[Feature: Cancer and Society] Roundtable Discussion: The Ideal State of Society to Support Cancer Care and Patients

Today, I would like to talk with everyone on the theme of "Cancer and Society." The image of cancer as being "side-by-side with death" has faded considerably compared to the past. While it is certainly a frightening disease, I believe the image has taken root in recent years that anyone can get it, and if treated early, one can fully recover and return to their original life, or live for a long time while coexisting with cancer.

Furthermore, in terms of policy, since the Cancer Control Act was enacted in 2006, the Basic Plan to Promote Cancer Control Programs has been decided by the Cabinet every five or six years, and priority areas have been successively indicated by the government. I believe that the formulation and implementation of measures by each prefecture based on these plans has also led to progress in equalization (the ability to receive high-quality medical care anywhere in the country).

On the other hand, from the perspective of patients or those on the front lines of providing medical care, there may still be things that are felt to be insufficient, and there may be challenges felt from the standpoint of administration and policy planning.

First, I would like to ask Mr. Muramoto to introduce himself and talk about the awareness of issues he currently holds regarding cancer.

I am 60 years old now, but in 2011, 14 years ago, I had my larynx, including my vocal cords, completely removed during surgery for a recurrence of cervical esophageal cancer. Since then, I have mastered the esophageal speech method and am able to speak.

At Sapporo Breweries, experience in the human resources department accounted for two-thirds of my career, and I was the Director of the Human Resources and Administrative Affairs Office when I had the recurrence surgery, but now I have transitioned to a so-called professional role.

Within the company, I am also involved in promoting support systems for balancing work and treatment, and in 2019, I launched and have been operating an internal community for cancer survivors called "Can Stars." I have also had opportunities to serve as a member of the Ministry of Health, Labour and Welfare's Cancer Control Promotion Council, and I serve as Vice Representative Director alongside Ms. Akiyama at the Japan Cancer Survivorship Network, an NPO founded by Dr. Miyako Takahashi, who retired from the National Cancer Center.

Regarding my awareness of issues, I believe there are still various challenges in the process from cancer discovery to social reintegration. From the perspective of "Cancer and Society," which is the theme this time, when I think about "what the nature of society is," while it can be seen as being composed of various mechanisms and systems, I think society can also be seen as being made up of connections between people.

In that regard, when we place patients and families at the center, one perspective is the relationship between patients/families and medical professionals. A second angle is the relationship between patients/families and the people around them, including the workplace.

When considering communication between medical professionals and cancer patients/families, I wonder if patients and families are able to say what they want to say, given the assumption that doctors, especially their primary physicians, are busy and important people. I suspect there are times when they hold back, thinking that such things are not something to be said to a primary physician in the first place. Therefore, I believe one challenge is how the medical side can proactively reach out to and support patients and families.

Furthermore, for the government, administration, and medical professionals, cancer treatment and coexistence with cancer are important goals, but for patients and families, these are actually just means to an end. For patients and families, the grand purpose and goal is to live together with the people they love and the things they value. Since treatment and coexistence with cancer are merely means for that, the question is how to align these perspectives. I believe that is important between the patient side and medical professionals.

Regarding involvement with people around them, including the workplace, there are still differences in the perception of cancer depending on the person. Assumptions that one might not be able to work if they get cancer still remain, and in an atmosphere where people feel they shouldn't push the person too hard, it can become uncomfortable, so those things need to be aligned. I hope that the internal community for cancer survivors we have at the company can facilitate such alignment by sharing our own experiences and thoughts.

I graduated from the Keio University School of Medicine in 1997, and after completing my residency, I joined the Ministry of Health, Labour and Welfare, where I have been in charge of medical administration for about 25 years.

Regarding cancer, I served as the Director of the Cancer and Disease Control Division from 2020 to 2021. At that time, it was in the midst of COVID-19, and while there were difficulties in also handling duties for the COVID-19 Response Headquarters, it was a very rewarding job as it was exactly the time we were evaluating the 3rd Basic Plan to Promote Cancer Control Programs. Since last August, I have been involved in the education of students at the Hokkaido University School of Medicine.

As Ms. Akiyama mentioned at the beginning, in terms of policy, I believe two major achievements have been obtained within the framework of the Basic Plan to Promote Cancer Control Programs. One is that the clear results are that base hospitals have been established, treatment outcomes have improved, and cancer mortality rates and five-year survival rates have increased. The other is that the response to cancer, which had focused on "treating the disease," has evolved to include the perspective of "supporting life." It can be said that policy has also evolved through various stakeholders joining forces.

