https://orcid.org/0000-0003-3088-1091
ABSTRACT
Introduction
In Japan, two groups of women, HPV vaccinated and unvaccinated, are approaching age 20, when they should begin cervical cancer screening. To improve Japan’s current poor cervical cancer screening rate, we need to know how these women are thinking about screening.
Methods
We conducted an internet survey of 20-y-old women, exploring their understanding of HPV and cervical cancer screening. We then gave them leaflets with basic information about HPV and cervical cancer, stressing the importance of early detection by screening. We analyzed the leaflet’s effects on their attitudes based on their vaccination status.
Results
Our study of 618 women found a significantly higher intention for engagement for cervical cancer screening in women HPV-vaccinated as teenagers (29% versus 17%). They were also more aware that: (1) HPV is transmitted by sexual intercourse (49.1% versus 39.2%); (2) the HPV vaccine prevents cervical cancer (49.0% to 34.0%); and (3) the appropriate cervical cancer screening interval is every 2 y (63.3% versus 56.2%). Women in both groups responded well to the leaflet, with significant improvements in intention to receive screening. However, 65%-67% were not swayed.
Discussion
HPV-vaccinated women were more knowledgeable about cervical cancer and had a greater intention to receive screening. Our educational leaflet was moderately effective in both groups for increasing intentions to screen, but the majority in both groups were still resistant to screening.
Conclusion
Japan needs to develop more effective educational programs and tools to vigorously impart the importance of cervical cancer screening.
Introduction
Cervical cancer is both the fourth most common cancer in women worldwide and the fourth leading cause of their cancer-related deaths. In Japan alone, the number of deaths due to cervical cancer in 2018 was 2,817, as reported by the National Cancer Center Japan.Citation1 Because it is so deadly, the standard treatment of cervical cancer is hysterectomy. However, for early-stage 1A cases, if the patient wishes to keep her fertility, there is the alternative of cervical conization treatment. However, studies have shown that after conization there remain mild risks for future second-term miscarriages and preterm births.Citation2,Citation3
Science has shown that more than 90% of the lesions which lead to cervical cancer are caused by sexually transmitted infections of the human papillomavirus (HPV), which are preventable by the HPV vaccine. These pre-cancerous lesions, when found early, require only conization for effective treatment. They can be easily detected by appropriate and very inexpensive cervical cancer screening methods; thus, screening is highly recommended for all women who have experienced any prior form of sexual intercourse where HPV may have been transmitted. In Japan, this screening is recommended to begin at age 20 and is to be continued biennially thereafter.
By comparison to other similarly economically advanced countries, Japan has a major dilemma: the cervical cancer screening rate for its adult women is only 32%, one of the lowest rates in its group of nations. When the screening rate comparison is limited to just women in their twenties, the discrepancy is even more striking, for women 20–25 in Japan, it is 10.2%, and is only slightly better, 24.2%, for 26–30-y olds.Citation4,Citation5 It is abundantly clear that there is an urgent need for our health-care system to motivate young Japanese women, on a massive scale, to begin a life-style change of engaging in early and routine cervical cancer screening.
Following the US Food and Drug Administration (FDA)’s approval of the quadrivalent HPV (qHPV) vaccine in 2006, HPV vaccines have been accepted as an affordable and effective means of preventing HPV-caused cervical cancer via national immunization programs in 130 of the world’s nations. National vaccination projects have achieved success rates of 86% coverage in England, 80% in Sweden, and 78.6% in Australia.Citation6–8
In 2014, a nonavalent HPV vaccine (9vHPV) was licensed by the FDA in the US. It has since been licensed by Australia, Canada, the European Union, and a number of countries in Asia, such as China and Korea. This vaccine contains material for an additional five oncogenic types of HPV and has the potential to prevent up to 93% of all cervical cancers. 9vHPV has replaced qHPV in the national immunization programs of several countries, such as the U.S., Australia, and Canada.Citation9
The history of HPV vaccination in Japan started out promisingly enough, with the Ministry of Health, Labor, and Welfare (MHLW) running a national promotional program to vaccinate girls 12–16 y of age. By early 2013, Japan had achieved an enviable HPV vaccination rate approaching 70% in the group of teenage girls they were targeting.Citation10 However, late in the spring of 2013 news media reports of putative ‘adverse medical events’ occurring in young girls following their HPV vaccination began to circulate.Citation11 In response, on June 2013, the MHLW proclaimed a temporary suspension of its recommendation for girls to get the HPV vaccine, with the almost immediate result a plunge of the HPV vaccination rate.
