Archive for the ‘Cancer’ Category

Gastric cancer screening program in Japan

August 18, 2018

Upper gastrointestinal series(UGIS) and Esophagogastroduodenoscopy(EGD)


Gastric cancer in the third leading cause of cancer deaths and the prevalence of gastric cancer is the highest among all cancers. The 5-year survival rate of gastric cancer is more than 90 percent if gastric cancer is detected and treated at an early stage.

Japan cancer society recommends upper gastrointestinal series (UGIS) or esophagogastroduodenoscopy (EGD) as the screening modalities biannually. The Japanese society of Gastrointestinal Cancer Screening published the manual of gastric cancer screening using EGD in which it is recommended to receive EGD biannually.
Helicobacter pylori (H. pylori) is the important risk factor for gastric cancer. The cohort study performed in Japan demonstrated that gastric cancer developed in populations infected with H. pylori but not in uninfected populations.


Japan Research Foundation of Prediction, Diagnosis and Therapy for Gastric Cancer proposed the gastric cancer screening using serum anti-H. pylori IgG antibody and serum pepsinogen levels, “ABC method”.

Although the risk of gastric cancer is quite different between H.pylori positive and H. pylori negative populations and the proportion of H.pylori infection in the Japanese population is gradually decreasing, H.pylori infection status is not considered in UGIS and EGD programs and all people are supposed to receive these modalities.

Prevalence of H.pylori

Although implementation of gastric cancer screening program is in charge of local governments and many stakeholders including organizations, cancer screening hospitals, and companies are involved in gastric cancer screening program, the limited resources should be used effectively considering public health.

We support H.pylori-based gastric cancer screening. Because it is not cost-effective that all people receive UGIS or EGD regardless of H.pylori infection status, H.pylori is the most important risk factor for gastric cancer. Sensitivity and specificity for the detection of gastric cancer are high in EGD, and positive predictive value is associated with disease prevalence and specificity used.

We suggest that H.pylori-based screening program is firstly performed for all the people at the age of 50 and EGD is applied only to H.pylori-positive subjects for the early detection of gastric cancer. The Japanese government should set the law for this mandatory screening.

Human papillomavirus vaccination crisis in Japan

August 16, 2018

Human papillomaviruses (HPV) are associated with the development of cervical cancer, and the mortality and incidence of cervical cancer is increasing in the last decade among Japanese women. Two prophylactic vaccines, a bivalent vaccine and a quadrivalent vaccine, were licensed in Japan, and in 2011, the Japanese Ministry of Health, Labor and Welfare (JMHLW) recommended a fully financed HPV vaccination policy of girls aged 12 to 15. However, in 2013, several cases of “vaccination-associated neuro-immunopathetic syndrome” were reported (although it was not based on scientific evidence), and it was lionized by the media. After these events, the JMHLW suspended the policy and stopped promoting the vaccine usage, leading to drastic decrease in vaccination coverage from 70% to less than 1% (figure).

Uptake rates for the human papillomavirus vaccine in Sapporo, Japan, as of March, 2014. Lancet. 2013;382:768

Uptake rates for the human papillomavirus vaccine in Sapporo, Japan, as of March, 2014. Lancet. 2013;382:768.


Many stakeholders support the resumption of HPV vaccination policy. For instance, Japan Society of Obstetrics and Gynecology (JSOG) approved of the resumption of HPV vaccination policy in 2015. And in 2017, JSOG and other organizations proposed a joint statement calling for the prompt resumption of the HPV vaccine policy. The statement also demanded scientific research for “HPV vaccine-related side effects” claimed by the All Japan Coordinating Association of HPV Vaccine Sufferers . In fact, several members of this organization demanded compensation from the government and vaccine manufacturers and instituted proceedings in Tokyo court.

The governmental action has been stagnant for fear of harmful rumors and misinformation by opposing organizations and media; however, we firmly support the resumption of HPV vaccination policy in Japan because it is one of the most effective primary prevention methods to combat the scourge of HPV-related cervical cancer and it would save future healthcare cost.

