Effect of the 2024 Noto Peninsula earthquake on outpatient chemotherapy among cancer survivors in Japan: a retrospective study.

Background

On January 1, 2024, at 16:10 Japan Standard Time (JST), a magnitude 7.6 earthquake struck the Noto Peninsula region in Ishikawa Prefecture, Japan [ 1 , 2 ]. The earthquake (hereafter 2024NPE) followed a series of earthquake swarms, which frequently occur in the Noto Peninsula and were likely precursors to this major event [ 3 ]. Many municipalities in the Noto Peninsula experienced landslides and major disruption to transport routes [ 4 ]. Over 10,000 buildings were damaged, leading to disruptions in water, electricity, and supply chains [ 5 ].

Kanazawa Medical University Hospital (KMUH) is one of the main hospitals that offer collaborative cancer treatment and provides high-quality medical care to cancer survivors [ 6 ]. Although there were disruptions in water supplies and damage to houses and roads owing to ground liquefaction in the area in which KMUH is located, the hospital itself remained intact and its operation was not affected. As the university hospital closest to the earthquake epicenter, KMUH mobilized medical support efforts immediately following the earthquake [ 46 ].

Climate change is a major current threat to human health and has implications for cancer control efforts throughout the cancer care continuum. The many and increasingly complex direct and indirect effects of climate change on cancer risk, access to treatment, and outcomes require urgent attention and concerted action [ 7 ]. Previous research on disasters and cancer survivors has highlighted the greater psychological distress and barriers to care experienced by cancer survivors compared with non-cancer patients following disasters, particularly in the immediate aftermath [ 8 ]. These barriers can be particularly detrimental to cancer survivors requiring active cancer treatment or those with chronic conditions requiring ongoing therapy, as treatment disruptions have been associated with increased mortality risks [ 9 ].

Previous studies have documented disparities in healthcare access among communities in the aftermath of hurricane disasters [ 10 ]. Hurricanes pose a substantial threat to vulnerable cancer survivors not only during the storm but also in the aftermath. Environmental conditions deteriorate as a hurricane makes landfall, exposing survivors to a range of stressors. These include a scarcity of information and new social, physical, and biochemical stressors in the environment, which can persist for weeks or months after the disaster [ 11 ]. Cancer survivors are already vulnerable because of their condition, and may experience an increased risk of medical complications and mortality during disasters because of the complex nature of their cancer treatment. In September 2017, the occurrence of Hurricanes Irma and Maria in Puerto Rico and the US Virgin Islands highlighted the need for specific emergency response plans for cancer patients, which was subsequently recognized by the US states involved [ 12 ].

The COVID-19 pandemic has been categorized as a biological disaster [ 13 ], and has had a profound effect on cancer care delivery worldwide. Lockdowns and restrictions have led to considerable delays in cancer diagnosis, potentially contributing to increased mortality rates [ 14 – 16 ]. Studies on patients with lymphoma and those with breast, colorectal, and lung cancer have shown that such patients were disproportionately affected by the pandemic, and that COVID-19 infected cancer patients experienced higher rates of hospitalization and more severe outcomes [ 17 – 19 ]. Studies have shown that this vulnerable population experienced an increased risk of adverse cancer outcomes during the pandemic, including treatment delays, mental health issues, pain, and reduced quality of life [ 19 – 21 ]. The COVID-19 pandemic generated discussion on shifting away from the traditional model of cancer care, in which cancer survivors travel to specialized medical centers for treatment and care, toward more decentralized follow-up models that bring care and treatment closer to communities [ 22 ]. Even a 2-day delay in treatment for severely ill patients negatively affects cancer survival rates [ 23 ]. Therefore, it is essential to prevent situations arising that hinder cancer survivors from continuing their treatment.

