2025 Volume 30 Pages 15
Background: Quick accomplishment and responsiveness are behaviors related to time management by perceived control of time, such as a positive feeling of using one’s time well. In recent years, positive psychological states have been associated with a lower risk of cardiovascular disease (CVD). Thus, we investigated the associations of quick accomplishment and responsiveness with CVD mortality in a large cohort study.
Methods: The study participants were 75,049 (30,901 men and 44,148 women) aged 40–79 between 1988 and 1990 and followed until the end of 2009. Hazard ratios (HRs) and 95% confidence intervals (CIs) of mortality from CVD according to quick accomplishment, responsiveness, and their combination were calculated after adjustment for potential confounding factors using the Cox proportional hazard model.
Results: Quick accomplishment was associated with a lower risk of CVD mortality in women; a similar but marginally significant association was observed in men; the respective multivariable HR (95%CI) was 0.91 (0.83–0.99) and 0.93 (0.86–1.01). The presence of both quick accomplishment and responsiveness was associated with lower risk in men, which was confined to men aged 60–79; the respective multivariable HR (95%CI) was 0.88 (0.78–0.99) and 0.83 (0.72–0.96).
Conclusions: Quick accomplishment was associated with a lower risk of CVD mortality. Quick accomplishment and responsiveness combined were inversely associated with CVD mortality risk among older men.
Behavioral patterns such as quick accomplishment (a behavioral characteristic of trying to work efficiently) and responsiveness (a behavioral characteristic of making decisions quickly without procrastinating) are behaviors relating to time management. Time management consists of a behavior that aim to use the time while performing certain goal-directed activities effectively, and a behavior with a positive feeling of being able to use one’s time well [1]. While time management enhanced positive psychological states such as job satisfaction and well-being, it was associated with work-related stress, anxiety, emotional exhaustion, and depressive symptoms [2–7]. Some studies revealed these psychological states have been associated with the risk of cardiovascular disease [8–10]. However, no studies have investigated the associations of quick accomplishment and responsiveness with cardiovascular health. Thus, we investigated the associations of these behaviors with the risk of mortality from cardiovascular disease (CVD) in a large and long-term cohort.
Our a priori hypothesis is that quick accomplishment and responsiveness are inversely or positively associated with CVD mortality among middle-aged and older people.
The Japan Collaborative Cohort (JACC) Study for Evaluation of Cancer Risks, sponsored by the Ministry of Education, Sport, Science, and Technology in Japan, was conducted from 1988 to 1990. The sampling methods and other details of the JACC Study have been described elsewhere [11, 12]. A total of 110,585 participants (46,395 men and 64,190 women), 40–79 years of age from 45 areas throughout Japan, were enrolled at baseline. Of them, 5,675 (2,488 men and 3,187 women) participants were excluded because they had a history of cancer or CVD at baseline. Then, 24,264 participants (10,754 men and 13,510 women) in 13 areas where the questionnaire did not include quick accomplishment and responsiveness were excluded. Finally, we excluded 5,597 (2,252 men and 3,345 women) participants with missing data for the psychological questionnaires about quick accomplishment and responsiveness from the analysis. Consequently, we used the data of 75,049 (30,901 men and 44,148 women) who lived in 32 communities across Japan. Informed consent was acquired before participants completed the questionnaires or from community leaders instead of individuals [11]. The ethics committees of Nagoya University School of Medicine (approval number: 177), Hokkaido University Graduate School of Medicine (approval number: 14-044), and the Osaka University Graduate School of Medicine (approval number: 14285-6) approved the present study.
In each study site, investigators conducted a standardized review of death certificates sent to each public health center, and mortality data were collected and centralized at the Ministry of Health and Welfare. The underlying causes of death were coded by the 10th Revision of the International Classification of Diseases and Related Health Problems (ICD-10). The follow-up of participants lasted until the end of 2009 or until death, whichever occurred first, except in four areas where the follow-up had ended in 1999, another four areas where follow-up ended in 2003, and two areas where follow-up ended in 2008. Follow-up endpoints included deaths from CVD as ICD-10 codes of I01 to I99.