On the other hand, there are several challenges. If I were to name three in my own way, the first is whether patients and their families are properly and appropriately accessing correct information surrounding cancer.

The second is the cancer medical delivery system. As is common elsewhere, the medical field is facing a serious labor shortage, and not only equalization but also consolidation is necessary. I believe there is a need to be a bit more selective, such as consolidating truly advanced medical care.

The third is improving the screening rate for cancer and quality control. I believe there is still room for improvement here.

I graduated from the Juku Faculty of Law in 2006 and joined Nippon TV as a new graduate. Then, in May 2008, while I was busy as a fledgling reporter, Stage III breast cancer was discovered when I was 24 years old.

At that time, my world went dark. Until then, my health had been my only merit, and my first major illness was breast cancer. No one in my family, including my grandparents' generation, had ever had cancer, and the whole family was deeply shaken. Among the several hospitals I visited, there was one doctor who told my family—though he didn't tell me—that my five-year survival rate was 2.9%.

Thinking that they had to spend the remaining time with me meaningfully, my mother and sister quit their jobs, and my father, who was on a solo assignment in Bangkok, returned to Japan, and everyone supported me.

I also thought I was going to die, so much so that I feel the mental confusion was more difficult than the cancer treatment itself during my battle with the disease.

That said, the treatment was also hard. I took an eight-month leave of absence and returned after undergoing what could be called a full course of standard treatment: surgery, chemotherapy, radiation, hormone therapy, and molecular targeted drugs. As Mr. Komoto just mentioned, even for me, who was a reporter at the time and in a position to research and disseminate correct information, the fact that there was an overflow of confusing information felt like a major challenge. There were days when I couldn't sleep because I only reached information that made me anxious, and there were times when I didn't know what to believe after being recommended religions or new treatment methods.

There really is an overflow of all kinds of information.

Therefore, after my illness settled down, the first thing I launched was "STAND UP!!", an organization for young cancer patients in the AYA (Adolescent and Young Adult) generation. We started by publishing a free paper for people who got cancer at a young age, aiming to create something specialized in providing information that would be a source of hope for living with cancer. At that time, I could hardly find any personal accounts on SNS or blogs that used real names and faces. Even on TV, it was an era where people with cancer were shown with their faces blurred and voices changed, and even in hospital booklets, personal accounts were listed as "Ms. A (30s)," which didn't feel real.

So, I started it thinking that if I could just convey the information that there are people who get cancer young but are still living their lives with all their might afterward, that would be enough. Then, comrades started gathering one after another, and we have published one issue every year since 2008, with the 16th issue out now. I think it has become the largest organization in Japan among AYA generation groups.

Next, because I had many worries when I got cancer, such as choosing treatments and how to live with cancer, I wanted a place where I could always meet comrades I could consult with if something happened. I bought a house myself and was preparing to create such a place as a volunteer.

Then, by chance, at an international conference where I was invited as the founder of STAND UP!!, I was told, "What you want to do is close to Maggie's, so you should see the Maggie's Centres in the UK." When I looked it up, very stylish architecture came up, and it said it was all charity-based and completely free to use, and I thought it would be wonderful if such a thing existed. Moreover, it had workshop-like gatherings like I wanted to do, and one could drop in anytime to consult with cancer experts. I felt this was one step ahead of what I had envisioned.

That led to the launch of the current "Maggie's Tokyo," didn't it?

That's right. So, immediately after returning, I visited Ms. Masako Akiyama, a nurse who had been sharing that she wanted to create a Maggie's someday, and on the day I met her, I said, "Shall we make it together?" Including the operation, we are now in our eighth year. Since I am not a medical professional myself, I attend if there is someone who says they "want to meet me," but every time I listen to their stories, it's a place where challenges seem to gather again.

Then, I started wanting to solve those challenges.

I was saved thanks to the molecular targeted drug Herceptin, which was approved for insurance just after I got breast cancer in May 2008. I went to seven hospitals, and at three out of the seven, they said, "We can't treat you here."

Thinking about it that way, drug lag is a world of zero or 100 when viewed by a single patient, and I thought that survival rates would change significantly just by having drugs that have been developed and approved for insurance in Japan become widely available. How quickly we can spread treatment nationwide by everyone joining hands will lead to saving more lives.

So, I thought it would be great if people from industry, government, academia, the private sector, and medicine could gather beyond their positions to solve cancer-related challenges, and the next thing I launched was CancerX, an organization like an academic society. We started a large summit once a year in 2019, where diverse people such as medical professionals, those affected, and companies discuss themes like "Cancer x Society" and "Cancer x Working" to find ways to solve them.

