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Continuity of Care and Unmet Supportive Needs Among Women Living with Cancer:

A Patient-Centered Perspective

1 Riska Hediya Putri

1 Yunina Elasari

2 Tri Adi Nugroho

3 Agus Byna

1 Department of Nursing, Faculty of Health Sciences, Aisyah University of Pringsewu, Lampung, Indonesia

2 Department of Medical Record and Health Information, Faculty of Health Sciences, Aisyah University of Pringsewu, Lampung, Indonesia

3 Department of Information Systems, Faculty of Science and Technology, Sari Mulia University, Banjarmasin, Indonesia.

Article received: 05. 11. 2025.

Article accepted: 24. 02. 2026.

DOI: 10.24141/2/10/1/11

Author for correspondence:

Riska Hediya Putri

Faculty of Health Sciences, Aisyah University of Pringsewu, Lampung, Indonesia

E-mail: riskahediya17@aisyahuniversity.ac.id

Keywords: continuity of care, supportive care needs, wo- men with cancer, patient-centered care, oncology nursing

Abstract

Introduction. Continuity of care is a critical element in enhancing the quality of cancer management, particularly for women who frequently encounter fragmented care and numerous unmet supportive care needs throughout their cancer trajectory. Un- derstanding the extent of patients’ supportive care requirements and their perceptions of continuity of care is essential for improving patient-centered on- cology services.

Aim. This study aimed to explore women’s percep- tions of continuity of care and to identify their unmet supportive care requirements throughout various stages of the cancer care continuum.

Methods. A descriptive cross-sectional study was conducted among 134 women with cancer at Jen- dral Ahmad Yani Metro Hospital, Lampung, Indonesia, from 15 July to 9 August 2025, using the Supportive Care Needs Survey-SF34 and the Patient Continuity of Care Questionnaire-12 to assess supportive care needs and continuity of care. All procedures received ethical approval, and informed consent was obtained from participants.

Result. The highest unmet supportive care needs were observed in the Health System and Information domain, particularly regarding inadequate written information (71.6%) and information on cancer sta- tus, including whether the disease was under con- trol or in remission (67.2%). The Physical and Daily Living domain had the second-highest level of un- met needs, particularly for pain (79.9%) and fatigue

(79.1%). Psychological concerns were also frequent- ly reported, including fear of metastasis (63.4%) and anxiety about the future (59.7%). The Patient Care and Support domains as well as Sexuality domains demonstrated lower, but still notable, unmet needs (38–45%). The mean total PCCQ-12 score was 43.93 (SD = 6.04), indicating moderate to good continuity of care, with the highest mean observed in the Man- agement Continuity domain (15.65; SD = 2.27) and lower scores in informational and relational continu- ity domains.

Conclusion. Women with cancer experience sub- stantial unmet supportive care needs alongside mod- erate continuity of care. Strengthening communica- tion, coordination, and emotional support is essential to enhance patient-centered oncology nursing prac- tice and improve care continuity across transitions.

Introduction

Cancer stands as one of the foremost factors influ- encing health challenges and loss of life worldwide, with a significant impact on women. As reported by the Global Burden of Cancer (Globocan) 2020, female breast cancer was the most commonly diagnosed cancer worldwide, accounting for 11.7% of all new cases, and it also ranked among the leading causes of cancer-related mortality in women. It is followed by lung (11.4%), colorectal (10.0%), stomach (5.6%), and other site-specific cancers (1). The World Health Organization (WHO) documented a total of 396,914 cancer cases in Indonesia. Breast cancer was the predominant proportion, accounting for 42.1% of cases. Cervical cancer was the second most common malignancy, with 36,633 cases (9.2%), while ovarian cancer ranked third among women in Indonesia, with 14,896 cases (1,2). The Indonesian Cancer Founda- tion in Lampung stated that 5,672 of the 8,117,000 population were diagnosed with cancer, with the big- gest proportions of cases being breast, cervical, and ovarian cancer (3).

The effects of cancer and its treatments are deeply felt by individuals, highlighting the need for a holis- tic approach to care that goes beyond just medical treatment (4). This comprehensive viewpoint is es-

sential for women diagnosed with different cancers, due to their unique physiological and psychosocial challenges (5). Despite increasing acknowledgment of the significance of supportive care, a considerable burden of unmet needs continues to exist across mul- tiple supportive care areas for numerous cancer pa- tients throughout all stages of their illness (6). This unmet need frequently arises from inadequate care coordination and insufficient recognition of individ- ual patient requirements within intricate healthcare systems (7). Therefore, understanding these unmet requirements from a patient-centered perspective is essential for developing tailored interventions and enhancing overall well-being (8).

Women with cancer experience a noticeable emotion- al and physical burden; nonetheless, information con- cerning their specific supportive care requirements and access to pertinent treatments is still restricted

(9). Existing literature indicates that many women with cancer often report non-physical needs, such as anxiety about relapse or metastasis, more frequently than physical symptoms (10). Furthermore, this ho- listic assessment should also consider the profound impact of cancer on psychological well-being, includ- ing fears of recurrence, concerns for loved ones, and uncertainty about the future, which are frequently reported as high-priority unmet needs among can- cer survivors (11). This highlights the importance of healthcare professionals evaluating these complex needs thoroughly, extending beyond the treatment of physical conditions (12).

Effective coordination of care and comprehensive survivorship services are essential for addressing the diverse needs of cancer survivors, especially women who may face specific challenges associated with their cancer type and treatment (13,14). A key ele- ment of comprehensive care is continuous follow-up support to manage late and long-term side effects, monitor for relapse, and address new or pre-existing comorbidities (15). Continuous Nursing Care is a com- prehensive approach in which patients are actively involved in decision-making and in creating person- alized nursing care plans that cater to their unique needs, from admission to discharge. The objective of ongoing nursing care is to enhance patients' quality of life, promote physical rehabilitation, and support them in optimizing their health status in accordance with their individual needs (16,17).

Continuous nursing care from hospitalization to post-discharge follow-up is beneficial for patients.

