Breast-cancer treatment is not always the same

by Tomoko Otake

Getting tested or treated for a life-threatening disease is nerve-racking for anyone, but it can be all the more so when outside of your home country.

Japan’s approach to breast cancer, with the annual death toll exceeding 10,000 (lower than typical rates in the West) is unique to some degree, what with the country’s egalitarian health-care system and particularly its long-standing custom of surgeons doing all the work. Experts say that surgeons here do everything from making a diagnosis to performing surgery to even prescribing medication.

This is different from practices in the West, especially in the United States, where treatment is divided among a team of specialists that include radiologists, oncologists, surgeons and — in later stages of cancer — palliative-care specialists, says Hirofumi Mukai, a breast oncologist at the National Cancer Center Hospital East in Chiba Prefecture.

“The Japanese practice has some merit, in that there is a sense of continuity in the treatment,” Mukai says. “Many Japanese feel more comfortable dealing with one doctor who knows everything about them.”

But even the best surgeons cannot specialize in all aspects of care, so doctors who are strong in some areas, such as diagnostic skills or chemotherapy, can be weak in other areas, Mukai says.

Health-care systems vary from country to country. The good news in Japan is that the country has a national health insurance system, which requires everybody to be insured, either as individuals or through their employer. This universal care system provides treatments that are approved by the government relatively cheaply. The bad news is that unapproved treatments, including ones common in the West, are out of reach for most patients.

Take, for example, a drug called trastuzumab, more commonly known under the trade name of Herceptin. Herceptin is an antibody used in the treatment of breast cancer, which attacks the HER2 protein that can fuel tumors. It has “a big influence” on patients here, Mukai says, because it is known to reduce the recurrence of breast cancer by half and is the only “targeted therapy” drug for breast cancer approved in Japan. Targeted therapy refers to medications that block the growth of cancer by interfering with the molecules needed for tumor growth, rather than simply attacking rapidly-dividing cells.

In Japan, Herceptin is covered by insurance only after the cancer returns or spreads to different parts of the body; Mukai says that in the United States and many parts of Europe, the drug is available for use in post-surgery treatment to prevent the cancer from coming back.

Herceptin will probably be available insurance coverage for such usage next year, but currently those who want to have the drug prescribed must pay ¥3 million for the full-course, yearlong treatment, which excludes the cost of consultations with doctors and other fees, according to Mukai. What is worse, under Japanese law, patients who receive uninsured treatments such as Herceptin have their insurance coverage cut off for all other related procedures, because the government does not allow patients to mix insured and uninsured treatments. This could change, though, following a recent district court ruling that deemed such practices unlawful.

In Japan, more women are now having only parts of their breast removed and are keeping non-cancerous areas, whereas in the United States, the trend is going in the opposite direction. An October study published in the Journal of Clinical Oncology found that 4.5 percent of 152,755 breast-cancer patients examined had their unaffected breast surgically removed along with their affected breast in 2003, up from 1.8 percent in 1998. Todd Tuttle, the study’s lead author and chief of surgical oncology at the University of Minnesota Medical School, has been quoted in the New York Times saying: “The comment patients make is, ‘I just want to be done with it.’ They never want to have another mammogram again; they never want to have another biopsy again.”

Seigo Nakamura, director of breast surgical oncology and director of the Breast Center at St. Luke’s International Hospital in Tokyo, says that, unlike in the United States, a double mastectomy immediately followed by breast reconstruction surgery is not a treatment option here because breast construction is not insured and, besides, few reconstruction experts exist.

Another disadvantage for patients in Japan is that genetic testing for BRCA1 and BRCA2 genes, inherited mutations of which can greatly increase a woman’s breast-cancer risk, is not covered by insurance, either. St. Luke’s Breast Center is one of the few places that offer the test, but at a hefty cost of ¥200,000, Nakamura says.

The upside is, for anyone interested in a screening for breast cancer, most municipalities now offer subsidized mammography X-ray tests for women aged 40 or older. Screening programs vary from city to city, cover different age groups and are offered at different intervals. Most cities offer an X-ray exam every two years, either free of charge or for a nominal fee of ¥500 or ¥1,000. Some provide a combination of mammography and, if requested, screening using ultrasound.

Though both mammography and ultrasound screening can detect small tumors, some experts say ultrasound is preferred for those younger than 40 because the high density of mammary glands in women in their 30s makes it difficult for cancerous tissues to be found. Ultrasound is also widely used during surgery, as many Japanese surgeons are skilled at operating ultrasound machines and removing tumors on the spot, says Nakamura.

“That’s probably the only thing we can be proud of as being advanced in the world,” he says.