Our literature review on cancer survivor treatment continuity during disasters identified medication and treatment disruptions, loss of safe treatment environments, and stress from disruptions and chaos as substantial challenges that can severely affect disease status and overall well-being. Additionally, infrastructure disruptions can hinder communication with healthcare providers, leading to interruptions in critical treatment and care [ 24 ]. Furthermore, disaster severity can substantially affect the extent of these challenges. For example, disasters that cause disruptions to transport networks and widespread damage to buildings may generate greater barriers to accessing care compared with disasters involving less widespread infrastructure disruption [ 24 ]. In the aftermath of a major earthquake in Turkey, cancer survivors who remained in the affected area exhibited higher increases in stress, depression, and anxiety than those who evacuated [ 25 ]. Notably, patients with gastrointestinal or breast cancer experienced particularly elevated anxiety levels, probably because of the substantial effect of the disaster on their treatment process and quality of life. These effects included more severe problems with emotional and social functioning; an increase in symptoms such as fatigue, dyspnea, insomnia, constipation, and diarrhea; and financial difficulties [ 26 ]. Considering the potential effect of chemotherapy delays and disruptions on cancer patient outcomes [ 27 ], investigating the extent of the negative effects of disasters on patients and their effect on outpatient visits is extremely important for planning future disaster countermeasures.

The study aim was to elucidate the effect of the 2024NPE on outpatient visits among cancer survivors at KMUH. By analyzing the earthquake’s effect on cancer survivors and their ability to attend appointments, we sought to gain a deeper understanding of the disaster-related needs of cancer survivors in Ishikawa Prefecture, and to contribute to strengthening disaster response support systems. Additionally, this research may help to strengthen sustainable health systems during disasters.

Methods

Target area

The target area was Ishikawa and Toyama Prefectures, which face the Sea of Japan (Fig. 1 ). Located in the Hokuriku region (which also includes Fukui Prefecture), this area is long and narrow, runs from southwest to northeast, and comprises approximately 4,186 km 2 [ 29 ]. As of February 2022, the population was 1,114,791 [ 28 ].

Fig. 1 Ishikawa and Toyama Prefectures in the Target Area. Areas with a seismic intensity of ≥ 6 are shown with numerical seismic intensity distributions

Study participants and data collection

Participants were cancer survivors receiving outpatient chemotherapy at KMUH. The 2024NPE occurred on January 1, 2024, and KMUH resumed operations on January 4, 2024. Therefore, KMUH medical and nursing records for January 4–31, 2024, were retrospectively collected for analysis. The data collected included sex, age, family structure and number, cancer type, whether the patient was able to visit the hospital as scheduled, place of residence, and evacuation site. The 2024NPE seismic intensity distribution was obtained from the Japan Meteorological Agency’s seismic intensity distribution website [ 29 ].

Data analysis

Participant demographics were summarized using means and standard deviations of age and age group. Categorical variables were summarized using percentages. Descriptive data on disaster experiences were categorized by content and counted to obtain percentages. Totals and percentages of cancer survivors by municipality of residence were calculated. To examine the correlation between patients’ ability to visit the hospital as scheduled and other variables, the chi-square test or Fisher’s exact test was used. Age was classified into < 65 years and ≥ 65 years, family structure into couple-only households and households other than couples (living alone, other), and seismic intensity into < 6 and ≥ 6 for analysis. After checking the disease distribution, we selected for analysis patients in the three broad categories of breast cancer; lung cancer; and small intestine, colon, and rectal cancer (in order of the number of patients). The numbers and percentages of cancer survivors were visualized as bar graphs on base maps of Ishikawa and Toyama Prefectures using the Geographic Information System (GIS). To protect personal information, these values were plotted at the locations of municipal offices. Arc GIS Pro 3.2.1 (ESRI, Redlands, CA, USA) was used to conduct spatial analysis with GIS.