In Indonesia, only a limited number of hospitals have implemented follow-up procedures to assess patients' conditions after discharge. Evidence from other countries, including the United Kingdom, in- dicates that nurses who provide follow-up services after hospital discharge can enhance patients' qual- ity of life and effectively manage their ongoing care needs at home (18,19). Malignancies significantly impact women, with over one million survivors in the United States. This number is projected to increase by 33% over the next decade, underscoring the need for coordinated, ongoing supportive care to address persistent symptoms and potential long-term compli- cations (20). This continuity is crucial for optimizing patient satisfaction and health outcomes, particu- larly given the complex and often fragmented nature of post-treatment surveillance and long-term care. Without robust continuity, patients face increased risks of unmet needs, compromised care quality, and poorer psychosocial adjustment during a vulnerable period (12,14).

Aim

This study investigates patients’ perceptions of con- tinuity of care and identifies the types and extent of their supportive care needs, aiming to provide evidence to enhance patient-centered cancer care services.

Methods

Study design and participants

This research employed a descriptive cross-sectional design to examine patients’ perceptions of continuity of care and to identify the types and extent of their supportive care needs. The study was conducted us- ing a convenience sampling approach at Jendral Ah- mad Yani Metro Hospital in Lampung, Indonesia, over

a four-week period from 15 July to 9 August 2025. Participants were eligible if they were women diag- nosed with cancer, aged 18 years or older, currently receiving or having previously received cancer-relat- ed treatment at the hospital, able to communicate effectively, and willing to provide informed consent. Patients were excluded if they had severe cogni- tive impairment, were in critical clinical condition at the time of data collection, or submitted incomplete questionnaire responses.

The sample size was determined through an a pri- ori power analysis using G*Power software (version 3.1.9.4). Assuming a medium effect size (r = 0.30), a two-tailed significance level of 0.05, and a statis- tical power of 0.95, the minimum required sample size was calculated to be 134 participants. Accord- ingly, 134 eligible individuals were recruited and in- cluded in the final analysis. The questionnaires were distributed by trained research assistants directly to the participants in their hospital rooms. Partici- pants completed the questionnaires independently and returned them by placing the completed ques- tionnaires into a closed collection box located at the nurse station. This procedure ensured the anonymity and confidentiality of responses, adhered to ethical standards, and complied with voluntary participation requirements.

Ethics

Participants engaged in a survey that ensured their anonymity. Before completing the survey, partici- pants were informed about the research’s purpose, and their involvement was entirely voluntary. The research protocol was reviewed and approved by the Ethics Committee of Jendral Ahmad Yani Hospital, Lampung, Indonesia, with approval number 370/634/ KEPK-LE/LL-02/2025. All participants received com- prehensive information about the study’s objectives, methodologies, potential risks, and benefits. All par- ticipants provided written informed consent before data collection. Participation was completely volun- tary, and respondents were assured they could with- draw at any time without repercussions regarding their medical treatment or nursing care.

Instruments

Supportive care needs were assessed using the Sup- portive Care Needs Survey Short Form (SCNS-SF34). The SCNS-SF34 is a validated 34-item question-

naire comprising five domains: physical and daily liv- ing, psychological, patient care and support, health system and information, and sexuality. Each item is rated on a five-point Likert scale ranging from 1 (not applicable) to 5 (high need). In this study, responses scored as 1 (not applicable) or 2 (satisfied) were cate- gorized as indicating no unmet supportive care need. In contrast, responses scored 3 (low need), 4 (mod- erate need), or 5 (high need) were classified as in- dicating unmet supportive care needs, reflecting ad- ditional support that was not adequately addressed.

The SCNS-SF34 consists of 34 items divided into five domains: Psychological Needs (10 items), Health Sys- tem and Information Needs (11 items), Patient Care and Support Needs (5 items), Physical and Daily Liv- ing Needs (5 items), and Sexuality Needs (3 items). Scores were calculated using a Likert summated scale by summing individual item scores within each domain, in accordance with the SCNS scoring guide- lines. The resulting scores were analyzed either as crude totals or converted into standardized scores to enable comparison across scales with different num- bers of items. Standardized scores were calculated using the formula:

where m represents the number of items in the do- main and represents the maximum response value for each item. This scoring approach follows the recommendations outlined in the Supportive Care Needs Survey: A Guide to Administration, Scoring and Analysis (21). The SCNS-SF34 had a validity score of 0.302-0.792 and the reliability 0.933 (9).

The Patient Continuity of Care Questionnaire short version (PCCQ-12) was utilized to assess patients’ perceptions of continuity of care. The PCCQ-12 con- sists of three domains: informational continuity (4 items), management continuity (4 items), and re- lational continuity (4 items). Each item has five re- sponse options ranging from strongly disagree to strongly agree, scored from 1 to 5, with higher scores indicating better continuity of care. All items also in- clude a “not applicable” option, which is treated as a missing response and excluded from scoring. For each domain, the domain score is calculated by sum- ming the scores of its constituent items, using only responses scored 1–5. The domain score therefore ranges from 4 to 20 for each domain. The total PC-

CQ-12 score is the sum of all 12 items, with a poten- tial range from 12 to 60, where higher scores reflect better overall continuity of care (22). The PCCQ-12 were translated from English to Bahasa Indonesia by an academic language center, followed by a review conducted by an expert panel. The PCCQ-12 under- went piloting for validity and reliability testing, yield- ing validity scores ranging from 0.512 to 0.828 and a reliability score of 0.887.

Statistics

Descriptive statistics were used to summarize pa- tients’ demographic characteristics, perceptions of continuity of care, and supportive care needs. The normality of continuous variables was assessed us- ing the Kolmogorov-Smirnov test, which indicated that both perceptions of continuity of care and sup- portive care needs were normally distributed, justi- fying the use of parametric statistical analyses. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS version 26.0, IBM Corp.).

Results

The sociodemographic characteristics of women with cancer included in the study are presented in Table 1.

