Attitudes and Perception of Risk-stratified Cancer Screening among a Patient-Public Panel in National Cancer Center Japan: A Qualitative study

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Japan already provides a population-based cancer screening program through a standardized nationwide protocol, and public acceptance and perceptions of RSCS remain largely unexplored. In this study, we investigated public attitudes toward RSCS through discussions with a Patient-Public Panel at National Cancer Center Japan, using ABC Gastric Cancer Screening as a focal case study. Methods We organized a workshop on RSCS for a Patient-Public Panel in 2023. 69 panel members were provided with educational materials and lectures for the subsequent group discussion. After the workshop, 62 participants completed a web-based questionnaire on their attitudes toward RSCS and understanding of its benefits and harms. Open-ended responses in the questionnaire were evaluated by qualitative exploratory analysis, and concepts, categories, subthemes and themes were identified. Results While 22 (35.5%) of respondents supported the introduction of the RSCS, 34 (54.8%) expressed conditional acceptance only, dependent on specific factors. Three key themes were identified: perceived benefits of RSCS, concerns about RSCS, and challenges to future implementation. Regarding perceived benefits, respondents frequently noted that RSCS could enhance motivation for screening, but many expressed concern that rigorous implementation might limit personal choice and reduce screening opportunities consequent to risk assessment. Key challenges for RSCS implementation included the establishment of robust scientific evidence, effective public communication, and well-structured support systems. Conclusions Although some respondents recognized the benefits of RSCS, they were reluctant about its implementation. A comprehensive understanding of the reasons underlying these public opinions is critical, and will facilitate the development of effective communication strategies and establishment of support systems. Risk-stratified Cancer Screening Acceptability Patient and Public Involvement Background Japan's population-based cancer screening program covers five types of cancer: gastric, lung, colorectal, breast, and cervical cancer. For each type of screening, national policy defines a uniform screening method, targeted age group, and screening interval based on scientific evidence regarding each cancer type [ 1 ]. However, recent research has made it possible to estimate individual cancer risk [ 2 – 4 ]. Based on this scientific evidence, many countries have adopted risk-stratified cancer screening (RSCS). Examples include human papillomavirus testing for cervical cancer screening and low-dose computed tomography (LDCT) screening for lung cancer in heavy smokers. RSCS first customizes screening intervals, target ages, and modalities using individual cancer risk, and then provides intensive screening for high-risk populations to increase early detection and less frequent screening for low-risk groups to reduce screening harms, such as overdiagnosis and false positive cases. The benefit of this approach is to optimize the balance of the benefits and harms of screening. Nevertheless, the transition to RSCS represents a fundamental shift from current uniform screening practices, and various challenges can be anticipated in its implementation. Several studies have reported that individuals classified as low risk may experience dissatisfaction due to reduced screening opportunities, while those classified as high risk may also feel a psychological burden about developing cancer [ 5 – 10 ]. In addition, the complexity of RSCS may affect access to screening and reduce screening uptake. The success of RSCS therefore depends on sufficient uptake and public acceptability by the general population. In Japan, LDCT screening for heavy smokers is now under consideration, but wider discussion on RSCS is limited, and the public’s views on this approach have yet to be fully understood. Our institution is a leading public cancer center in Japan. Since 2008, we have organized the Patient-Public Panel, a forum in which to conduct a range of activities related to cancer control and research [ 11 ]. The Patient-Public Panel consists of approximately 100 active members, the majority of whom are cancer survivors or family members of patients. Some of the panel members have experience in patient support activities and public communication. They are therefore able to speak from both patient and public perspectives and provide essential suggestions on cancer research. Here, to investigate attitudes and perceptions of RSCS among the Japanese population and clarify the challenges of implementing RSCS in Japan, we organized a workshop for the Patient-Public Panel and collected the opinions of participants. Methods Study design and participants The study participants were selected from among the total of 99 active members of the Patient-Public Panel at our institute. Sixty-nine members attended the workshop, of whom 62 subsequently completed the questionnaire and were eligible for the study. The study was conducted under a qualitative design using open-ended responses from a self-administered, web-based questionnaire. Data collection The Patient-Public Panel management office sent all panel members an invitation, namely a short leaflet about RSCS, prior to the workshop in October 2023. The leaflet (two A4-sized pages) included an overview of cancer screening and the concept of RSCS. We asked them to complete a pre-workshop questionnaire about their demographic characteristics, comprehension, and impression of RSCS ( supplementary file 1). In November 2023, we held the workshop for the Patient-Public Panel to investigate the view on RSCS. During the workshop, two researchers delivered a 30-minute lecture about “gastric cancer screening using the ABC method 12 ” as an example of RSCS. The ABC method reflects the natural history of gastric cancer development, from H. pylori infection to atrophic gastritis and then to gastric cancer [ 12 , 13 ]. The combination of these two elements allows for the prediction of gastric cancer incidence. As shown in Table 1 , we provided accurate and neutral information on RSCS necessary for the subsequent group discussion. The one-hour discussion focused on the following three topics: (1) Would you personally want to undergo RSCS? (2) If RSCS were implemented, would most people accept it? (3) What forms of information dissemination would be most effective in increasing public acceptance? Since National Cancer Center Japan prefers to maintain open communication by not disclosing the content of Patient-Public Panel group discussions, we were unable to analyze the opinions and suggestions expressed in the discussion. Therefore, we asked the participants to complete a web-based questionnaire about RSCS approximately one week after the workshop. In the questionnaire, we asked participants about their overall impression of the workshop in an open-ended format first. Next, we asked multiple-choice questions to determine their comprehension of the benefits and harms of cancer screening, how information obtained at screening is disseminated, and their impression of RSCS. One question asked about their attitude to risk-stratified gastric cancer screening: Do you think risk-stratified screening such as the ABC method for gastric cancer should be actually performed? (yes/depends on the condition/not sure/no) , and then asked them to explain their choice in an open-ended format ( supplementary file 2). Table 1 Outline of the Workshop Lecture Category Details Characteristics of the cancer screening program in Japan There are various screening programs in Japan, such as population-based screening, opportunistic screening, and screening at the workplace. Benefits and harms of cancer screening Cancer mortality, cancer incidence Early detection False positive Psychological burden Overdiagnosis Rationale of risk-stratified cancer screening Rationale of RSCS a Benefits and harms of risk-stratified cancer screening More early detection by intensive screening for high-risk populations Less harm by expanded screening interval for low-risk populations Rationale of the ABC method b Risk-stratification of gastric cancer combining H. pylori antibody levels with the ratio of serum pepsinogen I and II Four risk categories (A, B, C, D) No study to investigate “effectiveness” Hypothetical gastric cancer screening using the ABC method Once in a lifetime risk assessment Fixed screening interval, based on risk category Individuals who had received H. pylori eradication therapy would be excluded from the screening program. False negative due to misclassification a RSCS: Risk-stratified cancer screening. b ABC method: Risk stratification of gastric cancer combining Helicobacter pylori antibody levels with the ratio of serum pepsinogen I to II. Data analysis Quantitative data were analyzed using descriptive statistics from the pre-workshop questionnaire, including age category (30–39/40–49/50–59/60–69/70 or over), sex (male/female), cancer history (self/ family), age at cancer diagnosis (20–39/40–49/50–59/60–69), cancer site, and process of cancer detection (screening/opportunistic screening/other). Qualitative data based on the open-ended questions about the overall impression of the workshop and the attitude to RSCS from the post-workshop questionnaire were subject to qualitative exploratory analysis. Coding was initially performed by TE. All contents were then read and discussed by three authors (TE, SH, and JM) to identify the ideas, concepts, categories, and themes based on similarities among them. To further validate the findings, another author (KSY) independently performed coding to verify the identified concepts, categories, subthemes, and themes. The coding and categorization processes were supported using NVivo 14 software (Lumivero, Denver, CO, USA). Results A total of 69 panel members attended the workshop, with 48 attending in person and 21 participating online. 