The Effects of Cancer Survivor Support Service on Distress in South Korea: A Nationwide Prospective Pilot Study

doi:10.21203/rs.3.rs-753682/v1

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The Effects of Cancer Survivor Support Service on Distress in South Korea: A Nationwide Prospective Pilot Study

https://doi.org/10.21203/rs.3.rs-753682/v1

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Background: To investigate the characteristics of cancer survivors and the effects of the services of the Korean Cancer Survivorship Center Pilot Project launched by the South Korean government on distress.

Methods: A prospective observational cohort study was performed in cancer survivors who completed primary treatment. Cancer survivors’ distress and symptoms such as fatigue, pain, depressive mood, anxiety, and insomnia were evaluated by well-trained nurses. Regarding to their needs, medical and psychosocial support services were provided.

Results: This study included 1,921 cancer survivors, with a mean age of 57.3 years (68.7% females). The breast cancer was most common, followed by stomach and colorectal cancer. Psychosocial and medical support decreased the percentage of the high-distress group from 50.9% to 30.5% and decreased the percentage of cancer survivors with high scores in fatigue, pain, anxiety, depressive mood, and insomnia. The independent predictors of a low distress level after the use of the services were older age, the relief of fatigue, pain, and insomnia.

Conclusions: This study showed that psychosocial and medical support is associated with the lower distress and physical and mental symptoms of cancer survivors. Psychosocial and medical support could contribute to distress relief in cancer survivors. Further management strategies for fatigue, pain, and insomnia are required.

Cancer Biology

Oncology

cancer survivor

cancer survivorship management

distress

support service

government-led

The numbers of cancer survivors are gradually increasing owing to advances in screening and treatment strategies. However, they still suffer from various difficulties including long-term treatment effects, late-effects of treatment, distress, anxiety, uncertainty, fatigue, secondary malignancy, and other medical illness [1–5]. Unmanaged distress has negative effects on all-cause and cancer-related morbidity and mortality, as well as quality of life [6, 7]. Distress is defined as ‘an unpleasant experience of a mental, physical, social, or spiritual nature’ [8]. Because distress is caused by physical, psychological, and social problems, psychosocial and medical support should be included in cancer care [9].

The 5-year relative survival rate of cancer patients in South Korea improved substantially from 41.2% for the period 1993–1995 to 70.6% for the period 2012–2016; there were approximately 1,740,000 cancer survivors in 2016 [10]. The age-standardized 5-year net survival rates in South Korea are among the highest of the 32 countries in the Organization for Economic Cooperation and Development (OECD); 5-year survival rates are 71.8% in colon cancer patients, 71.1% in rectal cancer patients, 68.9% in stomach cancer patients (ranked first among OECD countries) and 25.1% in lung cancer patients (ranked third among OECD countries) [11]. Nevertheless, South Korea has lacked a systematic support system for cancer survivors. To improve the health status of cancer survivors and facilitate their return to normal social lives, the Korean Ministry of Health and Welfare together with the National Cancer Center, a government-endorsed organization, launched the Korean Cancer Survivorship Center Pilot Project (K-CSCP) in July 2017.

We investigated characteristics of cancer survivors visiting cancer survivorship centers (CSCs) and the associations of the Korean Cancer Survivorship Center Pilot Program with survivors’ distress and distress-related symptoms including pain, fatigue, anxiety, depressive mood, and insomnia.

Study Design

This study was a prospective, observational cohort study performed from July 2017 to December 2018 in South Korea. Seven regional cancer centers and one national cancer center covering the regional areas in South Korea were designated in 2017, and one more center was joined in 2018.

Before supportive services, well-trained nurses evaluate cancer survivors in various areas including distress, distress related symptoms, and social welfare area. After the initial assessment, survivors were divided into low-risk groups (all areas with low symptom burden) and high-risk groups (one or more of the eight areas with moderate to high symptom burden). Cancer survivors in the high-risk group were evaluated by doctors at CSC’s cancer-survivorship clinic because of their greater symptom burdens and unmet needs for supportive care and referred to specialists in other medical departments as needed. Then, they were provided with cancer survivor support services (Supplementary Table 1) as needed. They were reassessed after 1 month or 3 months from baseline according to their risk levels using part of the initial assessment tool.