The information about behavioral patterns such as quick accomplishment and responsiveness was obtained using a self-administered questionnaire. Quick accomplishment was defined as persons who answered “definitely yes” or “yes” to the question: “Are you in a hurry to achieve your jobs?” whereas those who answered “maybe yes” or “no” were without quick accomplishment. Responsiveness was defined as persons who answered “yes” to the question: “Do you have a quick response to things you need to deal with?” whereas those who answered “maybe yes” or “no” were without responsiveness. The Kappa coefficient for quick accomplishment and responsiveness was similar between men and women: 0.22 and 0.20, respectively.
We divided the participants into two groups to examine the association between either quick accomplishment or responsiveness and the risk of CVD mortality and four groups to explore the association between the combination of quick accomplishment and responsiveness and the risk.
The statistical analysis was based on age-adjusted incidence rates of CVD mortality during the follow-up period from 1988 to 2009. The sex-specific hazard ratios (HRs) and their 95% confidence intervals (CIs) of CVD mortality were calculated after adjustment for age and other potential confounding factors using the Cox proportional hazard models. These confounding variables included age (year), body mass index (BMI; <18.5, 18.5–24.9, and ≥25.0 kg/m2), history of hypertension (yes or no), history of diabetes (yes or no), smoking status (never, ex-smoker, or current), alcohol intake (never, ex-drinker, current drinker of 1–45, 46–68, or ≥69 g per day), participation in sports (rarely, 1–4, or ≥5 hours per week), walking frequency (rarely, 30–59, or ≥60 min per day), education level (elementary, junior high school or less, high school, or college or higher), employment status (employed, self-employed, housekeeping, unemployed, or others), perceived mental stress (low, moderate, high), purpose of life (“ikigai”) (yes, not particular, or no), perceived life enjoyment (yes, not particular, or no), and likely to be angry (yes, not particular, or no).
We also performed the age-specific analysis (age 40–59 and 60–79 years old, corresponding to the timing before and after retirement for employees in Japan at the baseline survey).
The statistical analysis was performed with the Statistical Analysis System (SAS) for Windows (version 9.4; SAS Inc, Cary, NC, USA). All P-values for statistical tests were two-tailed, and values of <0.10 and <0.05 were considered marginally and statistically significant.
Table 1 shows the sex-specific baseline characteristics of participants according to quick accomplishment and responsiveness. Participants with quick accomplishment and responsiveness compared with those without them were younger, more likely to be smokers, highly educated and employed, angry, had higher perceived mental stress, the purpose of life, and life enjoyment, while they were less likely to be hypertensive for men and women.