62 of the 69 participants (89.9%) completed the post-workshop questionnaire. Demographic characteristics of the respondents are presented in Table 2 . The most common age category was 50–59 years, and female respondents were more prevalent. More than 75% of respondents had a personal history of cancer, of which breast cancer was the most prevalent (29.1%). The most common age at cancer diagnosis was 40–49 years (37.5%), and the median age was 48 (range: 29–68). The cancers of 17 individuals (35.4%) were identified through any cancer screening. Regarding attitudes toward risk-stratified gastric cancer screening, 22 (35.5%) respondents supported its implementation. In contrast, 34 (54.8%) selected “depends on the condition”, five respondents selected “Not sure”, and one selected “No”. A qualitative analysis of responses to open-ended questions to explain their choice identified three overarching themes: “Perceived Benefits of RSCS”, “Concerns about RSCS”, and “Challenges for Future Implementation”. For each theme, we identified the following subthemes (Table 3 ). Table 2 Characteristics of study participants (n = 62) Variable n (%) Age group (years) 30–39 2 (3.2) 40–49 10 (16.1) 50–59 23 (37.1) 60–69 20 (32.3) ≥70 7 (11.3) Sex Male 19 (30.6) Female 43 (69.4) Personal cancer history Yes 48 (77.4) No 8 (12.9) Unknown a 6 (9.7) Family history of cancer Yes 43 (69.3) No 13 (21.0) Unknown a 6 (9.7) Age at cancer diagnosis 20–39 9 (18.8) 40–49 18 (37.5) 50–59 16 (33.3) 60–69 5 (10.4) Cancer site b Breast 14 (29.1) Lung 9 (18.8) Hematologic malignancy 4 (8.3) Prostate 3 (6.3) Stomach 3 (6.3) Colon 3 (6.3) Other 14 (29.1) Process of cancer detection Screening 10 (20.8) Opportunistic screening 7 (14.6) Other 31 (64.6) a Six respondents did not complete the pre-workshop questionnaire. b Multiple responses allowed. Table 3 Themes and subthemes regarding attitudes toward risk-stratified gastric cancer screening (n = 62) Theme Subtheme Number of respondents with comments a Perceived Benefits of Risk-stratified Cancer Screening Increased motivation for screening 10 Reduced harms 8 Sense of security and anticipation 8 Concerns About Risk-stratified Cancer Screening Restrictions on personal choice 16 Potential harms 5 Possible misclassifications of risk assessment 4 Challenges for Future Implementation Information outreach regarding risk-stratified cancer screening 26 Need for detailed explanation 6 Supporting systems after risk assessment 8 Scientific evidence and validation 11 a Numbers indicate respondents who expressed comments aligned with each subtheme. Perceived benefits of risk-stratified cancer screening Increased motivation for screening Some respondents wanted to know their cancer risk. In contrast, others viewed RSCS as a social motivator that could increase public awareness and encourage participation in cancer screening programs, even though this view was not explained in the lecture. "Because we can assess our risk level and think about how to deal with it." (Female, aged 70 or over) "Even though it is unknown if I would be at low risk, I would accept the screening as it is unavoidable if I am at high risk." (Female, aged 50–59) "I think this opportunity is important because I have not had a thorough stomach screening." (Female, aged 50–59) "I feel that the need for screening will increase." (Female, aged 60–69, with no history of cancer) Reduced harms The researchers emphasized during the lecture that one advantage of RSCS was reduced harm, and some participants who favored RSCS indeed acknowledged the reduction in physical burden for low-risk individuals and the potential for extended screening intervals. "The low-risk group can reduce the stress caused by unnecessary tests." (Female, aged 60–69). "People evaluated as being at low risk in RSCS do not need to undergo screening every year, so they will be able to have a screening more easily." (Female, aged 50–59) A sense of security and anticipation Some respondents, particularly those without a history of cancer, had a positive perception of RSCS. They thought that the personalized screening intervals could help reduce anxiety, and that RSCS was more advanced than conventional cancer screening. "I had thought that I had to undergo screening every year and was anxious if I skipped it. However, once I knew I was at low risk, the decreased frequency of screening would be based on evidence, and would therefore reduce my sense of anxiety or guilt." (Female, aged 50–59, with no history of cancer) "It is efficient and natural to introduce a system suitable for both high-risk and low-risk groups." (Male, aged 70 or over, with no history of cancer) "With advances in medicine, it is natural for screening methods to change." (Female, aged 60–69, cancer history unknown) Concerns About Risk-stratified Cancer Screening Restrictions on personal choice In the workshop, we presented a hypothetical gastric cancer screening using the ABC method (Table 1 ). Since we explained that the screening would be strictly implemented, such as with regard to adherence to the predetermined screening intervals, some participants expressed concerns about RSCS. Many respondents expressed a desire to undergo screenings even during periods deemed unnecessary based on risk assessment. “Even if one is evaluated to be at low risk based on scientific evidence, a small risk is still present, and the person should still be able to undergo annual screening upon request.” (Female, aged 50–59; 15 others provided similar opinions.) “Even after the introduction of RSCS, those who prefer conventional tests should be able to take them.” (Male, aged 70 or over) “I think it is an effective method for people without cancer, but I think we need a system in which people can receive screening if they wish.” (Male, aged 70 or over) “Obligation is not recommended. People who are worried, even those at low risk, can undergo screenings themselves.” (Male, aged 70 or over, with no history of cancer) “I would like to undergo stomach screening every year, regardless of whether I need to pay. This is because I do not want to have cancer, although I understand the population-level benefits of the ABC method.” (Female, aged 30–39, with no history of cancer). Some respondents had the belief that individuals' preferences should be respected in RSCS. “I think it is acceptable, but I would like the choice of the individual to receive it or not to be respected.” (Female, aged 50–59) “However, this screening has something in common with genetic testing; therefore, one should be able to choose whether to undergo it.” (Female, aged 40–49) Potential harms Several respondents expressed concern for individuals classified at high risk and over false negatives and false positives. They also felt anxiety over the psychological distress and emotional burden on family members from risk assessment. Only one respondent expressed concern for low-risk individuals. "I also think that a person evaluated to be at high risk may be worried for the rest of their life that they will develop gastric cancer someday, and even if they are not diagnosed with gastric cancer at that time, this can pose a psychological risk" (Female, aged 50–59). "I suspect that the results of risk assessment will affect not only myself but also my family members" (Female, aged 50–59). "If health-conscious people are evaluated as at low risk, they would be worried and dissatisfied" (Female, aged 40–49). Possible misclassification of risk assessment Some respondents expressed concerns regarding misclassification, particularly the risk of overlooking high-risk individuals. "The four categories based on two factors are too rough. A more accurate screening program is needed, which can cover lower-risk individuals." (Male, aged 50–59) "Even if classified as Group A in stomach RSCS, there is still a possibility of developing stomach cancer" (Male, aged 60–69). Challenges for Future Implementation Information outreach regarding risk-stratified cancer screening The most frequently cited issue that should be addressed in the future concerned the provision and release of information. Various opinions were expressed, including the need to clearly communicate scientific evidence, deliver accurate information, use easy terminology, and address the negative connotations associated with "risk". "Correct information should be disseminated to everyone" (Female, aged 50–59, cancer history unknown). "Education is required to combat a variety of exclusions, such as post-screening insurance coverage and disadvantages at the workplace." (Female, aged 50–59) “RSCS, risks, benefits, harms, etc.; these terms may be difficult, and different expressions may be easier to