An incorporated nonprofit organization (NPO) called Mie Medical Network (MMN) for Breast Cancer Screening was set up on June 15, 2005, in order to promote mammographic screening in Mie prefecture. MMN is composed of about 40 medical and screening institutions where authorized physicians and radiological technologists perform mammographic examinations using standard equipment. The main work of this organization is to compile reports of breast cancer screening using common filing systems among the MMN institutions. Each file is numbered and registered for each subject after consent has been obtained. Registration was started in 25 institutions separately in July, 2005, and the total number of registered subjects was more than 15,000 by December, 2006.
In the second year, we have established a new network system for sharing of registered files among the MMN institutions. The filing system at each institution is connected to a central server using a Virtual Private Network (VPN) and SSL encryption to maintain security. The central server is linked directly to the main office of MMN, but access from each institute is restricted. The system has been operating in 22 institutions since October, 2006. No major problems have occurred during the four months since then. This system has a number of advantages because of its ability to provide the specific file for any subject quickly at any institution.
We now intend to develop a further advanced system enabling digital mammographic images to be shared among the MMN institutions.

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Since the number of patients who die of breast cancer and the breast cancer mortality rate have recently been rising in Japan, control of the disease has become a major issue in the nation's anti-cancer policy. Also it is notable that breast cancer is the leading cause of death of among thirties and forties women, who perform an important social role. Therefore solving this problem is an urgent priority, and an important approach for achieving this is to increase the rate of participation in breast cancer screening.
We present details of our efforts to promote breast cancer screening in Hokkaido, by introduction of activities to encourage participation in screening such as the “Pink Ribbon Movement in Sapporo”, providing lectures for mothers attending classes at elementary schools and junior high schools, presentation of a snow figure depicting “Dog Breast Cancer” at Sapporo Snow Festival, and a get-together meeting about breast care under the name “With You Hokkaido”.

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In order to search for a good method of increasing the rate of participation in breast cancer screening, we reviewed our previous records of breast cancer screening carried out by inspection and palpation during the preceding 32-year period. Screening by mammography was started in 2004, and in the following year became employed in all districts of Kochi Prefecture.
When mammography screening began, we hoped that the participation rate would be at least 20%, which was the level when breast cancer screening was performed by inspection and palpation. In fact, the participation rate was as high as 27.6% in the period 2004-2005, and the breast cancer detection rate was 0.38%. We think that this high participation rate was achieved through complete transition from screening by inspection and palpation to that by mammography, offering guidance to district health nurses and local government administrative staff, education of the public about the importance of breast self-palpation, and other informative activities.

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Despite the fact that breast cancer is currently an important issue for women, the actual rate of attendance for mass-screening is still unsatisfactory. Therefore physicians need to seek ways of improving this situation. Because the breast is a gender-specific organ for women, it is important for physicians to treat them with careful consideration in any kind of clinical examination. However, whether this approach is sufficiently acceptable for the patients themselves is poorly understood. In the present study we attempted to clarify differences in attitude between patient and physician with regard to breast examination, using a questionnaire survey.
Replies were received from 318 female patients who visited our hospital for screening or treatment and 41 male physicians who were working in the department of breast surgery. The results revealed that patients had more hesitation (47%) about breast palpation than male physicians realized (24%), and this attitude was shared by both elderly and young patients. Even if patients were accustomed to breast examination, their degree of hesitation was not decreased. In fact, 42% of patients stated that breast exposure was unnecessary, and that no consideration was given to this during consultation. Both patients and physicians considered it desirable for a female technician to be present during mammography or ultrasonic study. On the other hand, only 22.1% of patients preferred a female nurse to be in attendance during clinical examination, despite the fact that a majority of physicians (73.0%) had assumed that this would be desirable for the majority of patients. To improve the attendance rate for breast cancer screening, physicians need to be conscious of differences in attitude from patients, and to give due consideration to their expectations.

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In March 2002, an initial attempt was made to decrease breast cancer mortality by the Japan Society of Breast Health, by means of encouraging participation in sports. This was followed by other similar events. The present study was designed to examine whether these kinds of sport-associated events are actually effective for increasing the screening participation rate. We hoped that the results would reveal practical ways of organizing such programs.
One of these activities, the All Japan Women's Tennis Players' League, has called for amateur players to participate in an annual meeting of the Pink Ribbon Ladies' Tennis Tournament since 2003. A survey of their knowledge about breast cancer and their will to participate in breast cancer screening has been carried out annually in 2003, 2004 and 2005, by asking the participants to respond to our questionnaires. As a result, the number of participants has increased : from 7,201 women in 2003, to 7,846 in 2004 and to 8,572 in 2005. The questionnaires included items about participation in breast cancer screening, performance of self-examination, and participation in mammography screening. The participation rate increased year by year. The participation rate at mammography screening was 21% in 2003, and this increased to 26% in 2005. Thus this kind of sports event appears to promote knowledge about breast cancer screening and to increase the participation rate. On the other hand, it was found that the rate of self-examination decreased from 53% to 22%. Therefore problems that need to be addressed in the future include not only increasing women's motivation to undergo screening, but also the selection of appropriate screening methods, their combination, and distribution of accurate information.

