies between the original and translated scales. We conducted a pilot test using a convenience sample of ten health professionals to assess face validity. The participants were asked if anything was unclear and to provide suggestions for further amendment.

      Data analysis

      All measures were analyzed with descriptive statistics. Additionally, we conducted bivariate analyses and determined correlation coefficients to explore the relationships between the perception of responsibility, confidence levels, and frequency of survivorship care practice. Additionally, t-tests and analyses of variance were performed to explore the relationship between the frequency of survivorship care with demographic and professional characteristics. Statistical significance was set at P ​< ​0.05. All analyses were performed using IBM SPSS statistics, version 22.0 (IBM Japan Ltd., Tokyo, Japan).

      Results

      From 255 oncology healthcare workers, 209 (82.0%) respondents, including 181 oncology nurses, 20 doctors, and eight other professionals, completed the questionnaire. All responses from the oncology nurses were analyzed. Table 1 summarizes the demographic and professional characteristics of the participants. Most participants were aged < 40 years (66.9%) and female (96.1%). Moreover, most participants had > 5 years of experience in cancer care (67.4%), full-time employees (98.9%) and were working in inpatient (74.6%) and adult (98.9%) care settings at a metropolitan location (89.0%). Further, 49.2% of the participants had a diploma as the highest education level.
      Table 1Demographic and professional characteristics of the participants (n ​= ​181).
      Characteristicsn%
      Age (years)
       18–296133.7
       30–396033.1
       40–494826.5
       50–59126.6
      Gender
       Female17496.1
       Male73.9
      Highest education level
       Hospital certificate42.2
       Diploma8949.2
       Bachelor's degree7943.6
       Master's degree73.9
      Years of experience in cancer care
       < 142.2
       1–55530.4
       6–104524.9
       11–205832.0
       > 201910.5
      Work status
       Full-time17998.9
       Part time21.1
      Primary work setting
       Outpatient4022.1
       Inpatient13574.6
       Mixed63.3
      Primary patient setting
       Adults17998.9
       Mixed (including pediatrics)10.6
      Geographical location of workplace
       Metropolitan16189.0
       Regional63.3
       Rural52.8
       Mixed52.8
      ∗Several total percentages do not equal 100% because of missing data.

      Perceptions of responsibility, confidence levels, and frequency of survivorship care practice

      Table 2 shows the participants’ perception on responsibility, confidence, and the frequency of survivorship care practice in the context of the four subscales. Although participants generally acknowledged their responsibilities regarding care delivery in these subscales, the confidence levels and frequency of providing care were lower than the perception of responsibility. For all three elements, the intervention and prevention subscales showed the highest and lowest agreement levels, respectively.
      Table 2Descriptive statistics regarding perceptions of responsibility, confidence levels, and frequency of survivorship care practice (n ​= ​181).
      nPossible rangeUnadjusted scoreAdjusted score
      Scores are rescaled to the range from 0 to 100 for ease of comparison.
      MeanSDMeanSD
      Perceptions of responsibility
       Prevention1812–106.61.865.617.8
       Intervention17514–7059.36.584.79.3
       Surveillance1784–2016.22.980.714.5
       Coordination1779–4535.56.078.913.2
      Confidence levels
       Prevention1800–203.43.516.817.4
       Intervention1810–14062.623.744.716.9
       Surveillance1800–4016.28.740.521.8
       Coordination1800–9033.420.137.122.3
      Frequency
       Prevention1802–102.91.229.211.6
       Intervention17614–7033.110.147.214.4
       Surveillance1804–208.53.342.416.7
       Coordination1789–4518.17.040.315.6
      SD, standard deviation.
      a Scores are rescaled to the range from 0 to 100 for ease of comparison.
      All four subscales showed significant correlation between the frequency of providing survivorship care with other elements, especially confidence levels (all P ​< ​0.001, Table 3). Survivorship care practice showed a moderate positive correlation with confidence levels.
      Table 3Correlations among perceptions of responsibility, confidence levels, and frequency of survivorship care practice (n ​= ​181).
      Frequency
      PreventionInterventionSurveillanceCoordination
      Correlation coefficient (r)
      Perceptions of responsibility
       Prevention0.352∗∗∗
       Intervention0.366∗∗∗
       Surveillance0.315∗∗∗
       Coordination0.385∗∗∗
      Levels of confidence
       Prevention0.538∗∗∗
       Intervention0.428∗∗∗
       Surveillance0.565∗∗∗
       Coordination0.572∗∗∗
      ∗∗∗P ​< ​0.001.

