Commentary: Japanese point of view

Commentary

If you work in Japan the local government or the health department of your company will offer you a barium meal examination. You may choose to ignore this because you have no symptoms or because you had normal results the previous year. Suppose that later you feel epigastric discomfort for several days. Since there is no British-style general practice system in Japan you visit a private “gastrointestinal clinic” near your office (there are many of these in Japan, and no private insurance is needed). The doctor will ask whether you have taken breakfast and, if the answer is no, will suggest you have a gastroscopy in the clinic on that day. You may be frightened by the sudden offer, but you remember one of your colleagues who has recently undergone curative surgery for an early gastric cancer detected in the screening which you declined. The doctor examines your upper gastrointestinal tract meticulously, taking biopsy specimens, and may find an early gastric cancer.

The diagnosis of oesophagogastric cancer is often made before a patient attends hospital in Japan, and the patients are referred to hospital surgeons along with the endoscopic films and a copy of the pathology results. Surgeons try to attack the tumour as soon as possible especially in advanced disease.

Martin et al divided the total delay from onset of symptoms to surgical treatment into five stages. Each step took several weeks, making the total delay 21 weeks. This could be even longer in other parts of Britain where open access endoscopy is not available. In Japan the middle three referral steps can be omitted or shortened, and the delay from the first medical consultation to histological diagnosis is usually less than two weeks.

The delay from onset of symptoms to treatment is a practical problem, and it could be reduced by improvements in the referral system. However, the concept of early diagnosis in Japan is different in that the emphasis is placed on diagnosis before symptoms occur. More than six million adults have radiological screening for gastric cancer every year. Although several problems have been identified, such as low cost-effectiveness and the significant false negative rate, more than 7000 new cases are diagnosed as a result of the screening programme every year. The oesophagus is also screened “in passing.” The most important byproducts of the programme are widely available and easily accessed endoscopy services and a heightened public awareness of the disease. Most superficial oesophageal cancers and many early gastric cancers are incidentally found in the clinics during routine endoscopy for non-specific symptoms.

In the Japanese health care system many generous policies have been established without much consideration of the cost. The early detection of oesophagogastric cancer which is now possible in Japan may be one of the most important products of this strategy.