Now, 7 y later, the MHLW has yet to retract its ‘temporary suspension’ of its recommendation. As a consequence, Japan’s HPV vaccination program hangs in limbo and its vaccination rate hovers near 0%.Citation5 The outlook for the remainder of 2020 is the same as it was in 2015, when this study was conducted.
Japan faces two significant issues that one might not expect for a country of its economic stature: an almost non-existent HPV vaccination program – certain to lead to more future cervical cancers in our unprotected women – and a relatively very low rate of cervical cancer screening – something that could normally catch those cancers early – before they became lethal. This crisis of non-vaccination has unquestionably been caused by the continued suspension of the government’s recommendation for the HPV vaccine and accompanying lingering fears of vaccination side-effects. However, it is not as clear as to what is causing Japan’s problem with cervical cancer screening, which is inexpensive, readily available, highly recommended, and has no known side-effects. Thus, we have sought to find answers to this conundrum.
Today in Japan, there are two groups of women who are arriving at the age of 20, the recommended prime age to begin a lifetime of cervical cancer surveillance; one is a group of women who, as teenage girls of 13–16, received HPV vaccination at the height of the government’s vaccination program, whereas the other group of girls chose not to be vaccinated during that period. To begin to improve the current dismal rate of cervical cancer screening in Japan, we need to first know much more about the different ways these two groups think about their personal health care – especially as it relates to HPV vaccination and cervical cancer screening, and then to explore whether there are differences in their knowledge, perceptions, or attitudes regarding cervical cancer screening.
In the past, there have been legitimate public concerns about the outcome of vaccinating young girls against a sexually transmitted disease like HPV. First, there was the fear that HPV-immunized women might think they were completely protected from cervical cancers and they would no longer seek to receive routine cervical cancer screenings; second, that these young women would think that sex, in particular unprotected sex, was no longer a real danger to them because they were now protected from one of the deadliest of the sexually transmitted diseases, raising concerns related to increased sexual promiscuity and transmission of other, less fatal, STDs.
Here, we have conducted a web-based survey of 20-y-old women, divided into two groups based on whether or not they had been HPV vaccinated as teenagers. We asked them questions about cervical cancer, and about their inclinations toward cervical cancer screening. We explored possible ways we could better promote cervical cancer screening.
Methods
We conducted our internet survey from the 6th to the 23rd of September, 2015, using a structured and close-ended questionnaire. It included questions about the knowledge and attitudes of the respondents toward HPV vaccination, cervical cancer, and cervical cancer screening. We used 30 questions from our previous studies as a baseline and modified a few slightly for this study.Citation12,Citation13 The participants were recruited from a large commercial internet survey panel. To be eligible, they needed to be lived in Japan and be 20–21 y of age at the time of the survey.
Study enrollment was closed when the number of respondents with valid answers topped 300 for each of two groups, HPV-inoculated versus non-inoculated. Inoculated was defined as having ever received even one dose of an HPV vaccine. The limit on the number of respondents was chosen for convenience and no power calculations were done. Women who had replied on the same day as enrollment closed were included.
The initial few questions were to obtain data on responder characteristics, such as their area of residence and occupation. Excluding these questions, the response options to all other questions were either YES or NO. We probed the women’s understanding of cervical cancer, established their HPV vaccination status, and explored their attitudes toward cervical cancer screening. Details of the results of the 30-item questionnaire are shown in .
Table 1. Characteristics of the internet survey responders – Occupation the distribution of occupations between the two groups was not different
Table 2. Responses regarding cervical cancer or cancer screening
Table 3. Responder’s reasons for why, as 20-y-old women, they are not going to visit a clinic for cervical cancer screening within the next 2 y
Table 4. Questionnaire responses about home environment regarding cervical cancer
Our survey was done to consider ways to better motivate more young Japanese women to receive cervical cancer screening. We reused educational leaflets that we had developed for a previous studyCitation14 (Supplementary Figure 1). The leaflets provided readers with relevant information, asserted the importance of early detection of cervical cancer, and advocated for cervical cancer screening to achieve that goal. The educational leaflet was provided via the Internet and the responders were asked additional questions after viewing the leaflet. We analyzed the responses regarding their intentions for and against getting cervical cancer screening, both before and after the leaflet intervention.
