Lung cancer screening policy in Japan

Japan has a long history of lung cancer screening. A national chest X-ray (CXR) screening programme for lung cancer was introduced in 1987. Now in its 36th year, it offers annual screening for lung cancer to people aged 40 years or older.1-3

Guidelines for lung cancer screening were first developed in 2003. However, the last update in 2018 did not recommend population-based screening via LDCT. The responsibility of developing cancer screening guidelines now lies with the National Cancer Center.1

Instead, LDCT screening in Japan is commonly performed on a voluntary (opportunistic) basis. People interested in being screened for lung cancer can be referred in the community or during the mandatory workplace or annual medical check-ups.3

Because of the widespread uptake, the Japanese Lung Cancer Society publishes annual guidelines to ensure quality of LDCT screening.3 4 In addition, the Japanese Society of CT Screening (JSCTS) offers accreditation for healthcare professionals using LDCT. In 2022, there were around 1,500 physicians and radiologists accredited in Japan.4 5

Survey snapshot of the widespread use of LDCT screening in Japan (2000–2009) 3

2000 2004 2009
Institutions responding to survey 20 43 61
Participants 34,181 77,030 127,897
Positive screening result 10.9% 9.2% 7.2%
Participants confirmed to have lung cancer 113 174 195
Stage I lung cancer 78.8% 67.2% 67.7%

Results from the Quality Control Group of the Japanese Society of CT Screening 2009 nationwide survey.

 

Three decades of LDCT screening implementation research

LDCT screening was first piloted in Japan in 1993 as part of the Anti-Lung Cancer Association (ALCA) project in Tokyo – the first centre in the world to do so.5 The ALCA project targeted people aged 40–79 who smoke and demonstrated that 76.2% of people diagnosed with lung cancer via LDCT screening were still alive after five years.6

Building on these results, a mobile CT unit delivered three rounds of annual LDCT screening to 5,480 people aged 40–74 living in Matsumoto (Nagano prefecture).7 8 This pilot found that 88% percent of people detected to have lung cancer were diagnosed at stage I of the disease and 10-year survival in this group was 86% (83% when considering all-cause mortality).

Another well-known example of mass LDCT screening took place in Hitachi (Ibaraki prefecture). The Hitachi city pilots were one of the largest cohorts in Japan to demonstrate that LDCT screening can result in a dramatic reduction of lung cancer deaths.9 10 Between 1998 and 2006, over 25,000 people aged 50–69 were selected to participate at two centres in the city, which was estimated to represent around 30% of the total population in this age group.3

The impact of the mass LDCT screening pilots in Hitachi3 10 11

In 1998, The Hitachi Health Care Center worked with occupational health insurance groups to introduce LDCT screening into general health check-ups for employees and their spouses aged 50–69.9

After promising results from the first phase, in 2001 permission was granted by local government for a second site, Hitachi Medical Center, to expand the criteria to local residents aged 50 and over via a mobile CT screening unit in the community.

By 2006, a total of 210 people had been detected to have lung cancer via screening. Of these, only 25% had a history of heavy smoking (at least 30 pack-years). At the baseline scan, 91% of cases were diagnosed early at stage I and the majority of people diagnosed with lung cancer in the study were eligible to undergo surgery.3

The number of people found to have lung cancer that were still alive after five years was exceptionally high (90%) compared with other findings around the world, including randomised controlled trials.3

 

The future of LDCT screening in Japan

A nationwide randomised controlled trial for LDCT screening (JECS) was set up by the Ministry of Health, Labour and Welfare in 2010. People aged 50–70 who currently smoke or used to smoke undergo two LDCT scans over a 10-year study period, whereas a control group is offered a single CXR scan through the annual and workplace health check-ups. By 2021, over 20,000 participants had enrolled from across 25 prefectures in Japan, including the Tokyo metropolitan area, and follow-up is expected to end in 2035.

Studies of opportunistic screening have also provided valuable lessons for the implementation of an organised LDCT screening programme. In 2020, an observational study of people who underwent LDCT screening between 2004 and 2012 concluded that the opportunity to detect approximately 70% of lung cancer cases at an early stage of the disease may be missed if Japan were to adopt LDCT screening using criteria from the US National Lung Screen Trial (NLST).12

Instead, it was recommended that people who have never smoked and those who had smoked less heavily (<30 pack-years) should be eligible for screening. More recently, one study also concluded that LDCT screening was more cost-effective than no screening and CXR when it came to detecting lung cancer in people who have never smoked.13 Other pilot studies targeting people who have never smoked in South Korea (LEADER), Taiwan (TALENT) and Kazakhstan may offer further learning of how to target people in Japan who have never smoked for LDCT screening.

 

 

The Lung Cancer Policy Network is publishing brief case studies of countries that have implemented LDCT screening; you can read other examples here.

We will also continue to build the extensive implementation research in Japan into the second edition of the map.

View the interactive map

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References

  1. Hamashima C. 2018. Cancer screening guidelines and policy making: 15 years of experience in cancer screening guideline development in Japan. Japanese Journal of Clinical Oncology 48(3): 278-86

  2. Ministry of Health, Labour and Welfare. 2009. Handbook of cancer screening for family physicians: aiming to improve the rate of medical examinations. Tokyo: MHLW

  3. Nawa T, Nakagawa T, Mizoue T, et al. 2015. Low-dose computed tomography screening in Japan. Juornal of Thoracic Imaging 30(2): 108-14

  4. Japanese Accreditation Council for Lung Cancer CT Screening. 2022. Homepage. [Updated 10/02/22].  Available from: https://www.ct-kensin-nintei.jp/index.html [Accessed 21/02/22]

  5. Triphuridet N, Henschke C. 2019. Landscape on CT screening for lung cancer in Asia. Lung Cancer 10: 107-24

  6. Sobue T, Moriyama N, Kaneko M, et al. 2002. Screening for lung cancer with low-dose helical computed tomography: anti-lung cancer association project. Journal of Clinical Oncology 20(4): 911-20

  7. Sone S, Li F, Yang ZG, et al. 2001. Results of three-year mass screening programme for lung cancer using mobile low-dose spiral computed tomography scanner. British Journal of Cancer 84(1): 25-32

  8. Sone S, Nakayama T, Honda T, et al. 2007. Long-term follow-up study of a population-based 1996–1998 mass screening programme for lung cancer using mobile low-dose spiral computed tomography. Lung Cancer 58(3): 329-41

  9. Nawa T, Nakagawa T, Mizoue T, et al. 2012. A decrease in lung cancer mortality following the introduction of low-dose chest CT screening in Hitachi, Japan. Lung Cancer 78(3): 225-8

  10. Nawa T. 2019. Low-dose CT screening for lung cancer reduced lung cancer mortality in Hitachi City. International Journal of Radiation Biology 95(10): 1441-46

  11. Nawa T, Fukui K, Nakayama T, et al. 2019. A population-based cohort study to evaluate the effectiveness of lung cancer screening using low-dose CT in Hitachi city, Japan. Japanese Journal of Clinical Oncology 49(2): 130-36: 100329

  12. Kakinuma R, Muramatsu Y, Asamura H, et al. 2020. Low-dose CT lung cancer screening in never-smokers and smokers: results of an eight-year observational study. Translational Lung Cancer Research 9(1): 10-22

  13. Kowada A. 2022. Cost-effectiveness and health impact of lung cancer screening with low-dose computed tomography for never smokers in Japan and the United States: a modelling study. BMC Pulmonary Medicine 22(1): 19