Ethical considerations

This research was conducted in accordance with the Declaration of Helsinki, 1995 (as revised in Seoul, 2008), and carried out with the consent of the university medical research ethics review committees at the authors’ universities (No. C080), and the consent of the University of Kochi Nursing Research Ethics Review Committee (No. Kan-Rin, 23–52). Participants provided informed consent using an opt-out method. The informed consent letter was posted on both the KMUH website and in the treatment waiting room [ 30 ]. The letter informed participants about the study purpose, importance, and methods; that participation was voluntary; that their responses would be anonymous; and that they would not be identifiable from their responses. No one declined to participate in the study.

Results

Participant characteristics

A total of 286 participants took part. Of these, 147 (51.4%) were men and 139 (48.6%) were women. The mean participant age (standard deviation) was 67.5 years (12.4 years). Most patients were in their 70s (107, 37.4%) and their 60s (61, 21.3%). The most common family structure was the couple-only household (147, 51.4%), households other than lives alone and couple-only (98, 34.3%), and lives alone (41, 14.3%). The most common cancer types were breast cancer (58, 20.3%), lung cancer (53, 18.5%), and small intestine, colon, and rectum cancer (43, 15.0%). Table 1 provides an overview of the participant characteristics.

Table 1 Factors associated with attendance at outpatient appointments after 2024NPE ( N = 286) Attendance at Outpatient Appointments After NPE Item Category total No Yes n % n % n % p value Age, mean (SD) 67.5 (12.4) 0.468 Age < 65 years 98 34.3 5 5.1 93 94.9 1.000 a ≥ 65 years 188 65.7 9 4.8 179 95.2 Age group ≤ 39 years 7 2.4 40s 20 7.0 50s 44 15.4 60s 61 21.3 70s 107 37.4 ≥ 80 years 47 16.4 Gender Men 147 51.4 5 3.4 142 96.6 0.229 Women 139 48.6 9 6.5 130 93.5 Family structure Other than couple-only households 139 48.6 11 7.9 128 92.1 0.021 Lives alone 41 14.3 Other 98 34.3 Couple-only households 147 51.4 3 2.0 144 98.0 Seismic intensity < 6 209 73.1 2 1.0 207 99.0 < 0.001 a ≥ 6 77 26.9 12 15.6 65 84.4 Breast No 228 79.7 11 4.8 217 95.2 1.000 a Yes 58 20.3 3 5.2 55 94.8 Lung No 233 81.5 11 4.7 222 95.3 0.728 a Yes 53 18.5 3 5.7 50 94.3 Small intestine, colon, rectal No 243 85.0 14 5.8 229 94.2 0.139 a Yes 43 15.0 0 0.0 43 100.0 Other cancer types Esophageal, gastric 23 8.0 Pancreatic 16 5.6 Multiple myeloma 13 4.5 Gallbladder, bile duct 11 3.8 Malignant lymphoma 9 3.1 Oral, pharyngeal, laryngeal 8 2.8 Liver 8 2.8 Kidney, urinary tract 8 2.8 Bladder 6 2.1 Ovarian, endometrial 6 2.1 Prostate 5 1.7 Skin 5 1.7 Others 14 4.9 χ 2 test a Fisher’s exact test 2024 NPE, 2024 Noto Peninsula Earthquake; SD, standard deviation

Municipality of residence

The most common municipalities of residence were Kanazawa (47, 16.4%), Tsubata (42, 14.7%), and Uchinada (34, 11.9%). There were more cancer survivors (178 people, 62.2%) living in municipalities in the Noto Peninsula area than in the municipality where KMUH is located in the center of Ishikawa Prefecture. Shika recorded a seismic intensity of 7 and was home to 18 patients (6.3%). Wajima was home to 15 patients (5.2%). Nanao recorded a seismic intensity of 6 + and was home to 12 people (4.2%), and Suzu was home to 3 people (1.0%). Figure 1 shows the spatial distribution of the municipalities of residence and the number of cancer survivors.