Statistical analysis
Wilcoxon signed-rank analysis was used to determine statistically significant differences for the women’s occupations and sexual activity status. For all other analyses, Fisher’s exact test was used. The level of statistical significance was set at p = .05.
Results
The total number of the eligible women enrolled in our study was 618, with 309 in each group, HPV-vaccine inoculated and non-inoculated. shows the general characteristics of the women who participated. There were no statistically significant differences between the two groups in regards to their occupations, areas of residence, familial environment status, or sexual activity. There was no data about their familial income. Their answer about how they think of their familial economic status compared with that of a ‘normal family’ was not different between the two groups (p = .697). The rate of women who had already experienced sexual intercourse was 41% in the inoculated group of 20-y olds, and slightly higher, 44%, in the non-inoculated group; which, however, was not significantly different (p = .493; data not shown). Data regarding areas of residence are not shown, but there was no difference between the two groups.
When we analyzed the survey data for cervical cancer screening (when they reached 20) in regards to their HPV vaccination status, we found that there was a significantly higher engagement for cervical cancer screening for the HPV-inoculated group versus the non-inoculated group (29% (89/309) versus 17% (52/309); p < .05) (). Across the combined survey participants, the average rate for who had received cancer screening within the 2-y window of opportunity (age 20–21) was only 22.8% (141/618).
Figure 1. Women who received cervical cancer screening within the 2-y window. Significantly more women in the inoculated group received cervical cancer screening
The results from survey questions about cervical cancer are shown in . Significantly more women in the vaccinated group knew that HPV is transmitted by sexual intercourse than in the non-inoculated group (49.1% (106/309) versus 39.2% (120/309); p = .015). The same held true for knowledge about the cervical cancer preventative effects of the HPV vaccine, 49.0% (150/309) to 34.0% (104/309) (p = .001). There was also a significant difference in the respondent’s recognition of the need for an adequate cancer screening interval of at a minimum of every 2 y (or annually, if indicated): 63.3% (194/309) of the inoculated group knew this, versus 56.2% (172/309) of the non-inoculated group (p = .041). On the other hand, with the exception of their answers to these three questions, there were no statistical differences (based solely on their HPV vaccination status) in their knowledge about other important aspects of cervical cancer.
The various reasons the respondents gave, for why they had not yet visited a hospital or health clinic for cervical cancer screening, are listed in . We had responses to this question from 251 women in the inoculated group and 250 in the non-inoculated group. There were two reasons given which had a significant difference between the two groups. One defining excuse for not participating in screening was that the respondent did not think she was at risk for cervical cancer; only 19.9% (50/251) of the inoculated group gave this answer, whereas 27.2% (68/250) of the non-inoculated group thought they had little or no risk (p = .035). The other excuse for significant disparity was that the woman did not want to go to a hospital or clinic; only 45.1% (113/251) of the inoculated group gave this excuse whereas 60.1% (150/250) of the non-inoculated group did (p < .05). There were no statistically significant differences between the two groups in regard to the following three questions: Do you think it would be no problem to receive cancer screening several years later? [50.6% (127/251) to 45.2% (113/250); p = .063]; Do you, for now, have no symptoms related to cervical cancer? [73.7% (185/251) to 66.8% (167/250); p = .056]; Does it bother you to go to a hospital or clinic [56.6% (142/251) to 63.6% (159/250); p = .065].
As to the home environment, only around 27% of the 20-y-old respondents remembered receiving some form of advice from their mother or another family member regarding cervical cancer screening. For the 27% of each group who did remember receiving advice, that advice from their mother or family member was encouraging to receive cervical cancer screening for 73% of the time for the inoculated group and 67% of the time for the non-inoculated group, which had motivated some of them toward receiving the screening. The rate of getting positive advice was not statistically different between the inoculated group and non-inoculated group (p = .784).
In the much larger group of women (the 73% of all respondents who did not recall being advised by their mothers or a family member regarding screening), about 64% of the inoculated group and 58% in the non-inoculated group had felt motivated to receive cervical cancer screening – even when they were never advised by family to do so (the difference in percentage was not significant) (). Interestingly, in the group who did not remember getting family advice, 77.5% (237/309) of the inoculated group, but only 69.9% (214/309) of the non-inoculated group, answered that they would have willingly sought cervical cancer screening if they had been advised to do so by their partners or husbands; the difference in response between the two groups was statistically significant (p = .043).
