Japanese Journal of Clinical Oncology 31:133-134 (2001)
© 2001 Foundation for Promotion of Cancer Research
Editorial |
Structure of Radiotherapy in Japan
Division of Radiology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
Cancer Statistics in Japan
The number of cancer deaths has ranked top in the causes of death in Japan since 1981 and is further increasing gradually. Gastrointestinal tract cancers occupy a large proportion of the total cancer deaths and it is a conspicuous characteristic in Japan. Of all cancer deaths, the numbers due to gastric cancer and uterine cervical cancer have been decreasing, whereas those with lung, breast, bowel, prostate cancer and others have been increasing substantially since 1975.
The number and the rate of cancer incidence are also increasing. This is due especially to the increase in the number of elderly people in Japan. An estimate of the future annual cancer incidence is 889 587 by 2015 (1). The age at diagnosis of cancer is gradually increasing. Elderly cancer patients tend to refrain from surgery or chemotherapy, because of their evident or occult frailty. Radiotherapy can be applied to the elderly because of its lower invasiveness.
It is clear that the number of patients who have received radiotherapy is also increasing steeply. Above all, the numbers of patients treated with radiotherapy have been increasing very rapidly, with cancers of the esophagus, lung, breast, bowel, pancreas, hepatobiliary tract and other sites. This trend will probably continue into the future.
Contribution of Japan to the Development of Radiotherapy
Technology in medicine has been developing and improving and the field of radiation therapy technology is no exception. Japanese radiation oncologists have contributed remarkably to the development of this field. Conformation radiotherapy with multiple-leaf cams was developed by Professor Takahashi and intra-operative radiotherapy was developed and has come into practice. High dose rate intracavity brachytherapy was also introduced into clinical practice for the first time in Japan in the field of management of cancer of the uterine cervix and its application has been further extended to cancer of the esophagus and bronchus. Boron neutron capture therapy was conducted by Professor Hatanaka and Professor Mishima. We are still making efforts to develop new technologies, such as moving tracking radiotherapy and others.
Activity of JASTRO and PCS
The Japanese Society for Therapeutic Radiology and Oncology (JASTRO) was founded in 1989, to take over the activities of the Japanese Radiation Therapy System Society. JASTRO has 1589 active members as of August 2000, representing an 11% increase over 1999. It consists of 1076 medical doctors, 216 technologists, 84 physicists, 34 radiation biologists and others. It has 10 standing Committees, including the Database Committee. To secure the structure of radiation oncology, JASTRO conducted a Census of Radiation Oncology in Japan in 1990. This was the first one to show the structure of radiation oncology in Japan and many data and estimations have been derived from it, as illustrated by Imai et al.’s paper in this issue of JJCO. Subsequently, the census has been conducted biannually by the Database Committee of JASTRO.
According to the data from the Database Committee, the number of patients treated is showing a fairly steep increase, from 62 829 in 1990 to 71 696 in 1995, 86 041 in 1997 and 112 984 in 1999. The number of medical doctors has also been increasing, but it was not clear whether they were engaged in therapeutic or diagnostic or full-time or part-time duties.
Another activity in securing the structure was the Patterns of Care Study (PCS) in Japan. This was introduced in 1996 and was proved to be feasible. The survey proved that the stratification of institutions, including equipment and personnel, significantly affected the patterns of care for patients with cancer of various sites, e.g. the esophagus, lung, breast, uterine cervix and prostate. This was introduced in reviews by Teshima et al. to the members of JASTRO (2,3).
Structural Problems in Japan
However, it is still questionable whether the current status of radiation oncology in Japan is sufficient to deliver good-quality treatment to patients all over the country. There are certain problems in the structure of radiation oncology in Japan, as Imai et al. (4) mention. The most important is the shortage of manpower engaged in radiation oncology and co-medical work. There are very few radiation oncologists and radiation technologists whose work is devoted solely to radiation therapy. Above all, facility-based medical radiation physicists are very few or almost non-existent.
Teshima et al. (5) in 1996 compared the structure of radiation oncology in the USA and Japan. The survey showed that only 15% of US and 11% of Japanese facilities complied with the ‘Blue Book’ guidelines for the ratio of patients to full-time equivalent (FTE) radiation oncologists of 201–250, the most common ratios being 151–200 in the USA and 51–100 in Japan. They concluded that there was a major difference in the commitment to radiation therapy for treating overall cancers between the USA and Japan, i.e. 49% of all new cancer patients were treated in the USA compared with approximately 15% in Japan. Equipment structure in the USA was more complete than in Japan, with important differences in treatment simulators, treatment planning computers and support personnel.
Abe et al. (6) established guidelines for institutions providing radiotherapy with the support of a Grant-in-Aid from the Ministry of Health and Welfare. Imai et al. (7) surveyed the compliance rate with the guidelines, which was reported elsewhere. Almost all institutions have not met the guidelines. They stressed that both manpower and equipment are definitely needed in the improvement of the structure of institutions (7).
