Japanese Journal of Clinical Oncology 32:S22-S31 (2002)
© 2002 Foundation for Promotion of Cancer Research
Overview of Cancer Control Programs in Japan
Deputy Director, Growth Factor Division, National Cancer Center Research Institute, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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Japan has a population of about 127 million, with an average life expectancy that is one of the highest in the world. Cancer has been the leading cause of death in Japan since 1981. The incidence of cancer for all sites in 1994 was estimated to be 440 000; crude incidence rates per 100 000 for males and females were 416.3 and 299.4, respectively. In 1997, the number of cancer deaths was 275 413; crude death rates for males and females per 100 000 were 273.0 and 169.9, respectively. Projections for 2015 indicate that 890 000 people will develop cancer and 450 000 will die as a result. It is not too much to say that Japan is now amid a ‘Cancer Era’. Meanwhile, the progress in medical sciences is improving survival in cancer patients; in cancer patients diagnosed during 1987–89, relative 5-year survival was reported to be 41.2% for all sites and cancer survivorship research estimated the number of cancer survivors for all sites in 1998 who have lived for between 5 and 24 years after diagnosis to be 1.5 million. The Ministry of Health and Welfare is focusing on five different measures in the implementation of its cancer control programs: public health education, nationwide cancer screening programs, development and support of specialized medical institutions, training of specialists and promotion of basic and clinical cancer research. As a tool for public health education, the Ministry published in 2000 a 10-year health promotion program entitled ‘Healthy Japanese in the 21st Century’. In the plan, seven particular goals are enumerated with regard to cancer. In practice, issues of concern include the development of new modalities, telling the truth to cancer patients, clinical trials and bioethical issues.
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INTRODUCTION |
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Japan has a population of about 127 million, with an average life expectancy that is one of the highest in the world; in 1997, the expectancy for males was 77.19 years and that for females was 83.82 years (1). Until the middle of the twentieth century, deaths caused by infectious diseases such as pneumonia, tuberculosis and gastroenteritis were common among the Japanese. After World War II, however, these diseases have declined rapidly, resulting in the high average life expectancy described above. This phenomenon is probably due to the traditional lifestyle of the Japanese and their interest and knowledge in maintaining their own health. The efforts of health care givers, the government and the nation’s municipalities have also been important additional contributory factors.
At the same time, the success of health-promotion policies confronts Japan with a new issue: the aging of the population (2). The population projection in 1995 indicated that the percentage of the population aged 65 years and older accounted for 14.5% of the total, those aged 75 years and older for 5.7% and those aged 85 years and older for 1.3%. The same projection also estimated that in 2025 the percentages aged 65, 75 and 85 years and older were 27.4, 15.5 and 4.8%, respectively, and in 2050 they will have risen to 32.3, 18.8 and 6.4%, respectively. As this trend accelerates, there will be a rapid increase in the number of people developing such adult or geriatric diseases as cancer, heart disease and cerebrovascular disease (Table 1) (1). This is particularly true of cancer, which has been the leading cause of death in Japan since 1981. The incidence of cancer for all sites in 1994 was estimated to be 440 000 and in 1997 the number of cancer deaths was 275 413. It is estimated that cancer is a contributory factor in 1 out of 3.3 of all annual deaths nationwide. Projections for 2015 indicate that 740 000 people will develop cancer and 450 000 will die as a result. It is not too much to say that Japan is now amid a ‘Cancer Era’. This paper will discuss the issues and present an overview of cancer control programs in Japan.
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CANCER STATISTICS |
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Mortality
In 1997, the number of cancer deaths was 275 413. Among males, it was 167 076 and the crude death rate per 100 000 was 273.0; lung cancer is the most common form and accounts for 21.4% of all deaths from cancer. It is followed by cancers of the stomach, liver, colon, pancreas, esophagus, rectum and prostate (Table 2) (1). Among females, the number of cancer deaths was 108 337 and the crude death rate was 169.9; stomach cancer is the most common form (16.2% of all cancer deaths), followed by cancers of the lung, colon, liver, breast, pancreas, uterus and rectum (Table 3) (1).
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When the age-adjusted death rate (applied to the Japanese model population in 1985) was compared between 1975 and 1997, it was revealed that the rate showed a tendency to increase, but in females the rate showed a tendency to decline (Table 4). In males, deaths due to most types of cancers increased except for cancer of the stomach. In females deaths due to cancers of the colon, liver, lung, pancreas and breast increased and those due to cancers of the stomach, uterus, rectum and esophagus decreased.