| Quick accomplishment | Responsiveness | |||
|---|---|---|---|---|
| − | + | − | + | |
| Men | ||||
| No. of participants | 15,289 | 15,612 | 21,457 | 9,444 |
| Age, years | 58.1 (10.2) | 56.0 (9.9) | 57.6 (10.1) | 55.7 (10.1) |
| Body mass index, kg/m2 | 22.7 (3.1) | 22.7 (3.9) | 22.6 (3.6) | 23.0 (3.3) |
| History of hypertension | 2,741 (17.9) | 2,591 (16.6) | 3,874 (18.1) | 1,458 (15.4) |
| History of diabetes | 854 (5.6) | 907 (5.8) | 1,227 (5.7) | 534 (5.7) |
| Current smoker | 7,663 (52.9) | 8,095 (54.3) | 8,300 (54.5) | 4,330 (59.7) |
| Current drinker | 10,903 (74.4) | 11,601 (77.3) | 15,611 (75.9) | 6,893 (75.8) |
| Sports ≥5 h/week | 1,073 (7.0) | 1,092 (7.0) | 1,408 (6.6) | 757 (8.0) |
| Walking ≥1 h/day | 6,931 (45.3) | 7,174 (46.0) | 9,912 (46.2) | 4,193 (44.4) |
| College or more | 2,333 (15.3) | 2,731 (17.5) | 3,160 (14.7) | 1,904 (20.2) |
| Employment status | ||||
| Employed | 5,145 (33.7) | 6,524 (41.8) | 7,958 (37.1) | 3,711 (39.3) |
| Self-employed | 5,152 (36.8) | 5,294 (36.5) | 7,112 (35.7) | 3,334 (38.8) |
| House-keeping | 15 (0.1) | 9 (0.06) | 16 (0.08) | 8 (0.09) |
| Unemployed | 2,743 (19.6) | 1,930 (13.3) | 3,543 (17.8) | 1,130 (13.1) |
| Others | 936 (6.7) | 757 (5.2) | 1,278 (6.4) | 415 (4.8) |
| Perceive mental stress | 2,020 (13.2) | 4,811 (30.8) | 4,177 (19.5) | 2,654 (28.1) |
| Purpose of life | 6,492 (42.5) | 8,752 (56.1) | 9,017 (42.0) | 6,227 (65.9) |
| Perceive life enjoyment | 5,051 (33.0) | 6,665 (42.7) | 6,859 (32.0) | 4,857 (51.4) |
| Likely to be an angry | 1,690 (11.1) | 4,716 (30.2) | 3,688 (17.2) | 2,718 (28.8) |
| Women | ||||
| No. of participants | 24,582 | 19,566 | 34,221 | 9,927 |
| Age, years | 58.0 (10.1) | 56.4 (9.7) | 57.7 (10.0) | 56.1 (9.9) |
| Body mass index, kg/m2 | 23.1 (4.2) | 22.8 (3.0) | 22.9 (3.3) | 23.3 (4.8) |
| History of hypertension | 4,757 (19.4) | 3,475 (17.8) | 6,529 (19.1) | 1,703 (17.2) |
| History of diabetes | 859 (3.5) | 605 (3.1) | 1,142 (3.3) | 322 (3.2) |
| Current smoker | 985 (4.6) | 1,010 (5.8) | 1,277 (4.2) | 718 (8.0) |
| Current drinker | 4,934 (21.7) | 4,789 (26.2) | 7,045 (22.2) | 2,678 (28.7) |
| Sports ≥5 h/week | 965 (3.9) | 875 (4.5) | 1,332 (3.9) | 508 (5.1) |
| Walking ≥1 h/day | 11,094 (45.1) | 9,311 (47.6) | 15,917 (46.5) | 4,488 (45.2) |
| College or more | 2,139 (8.7) | 1,970 (10.1) | 2,851 (8.3) | 1,258 (12.7) |
| Employment status | ||||
| Employed | 4,869 (19.8) | 5,357 (27.4) | 7,804 (22.8) | 2,422 (24.4) |
| Self-employed | 3,734 (16.6) | 3,459 (19.4) | 5,327 (16.9) | 1,866 (21.1) |
| House-keeping | 7,458 (33.1) | 5,053 (28.4) | 9,786 (31.0) | 2,725 (30.9) |
| Unemployed | 5,238 (23.2) | 2,976 (16.7) | 6,812 (21.6) | 1,402 (15.9) |
| Others | 1,241 (5.5) | 979 (5.5) | 1,804 (5.7) | 416 (4.7) |
| Perceive mental stress | 3,110 (12.7) | 5,443 (27.8) | 6,138 (17.9) | 2,415 (24.3) |
| Purpose of life | 8,671 (35.3) | 9,433 (48.2) | 11,957 (34.9) | 6,147 (61.9) |
| Perceive life enjoyment | 7,854 (32.0) | 7,874 (40.4) | 10,627 (31.1) | 5,101 (51.4) |
| Likely to be an angry | 1,705 (6.9) | 3,721 (19.0) | 3,648 (10.7) | 1,778 (17.9) |
Age and body mass index are expressed as mean (standard deviation), and the others are expressed as numbers (percentages).