understand" (Female, aged 40–49) "People can have a negative image when they hear the word 'risk,' and it should be avoided." (Female, aged 50–59) Need for detailed explanation Some respondents emphasized the need for detailed explanations before and after RSCS to ensure that participants understand and accept the screening process, and its rationale. "I am skeptical when I hear that it is sufficient to perform a risk evaluation once in my lifetime. But if more details are given, for example, that it is sufficient to take this test once in a lifetime because this factor does not change throughout one’s life, I think I can accept this rationale." (Female, aged 50–59) "It is important to provide information based on the scientific backgrounds for stratified screening and information so that people can fully understand its strengths rather than limitations" (Female, aged 50–59). Supporting systems after risk assessment There were several opinions suggesting the need for a system to guide individuals classified as high-risk towards endoscopic examinations and to support their anxiety. "If a follow-up system (including mental support at a consultation desk, etc.) is established, I will be positive about taking the test" (Male, aged 60–69). "Although it is important to find cancer through cancer screening, I agree that mental support is also important when cancer is found" (Male, aged 60–69) Scientific evidence and validation To date, the effectiveness of the ABC method has not been investigated. Therefore, many respondents emphasized the importance of explicit evidence as a means of increasing the acceptance of the RSCS. “I will agree if the evidence is clarified.” (Female, aged 50–59) “The introduction cannot be confirmed without clear evidence. Again, the discussion should deepen after clear evidence is presented. This is fundamental to the introduction of RSCS." (Male, aged 60–69) Discussion In this study, the combination of a lecture with a group discussion allowed us to collect diverse opinions from the Patient-Public Panel at National Cancer Center Japan, and to identify attitudes and perceptions about RSCS among Japanese. Regarding acceptability, 35.5% of respondents accepted the implementation of RSCS. This rate is lower than those in previous studies [ 5 , 8 , 14 , 15 ]. The limited acceptability of the ABC method may be due to the lack of clear evidence that it could reduce gastric cancer mortality. Alternatively, since gastric cancer screening using endoscopy has already been implemented in Japan, there may be little public demand for a more complex screening program. In the workshop, we delivered a lecture covering the topics listed in Table 1 , and held a group discussion. Among the resulting opinions, some appeared to support the content of the lecture while others appeared to be based on the group discussion. For instance, as no randomized controlled trial of the ABC method has evaluated its effect in reducing the mortality of gastric cancer, several respondents called for clear evidence. In addition, concerns about misclassification of the ABC method were also frequently raised. In contrast, more respondents expressed the possibility that an awareness of cancer risk could encourage screening uptake, even though this view was not addressed in the lecture. High risk perception may lead to the adoption of protective health behavior, such as screening, which is well-known as Protection Motivation Theory [ 16 ]. In collaboration with the Patient-Public Panel, we identified more challenges and concerns than we had expected. This might be because most of the panel members were cancer survivors or patient advocates, who are well aware of the psychological stress associated with a cancer diagnosis and the physical burden of treatment, which in turn allowed them to concretely envision the challenges and concerns accompanying the transition to RSCS. A noteworthy subtheme in this qualitative analysis was the concern that RSCS may restrict personal choice. This subtheme was classified into two categories. First, some individuals wished to receive screening at their preferred intervals, rather than at intervals determined by risk assessment. Second, other individuals wished to decide for themselves whether or not to undergo risk assessment. The first category mainly consisted of older respondents, which might suggest that they felt uncertain or hesitant about a major shift from conventional screening to RSCS. Moreover, this may reflect the assumption that the Japanese healthcare system allows free access to medical care at the individual patient's own discretion. Similarly, Japanese can choose their screening intervals and modalities under opportunistic and workplace-based screening programs. Accordingly, many people might prefer receiving screening whenever they wished, even within a population-based screening program. Alternatively, the message that strict adherence to personalized screening intervals is essential to reducing harm might not have been fully understood. On the other hand, some respondents expressed concern that risk assessment might become mandatory and a public norm. Although the reason behind this concern was not completely clear, they might have been concerned about discrimination and stigma similar to those caused by genetic testing, or may have wished to avoid cancer-related anxiety. Loft et al. reported that approximately 20% of participants did not want to know their breast cancer risk [ 4 ]. To increase the acceptance of RSCS, we must thoroughly understand the perspectives of individuals who are hesitant about it. As the workshop topics included information outreach to increase public acceptance, feedback regarding this information outreach was most common. Although previous studies on the acceptability of RSCS have addressed outreach and risk communication related to it [ 8 , 10 , 14 ], discussion of these areas is ongoing. The panel members suggested that effective outreach should include the rationale for the ABC method; the screening protocol; its potential benefits and harms; approaches to reduce anxiety; and information on available supporting systems, such as consultation services and access to healthcare professionals. Information which will increase acceptability likely differs across countries and cultural backgrounds. Further research specific to the Japanese population is therefore warranted. To date, this is the first study to examine the attitude and perception of RSCS in Japan. A key strength of this study is the diverse responses obtained through open-ended survey questions. In addition, our study allowed the collection of thoughtful responses based on the lecture and group discussion in the workshop. However, this study had certain limitations. As the study relied solely on questionnaire data, it was not possible to consider the underlying reasons in greater depth. The membership of the panel primarily consists of cancer survivors and patient advocates, which means that the respondents may not be representative of the general population. However, they had the ability to clearly express their views and concerns about RSCS. Conclusions This study indicated that RSCS was not yet widely accepted in Japan and identified various challenges and concerns associated with its implementation. In particular, many participants had reservations about restrictions on personal choices, outreach strategies, and the availability of supporting systems. Further research is required to understand in-depth the concerns and preferences of the Japanese population. These findings might in turn help local government officials and healthcare professionals to develop reliable information outreach strategies and support systems. Additionally, researchers should make efforts to develop robust scientific evidence and improve risk assessment models tailored to the Japanese population, both of which are essential for the successful implementation of RSCS. Abbreviations RSCS Risk-stratified cancer screening LDCT Low-dose computed tomography Declarations Acknowledgments We thank the members of National Cancer Center Patient-Public Panel for contributing their experiences, insights, and time to this research activity. We are also grateful to the National Cancer Center Japan staff who manage the Patient-Public Panel and the workshop. Author Contributions TE conducted investigation, data curation, analysis, visualization, writing-original draft, writing-review and editing. SH was responsible for conceptualization, data analysis, investigation, methodology, project administration, supervision, visualization, writing-original draft, writing-review and editing. CY was responsible for conceptualization, investigation, project administration, resources, writing-review and editing. AM conducted data curation, investigation, resources, writing-review and editing. JM conducted formal analysis, investigation, writing-review and editing. JT conducted visualization, writing-review and editing. NT and RM conducted investigation, writing-review and editing. KSY validated formal analysis. TN was responsible for conceptualization, funding acquisition, investigation, supervision, writing-review and editing. Funding This study was supported by a Health and Labour Sciences Research Grant (23EA1005) from the Ministry of Health, Labour and Welfare, Japan. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data is not publicly available due to privacy restrictions. Competing interests The authors declare no competing interests related to this study. Ethics approval and consent to participate This study aimed to explore public attitudes and perceptions toward risk-stratified cancer screening. Therefore, the National Cancer Center Research Ethics Review Committee determined that the study fell outside the scope of the Ethical Guidelines for Life Sciences and Medical Research Involving Human Subjects and exempted it from ethical review (Notification No. 6000-080, September 19, 2023). 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A Protection Motivation Theory of Fear Appeals and Attitude Change1. J Psychol Sep. 1975;91:93–114. Additional Declarations No competing interests reported. Supplementary Files 6appendix1Pre20251010.docx 7appendix2Post20251010.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 24 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviewers invited by journal 05 Dec, 2025 Editor assigned by journal 01 Dec, 2025 Editor invited by journal 11 Nov, 2025 Submission checks completed at journal 10 Nov, 2025 First submitted to journal 10 Nov, 2025 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. 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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-8044461","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555837257,"identity":"de4f6a5c-e800-4452-b4f0-ab7568580e57","order_by":0,"name":"Takashi Enomoto","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Enomoto","suffix":""},{"id":555837258,"identity":"b4349621-bb80-4dc8-b6e9-7df017f3f59f","order_by":1,"name":"Satoyo 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Control","correspondingAuthor":false,"prefix":"","firstName":"Chikako","middleName":"","lastName":"Yamaki","suffix":""},{"id":555837260,"identity":"2d1b85f9-0771-4900-9691-24797940ad1b","order_by":3,"name":"Asako Mimura","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Asako","middleName":"","lastName":"Mimura","suffix":""},{"id":555837261,"identity":"82d04cfa-b07b-45eb-9ab3-3b87fdf606d8","order_by":4,"name":"Jin Miyazawa","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Miyazawa","suffix":""},{"id":555837262,"identity":"dd4d1266-f5a0-4732-a4bb-e9c8533855e1","order_by":5,"name":"Junko Tanaka","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Junko","middleName":"","lastName":"Tanaka","suffix":""},{"id":555837263,"identity":"b13c2d4b-6fd9-4f4b-bc67-9384d9dbb259","order_by":6,"name":"Noriaki Takahashi","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Noriaki","middleName":"","lastName":"Takahashi","suffix":""},{"id":555837264,"identity":"9f94a287-224d-41dc-bfab-f9b1ff389da6","order_by":7,"name":"Kyoko Sakamaki-Yamazaki","email":"","orcid":"","institution":"Teikyo University","correspondingAuthor":false,"prefix":"","firstName":"Kyoko","middleName":"","lastName":"Sakamaki-Yamazaki","suffix":""},{"id":555837265,"identity":"f3d488f2-663e-437d-a91b-0630e75c02d0","order_by":8,"name":"Ryoko Machii","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Ryoko","middleName":"","lastName":"Machii","suffix":""},{"id":555837266,"identity":"a0d0517b-e3bf-42d0-b194-5473c0d5fece","order_by":9,"name":"Tomio Nakayama","email":"","orcid":"","institution":"National Cancer Center Institute for Cancer Control","correspondingAuthor":false,"prefix":"","firstName":"Tomio","middleName":"","lastName":"Nakayama","suffix":""}],"badges":[],"createdAt":"2025-11-06 06:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8044461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8044461/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97769331,"identity":"1cb6a3db-d370-4b4c-b0be-85f82d663a9f","added_by":"auto","created_at":"2025-12-09 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07:40:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":38751,"visible":true,"origin":"","legend":"","description":"","filename":"6appendix1Pre20251010.docx","url":"https://assets-eu.researchsquare.com/files/rs-8044461/v1/19801bdfc74093153becd08c.docx"},{"id":97769335,"identity":"da448060-1a0f-45bc-864c-0b806bfb4114","added_by":"auto","created_at":"2025-12-09 07:40:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39504,"visible":true,"origin":"","legend":"","description":"","filename":"7appendix2Post20251010.docx","url":"https://assets-eu.researchsquare.com/files/rs-8044461/v1/10f2dd135a6f659d7ac144bd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Attitudes and Perception of Risk-stratified Cancer Screening among a Patient-Public Panel in National Cancer Center Japan: A Qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eJapan's population-based cancer screening program covers five types of cancer: gastric, lung, colorectal, breast, and cervical cancer. For each type of screening, national policy defines a uniform screening method, targeted age group, and screening interval based on scientific evidence regarding each cancer type [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, recent research has made it possible to estimate individual cancer risk [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on this scientific evidence, many countries have adopted risk-stratified cancer screening (RSCS). Examples include human papillomavirus testing for cervical cancer screening and low-dose computed tomography (LDCT) screening for lung cancer in heavy smokers. RSCS first customizes screening intervals, target ages, and modalities using individual cancer risk, and then provides intensive screening for high-risk populations to increase early detection and less frequent screening for low-risk groups to reduce screening harms, such as overdiagnosis and false positive cases. The benefit of this approach is to optimize the balance of the benefits and harms of screening. Nevertheless, the transition to RSCS represents a fundamental shift from current uniform screening practices, and various challenges can be anticipated in its implementation. Several studies have reported that individuals classified as low risk may experience dissatisfaction due to reduced screening opportunities, while those classified as high risk may also feel a psychological burden about developing cancer [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, the complexity of RSCS may affect access to screening and reduce screening uptake. The success of RSCS therefore depends on sufficient uptake and public acceptability by the general population. In Japan, LDCT screening for heavy smokers is now under consideration, but wider discussion on RSCS is limited, and the public\u0026rsquo;s views on this approach have yet to be fully understood.\u003c/p\u003e\u003cp\u003eOur institution is a leading public cancer center in Japan. Since 2008, we have organized the Patient-Public Panel, a forum in which to conduct a range of activities related to cancer control and research [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The Patient-Public Panel consists of approximately 100 active members, the majority of whom are cancer survivors or family members of patients. Some of the panel members have experience in patient support activities and public communication. They are therefore able to speak from both patient and public perspectives and provide essential suggestions on cancer research.\u003c/p\u003e\u003cp\u003eHere, to investigate attitudes and perceptions of RSCS among the Japanese population and clarify the challenges of implementing RSCS in Japan, we organized a workshop for the Patient-Public Panel and collected the opinions of participants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eThe study participants were selected from among the total of 99 active members of the Patient-Public Panel at our institute. Sixty-nine members attended the workshop, of whom 62 subsequently completed the questionnaire and were eligible for the study. The study was conducted under a qualitative design using open-ended responses from a self-administered, web-based questionnaire.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe Patient-Public Panel management office sent all panel members an invitation, namely a short leaflet about RSCS, prior to the workshop in October 2023. The leaflet (two A4-sized pages) included an overview of cancer screening and the concept of RSCS. We asked them to complete a pre-workshop questionnaire about their demographic characteristics, comprehension, and impression of RSCS (\u003cb\u003esupplementary file 1).\u003c/b\u003e In November 2023, we held the workshop for the Patient-Public Panel to investigate the view on RSCS. During the workshop, two researchers delivered a 30-minute lecture about \u0026ldquo;gastric cancer screening using the ABC method\u003csup\u003e12\u003c/sup\u003e\u0026rdquo; as an example of RSCS. The ABC method reflects the natural history of gastric cancer development, from H. pylori infection to atrophic gastritis and then to gastric cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The combination of these two elements allows for the prediction of gastric cancer incidence.\u003c/p\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, we provided accurate and neutral information on RSCS necessary for the subsequent group discussion. The one-hour discussion focused on the following three topics: \u003cem\u003e(1) Would you personally want to undergo RSCS? (2) If RSCS were implemented, would most people accept it? (3) What forms of information dissemination would be most effective in increasing public acceptance?