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Incidence
The Research Group for Population-based Cancer Registration in Japan has estimated the incidence of cancer based on data from seven registries (3), covering ~12% of Japan’s total population. The total for all sites in 1994 was estimated to be 440 000 (males, 252 000; females, 188 000). Among males, the stomach was the most common cancer site, followed by the lung, liver, colon and rectum (Table 5) (3). Among females, the stomach was also the most common site, followed by the breast, uterus, colon and lung (Table 6) (3). The time trend of age-standardized incidence for these major sites in 1975–94 (applied to the Japanese model population in 1985) revealed that, among males, stomach cancer is decreasing, whereas other forms, including prostate cancer, are increasing. Among females, the incidence rates of stomach, uterus and esophageal cancers are decreasing, whereas those of the breast, colon, lung, rectum and liver are increasing. It is worth noting that cancers of the stomach and the breast in females showed almost identical incidences in 1994.
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Predictions of cancer incidence in Japan in 2015 are based on data gathered by the Research Group for Population-based Cancer Registration in Japan and indicate that the total number will reach 890 000 (males, 554 000; females, 336 000) (4). It is predicted that among males, the lung will be the leading cancer site, followed by the stomach, colon, liver, rectum, prostate and pancreas; among females, the colon will be the leading site, followed by the breast, stomach, lung, liver, gallbladder/bile duct, pancreas, rectum and uterus.
Survival
Data on the survival of cancer patients is an important factor in any evaluation of the efforts being made towards cancer control. The Osaka Cancer Registry has presented reliable statistics on this subject, with recent trends summarized in a report entitled ‘Survival of Cancer Patients in Osaka 1975–89’ (5). In cancer patients diagnosed during 1987–89, the relative 5-year survival was 41.2% for all sites of both genders: female patients showed a higher survival rate (49.2%) than males (35.2%). In terms of relative 5-year survival, cancers were divided into three groups, ‘better’, ‘intermediate’ and ‘worse’, based on their prognosis. Cancers of the larynx, breast, uterus and urinary bladder were classified as the ‘better’ survival group, showing relative 5-year survival rates ranging from 67.0 to 83.3%. Cancers of the stomach, colon, rectum, ovary, prostate, lymphatic tissue and brain were classified as the ‘intermediate’ survival group, with relative 5-year survival rates ranging from 34.8 to 53.3%. Cancers of the liver, gallbladder and extrahepatic bile duct, pancreas and lung showed ‘worse’ survival, with relative 5-year survival rates ranging from 4.9 to 11.7%. When the relative 5-year survival of cancer patients in all sites diagnosed in 1987–89 were compared with those in 1975–77, the rate had increased from 30.4 to 41.2%. The indication is that efforts in cancer control in this area have met with some success.
Cancer Survivors
Cancer survivorship research, supported by a grant from the Ministry of Health and Welfare, has estimated the number of cancer survivors (6), based on data from the Research Group for Population-based Cancer Registration in Japan (3) and data on the survival of cancer patients from the Osaka Cancer Registry (5). The number of cancer survivors for all sites of both genders who live for between 5 and 24 years after diagnosis is 1.5 million, comprising 662 000 males and 876 000 females. When these survivors were analyzed based on the site of the disease, the leading five are the stomach, colon/rectum, breast, uterus and urinary bladder, which covered 75% of all survivors. A noteworthy point which emerges here is that the types and rankings of cancer in cancer survivors are different from those in the figures for both mortality and incidence. From this we learn that the types of disease experienced by cancer survivors should be taken into consideration when developing cancer control programs that focus on survivors.
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HEALTH INSURANCE SYSTEM |
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In all fields of disease, including cancer, a key factor in successful control is a medical care system which allows all patients to access medical institutions easily and at low cost. Japan’s Health Insurance System operates on the principles of ‘free access for patients to all medical institutions at any time they want’ and ‘universal health insurance for Japan’s 127 million citizens’. Bennett et al. summarized cancer insurance policies in Japan and the USA (7); they indicated that medical care in Japan accounts for 6.8% of the total gross national product, about half that of the USA. In 1958, the National Insurance Law was amended, making coverage mandatory and universal for all Japanese and in 1961 universal health care was enacted nationwide.