I am also participating as Chief Communication Officer in a venture company called Smart Opinion, which develops and promotes diagnostic support equipment that enables double reading of breast ultrasound exams by AI and human eyes. This is something we have been co-developing with Professor Satoshi Hayashida of the Breast Surgery department at Keio, and it is scheduled to launch soon.

When you get cancer, treatment is of course important, but how you live your life afterward while interacting with the people around you is equally important. I want to continue activities that support how to live with cancer from various aspects.

Now, Dr. Takeuchi, please.

I originally graduated from the Keio Faculty of Science and Technology, not the School of Medicine, and afterward, I was researching cancer in the Master's Program in Medical Sciences at the Graduate School of Medicine. It was the era of the Human Genome Project and such, and I wanted to unravel cancer through gene research.

However, after various twists and turns, I decided I wanted to actually see patients and be able to cure cancer, so I entered Shimane Medical University as a transfer student.

After graduating from there, I did my residency at Keio, and through encounters with various patients, I was made to realize that cancer is not just a matter of being cured. I had several experiences where I thought patients could smile this much by easing their suffering through palliative care, so I decided I wanted to specialize in palliative care and transferred to the Department of Neuropsychiatry to first specialize in mental care.

At that time, there were almost no places where one could specialize in palliative care, and the term "palliative care" was just beginning to emerge. It was still an era where "palliative care = end-of-life care," but the Cancer Professional Training Plan started under the leadership of the Ministry of Education, Culture, Sports, Science and Technology, and as a member of its first class, I was blessed with the opportunity to specialize in palliative care.

From that era when palliative care was not yet generally familiar, I believe it has finally spread, pushed by the power of the Ministry of Health, Labour and Welfare, academic societies, and patients. Keio has been providing palliative care for a long time, but the Palliative Care Center as an organization is still new, having just reached its 12th year. I work while feeling challenges every day.

What I feel as a challenge is the shortage of palliative care specialists. Even so, Keio has quite a few palliative care physicians, with four doctors, and all four hold specialist certifications as palliative care instructors. However, looking nationwide, there is still a shortage of palliative care physicians, and there are cases where people want to receive palliative care but there is no department to consult. There are still disparities between facilities and regions; while I think Tokyo has many, there are still disparities depending on the hospital, and specialists are insufficient. Therefore, I believe it is also our role at the university to provide education so that medical professionals who are not specialists can provide basic palliative care, and I just gave a lecture to students today.

Also, a challenge I am working on is the issue of follow-up for patients after treatment. As Ms. Suzuki mentioned, cancer is not over just because treatment is finished; I believe support for patients in the process of returning to society amidst the anxiety that the disease might recur is also important, but the current situation is that there are still few hospitals and medical institutions that can provide that.

In my outpatient clinic, I have a system where patients can visit if they wish even after treatment is over, and I tell them it's okay even if they only come once a year.

Another interest is the care of families, and I run a family outpatient clinic. I was moved when I heard that Ms. Suzuki's mother and sister quit their jobs when her illness was discovered, and I believe care for the families supporting the patients is also important. However, the reality is that there are still few places where that can be done.

At Keio University Hospital, we launched a team to support the children of cancer patients in 2014, providing support for telling children about a parent's illness and support for the children themselves. For example, we hold events where children can explore the inside of the hospital. Just seeing and knowing where their father or mother is being treated can lead to peace of mind for children in some cases.

Furthermore, support for AYA generation cancer patients has recently received a lot of general attention, but there are still few medical institutions that can provide it. In particular, there are few places where adolescents can gather. I believe a place to vent various feelings is necessary, whether for the patient or the patient's child. Adolescence is an age that already holds difficult problems, and I believe many are enduring things in a situation where they or their family are ill, so I think support for the adolescent generation is also very important.

I think palliative care can be difficult for the general public to imagine. When you say there is a shortage of palliative care specialists, does that mean there is a shortage of specialists who relieve physical pain, or that there are no specialists to ease suffering in a broader sense?

I think the current situation is that there is a shortage of medical professionals specializing in palliative care, including both physical and mental care. Naturally, cancer base hospitals have palliative care outpatient clinics, but outside of base hospitals, there are few hospitals with doctors dedicated exclusively to palliative care.

There are still only about 500 specialists in the Japanese Society for Palliative Medicine. This doesn't mean that one isn't a palliative care physician if they aren't a specialist, but the number of medical professionals doing palliative care itself is small.

In terms of direction, would it be better if all doctors involved in cancer treatment became able to provide a certain level of palliative care?

Yes. Unless all medical professionals can provide basic palliative care, early palliative care cannot be realized in the current situation where specialists are insufficient. In that sense, education for medical professionals is important.