      Survivorship care practice for patients with cancer

      Table 4 shows the frequency of survivorship care practice for each item. The delivery status was determined based on the responses from either being often to all the time. The most frequently performed care practices were discussing and managing patient pain (75.7%) and long-term physical side effects/late effects (57.5%) in the intervention subscale. The remaining items did not reach a 50% delivery status. The care practices with the least frequent delivery status included discussing and managing fertility issues (3.9%) in the intervention subscale. This was followed by discussing information on genetic counseling and testing to identify high-risk individuals (6.1%) as well as discussing information on known effective chemoprevention strategies for secondary prevention as appropriate (9.4%) in the prevention subscale.
      Table 4Frequency of survivorship care practice of each item (n ​= ​181).
      Items
      Items on each subscale were ranked in descending order according to the delivery status.
      NeverOccasionallyOftenVery oftenAll of the timeDelivery status
      Delivery status were the extent of responses from often to all of the time.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      Prevention
       As appropriate, discussing information on known effective chemoprevention strategies for secondary prevention8547.07843.1126.621.131.7179.4
       Discuss information on genetic counseling and testing to identify high-risk individuals who could benefit from more comprehensive cancer surveillance, chemoprevention, or other risk-reducing treatment14781.22312.784.421.110.6116.1
      Intervention
       Discussing and managing pain126.63117.15329.33619.94826.513775.7
       Discussing and managing long-term physical side effects/late effects179.45932.65530.42111.62815.510457.5
       Discussing psychological side effects189.97440.94524.93016.6147.78949.2
       Discussing and encouraging appropriate exercise and physical activity189.97440.95429.82513.8105.58949.2
       Encouraging health behaviors including sunscreen use, smoking and alcohol consumption2011.07843.14927.1179.4179.48345.9
       Providing healthy diet recommendations including alcohol consumption1910.57943.65630.9158.3116.18245.3
       Providing health education to survivors regarding their diagnoses, treatment exposures, and potential late and long-term effects3117.17541.44424.3147.7168.87440.9
       Conducting distress screening for psychological risks4424.36435.43821.0126.62312.77340.3
       Discussing and managing parenting and other help at home2916.09753.63720.4158.331.75530.4
       Providing resources to assist with financial and insurance issues5932.68748.12413.363.352.83519.3
       Discussing and managing employment and financial consequences of cancer6334.89150.31910.563.321.12714.9
       Discussing patient/family peer support groups6737.08647.5158.384.431.72614.4
       Discussing and managing intimacy and sexuality issues7340.38547.0158.363.321.12312.7
       Discussing and managing fertility issues10859.76636.542.231.700.073.9
      Surveillance
       Addressing psychological impacts from their fear of cancer recurrence/relapse2111.68547.03921.52011.0168.87541.4
       Carrying out medical check-ups at follow-up, including taking history6636.56435.42111.6137.2179.45128.2
       Providing screening recommendations for second cancers; periodic testing and examination, and the schedule on which they should be performed7843.17239.81910.563.352.83016.6
       Providing information about how to identify signs of cancer spreading or recurrence6234.39049.72011.042.252.82916.0
      Coordination
       Empowering survivors to advocate for their own healthcare needs3619.97642.03921.52011.0105.56938.1
       Providing information on who to contact with questions and problems3418.88848.63720.495.0137.25932.6
       Communicating the survivorship care provided with the rest of the healthcare team4726.07642.03117.1189.995.05832.0
       Using treatment summaries and/or care plans7340.35228.73318.2126.6116.15630.9
       Ensuring linkage with appropriate external supportive services6535.97340.32413.3126.663.34223.2
       Organizing/ensuring the patient has a schedule of follow-up appointments with the cancer care doctors8446.46033.12011.084.484.43619.9
       Communicating the survivorship care provided with the patient's primary healthcare providers7440.97340.32212.273.952.83418.8
       Providing referrals to specialists and resources as indicated9753.65932.6116.195.052.82513.8
       Ensuring the patient has a schedule of follow-up appointments with primary healthcare providers9250.86636.5126.663.342.22212.2
      a Items on each subscale were ranked in descending order according to the delivery status.
      b Delivery status were the extent of responses from often to all of the time.
      c The total numbers do not equal 181 because of missing data.