Table 1 findings indicated that the majority of re- spondents belonged to the middle adulthood group (43.3%), with educational backgrounds primarily at the lower and upper secondary education levels. A significant proportion of respondents were unem- ployed (65.7%) and had incomes below the minimum wage (76.9%), reflecting constrained socioeconomic conditions. Breast cancer was the most prevalent type reported, accounting for 79.9%, whereas other cancers, including colon cancer, rectal cancer, and multiple myeloma, were identified in a minor percent- age of respondents. A significant majority of patients (48.5%) were diagnosed at advanced stage (III), indi- cating a low rate of early detection. The predominant ethnicity among respondents was Javanese, compris- ing 79.1% of the sample. The predominant treatment duration ranged from 1 to 6 months, accounting for

61.2% of cases, while the combination of surgery and chemotherapy was the most commonly utilized therapy, representing 85.1% of instances.

Table 2. Supportive Care Needs variables among women with cancer

Variables

Frequency

Supportive Care Needs

%

Tables 2 and 3 present the supportive care needs among women with cancer, with Table 2 showing the distribution of needs across domains and Table 3 highlighting the prevalence of moderate-to-high unmet needs in each domain.

No Need

Unmet Need

16

118

11.9

88.1

Physical and Daily Living Domain

No Need 25 18.7

Psychological Domain

No Need

Unmet Need

42

92

31.3

68.7

Unmet Need 109 81.3

Patient Care and Support Domain

No Need 57 42.5

Health System and Information Domain

No Need

Unmet Need

24

110

17.9

82.1

Unmet Need 77 57.5

Sexuality Domain

No Need 80 59.7

Unmet Need 54 40.3

Table 2 and Table 3 present the distribution of un- met supportive care needs among cancer patients across five primary domains. Unmet supportive care needs were defined as item responses scored 3 (low need), 4 (moderate need), or 5 (high need) on the Supportive Care Needs Survey (SCNS). Scores of 1 (not applicable) and 2 (satisfied) indicate no unmet need. Domain-level unmet needs represent summary categories derived from item-level responses within each SCNS domain.

The findings indicate that the Health System and In- formation domain exhibited the highest proportion of unmet needs. Patients most frequently reported requiring adequate written information regarding ill- ness management and treatment outcomes (71.6%),

as well as information on cancer status, including whether the disease was under control or in remis- sion (67.2%).

The Physical and Daily Living domain had the sec- ond-highest level of unmet needs. Pain (79.9%) and fatigue/lack of energy (79.1%) were the predomi- nant issues, suggesting that physical symptoms remain the most significant challenges in patients’ daily lives. Psychological needs were also frequent- ly reported, including feelings of sadness (61.2%), anxiety and concern about the future (59.7%), and fears of cancer spreading (63.4%), indicating that emotional distress among patients is substantial and often insufficiently addressed. The Patient Care and Support domain and Sexuality domain showed low- er, yet meaningful levels of unmet needs, with ap- proximately 38–45% of patients reporting challenges related to changes in sexual feelings, interpersonal relationships, and insufficient information regarding sexuality.

Table 4 presents the results of the Patient Continu- ity of Care Questionnaire short version (PCCQ-12), in- cluding mean scores for each domain and the overall total score.

The mean scores for the Patient Continuity of Care Questionnaire short version (PCCQ-12) are displayed in Table 4, including three domains and the overall patient perception score. The results suggest that patients experienced moderate to good continuity of care. The Informational Continuity domain recorded a mean score of 14.15 (SD = 2.623), where the item with the highest score pertained to comprehensive information on medications, while the item with the lowest score was associated with clarity of progno- sis. The Management Continuity domain exhibited the highest overall mean (15.65; SD = 2.265), indi- cating effective coordination and follow-up arrange- ments post-discharge, although the consistency of information among providers was relatively lower. The Relational Continuity domain yielded a mean score of 14.12 (SD = 2.271), suggesting that pa- tients perceived themselves as sufficiently prepared for discharge, yet reported a lack of familiarity with providers post-discharge. The total score reflecting patients’ perceptions of continuity of care was 43.93 (SD = 6.038), with a range of 31–60. Higher scores in- dicate better perceived continuity of care. Clinically, this suggests that the participants experienced mod- erate to good continuity of care.

Discussion

Supportive care needs encompass the requirements for managing symptoms and treatment-related side effects, enhancing adaptive and coping abilities, op- timising understanding and access to information for informed decision-making, and minimising impair- ments in physical functioning (23). Consistent with this framework, the findings of the present study demonstrate that women with cancer reported the highest unmet supportive care needs in the Health System and Information domain, followed by the Physical and Daily Living domain, with consider- able unmet needs also evident in the Psychological domain. This distribution indicates that gaps in in-

formation provision and communication within the healthcare system may undermine patients’ capacity to manage physical symptoms, adapt psychologically, and maintain daily functioning. Adequate, timely, and comprehensible information is therefore fundamen- tal to strengthening patients’ self-efficacy, support- ing effective coping strategies, and promoting active engagement in self-care. In this context, nurses play a central role in identifying unmet supportive care needs and delivering person-centred education and support tailored to patients’ informational, physical, and psychological concerns.

Supportive care requirements are categorised into five domains: physical, psychological, patient care and support, health system and information, and sexual- ity. This study found that 88.1% of cancer patients

required supportive care. In the physical domain, 81.3% of cancer patients indicated a requirement for supportive care, whereas in the health system and information domain, 82.1% reported comparable needs. These results highlight that, although cancer care often emphasizes physical treatment, patients continue to experience significant unmet supportive care needs, particularly in the physical, emotional, and informational domains. Overall, the findings em- phasize the necessity of a comprehensive, patient- centered approach to oncology nursing that address- es not only physical treatment but also emotional, informational, and psychosocial aspects of care to meet patients’ supportive care needs adequately.

