Timing and contents of early palliative care preferred by patients with advanced cancer in Japan: an Internet-based questionnaire survey

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Methods We conducted an Internet-based anonymous questionnaire survey on adult patients with advanced cancer. We assessed the patients’ wishes for palliative care delivered by a team or at outpatient clinics while asymptomatic, as well as the preferred intervention timing and preference for continuing care lifelong. Palliative care contents, cancer status, understanding and goals of cancer treatment, symptoms, and background factors were compared among these three preferences. Results In total, 531 patients responded (mean age, 61 years; men, 70%; major primary cancer sites, urological tract and breast), of whom 345 patients (65%) wished for palliative care while asymptomatic, and multivariate analysis revealed that a desire to address daily living and financial issues; wishing for consultations regarding illness, treatment, and end-of-life care; young age; primary sites other than hematological or urological sites; and increased physical distress were significantly associated with this wish. Approximately 51.3% of patients preferred palliative care before completing cancer treatment, while 40% preferred continuing palliative care lifelong. Young patients preferred early palliative care, and patients with a desire to address social distress preferred continuing palliative care. Conclusion The results highlight the importance of early palliative care planning in patients with advanced cancer; however, evaluating the eligibility for palliative care is essential. early palliative care advanced cancer internet survey younger age social distress Background and Objectives Palliative care for advanced cancer has been recommended not only at the end-of-life stage but also at an early stage, such as when the disease is confirmed to be incurable [ 1 ]. Palliative care during early stages has been shown to have positive effects on the quality of life, depression, and survival of patients [ 2 – 4 ]. Based on these reports, the American Society of Cancer Oncology recommends that palliative care should be initiated during the cancer treatment phase [ 19 ]. Some studies have compared two types of early palliative care interventions [ 6 , 7 ]: one involves intervening at a certain stage of the disease, and the other is to intervene on-demand when patients become symptomatic. Various proposals for initiating palliative care interventions exist [ 8 ]. A study conducted in the United States investigated the appropriateness of the timing of palliative care interventions [ 18 ] and reported that outpatient supportive care clinic referral was perceived by most patients as timely and useful, and a low symptom burden was associated with the perception of being referred early. In Japan, the 2012 Basic Law on Cancer Control recommends “promotion of palliative care from the time of advanced cancer diagnosis” [ 20 ]. However, no studies have investigated the preferences of patients with advanced cancer for early palliative care. Our previous study was conducted among bereaved families of patients with cancers who died in palliative care units [ 9 ]. Thus, early palliative care from a patient's perspective is not fully understood. The primary aim of this study was to determine the timing and contents of early palliative care preferred by patients with advanced cancer in Japan. The secondary aim was to explore preferences of patients for continuing palliative care. Methods This was an Internet-based anonymous questionnaire survey conducted in February 2023. Participants provided consent using the opt-in consent method. The study was reviewed and approved by the ethics committees of Kyoto University Graduate School and Faculty of Medicine, Kyoto University Hospital, in compliance with Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan (approval number: R3810). Because this study was a questionnaire survey, with no invasive interventions, of patients who voluntarily enrolled, no risks or disadvantages were anticipated. The study was conducted by a private contractor, and the researchers did not collect any personal information about the patients. The study was conducted in compliance with the Declaration of Helsinki and Ethical Guidelines for Medical Research Involving Human Subjects and initiated after the research protocol was approved by the ethics committees of all institutions to which the researchers belonged. An introductory page was created, ample opportunity for refusal was provided, and a response was considered consent. Subjects The survey included adult patients with advanced cancer who were registered anonymously on the web panel of the Japanese online research company Macromill Inc. (Tokyo, Japan). Macromill Inc. was selected because of the ensured quality of procedures enabling inclusion of patients with advanced cancer nationwide. To recruit respondents, e-mails were sent to 5,000 candidates, of whom 500 passed the screening questionnaire assessment to identify suitable respondents. The screening questionnaire included questions such as whether the participants had cancer and whether the cancer was either locally advanced or metastasized. Patients with no recurrence or metastasis, under 18 years of age, and who were unable to respond online were excluded. Survey items The parameters assessed in the survey were the following. Patients’ preference for interventions by the palliative care team or at outpatient palliative care clinics while asymptomatic The preferred timing was selected from the following [9]: when the disease was confirmed incurable or recurrent, during treatment or follow-up, when treatment became ineffective or the disease worsened, or when they became unable to take care of themselves. Patients’ preference for the continuation of