The result of the Nagoya study, showing no association between HPV vaccines and reported post-vaccination symptoms, was a ray of hope for the JMHLW to advocate for the resumption of the HPV vaccine policy.

We make two requests to the JMHLW: (1) providing correct information of HPV vaccines and prevent the public from being deceived by the flood of disinformation; (2) supporting scientific research for “HPV vaccine-related side effects.”


Regulation by Florida of Cancer Treatment Costs for Medicare Beneficiaries

August 20, 2017

Cancer comes with one of the costliest medical expenses. Doctors often diagnose individuals 65+ years old with new cancers, so Medicare and its beneficiaries must pay for the high treatment costs. Medicare requires high-cost sharing among its beneficiaries, which leads to financial distress for example bankruptcy. Florida has one of the largest populations of senior citizens (19.9%), two million of which are Medicare beneficiaries. The high out-of-pocket burden from cancer treatment costs leads Medicare beneficiaries towards decreased medication adherence or medical care postponement. Overall, beneficiaries have poorer cancer treatment outcomes compared to privately insured individuals.


Photo from: NCI Visuals Online

The Florida Department of Health, along with Gov. Rick Scott, should negotiate cancer treatment costs at quality cancer centers in Florida, such as Moffitt Cancer Center, and with pharmaceutical companies like Bristol-Myers Squibb to reduce out-of-pocket expenses for Medicare beneficiaries. The Florida Department of Health should place caps on cancer treatment costs to maintain them at reasonable prices. This political action would test whether cancer treatment cost negotiations at the state level are more effective than federal level negotiations. Biomedical companies can flexibly negotiate cancer treatment prices based on prevalences and morbidities in distinct states.

Florida’s House will not expand Medicaid health insurance coverage, and pharmaceutical companies refuse to negotiate drug prices for Medicare beneficiaries. Placing treatment cost negotiations and caps in the state’s health department’s hands may reduce Medicare beneficiaries’ substantial out-of-pocket cancer treatment expenses. Cancer incidence and morbidity has declined. However, cancer treatment costs and Medicare spending have only risen and are expected to continue growing.

Besides other factors that affect cancer treatment like transportation costs, psychosocial stressors, and reduced quality of life, add stress to a patient’s cancer care experience despite the financial resources provided by organizations like the American Cancer Society.

Opposition takes aim at Rhode Island’s successful HPV mandate

August 18, 2017

In 2015, Rhode Island led the fight against cancer by mandating that all students be vaccinated against Human Papilloma Virus (HPV) prior to the seventh grade. As a result, Rhode Island now has the highest rate of compliance in the country with the Center for Disease Control and Prevention (CDC) recommendation. However, several interest groups have recently mounted legislative opposition to the mandate in an effort to dismantle the policy.

HPV is recognized as the leading cause of cervical cancer, and also contributes to several head and neck cancers. The CDC recommends protecting children early in life by providing two doses of an HPV vaccine at least 6 months apart between ages 11 and 12. Since its introduction, the vaccine has been shown to be safe and highly effective in reducing the rates of HPV by 64% among women aged 14-19.

The 2015 HPV mandate in Rhode Island to provide free HPV vaccines was championed by the Department of Health, under the authority of state statute. The Rhode Island Medical Society, the American Medical Association, the American Academy of Pediatrics and the CDC all strongly supported this decision. Appropriate medical and religious exemptions to the HPV vaccine are granted, but in the interest of child welfare, the process to seek exemptions is rigorous to ensure that no child’s health is neglected.

In April 2017, two opposing bills were introduced into the Rhode Island General Assembly which proposes that guardians be allowed to opt their children out of the HPV vaccine and any other vaccines in which “non-casual contact diseases are transmitted by sexual contact”. A third bill proposes a philosophical exemption to the vaccine, while a fourth bill attempts to revoke the Health Department’s legislative ability to mandate the HPV vaccine entirely. These efforts were led by interest groups including The Gaspee Project and Rhode Islanders Against Mandated HPV.

