Revision of a breast cancer screening system

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In March 12, 2004, a working group in the Ministry of Health, Labour and Welfare, which was conducting a review of cancer screening, summed up an opinion that the target age of breast cancer screening should be raised from 30 years old (or over) to 40 years old (or over), as well as abolishing the screening for women in thirties. Thus, the Ministry announced it to municipalities in the notice dated March 31.

Purpose of health policy or idea

In March 12, 2004, a working group in the Ministry of Health, Labour and Welfare, which was conducting a review of cancer screening, decided to raise the target age of breast cancer screening from 30 years old (or over) to 40 years old (or over), and to abolish the screening for women in their thirties.

The reason for the abolition is that screening of women under 40 is not confirmed to be associated with lowering the mortality rate. There are many cases in which breast cancer is not detected in women in thirties, even when mammography is used, because their mammary gland is likely to grow heavily. Some doctors recommend ultrasound examination, but its effect has not been confirmed, either. In addition, continuing screenings only by ocular inspection and palpation, which are judged as ineffective, was also judged as ineffective for women in thirties. Thus, the Ministry decided the abolition in April 2004 and announced it to municipalities in the notice dated March 31.

Decision on the actual target age is left to municipalities in charge of the screening. In addition, screening only by ocular inspection and palpation is allowed to continue until organization of the screening in the municipality is completed.

In terms of screening for women 40 years old or over, ocular inspection and palpation remains in the screening process in cases where the equipment does not work accurately.  Accuracy of ocular inspection and palpation is ensured, by requiring doctors in charge of the screening to participate in training programs by medical associations and academic societies.

A survey will be conducted on the status of introducing mammography equipment, followed by measures to enable all the municipalities to conduct breast cancer screening by mammography. 

Meanwhile, the decision stipulated that related research and study shall be continued, reflecting the opinion that abolishing the present system should be accompanied by evidence to support the decision. 

Main points

Main objectives

To improve the effectiveness of health examinations for breast cancer

Type of incentives

Non financial: To improve the effectiveness of health examinations for breast cancer

Groups affected

Women of age 30 and over (target group of the screening), Local governments (municipalities): entity to manage the screening, Medical Associations

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

It is appreciated that items of indecisive scientific effectiveness were eliminated from the screening components.

However, this revision of guidelines is not a compulsory one, leaving decision to each municipality. In addition, the Ministry had already promoted, since 2000, the use of mammography in the screening for women aged 50 and over, though it has been introduced in only the half of the municipalities. Consultations with officials between the Ministry of Health, Labour and Welfare and the Ministry of Public Management, Home Affairs, Posts and Telecommunications (in charge of block grants to local governments) already started to decide on what entity will pay for expensive equipment of mammography (30 million yen = approx. 230,000 Euro per piece), as well as for the expenses in the screening managed by the municipality, etc., though the prospects of the consultation are still ambiguous at present. 

Political and economic background

In terms of cancer screening, subsidies from the central government were abolished in 1998, redefining the screening as a program that municipalities propose, plan and operate for themselves. The Ministry of Health, Labour and Welfare established the Guideline for Health Education Focusing on Preventing Cancer and Conducting Cancer Screening (March 31, 1998 - revised in March 31, 2000). It provides technical support to municipalities producing among other things, instruction manuals for the screening process.  

In terms of breast cancer screening, it had been pointed out that some doctors are designated for breast cancer screening without mammography equipment or proper training for breast cancer screening, and that they have a possibility of using only ocular inspection and palpation and of finally failing in detecting breast cancer. A series of social movement, triggered by a newspaper article in summer of 2003 about a failure in detecting breast cancer in screening of a woman (age 39), promoted a debate on breast cancer screening and caused a controversy.

Receiving a report of a research group which demands introduction of mammography because of ineffectiveness of screening only by ocular inspection and palpation, the Ministry of Health, Labour and Welfare announced a guideline, in 2000, which urged the use of mammography once in two years in principle for women in fifties or over. However, only the half of the municipalities obeyed the guideline.

In the working group held in February 2004, it was decided to lower the target age of screening by combination of ocular inspection, palpation and mammography from 50 years old (or over) to 40 years old (or over). In terms of the screening for women in thirties, screening only by ocular inspection and palpation tentatively remained without enough discussion, but some members of the group raised questions about continuing it.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

A basic guideline provided in November 6, 2003, by the Research Group on Improving Accuracy and Efficiency of Breast Cancer Screening (in the Ministry of Health, Labour and Welfare), which demands lowering of the target age of mammography from 50 years old (or over) to 40 years old (or over).

Approach of idea

The approach of the idea is described as:
amended: from the breast cancer screening in the past

Innovation or pilot project

Local level - breast cancer screening in the past

Stakeholder positions

There was a fierce controversy between researchers and providers in the following way; 

• Researchers' side (seeking for abolition of ocular inspection and palpation)
• "There is no evidence of their effectiveness. Screening only by ocular inspection and palpation should not be continued."
• Providers' side (seeking for their continuation)

"It is not logical to abolish the screening only because no effect in reducing mortality rate is confirmed. It is important to consider other indicators such as the quality of life (QOL) of the patient." "Raising consultation rates is the top priority." "There is no evidence either to prove that ocular inspection and palpation have no effect."

At last, it was decided to abolish the screening, following an initiative of the chairman of the Working Group

Influences in policy making and legislation

In March 2004, the Working Group on Cancer Screening (in the Ministry of Health, Labour and Welfare) basically agreed to the contents of the report on the review of breast cancer and uterus cancer screening. The Ministry announced to municipalities on abolition of the screening from April.  

Legislative outcome

major changes

Monitoring and evaluation

There are no agencies or institutions with a special mandate to evaluate the result of the reform, but the decision stipulates that related research and study shall be continued.  Also, the results will draw attention of many researchers/scholars because they are significant matters of concern from medical perspectives.   

Expected outcome

Effectiveness of health examinations for breast cancer will be improved.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Breast cancer is the most prevalent cancer for women in Japan that causes 10,000 deaths in a year (mortality rate is 10.8 per 100,000 persons). Therefore, it can be said that a decision on guidelines for breast cancer screening for the purpose of its early detection will have a considerable impact to women in the target age of the screening. 

References

Sources of Information

• Journals (e.g. Shakai-hoken-junpo (in Japanese))
• http://www.ne.jp/asahi/citizen/information/medinfo/screening3.html
• Newspaper
• National Cancer Center

Author/s and/or contributors to this survey

Tetsuya Aman, Masayo Sato

Empfohlene Zitierweise für diesen Online-Artikel:

Tetsuya Aman, Masayo Sato. "Revision of a breast cancer screening system". Health Policy Monitor, June 2004. Available at http://www.hpm.org/survey/jp/c3/5