\u003c/em\u003e Since National Cancer Center Japan prefers to maintain open communication by not disclosing the content of Patient-Public Panel group discussions, we were unable to analyze the opinions and suggestions expressed in the discussion. Therefore, we asked the participants to complete a web-based questionnaire about RSCS approximately one week after the workshop. In the questionnaire, we asked participants about their overall impression of the workshop in an open-ended format first. Next, we asked multiple-choice questions to determine their comprehension of the benefits and harms of cancer screening, how information obtained at screening is disseminated, and their impression of RSCS. One question asked about their attitude to risk-stratified gastric cancer screening: \u003cem\u003eDo you think risk-stratified screening such as the ABC method for gastric cancer should be actually performed? (yes/depends on the condition/not sure/no)\u003c/em\u003e, and then asked them to explain their choice in an open-ended format (\u003cb\u003esupplementary file 2).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutline of the Workshop Lecture\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDetails\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics of the cancer screening program in Japan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThere are various screening programs in Japan, such as population-based screening, opportunistic screening, and screening at the workplace.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eBenefits and harms of cancer screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCancer mortality, cancer incidence\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEarly detection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFalse positive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePsychological burden\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOverdiagnosis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRationale of risk-stratified cancer screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRationale of RSCS\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBenefits and harms of risk-stratified cancer screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMore early detection by intensive screening for high-risk populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLess harm by expanded screening interval for low-risk populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eRationale of the ABC method\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRisk-stratification of gastric cancer combining \u003cem\u003eH. pylori\u003c/em\u003e antibody levels with the ratio of serum pepsinogen I and II\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFour risk categories (A, B, C, D)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo study to investigate \u0026ldquo;effectiveness\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eHypothetical gastric cancer screening using the ABC method\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnce in a lifetime risk assessment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFixed screening interval, based on risk category\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividuals who had received \u003cem\u003eH. pylori\u003c/em\u003e eradication therapy would be excluded from the screening program.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFalse negative due to misclassification\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e RSCS: Risk-stratified cancer screening.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003eb\u003c/sup\u003e ABC method: Risk stratification of gastric cancer combining Helicobacter pylori antibody levels with the ratio of serum pepsinogen I to II.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eQuantitative data were analyzed using descriptive statistics from the pre-workshop questionnaire, including age category (30\u0026ndash;39/40\u0026ndash;49/50\u0026ndash;59/60\u0026ndash;69/70 or over), sex (male/female), cancer history (self/ family), age at cancer diagnosis (20\u0026ndash;39/40\u0026ndash;49/50\u0026ndash;59/60\u0026ndash;69), cancer site, and process of cancer detection (screening/opportunistic screening/other).\u003c/p\u003e\u003cp\u003eQualitative data based on the open-ended questions about the overall impression of the workshop and the attitude to RSCS from the post-workshop questionnaire were subject to qualitative exploratory analysis. Coding was initially performed by TE. All contents were then read and discussed by three authors (TE, SH, and JM) to identify the ideas, concepts, categories, and themes based on similarities among them. To further validate the findings, another author (KSY) independently performed coding to verify the identified concepts, categories, subthemes, and themes. The coding and categorization processes were supported using NVivo 14 software (Lumivero, Denver, CO, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 69 panel members attended the workshop, with 48 attending in person and 21 participating online. 62 of the 69 participants (89.9%) completed the post-workshop questionnaire. Demographic characteristics of the respondents are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The most common age category was 50\u0026ndash;59 years, and female respondents were more prevalent. More than 75% of respondents had a personal history of cancer, of which breast cancer was the most prevalent (29.1%). The most common age at cancer diagnosis was 40\u0026ndash;49 years (37.5%), and the median age was 48 (range: 29\u0026ndash;68). The cancers of 17 individuals (35.4%) were identified through any cancer screening.\u003c/p\u003e\u003cp\u003eRegarding attitudes toward risk-stratified gastric cancer screening, 22 (35.5%) respondents supported its implementation. In contrast, 34 (54.8%) selected \u0026ldquo;depends on the condition\u0026rdquo;, five respondents selected \u0026ldquo;Not sure\u0026rdquo;, and one selected \u0026ldquo;No\u0026rdquo;. A qualitative analysis of responses to open-ended questions to explain their choice identified three overarching themes: \u0026ldquo;Perceived Benefits of RSCS\u0026rdquo;, \u0026ldquo;Concerns about RSCS\u0026rdquo;, and \u0026ldquo;Challenges for Future Implementation\u0026rdquo;. For each theme, we identified the following subthemes (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of study participants (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(3.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(16.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(37.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(32.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;70\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(11.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(30.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(69.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersonal cancer history\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(77.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(12.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(9.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily history of cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(69.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(21.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(9.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at cancer diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(18.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(37.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(10.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCancer site\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(29.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(18.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematologic malignancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProstate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(6.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStomach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(6.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(6.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(29.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProcess of cancer detection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScreening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunistic screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(14.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(64.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Six respondents did not complete the pre-workshop questionnaire.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Multiple responses allowed.