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[in Japanese]

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The rate of participation in breast cancer screening carried out by inspection and palpation associated with mammography in Kyoto Prefecture has been still low. In order to decrease the rate of breast cancer death, a high rate of screening participation must be achieved. We have organized the Kyoto Executive Committee of Pink Ribbon Activity aiming at the goal of achieving a 50% rate of participation in mammography screening by the end of 2010, and undertaken the following campaign activities : 1) performing free screening, 2) distribution and display of posters and leaflets about breast cancer screening, 3) cooperation with various media to spread educational and informative messages, 4) cooperation with a commercial institute in Kyoto City to distribute useful information, performing free breast cancer screening, and holding public lecture meetings, 5) distribution of leaflets at student festivals at universities and colleges in Kyoto, and 6) holding a “Pink Ribbon symposium” in a cosponsored company. All the above projects were performed successfully and many participants attended. We will continue these activities until the 50% participation rate is achieved.

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To evaluate the effectiveness of ultrasound (US) for breast cancer screening, we conducted a retrospective survey of 856 breast cancer patients who were preoperatively examined by mammography (MMG) and US. Their average age was 54.7 years, with a range of 24 to 92 years. MMG revealed positive findings in 771 patients (90.1%), and negative findings in the remaining 85 patients (9.9%). Likewise, US revealed positive findings in 835 patients (97.5%), and negative findings in the remaining 21 patients (2.5%). Accordingly, the proportion of positive finding in US was significantly higher than that in MMG (chi-square test, p<0.0001).
The incidence of negative findings with MMG was inversely related to age : 5.8% for patients in their 70s, 5.7% for those in their 60s, 8.3% for those in their 50s, 11.1% for those in their 40s, and 26.2% for those in their 30s or younger, because of the higher breast density in younger women (chi-square test, p<0.0001). The incidence of positive findings was 99.4% for tumors 2.1 to 3.0 cm in size, 96.3% for those measuring 1.6 to 2.0 cm, 94.3% for those measuring 1.1 to 1.5 cm, and 75.4% for those less than or equal to 1.0 cm (chi-square test, p<0.0001). Among the 85 patients with negative findings by MMG, 70 (82.4%) were positive and 15 (17.6%) were negative by US. As findings of calcification by US, high echo spots plus a tumor lesion were observed in 59 patients (71.1%), high echo spots only were noted in 22 patients (26.5%), and high echo spots were not seen in 2 patients (2.4%).
In conclusion, parallel use of MMG and US is recommended for breast cancer screening, especially for women in their 50s or younger, to reduce the incidence of misdiagnosis.

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We present the results of our approach for breast cancer screening using both mammography and echography. A total of 4,632 participants underwent screening with our own combined method using mammography and echography at our clinic during a two-year period in 2005 and 2006. Recall studies were carried out in 364 women (recall rate, 79%), and breast cancer was detected in 36 women (cancer detection rate, 0.78%). When the detected cancers were classified histopathologically, 22 were invasive ductal cancers and the remaining 14 were non-invasive cancers. Of the 22 women who proved to have invasive cancers, 14 had been unaware of their tumors, which were non-palpable.
If an invasive cancer is overlooked, the consequences may be more serious than if a non-invasive cancer is missed, because the former is can be potentially fatal. In order to decrease breast cancer mortality, invasive cancers must be detected when they are small. Since we were able to detect many small and non-palpable breast cancers that had not been noticed by the participants, our current breast cancer screening system appears to be more efficient for life-saving than other systems.

