In order to promote a breast cancer screening program with the use of mammography in all areas of Osaka Prefecture, we have tried to clarify the current situation and future problems by sending annual questionnaires to health centers of individual municipalities.
By 2004, 25 municipalities (57% of all in Osaka Prefecture) had adopted a screening program involving both physical examination and mammography, and 10 others intend to introduce the program in 2005. Thus the new practice guidelines stipulated by the Ministry of Health, Labour and Welfare have gradually been accepted. At present, however, in many of those municipalities that have adopted the new guidelines, screening is carried out either by physical examination (inspection and palpation) alone or by a combination of physical examination and mammography. It appears that there is not always good communication and cooperation between health centers and medical associations, which are composed mainly of primary-care physicians. Doctors seem to have acquired insufficient knowledge about the need for quality control and the activity of the Central Committee for Quality Control of Mammographic Screening, although some improvements have become evident recently.
Thus far the participation rate has been low, suggesting that much more education about breast health is needed not only for women in general but also for primary-care physicians and health center officials.
We, the members of the Osaka Working Group for Breast Cancer Screening, have made several plans and actually performed several activities such as a mammography study course, an academic lecture meeting and an educational meeting for citizens. In the future, we must make more effort to act as coordinators between the public, physicians' associations and local officials in order to increase the quality of breast cancer screening.

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In 1998 the Research Group for Evaluating the Effectiveness of Cancer Screening Programs in Japan reported that the effectiveness of breast cancer screening by clinical breast examination has not yet been demonstrated epidemiologically, and recommended the introduction of mammography. Kyoto Prefectural Medical Association then took steps to establish mammography screening for breast cancer within the prefecture. We have made inquiries about breast cancer screening in all the municipalities of Kyoto prefecture, and from 1999 held annual study meetings for persons in charge of breast screening. Of 44 municipalities, the number of that introduced mammography for breast screening amounted to one in 2001, 18 in 2002, 26 in 2003, and 34 in 2003. By 2006, it is expected that all municipalities will have introduced mammography.

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The Ministry of Health, Labour and Welfare officially announced new practice guidelines for breast cancer screening (No.0427001) in April, 2004. The new guidelines include the following four revisions : 1) abolition of screening by simple inspection and palpation, 2) biennial screening of women aged 40 years or over, consisting of inspection and palpation, associated with mammography, 3) at the screening, simultaneous performance of both physical examination (inspection and palpation) and mammography, and 4) two-projection mammography for women in their fifth decade.
We considered that the government's new revisions were insufficient for increasing the curability of breast cancer, and proposed our own trial : 1) annual physical examination including inspection and palpation for women aged 30 years or over, 2) annual additional one-projection mammography for women aged 40 years or over. A primary screening (inspection and palpation) is performed by primary-care physicians who have been authorized by the Okayama Prefecture Medical Association. This trial was officially announced by the Okayama Prefectural Government on July 28, 2004. With this trial we have devised, we hope to improve quality control and promote screening participation, thus increasing the overall cure rate of breast cancer.
In a few years time, analysis will be done to compare our results with those from other prefectures that follow the Japanese Government's guidelines.

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For 31 years up to December 2003, we had been conducting breast cancer mass screening by physical examination including inspection and palpation, and then in 2004 we started a new trial using mammography. The new screening method was carried out in two different ways. In Method A, the screening consisted of two-projection mammography without physical examination and the participant's self-palpation. In Method B, an individual participant took a screening examination at an institution which fulfilled the requirements stipulated by the Ministry of Health, Labour and Welfare in terms of equipment, staff, and the types of examination available. Screening with Method B was available only in Kochi city. Method A screening was available in the other 52 districts of Kochi Prefecture, including cities, towns and villages. In Method A, 14, 478 women participated in the screening during a 9-month period from April through December, 2004, with a recall rate of 9.0% (1, 307 women), and a breast cancer detection rate of 0.31% (45 women). In Method B, 1, 216 women were screened during a 3-month period from October through December, 2004, with a recall rate of 11.4% (139 women) and a breast cancer detection rate of 0.41% (5 women). When we compared the cancer detection rate between the two groups, it appeared that slightly less than 10% of breast cancers were not detected by mammography in Method A.
In the future, we hope to reduce the incidence of false negative mammogram readings, and to determine whether Method A is a truly satisfactory screening approach.