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and subthemes regarding attitudes toward risk-stratified gastric cancer screening (n\u0026thinsp;=\u0026thinsp;62)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubtheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of respondents with comments\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePerceived Benefits of Risk-stratified Cancer Screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncreased motivation for screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReduced harms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSense of security and anticipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eConcerns About Risk-stratified Cancer Screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRestrictions on personal choice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePotential harms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePossible misclassifications of risk assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eChallenges for Future Implementation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInformation outreach regarding risk-stratified cancer screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeed for detailed explanation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupporting systems after risk assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScientific evidence and validation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e Numbers indicate respondents who expressed comments aligned with each subtheme.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003ePerceived benefits of risk-stratified cancer screening\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eIncreased motivation for screening\u003c/h2\u003e\u003cp\u003eSome respondents wanted to know their cancer risk. In contrast, others viewed RSCS as a social motivator that could increase public awareness and encourage participation in cancer screening programs, even though this view was not explained in the lecture.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Because we can assess our risk level and think about how to deal with it.\" (Female, aged 70 or over)\u003c/p\u003e\u003cp\u003e\"Even though it is unknown if I would be at low risk, I would accept the screening as it is unavoidable if I am at high risk.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\"I think this opportunity is important because I have not had a thorough stomach screening.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\"I feel that the need for screening will increase.\" (Female, aged 60\u0026ndash;69, with no history of cancer)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eReduced harms\u003c/h3\u003e\n\u003cp\u003eThe researchers emphasized during the lecture that one advantage of RSCS was reduced harm, and some participants who favored RSCS indeed acknowledged the reduction in physical burden for low-risk individuals and the potential for extended screening intervals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"The low-risk group can reduce the stress caused by unnecessary tests.\" (Female, aged 60\u0026ndash;69).\u003c/p\u003e\u003cp\u003e\"People evaluated as being at low risk in RSCS do not need to undergo screening every year, so they will be able to have a screening more easily.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eA sense of security and anticipation\u003c/h3\u003e\n\u003cp\u003eSome respondents, particularly those without a history of cancer, had a positive perception of RSCS. They thought that the personalized screening intervals could help reduce anxiety, and that RSCS was more advanced than conventional cancer screening.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I had thought that I had to undergo screening every year and was anxious if I skipped it. However, once I knew I was at low risk, the decreased frequency of screening would be based on evidence, and would therefore reduce my sense of anxiety or guilt.\" (Female, aged 50\u0026ndash;59, with no history of cancer)\u003c/p\u003e\u003cp\u003e\"It is efficient and natural to introduce a system suitable for both high-risk and low-risk groups.\" (Male, aged 70 or over, with no history of cancer)\u003c/p\u003e\u003cp\u003e\"With advances in medicine, it is natural for screening methods to change.\" (Female, aged 60\u0026ndash;69, cancer history unknown)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eConcerns About Risk-stratified Cancer Screening\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eRestrictions on personal choice\u003c/h2\u003e\u003cp\u003eIn the workshop, we presented a hypothetical gastric cancer screening using the ABC method (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Since we explained that the screening would be strictly implemented, such as with regard to adherence to the predetermined screening intervals, some participants expressed concerns about RSCS. Many respondents expressed a desire to undergo screenings even during periods deemed unnecessary based on risk assessment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Even if one is evaluated to be at low risk based on scientific evidence, a small risk is still present, and the person should still be able to undergo annual screening upon request.\u0026rdquo; (Female, aged 50\u0026ndash;59; 15 others provided similar opinions.)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Even after the introduction of RSCS, those who prefer conventional tests should be able to take them.\u0026rdquo; (Male, aged 70 or over)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think it is an effective method for people without cancer, but I think we need a system in which people can receive screening if they wish.\u0026rdquo; (Male, aged 70 or over)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Obligation is not recommended. People who are worried, even those at low risk, can undergo screenings themselves.\u0026rdquo; (Male, aged 70 or over, with no history of cancer)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I would like to undergo stomach screening every year, regardless of whether I need to pay. This is because I do not want to have cancer, although I understand the population-level benefits of the ABC method.\u0026rdquo; (Female, aged 30\u0026ndash;39, with no history of cancer).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome respondents had the belief that individuals' preferences should be respected in RSCS.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think it is acceptable, but I would like the choice of the individual to receive it or not to be respected.\u0026rdquo; (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\u0026ldquo;However, this screening has something in common with genetic testing; therefore, one should be able to choose whether to undergo it.\u0026rdquo; (Female, aged 40\u0026ndash;49)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePotential harms\u003c/h2\u003e\u003cp\u003eSeveral respondents expressed concern for individuals classified at high risk and over false negatives and false positives. They also felt anxiety over the psychological distress and emotional burden on family members from risk assessment. Only one respondent expressed concern for low-risk individuals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I also think that a person evaluated to be at high risk may be worried for the rest of their life that they will develop gastric cancer someday, and even if they are not diagnosed with gastric cancer at that time, this can pose a psychological risk\" (Female, aged 50\u0026ndash;59).\u003c/p\u003e\u003cp\u003e\"I suspect that the results of risk assessment will affect not only myself but also my family members\" (Female, aged 50\u0026ndash;59).\u003c/p\u003e\u003cp\u003e\"If health-conscious people are evaluated as at low risk, they would be worried and dissatisfied\" (Female, aged 40\u0026ndash;49).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePossible misclassification of risk assessment\u003c/h2\u003e\u003cp\u003eSome respondents expressed concerns regarding misclassification, particularly the risk of overlooking high-risk individuals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"The four categories based on two factors are too rough. A more accurate screening program is needed, which can cover lower-risk individuals.\" (Male, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\"Even if classified as Group A in stomach RSCS, there is still a possibility of developing stomach cancer\" (Male, aged 60\u0026ndash;69).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eChallenges for Future Implementation\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eInformation outreach regarding risk-stratified cancer screening\u003c/h2\u003e\u003cp\u003eThe most frequently cited issue that should be addressed in the future concerned the provision and release of information. Various opinions were expressed, including the need to clearly communicate scientific evidence, deliver accurate information, use easy terminology, and address the negative connotations associated with \"risk\".\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Correct information should be disseminated to everyone\" (Female, aged 50\u0026ndash;59, cancer history unknown).\u003c/p\u003e\u003cp\u003e\"Education is required to combat a variety of exclusions, such as post-screening insurance coverage and disadvantages at the workplace.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\u0026ldquo;RSCS, risks, benefits, harms, etc.; these terms may be difficult, and different expressions may be easier to understand\" (Female, aged 40\u0026ndash;49)\u003c/p\u003e\u003cp\u003e\"People can have a negative image when they hear the word 'risk,' and it should be avoided.