palliative care This was selected as continuation until the end of life or temporary. Patients’ preference for the contents of palliative care interventions This was selected based on the following items using a 5-point scale (1, not desired; 5, desired): dealing with physical distress, dealing with mental distress, dealing with families’ distress, addressing daily life and financial issues, consultation regarding illness and treatment, consultation regarding terminal care, and counseling for meaning of life. Cancer status Cancer treatment status (i.e., undergoing cancer treatment or follow-up, cancer treatment completed, etc.), length of time since the diagnosis of recurrence or metastasis, prior palliative care interventions, and Eastern Cooperative Oncology Group performance status were assessed. Patients’ understanding of cured status and goals of cancer treatment [11] Patients’ understanding of cancer as cured or cured by treatment was assessed using a 4-point scale ranging from 1 (highly likely) to 4 (not at all likely). Patients’ understanding of the goals of cancer treatment were selected from the following: relieving distress, maintaining hope, ensuring that all treatments have been completed, prolonging life as long as possible, curing cancer, helping cancer research, etc. Patients’ current symptoms The symptoms were assessed according to the Integrated Palliative Care Outcome Scale-Japanese Version (IPOS-j [10]; score range, 0 [not at all] to 4 [overwhelming]) and included physical distress, mental distress, social distress, and spiritual pain. Patients’ background factors Factors, including age, sex, primary site, area of residence, highest educational qualification, profession, personal and family income, cohabitator details, marital status, details of children, and religious beliefs, were assessed. Statistical analysis As the primary outcome, we calculated the frequency distribution of item a. Subsequently, we compared items c to g using univariate analysis (i.e., Welch’s test or Fisher’s exact test) according to the wish to undergo palliative care, and items with a p -value < 0.200 in the univariate analysis were compared using multiple logistic regression analysis. Next, in patients who wished to undergo palliative care, we compared items c to g according to the preferred intervention timing in the same manner as mentioned above. Since no difference was observed in the univariate results among the four intervention timings (i.e., when the disease was confirmed incurable or recurrent, during treatment or follow-up, when treatment became ineffective or the disease worsened, or when they became unable to take care of themselves) and two intervention timings (i.e., before and after completing anticancer treatment), we compared the items using the latter timings. In addition, as the secondary outcome, we calculated the frequency distribution of item b. We also compared items c to g using the same univariate and multivariate analyses according to the preference for continuing palliative care. All analyses were performed using SPSS 19.1 (IBM Japan, Tokyo, Japan); a p -value < 0.05 was considered significant, and missing values were not analyzed. Results Five hundred and thirty-one adult patients with advanced cancer responded to the survey (average age, 61.2 years; men, 70.8%; major primary sites, urological tract and breast), and 98.3% of them were undergoing cancer treatment or follow-up. In addition, 116 patients (21.8%) indicated that they had received palliative care interventions (Table 1). Of the 531 patients, 345 (65.0%) wished to undergo palliative care team/outpatient interventions while asymptomatic. Items significantly associated with considering palliative care interventions were a desire to address daily living and financial issues; consultations regarding illness, treatment, and end-of-life care; young age; primary sites other than hematological or urological sites; and increased physical distress (Table 2). Of the 345 patients who wished to undergo palliative care, 74 (21.4%) preferred interventions when the disease was confirmed incurable or recurrent, 103 (29.9%) preferred interventions during treatment or follow-up, 123 (35.7%) preferred interventions when treatment became ineffective or the disease progressed, and 45(13.0%) preferred interventions when they became unable to take care of themselves. In the multivariate analysis, young age was significantly associated with the preferred time of intervention before completing cancer treatment (Table 3). Regarding the preference for continuing palliative care, 205 (39.9%) of the 514 (17 with missing data) patients wished to continue palliative care until the end of life, whereas 309 (60.1%) preferred temporary palliative care. In the multivariate analysis, the items significantly associated with considering continuing palliative care until the end of life were a desire to address daily life and financial issues, believing less that treatment would cure the disease, and having treatment goals other than prolonging life or curing cancer (Table 4). Discussion To the best of our knowledge, this is the first study in Japan on preferences for timing, content, and continuing palliative care based on a survey of patients themselves. The most important result was that 65.0% of patients wished to undergo palliative care while asymptomatic, and 51.3% of them wished to undergo interventions before completing cancer treatment. However, palliative care interventions were provided to only 21.8% of patients in this study. In our previous study [ 9 ], in which we surveyed bereaved families of cancer patients, 32.3% of patients received palliative care during cancer treatment, and a large percentage of patients’ relatives judged the timing of palliative care referral as appropriate compared with the families of patients who received palliative care after cancer treatment, and