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Breast cancer screening was carried out at our institution in a “Human Dock” style health check, by inspection and palpation, together with ultrasonography. Breast cancers detected were reviewed and the utility of ultrasonography was evaluated. A total of 14,063 women underwent the screening and the results were good, with a recall rate of 3.4%, a cancer detection rate of 0.30%, and a positive predictive value of 8.7%. Of 42 breast cancers detected by ultrasonography, 30 (71%) were 1.5cm or less in diameter. For breast cancers detected by inspection and palpation, the detection rate for small cancers measuring 1.5cm or less was 33% (10 out of 30 women), and 100% (12 women) for tumors measuring more than 1.5cm. The cancer detection rate by mammography was 39% (9 out of 23 cancers) for tumors measuring 1.5cm or less, and 91% (10 out of 11 cases) for those larger than 1.5cm. Thus cancer detection by ultrasonography was optimal for tumors measuring 1.5cm or less. Histologically proven lymph node metastasis was positive in 8 (25%) of 32 patients, among whom some had primary cancers measuring 1.5cm or less.
Tumor volume doubling time (TVDT) was measurable in 10 women ; there was no change in size in one instance, and in the others TVDT was 4.8 to 32.5 months (mean 15.5 months), small cancers approximately 1cm in size having a long TVDT. In women whose cancer size could be determined twice or more, TVDT tended to be short when a cancer measured about 1cm or more. Cancers with a long TVDT showed low histological malignancy, and thus detection of breast cancers with a long TVDT at screening appears to be rewarding.

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Assuming that 40,000 women are affected by breast cancer annually in Japan, and approximately 10% of those cancers are noninvasive cancers, 36,000 women will have invasive cancers. If these invasive cancers are detected early when as small as 2cm or less and are properly treated, annual breast cancer mortality might be 3,600, since the ten-year survival rate is 90%. However, actual breast cancer death accounts for over 10,000 yearly. My plan for reducing breast cancer death by using ultrasonography screening is as follows :
1) Since almost all invasive breast cancers form a tumor, which is easily detected by ultrasonography, experienced sonographers can detect tumors as small as 0.5cm in the size. When a tumor is 1cm in diameter, it occupies four times the area of a 0.5cm tumor. Therefore ultrasonography capable to detect much less than 2cm, even in screening system, for example as small as 1cm in diameter.
2) Ultrasonography is expected to detect noninvasive cancers as well. Approximately 35% of noninvasive ductal cancers form a tumor such as an intracystic tumor or a solid tumor. Such tumors are easily detected by ultrasonography. Other tumors form a flat hypoechoic image, and these are the commonest type, accounting for about 40% of all noninvasive cancers. Sonographers must be trained to recognize this type for increasing the detection rate of noninvasive ductal cancer dramatically.
In summary, effort toward detection of tumors of 1cm in diameter, and of flat hypoechoic image, by ultrasonography is the key to decreasing the rate of breast cancer death.

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In Japan, breast cancer screening for women aged over 40 years using mammography (MMG) started in 2004. However, the breast composition of women in their 40s is heterogeneously dense or extremely dense, and tumors are difficult to recognize. Ultrasound (US) is not useful for detection of microcalcifications, but is useful for detection of tumors even in dense breast tissue. In this study, we examined the usefulness of US screening for young women. Since 1991 mass screening for breast cancer using US has been carried out in the Health Check Division of TOYOTA Memorial Hospital. From 1991 through 2005, 52, 296 women underwent US screening. Among them, 83 breast cancers were detected (detection rate 0.16%). Through improvements in both technology and examiner skill, the recall rate has decreased and the detection rate increased. Among 42 mammogram images of US screening-detected breast cancer since 2000, 18% showed category 1, and the proportion of category 1 was higher younger patients. Among 354 mammogram images of surgically treated breast cancer taken at the hospital since 2000, 14% showed category 1. The rate of category 1 was 38% in women in their 30s and 18% in women in their 40s. On the other hand, only 2% of cases (0% in the 30s group and 2% in the 40s group) were not detected by US.
These results indicate that US is more useful than MMG for breast cancer imaging in women in their 30s and 40s. Currently, the coverage rate of MMG screening is less than 10%. On the other hand, many local self-governing bodies employ US screening but the results is have been poor due to limited technology and screening skill. Use of high-performance machines and well trained screeners will help to increase the rate of breast cancer detection in women in their 30s and 40s.

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In order to reduce death due to breast cancer, which has recently been increasing in Japan, we must develop a high-quality screening system and ensure it is widely employed. Of course, promotion of mammographic screening is important, but since breast cancer frequently occurs in Japanese women their 5th and 6th decades, when breast tissue is dense, introduction of ultrasonography screening for women in this age brackets should also be urgently be considered.
We performed both mammography and ultrasonography on all breast cancer screening participants during a 5-year period from 2000 through 2004. In this period, 69,220 women participated and breast cancers were detected in 170 of them (cancer detection rate 0.25%, recall rate 9.5%, and proportion of early cancers 76.2%). Based on an analysis of breast cancer detection rates according to age, the comparative sensitivity of each modality was studied. In women in their 5th decade, the sensitivity of ultrasonography was 82.5% and that of mammography was also 82.5%. In women in their 6th decade, the corresponding sensitivities were 75.9% and 70.7%, respectively. These results imply that if we perform either ultrasonography or mammography alone, then the cancer detection rate would be lowered to between 29% and 17%. We think that both mammography and ultrasonography must be used for breast cancer screening in women of these age brackets.
We assume that breast cancers detected only by ultrasound were mostly small invasive cancers, whereas those detected only by mammography were mostly noninvasive ductal carcinomas revealed by microcalcifications. Thus, adoption of both modalities appears to be reasonable for raising the cancer detection rate in women in their 5th and 6th decades.