In Japan, all 127 million citizens belong to one of three groups of health insurance systems. One is the health insurance cooperatives run by the big companies, to which 33 million employees and their dependents belong. The second group is the government-run system for small business companies and public organizations, to which 38 million belong. These two groups make a 10% co-payment for all medical care, while their dependents pay 20% for in-patient care and 30% for outpatient treatment. The employees’ health insurance premiums represent about 8% of income, at least half of which is paid by their company or organization. The third group is composed of the remaining 41 million self-employed persons, retirees and their dependents, belonging to municipally run health insurance programs. The subscribers and their dependents pay a 30% fee for all medical care, while retirees pay 20%. Premiums are based on the total income of the family members and are paid solely by the insured. In these three groups, to limit the expense of high-cost care, the maximum contribution per month is from 35 000 to 121 800 yen or more, with any further costs met by the government.
Low-cost health care is provided for all Japanese aged 70 years or over. Japan’s medical insurance system is thought to be the best in the world, but as the number of elderly people increases, there will be a corresponding annual rise in medical costs. For this reason, some aspects of the system will need to be reformed.
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CANCER CONTROL PROGRAMS IN JAPAN |
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The Ministry of Health and Welfare is focusing on five different measures in the implementation of its cancer control programs:
1. public health education;
2. nationwide cancer screening programs carried out by municipalities, with government support;
3. development and support of specialized medical institutions;
4. training of specialists in public health, cancer diagnosis and treatment, nursing and other specialists;
5. promotion of basic and clinical cancer research.
The content of these activities is presented below, together with a summary of the work of cancer specialists in various fields.
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EDUCATIONAL APPROACH |
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Public health education is carried out in several ways by both central and local government, community health centers, hospitals, clinics, a variety of public and private foundations, newspapers, TV programs, etc. Their activities focus on spreading awareness of better lifestyles in terms of cancer prevention and on anti-smoking programs. Efforts are also being made to increase the number of people being screened for cancer and to help people recognize its early symptoms.
As a tool for public health education, the National Cancer Center has put forward ‘12 precautions for cancer prevention’ (Table 7), which were originally proposed in 1978 (8). The basis of these precautions is that a proportion of the incidence of cancer can be prevented by paying attention to lifestyle habits, including smoking and diet. These precautions have been widely used in public health education.
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The Ministry of Health and Welfare published its First and Second Plans to promote The Health of the Nation in 1978 and 1988. The Third Plan, released by the Ministry in 2000, is a 10-year health promotion program entitled ‘Healthy Japanese in the 21st Century’ and will serve as a guideline for improving the general health of people throughout the country (9). The plan focuses on several lifestyle-related diseases and sets specific numerical targets to be achieved. These targets are modeled on the ‘Healthy People’ series published by the US government (10).
The plan analyzes the present situation and puts forward recommendations designed to reduce lifestyle-related diseases. Subjects covered include diet, exercise, mental health, smoking, alcohol, dental health, diabetes, heart and cerebrovascular diseases and cancer. With regard to cancer, seven particular goals are enumerated in Table 8.
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Regarding the early detection of cancer symptoms, the Japanese Cancer Society has published eight warning signals for a variety of cancers (Table 9). This information always forms part of public health education programs.
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PREVENTION |
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Efforts to prevent cancer in Japan are being made in several areas, including anti-smoking programs, dietary improvement, control of cancer-associated infections and regulation of environmental carcinogens.
Putting an End to Smoking
Anti-smoking programs are now recognized as the most important tool for preventing both cancer and other lifestyle-related diseases. This is clearly emphasized in the aforementioned ‘Healthy Japanese in the 21st Century’, which puts forward four targets to reduce the number of smokers.
In Japan, the smoking rate is higher than in other industrialized countries. According to a National Nutrition Survey conducted in 1995, the smoking rate among adults is 31.7% (52.7% of males, 10.6% of females). The rate among males is the highest of any industrialized country. Annual trends indicate that the rate among males has been decreasing, while remaining constant among females. The above survey also spotlights the relatively high rate of smoking in younger age groups: ~20% of all junior high and senior high school students surveyed smoked during the past year, even though smoking is prohibited in Japan for people aged under 20 years.