This finding is consistent with the study by Effendy et al., which reported a wide range of unmet physi- cal symptom needs among patients with advanced cancer. Specifically, unmet needs were reported for pain (66.4%), fatigue (60.0%), sleeping problems

(65.6%), shortness of breath (67.3%), cough (63.2%), itch (61.7%), numbness (54.1%), and night sweats (76.2%). The higher proportions observed in the pre- sent study, particularly for pain and lack of energy, may be partly explained by differences in study pop- ulations. Effendy et al. included only patients with advanced-stage cancer, who often experience more complex and fluctuating symptom patterns and may receive more intensive palliative-oriented care. In contrast, variations in disease stage and treatment trajectories in the present study may have contrib- uted to differences in symptom burden and access to supportive care services. Price et al. conducted an in- vestigation into physical symptoms in patients with ovarian cancer, identifying lack of energy, abdominal bloating, pain, and nausea as the most commonly re- ported symptoms. Key issues associated with cancer and its treatment include disruptions in physical con- dition, social functioning, and body image. Patients frequently encounter uncertainty about the signifi- cance of unexplained physical symptoms and the management of ongoing treatment effects during their care (24,25).

These findings highlight two interrelated challenges in cancer care: the burden of treatment-related phys- ical symptoms and the persistent gap in patients’ ac- cess to clear and reliable health information. Physical challenges such as fatigue and pain remain among the most prevalent adverse effects of cancer treat- ment, underscoring the need for effective symptom management strategies. Evidence suggests that im-

proved symptom control can substantially enhance patients’ quality of life, as demonstrated by Li et al.

(26). In parallel, unmet informational needs reflect an emerging “infodemic” in healthcare, in which pa- tients may experience confusion or anxiety due to fragmented or inconsistent information. Holden et al. (2021) emphasised the critical role of health literacy and the responsibility of healthcare professionals to provide accurate and comprehensible information to mitigate patient distress (27). Collectively, these observations are consistent with previous studies highlighting that integrated attention to both physi- cal and informational needs is essential for improving overall patient well-being.

Unmet psychological needs were reported by 68.7% of respondents. The diagnosis and treatment of can- cer frequently induce anxiety, depression, and con- cerns regarding relapse. Cancer patients undergoing therapy encounter not only physical symptoms but also emotional alterations, including anxiety and depression, alongside concerns regarding a poten- tial decline in their quality of life due to uncertainty about their prognosis. Cancer patients frequently present with multiple interrelated symptoms; for ex- ample, depression may correlate with fatigue. The interaction of concurrent symptoms may intensify existing symptoms or contribute to the emergence of new symptoms (28). Emotional well-being is the di- mension most adversely impacted during chemother- apy. Cancer patients receiving treatment necessitate emotional support to manage anxiety, sadness, and fear during the diagnosis and treatment phases (29).

One of the most alarming discoveries in this study is that nearly 89% of respondents were diagnosed with breast cancer at advanced stages (II and III). This highlights a major challenge in the early detec- tion process. According to Siegel et al. (2022), early detection remains the key to improving survival rates, even with advances in treatment options. In- sufficiently organized and cost-effective screening initiatives, coupled with a general unawareness of the initial signs of cancer, are often associated with delayed diagnoses (30). Following established global clinical guidelines, the typical treatment strategy for stage II and III breast cancer involves a combination of chemotherapy and surgery, a choice favored by most patients.

The treatment typically lasts from one to six months, though this timeframe can vary. Papalexis et al. con- ducted a systematic review highlighting the impor-

tance of tailored therapy and the thorough manage- ment of side effects, especially for patients receiving long-term chemotherapy (31). The significant pres- ence of respondents from the Javanese ethnic group likely reflects the study’s geographical context; how- ever, it is crucial to consider the influence of ethnic- ity and culture. Özdemir et al. (2017) illustrated that ethnic background and genetic lineage can influence particular cancer types and treatment responses. Cultural influences, such as the stigma associated with illness and reliance on traditional medicine, may prevent patients from seeking professional medical attention, resulting in diagnoses occurring at more advanced stages (32). Consequently, it is impera- tive for nurses to actively provide supportive care by facilitating effective communication with patients and disseminating vital care-related information to enhance the quality of life for cancer patients. Con- tinuous Nursing Care is an extensive nursing care ap- proach that engages patients in decision-making and the formulation of personalised care plans, extend- ing from hospital admission to discharge and custom- ised to each patient’s distinct needs.

Continuity of care, which encompasses seamless coordination and effective transitions across health- care services, is widely recognised as a key indicator of healthcare quality. In the context of cancer care, where management extends beyond curative treat- ment to include supportive, rehabilitative, and pal- liative services delivered by multidisciplinary teams, patients’ favourable perceptions of continuity of care are associated with better perceived health status and overall well-being (16,17). The findings of the present study suggest that coordination and commu- nication among healthcare providers were generally perceived as adequate; however, opportunities for improvement remain, particularly in informational and relational continuity. When patients perceive that their supportive care needs are adequately met, they are more likely to report a positive perception of continuity of care, highlighting the importance of in- tegrated, patient-centred approaches to cancer care.

Cancer patients' needs encompass not only medi- cal interventions like chemotherapy, surgery, or ra- diotherapy but also emotional, spiritual, and financial support. A favourable perception of care continuity enables patients to regard the treatment process as organised, consistent, and conducive to their over- all well-being. Chen et al. (2019) conducted a study indicating that breast cancer survivors exhibiting a

high Continuity of Care Index (COCI), regardless of whether oncologists or primary care providers man- aged their care, were more inclined to participate in routine screenings (e.g., mammography/ultrasound), experienced reduced hospitalisation rates, and had fewer emergency department visits in comparison to those with low continuity of care (33).

This study highlights the critical role of uninterrupted continuity of care and the systematic identification of unmet supportive care needs as essential compo- nents of patient-centered cancer care. The findings emphasize the importance of strengthening inter- professional communication, improving the clarity and consistency of information provided to patients, and enhancing care coordination, particularly during transitions from hospital to home. Clinically, these results support the implementation of structured patient education programs, routine monitoring of supportive care needs, and targeted nursing inter- ventions focused on informational and emotional support. Future research should employ longitudinal and interventional designs to further evaluate the effectiveness of continuity of care models and sup- portive care interventions across different stages of the cancer trajectory and healthcare settings.

