A content analysis of Japanese cancer documentaries across 25 years

Abstract We analysed Japanese television documentaries to (1) assess how cancer and the difficulties of patients with cancer were portrayed in documentaries on major Japanese national broadcasting networks and (2) evaluate changes in quality of life in Japan’s history of medicine as depicted in these documentaries to identify any trends. We analysed television documentaries aired from 1965 to 2015 on two major national broadcasting networks in Japan. Sixteen programmes on 24 patients with cancer aged 23–85 years were broadcast. The most common difficulty depicted was patient’s disease and care (n = 17). After 2006, more survivors discussed ongoing problems during cancer treatment. Over time, the proportion of programmes dealing with survivorship increased.


Introduction
According to Ostherr (2013), documentaries present information that the people of the era would like to know and can be characterised as immediate and authentic. Television documentaries can also provide information about the people of a particular era, including patients with specific diseases such as cancer. These documentaries can reveal a great deal about the social and cultural context at a particular time because they present information that is of interest to people of the era. The specific difficulties presented for patients also reflect the surrounding social and cultural context regarding how patients with certain diseases are viewed. We analysed Japanese television documentaries to

PUBLIC INTEREST STATEMENT
We analysed Japanese television documentaries to (1) assess how cancer and the difficulties of patients with cancer were portrayed in documentaries on major Japanese national broadcasting networks and (2) evaluate changes in quality of life in Japan's history of medicine as depicted in these documentaries to identify any trends. We analysed television documentaries aired from 1965 to 2015 on two major national broadcasting networks in Japan. Sixteen programmes on 24 patients with cancer aged 23-85 years were broadcast. The most common difficulty depicted was the patient's disease and care (n = 17). After 2006, more survivors discussed ongoing problems during cancer treatment. Over time, the proportion of programmes dealing with survivorship increased. assess how the difficulties of patients with cancer were portrayed in documentaries on major Japanese national broadcasting networks. We also evaluated changes in Japan's history of medicine as depicted in these documentaries to identify any trends. We examined the demographic characteristics of patients in the documentaries, the difficulties that these patients had and patient information (age group, gender, employment status, occupation, marital status, and place of residence). Additionally, we aimed to determine how the depiction of quality of life (QOL) in Japan's history of medicine has changed over time, as depicted in these documentaries. This study will increase people's understanding of how perceptions of cancer in Japan have changed over time.