In Japan, voluntary restraint by industry and efforts by both companies and individuals play important roles in the reduction of smoking-related dangers. These efforts include the imposition of restrictions on advertising, vending machines and smoking areas, as well as the requirement for a health warning to be printed on every pack of cigarettes. Voluntary restraints in advertising include a 3-year limit on TV and radio commercials for new products and on-air time limits for TV commercials. Late-night sales from vending machines are also voluntarily restricted. In the case of cigarette packs, tobacco companies are required by law to print a warning on each pack, such as ‘Smoking may damage your health. Avoid excessive smoking’.
With regard to smoking areas, medical institutions are required to conform to official guidance on separating smokers from non-smokers and public transport companies are encouraged to increase the number of non-smoking seats. The Ministry of Health and Welfare, the Ministry of Labor and the National Personnel Authority are all seeking to promote the separation of smokers from non-smokers in the workplace and the Ministry of Education, Science, Culture and Sports and police are doing what they can to prevent young people from smoking.
With regard to drugs for stopping smoking, nicotine gum has been available on prescription since 1994 in Japan, where smoking is still widely seen as a lifestyle choice rather than a drug addiction. The cost is not covered by medical insurance. Nicotine patches, also prescription only, became available in Japan in 1999.
Other Activities
Japanese people’s traditional low-fat diet has certainly been effective in cancer prevention, but high-salt dishes should be considered a potent risk factor in the development of stomach cancer. Lowering the daily salt intake is a key step in avoidance of this disease.
It is well established that certain viral infections are closely related to various types of cancer. About 95% of cases of hepatocellular carcinoma are associated with hepatitis B or C infection. Babies born to hepatitis B-infected mothers are routinely vaccinated at maternity clinics. Adult T-cell leukemia develops in patients infected with the HTLV-1 virus and infection can be transmitted by breast-feeding, so this is now prevented by enabling infected mothers to use alternative feeding methods.
The government and regional municipalities are continuing to make efforts to detect and reduce environmental carcinogens. In the past several years, dioxins, carcinogens in automobile exhaust fumes and in liquid industrial wastes, have attracted considerable attention and the government is seeking to improve the situation in respect of these problems.
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CANCER SCREENING PROGRAMS |
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In the 1960s, Japan introduced a cancer screening program implemented by regional municipalities with central government support. Up to now, screening for cancer of the stomach, uterus, breast, lung and colo-rectum has been conducted by municipal authorities according to instructions issued by the Ministry of Health and Welfare in line with the health care law for the elderly. Until 1998, the Ministry paid a third of the cost in the form of subsidies and the nation’s municipalities paid the balance. In fiscal 1998, these mandatory cancer screening programs by local governments were abolished.
Today, the standard cost of conducting screening is included in the central government transfer payments that come under the control of the Ministry of Home Affairs. Municipal authorities should therefore provide appropriate screening services, paying due regard to current official evaluations of effectiveness and regional characteristics such as the current screening techniques.
Naturally, the effectiveness of cancer screening programs varies widely according to the type and location of the cancer. Since considerable attention has been paid to the actual effectiveness of the cancer screening, a study group from the Ministry of Health and Welfare has carefully evaluated scientific documentation on the subject published both in Japan and abroad. In 1998, the study group issued a report which made the following points (11): two types of hitherto mandatory screening for uterine cervical and colo-rectum cancer have proved effective. Screening for stomach cancer also has been considered effective, but examinees should be advised that it fails to detect the cancer in up to 40% of all cases. Lung cancer is often detected at too advanced a stage to be cured, so screening is seen as having relatively little impact on reducing the number of resulting deaths. With regard to the current test for breast cancer, in which doctors attempt to detect the condition visually and by touch, the report said that there are insufficient grounds for assuming effectiveness. To improve the results of breast cancer screening, mammography should be introduced. The report also stated that particular improvement is needed in the way relevant information is provided to patients. Surveys reveal a contradiction, showing that on the one hand, staff believe they are properly explaining the pros and cons of an examination, but that on the other hand, participants in cancer screening programs consider that they are inadequately informed.
Although the Ministry’s policy to include the standard cost of conducting screening in the central government transfer payments and its report analyzing the effectiveness of the programs will leave many people confused about whether they should undergo cancer screening or not, the Ministry is going ahead with the idea of introducing mammography to reinforce cancer screening in Japan. In the 10-year health promotion plan, ‘Healthy Japanese in the 21st Century’, the Ministry made a strong case for the importance of screening as a measure to control cancer.