Participants

This program was targeted to any adult cancer survivor who completed curative-intent anti-cancer treatment including surgery, chemotherapy, or radiotherapy. Survivors undergoing maintenance hormonal therapy were also included. This study excluded individuals at the end-stage of cancer needing hospice-palliative care. Cancer survivors were recruited through a variety of channels, such as referrals from medical staff, recommendations from other patients, or advertisements. A total of 2,601 cancer survivors registered to the CSCs, however, 156 individuals refused to participate in this study; therefore, 2,445 subjects were finally included. Of these, 1,921 subjects completed re-assessment of distress and were included in the analyses. Informed consent was obtained from each study participant. The study was approved by the institutional review boards of National Cancer Center (IRB No.: NCC2017-0204) and other seven hospitals.

Outcome Measures

Tools included physical and mental health, and social welfare items. The baseline assessment tool comprised a self-report questionnaire and an observer-assessment tool used by nurses. We gathered data about basic sociodemographic factors (age, sex, education level, and marital status), income, life behavior (smoking and drinking habits), health conditions (body mass index, comorbidity), distress, and distress related symptoms including anxiety, depression, insomnia, fatigue, and pain by paper questionnaire and interview. We used patient treatment summaries to obtain clinical information related to cancer diagnosis and treatment.

We used the National Comprehensive Cancer Network (NCCN) distress thermometer (DT) and Problem list for distress screening, which were validated in Korean [12, 13]. The DT was a one-item measure of distress – on a scale of zero to 10, 10 being the worst. A cut-off of ≥ 4 has been accepted by the NCCN to indicate clinically meaningful distress [8]. Using this cut-off, cancer survivors were divided into high- and low-distress groups. For screening other domain including fatigue, pain, anxiety, depressive mood, and insomnia, we used 11-point (0–10) Likert scales [14, 15]. We used the EuroQuo-visual analog scale (EQ-VAS) to assess the quality of life [16, 17].

Cancer Survivor Support Service

A multidisciplinary cancer survivor support team comprising doctors, nurses, and social workers provided the cancer survivor support services. The CSC nurses who were oncology nurses or nurses with at least 2-year experience in cancer care conducted individual education or counseling during the baseline assessment. The CSC social workers were medical social workers or social workers with at least 2-year experience in counseling in other institutions.

When the assessment score was 4 or more, we provided services by symptom categories. Primarily several educational programs of various topics, including management of adverse effects of cancer treatment, proper nutrition, undergoing secondary malignancy screening, the importance of vaccinations, and maintaining a healthy lifestyle such as quitting smoking or alcohol, managing distress, and ensuring good sleep routines were provided. In addition, counseling, group programs such as programs of exercise and psychological support, social welfare counseling or cancer survivorship clinics treatment were provided if needed. The composition of the program differed according to the conditions in each CSC.

Statistical Analyses

We analyzed the continuous variables using an independent t-test, and categorical variables using the chi-square test (or Fisher’s exact test, if appropriate). We used the McNemar test to evaluate the changes in proportion of distress, and distress related symptoms including fatigue, pain, anxiety, depressive mood, and insomnia. Multivariate analysis of covariance was used to examine estimated mean scores in EQ-VAS, distress, pain, fatigue, anxiety, depressive mood, and insomnia according to distress levels after adjusting for age, sex, education levels, economic status, cancer diagnosis, cancer treatment, and time from diagnosis to CSC visit. Univariate logistic regression was carried out, and significant variables were entered into multivariate logistic regression to determine predictors of a low-distress level after services. Statistical analyses were performed using SAS (version 9.4, SAS Inc., Cary, NC, USA). A two-sided P-value < 0.05 was considered to indicate significance.

