Abstract
Background/Aim: Disasters can jeopardize breast cancer care and Japan’s triple disaster in 2011 (earthquake, tsunami, and nuclear accident) is no exception. However, detailed information is lacking regarding the care of breast cancer related lymphedema (BCRL) following the disaster. We aimed to explore the process by which local patients become aware of BCRL, the problems faced, and the support they require. We also aimed to clarify the effects of the 2011 disaster on experiences related to lymphedema in the target population. Patients and Methods: Patients who developed BCRL after breast cancer treatment were recruited from Iwaki city, a municipality located in the southern coastal region of Fukushima (N=16). In-depth, semi-structured, face-to-face interviews were conducted, and the obtained data were appraised using thematic analysis. Results: Five themes related to BCRL were identified: 1) the process of becoming aware of BCRL, 2) troubles or worries/concerns due to BCRL, 3) information sources regarding BCRL management, 4) strategies to cope with BCRL, and 5) the adverse impacts of the 2011 disaster on BCRL management. Conclusion: Except for the disaster context, the themes are in line with those of previous studies conducted in the non-disaster context. Nonetheless, there were limited but non-negligible adverse effects of the 2011 disaster on long-term local BCRL management. The findings of this study demonstrate the necessity for individualizing coping strategies against BCRL among healthcare professionals in the Fukushima coastal area and beyond.
Breast cancer is the most common cancer in women, with an estimated 2.3 million cases and 690,000 deaths reported worldwide in 2020 (1). It has been demonstrated that disasters and crises could jeopardize various aspects of breast cancer care (2-5), potentially causing an increased morbidity and mortality related to the condition (6). Excluding the coronavirus disease pandemic, the largest evidence related to the impacts of disasters and crises on breast cancer care has been accumulated following the Japan’s triple disaster (earthquake, tsunami, and nuclear power plant accident) (3-6). While this composite disaster led to a decreased adherence to the breast cancer screening program and a delayed help-seeking behavior among undiagnosed symptomatic breast cancer patients compared with those before the disaster in the coastal area of Fukushima (3), their treatment was reportedly initiated in a timely manner even after the disaster (3). In our previous studies, we found that the timing of initial consultations for breast cancer patients was delayed after the disaster and that the breast cancer screening adherence rate declined (3). Although it was clear that breast cancer treatment had been initiated without delay after the disaster when compared with that before the disaster (7), the data lack details on the care that the patients received following treatment initiation.
In this context, it is worth exploring the care provided to patients with breast-cancer-related lymphedema (BCRL) when examining the impact of the 2011 triple disaster on breast cancer care in the coastal areas of Fukushima. BCRL is caused by damage to the lymphatic system resulting from axillary surgeries, particularly lymph node dissection, radiation therapy, chemotherapy, and environmental stimuli (8). BCRL frequently occurs in patients with breast cancer, with a prevalence of 21.4% (9), causing psychological distress and an increased risk for complications (such as infections, inflammation, and erysipelas) (10). Further, BCRL is the most severe complication of breast cancer treatment that reduces patients’ quality of life (QOL) (10). To mitigate its health burden, timely detection of BCRL and appropriate interventions, namely lymphatic drainage massage and compression sleeve, are essential (11, 12).
The burden of BCRL cannot be neglected in the coastal area of Fukushima for two reasons. Japan has recently seen a surge in breast cancer incidence, reaching approximately 91,605 cases in 2020 (13), and more than 50% of post-surgery breast cancer patients have been reported to develop BCRL (14). Second, the area has suffered from a lack of healthcare professionals with expertise in BCRL care, with only a few available in an area of 2,969 km2 and a population of 441,112. Although Japan has established a training program for lymphedema care following the curriculum proposed by the International Society of Lymphology and approximately 250 healthcare professionals receive this training program annually, a significant geographical disparity is present, as observed in the coastal area of Fukushima.
Considering previous evidence, compared with other countries, experiences related to BCRL have not been sufficiently investigated in Japan and in the coastal area of Fukushima (15-17). Consequently, there is a lack of understanding regarding when and how patients become aware of BCRL, the potential problems faced, and the support needed by these patients. Therefore, in this small-scale, qualitative study based on face-to-face semi-structured interviews with Japanese patients with breast cancer who developed BCRL, we aimed to clarify when and how the patients became aware of their BCRL and to explore the potential problems faced and the support needed by these patients in the long-term aftermath of the 2011 triple disaster. We also aimed to identify the potential adverse impacts of the disaster on local BCRL management.