appropriateness of timing and good quality of death were significantly associated. The present study also suggests that the timing of palliative care interventions should be earlier. However, not everyone requires palliative care; therefore, evaluating the eligibility of patients is essential. The next important result was concerning the items related to wishing for palliative care interventions while asymptomatic: a wish to address daily living and financial issues; consultations regarding illness, treatment, and end-of-life care; young age; and increased physical distress. However, if the primary sites were hematological or urological, the patients did not request palliative care interventions. Young age was also associated with wishing for palliative care before completing cancer treatment. According to the 2018 patient experience survey report by the National Cancer Center’s Cancer Control and Information Center [ 16 ], young patients had disadvantages in terms of finances, employment status, building relationships, and dialogue with healthcare providers, indicating that they had higher care needs than older patients, consistent with the present results. Although palliative care has conventionally focused on the palliation of physical and psychological distress, a strong wish to address social distress and undergo early palliative care interventions seems to exist among young patients. In the present study, another request for palliative care was related to consultations regarding illness and treatment, which was reported in the classic early palliative care study by Temel et al. [ 12 ] as well. The importance of advanced care planning in palliative care has also been noted [ 17 ], as suggested by the present study. In contrast, patients with hematological and urological cancers did not wish to receive palliative care. Hematological cancers may be treated even in advanced disease states, and palliative care interventions tend to be delayed [ 13 , 14 ]. Patients with urological cancers are relatively old [ 15 ], and they may have less preference for early palliative care. Another important result of this study was that 39.9% of patients preferred continuing palliative care until the end of life. This preference was associated with a desire to address social problems and a lack of motivation for undergoing cancer treatment. Since social problems can persist over the entire trajectory of an illness, patients with social problems may wish to continue palliative care. The present study had some limitations. First, although this study included patients with advanced cancer, the advanced cancer status was confirmed only by self-reporting. Second, we recruited only patients registered with a private monitoring provider, which might have introduced a background bias. As shown in Table 1, data for all regions, cancer sites, and income levels were obtained. However, the average age of the patients is 61 years, which is less than that of all patients with cancer, possibly because of the Internet-based responses. Young age was associated with a preference for early palliative care, and fewer early palliative care seekers may have resulted if all age groups were included. In the present study, a large proportion of patients wished for early palliative care compared with the previous study on bereaved families [ 9 ]. Finally, most of the patients were undergoing cancer treatment or follow-up (Table 1). Palliative care preferences differ among patients who cannot be treated for cancer. Therefore, clarifying the preferences of such patients who are targets of early palliative care is essential. Conclusion In the present study conducted in Japan, approximately 2/3rd of patients with advanced cancer preferred palliative care interventions while asymptomatic, and half of them wished to undergo palliative care before completing cancer treatment. Forty percent of patients wished to continue palliative care until the end of life. Young patients wished to undergo early palliative care, whereas those who wished to address social distress preferred to continue palliative care. Declarations Competing interests The authors have no conflicts of interest. Ethics approval This study was conducted in compliance with the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan and approved by the ethics committees of Kyoto University Graduate School and Faculty of Medicine, Kyoto University Hospital (approval number: R3810). Consent to participate Participants provided consent using the opt-in consent method. Consent to publish All authors agree to publish this article. Funding This work was supported by the Ministry of Health, Labor, and Welfare of Japan (Health Labor Science Research Grant, Grant No. 20EA1009). The funder had no role in the conception and/or design of the work; the acquisition, analysis, and interpretation of data; and/or the drafting of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation and data collection were performed by Yu Ueno. Analysis and the first draft of the manuscript were performed by Hitoya Sano and Takuya Odagiri. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgement This work was supported by the Ministry of Health, Labor, and Welfare of Japan (Health Labor Science Research Grant, Grant No. 20EA1009). We would like to thank Editage (www.editage.jp) for English language editing. References . Temel JS, Greer JA, Muzikansky A et al (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363(8):733–742. https://doi.org/10.1056/NEJMoa1000678 . Huo B, Song Y, Chang L, Tan B (2022) Effects of early palliative care on patients with incurable cancer: a meta-analysis and systematic review. Eur J Cancer Care (Engl) 31(6):e13620. https://doi.org/10.1111/ecc.13620 . Haun MW, Estel S, Rücker, et al (2017) Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 6(6):CD011129. https://doi.org/10.1002/14651858.CD011129.pub2 . Gaertner J, Siemens W, Meerpohl JJ et al (2017) Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ 357:j2925. https://doi.org/10.1136/bmj.j2925 . Ferrell BR, Temel JS, Temin S et al (2017) Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 35(1):96–112. https://doi.org/10.1200/JCO.2016.70.1474 . Maltoni M, Scarpi E, Dall’Agata M et al (2016) Systematic versus on-demand early palliative care: results from a multicentre, randomised clinical trial. Eur J Cancer 65:61–68. https://doi.org/10.1016/j.ejca.2016.06.007 . Scarpi E, Dall’Agata M, Zagonel V et al (2019) Systematic vs. on-demand early palliative care in gastric cancer patients: a randomized clinical trial assessing patient and healthcare service outcomes. Support Care Cancer 27(7):2425–2434. https://doi.org/10.1007/s00520-018-4517-2 . Kayastha N, LeBlanc TW (2020) When to integrate palliative care in the trajectory of cancer care. Curr Treat Options Oncol 21(5):41. https://doi.org/10.1007/s11864-020-00743-x . Tagami K, Masukawa K, Inoue A, et al (2022) Appropriate referral timing to specialized palliative care service: survey of bereaved families of cancer patients who died in palliative care units. Support Care Cancer 30(1):931–940. https://doi.org/10.1007/s00520-021-06493-2 . Sakurai H, Miyashita M, Imai K et al (2019) Validation of the Integrated Palliative care Outcome Scale (IPOS) – Japanese Version. Jpn J Clin Oncol, Japanese version 49(3):257–262. https://doi.org/10.1093/jjco/hyy203 . Janssens A, Derijcke S, Lefebure A et al (2017) Addressing the palliative setting in advanced lung cancer should not remain a barrier: a multicenter study. Clin Lung Can 18(4):e283–e287. https://doi.org/10.1016/j.cllc.2017.01.001 . Greer JA, Pirl WF, Jackson VA et al (2012) Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol 30(4):394–400. https://doi.org/10.1200/JCO.2011.35.7996 . Moreno-Alonso D, Porta-Sales J, Monforte-Royo C et al (2018) Palliative care in patients with haematological neoplasms: an integrative systematic review. Palliat Med 32(1):79–105. https://doi.org/10.1177/0269216317735246 . Howell DA, Shellens R, Roman E et al (2011) Haematological malignancy: are patients appropriately referred for specialist palliative and hospice care? A systematic review and meta-analysis of published data. Palliat Med 25(6):630–641. https://doi.org/10.1177/0269216310391692 . Raghavan D, Skinner E (2004) Genitourinary cancer in the elderly. Semin Oncol 31(2):249–263. https://doi.org/10.1053/j.seminoncol.2003.12.034 . https://www.mhlw.go.jp/content/10901000/00860132.pdf Accessed Aug 30, 2023 . Bischoff K, O’Riordan DL, Marks AK, Sudore R, Pantilat SZ (2018) Care planning for inpatients referred for palliative care consultation. JAMA Intern Med 178(1):48–54. https://doi.org/10.1001/jamainternmed.2017.6313 . Wong A, Vidal M, Prado B et al (2019) Patients’ perspective of timeliness and usefulness of an outpatient supportive care referral at a comprehensive cancer center. J Pain Symptom Manage 58(2):275–281. https://doi.org/10.1016/j.jpainsymman.2019.04.027 Ferrell BR, Temel JS, Temin S, et al (2024) Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 35(1):96–112. https://doi.org/10.1200/JCO.2016.70.1474 Cancer Control Act (in Japanese). https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/gan_keikaku02.pdf Tables Tables 1-4 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table.xlsx Cite Share Download PDF Status: Published Journal Publication published 09 Sep, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted Editorial decision: Revision requested 22 Mar, 2025 Reviews received at journal 18 Jul, 2024 Reviewers agreed at journal 09 Jul, 2024 Reviewers invited by journal 04 Jul, 2024 Editor assigned by journal 04 Jul, 2024 Submission checks completed at journal 04 Jun, 2024 First submitted to journal 03 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4521040","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":310304892,"identity":"d5ba4b02-6205-40c2-b898-c09c8fb43b51","order_by":0,"name":"Hitoya Sano","email":"","orcid":"","institution":"Gifu Welfare Federation of Agricultural Cooperatives, Gifu Seino Medical Center, Seino Kosei Hospita","correspondingAuthor":false,"prefix":"","firstName":"Hitoya","middleName":"","lastName":"Sano","suffix":""},{"id":310304893,"identity":"ef4f40fe-3e17-4351-bc8c-687e3c589f8e","order_by":1,"name":"Takuya Odagiri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYLACHhBiZj4G5rCxE1YN08KWxsCQANTCTKQWEGkG1sJASIu9RALjgzc1tTLm7TzfHnz8sU2ej5mB8cPHHDy2SCQwG845dpxH5jDvdsMZCbcN25gZmCVnbsOnJf+bNA/bMR4JZt5t0jwJtxmBWtiAbLy2sEnz/ANp4XkG0mJPnBbethqQFjaQlkTCWs48YDac23cAqIXNTHJG2u3kNmbGZrx+YW8Hhdi3OnsJ/sPPJD7Y3Lad39588MNHPFoYBBJA5GFkIcYGPOqBgP8AiKzDr2gUjIJRMApGNgAA05xCAfB19OMAAAAASUVORK5CYII=","orcid":"","institution":"Gifu Welfare Federation of Agricultural Cooperatives, Gifu Seino Medical Center, Seino Kosei Hospita","correspondingAuthor":true,"prefix":"","firstName":"Takuya","middleName":"","lastName":"Odagiri","suffix":""},{"id":310304894,"identity":"4150f6a9-bc8a-4ffa-8f83-71f2b7917c5b","order_by":2,"name":"Keisuke Tagami","email":"","orcid":"","institution":"Yamato Home Care Clinic Tome","correspondingAuthor":false,"prefix":"","firstName":"Keisuke","middleName":"","lastName":"Tagami","suffix":""},{"id":310304897,"identity":"bc47a584-41c7-4325-8a62-e413a62d182a","order_by":3,"name":"Yu Uneno","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Uneno","suffix":""},{"id":310304899,"identity":"ab7ae6d6-2893-4c1f-ac9a-3d7c9f35a5cf","order_by":4,"name":"Manabu Muto","email":"","orcid":"","institution":"Kyoto University","correspondingAuthor":false,"prefix":"","firstName":"Manabu","middleName":"","lastName":"Muto","suffix":""}],"badges":[],"createdAt":"2024-06-03 10:06:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4521040/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4521040/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-09883-y","type":"published","date":"2025-09-09T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91359050,"identity":"5f80d425-f93b-4ca9-b075-5897e745a8e8","added_by":"auto","created_at":"2025-09-15 16:04:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":388131,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4521040/v1/64acbdad-a473-4023-8ffc-efb84db6a721.pdf"},{"id":58523234,"identity":"1aff7b20-22b3-47d4-86ce-7d5b2364f9a3","added_by":"auto","created_at":"2024-06-17 19:29:38","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":29904,"visible":true,"origin":"","legend":"","description":"","filename":"Table.