Baseline characteristics

This study included 1,921 cancer survivors, with a mean age of 57.3 years (68.7% females). The most common cancer was breast cancer (41.3%), followed by stomach cancer (21.7%), colorectal cancer (11.5%), and other cancers. Cancer survivors were grouped by their DT scores; 49.1% had low distress (DT score < 4) and 50.9% had high distress (DT score ≥ 4). Compared to the low-distress group, the high-distress group were younger and had a higher percentage of the high-risk groups in terms of symptom burdens at baseline, being female, having breast cancer, and undergoing non-surgical treatment modalities (chemotherapy, radiotherapy, or other anti-cancer treatment). Conversely, the high-distress group had a lower percentage of patients with stomach or colorectal cancers, compared to the low-distress group (Table 1).

Table 1

Characteristics of cancer survivors according to distress level at baseline
Variables			Total n = 1,921		Low-distress group^† n = 943 (49.1%)		High-distress group^‡ n = 978 (50.9%)		p-value
Variables			n	(%)	n	(%)	n	(%)	p-value
Age, year			57.3 ± 11.2		58.8 ± 10.9		55.9 ± 11.2		< 0.001^**
Female			1320	(68.7)	603	(63.9)	717	(73.3)	< 0.001^**
Education
	<High school		563	(29.3)	294	(31.2)	269	(27.5)	0.077
	High school		702	(36.5)	342	(36.3)	360	(36.8)	0.805
	>High school		635	(33.1)	299	(31.7)	336	(34.4)	0.217
Income, dollars/month
	< 850		395	(21.9)	183	(20.7)	212	(23.0)	0.244
	850 ~ 1,700		319	(16.6)	154	(16.3)	165	(16.9)	0.750
	1,700 ~ 2,550		333	(17.3)	163	(17.3)	170	(17.4)	0.955
	2,550 ~ 3,400		304	(15.8)	160	(17.0)	144	(14.7)	0.178
	≥ 3,400		456	(23.7)	224	(23.8)	232	(23.7)	0.987
Married/living with partner			1,577	(82.9)	789	(84.2)	788	(81.6)	0.128
With jobs			644	(33.6)	329	(34.9)	315	(32.4)	0.244
Time from cancer diagnosis, years			3.4 ± 3.7		3.6 ± 4.1		3.1 ± 3.3		0.003^*
Cancer diagnosis
		Breast cancer	792	(41.3)	359	(38.2)	433	(44.4)	0.005^*
		Stomach cancer	415	(21.7)	227	(24.1)	188	(19.3)	0.010^*
		Colorectal cancer	221	(11.5)	124	(13.2)	97	(9.9)	0.027^*
		Other cancer	488	(25.5)	231	(24.5)	257	(26.4)	0.363
Cancer treatment
		Surgery	1,816	(95.8)	890	(95.4)	926	(96.2)	0.406
		Chemotherapy	973	(51.3)	454	(48.7)	519	(54.0)	0.021^*
		Radiotherapy	895	(47.2)	411	(44.1)	484	(50.3)	0.007^*
		Other cancer treatment (hormone therapy, etc)	515	(27.4)	223	(24.1)	292	(30.6)	0.002^*
CSC visit route
		Recommendation of hospital staff	639	(33.3)	358	(38.0)	281	(28.7)	< 0.001^**
		Recommendation of oncologist	365	(19.0)	210	(22.3)	155	(15.8)	< 0.001^**
		In-hospital advertising (poster, leaflet, banner, etc.)	339	(17.6)	117	(12.4)	222	(22.7)	< 0.001^**
		Recommendation from other patients	159	(8.3)	68	(7.2)	91	(9.3)	0.096
		Recommendation from family and friends	77	(4.0)	38	(4.0)	39	(4.0)	0.963
		Advertising media	36	(1.9)	18	(1.9)	18	(1.8)	0.912
		Other	136	(7.1)	68	(7.2)	68	(7.0)	0.826
Scores at baseline
		EQ-VAS	67.4 ± 18.0		72.8 ± 16.9		62.1 ± 17.5		< 0.001^**
		Distress	4.0 ± 2.5		1.9 ± 1.1		6.0 ± 1.6		< 0.001^**
		Fatigue	4.2 ± 2.6		3.1 ± 2.2		5.3 ± 2.5		< 0.001^**
		Pain	2.4 ± 2.7		1.6 ± 2.1		3.2 ± 2.9		< 0.001^**
		Anxiety	2.8 ± 2.7		1.5 ± 1.9		4.0 ± 2.8		< 0.001^**
		Depressive mood	2.5 ± 2.7		1.1 ± 1.6		3.8 ± 2.9		< 0.001^**
		Insomnia	2.8 ± 2.9		1.8 ± 2.3		3.8 ± 3.1		< 0.001^**
High-risk group^§			1,475	(76.8)	622	(66.0)	853	(87.2)	< 0.001^**
^†Low-distress group had distress thermometer (DT) scores < 4; ^‡High-distress group had DT scores ≥ 4; ^§The high-risk group had moderate to high symptom burdens in one or more areas among eight areas (nutrition and diet, fatigue, pain, anxiety, depressive mood, insomnia, exercise, and social welfare) ^p value < 0.05, ^*p value < 0.001, CSC, Cancer Survivorship Center