Literature review
Patients with cancer have many difficulties during their treatment. According to Young et al. (2014), lung cancer survivors experienced more employment difficulties compared with the general population. Takeuchi et al. (2018) identified 14 categories of cancer-associated social problems from the perspectives of both patients and their spouses: "difficulty in performing activities of daily living", "difficulty in seeking expert advice on the disease state and treatment", "complaints with health care providers", "lack of information on treatment and disease state", "lack of information on self-care", "conflict over family relationships", "concerns for family members", "difficulty in planning life", "conflict over relationships with non-family members", "difficulty in adapting to changes in the social environment", "lack of local support services", "difficulty in solving work-related issues", "difficulty in making financial arrangements" and "lack of information on welfare services available during treatment". Although patients had higher scores than their spouses on most subcategories, spouses aged 39 years or younger and female spouses had difficulty scores as high as those of the patients on many subcategories. Oflaz et al. (2010) examined the emotional difficulties of nurses caring for patients with cancer in Turkey, finding that nurses had difficulty in talking to patients with cancer about end-of-life issues. Thus, previous research has supported the idea that the difficulties of patients with cancer vary and that their spouses and caregivers also experience difficulties. The development of cancer treatments has prolonged these patients' life expectancy, but other difficulties have arisen for them. Patients have to work to earn enough money to pay for treatment, and it is sometimes difficult to work while undergoing cancer treatment. For those who are raising children, it can be particularly difficult to save money for their treatment because raising children also requires money.
Television documentaries present patient narratives that include these patients' difficulties. In previous work, patient narratives have been useful resources for understanding the individual meaning of an illness from the patient's point of view. As Kalitzkus and Matthiessen (2009) asserted, narratives about being ill provide insight into individual experience, and Greenhalgh and Hurwiz (1998) concluded that narrative provides meaning, context, and perspective for the patient's problems. Patient narratives also provide an opportunity for the media to cover human struggle. A patient's narrative should be presented in the patient's own voice, rather than the voice of a friend or family member, because illness is a personal experience with individual meaning; no one else should represent the patient on these issues. Kleinman (1989) discussed how illness narratives arrange an individual's experience and process of illness. Patients are not medical experts, but they play a significant role in medical care. Understanding patients' points of view can help medical professionals to understand the impact of their care for patients. The existence of patients as laypeople is increasingly considered to be important, and their narratives appear not only in books but also on television programmes such as documentaries.
We therefore aimed to examine how disease and patients' difficulties have been described in documentaries appearing on Japanese major national broadcasting networks. Looking at trend developments in these narratives is important for gaining a better understanding of the changes over time in the difficulties patients with cancer experience. Vanhoven (2008) conducted an empirical study of the historical development of the representation of medical science on television from 1961 to 2000, carrying out a content analysis of Dutch nonfiction medical television programmes spanning a period of 40 years. The results suggested that there have been three periods of medical television: a scientific (medical lecture) period, a journalistic (seminar with public participants) period and a lay period. The increase in the speaking time allotted to laypeople shows the development of the role and position of laypeople over time. By tracing how medical science was represented in television programmes broadcast over 40 years, Vanhoven (2008) contributed to categorising the historical development of this representation in the Netherlands. We assumed that there has also been historical development in the representation of the difficulties of patients with cancer in Japan. We sought to categorise this development to better understand the changes in the difficulties of patients with cancer and how caregivers can communicate to support these patients.
As discussed by Kato et al. (2018), media representations of disease have been linked to important policy developments in Japan. According to Nichigai Associates (2013), in 1983, a 10year anti-cancer plan was established by the Cabinet of Japan, and the media representation of cancer emerged. In 1994, QOL improvement for patients with cancer was included in a new 10year anti-cancer plan, and this year represented a turning point for patients with cancer in Japan. QOL for patients with cancer refers to the physical, mental, social, and financial aspects of QOL patients receiving medical treatment. Beginning in the late 1990s, the taboo against doctors revealing cancer diagnoses to patients faded. In the first decade of the 21 st century, the Japanese government established several cancer information centres, facilitating public discussion of the treatment of cancer among people in Japan. In 2006, the National Cancer Center in Japan established the Cancer Information Center to help patients, including survivors. The reason for the increase in the number of cancer programmes may be that the government wanted to circulate information about cancer strategies and treatment policies among the public. In 2007, a basic law on countermeasures against cancer came into effect in Japan. This law explicitly mentioned improving QOL for patients with cancer. The law pointed out that the difficulties experienced by patients with cancer are not only physical, but also mental and social. Thus, the purpose of the law is to establish a plan to mitigate physical, mental, and social difficulties to improve QOL for patients with cancer. Living with cancer is now very common, which creates new difficulties for patients in daily life. Nevertheless, the description of the diseases and difficulties experienced by patients with cancer in documentaries has not been discussed in previous studies.
We speculated that there is a link between important policy developments in Japan and the media representation of cancer. Frank (2002) has argued that the creation of illness narratives is dependent on historical issues and the social environment. We aimed to examine how the depiction of QOL in Japan's history of medicine has changed over time, as depicted in television documentaries about cancer.

Objectives
The present study aimed to use content analysis to examine portrayals of patients with cancer in Japanese television documentaries about these patients. Video content analysis has often been used to examine how images can communicate stereotypes, as well as attitudes towards numerous health topics, such as diabetes, and other public issues. Thus, this method was selected for the present study to examine portrayals of patients with cancer in television documentary programmes about cancer topics aired on two major national broadcasting networks in Japan. We conducted a content analysis of television documentaries to answer two main research questions (RQs): RQ1: How were diseases and patients' difficulties described in documentaries on Japanese major national broadcasting networks?
RQ2: How has the depiction of QOL in Japan's history of medicine changed over time, as depicted in these documentaries?