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Purpose : Breast cancer screening with mammography has been adopted by the Sendai City Medical Association since 2001. Only doctors qualified at Level C or above in the Mammography Reading Examination are allowed to conduct breast cancer mass screening. During the first one-year period, the recall rate was unexpectedly high and the number of breast cancers detected by the double check system was also high. The quality of mass screening during the three-year period after introduction of the new trial was retrospectively examined.
Subjects and Methods : During the study period, a total 47, 826 women and 96 doctors participated in the screening (in the year 2003). Two attempts to improve screening quality were made before the start of the 3rd year screening : (1) an individual doctor was informed of the quality result at his or her screening examination during the first one-year period, and (2) all doctors were requested to attend a training course in which mammograms of all patients with detected breast cancers were shown for reading study, and the advantage of combined mammography with physical examination at breast cancer screening was confirmed.
Results : Primary-care physicians who performed the initial screening examination gave recall rates of 7.7%, 7.3%, and 5.6% in the 1st, 2nd, and 3rd years, respectively. Thus the recall rate in the 3rd year was significantly lower than in the two preceding years. The rate of cancer detection by a double-heck reading in each the three years was 29%, 29%, and 20%, respectively. This showed an increase in the rate of cancer detection at the primary examination carried out by primary-care physicians.
Comments : These results imply that there is an advantage in combining mammography with physical examination for breast cancer screening, and that a trial feedback system can successfully control the quality of mass screening.

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Biennial screening mammography for breast cancer examinations has been carried out in Yokohama City for women aged 50 years and older since October 2001. In two and a half years, 33, 642 eligible women have been screened, 89 have been diagnosed as having cancer, and the cancer detection rate has been 0.26%. Although quality control was not satisfactory in the first year-with a 19.1% rate of women requiring a detailed re-examination-the rate was reduced to 6.9% in the last year by efforts to change the system without decreasing of the cancer detection rate. It was the main change to the system that the second mammogram reading for double-checking had been made more important than before. Another significant change was a dramatic reduction in the requirement rate for re-mammography (2.53%→0.13%), indicating a large improvement in the technical aspects of mammography at the institutions concerned.
Since 76.3% of the diagnosed cancers were classified as stage 0 and I, this screening system is considered to have contributed to improving the prognosis of the examinees.

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We have been conducting breast cancer mass screening since 1977, and the rate of participation in a precise, diagnosis-confirming re-screening examination (abbreviated simply as “re-screening”) has always been 98% or above up to 2002. In the present study, the proportion of women who were advised to undergo breast cancer re-screening in 2002, the actual re-screening participation rate, and how the re-screening was managed depending on the screening result, were investigated. A few women who were required to undergo re-screening, but did not, were also interviewed.
We have adopted a breast cancer screening program involving both mammography and clinical breast examination performed simultaneously. In 2002, 47, 761 women participated in the primary screening, and 3, 892 (8.1%) were required to undergo re-screening. Of those women, 2, 563 underwent the re-screening immediately after the initial screening at the same institution, where all the necessary equipment and expertise were available.
A total of 1, 329 women were later referred to medical institutions authorized by the Breast Cancer Screening Center in order to undergo re-screening and/or medical treatment. These included 733 women who either could not be definitely diagnosed on the day of initial screening or needed to undergo medical treatment, 455 women whose mammograms showed abnormal findings at a double check carried out within 2 weeks after the routine screening, and 141 women who were advised to undergo re-screening at 1 to 6 months after the routine screening. We confirmed that 1, 322 women (99.5%) had actually undergone re-screening. Of 7 women who were known not to have responded to our request, 3 told us that they had been informed of the breast abnormality by their doctors and the other 2 were too busy to attend.
The findings of the present study indicate that all of our efforts at breast cancer screening work successfully to maintain an extremely high rate of participation in re-screening. These measures include re-screening immediately following an initial screening, adoption of simultaneous physical and mammographic examinations, explanation of the screening result to a participant by a doctor, guidance by a nurse, orientation before screening, inquiry about the re-screening result at a referred institute, and referral of a participant to a well coordinated institution.