Children are counting on Governor Gina Raimondo to stand up for their health by continuing to defend the legislative authority of the Department of Health and oppose these bills which attempt to overturn a critical public health policy.

Suspension of Recommendation for HPV vaccines in Japan since 2013

August 12, 2017


Roles of HPV vaccines

Human papillomavirus (HPV) causes more than 99 percent of cervical cancer. Persistent infection with certain types of HPV can lead to specific cancer such as cervix, anus, vagina, vulva, penis, mouth, or sinuses. In Japan, HPV infection leads to cervical cancer in about 10,000 women every year and 2,700 women die of cervical cancer every year. World Health Organization (WHO) recommends HPV vaccines in adolescents more than 9 years of age to prevent infection with types of HPV known to cause cervical cancer. It is clear that these vaccines significantly reduce the number of women who develop cervical pre-cancer. It is estimated that mortality rate of cervical cancer could be reduced by 70 to 80% if they are available diffusely on targeted population throughout the nation.

Government’s Decision to Suspend Recommendation of HPV Vaccines

There were two types of vaccines (Gardasil and Cervarix) available to prevent infection with types of HPV known to cause cervical cancer in Japan. In 2009, the Ministry of Health, Labour and Welfare (MHLW) started to approve HPV vaccines. The vaccination rate rapidly rose up to 70%. However, more than 30 cases of adverse effects were reported by mass media with emphasis in 2013, which led to viewpoint switching into not recommending these HPV vaccines by MHLW. The causal association between those reported adverse effects and vaccination had not been proved either epidemiologically or scientifically. The Representative of Japan Cervical Cancer Sufferers Organization announces and advocates complete withdrawal of HPV vaccines in Japan as well as victim’s compensation. WHO raised concern about case reports of pain syndromes in Japan because those reports did not show scientific causalities. These vaccines could be still available at government expense but the vaccination rate dramatically decreased to only 1 percent of targeted girls in 2016.

Increased Risk of HPV Infection Estimated Unless Encouraging Resumption

It was concerned that risk of HPV type 16/18 infection at the age of 20 would noticeably increased among girls born between 2000 and 2003 compared to other age groups (Fig A). This negative effect was estimated to be worse if resuming encouragement was extended until 2020. However, MHLW has not changed their policy yet in 2017 although the Japan Society of Obstetrics and Gynecology released statement of resumption of HPV vaccines encouragement.Graph1

How to resume HPV vaccines encouragement

Japan Medical Association issued guidelines for treating affected subjects with any symptoms after administering HPV vaccines in 2015. Those victims after HPV vaccination should be cared comprehensively even if the causality is not proved epidemiologically. Resumption of HPV vaccination is awaited to minimize the risk of cervical cancer in young girls and women in Japan because of recent evidence to support non-causality between HPV vaccination and presumed pain syndrome.

Lung Cancer Screening: what we know and what we can do in Maryland

August 15, 2016

Lung cancer is the second most common cancer and the leading cause of cancer death in both men and women in Maryland. The incidence and mortality of lung cancer keep in as high as national level based on the 2014 cancer report of Maryland. Smoking is the most common high risk in lung cancer responsible for 90% of lung cancer in male and 78% of lung cancer in female in Maryland. There is 14.9% of the adult population (aged 18+ years)—over 640,000 individuals— who are current cigarette smokers. Across all states, the prevalence of cigarette smoking among adults ranges from 9.3% to 26.5%. According to the largest National Lung Screening Trial (NLST) in America, LDCT (Low-dose CT) screening for lung cancer had a 15 to 20 percent lower risk of dying from lung cancer than participants who received standard chest X-rays.


Source: National Cancer Institute; National Lung Screening Trial (NLST)

USPSTF defined the people who are under the high risk of lung cancer as having the history of heavy smoking (smoking at least one pack a day for 30 years, either the current smokers or former smokers who quit within the past 15 years) between the ages of 55 to 80, and also recommended annual screening(level B) for lung cancer with LDCT in this selected population.