The research questions of this study were as follows. 1) When and how were patients aware of BCRL in the long-term aftermath of the 2011 triple disaster? 2) What problems were faced by patients with BCRL in the long-term aftermath of the 2011 triple disaster? 3) What support was required by patients with BCRL in the long-term aftermath of the 2011 triple disaster? 4) Was there any long-term adverse impact of the 2011 triple disaster on local BCRL management?
Patients and Methods
Study site. This study was conducted at the Jyoban Hospital in Iwaki city, Fukushima, Japan. Iwaki city is located in the southern coastal area of Fukushima and has a population of approximately 320,000 as of 2022, making it the prefectures with the second largest population of all prefectures in the Tohoku Region of Japan. There was a consistent shortage of physicians in the city, which worsened following the 2011 triple disaster. By 2022, the number of physicians per 100,000 in the city was 167, approximately two-thirds of the national average (247). Regarding breast cancer care, only two board-certified specialists are currently available in the city.
Jyoban hospital is a core hospital in Iwaki city, where specialized breast cancer care was initiated in 2018. The total number of outpatient visits was 5,300 in 2021, with 102 breast cancer surgeries and 693 outpatient chemotherapy treatments in the same year. Furthermore, Jyoban hospital was reported to have the highest number of breast cancer inpatients in the coastal area of Fukushima, with 119 in 2020, which was the fourth highest in the entire region of Fukushima prefecture. With one board-certified breast cancer specialist and two healthcare professionals who have received lymphedema training, it can be regarded as a core facility for breast cancer and BCRL in the coastal area of Fukushima.
Participants. Since its establishment in 2018, the number of surgeries has steadily increased, with 90 surgeries in 2020 and 102 surgeries in 2021. Consequently, an increasing number of patients have developed BCRL over time. Interviewees, including those diagnosed with lymphedema at the hospital, were recruited between 2020 and 2022. All recruited patients agreed to participate and 16 were interviewed.
For the recruitment process, AO referred study patients who had been diagnosed with lymphedema during their outpatient visits. AO then informed NK, who set up the date and time for the interviews by phone directly with the participants. NK then explained the protocol using an explanation form, and those who provided their consent were included in this study. The participants were also instructed to perform lymph drainage massage and wear compression sleeves to ease their symptoms or prevent further development when necessary.
Interview. Face-to-face semi-structured interviews were conducted, lasting approximately one hour per participant. The interviews were recorded with the consent of each participant. Patients were asked questions regarding the following characteristics: i) sociodemographic and clinical characteristics; ii) the process of becoming aware of BCRL; iii) troubles or worries/concerns due to BCRL; iv) information sources regarding BCRL management; v) how to cope with BCRL; vi) adverse impacts of the 2011 triple disaster on local BCRL management; and vii) others. These questions were developed based on the previous literature and local context of breast cancer care (3-5, 7, 18).
Analysis. The interview data collected was categorized and analyzed through thematic analysis, a six-step process proposed by Braun and Clarke in their 2006 work, which was used in this study (19).
1) Comprehension: Interviews were read repeatedly by NK to establish initial interpretations and patterns.
2) Initial coding: Initial coding was conducted to organize interview data as below by NK.
3) Theme search: NK analyzed the obtained data and categorized the codes into potential themes.
4) Theme considerations: The following five themes were identified: the process of becoming aware of BCRL, troubles or worries/concerns due to lymphedema, information sources regarding BCRL management, strategies to cope with BCRL, and adverse impacts of the 2011 disaster on BCRL management.
5) Theme definition and naming: During this stage, NK refined each theme and ensured that the themes and data obtained were coherent and consistent. Each theme was reviewed using interview data from NK, AO, and YK to ensure coherence and consistency. After independent reviews, multiple meetings were held to reach agreed-upon themes. The themes identified by NK in step 4 were confirmed by all authors. The codes and themes obtained from the patients’ interviews were those indicated in Table I.
Codes and themes derived from the patients’ interview.
Ethical clearance. This study was approved by the Ethical Committee of Jyoban hospital of the Tokiwa Foundation (JHTF-2020-013). All participants provided informed consent before participating in the study.
Results
Table II presents the characteristics of the 16 women who participated in this study. They were between 40 and 70 years of age and had BCRL in the diseased upper extremity.
Clinical characteristics of participants.