Effect of the earthquake on scheduled medical appointments

Figure 2 illustrates the effect of the earthquake on scheduled medical appointments. A total of 272 participants (95.1%) were able to attend their appointments as scheduled, whereas 14 (4.9%) were unable to attend. Among the 14 patients who were unable to attend their appointments, 12 (85.7%) resided in areas that experienced an earthquake with a magnitude of ≥ 6 (Fig. 2 ) and so were unable to attend their appointments. Of these patients, 7 (58.3%) were able to reschedule their appointments and attend later. Of the remaining 5 patients, 4 (33.3%) did not request to reschedule their appointments and 1 (8.3%) rescheduled but was still unable to attend. In other words, a total of 6 participants were unable to attend their appointments even 1 month after the earthquake.

Fig. 2 Spatial Distribution of 14 Cancer Survivors Who Missed Appointments. Areas that experienced an earthquake with a magnitude of ≥ 6 are indicated in red

Eight participants were unable to attend their second scheduled appointment in January, despite being able to attend their first appointment. Three of these participants reported that they were unable to attend their appointments because of the effect of the earthquake. Specifically, one participant was hospitalized owing to the earthquake, another participant requested to postpone their appointment because of the earthquake, and another participant relocated out of Ishikawa Prefecture to avoid the effect of the earthquake. The remaining five participants cited other reasons for being unable to attend their appointments: one participant contracted COVID-19, one participant was hospitalized for a change in their treatment plan, one participant was hospitalized for surgery, and one participant provided no reason for non-attendance.

Of the 280 participants (97.9%) who attended appointments in January 2024, 170 (59.4%) had one appointment, 82 (28.7%) had two appointments, 25 (8.7%) had three appointments, and 3 (1.0%) had four appointments.

A total of 53 participants were unable to receive chemotherapy despite attending their appointments. The reasons for this were neutropenia in 13 participants (24.5%); progressive disease, rash, and anemia in 3 participants (5.7%); and COVID-19 infection, chemotherapy side effects, liver dysfunction, thrombocytopenia, hypothyroidism, abnormal cardiac function, poor general condition, and pneumonia in 2 participants each (3.8%). Other reasons included high blood pressure, diarrhea, loss of appetite, leukemia-related abnormalities, and general side effects (1 participant each, 1.9%). Three participants (5.7%) cited multiple reasons (multiple answers).

Factors related to medical visit status after 2024NPE

The following variables were significantly associated with inability to attend outpatient.

appointments: living in a couple-only household ( n = 11, 7.9%; p = 0.021) and seismic intensity of ≥ 6 ( n = 12, 15.6%; p < 0.001) (Table 1 ).

Evacuation sites for cancer survivors

Of the 286 participants, 25 (8.7%) reported their current evacuation site when they visited KMUH. The evacuation sites included their own homes for 8 participants (28.6%), public shelters for 7 (25.0%), apartments near the hospital for 4 (14.3%), and other locations for 9 number of answers (32.1%) (multiple answers). Table 2 provides a detailed breakdown of the evacuation sites.

Table 2 Evacuation sites for cancer survivors and reported effects of earthquake on cancer survivors Item Category Number of people Number of answers % Evacuation sites for cancer survivors (multiple answers) 25 28 Home 8 28.6 Public shelter 7 25.0 Apartment near hospital 4 14.3 Family home within prefecture 3 10.7 Prefecture-level accommodation (secondary evacuation site) 3 10.7 Family home outside prefecture 2 7.1 Car evacuation 1 3.6 Reported effects of earthquake on cancer survivors (multiple answers) 62 133 My home suffered structural damage due to the disaster 56 42.1 I struggled with the water outage 23 17.3 I have not been affected by the earthquake 7 5.3 My family members arranged transportation for me to attend my medical appointment 6 4.5 I have moved to a new location owing to the disaster 4 3.0 The provided food is limited in quantity and lacks nutritional variety 4 3.0 I am living in (or had been living in) an evacuation shelter 3 2.3 I am unable to return home owing to road damage 3 2.3 I have sought shelter at a family member’s residence 3 2.3 I have been unable to work because of the effects of the disaster 2 1.5 I have been drinking less water since the disaster 2 1.5 Despite the road damage and inconveniences, I can still attend my medical appointments 2 1.5 Family members have evacuated to my house 2 1.5 I am worried about running out of Oxinorm (oxycodone hydrochloride hydrate) and not being able to take it 2 1.5

Disaster-related difficulties and coping strategies in cancer survivors

A total of 62 participants reported their disaster experiences; details are shown in Table 2 . The most common responses were “My home suffered structural damage due to the disaster” (56 participants, 42.1%), “Struggled with the water outage” (23, 17.3%), and “I have not been affected by the earthquake” (7, 5.3%).