Changes of proportion of distress and distress related symptoms after using the cancer survivor support services

Cancer survivors receiving support services decreased the proportion of people with high symptoms scores (4 point or more), such as distress (978, 50.9% vs 586, 30.5%), fatigue (1,078, 59.2% vs. 726, 39.8%), pain (567, 31.6% vs. 380, 21.2%), anxiety (678, 37.5% vs. 322, 17.8%), depressive mood (571, 31.7% vs. 275 15.2%), and insomnia (682, 37.6% vs. 409, 22.5%), as assessed after 1 or 3 months compared to baseline (all p < 0.001) (Fig. 1).

Characteristics of cancer survivors according to distress levels after using cancer survivor support services

Table 2 shows demographic and clinical characteristics in low- and high-distress group after cancer survivor support services. Compared with the low-distress group after receiving the service, the high-distress group was younger, the proportion of male, those with a monthly income of 2,550 ~ 3,400 dollars, those with high school graduates and below were low, and the proportion of those with a monthly income of ≥ 3,400 dollars was high. The proportion of stomach and colorectal cancer survivors in the low-distress group was higher. The proportion of breast cancer survivors was higher in the high-distress group, and the proportions of survivors who received chemotherapy, radiotherapy, and other cancer treatment (e.g., hormonal therapy, targeted therapy, endoscopic mucosal resection, radioactive iodine therapy, etc.) was higher. The high-distress group had lower quality of life and higher fatigue, pain, anxiety, depressive mood, and insomnia than the low-distress group, after adjusting for age, sex, education levels, economic status, cancer diagnosis, cancer treatment and time from diagnosis to visit.

Table 2

Characteristics of cancer survivors according to distress levels after using cancer survivor support services
		Low-distress group^† n = 1,335 (69.5%)		High-distress group^‡ n = 586 (30.5%)		p-value
		n	(%)	n	(%)	p-value
Age, year		58.3 ± 11.0		55.0 ± 11.1		< 0.001^**
Female		872	(65.3)	448	(76.5)	< 0.001^**
Education
	<High school	414	(31.0)	149	(25.4)	0.013^*
	High school	484	(36.3)	218	(37.2)	0.692
	>High school	424	(31.8)	211	(36.0)	0.068
Income, dollars/month
	< 850	277	(22.0)	118	(21.5)	0.783
	850 ~ 1,700	219	(16.4)	100	(17.1)	0.720
	1,700 ~ 2,550	231	(17.3)	102	(17.4)	0.956
	2,550 ~ 3,400	230	(17.2)	74	(12.6)	0.011^*
	≥ 3,400	300	(22.5)	156	(26.6)	0.049^*
Married/living with partner		1105	(83.4)	472	(81.7)	0.356
With job		466	(34.9)	178	(30.6)	0.064
Time from cancer diagnosis, year		3.5 ± 3.8		3.1 ± 3.4		0.015^*
Cancer diagnosis
	Breast cancer	504	(37.9)	288	(49.2)	< 0.001^**
	Stomach cancer	330	(24.8)	85	(14.5)	< 0.001^**
	Colorectal cancer	170	(12.8)	51	(8.7)	0.011^*
	Other cancer	327	(24.6)	161	(27.5)	0.172
Cancer treatment
	Surgery	1267	(96.3)	549	(94.5)	0.064
	Chemotherapy	645	(49.0)	328	(56.6)	0.003^*
	Radiotherapy	570	(43.4)	325	(55.8)	< 0.001^**
	Other cancer treatment	323	(24.7)	192	(33.5)	< 0.001^**
Scores after services^§
	EQ-VAS	78.7 ± 0.9		66.9 ± 1.0		< 0.001^**
	Distress	1.8 ± 0.1		5.1 ± 0.1		< 0.001^**
	Fatigue	2.7 ± 0.1		4.8 ± 0.1		< 0.001^**
	Pain	1.1 ± 0.1		3.0 ± 0.2		< 0.001^**
	Anxiety	1.3 ± 0.1		3.2 ± 0.2		< 0.001^**
	Depressive mood	1.3 ± 0.1		3.1 ± 0.1		< 0.001^**
	Insomnia	0.9 ± 0.1		2.8 ± 0.1		< 0.001^**
^†Low-distress group had distress thermometer (DT) score < 4; ^‡High-distress group had DT scores ≥ 4; ^§MANCOVA, estimated mean ± standard error; adjusted for age, sex, education levels, economic status, cancer diagnosis, cancer treatment and time from diagnosis to visit ^p value < 0.05, ^*p value < 0.001 EQ-VAS, EuroQuo-visual analog scale