To conclude our survey, we assessed the respondent’s attitudes both before and after they had read our educational leaflets about cervical cancer; these results are shown in . We wanted to see how our leaflet affected their apperception toward cervical cancer screening. The leaflet gave them basic information about HPV, cervical cancer, and cervical cancer screening, and provided detailed information as to where and how they could visit a clinic for screening.
Figure 2. The effects of reading the informational leaflet. Their intention to receive cervical cancer screening within the next 2 y were significantly improved in both groups after reading the leaflets
Before reading the leaflets, 19.1% (59/309) of the inoculated group answered that they intended to receive cervical cancer screening within the next 2 y. Afterward seeing the leaflet, their intention rate was improved significantly, to 35.0% (108/309; p < .05). In the non-inoculated group, their intentions before and after reading the leaflet were 18.8% (58/309) and 32.7% (101/309), showing a very similar significantly improved motivation to receive screening (p < .05).
Still, in both groups, even after reading the leaflets, and regardless of their inoculation status, the majority of individuals (65% and 67%, respectively) responded that they did not intend to have cervical cancer screening within the next 2 y. The three main excuses given were: one, because they had not yet experienced sexual intercourse; two, they were asymptomatic for cervical cancer; and three, they did not want to go to a hospital or clinic (). In the non-inoculated group, the reason for not wanting to go to a hospital or clinic was cited significantly more often than in the inoculated group.
Table 5. Reasons why responders still did not intend to receive cancer screening after reading the leaflet
Discussion
Given the woeful combination of negligible rates of HPV vaccination and low rates of cervical cancer screening that Japan continues to endure in 2020, we have conducted what we feel was a timely internet survey to investigate the knowledge, understanding, perceptions, and attitudes of 20-y-old women toward cervical cancer and cervical cancer screening. We have analyzed their responses to see if their prior HPV vaccination status as a teenager was somehow linked to their decisions as young adults regarding engaging in sexual intercourse and their actions and intentions for accessing appropriate cervical cancer screening.
We found in our survey that women who were previously inoculated against HPV now have significantly more intention to receive cervical cancer screening than women who were not inoculated (). We also were pleased to discover that a major public concern with HPV vaccination was revealed to be incorrect, i.e., that inoculated teenagers might grow up to be women who, because of their vaccination status, would think that they no longer needed cervical cancer screening – because they were now protected from HPV. Yet another assumption was disproven as well, that, with less fear of HPV, inoculated girls would become more sexually active than non-inoculated women.
Regarding their level of knowledge about cervical cancer, we found that the women in both groups had a similar level of understanding, regardless of their inoculation status. However, the inoculated group had a significantly better understanding of HPV infection and the preventative effect of the HPV vaccine against cervical cancer than did the non-inoculated group. Still, only 49% of the inoculated group, versus 34% of the non-inoculated group, answered correctly that the precise preventative effective of the HPV vaccine was 60–70%. Perhaps this was too fine a detail for them to know.
Three likely reasons as to why the inoculated group was more cognizant of the benefits of the vaccine and received more cervical cancer screening might have been: (1) Because this had been explained to them by their doctors when they received their HPV vaccine, (2) They and/or their parents may have had a greater long-term interest in their health care than those in the non-inoculated group, (3) There may be more anti-vaccine people within, or associated with, the non-inoculated group, which could have corrupted their level and acceptance of knowledge regarding HPV and cervical cancer.
Nonetheless, few of the women in either group had what we might consider today to be an adequate knowledge about HPV infections, cervical cancer, and cervical cancer screening. For example, only about 30% of the women in both groups knew that the most common cause of cervical cancer is an HPV infection. For comparison to other nations, 45% of female university students in India, 55% of university students in Pakistan, 73% of university female students in the United States, and 86% of female over 25 in the United Kingdom answered correctly that HPV causes most cervical cancers,Citation15–18 while in Japan, in our current survey, only 30% of the women of similar age knew this answer.
The opportunities for sex education in Japan, in particular about HPV, cervical cancer, and cervical cancer screening, are inadequate.Citation19 Clearly, much more education is needed to promote cervical cancer screening as a fundamental way to decrease the number of cervical cancer cases and deaths. Teaching about HPV and cervical cancer should begin in higher primary or junior high school, and it should be compulsory – because all adolescents, both male and female, need to be educated about HPV. In addition, the culture of awareness should be continued from high school through university, where many females reach 20, the age at which cervical cancer screening is begun in Japan.
