[Feature: Cancer and Society] Daisuke Fujisawa: The Future of Cancer Care Looking Toward 2040

2025/07/04

Cancer care in Japan has been promoted in the fields of cancer prevention, cancer medical care, and coexistence with cancer based on the Basic Act on Cancer Control enacted in 2006 and the Cancer Control Promotion Plan, which is revised at least every six years.

It can be said that cancer policy to date has basically focused on equalization. Specifically, centered around Designated Cancer Hospitals, the goal has been to eliminate regional disparities and ensure that "the same medical care can be received anywhere in Japan," covering everything from surgery, chemotherapy, and radiotherapy to consultation support, palliative care, supportive care, rehabilitation, survivorship support (appearance care, support for balancing work and treatment, etc.), and genomic medicine *1.

The so-called "2040 problem"—the aging of the population and the decline in the working-age population, which are predicted to accelerate further in Japan—is having a major impact on the direction of medical care.

Discussions in the New Regional Medical Vision compiled in December 2024 *2  stated that, based on demographic trends and considering sustainable working styles for healthcare professionals, it is important to clarify the division of roles between medical institutions responsible for "curative medicine" and those responsible for "curative and supportive medicine" according to regional circumstances, and to coordinate, reorganize, and centralize medical institutions. It was stated that medical institutions serving as acute care hubs should provide centralized medical care for cases requiring significant medical resources, such as surgery and emergency medicine.

Aging also affects cancer care. While cancer incidence rates rise with age, the implementation rates of surgery, chemotherapy, and radiotherapy for cancer patients aged 85 and older decrease due to factors such as reduced treatment tolerance associated with comorbidities and changes in values regarding aggressive treatment.

Furthermore, regardless of patient age, the number of outpatient cancer patients is increasing, while the number of inpatient cancer patients is decreasing. The decrease in inpatient cancer patients is thought to be due to the shortening of the average length of hospital stay. A further decrease in the number of inpatient cancer patients is expected in the future due to changes in medical demand and an increase in minimally invasive treatments.

With the aim of equalizing cancer care, 461 hub hospitals and other facilities have been established and developed nationwide. However, as of April 2024, there were 56 "blank" cancer medical districts nationwide where no hub hospitals exist. In the future, the population in such blank cancer medical districts is expected to decrease even more significantly than the national average, and the number of inpatient cancer patients is expected to decrease further.

The 4th Basic Plan for the Promotion of Cancer Control, published in 2023, states regarding the medical delivery system: "(...) ...In accordance with regional circumstances, we will promote equalization and, toward the provision of sustainable cancer care, promote centralization based on the division of roles among hub hospitals and other facilities."

At the "Study Group on the Ideal State of the Cancer Care Delivery System" held in March 2025, it was stated that "Based on the 4th Basic Plan for the Promotion of Cancer Control, prefectures need to divide the roles of hub hospitals and other facilities according to regional circumstances toward the provision of sustainable cancer care looking toward 2040 *3." The following were cited as examples of medical care to be targeted for centralization:

1. From the perspective of medical supply and demand:

① Medical care where demand is high but the delivery system is not necessarily sufficient

② Medical care where an imbalance between demand and the delivery system may occur due to the scattering of medical resources

③ Medical care where the delivery system is sufficient, but demand is low, resulting in an inefficient delivery system

2. From the perspective of medical technology:

① New modalities or advanced medical care that cannot be said to be standardized

② Medical care requiring special equipment, etc.

The above were listed as candidate examples.

The centralization of cancer care is also beneficial from the perspective of ensuring the quality of care. For surgical therapy and radiotherapy, data has been reported for multiple cancer types showing that facilities with a higher volume of cases have better treatment outcomes.

Specific candidates for centralization include the diagnosis and treatment of low-frequency diseases such as pediatric and rare cancers, advanced surgeries for esophageal and pancreatic cancer, advanced drug therapies, medical care requiring special equipment such as particle beam and Nuclear Medicine therapy, and interventions requiring specialized skills with low frequency such as fertility preservation therapy (Figure 1).

It has been decided that which medical services will be centralized at which medical institutions in each region will be discussed at the Cancer Care Coordination Council of each prefecture.

In contrast to centralization, the "Study Group on the Ideal State of the Cancer Care Delivery System" cited screenings, cancer rehabilitation, supportive care, and palliative care as medical services for which equalization should be promoted. It stated that it is desirable for as many medical institutions as possible, including clinics, to be able to handle these services from the perspectives of cancer prevention, aging, and coexistence with cancer. In other words, for these types of medical care, the goal is not just "equalization among Designated Cancer Hospitals" but "equalization across a wide range of regional medical institutions."

Based on the discussions so far, I will describe what kind of responses are expected from each medical institution, including some of my personal views.

Highly specialized hospitals, such as Prefectural Designated Cancer Hospitals and main university hospitals, are expected to provide care for cases with high treatment difficulty and relatively low frequency (e.g., esophageal and pancreatic cancer) by receiving more referrals from surrounding medical institutions than before. To secure internal resources (staff labor, operating room slots, etc.) for providing such care, it may become necessary to refer standard treatments that can be performed at other hospitals (e.g., surgery for relatively early-stage colorectal or breast cancer) to other institutions. For treatments requiring dedicated equipment (e.g., heavy ion radiotherapy) or advanced chemotherapy (e.g., CAR-T therapy), it is necessary to accept patients widely from within the prefecture. The same applies to the treatment of pediatric and rare cancers. Furthermore, it is desirable to widely accept cases from the region for low-frequency medical technologies such as fertility preservation surgery.

Hospitals other than Prefectural Designated Cancer Hospitals and main university hospitals are expected to implement standard treatments within the cancer medical district (mainly secondary medical districts), receiving referrals from university hospitals or Prefectural Designated Cancer Hospitals depending on the situation. They are also expected to provide palliative care and cancer rehabilitation.

Medical institutions that are not so-called cancer specialty hospitals, such as clinics, are expected to provide palliative care, cancer rehabilitation, and screenings. For patients whose cancer treatment has stabilized, a care model has been proposed internationally (Survivorship Plan) in which the primary responsibility for care is shifted from the cancer specialty hospital to a local primary care physician. Survivorship plans include periodic examinations (detection of cancer recurrence, regular checkups), management of residual symptoms and late effects, and management of comorbidities and general health (including vaccinations). For such survivorship plans to take root in Japan, a change in awareness and reskilling on the part of healthcare providers, as well as understanding on the part of patients, will be necessary. Additionally, the need for home medical care is expected to increase further by 2040.

As the centralization of cancer care progresses, the hospitals where treatment for specific cancers can be received may become limited within a region, such as "Hospital A for Cancer X" and "Hospital B for Cancer Y." Some citizens may need to travel long distances to receive cancer treatment. Furthermore, after advanced treatment has stabilized, patients may be required to move their place of treatment from a Designated Cancer Hospital to a nearby hospital, and patient preferences such as "I want the doctor who performed my surgery to continue seeing me" may no longer be fulfilled.

Administrative agencies need to consider the placement and functions of medical institutions more carefully than ever before, and it is desirable for citizens to think about how to use medical institutions together with their communities.

The impact of centralization is expected to be significant in sparsely populated or depopulating areas, while the impact in densely populated areas such as urban centers or areas where the population will continue to increase is expected to be relatively small.

Above, I have described recent trends and future predictions regarding cancer care policy. Looking ahead to changes in demographics and the resulting changes in disease structure, it is necessary to consider the cancer care delivery system within frameworks that go beyond cancer care alone, such as the new regional vision.