Screening histroy of USPSTF.jpg

Source: Lung Cancer Alliance (LCA)

Center for Cancer Prevention and Control in Maryland Department of Health and Mental Hygiene plans to implement LDCT lung cancer screening among the heavy smoking population over the state. We Marylanders will get continuous smoking cessation education and qualified screening process guideline, and the screening centers will be monitored in instruments, physicians and technicians following the quality and safety standard of ACR. In addition, the follow-up schedules and treatment strategies will be built up simultaneously.

The percentage of smokers is parallel with the education and income level nation widely. The LDCT screening among heavy smokers can be better intervened based on the policy and financial support from government, it’s really critical to make efforts for the better future of heavy smokers in Maryland.


A Patient Navigator’s Support for the New York State Breast Cancer Initiative’s 4-Hour Leave for Breast Cancer Screening

March 8, 2016

Breast cancer is the most common cancer among women in New York State,[1] and mammography has been shown to be effective at detecting tumors at earlier stages of development than clinical breast exam.[2]



All eligible New York State public employees are currently entitled to one annual 4-hour leave from work in order to undergo mammography for early detection of breast cancer. Governor Cuomo wants to expand this policy to cover the private sector, so that all New Yorkers will have the right to life-saving screening without putting their employment status in jeopardy.

As a patient navigator in a cancer center in East Harlem, I believe that this policy will be instrumental in saving lives. Many of the patients we see would be classified as “working poor” – despite often holding two jobs and working constantly, they still live in a state of poverty. Even one day’s lost wages could upset the extremely delicate balance they live and cast them into a state of catastrophe. As a result, many people will often choose the work they need to put food on the table over getting a screening that has little apparent immediate benefit. Unfortunately, this often results in the women who do develop breast cancer only finding out they have the disease at a later stage, making it much more difficult to treat.

Numerous private sector businesses, including M&T Bank and Amneal Pharmaceuticals, have indicated their support for the policy. This is not to say that everyone is on board – there are those organizations[3] who believe that even the state employees’ guaranteed leave for screening is s superfluous use of New York State citizens’ tax dollars. I, however, would disagree – increased screening coverage would not only save lives, but it would also save the state money in the long run. Treating late stage breast cancer is extremely expensive compared to early stage cancer. Since screening should ensure that most breast cancers are caught and treated early, this will reduce the burden on the economy,[4] and especially on the state’s budget by reducing costs for Medicaid and Medicare Services, which insure a great deal of the people who would benefit from the new policy.





[4] Mandelblatt, Jeanne, Harold Freeman, Deidre Winczewski, Kate Cagney, Sterling Williams, Reynold Trowers, Jian Tang, and Jon Kerner. “Implementation of a Breast and Cervical Cancer Screening Program in a Public Hospital Emergency Department.” Annals of Emergency Medicine 28, no. 5 (November 1996): 493–98. doi:10.1016/S0196-0644(96)70111-7.


Development of a National Breast Cancer Screening Policy in Jamaica

August 14, 2015

Too many Jamaican women are dying from breast cancer. Although the rate of breast cancer was expected to rise with the introduction of mammography, as it did in other countries, it has remained relatively stable. This discordance is due to Jamaica’s under-utilization of mammography services and lack of a national breast cancer screening policy. In the absence of a screening policy, many cancers go undetected at early stages when cancer is most treatable.

Currently, mammography is not available in the public sector, effectively excluding those who cannot afford it at a private clinic or pay for the lower cost mammography through the Jamaica Cancer Society (JCS). Furthermore, those women who can pay are unlikely to seek screening without a physician referral. A national screening policy would standardize age at screening, encourage mammogram referrals, and allocate funding for public mammography services. This policy may also encourage partnerships amongst the stakeholders to provide additional sources and mobilize all available resources.

Though many stakeholders support the development of a screening policy, governmental action has been stagnant due to funding limitations. The JCS has been active in raising breast cancer awareness and providing screening services to low-income individuals, but it is severely handicapped by lack of funding. Furthermore, with the threat of increasing breast cancer incidence due to wider adoption of western diets and lower exercise levels, more women are at risk for developing disease that may go undetected.