Predictors Of Low Distress Level After Using The Services

Univariate analyses revealed that older age, male, a lower education level, longer length of time from cancer diagnosis, stomach, and colorectal cancer (vs. breast cancer), no history of chemotherapy, radiotherapy, or other anti-cancer treatment, and improvement of fatigue, pain, anxiety, and insomnia were associated with a low distress level after services. Multivariate logistic regression analysis showed that after using services, older age and improvement of fatigue, pain, and insomnia were independently associated with a low distress level (Table 3).

Table 3

Predicting factors of a low distress level after services
Cancer-survivor characteristics		Univariate analysis			Multivariate analysis
Cancer-survivor characteristics		OR	95% CI	p-value	OR	95% CI	p-value
Age, year		1.028	1.019–1.037	< 0.001^**	1.023	1.010–1.037	< 0.001^**
Female (ref = male)		0.580	0.465–0.724	< 0.001^**	0.825	0.598–1.137	0.240
Education level		0.853	0.754–0.965	0.012^*	1.042	0.888–1.222	0.615
Income		0.980	0.916–1.048	0.550
Cancer survivors with jobs (ref = without jobs)		1.219	0.989–1.502	0.064
Married/living with partner (ref = single/divorced, widowed)		1.128	0.874–1.456	0.356
Time from cancer diagnosis, year		1.036	1.007–1.065	0.016^*	0.995	0.964–1.027	0.760
Cancer diagnosis	Breast cancer	Ref			Ref
	Stomach cancer	2.218	1.679–2.932	< 0.001^*	1.235	0.775–1.967	0.374
	Colorectal cancer	1.905	1.349–2.689	< 0.001^*	1.183	0.736-1.900	0.487
	Other cancer	1.161	0.915–1.472	0.220	0.811	0.573–1.149	0.239
Cancer treatment	Surgery (ref = no surgery)	1.539	0.973–2.433	0.065
	Chemotherapy (ref = no chemotherapy)	0.740	0.608-0.900	0.003^*	0.796	0.627–1.010	0.060
	Radiotherapy (ref = no radiotherapy)	0.606	0.498–0.737	< 0.001^*	0.846	0.624–1.148	0.284
	Other treatment (ref = no other treatment)	0.650	0.525–0.805	< 0.001^*	0.898	0.685–1.178	0.437
Change of scores from baseline	∆Fatigue	1.163	1.109–1.220	< 0.001^*	1.124	1.064–1.187	< 0.001^**
	∆Pain	1.122	1.066–1.181	< 0.001^*	1.065	1.004–1.129	0.036^*
	∆Anxiety	1.054	1.005–1.104	0.029^*	0.996	0.943–1.052	0.881
	∆Depressive mood	1.039	0.991–1.089	0.114
	∆Insomnia	1.112	1.063–1.164	< 0.001^*	1.079	1.024–1.137	0.004^*
^p value < 0.05, ^*p value < 0.001 OR, Odds ratio; CI, confidence interval; ref, reference

This study showed that using the cancer survivor support services was related to amelioration of the distress and symptoms such as fatigue, pain, anxiety, depressive mood, and insomnia in cancer survivors. Our multidisciplinary cancer survivor support services include education, counseling, programs of exercise, or psychological support and cancer survivorship clinics, if needed. Previous studies showed that psychoeducational intervention, exercise, and education programs could improve symptom clusters including fatigue, depression, insomnia, pain, functional performance, and quality of life [18].