Discussion

We analyzed the effect of 2024NPE on outpatient visits for cancer survivors receiving chemotherapy at KMUH in Japan.

The findings highlight the resilience of cancer survivors during large-scale disasters. Immediately after the earthquake, the people of Noto Peninsula experienced considerable difficulties, including substantial damage to roads, fires, and water outages [ 31 ]. However, most cancer survivors receiving outpatient treatment at KMUH were able to maintain their chemotherapy schedule. However, previous major earthquakes have resulted in the interruption or delay of treatment for many cancer survivors. After an earthquake, hospitals tend to prioritize patients who need critical treatment, and outpatient chemotherapy for cancer survivors is often postponed [ 32 – 35 ]. Moreover, earthquakes not only cause direct harm to cancer survivors but also hinder treatment owing to damage to medical facilities and disruption of electronic records [ 36 ]. The success of KMUH cancer survivors in maintaining their chemotherapy schedules may be attributed to their awareness of the need for continuous treatment during and after disasters, and the dedicated support of family and caregivers in the aftermath of the earthquake. Additionally, KMUH is located at the beginning of the Noto Peninsula, far from the epicenter [ 6 ]. It is possible that the limited damage to KMUH and its ability to maintain medical services played a role in the positive outcomes for cancer survivors. Additionally, only 16.7% of cancer survivors lived in municipalities with seismic intensity levels of 6 or 7; therefore, they may have been less affected by collapsed houses and road damage, which may have contributed to their ability to continue treatment.

However, we identified a small group of cancer survivors who were unable to attend KMUH on the day of their scheduled appointment. Univariate analysis showed that residing in areas with seismic intensity levels of ≥ 6 and belonging to household types other than couple-only households (living alone or other) were associated with an inability to attend scheduled appointments. Although medical assistance teams responded rapidly, the damage to roads made it extremely difficult for rescuers and responders to reach the affected areas [ 37 ]. It is possible that participants who decided not to attend their medical appointments lacked transport or were otherwise affected by earthquake damage.

KMUH patients who wish to change their outpatient appointment must either phone or visit the outpatient clinic in person to reschedule [ 38 ]. No alternative resources were available for patients who could not reschedule their appointments. In recent years, some hospitals in Japan have begun using smartphone apps that allow patients to manage their outpatient schedules and appointments [ 39 ]. However, many hospitals still require patients to phone or visit to reschedule their appointments [ 40 ]. KMUH also urged patients who were unable to attend scheduled outpatient appointments because of the earthquake to contact the appointment center or the outpatient clinic directly to reschedule their appointments [ 38 ]. Because of communication problems caused by the disaster, some cancer survivors who could not attend their scheduled appointments may have been unable to contact the hospital to reschedule their appointments. Therefore, alternative options to phone contact are needed in future to make it easier for patients to reschedule.

Partner support plays an important role in enabling cancer patients to persevere through lengthy treatments [ 41 , 42 ]. It is possible that the mutual support and dedication among couple-only households contributed to the higher attendance rates of patients in these households compared with those in other household types. Living alone, in particular, may increase the challenge of accessing support and information from others.