Study population
We analysed television documentaries broadcast from 1965 to 2015 on two major national broadcasting channels-NHK (Nippon Hoso Kyokai; Japan Broadcasting Corporation) general analogue/digital and NHK Education analogue/digital-using the NHK archived chronicle database website. NHK is a national television broadcasting organisation funded by a television licence fee paid by the Japanese public. Because of the absence of sponsors, programme coverage is considered relatively fair; therefore, we chose documentaries aired on NHK for the analysis. We searched the database from January 1965 to December 2015.
Included programmes were documentaries related to cancer that featured at least one patient. Exclusion criteria were as follows: dramas without a patient narrative, news programmes, educational programmes, programmes focusing mainly on caregivers, programmes focusing on the healthcare system or specific diseases, programmes produced in countries other than Japan, symposia sponsored by pharmaceutical companies, programmes focusing on handicapped people and programmes featuring lectures without patients.
Using these criteria, we searched videos with the search term "患者" or kanja, meaning "patient", which yielded a total of 1428 programmes; 1301 were rejected using the exclusion criteria, and 127 remained for further review. We found that some of the programmes included more than three patients, and each patient's timeframe was as short as a few minutes. Therefore, during our screening, we decided to set a new criterion to choose only programmes that focused mainly on one or two patients. Thus, 49 additional programmes were excluded, and 78 were included for review. From the remaining 78 videos, each programme was initially screened to determine whether the primary topic of the programme was the narrative of patients with cancer, resulting in the selection of 16 videos focusing on these narratives.

Measurements
The number of documentaries presenting narratives of patients with cancer was assessed by two researchers. Each television documentary about patients with cancer was analysed using a coding manual that we created based on the "Comprehensive Survey of Living Conditions", which is conducted by the Japanese Ministry of Health, Labour and Welfare (MHLW). According to the Ministry of Health, Labour and Welfare (2020), "The purpose of this survey is to research basic subjects of living conditions such as health, medical care, welfare, pension and income and to obtain basic data on the Japanese general public required for the planning and management for the health, labour and welfare administration". The "Comprehensive Survey of Living Conditions" is a nationwide survey of households and household members in Japan that covers basic matters of national life such as health, medical care, welfare, pensions and income.
Data on patients' demographic characteristics were collected using the "Comprehensive Survey of Living Conditions". To collect basic data necessary for the MHLW's planning and operations, large-scale surveys have been conducted every three years since 1986. In the present study, we used items from this survey to determine which data to collect on the demographic characteristics, including age group, gender, employment status, occupation, marital status and place of residence, of the patients appearing in the analysed documentaries. We divided patients with cancer into four age groups according to their lifestyle: < 23 years; 23-39 years, when most people in Japan graduate from university and start to work; 40-64 years, when most people in Japan have children and work to provide for the family unit or stay home and support the family by doing domestic chores; and ≥ 65 years, when most people in Japan have retired from their regular work. In addition to these items, we also assessed whether the patients in the documentaries had children and with whom the patients lived because we thought there might be a relationship between these factors and the depiction of the patients' difficulties.
To analyse the descriptions of the patients' diseases and difficulties (RQ1), we created categories of patients' difficulties following the "Public Opinion Survey Concerning People's Lifestyles", a nationwide survey conducted by the Cabinet Office, Government of Japan (2020) to capture various points of view on people's awareness and needs concerning their lives, such as perspectives about their families and homes and about current and future lifestyles in Japan. A total of 17 categories of patient's difficulties were used in our study, including patient's disease and care, finding a reason for living, family, vocation, human relationships, disease and care of a family member, and income, debt, and other money matters. Although the category of finding a reason for living is not directly related to a specific "difficulty" patients with cancer faced, we used this category in the analysis because, when people have a serious illness and become aware of having a limited time to live, they often think about their reason for living, sometimes suffering in cases where they do not identify a reason for living.
The individual meaningful statements in the documentary programmes were the unit of analysis in this study. The presence of a particular type of difficulty was confirmed by each coder when a narrator, the patient or family members appearing in the programme expressed a difficulty experienced by the patient. The coding of patients' difficulties was thus not always based on a patient's direct verbal remarks in the documentary programme. For each meaningful statement, the coding was applied using dichotomous responses (i.e. yes or no) for each category.
After collecting the titles and broadcast years of all documentaries meeting the inclusion criteria, the depiction of change in the depiction of QOL in Japan's history of medicine (RQ2) was assessed by two researchers by comparing the main themes regarding cancer care and patients across different time periods. We began by qualitatively analysing the titles of these programmes.
However, to answer RQ2, we also examined the full contents of the selected programmes when more than the title of the programme was required to determine the main themes in how cancer care and patients were depicted.