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4521040/v1/71198b9c744eb710495407a5.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTiming and contents of early palliative care preferred by patients with advanced cancer in Japan: an Internet-based questionnaire survey \u003c/p\u003e","fulltext":[{"header":"Background and Objectives","content":"\u003cp\u003ePalliative care for advanced cancer has been recommended not only at the end-of-life stage but also at an early stage, such as when the disease is confirmed to be incurable [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Palliative care during early stages has been shown to have positive effects on the quality of life, depression, and survival of patients [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on these reports, the American Society of Cancer Oncology recommends that palliative care should be initiated during the cancer treatment phase [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome studies have compared two types of early palliative care interventions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]: one involves intervening at a certain stage of the disease, and the other is to intervene on-demand when patients become symptomatic. Various proposals for initiating palliative care interventions exist [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A study conducted in the United States investigated the appropriateness of the timing of palliative care interventions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and reported that outpatient supportive care clinic referral was perceived by most patients as timely and useful, and a low symptom burden was associated with the perception of being referred early.\u003c/p\u003e \u003cp\u003eIn Japan, the 2012 Basic Law on Cancer Control recommends \u0026ldquo;promotion of palliative care from the time of advanced cancer diagnosis\u0026rdquo; [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, no studies have investigated the preferences of patients with advanced cancer for early palliative care. Our previous study was conducted among bereaved families of patients with cancers who died in palliative care units [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Thus, early palliative care from a patient's perspective is not fully understood.\u003c/p\u003e \u003cp\u003eThe primary aim of this study was to determine the timing and contents of early palliative care preferred by patients with advanced cancer in Japan. The secondary aim was to explore preferences of patients for continuing palliative care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was an Internet-based anonymous questionnaire survey conducted in February 2023. Participants provided consent using the opt-in consent method. The study was reviewed and approved by the ethics committees of Kyoto University Graduate School and Faculty of Medicine, Kyoto University Hospital, in compliance with Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan (approval number: R3810). Because this study was a questionnaire survey, with no invasive interventions, of patients who voluntarily enrolled, no risks or disadvantages were anticipated. The study was conducted by a private contractor, and the researchers did not collect any personal information about the patients. The study was conducted in compliance with the Declaration of Helsinki and Ethical Guidelines for Medical Research Involving Human Subjects and initiated after the research protocol was approved by the ethics committees of all institutions to which the researchers belonged. An introductory page was created, ample opportunity for refusal was provided, and a response was considered consent.\u003c/p\u003e\n\u003cp\u003eSubjects\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The survey included adult patients with advanced cancer who were registered anonymously on the web panel of the Japanese online research company Macromill Inc. (Tokyo, Japan). Macromill Inc. was selected because of the ensured quality of procedures enabling inclusion of patients with advanced cancer nationwide. To recruit respondents, e-mails were sent to 5,000 candidates, of whom 500 passed the screening questionnaire assessment to identify suitable respondents. The screening questionnaire included questions such as whether the participants had cancer and whether the cancer was either locally advanced or metastasized. Patients with no recurrence or metastasis, under 18 years of age, and who were unable to respond online were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurvey items\u003c/p\u003e\n\u003cp\u003eThe parameters assessed in the survey were the following.\u003c/p\u003e\n\u003col start=\"1\"\u003e\n \u003cli\u003ePatients\u0026rsquo; preference for interventions by the palliative care team or at outpatient palliative care clinics while asymptomatic\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe preferred timing was selected from the following [9]: when the disease was confirmed incurable or recurrent, during treatment or follow-up, when treatment became ineffective or the disease worsened, or when they became unable to take care of themselves.