NATIONAL SCIENCE FOUNDATION
TOKYO REGIONAL OFFICE

The National Science Foundation's (NSF) Tokyo Office periodically receives and disseminates reports on research developments in Japan that are related to the Foundation's mission. NSF-sponsored researchers currently working in Japan prepare many of these reports. These reports present information for use by NSF program managers and policy makers; they are not statements of NSF policy.

Special Scientific Report #00-13 (November 16, 2000)

Cancer Screening Services: Comparisons Between Japan and the United States

Ms. Rina Kitazawa, a graduate student in the School of Public Health and Social Work at Columbia University prepared the following report.  Ms. Kitazawa was a participant in the 2000 Summer Institute sponsored in the United States by NSF/NIH/USDA and the Science and Technology Agency and Japan Science and Technology Corporation in Japan.  Dr. Shinji Takemura of the National Institute of Public Health in Tokyo hosted Ms. Kitazawa.  Ms. Kitazawa can be reached via email at: rinakitazawa@hotmail.com.

During my six weeks as a visiting graduate student researcher at the National Institute of Public Health in Tokyo, I was able to:

•              compare and contrast the U.S and Japanese health care systems;

•              study the differences in the use of cancer screening services in each country;

•             study the differences in how these cancer screening services are perceived by the residents of each country    as well as their willingness to take part in cancer screening tests;

•             study the differences in the types of social services and programs that are available to cancer patients and their families in Japan and the U.S..

U.S. and Japanese Health Care Systems:

With four times as many magnetic resonance imagers (MRIs) as Germany and eight times as many as Canada, the United States boasts a highly technological and advanced health care system (Reagan, 1992). Access to this system, however, is limited to individuals who have health insurance through their employers. Although government health insurance programs, such as Medicaid and Medicare, were created to extend health care coverage to individuals who do not have private insurance, millions of Americans continue to go without health care because they do not meet the stringent eligibility requirements for these programs. Many uninsured adults are under 65, the age at which one qualifies for Medicare.  Many uninsured people work, but their incomes, below $25,000 a year, make them ineligible for Medicaid. In fact, Medicaid “serves only a minority of the poor, whose income falls below the federally defined poverty level, e.g., $14,419 for a family of three” (Reagan, 1992, 20). 

Currently, more than forty four million individuals in the U.S. lack health insurance in the United States (Lagnado, 1999; U.S. Department of Health and Human Services, 2000).  Moreover, there are millions of Americans who have health insurance, but do not have adequate health care coverage. The Commonwealth Fund in New York found that, “simply having benefits doesn’t guarantee access to adequate health care” (Lagnado, 1999,2). According to their study of 5,000 working Americans in low-income neighborhoods, only 59 percent of individuals with incomes under $20,000 have access to preventive services such as check-ups and cancer screening tests compared with 80 percent of individuals with incomes that exceed $60,000 (Lagnado, 1999, 2).  The U.S. can evidently be characterized by a system that provides quality care to certain members of the population who are protected by adequate health insurance policies.

The Japanese health care system differs significantly from the U.S. health care system in that it provides equal access to health care to all its residents. In fact, “All patients, rich or poor, are assured equal access to all medical services due in large part to a uniform fee schedule for reimbursement” (Yoshikawa, Bhattacharya, & Vogt, 1996, 4).  Most individuals in Japan have insurance through their employers, similar to the United States. Those who do not have insurance through their employers can enroll in the National Health Insurance Program. Thus, with the National Health Insurance Program in place, virtually everyone in Japan has health care coverage, including those who are not employed (Japan International Social Security Association, 1999).

The Japanese have access to almost all hospitals and clinics to receive medical care and to prefectural and municipal health centers to receive (preventive) health services.  The prefectural and municipal health centers, which are unique to Japan, offer a variety of services at the local level, such as maternal and child health programs, family planning services, AIDS testing, health education classes, and comprehensive physical examinations.  Having visited a few municipal and prefectural health centers in Japan, I found that Japan offers more preventive services as well as other services to its residents compared to the United States.  I was even able to observe a rehabilitation program for stroke victims at one health center in Yokohama.  There are, of course, concerns about the health care system in Japan, including long waiting periods, impersonal medical staff members, over prescribing of drugs, and insufficient explanation of medical conditions by physicians (Tanaka & Sone, 1996). However, although the Japanese health care system has its limitations, almost all Japanese are guaranteed health care coverage and access to preventive services, including cancer-screening tests, either through their employers or through local government.