Supplemental Table 2 shows the sex-specific baseline characteristics of participants by the combination of quick accomplishment and responsiveness, and Supplemental Table 3 shows them stratified by age. Similar trends were observed between ages 40–59 and 60–79, as seen in Table 1 and Supplemental Table 1, respectively.
During 1,219,108 person-years of follow-up (median follow-up period 19.1 years), we documented 2,546 men and 2,403 women died from CVDs. Table 2 indicates the sex-specific HRs of CVD mortality according to quick accomplishment, responsiveness, and combination. After multivariable adjustment, quick accomplishment was associated with a lower risk of CVD mortality in women; a similar and marginally significant association was observed in men; the respective multivariable HR (95%CI) was 0.91 (0.83–0.99) and 0.93 (0.86–1.01). Responsiveness was not associated with the risk of CVD mortality in men and women. When examined by the combination of quick accomplishment and responsiveness, the presence of both quick accomplishment and responsiveness was associated with a lower risk of CVD mortality compared to their absence in men, a similar but not statistically significant association was observed in women. The multivariable HR (95%CI) of CVD mortality was 0.88 (0.78–0.99) and 0.92 (0.80–1.05), respectively.
| Quick accomplishment | Responsiveness | |||
|---|---|---|---|---|
| − | + | − | + | |
| Men | ||||
| No. at risk | 15,289 | 15,612 | 21,457 | 9,444 |
| Person-years | 238,251 | 252,850 | 337,878 | 153,224 |
| No. of cases | 1,420 | 1,126 | 1,878 | 668 |
| Age-adjusted HR (95%CI) | Ref. | 0.90 (0.83–0.97)** | Ref. | 0.91 (0.84–1.00)** |
| Multivariable HR (95%CI)a | Ref. | 0.93 (0.86–1.01)* | Ref. | 0.93 (0.84–1.02) |
| Women | ||||
| No. at risk | 24,582 | 19,566 | 34,221 | 9,927 |
| Person-years | 399,089 | 328,917 | 561,257 | 166,749 |
| No. of cases | 1,495 | 908 | 1,927 | 476 |
| Age-adjusted HR (95%CI) | Ref. | 0.90 (0.83–0.98)** | Ref. | 0.97 (0.81–1.15) |
| Multivariable HR (95%CI)a | Ref. | 0.91 (0.83–0.99)** | Ref. | 1.01 (0.91–1.13) |
| Quick accomplishment | − | + | − | + |
| Responsiveness | − | − | + | + |
| Men | ||||
| No. at risk | 12,323 | 9,134 | 2,966 | 6,478 |
| Person-years | 190,827 | 147,051 | 47,425 | 105,799 |
| No. of cases | 1,186 | 692 | 234 | 434 |
| Age-adjusted HR (95%CI) | Ref. | 0.92 (0.84–1.01)* | 0.95 (0.83–1.09) | 0.85 (0.76–0.95)** |
| Multivariable HR (95%CI)a | Ref. | 0.95 (0.86–1.04) | 0.96 (0.83–1.11) | 0.88 (0.78–0.99)** |
| Women | ||||
| No. at risk | 21,140 | 13,081 | 3,442 | 6,485 |
| Person-years | 342,282 | 218,975 | 56,806 | 109,942 |
| No. of cases | 1,313 | 614 | 182 | 294 |
| Age-adjusted HR (95%CI) | Ref. | 0.91 (0.83–1.00)* | 1.03 (0.88–1.20) | 0.88 (0.77–1.00)** |
| Multivariable HR (95%CI)a | Ref. | 0.92 (0.83–1.01)* | 1.10 (0.93–1.29) | 0.92 (0.80–1.05) |
*p < 0.10, **p < 0.05
aAdjusted further for age, body mass index, smoking status, alcohol intake, education level, history of hypertension and diabetes, employment status, sports, walking, perceived stress, purpose of life, life enjoyment, and likely to be angry. HR: hazard ratio, CVD: cardiovascular disease, 95%CI: 95% confidence interval.