We are calling for the development of a national breast cancer screening policy in Jamaica and we urge the Ministry of Health to act now in making this a national priority. The cost of implementing such a policy should be viewed in the broader context of cost savings from the early detection of breast cancer and thus decreased utilization of expensive late stage cancer care.

Renewing the debate for an HPV school-entry vaccination mandate in Maryland

August 14, 2015

HPV vaccine being administered (JOE RAEDLE / GETTY IMAGES)

In 2007, a human papillomavirus (HPV) school-entry vaccination mandate was introduced and then withdrawn in the Maryland legislature.  The major concerns at the time was that the vaccine was too new, it was too costly, and that it was intended to prevent a sexually transmitted disease.

Since then, no substantial action has been taken and there has been no formal deliberation about re-introducing an HPV vaccine mandate in Maryland.  In the years since the mandate was introduced, cervical cancer has continued to rise in Maryland with nearly 200 new cases per year according to the most recent data from the Maryland Department of Health.

It is unanimous among the scientific community that nearly all cervical cancer cases are caused by HPV.  It is understandable that the public was apprehensive of the HPV vaccine in the past, but now we know that:

  • The vaccine has been administered for nearly 10 years and is proven to be safe
  • The vaccine is very effective and can prevent thousands of deaths from cervical cancer
  • There is no evidence that the HPV vaccine increases the chances of risky sexual behavior
  • Insurance plans are required to cover the cost of the vaccine under the ACA and it is also available at no cost through Medicaid’s Vaccines for Children Program

Virginia, the District of Columbia, and recently Rhode Island have enacted school-entry mandates for HPV vaccination.  DC passed the law in 2007 and as a result, they are now a national leader in HPV vaccination coverage.

It has been eight years since the HPV vaccine mandate was first debated in Maryland and it is time to renew that debate.  If Maryland is serious about preventing a deadly form of cancer, they should follow their neighbors’ lead and enact a school-entry HPV vaccination mandate.

Addressing a root cause of the most pervasive killers in Mongolia: an unhealthy diet

March 6, 2015

MyPlateIn land of blue sky, non-communicable diseases (NCDs) are on the rise. The most prominent sources of mortality and morbidity among Mongolians are cardiovascular disease, cancer, and adult-onset diabetes. According to the World Health Organization (WHO), NCDs “are estimated to account for 79% of total deaths” within the population. Hence, there is a desperate need to address one of the leading causes of the most pervasive killers in Mongolia – an unhealthy diet.

As populations all over the world are experiencing epidemic rates of overweight and obesity, online resources and tools can help to empower people to make healthier food choices for themselves, their families, and their children. is a website that has a plethora of tools and resources that could assist Mongolians in healthier meal planning. The photo above demonstrates the appropriate balance for a healthy meal using the five different food groups within a typical place setting. The site also has a Healthy Eating on a Budget section, which has tips for grocery shopping, preparing healthy meals, sample menus, and resources for professionals. For eating outside of the home, vegetarian restaurants are becoming more popular in Mongolia and a list of them can be found here. Finally, the SuperTracker helps people log food consumption and physical activity throughout the day to analyze what they can improve on to make their lifestyle choices healthier. A screenshot of this terrific resource can be found below.



A call for action: Additional behavior change advocacy is needed on the national level and within the capital of Ulaanbaatar (where a majority of the country’s population resides) to incite healthier eating practices in Mongolia. There is a need for more behavior change advocacy programs by the Ministry of Health (MoH) targeted at the workplace level as well as within the school systems. The MoH could utilize the Network of Health Related Organizations in Mongolia to ensure a cohesive, nationwide approach.  Another critical resource for spreading the message of healthy eating will be the Business Council of Mongolia.  Furthermore, the WHO is well positioned to assist the MoH with the implementation of additional efforts and could also help reinvigorate the Association of the National Mongolia Network for Workplace Health Promotion.  A coordinated effort on behalf of the Mongolian population to help assist with addressing unhealthy eating behaviors and incentivizing people to integrate more fruits and vegetables into their dietary routine is necessary in order to quell the rise of NCDs among the population.