Hyperbaric oxygen therapy (HBOT) has evolved from its initial applications in decompression sickness to become an established treatment modality for diverse medical conditions. Hyperbaric oxygen therapy (HBOT) involves the administration of near-100% oxygen at pressures exceeding atmospheric pressure, typically ≥1.5 atmospheres absolute (ATA), in a specialized chamber, in accordance with definitions from international hyperbaric medicine societies; exposures below 1.5 ATA are generally classified as mild hyperbaric oxygen therapy and are not considered conventional HBOT (1). The therapy has gained recognition for its efficacy in treating conditions characterized by tissue hypoxia and impaired wound healing, with well-documented benefits in radiation-induced tissue injury, diabetic wounds, and certain infections (2).

Despite advances in conventional cancer treatments, including surgery, chemotherapy, and radiotherapy, significant challenges persist in managing radiation-induced toxicities that can severely impact patients’ quality of life. Approximately 50% of cancer patients undergo radiotherapy as part of their treatment, and among long-term survivors, 5-15% respectively experience serious radiation-related complications months or years after treatment (3, 4). These late radiation tissue injuries (LRTI) manifest as progressive deterioration characterized by reduced microvasculature, chronic inflammation, and fibrosis, eventually resulting in insufficient oxygen supply to maintain normal tissue function. Beyond its established role in alleviating radiation-induced tissue injury, hyperbaric oxygen therapy (HBOT) has also been explored for its potential to enhance the effects of conventional cancer treatments. Evidence supporting the use of HBOT in combination with radiotherapy is relatively consistent and reassuring, particularly in the management of radiation-induced toxicities and in improving tissue oxygenation following irradiation. In contrast, data regarding the interaction between HBOT and chemotherapy are less robust and remain heterogeneous, with studies reporting variable and sometimes conflicting findings depending on tumor type, treatment regimen, and timing of exposure (5). Therefore, while HBOT is widely regarded as a safe and effective adjunct in the context of radiotherapy-related complications, its role alongside chemotherapy warrants cautious interpretation and further investigation. The theory of KAP (Knowledge, Attitude and Practice) shows that knowledge is the basis of behavior change, while attitude and belief are the motive force of behavior change (6). As stated by KAP theory, the process of human behavior change can be divided into three steps: acquiring knowledge, generating attitudes/beliefs, and forming practice/behaviors (7). In the context of HBOT implementation, healthcare professionals’ knowledge about its mechanisms, especially benefits in radiation-induced tissue damage constitutes the foundation for their clinical decision-making. However, cognitive change caused by knowledge acquisition does not necessarily lead to behavior change; it should first lead to a change in perception, and then change people’s behavior through the change in perception (8). This theoretical framework is particularly relevant when examining how healthcare providers’ understanding of HBOT influences their decisions to integrate it into treatment protocols for cancers.

Healthcare professionals play a pivotal role in clinical decision-making regarding HBOT implementation, yet research examining their knowledge, attitudes, and practices in this domain remains limited, particularly in China. The challenges in implementing HBOT include availability of facilities, provider awareness of appropriate indications, and integration into standard treatment pathways (2). Our study aims to assess the knowledge, attitudes, and decision-making of healthcare professionals in China regarding HBOT for radiation-induced toxicities and its other applications in oncology, such as sensitizing chemotherapy and radiotherapy, and improving tumor oxygenation. This research will identify potential barriers to implementation and opportunities for educational interventions. It will provide valuable insights to optimize the integration of HBOT into comprehensive cancer treatment pathways, potentially improving the efficacy of tumor treatment and the prognosis of patients with radiation-induced tissue injuries.

Healthcare professionals involved in HBOT and oncology-related fields demonstrated moderate to generally favorable levels of knowledge, attitudes, and decision-making regarding the use of HBOT as an adjunctive cancer treatment, with attitudes playing a key mediating role between knowledge and clinical practice. These findings underscore the need to incorporate targeted educational strategies that strengthen both knowledge and attitudes toward HBOT in oncology, thereby supporting more evidence-informed and confident clinical decision-making.

This study offers a detailed understanding of how healthcare professionals in HBOT units and oncology-related departments perceive and apply HBOT as an adjunctive cancer treatment. The findings revealed an overall pattern of moderate to favorable performance across knowledge, attitude, and decision-making dimensions, with significant interrelationships among the three. These results reflect a partially integrated KAP framework, in which knowledge appears to influence decision-making both directly and through its effect on attitude. Such a structure is consistent with previous KAP-based models, which emphasize that knowledge alone is not sufficient to change behavior without the reinforcement of favorable attitudes (10, 11). In our study, attitude emerged as a particularly important mediator, as supported by the structural equation modeling results showing both direct and indirect effects between knowledge, attitude, and decision-making.

The knowledge scores among participants were generally satisfactory, particularly with respect to basic concepts and commonly recognized clinical applications of HBOT. This finding is supported by the item-level results showing relatively higher proportions of “Very aware” responses for questions addressing the definition of HBOT, its traditional indications, safety profile, contraindications, and its established role in managing radiation-induced tissue injury (Supplementary Table S1, items K1–K5 and K7–K9). However, a closer examination of item-level distributions revealed uneven familiarity with more specialized or emerging aspects of HBOT, including its immunological mechanisms and its potential role in enhancing radiotherapy or chemotherapy sensitivity, as reflected by lower “Very aware” response rates for items related to mitochondrial effects, immune modulation, and treatment sensitization (Supplementary Table S1, items K10–K14). This pattern was particularly evident among participants from oncology departments, those with shorter work experience, and those without prior HBOT-related training, consistent with the subgroup differences reported in Table 1. Similar observations have been reported in previous studies, in which awareness of HBOT’s traditional indications is relatively widespread, whereas its emerging roles in oncology remain less familiar outside specialized hyperbaric settings (12, 13).