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003ePatients\u0026rsquo; preference for the continuation of palliative care\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis was selected as continuation until the end of life or temporary.\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003ePatients\u0026rsquo; preference for the contents of palliative care interventions\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis was selected based on the following items using a 5-point scale (1, not desired; 5, desired): dealing with physical distress, dealing with mental distress, dealing with families\u0026rsquo; distress, addressing daily life and financial issues, consultation regarding illness and treatment, consultation regarding terminal care, and counseling for meaning of life.\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eCancer status\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eCancer treatment status (i.e., undergoing cancer treatment or follow-up, cancer treatment completed, etc.), length of time since the diagnosis of recurrence or metastasis, prior palliative care interventions, and Eastern Cooperative Oncology Group performance status were assessed.\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003ePatients\u0026rsquo; understanding of cured status and goals of cancer treatment [11]\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003ePatients\u0026rsquo; understanding of cancer as cured or cured by treatment was assessed using a 4-point scale ranging from 1 (highly likely) to 4 (not at all likely). Patients\u0026rsquo; understanding of the goals of cancer treatment were selected from the following: relieving distress, maintaining hope, ensuring that all treatments have been completed, prolonging life as long as possible, curing cancer, helping cancer research, etc.\u0026nbsp;\u003c/p\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003ePatients\u0026rsquo; current symptoms\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe symptoms were assessed according to the Integrated Palliative Care Outcome Scale-Japanese Version (IPOS-j [10]; score range, 0 [not at all] to 4 [overwhelming]) and included physical distress, mental distress, social distress, and spiritual pain.\u0026nbsp;\u003c/p\u003e\n\u003col start=\"7\"\u003e\n \u003cli\u003ePatients\u0026rsquo; background factors\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eFactors, including age, sex, primary site, area of residence, highest educational qualification, profession, personal and family income, cohabitator details, marital status, details of children, and religious beliefs, were assessed.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;As the primary outcome, we calculated the frequency distribution of item a. Subsequently, we compared items c to g using univariate analysis (i.e., Welch\u0026rsquo;s test or Fisher\u0026rsquo;s exact test) according to the wish to undergo palliative care, and items with a \u003cem\u003ep\u003c/em\u003e-value \u0026lt; 0.200 in the univariate analysis were compared using multiple logistic regression analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Next, in patients who wished to undergo palliative care, we compared items c to g according to the preferred intervention timing in the same manner as mentioned above. Since no difference was observed in the univariate results among the four intervention timings\u0026nbsp;(i.e.,\u0026nbsp;when the disease was confirmed incurable or recurrent, during treatment or follow-up, when treatment became ineffective or the disease worsened, or when they became unable to take care of themselves)\u0026nbsp;and two intervention timings (i.e., before and after completing anticancer treatment), we compared the items using the latter timings.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In addition, as the secondary outcome, we calculated the frequency distribution of item b. We also compared items c to g using the same univariate and multivariate analyses according to the preference for continuing palliative care. All analyses were performed using SPSS 19.1 (IBM Japan, Tokyo, Japan); a \u003cem\u003ep\u003c/em\u003e-value \u0026lt; 0.05 was considered significant, and missing values were not analyzed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFive hundred and thirty-one adult patients with advanced cancer responded to the survey (average age, 61.2 years; men, 70.8%; major primary sites, urological tract and breast), and 98.3% of them were undergoing cancer treatment or follow-up. In addition, 116 patients (21.8%) indicated that they had received palliative care interventions (Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eOf the 531 patients, 345 (65.0%) wished to undergo palliative care team/outpatient interventions while asymptomatic. Items significantly associated with considering palliative care interventions were a desire to address daily living and financial issues; consultations regarding illness, treatment, and end-of-life care; young age; primary sites other than hematological or urological sites; and increased physical distress (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eOf the 345 patients who wished to undergo palliative care, 74 (21.4%) preferred interventions when the disease was confirmed incurable or recurrent, 103 (29.9%) preferred interventions during treatment or follow-up, 123 (35.7%) preferred interventions when treatment became ineffective or the disease progressed, and 45(13.0%) preferred interventions when they became unable to take care of themselves. In the multivariate analysis, young age was significantly associated with the preferred time of intervention before completing cancer treatment (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eRegarding the preference for continuing palliative care, 205 (39.9%) of the 514 (17 with missing data) patients wished to continue palliative care until the end of life, whereas 309 (60.1%) preferred temporary palliative