Cancer Screening Services in the United States and Japan:

This summer I decided to take a close comparative look at the use of cancer screening tests in both Japan and the United States.  Cervical, breast, prostate, skin, and colon cancer can all be treated and managed if detected early enough with screening tests (American Cancer Society, 2000).  However, use of cancer screening tests remains low in both Japan and the United States, particularly among low-income populations in the United States. (American Cancer Society, 2000). In 1997 only 5.9% of women in Tokyo received screening tests for breast cancer.  Additionally, only 7.2% of women in Tokyo received screening tests for cervical cancer (Ministry of Health and Welfare, 1998).  The American Cancer Society attributes the low screening rate in the United States to the fact that many low-income individuals do not have health insurance and access to preventive services, and cancer-screening tests are far too expensive for those who do not have health insurance. A study published in the journal Cancer this year found that Asian American women utilize breast and cervical cancer screening services less often than white women because they lack insurance and the income to pay for these services, and are “more vulnerable to structural barriers” (Kagawa-Singer & Pourat, 2000, 696). As a result, the number of deaths from breast and cervical cancer has increased by 200% in the last ten years among this population.  In fact, the American Cancer Society (2000) reports that, “The country’s poor and underserved population bears an unequal share of the nation’s cancer burden.”

In Japan, however, these tests are available to virtually everyone. Depending on what type of health care coverage an individual has, he/she can receive screening tests for various types of cancer either through the employer or through the community. Moreover, anyone over 40 is eligible to receive a screening test under the 1995 Health and Medical Service Law for the Aged. Under this same law, women over 30 are eligible to receive screening tests for cervical cancer.  Almost all municipal health centers offer free or low cost screening tests every year to individuals over forty.  Yet the following questions remain: if lack of access to preventive services is not a problem in Japan, what are the reasons for the low use of screening tests by the Japanese people? Moreover, what marketing techniques should be used to increase the number of people who utilize screening test services?

With the help of Dr. Takemura, I created a community based survey to find out why people in Japan were choosing not to receive cancer screening tests, as well as to find out the ways in which information about cancer screening could best be disseminated to them.  The survey, which utilized items from a screening survey used by Mizoue, Takano, and Yoshimura, (1992) asked the following questions:

•             Have you ever been screened for cancer? (for Machida residents)

•              If not, why haven’t you been screened for cancer? (for Machida residents)

•              Do you feel that cancer-screening tests would improve the quality of your life?

•              Do you feel that cancer-screening tests would improve the general quality of life for people in Japan?

•             How have you learned about screening tests in the community?  Where, if ever, have you seen advertisements for cancer screening tests?

•             What would be some effective ways to get information to you?

We implemented the survey in two communities: Machida and Takenozuka.  It is important to point out that the people who took part in this research were not a random sample and therefore not representative of the general population. The Takenozuka sample comprised men and women between the ages of 39 and 60 who had recently taken part in comprehensive physical examinations at the Takenozuka municipal health center; they had all received cancer screening tests as part of an annual physical examination. The Machida sample comprised women between the ages of 43 and 76 who were all members of a “rhythm dance” club that met weekly.  The individuals who made up the study population are evidently not representative because these individuals demonstrate more concern about their health than the average person in Japan. The Machida sample is also not representative because they were all women.  The information provided by these two groups was merely used to get a better understanding of why people in Japan are choosing not to receive screening tests for cancer. 

Results from Takenozuka:

(The survey was completed by 44 individuals, males and females, in Takenozuka who have received screening tests). 

·        Table 1.  In your opinion, why aren’t many Japanese receiving screening tests? (multiple answers)

 ·        Table 2.  How have you learned about cancer screening tests in the community? (multiple answers) 

·        Table 3. What would be effective ways to get cancer –related information to you?  (multiple answers)

Results for Machida:
(The survey was completed by 57 women in Machida).  

62.3 percent of the women in Machida have taken part in a cancer-screening test. 
37.7 percent have never taken part in a cancer-screening test.

·        Table 4. Why have you chosen not to be screened for cancer? (multiple answers)
(This question was asked of the women who have never been screened)

·        Table 5.  In your opinion, why aren’t many Japanese receiving screening tests? (multiple answers)

·        Table 6.  How have you learned about cancer screening tests in the community? (multiple answers)

·        Table 7.  What are effective ways to get cancer-screening information to you? (multiple answers)

A t-test was also conducted to detect any differences in responses between individuals who have been screened and individuals who have not been screened for cancer.  A statistically significant difference (p<0.05) was detected for the following question.   

·        Table 8.  Do you think that if more Japanese received screening tests, the overall health and quality of life of the Japanese people would improve?

P-value 0.044 

Although these results cannot be generalized to the Japanese population, I found that the responses of the Takenozuka and Machida study participants allowed me to obtain a better understanding of why the screening rate in Japan may be so low.  Interestingly, the top three reasons for the lack of participation in screening tests in Japan were the same for the Takenozuka and Machida population, as shown in Table 1 and Table 5.  They both stated that the cancer-screening rate may be low in Japan because: 

1.  people are too busy to get screened for cancer.