The biggest excuse the women in our survey gave as to why they were not interested in receiving cervical cancer screening was they did not feel that they currently had any symptoms of cervical cancer. About 70% of both groups seemed to hold this viewpoint. They did not know that the precursor lesions and earliest stages of cervical cancer are typically asymptomatic, and that by the time symptoms appear it would often be too late to save their uterus.
The second most common reason given was that they worried about the cost of cervical cancer screening; 60% of both groups gave this as one of their reasons. They did not know that the cost of cervical cancer screening is usually free or at least greatly reduced by being subsidized by their local government. A similar common reason they gave was that, because they had not yet experienced sexual intercourse, they did not think they were at risk of cervical cancer yet; 62.8% of the group selected this reason.
In the non-inoculated group, 52.0% selected as their reason for not seeking screening was that they had no suggestive symptoms related to cervical cancer; 52.8% selected the reason that they did not want to spend the time for screening; 39.9% selected that they do not like to go the hospital, or that they seemed to feel it was a bother to go to the hospital. Better education about these points is needed.
The differences between the inoculated and non-inoculated groups in rationalizing why they were not seeking screening were mainly seen as two reasons: the non-inoculated group was more likely to think that they were not going to be affected by cervical cancer and they had a higher aversion to going to a hospital than did women in the inoculated group. This latter stance might be a key reason why they did not seek HPV vaccination in the first place (). If so, this psychological problem needs to be addressed, perhaps by improving the hospital and clinic visit experiences, or by conducting more of the HPV vaccinations and cervical cancer screenings at schools, work, and other places more comfortable to young girls and women.
Regarding our questions about their home environment and how it influenced their thinking and actions about cervical cancer and screening, although there were no significant differences between the inoculated and non-inoculated groups in such thinking, the women in the inoculated group tended to be more motivated when they were advised to receive cervical cancer screening by their mother, father, or other family members. It may be that families more eager for their daughter’s health are more likely to persuade them to receive the HPV vaccine, and this attitude carried over into later life.
Significantly more women in the inoculated group (p = .043) answered that they would be willing to get cervical cancer screening if their husband or partner advised them to do so. An interesting solution to this problem may be through the husbands and partners, who seem to have outsized influence with some women, by finding ways to better educate them, so they will be more likely to encourage their female partners to get screened for the sake of the ‘health’ of their relationship. There are likely to be significant differences between the roles mothers and partners play in the decision-making of these young women, especially for those who are inoculated versus those who were not. Personality traits, such as obedient versus rebellious, and ability and willingness to make decisions, might make a great difference in how health advice is accepted and acted upon.
In both groups, we found that the women’s intention to seek cancer screening significantly improved after they were provided with educational leaflets. After reading the leaflet, 35.0% in the non-inoculated group and 32.7% in the inoculated group had an intention to receive cervical cancer screening. There are several reports now that health promotion educational leaflets in the form of a comic strip are effective tools with youth.Citation14,Citation20 However, despite the significant improvement in intentions after reading the leaflets, 65.0% of the non-inoculated group and 67.3% of the inoculated group still responded that they had no intention of receiving cervical cancer screening. We now need to explore what different kinds of messages might better motivate the intentions for cervical cancer screening between the inoculated and non-inoculated groups.
We realize we have not perfected our messaging yet, because, even after exposure to the information leaflet, the majority of women respondents persisted in thinking they did not need to receive cervical cancer screening, either because they currently had no symptoms related to cervical cancer, or because they had not yet experienced sexual intercourse, or they felt they did not have enough time for a medical checkup. The respondents in the non-inoculated group were particularly strong in their negative opinions about not wanting to go to a hospital or clinic, and for ignoring the necessity of the visit because they felt free from any suggestive cancer symptoms.
We note that certain misperceived barriers for cancer screening actually were overcome by the information leaflet, such as its imagined cost, and that the women were provided enough knowledge by the leaflet about cervical cancer and cervical cancer screening to help them make better health-care decisions for themselves. Going forward, we found from our survey that any new messaging should better articulate that precancerous lesions and early-stage cervical cancers are usually asymptomatic, and that by the time they do have symptoms, the options for the treatment of cancer rarely include retention of fertility. It is not clear how to resolve the remaining issue of their reluctance to visit a hospital or clinic. This may require a deep-dive survey of its own to explore that aspect of their psychology.