Within this study population, 75% were stomach, colorectal or breast cancer survivors, reflecting the current cancer epidemiological profile and clinical outcomes. In South Korea, the most common malignancy is stomach cancer (13.3%), followed by colorectal cancer (12.3%); breast cancer is the fifth most common cancer (9.5%) in the entire population and the most common cancer among females (19.9%). Furthermore, these three cancers have high 5-year survival rates (76.0, 75.9, and 92.7%, respectively) [10].

Younger cancer survivors experienced more distress levels at baseline and were not likely to improve the distress after using cancer survivor support services. A previous study [19] implied that younger patients may suffer a higher level of distress [19], perhaps due to economic vulnerability from decreased income, the larger disruption of social and familial roles in earlier developmental stages [20], a higher fear of progression, and more aggressive anti-cancer treatments [21]. In a previous study, younger survivors also reported more pain impact and intensity than older survivors [22].

At baseline, the high-distress group had high female predominance, with breast cancer survivors accounting for about half of this population. The need for supportive care among breast cancer survivors is relatively high [23]. Chemotherapy, radiotherapy, and long-term hormone therapy are widely applied to reduce the risks of breast cancer recurrence [24]. In particular, the many physical and mental symptoms caused by hormone therapy, e.g., hot flushes, night sweats, arthralgia, osteoporosis, insomnia, and depression [25], may lead to higher distress in survivors.

Older age, greater improvement of fatigue, pain and insomnia were independently associated with a low distress level after using the services in this study. Since our services focused on the general problem of cancer survivors and most cancer survivors visiting the CSC were middle-aged or old, specialized services for young cancer survivors are lacking. Therefore, they were unlikely to improve their distress after using support services.

Cancer-related fatigue is a common and distressing adverse effect of cancer and cancer therapy [26, 27]; fatigue is a common barrier for returning to work and the activities of daily life [28, 29]. Fatigue and distress have reciprocal effects on each other [30]. A study of prostate cancer survivors showed that the risk of distress was positively associated with fatigue, insomnia, urinary, bowel and androgen deprivation therapy-related symptoms, and financial difficulties [31]. Pain is also a common problem in cancer survivors [32]. Insomnia is related to fatigue itself. Insomnia contributes to additional risk for persistent fatigue after cancer treatment [33]. However, from a recent study [34], cognitive behavioral therapy did not significantly improve fatigue, although it could improve sleep.

Our project has several strengths. First, to the best of our knowledge, this pilot project is the first government-led national cancer survivor management program with adequate follow-up, worldwide. Our cancer survivorship management program is government-funded and based in academic cancer centers that were designated as regional cancer centers by the government to reduce the regional inequality of cancer care. South Koreans have good access to medical services. However, due to the lack of support systems for health and social welfare beyond the medical treatment of cancer survivors, this project was designed to develop and disseminate national programs, and to develop and operate services according to regional characteristics. Several countries have other cancer survivorship management models. For example, cancer survivorship management in the United States of America is conducted mainly by academic cancer centers. In the United Kingdom, the survivorship care model is based on the country-wide healthcare system, although medical care and other supportive services are provided by community-based primary-care clinics, private institutions, or cancer charities [35]. In Australia, medical care and other supportive services for cancer survivors are provided by cancer centers in public hospitals, in part supported by the state government and private foundation. Their supportive services include providing information to cancer survivors and training for healthcare professionals [36]. Compared to previous studies, the advantage of our study was that it provided integrated support services to cancer survivors that manage various biopsychosocial issues and include psychosocial and medical support.