Theme 1: Process of becoming aware of BCRL. The majority of participants were treated with chemotherapy and developed BCRL immediately after chemotherapy. Patient testimonials are presented below: “I remember I had chemotherapy four times per three weeks, followed by radiation therapy. This was the timing when I noticed a swollen arm.” (Participant 1); “My arm started swollen at maybe around the last administration of chemotherapy” (Participant 6); “I guess it started around the last treatment of anticancer drugs. Around that time, I thought I was getting an edema in my arm” (Participant 5); “I got sepsis after the anticancer drug. I became aware of an edema of my arm just after I was hospitalized for sepsis” (Participant 3); “It was my second operation and I thought I didn’t have anything to do with it because I didn’t have oedema during the previous operation, but this time I noticed oedema as soon as I did the treatment” (Participant 11); “Immediately after surgery, edema was noticed” (Participant 13).
After becoming aware of edema in their arms, some patients consulted healthcare professionals and received treatment. Some patient testimonials are shown below:
“Every time I went to see the doctor for chemotherapy, I told him that I had an edema in my arms” (Participant 4); “I told the nurse when I started to feel an edema in my arms” (Participant 5); “I consulted my doctor immediately after I became aware of the situation” (Participants 9 and 15). Participant 15 has also mentioned the same concerns.
Some participants also commented that they were not aware of edema in their arms but perceived discomfort. Certain testimonials are presented below:
“I wasn’t really aware of an edema of my arm, but the doctor said I might have it. It felt very stiff. Even when I stretched my arm, it still felt tight.” (Participant 2); “Not aware of oedema, but when she showed her arm to her doctor, he pointed out the oedema” (Participant 12).
Therefore, many participants were treated with concomitant chemotherapy, and most became aware of the edema in their arms immediately after treatment. Subsequently, some patients consulted healthcare professionals to manage their symptoms. A few participants were not aware of the edema in their arms but perceived discomfort.
Theme 2: Troubles or worries (concerns) about BCRL. The troubles and worries related to BCRL varied considerably among patients, and each patient expressed different concerns depending on their lifestyle. These concerns are associated with a decline in the QOLs. The patients’ comments varied widely and were personal. Most perceived discomfort in their daily lives or at work and mentioned that it had an impact on their mental health. Some patient testimonials are presented below: “I had no power and felt numb. I was frustrated that I could not work. I had a hard time keeping up with it emotionally. The edema was just too much. I felt very overwhelmed. My hand got pumped up like a glove. I couldn’t bend my joints and couldn’t grip anything. I couldn’t write. I couldn’t even use a computer without making mistakes” (Participant 3); “This hand edema was very noticeable in the workplace. I was often stared at. It was the time of year for short sleeves, so it was a matter of appearance. Some of my male colleagues were wearing short sleeves with sports-type innerwear, so I didn’t feel any discomfort in wearing such underwear. However, I am personally sensitive to heat, so I think it would be too hot to wear long sleeves in addition” (Participant 4); “At first, I couldn’t dry the laundry because I couldn’t raise my hand” (Participant 5); “Pain, lethargy, or other discomfort” (Participants 9, 11, and 12). Participants 11 and 12 have also mentioned the same concerns.
However, several people commented that BCRL did not interfere with their daily lives and did not significantly affect them. Some patient testimonials follow: “It’s heavy, but that doesn’t mean I can’t do anything” (Participant 1); “I didn’t know (about BCRL) because I haven’t compared myself to others. I have no way to deal with it, so I have to live with it” (Participant 7); “It didn’t hinder me in any particular way, but I knew it would be difficult if the oedema got worse” (Participant 14). One patient complained that she could have appropriately coped with BCRL if provided with more information on the condition beforehand; “I think it would have been a little different if there was a way for them to tell us when we wanted care rather than just giving us chemotherapy” (Participant 8).
While there were significant differences in experiences between the patients, the majority perceived discomfort in their daily lives and work, and experienced mental difficulties because of BCRL. A minority of patients did not particularly perceive difficulties by BCRL.
Theme 3: Information source regarding BCRL management. All patients consulted healthcare professionals to gather the necessary information. While the majority of the patients knew about BCRL before consultation, some had never heard of it until they were diagnosed: “I asked the hospital staff about how to do the drainage. I also searched (the relevant information) on my smartphone. I saw the same symptoms as mine and I knew it was lymphedema” (Participant 4); “I thought I was getting edema. I consulted a nurse” (Participant 6). Three of the participants also gathered information from books and the Internet: “I bought a medical book as soon as I found out that I had breast cancer” (Participant 3). Two said that they only gathered information from healthcare professionals and did not dare search the internet, as there was abundant information that was confusing: “Gathered information from healthcare professionals and did not dare to use the internet” (Participants 10 and 12); Participant 12 also mentioned the same concerns.