care. In the multivariate analysis, the items significantly associated with considering continuing palliative care until the end of life were a desire to address daily life and financial issues, believing less that treatment would cure the disease, and having treatment goals other than prolonging life or curing cancer (Table\u0026nbsp;4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study in Japan on preferences for timing, content, and continuing palliative care based on a survey of patients themselves. The most important result was that 65.0% of patients wished to undergo palliative care while asymptomatic, and 51.3% of them wished to undergo interventions before completing cancer treatment. However, palliative care interventions were provided to only 21.8% of patients in this study. In our previous study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in which we surveyed bereaved families of cancer patients, 32.3% of patients received palliative care during cancer treatment, and a large percentage of patients\u0026rsquo; relatives judged the timing of palliative care referral as appropriate compared with the families of patients who received palliative care after cancer treatment, and appropriateness of timing and good quality of death were significantly associated. The present study also suggests that the timing of palliative care interventions should be earlier. However, not everyone requires palliative care; therefore, evaluating the eligibility of patients is essential.\u003c/p\u003e \u003cp\u003eThe next important result was concerning the items related to wishing for palliative care interventions while asymptomatic: a wish to address daily living and financial issues; consultations regarding illness, treatment, and end-of-life care; young age; and increased physical distress. However, if the primary sites were hematological or urological, the patients did not request palliative care interventions. Young age was also associated with wishing for palliative care before completing cancer treatment. According to the 2018 patient experience survey report by the National Cancer Center\u0026rsquo;s Cancer Control and Information Center [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], young patients had disadvantages in terms of finances, employment status, building relationships, and dialogue with healthcare providers, indicating that they had higher care needs than older patients, consistent with the present results. Although palliative care has conventionally focused on the palliation of physical and psychological distress, a strong wish to address social distress and undergo early palliative care interventions seems to exist among young patients. In the present study, another request for palliative care was related to consultations regarding illness and treatment, which was reported in the classic early palliative care study by Temel et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] as well. The importance of advanced care planning in palliative care has also been noted [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], as suggested by the present study. In contrast, patients with hematological and urological cancers did not wish to receive palliative care. Hematological cancers may be treated even in advanced disease states, and palliative care interventions tend to be delayed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Patients with urological cancers are relatively old [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and they may have less preference for early palliative care.\u003c/p\u003e \u003cp\u003eAnother important result of this study was that 39.9% of patients preferred continuing palliative care until the end of life. This preference was associated with a desire to address social problems and a lack of motivation for undergoing cancer treatment. Since social problems can persist over the entire trajectory of an illness, patients with social problems may wish to continue palliative care.\u003c/p\u003e \u003cp\u003eThe present study had some limitations. First, although this study included patients with advanced cancer, the advanced cancer status was confirmed only by self-reporting. Second, we recruited only patients registered with a private monitoring provider, which might have introduced a background bias. As shown in Table\u0026nbsp;1, data for all regions, cancer sites, and income levels were obtained. However, the average age of the patients is 61 years, which is less than that of all patients with cancer, possibly because of the Internet-based responses. Young age was associated with a preference for early palliative care, and fewer early palliative care seekers may have resulted if all age groups were included. In the present study, a large proportion of patients wished for early palliative care compared with the previous study on bereaved families [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Finally, most of the patients were undergoing cancer treatment or follow-up (Table\u0026nbsp;1). Palliative care preferences differ among patients who cannot be treated for cancer. Therefore, clarifying the preferences of such patients who are targets of early palliative care is essential.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the present study conducted in Japan, approximately 2/3rd of patients with advanced cancer preferred palliative care interventions while asymptomatic, and half of them wished to undergo palliative care before completing cancer treatment. Forty percent of patients wished to continue palliative care until the end of life. Young patients wished to undergo early palliative care, whereas those who wished to address social distress preferred to continue palliative care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors have no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e This study was conducted in compliance with the Declaration of Helsinki and Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan and approved by the ethics committees of Kyoto University Graduate School and Faculty of Medicine, Kyoto University Hospital (approval number: R3810).