Japan Cancer Society
The Japan Cancer Society plays an important role in mass-screening programs in Japan. The society is a non-profit, non-governmental organization which was established in 1958 with the support of the Japan Medical Association, the Ministry of Health and Welfare and one of Japan’s leading newspaper groups, the Asahi Shimbun Publishing Company. The main aims of the society are to encourage people to take part in cancer screening programs, to transmit information on cancer prevention and treatment to the general public and to promote medical and social care for cancer patients and survivors. The society has 46 prefectural branch offices, with a total of 4500 staff members and 700 mass-screening vehicles. In terms of organization and finance, branch offices are independent of the society’s head office and work together with other branch offices.
The branch offices carry out mass screening for cancer using vehicles and at facilities provided by local governments and screen a total of more than 10 million people a year. Support from the society takes the form of gathering subsidies from other organizations and using them to help equip the branch offices with vehicles and screening machines. In order to disseminate information about cancer as widely as possible, the society publishes a variety of informative pamphlets and magazines, including the ‘Eight Warning Signals of Cancer’ described above (Table 9). ‘Cancer Prevention and Treatment Month’ activities are organized by the society every September throughout the country and have become well known.
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MEDICAL FACILITIES |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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In Japan, 28 clinical cancer centers, ~100 hospitals belonging to universities or medical colleges and a large number of general or district hospitals and hospices play an important role in the medical treatment of cancer patients
Clinical Cancer Centers
As early as 1965, several cancer centers started informal discussions to talk about cancer problems in Japan. Based on these discussions, the Japanese Association of Clinical Cancer Centers was established in 1973, with the National Cancer Center in Tokyo as the core center. By 1999, a total of 28 clinical cancer centers throughout Japan had become members of the Association (12). The centers are divided into two types according to their sources of funding; some are supported by the central government and the remainder by local prefectural governments or private foundations. Although their funding sources are different, all the centers share common features as institutes where all or most of their patients are cancer sufferers.
Before being accepted as member institutes, each center’s qualifications are examined by executive board members to determine their suitability as clinical cancer centers. The main aims of the Association are as follows:
1. to establish state-of-the-art standards in oncology practice and to apply them throughout Japan;
2. to conduct and share clinical research through the network of cancer centers;
3. to train cancer specialists for dispatch to anywhere in the country where they may be needed;
4. to set a common agenda for voicing opinions to the Government in order to establish or improve health insurance policy.
Two important activities are directed towards achieving these aims. One is the Clinical Cancer Research Forum, which is held every year with the participation of all the member centers. The other is a system of weekly teleconferences at which oncological problems are discussed; 14 out of the 28 centers currently participate in this information network.
University Hospitals and General Hospitals
About 100 hospitals belonging to universities or medical colleges play a very important part in educating young doctors in the fields of clinical oncology and cancer research. In addition, there are ~250 general hospitals with more than 500 beds in Japan, which also play a valuable role in providing care and treatment to cancer patients.
Hospices
About half of all cancer patients in Japan will require terminal care. Many of these patients are already admitted to general or local hospitals, but the medical staff who care for them are well aware that to relieve the anxiety, pain and loneliness suffered by terminal patients, hospice care or palliative care should be provided if possible. In 1990, the Ministry of Health and Welfare enacted regulations for facilities at hospices and palliative care units and set special medical fees for these facilities. The following year, the Japan Association of Hospice and Palliative Care Units was established by five institutions. In 2000, a total of 75 institutions satisfied the regulation criteria and a further 52 institutions awaiting approval or under construction are registered with the Association (13). Many of these institutions are now beginning to come to grips with the provision of hospice care at home.
Recent Progress in Cancer Diagnosis and Treatment
Developments in cancer diagnostics have made it possible to detect cancer at an earlier stage than before, leading to improved survival and a better quality of life for cancer patients. In particular, there has been important progress in imaging diagnostic technology. Computed tomography (CT) scanning has developed to the second generation of helical CT scan equipment and almost all hospitals that care for cancer patients have introduced this type of CT scan. Nowadays, multi-slice CT scans have begun to be introduced at some of these hospitals. Magnetic resonance imaging technology has proved especially useful in diagnosing tumors of the brain, spinal cord, liver, ovary, kidney and bone.
Ultrasound sonography has also improved rapidly and is now used in various fields of cancer diagnosis. Progress in cancer imaging diagnostics has led to the development of new intervention techniques for cancer diagnosis and treatment. It is also worth noting that plain X-ray examinations are increasingly conducted by computer-based radiology systems.