Several limitations should be considered when inter- preting these findings. The cross-sectional design does not allow causal inferences, and the use of con- venience sampling within a single hospital setting may limit transferability to other contexts. In addition, reliance on self-reported data may introduce response bias. Furthermore, the Patient Continuity of Care Ques- tionnaire (PCCQ-12) includes only positively phrased statements, which may have led to more favorable re- sponses than participants actually experienced.

Conclusion

This study indicates that women living with cancer reported varying levels of continuity of care across informational, management, and relational domains. Management continuity showed higher scores than informational and relational continuity, while gaps were identified in the clarity of prognostic informa- tion and in patients’ familiarity with healthcare pro- viders after hospital discharge. In addition, substan-

tial unmet supportive care needs were identified, particularly in the physical and daily living domain, in- cluding pain and fatigue, as well as in the psychologi- cal domain, such as emotional distress, anxiety, and fear of disease progression. Moderate unmet needs were also reported in the areas of patient care, sup- port, and health system information. Overall, these findings reflect key challenges in delivering patient- centered cancer care that adequately addresses both continuity of care and patients’ multidimensional supportive care needs.

Declaration of Generative AI in Writing

During preparation, the author(s) used ChatGPT from OpenAI for language enhancement.

Author Contributions

Conceptualization (RHP, YE); Data Curation (RHP, YE); Methodology (RHP, AG); Data Analysis (RHP, AG); Writing – Original Draft (RHP, YE); Writing—review and editing (RHP, TAN). All authors have approved the fi- nal manuscript.

Conflict of Interest

The authors declare that there are no conflicts of in- terest regarding the publication of this paper.

Acknowledgments

The authors acknowledge the invaluable support and participation of the staff and patients at Jendral Ah- mad Yani Public Hospital throughout the data collec- tion phase. We extend our gratitude to the team and colleagues who contributed to the development and finalization of this study. This study was supported by the Directorate of Research and Community Ser- vice, Directorate General of Research and Develop- ment, Ministry of Higher Education, Science, and Technology of the Republic of Indonesia.

Funding

This study was funded by the Directorate of Research and Community Service, Directorate General of Re- search and Development, Ministry of Higher Educa- tion, Science, and Technology, Republic of Indonesia.

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Croat Nurs J. 2026; 10(1): 121-134 Review

Efficacy of High-Flow Nasal Cannula in Preventing Hypoxemia During Sedated Endoscopic Procedures:

A Literature Review

1,2Valentina Ješić

3 Jadranka Pavić

1 Marinko Vučić

1 Tihana Magdić Turković

3 Martina Smrekar

1 Sestre milosrdnice University Hospital Center, Zagreb, Croatia, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Zagreb, Croatia

2 Faculty of Health Sciences, University of Novo Mesto, Novo Mesto, Slovenia

3 University of Applied Health Sciences, Zagreb, Croatia

Article received: 26. 08. 2025.

Article accepted: 20. 10. 2025.

DOI: 10.24141/2/10/1/12

Author for correspondence:

Valentina Ješić

Sestre milosrdnice University Hospital Center, Zagreb, Croatia

E-mail: valentina.matic@yahoo.com

Keywords: high-flow nasal cannula, hypoxemia, endosco- pic procedures, sedation

Abstract

Introduction. Hypoxemia is a common and poten- tially serious complication during endoscopic proce-

dures performed under sedation, particularly in pa- tients with obesity, chronic respiratory disease, or reduced pulmonary reserve. The high flow nasal can- nula (HFNC) delivers heated and humidified oxygen at high flow rates with a stable fraction of inspired oxygen (FiO2), thereby reducing desaturation and improving oxygenation compared with conventional oxygen delivery methods.

Aim. This review evaluated the efficacy of HFNC in preventing hypoxemia during gastrointestinal endos- copy, bronchoscopy, and endoscopic retrograde chol- angiopancreatography (ERCP) under sedation, focus- ing on clinical applicability and patient safety.

Methods. A systematic search of PubMed, Web of Science, and Scopus (2015–2025) identified English language studies, including randomized trials, com- parative and observational studies, and reviews. Pre- defined inclusion criteria were applied, and outcomes included the incidence of hypoxemia, minimum SpO2, and the need for airway interventions.

Results. Of 628 records screened, 30 studies met the inclusion criteria (13 randomized trials, 3 prospective comparative, 1 observational, 3 retrospective, and 10 systematic reviews or meta-analyses). Most confirmed that HFNC reduces hypoxemia, increases minimum SpO2, and improves ventilation stability compared with conventional oxygen therapy. The greatest ben- efits were observed among high-risk patients such as elderly, obese, and those with respiratory disease. Op- timal flow rates ranged from 50 to 60 L/min, ensuring efficacy, comfort, and safety.

Conclusion. HFNC provides effective oxygenation support during sedated endoscopic procedures, reducing desaturation and the need for airway in- terventions. Standardized protocols and further re- search on long term outcomes are recommended.

Introduction

Hypoxemia is one of the most common and serious complications during sedated endoscopic procedures, particularly in patients at increased risk due to res- piratory diseases, obesity, or other factors that re- duce pulmonary reserve (1). Conventional methods of oxygenation support, such as conventional oxy- gen therapy (COT) delivered via nasal cannula or face mask, are often insufficient to maintain adequate ox- ygenation in conditions of increased oxygen demand and reduced respiratory volume caused by sedation

(2). Therefore, advanced non-invasive oxygenation methods are increasingly being applied in clinical practice, among which the high-flow nasal cannula (HFNC) is gaining an increasingly important role.

Despite the increasing use of HFNC, its application in procedural sedation and endoscopy has not yet been standardized, and the determination of optimal flow rates and indications varies across clinical cent- ers in different countries. In addition, considerable heterogeneity exists regarding study design, seda- tion protocols, and definitions of hypoxemia, which complicates the development of unified guidelines. Given the growing number of endoscopic procedures performed under sedation and the increasingly com- plex patient population, there is a need for a detailed analysis of the effectiveness of HFNC in this context. Numerous studies have shown that the incidence of hypoxemia during gastrointestinal endoscopy under sedation may range from as low as 1.8% to as high as 69% (9–12).