      Comparison of survivorship care practice with different characteristics

      The surveillance subscale scores significantly differed according to the years of experience in cancer care (P = ​0.02). Based on the post-hoc Games–Howell test, participants with > 10 years of experience in cancer care had significantly higher surveillance scores than those with ≤ 5 years of experience (9.0 ​± ​3.8 vs. 7.5 ​± ​2.7, P = ​0.03). The other subscale scores did not differ based on the years of experience in cancer care. There were no other significant differences with respect to age, highest education level, and primary work setting (Table 5).
      Table 5Frequency of survivorship care practice stratified according to the demographic and professional characteristics (n ​= ​181).
      Demographic and professional characteristicsFrequency
      PreventionInterventionSurveillanceCoordination
      MeanSDMeanSDMeanSDMeanSD
      Age (years)
       18–292.91.233.38.58.22.818.56.1
       30–392.81.133.410.18.43.118.06.8
       40+3.01.332.411.68.94.117.98.1
      P (One-way ANOVA)0.690.870.520.89
      Highest education level
       Hospital certificate/diploma3.01.132.910.98.43.317.67.5
       Bachelor's degree/master's degree2.91.233.29.38.63.518.76.4
      P (Independent t test)0.770.830.740.30
      Years of experience in cancer care
       ≤ 52.81.031.78.77.52.717.26.3
       > 5–103.01.333.49.68.83.218.96.5
       > 103.01.233.911.39.03.818.47.7
      P (One-way ANOVA)0.520.440.02∗0.44
      Primary work setting
       Outpatient/mixed3.21.332.611.68.73.617.17.0
       Inpatient2.81.133.29.58.43.318.57.0
      P (Independent t test)0.120.720.670.24
      ANOVA, analysis of variance; SD, standard deviation.
      P ​< ​0.05.

      Factors that limit the provision of survivorship care

      Table 6 shows the factors impeding the provision of survivorship care. The limiting status was calculated as the sum of responses regarding limiting factors from quite a lot to a great deal. The limiting status of all individual, organizational, and professional factors was > 50%. Furthermore, 11 out of the 16 factors showed a limiting status of > 70%. The top factors that limited the provision of survivorship care were lack knowledge and skills (87.8%), lack time (81.8%), not seeing the value of survivorship care (79.6%), lack of dedicated educational resources for patients (79.0%), and not knowing what survivorship care is (78.5%).
      Table 6Perceived factors limiting the provision of survivorship care for patients with cancer (n ​= ​181).
      Factors
      Factors were ranked in descending order according to the limiting status.
      Not at allSomewhatQuite a lotA great dealLimiting status
      Limiting status were the extent of factors impeding from quite a lot to a great deal.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      The total numbers do not equal 181 because of missing data.
      n%
      Individual
       Lack knowledge and skills21.1158.35530.410457.515987.8
       Lack time21.12815.58144.86737.014881.8
       Do not see the value of survivorship care73.92916.07038.77440.914479.6
       Do not know what survivorship care is73.93117.16737.07541.414278.5
       Do not know where the patient is at in their disease trajectory105.53016.66133.77943.614077.3
       Communication barriers between you and the patient105.53217.75630.98245.313876.2
       Communication barriers between you and the family members105.53619.96636.56837.613474.0
       Do not know when patients are completing their treatment116.14625.46636.55731.512368.0
      Organizational
       Survivorship care is not a priority for my organization158.33619.98748.14223.212971.3
       No end of treatment consultation dedicated to survivorship care in my organization95.04424.37843.14424.312267.4
       Lack an appropriate physical location (e.g., a quiet room)2413.36033.16535.93117.19653.0
      Professional
       Lack of dedicated educational resources for patients42.23318.28547.05832.014379.0
       Lack of dedicated educational resources for family members42.23619.98345.95731.514077.3
       Lack of evidence-based practice guidelines informing survivorship care31.74726.07843.15128.212971.3
       Patients' lack of interest147.74223.25932.66535.912468.5
       Family members lack of interest137.24826.55932.66033.111965.7
      a Factors were ranked in descending order according to the limiting status.
      b Limiting status were the extent of factors impeding from quite a lot to a great deal.
      c The total numbers do not equal 181 because of missing data.