Endoscopic diagnosis of cancer has also made remarkable progress. Equipment is now digitized and still cameras have been replaced by video cameras, producing significant improvements in diagnostic accuracy. This change has also made it possible for specialists to educate several doctors simultaneously, for instance by demonstrating lesions via television systems. Another area in which important progress has been made is in endoscopic surgery for early gastric, esophageal and colon cancers. Video-assisted laparoscopic and thoracoscopic surgery is now used for cases of colon, stomach, esophageal, ovary, renal, adrenal and lung cancers. It should also be noted that the rapid progress of digitization of medical information technology, including imaging and endoscopic diagnostics, is bringing revolutionary changes in information exchange within hospital information systems and also between remote medical institutions.
Biochemical methods of cancer diagnosis have also seen new developments. Powerful new tumor markers developed based on the biochemical characteristics of cancer cells are now available (14). Genetic testing for familial cancer syndromes is another example. Tests for responsible genes in the kindred of familial cancer syndromes allow the prediction of the risks of future development of neoplasms and also provide genetic information concerning the future health of a patient’s relatives. The insights provided by this technology have opened the new field of ‘predictive medicine’ for cancer diagnosis and treatment. In addition, the analysis of germline mutations and polymorphisms of familial cancer genes and DNA repair enzyme genes will become an increasingly important field of research to detect individuals with cancer susceptibility.
With regard to cancer treatment, there are many examples of recent progress. In respect of surgery, minimum invasive techniques to improve the patient’s quality of life have been developed. Examples include the endoscopic surgery mentioned above, including laparoscopic and thoracoscopic surgery. In the field of radiation therapy, heavy particle and proton therapies are now undergoing clinical evaluation. In the case of chemotherapy, treatment tailored to an individual’s cancer cell characteristics will be developed in the near future, by analyzing the biochemical and genetic characteristics of tumor tissues. For high-dose chemotherapy, peripheral blood stem cell transplantation has now become the standard methodology. The use of partially mismatched transplants with allogeneic CD34-positive blood cells from a related donor is now under investigation (15). Recent progress in cancer research on oncogenes and tumor suppressor genes has revealed that carcinogenesis is due to genetic and epigenetic changes. This discovery has been used to start the development of new anti-cancer agents which target an abnormal molecule in cancer cells; this is termed ‘molecule-targeted therapy for cancer’. In the field of immunology, new therapies such as cancer vaccines, monoclonal antibodies and dendritic cell therapies are currently being evaluated. It is well established that multi-modality cancer therapy improves the results of cancer treatment, especially for intractable cancers. More importantly, the development of new therapeutic methodologies makes it possible for doctors to select treatment modalities based on individual patients’ conditions. In patients with hepatocellular carcinoma, for example, at least three types of treatments could be considered: conventional surgery, percutaneous ethanol injection or hepatic artery chemoembolization. It has also been claimed that proton therapy achieves a good response rate in this form of cancer. Selecting treatment modalities in this way is increasingly seen in various fields of cancer treatment.
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TRAINING OF SPECIALISTS |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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Generally, cancer specialists are trained in universities, cancer centers and research institutes belonging to cancer centers. In the university hospitals, young doctors are trained in cancer clinics and various types of cancer research are also conducted in the university’s departments of medicine, pharmacy, science, biology, social science and social welfare. Wide-ranging clinical research is also conducted by the medical staff at clinical cancer centers. As an official training course for young doctors intending to be cancer specialists, the National Cancer Center Hospital and the National Cancer Center Hospital East accept 30 clinical residents for a 3-year course and 10 chief residents for a 2-year course, every year. Clinical residency programs are also in operation at many clinical cancer centers.
The Foundation for Promotion of Cancer Research (described below) supports postdoctoral research fellowships for educating young cancer researchers, under the auspices of the Comprehensive 10-year Strategy for Cancer Control Program. Every year, 30 fellows are accepted, two-thirds of whom are engaged in cancer research at the National Cancer Center Research Institute.
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CANCER INFORMATION |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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In 1993, the Ministry of Health and Welfare decided to implement a cancer information system by linking the National Cancer Center with local clinical cancer centers via an online network. A mainframe computer system was installed at the National Cancer Center and used to create a database for basic and clinical cancer research. Use of a mainframe system allows the development of tools for protein and gene analysis, an imaging database of cancer detected by CT scanners and magnetic resonance imaging, a patient information database and other valuable applications.