One patient did not seek help even after developing BCRL:“I did not consult doctor… I thought it would never recover” (Participant 1).
One of the participants already knew about BRCA from the explanations they received from healthcare professionals before and after their surgeries, or from the rehabilitation that they had undergone during their hospitalization: “Before the surgery, the doctor and nurses explained everything to me. So, I knew it was something like that. I also learned about it from the rehabilitation staff while I was in the hospital” (Participant 2).
Theme 4: Strategies to cope with BCRL. Most patients consulted healthcare professionals regarding BCRL and adopted appropriate action. They said that they learned about lymphatic drainage massage from a pamphlet prepared by the hospital after consulting healthcare professionals, whereas others said that they had received care and support from rehabilitation services. Additionally, some were introduced to compression sleeves. Some of the patients testimonials are presented below: “When I was in the hospital, I asked the staff in the rehabilitation department about what to do when I had edema” (Participant 2); “When I had an edema in my arm, I consulted with my doctor and nurse and considered purchasing a compression sleeve” (Participant 3); “I was actually taught how to perform drainage in outpatient rehabilitation” (Participant 4); “I think it’s getting so easier now that I’ve been introduced about the sleeve” (Participant 6); “The attending doctor suggested rehabilitation” (Participants 14, 15, and 16); Participants 15 and 16 also mentioned the same concerns.
In summary, most patients commented that they had learned about lymphatic drainage massage and compression sleeves from healthcare professionals. They also said that they were under care related to BCRL when they were interviewed by us, but others said that their BCRL improved to the point where it was no longer a concern due to compression sleeves, and some had stopped using them. Some patients talked about how comfortable they felt after dealing with their symptoms using compression sleeves.
Theme 5: Adverse impacts of the 2011 disaster on BCRL management. Most participants mentioned that the disaster did not affect their BCRL care. Some of their testimonials are presented below: “The earthquake did not particularly affect me” (Participants 3 and 8); “Not particularly affected, but asked about the earthquake when visiting another hospital” (Participant 16); However, one participant mentioned that medical facilities became crowded after the earthquake:
“After the earthquake, medical institutions became crowded, and I had to refrain from seeing a doctor. I also searched the Internet for breast surgeons in my area but could not find any. I felt that there might be a shortage of doctors” (Participant 4).
Therefore, we can assume that the negative impact of the 2011 triple disaster on local BCRL management was limited. However, it has become clear that some were affected.
Discussion
Our qualitative analysis of interviews with patients with breast cancer who developed BCRL following their treatment in a hospital located in the coastal area of Fukushima, where the impact of the 2011 triple disaster remains strong, identified five themes related to BCRL experiences: the process of becoming aware of BCRL (theme 1), troubles or worries/concerns due to lymphedema (theme 2), information sources regarding BCRL management (theme 3), coping with BCRL (theme 4), and adverse impacts of the 2011 disaster on BCRL management (theme 5). Given that findings similar to themes 1-4 were observed in previous studies conducted in non-disaster settings, these findings demonstrate the importance of improving BCRL care in the area, as has been conducted in other non-disaster settings. Although we observed only limited adverse impacts of the disaster on local BCRL management (theme 5), how BCRL would impact the health and QOL of patients with breast cancer in the long term following a disaster should not be neglected. The current findings are also important for improving the awareness of healthcare professionals and patients and for developing necessary interventions in such a context.
Regarding theme 1, previous studies have shown that patients treated with mastectomy, lymph node dissection, radiation therapy, and chemotherapy have a higher risk for developing BCRL (18). The overall incidence of upper extremity BCRL has also been reported to range from 8% to 56% in the two-year postoperative period (18), which is consistent with that reported in this study, given that all patients developed BCRL within two years. Previous studies have noted that words, such as “painful”, “heavy”, “tight”, and “pulling” are commonly used by patients to describe discomfort that may be present before visible signs of edema are noticed (18). It is possible that patients who reported these perceptions were also in the early stages of BCRL. Early intervention would lead to better cosmetic and functional outcomes than late intervention (20, 21). Thus, effort should be made to enhance awareness in BCRL among both healthcare professionals and post-treatment breast cancer patients.