Because of the result of this study, we are convinced that providing a better educational leaflet to our 20-y-old females will be effective for reducing the cervical cancer rate in Japan. Our studies also showed that sending an educational leaflet and a letter to their parents might spur a parental recommendation for screening.Citation14,Citation21 However, even these measures are not enough to improve the cervical cancer screening rate in Japan adequately. We need to dramatically change the school sex-health education programs. More governmental campaigns are needed, including reminder letters, phone calls, and e-mails, which have proven to be effective in other countries.Citation22 New options for improving cervical cancer screening may include sensitizing social network messages. There is a report of a trial for raising awareness about cervical cancer using Twitter in the United Kingdom.Citation23 A wide range of approaches for raising awareness of the desirability of cervical cancer screening should be developed in Japan.
To our knowledge, this is the first survey to show differences in the knowledge levels about cervical cancer and their attitudes toward cervical cancer screening between HPV-inoculated and non-inoculated women arriving at the age of 20, when they should begin undertaking such screening, in the current climate of anti-HPV vaccination and indifference toward screening. We have observed certain differences depending on their inoculation status that should be considered in Japan’s future messaging approaches.
At its peak, in 2013, the cervical cancer screening rate in Japan was only 42.1%, much lower than for other developed countries.Citation24 For comparison, around 2016 the screening rate among females aged 20–69 in developed countries such as Australia was 86.6%, 81.7% in Sweden, and 76.5% in England, as reported by the Organization for Economic Cooperation and Development.Citation25 Jointly, both the HPV vaccination and cervical cancer screening rates are usually ‘high’ in other developed countries. However, ‘high’ is not the same as 100%, as there are still many women in those countries who do not get the HPV vaccination or cervical cancer screening – for various untenable reasons. This study should be helpful to such countries in finding ways to better motivate their holdouts to seek cervical cancer screening, regardless of their inoculation status.
Limitations
One of the limitations of the study is the participants were recruited from an internet survey panel, so there may exist an unrecognized bias.
Another limitation is that there were no questions about the responder’s feeling toward the HPV vaccine; thus, we could not know if any lingering negative feelings toward the HPV vaccine affected their intentions for cervical cancer screening. The other limitation is that we have not yet carefully considered whether socioeconomic backgrounds made any difference in the behaviors of our respondents because there are some reports that cervical cancer screening rates of females who have a low socioeconomic status and/or live in urban areas are comparatively lower.Citation26,Citation27
Conclusion
We have analyzed the responses of 618 twenty-year-old Japanese women to 30 survey questions pertaining to their understanding of the HPV vaccine and cervical cancer, and their intention to undertake cervical cancer screening, by studying the attitudes of two groups of women – those who were HPV-inoculated as teenagers versus those who were not. We found that the HPV-vaccinated group of young women was more likely to intend to receive cancer screening and were more knowledgeable about cervical cancer than the non-inoculated women. The educational leaflet we provided both groups was moderately effective at increasing the intentions of some to seek screening, but the majority still had no intention of seeking cancer screening. To improve the cervical cancer screening rate in Japan, we need to develop a variety of approaches, including educations at schools, governmental campaigns, and social networking systems and tailor them to the socioeconomic status and living areas of the targets of those endeavors.
Abbreviations
| HPV | = | Human Papillomavirus |
| MHLW | = | Japanese Ministry of Health, Labor, and Welfare |
| WHO | = | World Health Organization |
Disclosure of potential conflicts of interest
AY, TE, and YU have received lecture fees from Merck Sharp & Dohme (MSD), a maker of HPV vaccines. YU and TK have received research grants (J550703673 and VT#55166, respectively) from MSD.
Ethics approval and consent to participate
The researchers obtained informed consent from participants of the internet survey. We included only those who consented to participate. This study was approved by the Institutional Review Board and the Ethics Committee of the Osaka University Hospital.
Supplemental Material
Download PDF (946 KB)Acknowledgments
We would like to express our deepest appreciation to Ms. Kanako Sakiyama and Hazuki Abe for their secretarial help. We would also like to thank Dr. G.S. Buzard for his constructive critiquing and editing of our manuscript.
Supplementary material
Supplemental data for this article can be accessed on the publisher’s website.
Additional information
Funding
References
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