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We compared the cost-effectiveness ratio, defined as the cost required for a life-year saved, among the following three strategies of screening breast cancer screening : (1) annual ultrasonography (US alone) ; (2) annual mammography (MMG alone) ; and (3) annual ultrasonography combined with mammography (US & MMG) for women aged 40-49 years using a hypothetical cohort of 100,000. The sensitivity, specificity and early breast cancer detection rates were derived from data conducted from 2000 to 2004 in Tochigi Prefecture. The treatment costs were based on a survey conducted at Tohoku University Hospital in Japan. We used updated parameters that were needed in the analysis. The effectiveness of treatment in terms of the number of expected survival years was highest for US & MMG, followed by US alone and MMG alone. US alone was found to provide the highest cost-effectiveness, followed by MMG alone and US & MMG.

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Recent reviews have focused on two randomized clinical trials, one in Russia and the other in Shanghai, which are commonly cited as evidence that breast self-examination (BSE) is ineffective. However, in both trials there appears to have been a trend for breast cancers to be detected at an earlier stage in the BSE arms, and in addition there are some issues requiring critical review. In the Russian study, only 23.3% of breast cancers in the BSE arm were T1 or smaller, which is in contrast to the corresponding figure of 48.8% in the Shanghai study, making it unreasonable to summate these diverse data as evidence for the ineffectiveness of BSE. In the Shanghai study the BSE arm had significantly fewer deaths from all causes, suggesting a non-negligible difference between the backgrounds of the two arms and the possibility of unreliable determination of cause of death. Furthermore, the study was a trial of BSE instruction, not of BSE per se as the authors stated, and the results should be interpreted to suggest that a program of BSE instruction did not significantly reduce breast cancer mortality in a population that was already aware of breast symptoms. BSE provides an entry strategy towards breast familiarity and breast cancer awareness, and should remain indispensable in Japan where quality control of MMG, US or clinical breast examination remains marginal and access to high-quality examination is still limited.

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Biennial screening mammography for breast cancer detection has been carried out in Yokohama City for women aged 50 years and older since October 2001. In three and a half years 49,795 eligible women have been screened, 123 have been diagnosed as having cancer, and the cancer detection rate has been 0.25%. Since 73% 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.
With regard to quality control, although the rate of women requiring a detailed re-examination has been reduced significantly from 19.1% to 6.9%, the positive predictive value of less than 4% is still insufficient. It is therefore considered that there are some problems with detailed re-examinations.
Since screening mammography for breast cancer was extended to women aged 40-49 years in Yokohama City in July 2005, the rate of cancer not detected by mammography was examined in age cohorts of five years among 138 women who were clinically diagnosed as having breast cancer. Because 12.2% of women aged 44 years and younger had no findings on mammography, and cancer was detected in 87.5% of these women by ultrasonography (US), it is recommended that US should be added to mammography for breast cancer examination at this age.

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Recently, the attendance rate for breast screening has been increasing in Japan. However, little is known about how to conduct effective breast cancer screening, especially for patients with mental disability. The purpose of this study was to clarify the present status of breast cancer screening for severely disabled patients.
Breast screening was performed for 160 disabled patients by physical examination and ultrasound from 2002 to 2005. The patients included 158 women and two men, with an average age of 59 years old. Ten disabled patients (10/160 ; 6.3%) showed abnormal findings on physical examination and four (4/160 ; 2.5%) showed probably benign findings by ultrasound examination. Mammography (MMG) screening was performed for only 33 patients (33/160 ; 21%), one of whom needed further examination. One lesion was diagnosed as breast cancer (1/160 ; 0.63%).
Breast ultrasound is useful for severely disabled patients because it is painless, easy and rapid to perform. On the other hand, it is sometimes difficult for such patients to participate in MMG screening because of their inability to adapt to the examination. Therefore, some psychological method, for example operant conditioning, will be necessary for breast screening of patients with severe mental disability.

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