Table 3 indicates sex- and age-specific HRs of CVD mortality according to quick accomplishment, responsiveness, and combination. After multivariable adjustment, quick accomplishment was associated with a lower risk of CVD mortality in men and women aged 60–79 with marginally statistical significance; the respective multivariable HR (95%CI) was 0.92 (0.83–1.01) and 0.92 (0.84–1.01). Responsiveness was associated with a lower risk of CVD mortality in men aged 60–79 but not in those aged 40–59; the respective multivariable HR (95%CI) was 0.89 (0.79–0.99) and 1.02 (0.85–1.23). The presence of both quick accomplishment and responsiveness compared to their absence was also associated with a lower risk of CVD in men aged 60–79 but not in those aged 40–59; the respective multivariable HR (95%CI) was 0.83 (0.72–0.96) and 0.99 (0.78–1.26). Women did not have such an age difference in the association.
| Quick accomplishment | Responsiveness | |||
|---|---|---|---|---|
| − | + | − | + | |
| Men aged 40–59 years | ||||
| No. at risk | 8,062 | 9,738 | 11,882 | 5,918 |
| Person-years | 141,076 | 170,818 | 207,847 | 104,047 |
| No. of cases | 276 | 306 | 390 | 192 |
| Multivariable HR (95%CI)a | Ref. | 0.97 (0.81–1.15) | Ref. | 1.02 (0.85–1.23) |
| Men aged 60–79 years | ||||
| No. at risk | 7,227 | 5,874 | 9,575 | 3,526 |
| Person-years | 97,174 | 82,032 | 130,030 | 49,176 |
| No. of cases | 1,144 | 820 | 1,488 | 476 |
| Multivariable HR (95%CI)a | Ref. | 0.92 (0.83–1.01)* | Ref. | 0.89 (0.79–0.99)** |
| Women aged 40–59 years | ||||
| No. at risk | 13,272 | 12,012 | 19,112 | 6,172 |
| Person-years | 233,824 | 214,906 | 338,896 | 109,833 |
| No. of cases | 206 | 163 | 286 | 83 |
| Multivariable HR (95%CI)a | Ref. | 0.88 (0.71–1.09) | Ref. | 0.95 (0.73–1.23) |
| Women aged 60–79 years | ||||
| No. at risk | 11,310 | 7,554 | 15,109 | 3,755 |
| Person-years | 165,264 | 114,012 | 222,361 | 56,915 |
| No. of cases | 1,289 | 745 | 1,641 | 393 |
| Multivariable HR (95%CI)a | Ref. | 0.92 (0.84–1.01)* | Ref. | 1.02 (0.91–1.15) |
| Quick accomplishment | − | + | − | + |
| Responsiveness | − | − | + | + |
| Men aged 40–59 years | ||||
| No. at risk | 6,311 | 5,571 | 1,751 | 4,167 |
| Person-years | 110,314 | 97,533 | 30,762 | 73,285 |
| No. of cases | 217 | 173 | 59 | 133 |
| Multivariable HR (95%CI)a | Ref. | 0.98 (0.79–1.20) | 1.05 (0.78–1.41) | 0.99 (0.78–1.26) |
| Men aged 60–79 years | ||||
| No. at risk | 6,012 | 3,563 | 1,215 | 2,311 |
| Person-years | 80,512 | 49,517 | 16,662 | 32,514 |
| No. of cases | 969 | 519 | 175 | 301 |
| Multivariable HR (95%CI)a | Ref. | 0.95 (0.85–1.06) | 0.93 (0.79–1.10) | 0.83 (0.72–0.96)** |
| Women aged 40–59 years | ||||
| No. at risk | 11,193 | 7,919 | 2,079 | 4,093 |
| Person-years | 197,256 | 141,640 | 36,568 | 73,265 |
| No. of cases | 181 | 105 | 25 | 58 |
| Multivariable HR (95%CI)a | Ref. | 0.83 (0.64–1.06) | 0.81 (0.53–1.24) | 0.90 (0.66–1.24) |
| Women aged 60–79 years | ||||
| No. at risk | 9,947 | 5,162 | 1,363 | 2,392 |
| Person-years | 145,026 | 77,334 | 20,238 | 36,677 |
| No. of cases | 1,132 | 509 | 157 | 236 |
| Multivariable HR (95%CI)a | Ref. | 0.94 (0.85–1.05) | 1.16 (0.97–1.37) | 0.92 (0.79–1.07) |
*p < 0.10, **p < 0.05