Coding
The 16 selected videos were systematically evaluated by a team of two trained coders. Each coder watched all 16 programmes and coded instances of patients talking on the screen. The coders coded these programmes independently and discussed them to reach agreement. If a patient mentioned the same difficulty more than once, we coded the number of times it was mentioned. Before finishing the coding, the coders discussed any inconsistencies and, after discussion, agreed on consistent coding. The duration of coding was 20 days (6 hours per day, 120 hours in total) because of stipulations of the NHK database administrator. The NHK archives centre is used by various researchers; therefore, we were allowed limited access during timeslots allocated by the NHK database administrators. To answer RQ2, the broadcast year for each selected documentary programme was compared with the prominent events recorded for that year in the Japanese Medical History Encyclopedia (Nichigai Associates, 2013).

Number of documentaries presenting narratives of patients with cancer
Of the 78 videos reviewed, 16 of the programmes broadcast were about patients with cancer. Details of the database are presented in Table 1. The mean length of the videos was 42 minutes (standard deviation = 23.0), with a median of 30 minutes. The shortest video lasted 23 minutes, and the longest video lasted 89 minutes. Of the videos, three were originally broadcast from 1990 to 1999, eight from 2000 to 2009 and five from 2010 to 2015. Analysis was only possible for the period from 1991 to 2015 because of the availability of episodes; before 1991, the broadcasting organisation did not record whole episodes but only archived filmed reports. Table 2 shows the demographic characteristics of the patients with cancer portrayed in the analysed videos. Again, of the 78 programmes reviewed, 16 related to cancer. In these programmes, 24 patients were identified for analysis. Their ages ranged from 23 to 85 years (mean age = 47 ± 17 years). The most frequently observed age group was 23-39 years (N = 7). The patients were mostly female (female: 17, male: 7). The most frequently observed disease was breast cancer. The programmes were produced all over Japan. Eleven of the patients were employed, 10 patients had spouses and all married patients were cohabiting with their spouses. Eight patients had at least one child, and four lived with their children. Some names, faces and voices of patients with cancer were concealed when they appeared on television. When the patients' names, faces or voices were concealed, we were usually able to determine their ages and genders from the other available information (i.e. from the title of the programme, the narration, the patient's name or the type of cancer).  Table 3 shows the numbers of patients with cancer (total n = 24) dealing with frequently seen difficulties addressed in the videos. The most common element reported was disease and care (n = 17), followed by finding a reason to live (n = 11), family (n = 9), vocation (n = 9), human relationships (n = 6), disease and care of family members (n = 5), and income, debt and other money matters (n = 3). It is notable that the majority of the total of 24 patients mentioned the patient's own disease and care (n = 17). Patients wanted not only to recover from their illness but to also to have a good QOL, represented by a reason to live. Income, debt and other money matters (n = 3) were not among the top of difficulties, likely because cancer treatment is very expensive in Japan, causing people to take this difficulty for granted and not mention it as a problem.

Descriptions of diseases and patients' difficulties (RQ1)
Similar to Vanhoven's (2008) suggestion of three periods of Dutch medical television across 40 years, we found that developments in the documentaries could be separated into three major phases, reflected roughly by the three decades in the study period (the 1990s, the 2000s and the 2010s). Therefore, we divided the analysed videos into three phases. From the 16 programmes, we selected three programmes that were representative of the three periods to discuss the qualitative findings in depth. We chose these three programmes because each of them focused on one patient, and the time devoted to describing the patient's difficulties was longest in these documentaries.