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003eParticipants provided consent using the opt-in consent method.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003e All authors agree to publish this article.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the Ministry of Health, Labor, and Welfare of Japan (Health Labor Science Research Grant, Grant No. 20EA1009). The funder had no role in the conception and/or design of the work; the acquisition, analysis, and interpretation of data; and/or the drafting of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by Yu Ueno. Analysis and the first draft of the manuscript were performed by Hitoya Sano and Takuya Odagiri. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis work was supported by the Ministry of Health, Labor, and Welfare of Japan (Health Labor Science Research Grant, Grant No. 20EA1009). We would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e. 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JAMA Intern Med 178(1):48\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jamainternmed.2017.6313\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2017.6313\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e. Wong A, Vidal M, Prado B et al (2019) Patients\u0026rsquo; perspective of timeliness and usefulness of an outpatient supportive care referral at a comprehensive cancer center. J Pain Symptom Manage 58(2):275\u0026ndash;281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpainsymman.2019.04.027\u003c/span\u003e\u003cspan address=\"10.1016/j.jpainsymman.2019.04.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrell BR, Temel JS, Temin S, et al (2024) Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 35(1):96\u0026ndash;112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1200/JCO.2016.70.1474\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2016.70.1474\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCancer Control Act (in Japanese). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/gan_keikaku02.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/gan_keikaku02.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"early palliative care, advanced cancer, internet survey, younger age, social distress","lastPublishedDoi":"10.21203/rs.3.rs-4521040/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4521040/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo clarify the preferred timing and contents of early palliative care and preference for continued care delivery among patients with advanced cancer in Japan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted an Internet-based anonymous questionnaire survey on adult patients with advanced cancer. We assessed the patients\u0026rsquo; wishes for palliative care delivered by a team or at outpatient clinics while asymptomatic, as well as the preferred intervention timing and preference for continuing care lifelong. Palliative care contents, cancer status, understanding and goals of cancer treatment, symptoms, and background factors were compared among these three preferences.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 531 patients responded (mean age, 61 years; men, 70%; major primary cancer sites, urological tract and breast), of whom 345 patients (65%) wished for palliative care while asymptomatic, and multivariate analysis revealed that a desire to address daily living and financial issues; wishing for consultations regarding illness, treatment, and end-of-life care; young age; primary sites other than hematological or urological sites; and increased physical distress were significantly associated with this wish. Approximately 51.3% of patients preferred palliative care before completing cancer treatment, while 40% preferred continuing palliative care lifelong. Young patients preferred early palliative care, and patients with a desire to address social distress preferred continuing palliative care.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results highlight the importance of early palliative care planning in patients with advanced cancer; however, evaluating the eligibility for palliative care is essential.\u003c/p\u003e","manuscriptTitle":"Timing and contents of early palliative care preferred by patients with advanced cancer in Japan: an Internet-based questionnaire survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-17 19:29:33","doi":"10.21203/rs.3.rs-4521040/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-23T03:36:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T10:52:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303201764415956017026836170697220474650","date":"2024-07-09T16:58:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-04T19:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-04T19:51:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-04T06:39:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-06-03T10:03:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa44249e-34c8-4406-b7fa-8f3976ab1afc","owner":[],"postedDate":"June 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T16:01:14+00:00","versionOfRecord":{"articleIdentity":"rs-4521040","link":"https://doi.org/10.1007/s00520-025-09883-y","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-09-09 15:57:06","publishedOnDateReadable":"September 9th, 2025"},"versionCreatedAt":"2024-06-17 19:29:33","video":"","vorDoi":"10.1007/s00520-025-09883-y","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09883-y","workflowStages":[]},"version":"v1","identity":"rs-4521040","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4521040","identity":"rs-4521040","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}