In this issue of JJCO, Imai et al. (4) analyze this topic in more detail, i.e. stratification of the facilities. They estimated the number of radiation oncologists in the future and evaluated whether it meets the future demands of patient numbers. They randomly selected 106 facilities that had participated in PCS for radiation oncology from 556 facilities throughout Japan. Facilities were stratified into A and B, the former being academic institutions and cancer centers and the latter non-academic institutions such as national, prefectural and municipal hospitals. They were further stratified according to the number of patients treated with radiotherapy per year in 1995. The authors concluded that the number of patients being treated with radiotherapy will reach 190 000 in 2015. The number of FTE radiation oncologists should be increased to 936, i. e. at least 26 FTE radiation oncologists should be added each year in order to maintain the patient load per FTE radiation oncologist as it is now.
Their paper puts another structural problem to readers. According to the authors’ figures, the mean overall patient load per FTE radiation oncologist was 203, which is consistent with the figure shown in the ‘Blue Book’ in the USA. However, we may have to recognize that the manpower had been dispersed with poor efficacy in smaller hospitals. Even in facilities of Group A2 (academic), one to two FTE radiation oncologists treated less than 300 patients per year with one to two machines. This suggests a low activity of the radiation oncology section, even though the patient load per FTE radiation oncologist is sufficient.
In B1 facilities nearly one FTE radiation oncologist treated with one machine a patient load of about 200 per year. B2 facilities show an extreme in that less than one FTE radiation oncologist treated patients with one machine with a patient load of less than 200 per year. The patient load per FTE radiation oncologist is very diverse, with up to more than 400 per year, because patients are seen on a once-a-week part-time basis. The number of patients being treated in the future is grossly consistent among the four stratified groups, as shown in Imai et al.’s paper. However, in the Editor’s opinion, it is not certain whether the number of Group B2 facilities and the resultant number of patients in B2 will grow or not, because it is questionable whether the delivery of good-quality treatment can be maintained consistently at each facility.
Future Directions
Recently, the Japanese social insurance fund accepted that facilities could charge additional fees for radiotherapy specialty, for patients who receive radiotherapy at each facility, to provide a linear accelerator, a full-time radiation oncologist and technologist(s), a simulator and treatment planning computers.
The Education Committee of JASTRO has been promoting the teaching of radiation oncology both to medical students and to members. The Summer Seminar for Medical Students has been held since 1995 for the recruitment of students from all over the country and the Summer Seminar for Fresh-coming Radiation Oncologists since 1999. JASTRO has certified 302 radiation oncologists through 1999–2000, with the advice of the Certifying Committee for Radiation Oncologists.
There are only a few radiation physicists and related posts. However, the former Ministry of Health and Welfare (the present Ministry of Health, Labour and Welfare) assigned two medical radiation physicists who were engaged in a proton treatment facility not to a medical position, but to a non-medical position in the National Cancer Center Hospital East in 1998. This was the first official assignment of physicists in the field of radiation medicine in Japan. As they ensure the quality of medical beams in proton facilities, physicists will gradually become acknowledged for their importance and will be assigned as medical staff. Concerning the supply of physicist manpower, we can expect a faint ray of hope. Many former vocational schools for radiation technologists with a 3-year term have gradually promoted their curriculum into that of colleges with a 4-year term, and will produce graduate physicists.
We radiation oncologists will strive to increase the available manpower, while maintaining the improvement of radiation oncology quality assurance and, it is hoped, the improvement of the quality of medicine in Japan through these activities.
REFERENCES
1 Tominaga S, Ohshima A, Kuroishi T, Aoki K, editors. Cancer Statistics 1999. Tokyo: Shinohara Shuppan 1999.
2 Teshima T, Abe M, Ikeda H, Hanks GE, Owen JB, Hiraoka M, et al. Patterns of care study of radiation therapy for esophageal cancer in Japan: influence of the stratification of institution on the process. Jpn J Clin Oncol 1998;28:308–13.
3 Teshima T. Patterns of care in radiation oncology – History, methodology and important results in the United States. J Jpn Soc Ther Radiol Oncol 1999;11:247–54.
4 Imai A, Teshima T, Ohno Y, Inoue T, Yamashita T, Mitsuhashi N, et al. The future demand for and structural problems of Japanese radiotherapy. Jpn J Clin Oncol 2001;31:135–41.
5 Teshima T, Owen JB, Hanks GE, Sato S, Tsunemoto H, Inoue T. A comparison of the structure of radiation oncology in the United States and Japan. Int J Radiat Oncol Biol Phys 1996;34:235–42.[Web of Science][Medline]
6 Abe M, Nagata Y, Hiraoka M, Inoue T, Sumi M, Ikeda H, et al. The proposal of JASTRO guidelines by the Cancer Research Group of the Ministry of Health and Welfare (8–27). J Jpn Soc Ther Radiol Oncol 1998;10:249–57.
7 Imai A, Teshima T, Sato S, Inoue T, Nishio M, Yamashita T, et al. The compliance of the structure of radiation oncology in Japan with the JASTRO guidelines proposed by the Cancer Research Group of the Ministry of Health and Welfare (8–27). J Jpn Soc Ther Radiol Oncol 2000;12:267–71.
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