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eNeed for detailed explanation\u003c/h2\u003e\u003cp\u003eSome respondents emphasized the need for detailed explanations before and after RSCS to ensure that participants understand and accept the screening process, and its rationale.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I am skeptical when I hear that it is sufficient to perform a risk evaluation once in my lifetime. But if more details are given, for example, that it is sufficient to take this test once in a lifetime because this factor does not change throughout one\u0026rsquo;s life, I think I can accept this rationale.\" (Female, aged 50\u0026ndash;59)\u003c/p\u003e\u003cp\u003e\"It is important to provide information based on the scientific backgrounds for stratified screening and information so that people can fully understand its strengths rather than limitations\" (Female, aged 50\u0026ndash;59).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eSupporting systems after risk assessment\u003c/h2\u003e\u003cp\u003eThere were several opinions suggesting the need for a system to guide individuals classified as high-risk towards endoscopic examinations and to support their anxiety.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"If a follow-up system (including mental support at a consultation desk, etc.) is established, I will be positive about taking the test\" (Male, aged 60\u0026ndash;69).\u003c/p\u003e\u003cp\u003e\"Although it is important to find cancer through cancer screening, I agree that mental support is also important when cancer is found\" (Male, aged 60\u0026ndash;69)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eScientific evidence and validation\u003c/h2\u003e\u003cp\u003eTo date, the effectiveness of the ABC method has not been investigated. Therefore, many respondents emphasized the importance of explicit evidence as a means of increasing the acceptance of the RSCS.\u003c/p\u003e\u003cp\u003e\u0026ldquo;I will agree if the evidence is clarified.\u0026rdquo; (Female, aged 50\u0026ndash;59)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The introduction cannot be confirmed without clear evidence. Again, the discussion should deepen after clear evidence is presented. This is fundamental to the introduction of RSCS.\" (Male, aged 60\u0026ndash;69)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the combination of a lecture with a group discussion allowed us to collect diverse opinions from the Patient-Public Panel at National Cancer Center Japan, and to identify attitudes and perceptions about RSCS among Japanese.\u003c/p\u003e\u003cp\u003eRegarding acceptability, 35.5% of respondents accepted the implementation of RSCS. This rate is lower than those in previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The limited acceptability of the ABC method may be due to the lack of clear evidence that it could reduce gastric cancer mortality. Alternatively, since gastric cancer screening using endoscopy has already been implemented in Japan, there may be little public demand for a more complex screening program.\u003c/p\u003e\u003cp\u003eIn the workshop, we delivered a lecture covering the topics listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and held a group discussion. Among the resulting opinions, some appeared to support the content of the lecture while others appeared to be based on the group discussion. For instance, as no randomized controlled trial of the ABC method has evaluated its effect in reducing the mortality of gastric cancer, several respondents called for clear evidence. In addition, concerns about misclassification of the ABC method were also frequently raised. In contrast, more respondents expressed the possibility that an awareness of cancer risk could encourage screening uptake, even though this view was not addressed in the lecture. High risk perception may lead to the adoption of protective health behavior, such as screening, which is well-known as Protection Motivation Theory [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn collaboration with the Patient-Public Panel, we identified more challenges and concerns than we had expected. This might be because most of the panel members were cancer survivors or patient advocates, who are well aware of the psychological stress associated with a cancer diagnosis and the physical burden of treatment, which in turn allowed them to concretely envision the challenges and concerns accompanying the transition to RSCS.\u003c/p\u003e\u003cp\u003eA noteworthy subtheme in this qualitative analysis was the concern that RSCS may restrict personal choice. This subtheme was classified into two categories. First, some individuals wished to receive screening at their preferred intervals, rather than at intervals determined by risk assessment. Second, other individuals wished to decide for themselves whether or not to undergo risk assessment. The first category mainly consisted of older respondents, which might suggest that they felt uncertain or hesitant about a major shift from conventional screening to RSCS. Moreover, this may reflect the assumption that the Japanese healthcare system allows free access to medical care at the individual patient's own discretion. Similarly, Japanese can choose their screening intervals and modalities under opportunistic and workplace-based screening programs. Accordingly, many people might prefer receiving screening whenever they wished, even within a population-based screening program. Alternatively, the message that strict adherence to personalized screening intervals is essential to reducing harm might not have been fully understood. On the other hand, some respondents expressed concern that risk assessment might become mandatory and a public norm. Although the reason behind this concern was not completely clear, they might have been concerned about discrimination and stigma similar to those caused by genetic testing, or may have wished to avoid cancer-related anxiety. Loft et al. reported that approximately 20% of participants did not want to know their breast cancer risk [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To increase the acceptance of RSCS, we must thoroughly understand the perspectives of individuals who are hesitant about it.\u003c/p\u003e\u003cp\u003eAs the workshop topics included information outreach to increase public acceptance, feedback regarding this information outreach was most common. Although previous studies on the acceptability of RSCS have addressed outreach and risk communication related to it [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], discussion of these areas is ongoing. The panel members suggested that effective outreach should include the rationale for the ABC method; the screening protocol; its potential benefits and harms; approaches to reduce anxiety; and information on available supporting systems, such as consultation services and access to healthcare professionals. Information which will increase acceptability likely differs across countries and cultural backgrounds. Further research specific to the Japanese population is therefore warranted.\u003c/p\u003e\u003cp\u003eTo date, this is the first study to examine the attitude and perception of RSCS in Japan. A key strength of this study is the diverse responses obtained through open-ended survey questions. In addition, our study allowed the collection of thoughtful responses based on the lecture and group discussion in the workshop. However, this study had certain limitations. As the study relied solely on questionnaire data, it was not possible to consider the underlying reasons in greater depth. The membership of the panel primarily consists of cancer survivors and patient advocates, which means that the respondents may not be representative of the general population. However, they had the ability to clearly express their views and concerns about RSCS.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study indicated that RSCS was not yet widely accepted in Japan and identified various challenges and concerns associated with its implementation. In particular, many participants had reservations about restrictions on personal choices, outreach strategies, and the availability of supporting systems. Further research is required to understand in-depth the concerns and preferences of the Japanese population. These findings might in turn help local government officials and healthcare professionals to develop reliable information outreach strategies and support systems. Additionally, researchers should make efforts to develop robust scientific evidence and improve risk assessment models tailored to the Japanese population, both of which are essential for the successful implementation of RSCS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRSCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRisk-stratified cancer screening\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLDCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow-dose computed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the members of National Cancer Center Patient-Public Panel for contributing their experiences, insights, and time to this research activity. We are also grateful to the National Cancer Center Japan staff who manage the Patient-Public Panel and the workshop.