Regarding theme 2, previous studies have reported that BCRL is associated with lower QOL and physical function, especially in the long term, leading to a diminished role at home and work (18). In this study, the symptoms varied considerably between patients, with some describing no particular disturbance and others experiencing severe symptoms. We believe that variations in the participants’ occupations and lifestyles might have influenced how they perceived certain issues or found them troubling.
Additionally, one of the main problems noted by patients was the necessity of wearing compression sleeves. Substantial evidence indicates that certain aspects of women’s daily lives, including clothing, appearance, and activities, are adversely affected by BCRL (22). Despite the variety of sleeves currently available, improvements can be made to address these issues.
Regarding theme 3, healthcare professionals were one of the most important sources of information for patients. In a previous study, nurses were reported to be the most common source of information (23), and this finding is in line with the previous evidence. However, in this study, only a minority of patients received explanations from their healthcare professionals before and after surgery, which suggests the need for a better system for timely delivery of information related to BCRL.
Furthermore, these findings highlight the importance of enhancing patient education. Previous studies have shown that to improve patients’ knowledge and awareness about BCRL, it is necessary to provide holistic education, including BCRL management protocols (14, 15, 18). Education and training are essential components of management to ensure that appropriate care is provided for those with BCRL. These instructions are essential, given that Japanese and other Asian populations tend to avoid seeking help from healthcare professionals for their concerns (20, 21, 24).
Regarding theme 4, the treatment of BCRL is a multimodal approach that includes compression therapy, therapeutic exercises, and pharmacotherapy (18). Those who had been introduced to these interventions told us that they were much more comfortable, suggesting the importance of patient education in BCRL care (14, 25). In Japan, a change in the medical reimbursement system in April 2020 enabled physical and occupational therapists to be involved in patient education and rehabilitation during hospitalization, even for patients who only underwent sentinel node biopsy in breast cancer surgery. However, healthcare professionals’ interest in BCRL remains limited, their knowledge is insufficient, and it is difficult for most rehabilitation professionals to manage BCRL independently. Thus, collaboration among multiple professionals and continuous learning are essential.
In our hospital, a breast cancer specialist who started working in 2018 (AO) underwent a comprehensive lymphedema training program offered by the Life Planning Center Foundation under the supervision of the Ministry of Health, Labour and Welfare, which increased his skills in BCRL diagnosis and treatment. We also have rehabilitation staff with experience in the same training at the foundation (NK). Since then, these two staff members have worked together to develop a system for the proper diagnosis and treatment of BCRL. We now educate on the timing of BCRL development and its major symptoms in patients with breast cancer, encourage distributing the booklet on BCRL, and highlight the significance of timing of undergoing surgeries, detecting a swelling or dullness of the upper extremities at the diseased side at an early timing, applying lymphatic drainage and starting the use of compression sleeves. We also placed the BCRL bookshelf at the outpatient office, where patients could obtain it freely. Thus, we believe that most cases of BCRL were managed appropriately.
In the future, it will be necessary to expand educational programs targeting healthcare professionals regarding the pathophysiology and treatment of BCRL and the need for multidisciplinary cooperation. Further, considering that patients have different concerns depending on their symptoms and severity, as well as their lifestyles, their care should be individualized to meet the concerns of each patient.
Regarding theme 5, the impact of the disaster on local BCRL management was limited. The main reason for this is that more than ten years have passed since the disaster. In addition, as some patients still complained of the effects of the disaster even after 10 years, it is necessary to understand that in a large-scale disaster, the effects on the BCRL management remain for a long period. Specifically, there have been only a few doctors specializing in breast care in the affected area of Fukushima, and as a result, local breast cancer patients continue to lack access to specialized care related to BCRL. In the future, it will be necessary to improve the situation by training medical personnel in the region or recruiting them from other regions.
Study limitations. This study has several limitations. First, we considered only patients from one hospital in the affected area. While this factor might impact the generalizability of our findings, we reached saturation with the data we had. Additionally, the notion of generalizability in qualitative research continues to be a subject of ongoing discussion (26, 27). Second, the primary investigators are physicians who have been treating the patients/participants, and the patients may not have mentioned their true experience, which could have led to a bias in the observed findings. Third, because our department was established in 2018, we did not have pre-disaster data. Consequently, it was difficult to design a study to compare pre- and post-disaster data with regard to BCRL. Hence, it is important to use this pilot study to examine the impact of disasters on breast cancer care more extensively. However, our previous studies have shown that the impact of this disaster on local breast cancer management in the affected area persisted in the long term, mainly because of the nuclear power plant accident (3). Thus, this complex disaster can be considered a unique phenomenon worth exploring, even after ten years. Last, most of our patients developed BCRL approximately at a similar time following treatment (Table I), which made it difficult to evaluate the impact of the time interval between treatment and BCRL development on their experiences.