      Discussion

      To our knowledge, this is the first study to investigate the perspectives of oncology nurses on cancer survivorship care in Japan. The main findings were as follows: (1) survivorship care practice in oncology nursing did not match the perceived responsibility, (2) confidence levels in delivering survivorship care showed a significant positive correlation with the frequency of practice, and (3) individual and professional factors were the top limiting factors for optimal survivorship care provisions.
      Notably, we identified the primary factors that impeded the provisions of survivorship care. Most participants considered individual factors such as having knowledge and skills, knowing what survivorship care is, and seeing the value of survivorship care as relevant to survivorship care provision. The finding that most primary barriers were individual factors is a distinctive to Japan compared with other Asia–Pacific regions
      • Chan R.J.
      • Yates P.
      • Li Q.
      • et al.
      Oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the Asia-Pacific region: results from the STEP study.
      ; moreover, it demonstrates the need for educational support among Japanese oncology nurses. Appropriate education could enhance the professional confidence of nurses in delivering survivorship care. Further, we observed a positive correlation between the confidence levels in delivering survivorship care and the frequency of care provision. There was also a significant correlation between the perception of responsibility and practice of survivorship care; however, there were discrepancies between the perception of responsibility and care frequency, which is consistent with previous findings.
      • Li Q.
      • Lin Y.
      • Xu Y.
      • Molassiotis A.
      Cancer survivorship care after curative treatment: Chinese oncology practitioners' practices.
      Accordingly, although the perception of one's role is an important preparation, it may be insufficient for care delivery. A Japanese study reported that actively seeking to maintain self-confidence is a coping strategy for oncology nurses.
      • Hayashi N.
      • Komatsu H.
      • Sakai Y.
      • Iba N.
      • Tonosaki A.
      • Katagiri K.
      Perceived difficulties and coping as predictors of adaptation among cancer nurses.
      Therefore, educational support for oncology nurses to increase confidence in delivering survivorship care could help them adhere to their perceived responsibility.
      This study also investigated the frequency of survivorship care practice. Compared with care practices in other subscales, interventions for physical and psychosocial consequences of cancer and its treatment were the most frequently performed. Specifically, the practitioners frequently discussed and managed pain, long-term physical side effects, and late effects. Our findings suggest that oncology nurses tend to concentrate their efforts on physical care. This could be attributed to time restrictions, which is a typical barrier to the provision of survivorship care, and the high rates of physical symptoms among cancer survivors. Compared with western countries, the Asia–Pacific region has a higher prevalence of physical symptoms, with more than half of cancer survivors across the Asia–Pacific region showing physical symptoms.
      • Molassiotis A.
      • Yates P.
      • Li Q.
      • et al.
      Mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the Asia-Pacific region: results from the International STEP Study.
      However, during the post-treatment phase, survivors usually visit hospitals for follow-up medical consultations only once every several months. Oncology nurses might prioritize the management of physical symptoms since they need to provide targeted approaches for survivorship care with limited time available. However, cancer survivors have other needs related to a wider range of domains, including information and comprehensive cancer care.
      • Molassiotis A.
      • Yates P.
      • Li Q.
      • et al.
      Mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the Asia-Pacific region: results from the International STEP Study.
      Our findings demonstrate the importance of establishing a feasible model that covers multidimensional aspects of survivorship care.
      Regarding demographic and professional characteristics, participants with > 10 years of experience in cancer care performed surveillance for cancer recurrence more frequently than those with ≤ 5 years of experience. This is inconsistent with previous reports from China and Hong Kong,
      • Li Q.
      • Lin Y.
      • Xu Y.
      • Molassiotis A.
      Cancer survivorship care after curative treatment: Chinese oncology practitioners' practices.
      ,
      • Wong C.L.
      • So W.K.W.
      • Choi K.C.
      • et al.
      Oncology nurses' perspectives and practices toward the delivery of cancer survivorship care in Hong Kong.
      which indicated no significant relationship between the length of experience in cancer care and survivorship care practice. Although professional experience in cancer care could promote survivorship care practice, multifaceted assessments, rather than just lengthy assessments, are required to achieve an impact. Regarding other perspectives, a previous study observed that specialist training in cancer care was not a significant factor for increased survivorship care practice.
      • Wong C.L.
      • So W.K.W.
      • Choi K.C.
      • et al.
      Oncology nurses' perspectives and practices toward the delivery of cancer survivorship care in Hong Kong.
      Another previous study on oncologists reported that detailed training regarding the late and long-term effects of cancer was significantly associated with the provision and discussion of cancer survivorship care plans.
      • Blanch-Hartigan D.
      • Forsythe L.P.
      • Alfano C.M.
      • et al.
      Provision and discussion of survivorship care plans among cancer survivors: results of a nationally representative survey of oncologists and primary care physicians.
      There is a need for further studies to examine the utility of experience in survivorship care.
      This study had several methodological limitations. First, our sample was not representative due to its small size and the fact that it was constituted through convenience sampling. Accordingly, our findings have limited generalization. One possibility is that our results may reflect the views of oncology nurses concerned with survivorship care. Additionally, biased demographic and professional characteristics could have influenced our findings, with most participants working full-time for adult inpatients in metropolitan regions. Second, our findings are based on the nurses’ self-reports. Therefore, we cannot confirm whether the reported frequency of practice corresponded to the actual frequency of practice. Further, the possibility of underestimation must be considered. Third, given the cross-sectional design, we could not identify causal relationships. Although we assumed that perception of responsibility and confidence levels influenced the frequency of survivorship care practice, we need to interpret the relationships among them carefully. Nonetheless, the high response rate in our study yielded findings that could help elucidate the current status and issues of cancer survivorship care in Japan.