"Tomorrow we live together: gift from Akihito" (1996)
Akihito Wada, a public servant in Japan, was found to have leukaemia after his wife became pregnant. He died of cancer at the age of 39, when his son was 3 years old. For the dying patient, the main difficulty was leaving his loving family members behind, and dying itself was a fear. The documentary presented the narrative of Akihito and his wife. Immediately after he was told that he had cancer, he wandered the corridors of the hospital. He did not understand why he was afraid, thinking that if he is to live, he will live. Afterwards, he decided he would make every effort to live each day without being controlled by fear. The documentary ends with the image of an acorn tree. The tree is a metaphor for life, and, at the end of the documentary, the narrator says that, just as the acorn spreads its roots below and grows, one's life is connected to another life, and this takes over the importance of one's life. Vocation (e.g., Continuing to work in the same job is difficult) 9 Human relationships (e.g., They cannot see friends freely anymore) 6 Disease and care of a family member (e.g., If they are not well, they are not sure who can will take care for of their family members)

5
Income, debt and other money matters (e.g., They have no money or insufficient lack of money for treatment) This patient's illness experience was framed as change in his thoughts about living, which were presented through his self-talk.

"Kazuko Yanagihara: living with cancer" (2007)
Kazuko Yanagihara, a nonfiction writer, discovered that she had ovarian cancer when she was 47 years old. After a few years, her cancer metastasised. She visited many doctors to talk about her cancer therapy. She wanted to know about medical care that could give hope to patients with cancer. The documentary covers the process of her interview. After becoming a patient, Kazuko said that the actual difficulty was being dislocated from ordinary society, feeling that society does not have a word for those who suffer from incurable cancer and that living with cancer is exhausting. However, she changed her mind as she continued to talk with doctors. She recounted that, after 9 years, she felt that she wanted to live for the first time; previously, she could never say she wanted to live because others kept saying that her illness was incurable. She found that talking with doctors exposed her to medical care that can give hope to patients. She also described the joy of creativity, the hope that comes from a partnership connection between doctor and patient, and the humanity of medical care. She died in 2008; therefore, she was alive when the programme aired.
In this documentary, the illness experience was framed as change in the patient's thoughts about living, and this was also presented through her self-talk. The programme did not end with the patient's death; the thought conveyed was not about the acceptance of death but rather about living with cancer.

"Today's close-up: 'I am a cancer patient. I would love to have children.'" (2013)
Yuki Akasaka was a 34-year-old married woman with breast cancer. After she had already been diagnosed with cancer, she and her husband decided that they wanted to have children. When Yuki consulted her doctor, he told her that he did not know of any cases where a patient in her 20s experienced the menopause. However, after chemotherapy, Yuki was told she had reached the menopause. Yuki was told that there were some options such as freezing embryos or eggs, but not until after her menopause. She said that she received no information regarding such options from her doctor before undergoing chemotherapy. The difficulty for this patient was not receiving enough information before chemotherapy and not being able to choose, as a woman, to have a baby or even to have a period. Chikako Shimizu, a female doctor at the National Cancer Center Hospital, commented that, before her generation, doctors were told that curing cancer is of the utmost importance and that all other things can be considered negligible. She also said that it is only recently that they have started to think about the patient's life after being diagnosed with cancer.
Here, the illness experience was framed as the patient not receiving the required information as a social issue, which was presented through her self-talk and narration. However, this theme was not common for the programmes broadcast the second decade of the 21 st century. A common theme for the programmes broadcast in this decade is seeking QOL (in this case, becoming a mother) after living through cancer.