For communication between cancer centers dispersed over a wide area, teleconferencing has brought important progress. In 2000, 14 centers were linked into the system, allowing medical professionals to conduct real-time, on-screen discussions of various issues. The system also permits telepathology and teleradiology. The Cancer Information Service of the National Cancer Center plays a very important role by providing new information about diagnosis and treatment to Japanese citizens, who can access this service via fax or the Internet (16). Many doctors in Japan use it as an informative tool when seeking informed consent. Information for medical professionals is also provided (17). Furthermore, the reference database of the imaging diagnosis of cancer is developed by the G7 Global Healthcare Applications Project (18). The reference database was also developed at the National Kyushu Hospital in languages including Japanese, English and Chinese (19).
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PROMOTION OF CANCER RESEARCH |
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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In Japan, cancer research is mainly supported by central government, especially by the Ministry of Health and Welfare, the Ministry of Education, Science, Culture and Sports and the Science and Science Technology Agency. In 1997, the funds provided for cancer research totalled about 6200 million yen, not including most of the stipends and expenditure for the construction and maintenance of facilities. The two most important types of cancer research funds are
A. Grants-in-Aid for cancer research managed by the Ministry of Health and Welfare and the Ministry of Education, Science, Culture and Sports;
B. Grants-in Aid for the Comprehensive 10-Year Strategy for Cancer Control managed by the Ministry of Health and Welfare, the Ministry of Education, Science, Culture and Sports and the Science and Science Technology Agency.
The former support basic, clinical and public health research and various other fields. The latter aim for further substantiation of basic cancer research and its transfer to clinical research, with priority on the following research subjects:
1) the molecular mechanism of the onset of cancer;
2) cancer metastasis, infiltration and characteristics of cancer cells;
3) cancer diathesis and immunity;
4) cancer prevention;
5) the development of new diagnostic technologies;
6) the development of new therapies;
7) the quality of life (QOL) of cancer patients.
The Comprehensive 10-Year Strategy for Cancer Control also supports various postdoctoral fellowship programs, international exchange programs for researchers and clinicians, international symposia for clinical cancer research and public education.
Although cancer research in Japan is mainly supported by central government, several non-governmental organizations play very important roles in supporting basic and clinical research. One example is the Princess Takamatsu Cancer Research Fund, which was founded in 1968. Her Imperial Highness Princess Takamatsu has dedicated herself to promoting cancer research since her mother died of the disease in 1933. In 1954, the Princess founded an association with her school classmates to seek financial support for cancer research and this association was the forerunner of today’s Fund. The Fund conducts a variety of activities, including an International Symposium, which has been held in November every year since 1970 and is well known in the international scientific community. The Fund awards prizes to Japanese scientists who have made outstanding contributions to basic and clinical research on cancer and provides further support in the form of research grants. Both the Fund and its forerunner have played an important role for half a century in increasing public interest in cancer research and have been instrumental in bringing about governmental support for this important health problem in Japan.
The Foundation for the Promotion of Cancer Research, a non-governmental, non-profit organization which works in cooperation with the government and the National Cancer Center, was established by the Ministry of Health and Welfare in 1968. It is supported by a government subsidy and by donations from companies and individuals, especially from bereaved families who have lost family members to cancer. Programs conducted by the Foundation include postdoctoral fellowships to educate young cancer researchers, exchange programs between Japanese and foreign scientists to promote international cooperative study, activities of the International Symposium relating to clinical cancer research and public education via the publication of informative pamphlets and support for scientific lectures. The Foundation also publishes the monthly Japanese Journal of Clinical Oncology.
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Telling the Truth to Cancer Patients
Until recently, Japanese doctors rarely informed patients of their diagnosis, thinking that accurate knowledge of their condition would be psychologically damaging and therefore harmful to their quality of life. In many cases, doctors would inform a family member rather than the patient of the diagnosis. However, this situation is changing rapidly. A nationwide survey conducted in 1997, covering 24 separate facilities, revealed that 75% of 1215 adult patients were aware that they had cancer. This rate is more than double the figure recorded in previous government surveys. Throughout the country, it is estimated that the rate of informed patients is ~70–80% in clinical cancer centers and ~30% in general hospitals. The National Cancer Center has proposed guidelines for telling the truth to cancer patients (20,21).
