Country context

Japan is home to the oldest population in the world, with an average life expectancy of 81 years for men and 87 years for women. Non-communicable diseases (NCDs) are prevalent in this super-aged society and account for over half of all deaths in Japan. Lung cancer was the leading cause of cancer death in 2019, but increased screenings in recent years have led to a positive shift in the proportion of cases being caught in the early stages, and an improvement in overall survival rates. For example, in 2017, the three-year survival rates were 89 percent, 64.4 percent, 38.2 percent, and 12.3 percent for stages I, II, III, and IV, respectively, with an overall survival rate of 51.7 percent. As of 2022, Japan’s overall lung cancer incidence was 30.5 cases per 100,000 people, with a mortality rate of 14.2 cases per 100,000 people.

While health policy is passed at the national level, policies and health care are enacted at the prefecture level. Despite differences in income-level and accessibility, health inequality among prefectures is declining, due in part to the high level of choice afforded to patients, and the wide coverage of the national health insurance, first introduced in 1961. Japanese patients are able to choose their point of care, including cancer centers, of which there are now over 400 across the country, and medical care is available at 30 percent of its cost for patients under the age of 70, 20 percent of cost for patients aged 70 to 75, and 10 percent of cost for patients over 75. Health care expenses for patients with average incomes are capped at USD 850 per month. As a result, in 2018, of USD 400 billion in total health care spending, just one eighth was paid out-of-pocket by patients, with half financed by insurance and the rest covered by government funds. These cost-sharing arrangements are critical to reducing the burden on those diagnosed with lung cancer, which has the highest median cost-per-patient in the first year of treatment among Japan’s five leading cancers, at JPY 2,508,789 (USD 17,373.24) as of 2021. Japan also has an efficient process for approval of new cancer drugs, with regulation requiring cancer drugs already approved overseas to be assessed for approval in Japan within six months, making it easier for Japanese patients to access innovative treatments.

Assessing policies and programs

Cancer control in Japan was introduced via the Cancer Control Act, Act No. 98, first passed in 2006 and last amended in 2016. The Act forms and gives authority to the Cancer Control Promotion Council, which advises the Ministry of Health, Labour and Welfare (MHLW) in the creation and implementation of cancer control policies. The Council has 20 members, including representatives of patients or bereaved families, cancer health care professionals, and academics. The Council’s main role is to create implementation plans, most recently the Basic Plan to Promote Cancer Control Programs, which was last updated in 2018. The Basic Plan has three key goals: “(1) prevention and screening underpinned by scientific evidence; (2) patient-focused cancer treatment; (3) establishing society where lives are lived with dignity and security.” While the Basic Plan is not specific to lung cancer, it covers policies and articulates goals for all stages of the patient journey, including improving screening rates and follow-on appointments, designating core hospitals to lead on emerging treatments such as genomic medicine and immunotherapy, training cancer specialists, and programs and policies to support the well-being and mental health of patients and the terminally ill.

Notably, the Basic Plan aims to offer palliative care options from the time of diagnosis onward, counselling services—including help with physical appearance changes and fertility preservation—and support for cancer patients to continue attending school or work as they wish. While the 2018 Basic Plan represents just the latest in a series of cancer control policies for Japan, its impact is hard to quantify—the government has seemingly never undertaken monitoring and evaluation of previous plans, and the current plan takes a “philosophy-oriented” approach to impact. As a result, rather than identifying and tracking specific numerical targets, the Basic Plan sets broad, descriptive goals such as “prevention,” which are difficult to measure. However, independent analysis of the impact of government-led palliative care policies found that 90 percent of designated cancer hospitals surveyed had full-time palliative care staff, an interdisciplinary palliative care team, and dedicated palliative outpatient clinics. Despite this wide availability and integration of palliative care resources into cancer care, the same study found that less than 40 percent of designated cancer hospitals were routinely documenting advanced care planning for cancer patients.

In addition to the Basic Plan, Japan has a population-based lung cancer screening approach: chest radiography or x-rays are available free of charge to everyone over the age of 40, either through their workplace or via their regional health service. While screening has been available to anyone over 40 since 1987, the introduction of workplace screening has improved screening rates dramatically. As of 2019, 53.4 percent of Japanese men had been screened, compared to 26.4 percent in 2010, and 45.6 percent of women, compared to 23.0 percent in 2010. While low-dose computed tomography (LDCT) screening is not yet covered by public health insurance, it has been available privately since 1993—Japan ranks highly among OECD countries for access to CT, MRI, and PET scanners. As a result, according to the Basic Plan, 30 to 60 percent of cancer cases in Japan are caught through opportunistic screening. Beyond screening, some genomic diagnostics tests are partially or fully covered by national health insurance, including through a large clinical trial undertaken in collaboration among the government, industry, and academia. As a result of an uptick in genomic testing, Japan’s National Cancer Center for Cancer Genomics and Advanced Therapeutics (C-CAT) had accumulated over 20,000 cases of genomic abnormalities for use in research and clinical processes as of 2021.

In addition to the national screening program and cancer control policies, Japan has implemented several preventive laws relevant to lung cancer. In particular, the Health Promotion Act, last revised in 2020, includes clauses focused on reducing smoking and passive smoking. The 2020 revision includes a ban on smoking indoors in public facilities, public transport, restaurants, schools, hospitals, any facility for children, and government offices. Japan ratified the WHO Framework on Tobacco Control in 2004, but to date it has ranked low in terms of preventing second-hand smoke exposure, which the Health Promotion Act aims to change. However, while smoking restrictions are key to both cancer control and public health, Japan’s smoking rates are declining, and the frequency of lung cancers characterized by non-smoking is high, signifying that other lifestyle factors may be driving lung cancer.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

The Fourth Basic Plan to Promote Cancer Control Programs was proposed and agreed upon in March 2023, although it does not appear to have come into effect yet, with a draft budget of JPY 35.4 billion (USD 245 million). While not yet published in full, overviews of the plan indicate that its goal is to “promote cancer care that leaves no one behind, and work to overcome cancer with all citizens.” At a high level, its objectives appear to focus mainly on reducing inequity of care, both among prefectures and among different demographics, with a particular focus on older adults, and support for the mental health of cancer patients and survivors. The Fourth Basic Plan represents an opportunity to improve monitoring and evaluation of outcomes and investment by setting clear, data-based objectives for success that can be measured and compared at the end of the Plan’s implementation period. However, it is not clear whether such objectives have been set, or whether the Fourth Basic Plan will continue to take the so-called “philosophy-oriented” approach of previous plans.

Regionally, Japan is spearheading cancer research efforts focused on identifying and treating the cancers most prevalent in the Asia Pacific region, acknowledging that the region cannot rely on Europe and the U.S. to address region-specific abnormalities and rare diseases. The Asian Multicenter Prospective Study of Circulating Tumour DNA Sequencing (A-TRAIN) was launched in 2021 at the National Cancer Center Hospital in Japan to develop novel treatments using genomic analysis of blood samples. Expanding the project focus to include lung cancer would be impactful, given the high prevalence of lung cancer in Japan and across the region.