Change in the depiction of QOL in Japan's history of medicine (RQ2)
In the 1990s, patients' narratives were used mainly to depict terminal patients' lives. The programmes tended to focus on the lifestyle and suffering of terminal patients, and the patients were often shown in bed. For example, in "Tomorrow We Live Together: Gift from Akihito" (1996), Akihiko Wada was shown as a terminal patient in hospital. However, in the 2000s, themes became broader, dealing with topics rangsing from how to cope with the community and work to communication among patients. Especially after 2006, the image of cancer no longer focused on death, and more themes about survival were discussed. This is seen in "Relay for Life: 400 m for Living Hope (2006)", which was about an event for cancer survivors in Japan hoping to connect with the community and other patients. After 2009, social problems including job opportunities became one of the presented predicaments of cancer survivors. In "Today's close-up: 'Living with Cancer'" (2009), the main difficulty of patients with cancer presented was a fear of losing their jobs. Table 4 shows historical cancer-related events in Japan and the numbers of television programmes covering these events. In 1989, a meeting was conducted about how to care for terminal patients. In 1994, the 10-year anti-cancer plan, aiming to prevent the increase of the number of patients with cancer, was released; notably, QOL improvement was included in this plan. In 2005, the MHLW established the counter-cancer promotion headquarters. In 2006, the National Cancer Center established the Cancer Information Center. In 2007, the basic law for countermeasures against cancer came into effect. The countermeasure plan reflected the opinions of patients with cancer and their family members, as well as medical experts and academic researchers working on cancer. In 2012, the second basic plan for promoting countermeasures against cancer was enacted. Adding to the first basic plan, this new plan included in its overall goals the aim of building a society in which patients with cancer can live peacefully. After cancer became the leading cause of death in 1980s, the number of television programmes covering these events began to increase in the 1990s, rising sharply after 2006. Additionally, increasing numbers of cancer survivors discussed ongoing problems of cancer treatment in documentary appearances.