2.  people feel fine, and therefore do not see the need to get screened for cancer.

3.  people feel that screening tests are a hassle.  

If these conclusions are indeed true, they suggest that perhaps a health care program based on the Health Belief Model is necessary to increase the number of people who get screened for cancer.  If a greater number of Japanese people learn about the importance of screening tests (perceived benefits), perhaps they would be more likely to get screened for cancer even if they feel that they are too busy and that screening tests are a hassle (perceived barriers).  Moreover, their perceived susceptibility to cancer may increase after learning that they can be asymptomatic and still have cancer. 

Based on information that was provided by the Takenozuka and Machida individuals, it appears as though municipal notices are the most successful in communicating information about cancer-screening tests to the public, as shown in Table 3 and Table 7.  Other effective ways to disseminate cancer-screening information include: direct mail, community bulletin boards, and municipality notebooks.    

Social Programs for Cancer Patients and Their Families in U.S. and in Japan:

During my six weeks at the Public Health Institute in Tokyo, I was also able to learn about the social programs (or lack of social programs) that are available for cancer patients and their families in Japan.  I had the opportunity to visit the National Cancer Center (NCC) in Tokyo and meet with Mr. Omatsu, an oncology social worker at NCC. I realized through talking with Mr. Omatsu that there is a definite lack of social services and supportive programs for cancer patients and their families in Japan.  He informed me that he was the only social worker who was employed by the National Cancer Center and that he alone was responsible for arranging social services after the hospital discharge and for providing emotional support to the patients and their families at the National Cancer Center.    He also informed me that only six hospitals that specialize in oncology have social workers on staff, with each hospital having only one or at most two social workers on staff.   Moreover, Mr. Okano also stated that the administrators at the hospital told him that he did not have to “do social work”, that he was only hired “for show,” and that he was responsible for administrative work.  In my opinion, the lack of supportive programs demonstrated that social services are not valued or considered of importance in Japan.  Although Japanese cancer patients and their families do not face barriers in receiving medical care, it does appear as though they have tremendous difficulty finding programs that provide emotional support and financial assistance. Programs that help individuals deal with the emotional trauma of cancer are non-existent in Japan. 

The United States, on the other hand, offers a variety of supportive programs for cancer patients and their families.   Memorial Sloan-Kettering Cancer Center, the equivalent of the National Cancer Center in Tokyo, offers individual and group counseling services to help cancer patients and their families adjust to terminal illness and assists in communication with family members, including young children, about cancer.  They also offer a series of educational seminars, workshops, and a telephone information help-line.  Similar to the services provided by Memorial Sloan-Kettering, Cancer Care, a non-profit organization, also offers individual and group counseling, educational programs, and financial assistance to cancer patients and their families.   The National Cancer Institute provides yet another service for cancer patients and their families.  Any cancer patient or family member of a cancer patient who needs the latest and most up to date information can call the National Cancer Institute phone line for this information.   What differentiates the United States from Japan is that the United States offers a plethora of social programs compared to Japan, which currently lacks supportive programs for its residents.

References

              American Cancer Society (2000).  Cancer facts and figures–2000. Atlanta, Georgia:  American Cancer Society.  

              American Cancer Society (2000, April 20).  Fighting cancer in the poor and underserved. [WWW document].  URL http://www.cancer.org

Japan International Social Security Association (1999).  Outline of social insurance in Japan.  Tokyo.  

Kagawa-Singer, M. & Pourat, N. (2000).  Asian American and Pacific Islander breast and cervical cancer screening rates and Healthy People 2010 objectives. Cancer, 89(3), 696-705.

Lagnado, L. (1999, December 30).  Health insurance called often inadequate --- lower-income employees pay higher premiums, with benefits limited.  Wall Street Journal, p.A2.

Minister’s Secretariat, Ministry of Health and Welfare (1998).  Old-age health care annual.

Mizoue, T., Takano, Y., Yoshimura, T. (1992).  A population based survey of attendance at screenings in urban areas.  Nippon Koshu Eisei Zasshi, 39(5), 269-277.

Reagan, M.D. (1992)  Curing the crisis:  Options for America’s Health Care.  Boulder:  Westview Press. 

            Tanaka, S. & Sone, T. (1996).  Getting Sick in Japan.  Kyoto:  Kobunshi Kankokai, Inc.

            U.S. Department of Health and Human Services, Public Health Service.  Healthy People 2010: Understanding and Improving Health. Washington D.C.: January 2000.

Yoshikawa, A., Bhattacharya, J. & Vogt, W.B. (1996).  Health Economics of Japan:  Patients, Doctors, and Hospitals under a Universal Health Insurance System.  Tokyo:  University of Tokyo Press.