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTE\u003c/strong\u003e conducted investigation, data curation, analysis, visualization, writing-original draft, writing-review and editing. \u003cstrong\u003eSH\u003c/strong\u003e was responsible for conceptualization, data analysis, investigation, methodology, project administration, supervision, visualization, writing-original draft, writing-review and editing. \u003cstrong\u003eCY\u003c/strong\u003e was responsible for conceptualization, investigation, project administration, resources, writing-review and editing. \u003cstrong\u003eAM\u003c/strong\u003e conducted data curation, investigation, resources, writing-review and editing. \u003cstrong\u003eJM\u003c/strong\u003e conducted formal analysis, investigation, writing-review and editing. \u003cstrong\u003eJT\u0026nbsp;\u003c/strong\u003econducted visualization, writing-review and editing. \u003cstrong\u003eNT\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;RM\u0026nbsp;\u003c/strong\u003econducted investigation, writing-review and editing. \u003cstrong\u003eKSY\u003c/strong\u003e validated formal analysis. \u003cstrong\u003eTN\u0026nbsp;\u003c/strong\u003ewas responsible for conceptualization, funding acquisition, investigation, supervision, writing-review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a Health and Labour Sciences Research Grant (23EA1005) from the Ministry of Health, Labour and Welfare, Japan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data is not publicly available due to privacy restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to explore public attitudes and perceptions toward risk-stratified cancer screening. Therefore, the National Cancer Center Research Ethics Review Committee determined that the study fell outside the scope of the Ethical Guidelines for Life Sciences and Medical Research Involving Human Subjects and exempted it from ethical review (Notification No. 6000-080, September 19, 2023). The National Cancer Center Research Ethics Review Committee waived the requirement for written informed consent, and completion of the web-based questionnaire was considered as implied consent to participate. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHamashima C, Takahashi H. Cancer screening programs in Japan: Progress and challenges. J Med Screen. 2024;31:207\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans DGR, Harkness EF, Brentnall AR, van Veen EM, Astley SM, Byers H, et al. Breast cancer pathology and stage are better predicted by risk stratification models that include mammographic density and common genetic variants. Breast Cancer Res Treat Jul. 2019;176:141\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosono S, Ito H, Oze I, Watanabe M, Komori K, Yatabe Y, et al. A risk prediction model for colorectal cancer using genome-wide association study-identified polymorphisms and established risk factors among Japanese: results from two independent case-control studies. Eur J Cancer Prev. 2016;25:500\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaji OY, Duffy SW, Agbaje OF, Baker SG, Christiani DC, Cassidy A, et al. Predictive accuracy of the Liverpool Lung Project risk model for stratifying patients for computed tomography screening for lung cancer: a case-control and cohort validation study. Ann Intern Med. 2012;157:242\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLoft LH, Pedersen LH, Bigaard J, Bojesen SE. Attitudes towards risk-stratified breast cancer screening: A population-based survey among 5,001 Danish women. BMC Cancer. 2024;24:347.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDunlop K, Rankin NM, Smit AK, Salgado Z, Newson AJ, Keogh L, et al. Acceptability of risk-stratified population screening across cancer types: Qualitative interviews with the Australian public. Health Expect. 2021;24:1326\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLippey J, Keogh LA, Mann GB, Campbell IG, Forrest LE. A natural progression: Australian women's attitudes about an individualized breast screening model. Cancer Prev Res (Phila). 2019;12:383\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeisel SF, Pashayan N, Rahman B, Side L, Fraser L, Gessler S, et al. Adjusting the frequency of mammography screening on the basis of genetic risk: Attitudes among women in the UK. Breast. 2015;24:237\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.breast.2015.02.001\u003c/span\u003e\u003cspan address=\"10.1016/j.breast.2015.02.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHe X, Schifferdecker KE, Ozanne EM, Tosteson ANA, Woloshin S, Schwartz LM. How do women view risk-based mammography screening? A qualitative study. J Gen Intern Med. 2018;33:1905\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcWilliams L, Woof VG, Donnelly LS, Howell A, Evans DG, French DP. Extending screening intervals for women at low risk of breast cancer: Do they find it acceptable? BMC Cancer. 2021;21:637.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Cancer Center Institute for Cancer Control. 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BMJ open. 2019;9:e026002.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoitsalu M, Sprangers MA, Eklund M, Czene K, Hall P, Gr\u0026ouml;nberg H, et al. Public interest in and acceptability of the prospect of risk-stratified screening for breast and prostate cancer. Acta Oncol. 2016;55:45\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMbuya Bienge C, Pashayan N, Brooks JD, Dorval M, Chiquette J, Eloy L, et al. Women's views on multifactorial breast cancer risk assessment and risk-stratified screening: A population-based survey from four provinces in Canada. J Pers Med. 2021;11:95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRogers RW. A Protection Motivation Theory of Fear Appeals and Attitude Change1. J Psychol Sep. 1975;91:93\u0026ndash;114.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Risk-stratified Cancer Screening, Acceptability, Patient and Public Involvement","lastPublishedDoi":"10.21203/rs.3.rs-8044461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8044461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRisk-stratified cancer screening (RSCS) aims to increase the effectiveness of screening while reducing potential harms by tailoring screening intervals and modalities in accordance with the individual's cancer risk. Japan already provides a population-based cancer screening program through a standardized nationwide protocol, and public acceptance and perceptions of RSCS remain largely unexplored. In this study, we investigated public attitudes toward RSCS through discussions with a Patient-Public Panel at National Cancer Center Japan, using ABC Gastric Cancer Screening as a focal case study.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe organized a workshop on RSCS for a Patient-Public Panel in 2023. 69 panel members were provided with educational materials and lectures for the subsequent group discussion. After the workshop, 62 participants completed a web-based questionnaire on their attitudes toward RSCS and understanding of its benefits and harms. Open-ended responses in the questionnaire were evaluated by qualitative exploratory analysis, and concepts, categories, subthemes and themes were identified.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWhile 22 (35.5%) of respondents supported the introduction of the RSCS, 34 (54.8%) expressed conditional acceptance only, dependent on specific factors. Three key themes were identified: perceived benefits of RSCS, concerns about RSCS, and challenges to future implementation. Regarding perceived benefits, respondents frequently noted that RSCS could enhance motivation for screening, but many expressed concern that rigorous implementation might limit personal choice and reduce screening opportunities consequent to risk assessment. Key challenges for RSCS implementation included the establishment of robust scientific evidence, effective public communication, and well-structured support systems.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eAlthough some respondents recognized the benefits of RSCS, they were reluctant about its implementation. A comprehensive understanding of the reasons underlying these public opinions is critical, and will facilitate the development of effective communication strategies and establishment of support systems.\u003c/p\u003e","manuscriptTitle":"Attitudes and Perception of Risk-stratified Cancer Screening among a Patient-Public Panel in National Cancer Center Japan: A Qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-09 07:40:52","doi":"10.21203/rs.3.rs-8044461/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-24T10:19:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272489312764393096034797329066179002755","date":"2025-12-15T09:15:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-05T09:13:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-01T15:31:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-11T10:06:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-11T03:29:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-11T03:27:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2da43473-6723-4b70-8c71-c3441c860e4f","owner":[],"postedDate":"December 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-09T07:40:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-09 07:40:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8044461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8044461","identity":"rs-8044461","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}