These knowledge disparities likely stem from the absence of structured educational integration of HBOT in most general oncology training programs. While continuing medical education often includes updates on drug therapies and surgical techniques, it tends to overlook adjunctive modalities such as HBOT, especially when they are perceived as outside the core domain of oncology (14, 15). In this context, it is important that hospitals and academic institutions incorporate updated, evidence-based content on HBOT into multidisciplinary training modules. For departments not directly involved in delivering HBOT, cross-departmental seminars, clinical case sharing, and shadowing opportunities in hyperbaric units may help bridge this knowledge divide. Without these measures, the potential clinical benefits of HBOT in cancer treatment may remain underutilized simply due to informational asymmetry.

Attitudes toward HBOT were generally favorable, with most respondents recognizing its safety, potential efficacy, and collaborative value across specialties. Nonetheless, hesitations were observed around its cost-effectiveness and long-term impact on tumor progression, reflecting uncertainty in areas where high-quality clinical evidence is still evolving. This cautious optimism is not unique to our setting; studies in similar healthcare systems have reported comparable patterns, in which enthusiasm about HBOT’s supportive role coexists with skepticism about its integration into standard oncology protocols (16, 17). Interestingly, training experience and departmental affiliation were associated with differences in attitude scores, as indicated by the subgroup comparisons reported in Table 1.

What is particularly noteworthy is that attitude, rather than knowledge alone, was the strongest and most consistent predictor of decision-making behavior in our multivariate analysis. This aligns with findings from health behavior research showing that professionals are more likely to implement what they feel positively about, especially in complex or interdisciplinary domains (18, 19). Given that attitudes are shaped not only by formal education but also by institutional support, professional discourse, and firsthand clinical outcomes, strategies to foster favorable attitudes must go beyond individual learning. Hospitals could organize interdisciplinary case discussions and patient outcome reviews involving both oncologists and hyperbaric specialists, thus reinforcing shared understanding and clinical trust. Additionally, institutions should provide clear administrative pathways and referral systems that legitimize the use of HBOT in appropriate oncology cases, thereby reinforcing its perceived value.

The decision-making practices observed in this study were mostly proactive, but they were also shaped by structural and contextual factors. Clinicians frequently cited patient condition, previous treatment response, and family preference as decision drivers, but they also reported that infrastructure, staffing, and equipment availability played important roles. This indicates that even well-informed and positively inclined professionals may be constrained by system-level limitations. Other studies in similar resource settings have echoed this concern, showing that decisions about non-standard treatments are often moderated by institutional readiness and perceived administrative support (20, 21). In our data, those working in facilities without dedicated HBOT services or with less robust staffing appeared less likely to recommend the therapy, despite having comparable knowledge or attitude scores.

To enable more consistent and confident decision-making, healthcare systems should invest in the operational integration of HBOT into cancer treatment workflows. This includes not only expanding access to treatment chambers and trained personnel, but also ensuring that clinical guidelines explicitly acknowledge HBOT as a viable option in certain oncology scenarios (22, 23). At a policy level, health authorities could develop funding models or reimbursement schemes that reflect the long-term cost-benefit profile of HBOT, particularly in managing radiation-related side effects where its efficacy is better established (24, 25). Furthermore, oncology departments could assign dedicated liaisons to work with hyperbaric units, ensuring smoother communication and patient transitions.

However, this study has several limitations that should be acknowledged. First, the cross-sectional design limits the ability to establish causal relationships between knowledge, attitudes, and decision-making behaviors. Second, the use of self-reported questionnaires may introduce response bias, as participants might overestimate their knowledge or provide socially desirable answers. Third, the sample was limited to a specific geographic region and professional group, which may affect the generalizability of the findings to broader healthcare populations. In addition, it should be noted that the overall level of clinical evidence supporting HBOT as an adjunctive treatment in oncology remains limited. Large-scale randomized controlled trials in this field are scarce, and in some areas largely absent, which partly explains the ongoing skepticism regarding the efficacy of HBOT in cancer treatment. Therefore, favorable attitudes toward HBOT should be viewed not as definitive confirmation of efficacy, but as a foundation for promoting well-designed, larger clinical trials aimed at generating stronger and more conclusive evidence. Future studies could also expand the administration of the questionnaire to international institutions and healthcare systems, which may help obtain a more diverse and representative sample and allow for cross-cultural comparisons in knowledge, attitudes, and decision-making regarding HBOT in oncology.

In conclusion, the findings suggest that healthcare professionals in HBOT and oncology-related fields generally possess a solid understanding and hold favorable attitudes toward the use of HBOT in cancer treatment, with attitudes playing a mediating role between knowledge and clinical decision-making. To enhance evidence-based application of HBOT in oncology, targeted educational interventions that strengthen both knowledge and attitudes may further promote informed and proactive clinical decisions.