aAdjusted further for age, body mass index, smoking status, alcohol intake, education level, history of hypertension and diabetes, employment status, sports, walking, perceived stress, purpose of life, life enjoyment, and likely to be angry. HR: hazard ratio, CVD: cardiovascular disease, 95%CI: 95% confidence interval.
In this large and long-term cohort of approximately 75,000 Japanese men and women aged 40–79, with over a million person-years, we found that quick accomplishment was associated with a lower risk of CVD mortality in women, and a similar but marginally association was observed in men. Quick accomplishment and responsiveness combined were associated with lower CVD mortality risk in men; that inverse association was confined to men ages 60–79.
The mechanisms behind why behavioral characteristics such as quick accomplishment and responsiveness are associated with a lower risk of CVD mortality are not fully understood. We suppose that quick accomplishment and responsiveness are the behavior with a positive feeling of being able to use one’s time well [1]. The mechanisms by which a positive psychological state may reduce the CVD mortality risk could be explained in two pathways [13, 14].
As for a biological pathway, positive psychological states may stimulate the activation of autonomic and neuroendocrine processes and reduce systematic inflammation [15, 16]. Blood concentrations of inflammatory markers such as C reactive protein and interleukin-6 were associated with an increased CVD risk [17, 18]. A previous study of 985 adults aged 25–74 residing in the United States showed that people with positive psychological states had lower levels of plasma C reactive protein and interleukin-6 [19].
As for a psychological pathway, a positive psychological state may be closely linked with healthy behaviors since it was postulated that positive moods or emotions may broaden the thought-action repertoires that increase personal resources ranging from physical and intellectual ones to social and psychological ones [20]. A population-based prospective study of 773 Dutch men aged 64 to 84 showed that men with high levels of optimism, one of the positive psychological states, were more likely to have health-promoting behaviors such as being physically active, avoiding smoking, and drinking moderately than men with lower levels of optimism [21]. In our study, people with quick accomplishment and responsiveness were likelier to be smokers and drinkers than those without them, probably due to their higher stress and social interaction, but they engaged more in sports.
In our study, quick accomplishment but not responsiveness was associated with a lower risk of CVD mortality in women. A possible explanation is that a positive psychological state may reflect quick accomplishment (a behavioral characteristic of trying to work efficiently) throughout the occupation categories. In contrast, responsiveness (a behavioral characteristic of making decisions quickly without procrastinating) could be reflected by a positive psychological state for the employed (23% of total women) but not for other occupation categories (77%) because many women are unlikely to have pressure by being employed.