HFNC delivers heated and humidified oxygen at high           flow rates (typically 30–60 L/min) with precise con-

trol of the fraction of inspired oxygen (FiO2) (3). This technology provides partial positive pressure sup- port (PEEP effect), reduces dead space in the upper airways, improves alveolar ventilation, and enhances overall gas exchange (4). HFNC increases the partial pressure of arterial oxygen (PaO2), reduces respira- tory effort, and improves patient comfort compared with traditional methods (5). In addition, continuous airflow through the upper airways prevents rebreath- ing of carbon dioxide (CO2), thereby reducing the risk of hypercapnia, which is a common problem in sedat- ed patients during procedures such as bronchoscopy, gastroscopy, or endoscopic retrograde cholangiopan- creatography (ERCP).

The significance of HFNC is particularly evident in patients at high risk of developing hypoxemia, includ- ing elderly individuals, patients with elevated BMI, those with chronic lung diseases (e.g., COPD, intersti- tial lung disease), and patients undergoing prolonged or invasive endoscopic procedures (6,7). Numerous studies and meta-analyses report that HFNC reduces the incidence of hypoxemic episodes, the need for procedural interruptions, and additional airway in- terventions (e.g., mask ventilation, intubation), while simultaneously increasing minimum oxygen satura- tion (SpO2). Compared with COT or low-flow oxygen therapy, HFNC provides more stable oxygenation and better control of ventilation parameters, thereby con- tributing to the safer performance of procedures (8).

Aim

The purpose of this paper is to systematically ana- lyze the existing scientific literature on the effective- ness of high-flow nasal cannula (HFNC) in managing hypoxemia during endoscopic procedures. The study aims to identify the advantages of HFNC in compari- son with conventional methods of oxygenation sup- port. A particular emphasis was placed on outcomes such as improved oxygenation, reduced need for in- vasive ventilation, and patient safety.

Methods

A systematic literature search was conducted in July 2025 using the PubMed, Web of Science, and Sco- pus databases. Scientific articles published between 2015 and 2025 were reviewed. In accordance with PRISMA guidelines for systematic reviews, only arti- cles classified as Clinical Trial, Controlled Clinical Trial, Multicenter Study, Observational Study, Randomized Controlled Trial, Review, and Systematic Review were included.

Inclusion criteria comprised studies focusing on the use of high-flow nasal cannula (HFNC) in adult pa- tients with hypoxemia, including gastrointestinal endoscopy (gastroscopy, colonoscopy, EGD), bron- choscopy, and endoscopic retrograde cholangiopan- creatography (ERCP) performed under sedation. Pre- defined search keywords were used: “high flow nasal cannula,” HFNC, and hypoxemia. These terms were required to appear in the title, abstract, or keywords of the included articles to ensure their relevance.

Only studies published between 2015 and 2025 were included. This period was selected to capture the most recent decade of scientific evidence, re- flecting advances in high-flow nasal cannula technol- ogy, evolving procedural sedation protocols, and the growing number of clinical trials in this field. Studies published before 2015 were excluded to avoid out- dated technologies and practices that no longer rep- resent current standards.

The authors predefined the search objectives, es- tablished inclusion and exclusion criteria (see Table 1), and focused the analysis on studies investigating the use of HFNC compared with COT in adult patients. The search was further limited to articles available in English and required to contain either an abstract or full text. After duplicate removal using the Zotero ap- plication, a total of 628 records were identified for re- view (Figure 1). Two independent authors screened the titles and abstracts (n = 628), excluding 384 studies that did not meet the basic inclusion criteria or were deemed irrelevant. Full-text articles were re- trieved for 244 studies and assessed for eligibility. In the final selection round, 214 articles were excluded because they were not related to endoscopic proce- dures, resulting in 30 studies being included in the analysis, all directly addressing HFNC use in relation to endoscopic procedures.

Data extraction was conducted independently by two authors (VJ and JP), with accuracy verified through mutual comparison and consensus among all authors. The quality of the included studies was evaluated according to predefined criteria encom- passing study design, sample size, outcome report- ing, and overall methodological rigor.

Results

This systematic review includes 30 studies pub- lished between 2015 and 2025. The included stud- ies evaluated the effectiveness of high-flow nasal cannula (HFNC) in preventing hypoxemia during sedated endoscopic procedures, including gastroin- testinal endoscopy, bronchoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The PRISMA diagram (Figure 1) illustrates the selection

Identification of studies via databases and registers

Records identified from*: Databases (n = 3) PubMed (n = 37)

Web of Science (n = 174) Scopus (n = 570)

Records removed before screening:

Duplicate records removed (n

= 153)

Records screened (n = 628)

Records excluded** (n = 384 )

Reports sought for retrieval

(n = 244)

Reports not retrieved (n = 0)

Reports assessed for eligibility

(n = 30)

Reports excluded:

Reason 1

(n = 214)

Studies included in review

(n = 30)

Reports of included studies

(n = 0)

Included

Screening

Identification

Figure 1. PRISMA flow chart

process, and Table 2 provides a detailed overview of the included studies, including authors, study design, population characteristics, and key findings. To avoid redundancy, detailed numerical results are summa- rized in Table 2.

Most of the studies were conducted in China (n = 13), with additional studies originating from Japan (n

= 2), South Korea (n = 2), Australia (n = 2), Taiwan (n = 2), and Greece (n = 2), as well as single studies from Thailand, Egypt, Ecuador, France, India, and the United States. By study type, the included papers comprised 13 randomized controlled trials (RCTs), 3 prospective randomized comparative studies, 1 pro- spective observational study, 3 retrospective stud- ies, and 10 systematic reviews and meta-analyses.