This study had several limitations. First, selection bias might have occurred, in terms that those who were unable to visit a center during the daytime could not participate in this project. Second, the intervention services were diverse according to centers, and not standardized, making a quantitative assessment of their efficacies difficult. Further study designs should include standardized services. Third, primary due to lack of control group, our study result might be interpreted, considering the possibility that some people might experience self-remission even without any interventions.

This study is the first to report a nationwide government-led cancer survivor management program. Our pilot study showed positive effects on physical and mental health in cancer survivors. Predictors of a low-distress level after utilization of services were older age, and greater improvement in symptoms of fatigue, pain, and insomnia. Specialized support services to manage major issues for younger cancer survivors, i.e., childbearing, childcare, marriage, study, or career, are needed. Furthermore, management strategies to control fatigue, pain and insomnia are also required.

confidence interval; CSC:cancer survivorship center; DT:distress thermometer; EQ-VAS:EuroQuo-visual analog scale; K-CSCP:Korean Cancer Survivorship Center Pilot Project; NCCN:National Comprehensive Cancer Network; OECD:Organization for Economic Cooperation and Development; OR:odds ratio; ref:reference.

Acknowledgements

We would like to thank Textcheck (www.textcheck.com) for editing and reviewing this manuscript for English language.

Authors’ contributions

HJL: Conceptualization, Methodology, Formal analysis, Writing - Original Draft, Writing - Review & Editing YAK: Conceptualization, Methodology, Writing - Review & Editing, Supervision, Project administration SYR, MC, CYY, HTK, JHK1, JSH, JHK2, KHL, SYJ, HCK, EG, YSL, and EHY: Data Curation HYJ: Methodology YJC: Supervision, Project administration

All authors have read and approved the manuscript.

Funding

None.

Availability of data and materials

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the institutional review boards of National Cancer Center (IRB No.: NCC2017-0204) and other seven hospitals. Informed consent was obtained from each study participant due to the retrospective design.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Author details

¹Division of Cancer Control & Policy, National Cancer Center, Goyang, Korea

²National Cancer Survivorship Center, National Cancer Center, Goyang, Korea

³Department of Psychiatry and Behavioral Science, National Cancer Center, Goyang, Korea

⁴Department of Psychiatry, Seoul National University, Seoul, Korea

⁵Department of Surgery, Chonnam National University Medical School, Gwangju, Korea

⁶Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Korea

⁷Department of Internal Medicine, Chonbuk National University Medical School and Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Korea

⁸Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea

⁹Department of Family Medicine, Chungbuk National University Hospital, Cheongju, Korea

¹⁰Department of Family Medicine, Chungbuk National University College of Medicine, Cheongju, Korea

¹¹Division of Hematology-Oncology Department of Internal Medicine, College of Medicine, Gyeong-Sang National University, Jinju, Korea

¹²Department of Medicine, Gyeong-sang National University Hospital, Jinju, Korea

¹³Department of Urology, School of Medicine, Jeju National University, Jeju, Korea

¹⁴Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea

¹⁵Breast Cancer Center, National Cancer Center, Goyang, Korea

¹⁶Department of Radiation Oncology, Chonbuk National University Hospital, Jeonju, Korea

¹⁷Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute, Chonbuk National University Hospital, Jeonju, Korea

¹⁸Department of Radiation Oncology, Chonbuk National University Medical School, Jeonju, Korea

¹⁹Department of Family Medicine, Postgraduate Collage of Medicine, Kangwon National University, Chuncheon, Korea

²⁰Cancer Survivorship Branch, National Cancer Center, Goyang, Korea

²¹Department of Pediatrics, Samsung Medical Center, Seoul, Korea

²²Division of Cancer Registration & Surveillance, National Cancer Center, Goyang, Korea

²³Center for Cancer Prevention & Detection, National Cancer Center, Goyang, Korea

²⁴National Hospice Center, National Cancer Center, Goyang, Korea

²⁵Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, Korea

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The Effects of Cancer Survivor Support Service on Distress in South Korea: A Nationwide Prospective Pilot Study

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Background

Methods

Study Design

Participants

Outcome Measures

Cancer Survivor Support Service

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Results

Baseline characteristics

Predictors Of Low Distress Level After Using The Services

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