No association between the presence of both quick accomplishment and responsiveness and the risk of CVD mortality among middle-aged men was not expected and warranted for discussion. Quick accomplishment and responsiveness may be standard psychological states for middle-aged people, and thus, their presence or absence is unlikely to influence the biological and psychological markers associated with CVD risk. On the other hand, the presence of both quick accomplishment and responsiveness among older people may reflect their well-being in general. Our study found positive correlations between quick accomplishment and responsiveness with mental stress, anger, purpose of life, and life enjoyment in both middle and older people. However, the adjustment for these factors did not change the associations materially. Residual confounding by misclassifying these variables and unmeasured variables is likely to exist. We speculate that the lower risk of CVD mortality in older men with both quick accomplishment and responsiveness could be due to higher social interaction and participation, which could avoid social isolation and loneliness, known as CVD risk factors for older people [22, 23]. Social network and participation were generally higher in women than men from earlier life and benefit more mental health in women than men [24], so no age differences in the associations were likely to be observed in women.
The strengths of this study were the enrollment of many participants from all over Japan and a long follow-up duration of a median of 19.1 years. This study had several limitations. First, the assessment of quick accomplishment and responsiveness was based on self-reporting, which was inevitable for misclassification. Second, the evaluation of quick accomplishment and responsiveness was performed only once during the baseline survey, and it is uncertain whether the changes during the follow-up affected the results. Third, the magnitude of association was generally weak, albeit statistically significant. However, this is an intrinsic issue for the epidemiological investigation of psychological factors and disease risk because of the misclassification of self-report exposure variables. Fourth, we could not exclude the possible influence of residual confounding, although we adjusted for potential cardiovascular risk factors. Last, a small number of deaths was observed in some reference groups among women, which made it underpowered to show potential associations.
In conclusion, quick accomplishment was associated with a lower risk of CVD mortality independent of conventional CVD risk factors. Quick accomplishment and responsiveness combined were inversely associated with CVD mortality risk among older men. Further studies are needed on the underlying pathophysiological mechanisms of quick accomplishment and responsiveness in the development of CVD.
The ethics committees of Nagoya University School of Medicine (approval number: 177), Hokkaido University Graduate School of Medicine (approval number: 14-044), and the Osaka University Graduate School of Medicine (approval number: 14285-6) approved the present study.
Consent for publicationNot applicable.
Availability of data and materialDe-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.
Competing interestsAll authors declare there are no conflicts of interest to report.
FundingNot applicable.
Authors’ contributionsMM have designed of the work and analyzed the participant data regarding the time management and cardiovascular health (Original Draft & Editing). KS, H imano and AT were revised the manuscript. H iso and RK gave supervision to the conception, drafted the work, and major contribution in revising the manuscript. All authors read and approved the final manuscript.
AcknowledgmentsThis research was supported by Grants-in-Aid for Scientific Research from the Ministry of Education, Science, Sports and Culture of Japan (MEXT) (Monbukagaku-sho) and Ministry of Health, Labour and Welfare; Grants-in-Aid for Scientific Research on Priority Areas of Cancer, and Grants-in-Aid for Scientific Research on Priority Areas of Cancer Epidemiology from MEXT (Nos. 61010076, 62010074, 63010074, 1010068, 2151065, 3151064, 4151063, 5151069, 6279102, 11181101, 17015022, 18014011, 20014026, 20390156 and 26293138), and JSPS KAKENHI No. 16H06277 (CoBiA). This research was also supported by Grant-in-Aid from the Ministry of Health, Labour and Welfare, Health and Labor Sciences research grants, Japan (Research on Health Services: H17-Kenkou-007; Comprehensive Research on Cardiovascular Disease and Life-Related Disease: H18-Junkankitou [Seishuu]-Ippan-012; H19-Junkankitou [Seishuu]-Ippan-012; Comprehensive; H20-Junkankitou [Seishuu]-Ippan-013; H23-Junkankitou [Seishuu]-Ippan-005); H26-Junkankitou [Seisaku]-Ippan-001; H29-Junkankitou-Ippan-003, and 20FA1002. This study was supported by the National Cancer Center Research and Development Fund (27-A-4, 30-A-15, 2021-A-16), and JSPS KAKENHI Grant Number JP25330039. The authors declare they have no conflict of interest with respect to this research study and paper.