As shown in Table 2, most studies confirmed that HFNC significantly reduces the incidence of hy- poxemia compared with COT and maintains higher minimum SpO2 values. Systematic reviews and meta- analyses particularly highlighted the reduced risk of hypoxemia, fewer procedural interruptions, and a decreased need for airway interventions (13, 20, 23,

25, 31, 32, 35, 37–39).

Randomized controlled trials (n = 13) demonstrated the superiority of HFNC across different populations and procedures, including bronchoscopy, ERCP, gas- troscopy, and endoscopic submucosal dissection (17, 19, 21, 24, 26, 28–30, 33, 36, 40–42). Several studies

(14, 22, 34) observed that HFNC and other methods, such as NIV or low-flow oxygen, showed comparable efficacy; however, HFNC more consistently provided greater stability of oxygenation in high-risk patients.

Retrospective and prospective studies further con- firmed that HFNC significantly reduces the occur- rence of desaturation and maintains stable SpO2 dur- ing procedures (14–16, 18, 21, 22, 27, 34).

A concise summary of these findings is presented in Table 2, which consolidates the numerical outcomes and key methodological details of all included studies.

In conclusion, the findings indicate that HFNC is most effective in preventing hypoxemia during sedated endoscopic procedures, with optimal flow rates of 50–60 L/min, and is associated with a lower risk of complications and reduced need for procedural inter- ruptions (13, 19, 42).

Discussion

This systematic review analyzed evidence from randomized trials, observational studies, and meta- analyses, all of which consistently show that HFNC significantly reduces hypoxemia and improves oxy- genation compared with COT. The following discus- sion summarizes key findings by procedure type and patient population.

HFNC during gastrointestinal endoscopy

Sedation during upper gastrointestinal endoscopic procedures often causes hypoventilation and air- way obstruction, increasing the risk of hypoxemia. Numerous studies confirm that the use of HFNC sig- nificantly reduces this risk compared with standard low-flow oxygen therapy. Meta-analyses consistent- ly report a 60–75% relative risk reduction with HFNC use (20,39).

For instance, Thiruvenkatarajan et al. (2023) demon- strated a lower incidence of hypoxemia and higher minimum oxygen saturation with HFNC (20), while Zhang et al. (2022) additionally reported a reduced need for airway interventions in patients undergoing sedated gastrointestinal endoscopy (37). In practice, HFNC markedly decreases desaturation episodes and maintains higher oxygen saturation levels than COT

(37). In practice, HFNC markedly decreases desatura- tion episodes and maintains higher oxygen satura- tion levels than COT.

These findings have been further supported by rand- omized trials. The multicenter ODEPHI RCT by Nay et al. (2021) showed that HFNC substantially reduced critical desaturation events in high-risk patients com- pared with standard oxygen therapy (30). Beyond reducing hypoxemia incidence, HFNC also decreases the need for procedural interruptions and airway maneuvers (20,30). Other studies confirmed that HFNC lowers the need for airway maneuvers and procedural interruptions, with the most pronounced benefit observed in preventing severe desaturation (9,11,22,30,37,40). The meta-analysis by Khanna et al. (2023) involving more than 3,000 patients also demonstrated significant reductions in desaturation incidents and procedure interruptions, together with higher minimum oxygen saturation (39). Although

Wang R, Li H-C, Li X-Y, Tang X, Chu H-W,

Yuan X, Tong Z-H, Sun B, 2021 (40)

Prospective randomized controlled trial

To compare modified HFNC and COT during bronchoscopy in reducing SpO2 < 90%

China

HFNC significantly reduced hypoxemia (12.5% vs 28.8%, p < 0.001) and maintained higher SpO2 during and after bronchoscopy.

Zhang W, Yuan X, Shen Y, Wang J, Xie K, Chen X, 2024 (42)

Prospective randomized controlled trial

To determine the optimal HFNC flow rate for preventing desaturation during bronchoscopy

China

The optimal HFNC flow rate for preventing desaturation in 95% of patients was 43.2 L/min

Feng Y, Chen Z, Wang J, 2024 (41)

Randomized controlled trial

To investigate the effect of transnasal HFNC therapy on gag reflex and oxygenation in elderly patients during fiberoptic bronchoscopy

China

HFNC improved SpO‐, reduced hypoxemia and gag reflex, with no significant impact on hemodynamics.

(95% CI: 36.4–56.0); 50–60 L/

min is recommended.

Lee et al. (2016) did not find a significant difference in overall hypoxemia rates, their results indicated that HFNC reduces the risk of severe hypoxemia compared with COT (8).

Collectively, the evidence shows that HFNC enhanc- es respiratory safety during sedated gastrointesti- nal endoscopy, leading to fewer and less severe de- saturation events and reducing the need for airway interventions.

HFNC during bronchoscopy

Similar benefits of HFNC have been reported during sedated bronchoscopy. Patients, especially those with impaired lung function, are highly susceptible to hypoxemia due to sedation and airway obstruction. Several studies indicate that HFNC is more effective than COT in maintaining oxygenation in this setting. The systematic review and meta-analysis by Su et al. (2021), including five RCTs, showed that HFNC sig- nificantly reduced hypoxemic events and increased

minimum SpO2 compared with COT (25). In practice, this means patients receiving HFNC were less likely to reach critically low saturation levels during the procedure.

HFNC has also been compared with other oxygena- tion techniques. The RCT by Saksitthichok et al. (2019) found comparable protection against desatu- ration between HFNC and NIV in high-risk hypoxemic patients, with no significant difference in lowest SpO2

(14). Only in the most severely hypoxemic subgroup (baseline PaO2 < 60 mmHg) did NIV provide slightly more stable oxygenation, suggesting a marginal ad- vantage of mechanical support in that population.

Observational studies (15,16) further confirmed that HFNC maintains stable SpO2 levels, often above 95%, without significant hypoxemia or procedural interruptions. Overall, HFNC improves oxygenation reserve, allowing safer and more continuous bron- choscopy with fewer complications related to oxygen deficiency.