New Anti-cancer Drugs and Clinical Trials
In the field of cancer medicine, treatment is expected to be based on sound evidence. To obtain this evidence, clinical trials are conducted in clinical cancer centers, university hospitals and general hospitals. These clinical trials are of two types. One concerns the development of new anticancer drugs by pharmaceutical companies and the other is carried out by clinicians with the aim of establishing and improving cancer treatments by testing new therapeutic regimens and combined modalities.
With regard to the first type, pharmaceutical companies in Japan are making a major effort to develop new anti-cancer drugs, while international pharmaceutical companies who are well aware that Japan is a potentially large market for anticancer drugs would like to conduct clinical trials to test the efficacy of their products with the aim of winning official approval from the Japanese government. In this situation, quality assurance of the clinical trials is guaranteed by the revised guidelines for Good Clinical Practice published in 1998. The Japanese government also amended the Pharmaceutical Affairs Law and related regulations and then reformed the New Drug Application review system, for which purpose the Pharmaceuticals and Medical Devices Evaluation Center was established in 1997 (22).
In the case of trials conducted by clinicians, the Japan Clinical Oncology Group (JCOG) plays an important role in maintaining effective quality assurance (23). JCOG is a cooperative oncology group whose aim is to conduct, develop and coordinate clinical trials in the field of cancer treatment. Its organization consists of a data center, a clinical trial review committee, a monitoring committee and clinical study groups focusing on malignant lymphomas and cancers of the esophagus, lung, gastrointestinal tract, breast, uterus and ovary. As of November 1997, JCOG involves more than 600 oncological specialists belonging to about 200 medical institutions.
Bioethical Issues
In the 1960s, progress in life sciences and medical technology brought about the new science of bioethics, which confronts ethical problems regarding human rights and social utility from the viewpoints of science, ethics, philosophy, religion, jurisprudence and economics. After due deliberations on the adoption of bioethics in the USA and Europe, the Japanese government enacted laws and guidelines of its own. Examples include the guidelines on clinical research into gene therapy in 1994, the law concerning human organ transplants in 1997 and the law restricting human clone technology in 2000. In the field of cancer research, there has been a sharp growth of interest in the identification of germline mutations in patients with familial cancer syndromes and of somatic mutations of cancer tissues in patients with sporadic cancers. In fiscal 2000, the Japanese government initiated the Millennium Project, which focused on new technologies useful for improving human life in the twenty-first century. One of the research projects is human genomics for the treatment of disease and the development of new drugs, in which there will be extensive studies of the relationship between cancer susceptibility and single nucleotide polymorphism in cancer-related genes. It is well known that genetic testing has aspects that traditional medical research never had to deal with: in some genetic diseases, the future development of morbidity can be predicted not only in the patient but also in his/her next of kin with a common gene. The results of genetic analysis could therefore raise ethical, legal and social issues. To provide for this eventuality, two guidelines for bioethical problems associated with genetic research have been enacted in 2000: one is clarification of the fundamental principles of research on the human genome (24) and the other is concerned with bioethical problems deriving from general genetic research (25). Although the latter only focused on research associated with the Millennium Project, a new guideline for all kinds of genetic research conducted in Japan will be provided in 2001 (26).
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TOPABSTRACTINTRODUCTIONCANCER STATISTICSHEALTH INSURANCE SYSTEMCANCER CONTROL PROGRAMS IN...EDUCATIONAL APPROACHPREVENTIONCANCER SCREENING PROGRAMSMEDICAL FACILITIESTRAINING OF SPECIALISTSCANCER INFORMATIONPROMOTION OF CANCER RESEARCHISSUES OF CONCERNAcknowledgmentsREFERENCES |
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This work was supported by Grants-in-Aid from the Ministry of Health, Labour and Welfare of Japan for the Second Term Comprehensive 10-year Strategy for Cancer Control, for Cancer Research (11-20, 13-designated 3), and for Medical Frontier Strategy Research. It was also supported by the Program for Promotion of Fundamental Studies in Health Sciences of the Organization for Pharmaceutical Safety and Research of Japan.
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FOOTNOTES |
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+ For reprints and all correspondence: Ken Yamaguchi, Deputy Director, National Cancer Center Research Institute 1-1, Tsukiji 5-chome, Chuo-ku, Tokyo 104-0045, Japan. E-mail: kyamaguc@gan2.ncc.go.jp
Abbreviations: CT, computed tomography; QOL, quality of life; JCOG, Japan Clinical Oncology Group
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Received February 2, 2001; accepted July 30, 2001..
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