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Since 1991 at this center, we have been conducting screening for breast cancer using mammography (MMG) combined with breast self-examination guidance as part of the breast cancer medical examination and human dry dock system run by Kurume city local authority. We examined the breast self-examination execution rate and assessed the change in awareness of individuals who had undergone medical examination through our program.
In the 13-year period, 37, 656 women underwent screening for breast cancer. About 90% of them did so at the medical examination office and the human dry dock. MMG was used in combination in 83.3%. We showed the women a video and conducted group counseling using a pamphlet and a breast model. As a result, the breast self-examination execution rate rose from 24.4% in 1991 to 66. 8% in 2002. In an attitude survey conducted in 2001 about breast cancer medical examination (mishocshin), 84.3% of women stated that they wished to receive MMG, and in addition, 80.4% wanted to receive MMG every year, thus indicating a high public awareness of MMG.
Public awareness about breast cancer screening has risen considerably through education about the use of combined MMG and repeated guidance about breast self-examination. We intend to continue to raise public awareness in this way to detect breast cancers at an early stage.

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Since the old days, the hardness of tumor tissue has been one of the important findings in clinical examination. Even in real-time ultrasonic examination, dynamic test has been used for the evaluation of hardness, and the degree of distortion when being applied an external force has been observed. Elastography which was completed in 2003 has the ability of imaging the strain produced from applying an extremely light pressure to the breast. Elastography has become a very simple diagnostic method in which a breast cancer is diagnosed if it is colored blue.
The hardness is scored on a scale of 1 to 5. Score 4 is defined as an almost blue color consistent with a hypoechoic lesion, and score 5 as definite blue color beyond that of a hypoechoic lesion. Both score 4 and 5 represent malignancy.
Elastography appears to offer equivalent diagnostic capability, with results that are as accurate as or more accurate than those of conventional ultrasound. Furthermore, elastography has a specificity higher than that of conventional ultrasound.

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For breast cancer screening, physical examinations have increasingly been combined with diagnostic imaging evaluation, and consequently the performance of ultrasound examination has increased. Since screening examinations are carried out on a number of participants within a limited time, this generally requires not only high quality screening but also efficientlly performed screening. So far, there has been no officially determined instrumentation and standardized technology for ultrasound imaging, and these aspects have been left to individual medical practitioners. Here we describe our own trial at breast cancer sonography screening.
In our institution, probe management and image control are properly adjusted depending on the purpose of an examination, i.e. whether it is a screening or a diagnostic work-up. For breast cancer screening, we need to perform an examination as quickly as possible and, at the same time, increase the sensitivity for detecting abnormal lesions by clear demonstration of boundary echo, even though the procedure may somewhat minimize the quality of demonstrating the internal matrix of masses.The following six settings are important for fulfilling these requirements : (1) selection of a suitable probe with the highest clinically appropriate frequency, (2) gain, (3) dynamic range, (4) sensitivity time control (STC), (5) focus, and (6) auto gain control (AGC). We analyzed and evaluated the quality of echograms obtained by changing the individual settings using a phantom, and a similar evaluation was performed on echograms taken from participants.
Today many types of ultrasonography instruments improves are produced by many manufactures without any standardization. In the future, it will be important to standardize both image interpretation and technical settings of the equipment at the time of examination.

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Original phantoms were made for the quality control of ultrasound devices for breast examinations. The reference point was set for sight evaluation of phantom imaging, and 53 ultrasound devices for breast examinations in 28 facilities were evaluated. Digital evaluation was also carried out and a correlation was obtained. A subsequent survey investigation of the correlation with clinical images, the evaluation method, and the reference point will be done in multi-facilities using the improved phantoms. This should help establish a quality control method for breast screening.

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A 55-year-old woman visited our hospital because of left breast induration. Mammography showed widely spread unilateral diffuse microcalcifications with pleomorphic, linear or fine structures (category 5), but no mass was detected on ultrasonography. Core needle biopsy demonstrated invasive ductal carcinoma. Pectoral muscle-preserving mastectomy (Bt + Ax) was performed. Histological examination revealed invasive ductal carcinoma with a predominant intraductal component (WHO classification) without axillary lymph node metastases. Both estrogen and progesterone receptors were negative.

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