High-risk patient populations and specific procedural conditions

The advantages of HFNC are particularly evident in vulnerable patient populations and specific proce- dural conditions. In a recent multicenter RCT (2025) in obese patients (BMI ≥ 28) undergoing sedated endoscopy, HFNC markedly reduced the incidence of hypoxemia, from 21% with COT to only 2%. Sub- clinical respiratory depression (SpO2 90–94%) also decreased from 36% to 5%, while severe hypoxemia was virtually eliminated (0% vs 4%) (19). These re- sults highlight the importance of HFNC in obese pa- tients, who desaturate more rapidly due to obstruc- tive physiology.

Similarly, in elderly patients and those with comor- bidities, HFNC has shown clear superiority over COT. Yin et al. (2024) found that among geriatric patients (>65 years) undergoing sedated gastroscopy, hy- poxemia occurred in only 3% with HFNC versus 23% with standard therapy, with higher minimum SpO2 values (28). This suggests that older patients, often more sensitive to sedatives, derive substantial ben- efit from HFNC.

The method has proven effective even under extreme environmental conditions. At high altitude (3600 m), HFNC significantly reduced hypoxemia incidence during endoscopic procedures (9% vs 37% with COT), completely preventing severe desaturation (26). This demonstrates its potential beyond conventional hos- pital settings, including environments with baseline hypoxemia caused by hypobaric conditions.

In transplant populations with reduced respiratory re- serve, HFNC has also shown benefit. In a randomized trial in post–lung transplant patients, Ben-Menachem et al. (2020) reported that HFNC nearly halved desat- uration events (43% vs 90%) and reduced procedural interruptions compared with COT (29). Collectively, evidence confirms that high-risk populations, includ- ing obese, elderly, hypoxemic, and post-transplant patients, experience the greatest clinical advantage from HFNC.

Comparison of HFNC with other methods of oxygenation support

HFNC has become a valuable tool for preventing hy- poxemia during invasive procedures under sedation, yet its limitations and comparison with alternative strategies remain relevant. Compared with non-inva- sive ventilation (NIV), HFNC provides similar oxygen-

ation support in most patients (14). Its main advan- tages are simplicity, comfort, and patient preference for nasal cannula over pressurized masks (43). How- ever, in severely compromised patients, NIV can of- fer stronger positive pressure and ventilatory assis- tance, outperforming HFNC in preventing profound hypoxemia or hypercapnia (44).

Not all studies have reported uniform benefits. In the trial by Sawase et al. (2023) during ERCP under mod- erate sedation, HFNC was applied with room air only (FiO2 21%, 40–60 L/min) and compared with low-flow O2. Under these conditions, HFNC did not signifi- cantly reduce hypoxemia or hypercapnia compared with COT (8% vs 5%; p = 0.674) (34). These results suggest that the effectiveness of HFNC depends on the delivered FiO2 and that benefits are more pro- nounced when oxygen-enriched flow (40–100% O2) is used, as is typical in clinical practice.

Regarding safety, most studies have not identified an increased rate of adverse events such as arrhyth- mias, aspiration, or post-procedural complications (19,29,39,45). Moreover, Lee et al. (2016) reported that HFNC significantly reduced the need to esca- late to more invasive support methods, including mask ventilation or NIV, in three of four analyzed tri- als (46). HFNC is generally safe and well tolerated, with minimal risk of mucosal dryness due to heated and humidified gas. Proper device setup, flow adjust- ment, and cannula fixation are essential for optimal performance.

Cumulative evidence supports HFNC as an effec- tive standard for sedated endoscopic procedures in patients at increased respiratory risk (20). Its capac- ity to reduce hypoxemia and emergent airway inter- ventions represents a major advance in procedural safety (30). Consequently, many centers have incor- porated HFNC into routine practice, especially for el- derly, obese, and pulmonary patients. Future studies should refine application protocols, including optimal flow rates, FiO2 levels, and duration. Based on cur- rent data, HFNC makes a substantial contribution to respiratory safety and deserves wider clinical imple- mentation (20).

Limitations

This systematic review has several methodological limitations. First, the literature search was restricted to three databases (PubMed, Web of Science, and Scopus) and to articles available in English which may

have introduced language and publication bias. Sec- ond, most of the included studies were conducted in Asian countries, particularly in China, which may af- fect the generalizability of the findings due to poten- tial differences in sedation protocols, clinical practice, and population characteristics. Third, heterogeneity across studies, including variable definitions of hy- poxemia, different saturation thresholds and incon- sistent flow and FiO2 settings, makes direct compari- son of results and meta-analytic conclusions more challenging. Finally, several of the included studies analyzed relatively small patient populations which may limit the statistical power and precision of the estimated effects of HFNC.

Conclusion

The analyzed studies clearly confirm that HFNC is a more effective method than COT for the prevention of hypoxemia during sedated endoscopic procedures. In addition to reducing the risk of desaturation, HFNC provides better oxygenation and decreases the need for additional airway interventions. Optimal flow rates of 50–60 L/min have proven to be the most ef- fective and well tolerated.

From a nursing perspective, understanding the prin- ciples, indications, and clinical application of HFNC can significantly improve peri-procedural patient management, particularly in high-risk populations. Integrating HFNC protocols into routine nursing prac- tice enhances respiratory safety, supports timely recognition of hypoxemia, and reduces the need for emergency interventions.

Future research should aim to define standardized protocols for HFNC use, compare different flow and FiO2 settings, and evaluate long-term outcomes and cost effectiveness across diverse clinical environ- ments. Further interdisciplinary studies are encour- aged to assess nursing-led education, monitoring strategies, and the role of nurses in optimizing HFNC implementation and patient outcomes.

Author Contributions

Conceptualization (VJ, JP, MV, TMT, MS); Data Curation (VJ), Formal Analysis (VJ, JP, MS); Writing – Original Draft (VJ), Writing – Review & Editing (VJ, JP, MV, TMT, MS). All authors reviewed and approved the final ver- sion of the manuscript.

Conflict of Interest

The authors declare no conflicts of interest.

Acknowledgments

Not applicable.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not for- profit sectors.

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