Listening to everyone's stories, what I felt was the greatness of the power of patient survivors like Mr. Muramoto and Ms. Suzuki. In the process of walking through life after getting cancer, they have learned many things, gained knowledge, comrades, and networks, and are engaged in activities to change the environment and society surrounding cancer patients for the better. I felt that they are playing a major role by using their difficult experiences as nourishment.

In the current Basic Plan to Promote Cancer Control Programs, the promotion of patient and citizen participation is also a pillar. Amidst the current medical care where various things are in short supply, including the shortage of medical professionals that was pointed out, I feel that patient survivors have great potential.

I am not that familiar with patient and citizen participation, but it leads to the acquisition of new perspectives for research, and patient survivors can also gain new insights and make contributions, so I believe it should be promoted more and more. Also, people like me and Ms. Suzuki have the passion and are blessed with opportunities to take various actions, so I think such people should take action more and more.

On the other hand, what must not be forgotten is that not everyone can do that. There are those in harsh environments, or those who simply cannot engage in such activities due to their physical or mental state. Most importantly, we must not forget that at the beginning of getting cancer, everyone—including us—was just a single, bewildered human being filled with anxiety and confusion.

The term "patient power" is often used. Of course, studying is a wonderful thing, but when you say patient power, it becomes a matter of whether one has it or not, which feels like a top-down perspective. I think we must never forget that everyone is just a single human being harboring anxiety and confusion at first.

It means there are people in various phases, doesn't it? We must not forget that the differences among people who are often lumped together as "patients" are large.

That's right. Currently, "leaving no one behind" is held up in the basic plan, but everyone is just one person harboring anxiety and confusion at first. That's why I think standing by them is, after all, the basis.

Listening to Mr. Muramoto, I find myself empathizing with everything he said. When I got cancer, I was receiving treatment while praying, "If I can live, I will do what I can for people who are facing difficulties and suffering like myself, so please let me live." With those thoughts, I had always wanted to create the places and measures that I myself had wanted.

After getting cancer, I made it my goal to live healthily for 10 years and go on a trip around the world, so my husband and I went on a world tour for our honeymoon. However, around the time I finished the world tour, I started thinking that there might be people who are hurt by seeing my posts.

After getting cancer, I returned to work, and the first documentary I made was one where I went around asking seniors who had cancer, "How were you able to become positive?" In that, there was my former self who was wondering, "How will I ever be able to laugh again?" Just seeing people on TV laughing made me feel they were in a different world, and I was depressed, thinking I would never be able to laugh again. When I started thinking about people in the same situation as my former self, I became afraid to post on SNS, and there was a period when I declined interviews and roundtables like this.

Among my comrades, there are those in difficult situations now, and having lost many comrades, there are times when I worry about whether it's okay for me to be alive, and there are parts of me that are still worrying even now as I do these communications.

However, it is a fact that I can see challenges that I probably wouldn't have seen if I hadn't gotten cancer, and I think the way those challenges are seen differs depending on one's position. While everyone is different—the type and situation of the cancer they contracted, whether they have children, whether they are working, whether the company is understanding—I believe we can collect the challenges each person felt and utilize them for people who will get cancer later.

I think of it as "turning the cancer experience into value," and there was a part of me that felt I couldn't keep going unless I did that. I got cancer in the prime of my youth, was terrified of death for a long time, thought I couldn't even fall in love, and when I was young, there were times when I thought I wouldn't have suffered this much if I hadn't gotten cancer. I felt I had to make up for that.

I also wanted to have children someday, but since six out of the seven doctors I visited when starting treatment said it would be "difficult," I also had a strong feeling that I had to leave something in society instead of leaving children.

However, when I came back from the world tour and had it checked, I was told that my fertility was at a level appropriate for my age. Although I thought pregnancy was highly likely to be difficult partly due to the effects of chemotherapy, they said, "There is a sufficient possibility you can do it." And I was blessed with a daughter through natural pregnancy.

The worries and painful parts of the AYA generation include stories of romance, marriage, and fertility, and I'm sure there are also stories about employment.

When you get cancer young, everyone around you is sparkling, falling in love, and working, but you are in a situation where you are undergoing treatment, your hair falls out, you don't know when you can return to work, and you might die. Romance, marriage, academics, work, family—life is already hard to live during the youth of one's life stages, so having cancer layered on top of that was quite hard for me, and I think it's hard to watch as well.

Dr. Takeuchi, how do you feel seeing such people up close?

Illness is scary no matter how old you are, and I don't think it's a matter of being able to accept it just because one gets sick at an old age, but it is a major thing for someone at an age where they are young, everyone around them is healthy, and they have never even imagined getting cancer to become ill.