Discussion
In this study, we conducted a content analysis of television documentaries over 25 years in Japan. The first research question aimed to determine how diseases and patients' difficulties were described in documentaries on national broadcasting networks in Japan. The second research question asked about the change in the depiction of QOL in Japan's history of medicine, as depicted in these documentaries, with the objective of identifying any trends.
Overall, the results revealed that the number of documentaries focusing on the narratives of patients with cancer did differ across the examined period. A trend observed in the selected documentaries involved the attention given to survivors. In the 1990s, in the selected documentaries, patients suffered greatly from their diseases and had usually died before the broadcast appeared on television. In contrast, after the first decade of the 21 st century, most cancer survivors appearing in the selected television documentaries seem to be energetic and vital. Illness experiences were initially framed as inside the individual (1996), then in the patient's relationships with medical professionals (2007) and finally as social issues (2013). Vanhoven (2008) discussed the increase in the speaking time allotted to laypeople in Dutch nonfiction medical television programmes as illustrating an unexpected development in the role and position of laypeople. In the present study, in the 1996 programme, most of the speaking time was allotted to the patient's wife, and the 2007 programme consisted of interactions between the patient and her physicians. Most of the 2013 programme consisted of interviews with patients with cancer. Therefore, our results also suggested the development in the role and position of patients as laypeople. Looking at trend developments in narratives is important because it gives us information about how the status of patients has improved. Improvements in the status of patients may lead to empowered decision making by patients, resulting in patient-centred medicine.
In our study, the expressions in the titles of the documentaries initially reflected the patients fighting fiercely ("Tomorrow We Live Together: Gift from Akihito", 1991) but changed to focus on survival ("Kazuko Yanagihara: Living with Cancer", 2007) and then on seeking QOL ("Today's Close-up: 'I am a Cancer Patient. I Would Love to Have Children '", 2013). Through the first decade of the 21 st century, accepting their illness was presented as a great difficulty for patients with cancer. In contrast, in the next decade, patients accepted their illness and expressed a desire to have a daily life like when they were healthy, and maintaining good QOL in their daily lives was presented as a new difficulty for them. Married patients expressed the desire to have children. Employment did not receive much attention in the programmes, although over half of the patients presented in the documentaries worked part-time or full-time. The patient appearing in the first programme was a former public servant, but after becoming very ill, we assume that he was no longer working. The woman appearing in the second programme was a freelance writer. The employment status of the female patients appearing in the third programme was unclear. Therefore, we were unable to examine whether vocational status might be related to specific difficulties for patients with cancer. In the 1990s and 2000s, the central message of the documentaries was to encourage other patients with cancer. In the 2010s, providing information to meet survivors' diverse needs seemed to be the central message.
Regarding RQ1, the most frequently observed difficulties were in dealing with their own disease and care and, for some patients, difficulties in the workplace. The documentaries depicted patients who still had difficulties coping with their own illnesses and faced difficulties in their workplaces. Relationships with family members were another main difficulty for patients with cancer. The results of the present study were partly consistent with Takeuchi et al.'s (2018) findings, showing "difficulty in performing activities of daily living", "concerns for family members", "difficulty in planning life" and "difficulty in solving work-related issues" as difficulties experienced by patients with cancer. The results of the present study were also consistent with the findings of a previous study conducted by Koshizuka et al. (2005), which discussed the encouragement, understanding and support that families can give patients to enable them to fight against the disease and to cope with their treatment. The faces and voices of patients with end-stage cancer were all revealed in the documentaries, whereas the faces and voices of some young patients and their family members were hidden because of the possibility that they might return to the community or workplace and face stigma from having had cancer.
One intriguing finding was that having a reason for living was the second most frequently referenced category of difficulty, although this category is not directory related to the disease, hardships linked to fighting against the disease or struggles with obtaining support from others in this fight.
Our analysis of the change in the depiction of QOL in Japan's history of medicine as depicted in the selected documentaries revealed several tendencies. In the 1990s, there was a strong tendency for patients with cancer appearing in documentary programmes to be terminal patients. Our study results indicate that the frequency and number of cancer programmes broadcast might relate to socio-political events such as the introduction of anti-cancer strategies aimed at appealing to the general public.
People in Japan hold a certain image of cancer, and this view is decidedly negative. The Japan Cancer Society (2017) conducted interviews with 1815 people in 2016, finding that 72.3% had an impression of cancer as "scary" because of its image as an incurable disease. Indeed, until recently, people in Japan tended to think of cancer as incurable, with an image of it as being equivalent to death. Although the examined documentaries conveyed improved QOL among patients with cancer, throughout the study period, people in Japan generally continued to see cancer in a very negative light. Therefore, these documentaries did not correspond to people's actual perceptions of cancer. Rather, it might be said that these documentaries tried to change people's perceptions by suggesting a new way of seeing cancer and patients with cancer.
Geographically, about 70% of Japan is forested, mountainous and unsuitable for agricultural, industrial or residential use. People in Japan have lived with nature, and they have also been threatened by nature. Many natural disasters, including typhoons and earthquakes, hit Japan every year, and people in Japan fear or live in awe of Mother Nature. Nature is uncontrollable, and illness is thought of in a similar way. Therefore, for people in Japan, cancer is considered an incurable disease. In one of the selected documentaries, a patient with cancer expressed the fatalist thought that if he is to live, he will live. Such attitudes may be a reflection of the cultural values described above. This type of perception may have affected how difficulties are perceived by the patients with cancer in selected documentary programmes. For example, Kazuko Yanagihara, who appeared in the programme "Living with Cancer" (2007), said that, previously, she could never say she wanted to live because others kept saying that her illness was incurable. It could be argued that patients with cancer have been deprived of hope for life, and especially for QOL, by these cultural values.
The current study had several limitations. First, only Japanese television documentaries broadcast by Japan's national public television channels were analysed in the present study. Second, the NHK archives contain only programmes aired after 1965. Programmes aired before 1965 were therefore omitted, although television broadcasting in Japan began in 1953.Third, choosing only three programmes-one for each of the three major phases identified in the study-for in-depth analysis might have given rather too much weight to these individual documentaries; it is difficult to think only one programme can adequately represent a full decade. Studying a larger sample of programmes in depth was not feasible because not many programmes met the inclusion criteria. Our work remains valuable despite this limitation because no previous study has focused on how the difficulties of Japanese patients with cancer have been represented in multiple time periods. Our findings suggest that the status of patients might have improved, given that the time allotted for patients to speak in these documentary programmes has increased. However, we did not triangulate this finding by interviewing the producers of the documentaries to understand their decisions to include more of the patients' voices. It would be useful for a future study to explore this topic. In spite of these limitations, to our knowledge, this is the first study to examine portrayals of patients with cancer in Japanese television documentary programmes. An interesting finding was that several people expressed that they did not want to be a burden to their family members. We did not discuss this in depth because we did not have clear category that captured this type of statement; however, this preliminary finding represents another potentially fruitful direction for future research.
Analysing the change in the depiction of QOL in Japan's history of medicine as depicted in documentaries focusing on the narratives of patients with cancer, the present study found that the frequency and number of cancer programmes broadcast might relate to sociopolitical events such as the introduction of anti-cancer strategies aimed at appealing to the general public. We anticipate that, in the future, more programmes will discuss cancer survivorship.