      Conclusions

      This study indicated discrepancies between the perceptions of responsibility for survivorship care and care frequency. Oncology nurses in Japan face challenges in providing survivorship care contrary to their high levels of responsibility perception. Although there were multiple factors that limited optimal survivorship care provisions, most of them were individual factors. Our findings demonstrated the importance of developing and evaluating educational support specific to survivorship care in order to increase confidence levels among nurses in delivering survivorship care.

      Declaration of competing interest

      None declared.

      Funding

      Nil.

      Author contributions

      Sena Yamamoto: Formal analysis, Writing - Original Draft. Harue Arao: Conceptualization, Methodology, Investigation, Writing - Review & Editing, Supervision. Kaori Yagasaki: Conceptualization, Methodology, Investigation, Writing - Review & Editing, Supervision. Hiroko Komatsu: Conceptualization, Methodology, Writing - Review & Editing, Supervision, Project administration.

      Acknowledgments

      This study was a secondary analysis of Japanese data from the Survivorship care for patients with cancer after treatment completion in the Asia–Pacific Region: An international service-mapping study. The authors are grateful to Dr. Raymond Chan and Dr. Alex Molassiotis for their valuable advice and comments. The authors also thank the oncology practitioners who participated in this study and the clinical nurses for their support in the recruitment process.

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