Conclusion
In this qualitative assessment of the experiences related to BCRL in post-disaster Fukushima, Japan, we found five themes related to this condition. Most participants with BCRL were aware of this immediately after the initial treatment (theme 1). Each patient had different concerns regarding daily life, work, and mental anxiety (theme 2) and chiefly consulted healthcare professionals to solve her concerns, although few were reluctant (theme 3). This implies that BCRL care should be tailored to patients’ concerns (theme 4). These findings are basically in line with those of previous studies conducted in non-disaster settings, which means that it is important to coordinate BCRL care in disaster settings as in ordinary non-disaster settings. In addition, there were limited but non-negligible adverse effects of the 2011 disaster on long-term local BCRL management. Thus, there should be increased awareness regarding BCRL among patients with breast cancer, and healthcare professionals should proactively consider BCRL as a common complication of breast cancer and implement the necessary interventions in post-disaster settings even beyond Fukushima, Japan. Thus, as an easy countermeasure, healthcare professionals in charge of care should proactively look for clues to BCRL and suggest effective interventions, such as compression sleeves and lymphatic drainage massage. The findings of this survey demonstrate the necessity for individualizing coping strategies against BCRL among healthcare professionals in the Fukushima coastal area and beyond.
Footnotes
Authors’ Contributions
Conceptualization: Naomi Kobayashi, Akihiko Ozaki, Yasuhiro Kotera, Yudai Kaneda, Divya Bhandari, Katsumori Takamatsu, Tadashi Kasai, Megumi Arai, Junko Takasaki, Hiroaki Saito, Toyoaki Sawano, Yoshiaki Kanemoto, Hiroyuki Sato, Masaharu Tsubokura, Tomoihro Kurokawa, Kazunoshin Tachibana, Masahiro Wada, Tetsuya Tanimoto, Tohru Ohtake, Tomozo Ejiri, Hiroaki Shimmura, and Norio Kanzaki. Data curation: Naomi Kobayashi and Akihiko Ozaki. Formal analysis: Naomi Kobayashi and Akihiko Ozaki. Investigation: Naomi Kobayashi and Akihiko Ozaki. Methodology: Naomi Kobayashi, Akihiko Ozaki, Yasuhiro Kotera, Yudai Kaneda, Divya Bhandari, Katsumori Takamatsu, Tadashi Kasai, Megumi Arai, Junko Takasaki, Hiroaki Saito, Toyoaki Sawano, Yoshiaki Kanemoto, Hiroyuki Sato, Masaharu Tsubokura, Tomoihro Kurokawa, Kazunoshin Tachibana, Masahiro Wada, Tetsuya Tanimoto, Tohru Ohtake, Tomozo Ejiri, Hiroaki Shimmura, and Norio Kanzaki. Project administration: Naomi Kobayashi and Akihiko Ozaki. Writing – original draft: Naomi Kobayashi and Akihiko Ozaki. Writing – review & editing: Naomi Kobayashi, Akihiko Ozaki, Yasuhiro Kotera, Yudai Kaneda, Divya Bhandari, Katsumori Takamatsu, Tadashi Kasai, Megumi Arai, Junko Takasaki, Hiroaki Saito, Toyoaki Sawano, Yoshiaki Kanemoto, Hiroyuki Sato, Masaharu Tsubokura, Tomoihro Kurokawa, Kazunoshin Tachibana, Masahiro Wada, Tetsuya Tanimoto, Tohru Ohtake, Tomozo Ejiri, Hiroaki Shimmura, and Norio Kanzaki.
Conflicts of Interest
Akihiko Ozaki received personal fees from MNES Inc. outside of the submitted work. Tetsuya Tanimoto received personal fees from MNES Inc. and Bionics outside of the submitted work. The Authors declare no conflicts of interest in relation to this study.
- Received July 20, 2023.
- Revision received October 21, 2023.
- Accepted October 23, 2023.
- Copyright © 2024, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