Disasters may have several negative effects on the condition, treatment, and care of cancer survivors, including physical and mental burden, fatigue, risk of infection, and deterioration of physical condition [ 24 , 32 , 43 ]. Delaying or discontinuing treatment can affect cancer outcomes, depending on each patient’s cancer stage and comorbidities [ 27 ]. Therefore, cancer survivors who failed to attend medical treatments owing to the disaster may have experienced a range of negative physical and mental effects; however, it was not possible to examine all these effects in the present study. Additional studies are needed to investigate in detail the potential barriers to care and negative physical and mental effects of the 2024NPE. Additionally, we need to better understand why cancer survivors miss scheduled appointments, and why they may be unable to reschedule them.

Some participants in this study worried that they would be unable to obtain sufficient oxycodone hydrochloride hydrate and other stoma products owing to a lack of access to hospitals. Cancer survivors are a vulnerable group because of the effects of the disease and its treatment [ 44 , 45 ]. Although only a few participants reported such worries, it is possible that other cancer survivors experienced shortages of medicines and medical supplies essential to survival because of the earthquake. Further in-depth research is therefore needed on the effects of earthquakes on shortages of opioids and medical hygiene materials, and other barriers to care.

This study had several limitations that should be considered. The data were obtained from cancer survivors at a single hospital. The study period was short (1 month after the disaster), the sample size was relatively small, and data were collected retrospectively from medical records. Retrospective data collection is susceptible to inaccuracies in medical records owing to data entry errors and incomplete documentation. Furthermore, the lack of comparison with other healthcare institutions limits the generalizability of the findings. This may have introduced bias into the results. Furthermore, it would have been useful to compare the rates of scheduled outpatient chemotherapy before and after the earthquake using regression analysis. However, these analyses could not be performed as the study aim was to promptly focus on the immediate effect of the earthquake on cancer survivors’ access to outpatient chemotherapy.

To increase the generalizability of these findings, additional multicenter studies are needed with larger sample sizes.

Conclusions

We analyzed the effect of the 2024NPE on outpatient visits for cancer survivors receiving chemotherapy at KMUH. Many cancer survivors were able to maintain outpatient visits despite the effects of the earthquake. This may reflect patients’ recognition of the importance of regular treatment, assistance from family members and other supporters, and the location of KMUH. However, some patients decided not to (or were unable to) attend medical appointments. The limited damage to KMUH was probably an important factor in enabling many cancer survivors to continue their treatment. Additionally, as suggested by previous research, the mutual support and dedication in couple-only households may have contributed to higher attendance rates among this group. However, further research is warranted to determine the precise reasons for the observed behavior patterns and to elucidate the extent to which support systems played a role. Detailed investigations are also needed on the negative effects of shortages of opioids and medical hygiene materials following disasters. The main study limitation is that the data were collected on an emergent, retrospective basis. More comprehensive research and analysis are needed in future studies.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Acknowledgements

We thank Diane Williams, PhD, from Edanz ( https://jp.edanz.com/ac ) for editing a draft of this manuscript.

Author contributions

Y.K., H.N., M.Y., Y.M., and K.Y. did Conceptualization, methodology. Y.K. and I.N. did investigation. Y.K., I.N., and H.N did formal analysis, data curation. Y.K. and H.N wrote the main manuscript textand. Y.K. and I.N. prepared Tables 1 and 2. H.N prepared Figs. 1, 2, 3 and 4. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by KAKENHI JSP Grant-in-Aid for Scientific Research (C) [grant number 24K14099].

Data availability

Data Availability Statement: The data presented in this study are available on request from the corresponding author.

Declarations

Conflict of interest

The authors declare no conflict of interest.

Ethics approval and consent to participate

This research was conducted in accordance with the Declaration of Helsinki, 1995 (as revised in Seoul, 2008), and approved by the ethics committee of Kanazawa Medical University (No. C080) and the University of Kochi Nursing Research Ethics Review Committee (No. Kan-Rin, 23–52).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Informed consent statement

Participants provided informed consent using an opt-out method. No one declined to participate in the study.

Abbreviations

Japan Standard Time

Kanazawa Medical University Hospital

2024 Noto Peninsula Earthquake

Geographic Information System

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