We are in an era where cancer can be cured, but I feel there are many people who, even after being cured and returning to the same workplace or school, can never laugh with everyone in the same way as before.

Such people visit my outpatient clinic as well, but once treatment is over, they move further and further away from the hospital. Moving away is a good thing, but some people still need medical help. However, because treatment is over, there is no place to consult. The place for consultation doesn't have to be a medical setting, but I hope we can create such places within medicine as well.

Hospitals provide various consultation supports. For the working generation, balancing work and treatment is also important, but is such support progressing in the medical field as well?

I don't do social worker-like work myself, but cancer and employment is one challenge. When I actually talk to patients, even if the company rules have a system for returning, they won't understand unless the patient communicates their own physical condition themselves. But it is also painful in itself to say every single time, "I can't do this job," or "I want to go home early today." Some people come for mental care with consultations about how they should continue working.

Do you ever contact the company's industrial physician or the like?

We do sometimes coordinate with industrial physicians, but there is our own manpower to consider, and on the company side, I suspect there aren't that many companies where an industrial physician is stationed full-time.

In that regard, how is it at Sapporo Breweries?

As a large company, Sapporo Breweries of course appoints industrial physicians, but they are not full-time. On the other hand, we have public health nurses placed in each area to create a system where employees can consult at any time. Also, we put the perspective of employees who have experienced cancer at the forefront, and the internal community for cancer survivors participates in disseminating information and creating guidebooks for balancing work and treatment.

The topic of consultation support came up, and I believe that consultation support centers within medical institutions play an extremely large role for patients. In fact, looking at patient experience surveys conducted by the National Cancer Center, those who used a consultation support center reported a very high rate of finding it helpful.

However, it is unfortunate that even in the two most recent patient experience surveys, the recognition and utilization rates of consultation support centers cannot be called very high. Currently, among the designation requirements for cancer hospitals, there is a requirement to establish a system where everyone must visit a consultation support center at least once, but since it is a desirable requirement rather than a mandatory one, things might change if it becomes a mandatory requirement.

On the other hand, I hear that everyone at the consultation support centers is truly busy and in a very difficult situation, so how can we balance that and create a sustainable system? I think this is one aspect that is becoming important for patients and families in terms of a sustainable medical system, not only in terms of money but also in terms of people.

I heard from a social worker that many people visited the consultation support center at Keio Hospital today as well.

Since our hospital is not a cancer-specialized hospital, our social workers do not only handle consultations for cancer patients, and the reality is that they are truly busy.

While I think it is a great thing that the phrase "everyone should visit a consultation support center at least once" was included in the requirements for cancer hospitals, knowing the internal situation, I wonder who would handle all those consultations. Just as there is a shortage of palliative care physicians, the number of counselors is still insufficient.

I think the keywords there will be collaboration and connection. For cancer consultation support centers, there are places like Keio where many people come, while there are others where no one comes and people go to Maggie's for advice on what to do.

Since there are places where people concentrate and places that are underutilized, it would be good if we could create a mesh-like system so that people in need can reach the support they require. I believe that if people who want to provide support, both inside and outside the hospital, join forces, things can be greatly improved.

Among patients, there are likely those who want to consult and those who are in a phase where they want to be left alone for now, so I think it is very difficult to consider it uniformly.

It also comes back to the issue of information access.

When I got cancer without knowing anything, there were many times I thought, "If only I had known then."

In the community, there are resources available to patients, such as cancer patient salons and NPOs. In recent years, the term "social prescribing" has emerged, and it would be good if hospitals could identify such resources and connect patients by saying, "There are places like this too."

I also run a place called "Karada-kan" in a corner of the Tsuruoka Public Library. It originally started as a place to help people find information about cancer, but there are people with worries who come there to talk with the staff, organize their feelings, and leave feeling satisfied even without being provided with any specific information. I think it would be good to make effective use of resources in the community other than medical institutions.

Earlier, Ms. Suzuki mentioned that she was saved by molecular targeted drugs, and more recently, drugs like immune checkpoint inhibitors have emerged, which are said to be very effective despite having few side effects.

However, because they are extremely expensive, there is a debate that it is quite troubling when considering Japan's insurance finances under universal health coverage. Mr. Furumoto, what are your thoughts on this?

It is said that the major factor in rising medical costs is the evolution and spread of advanced medical care rather than the aging population. In the past, there was a tone that because insurance finances were tight, such high-cost medical care should utilize private insurance and be removed from public insurance. However, such voices seem to have quieted down recently. I personally believe that advanced medical care is exactly what should be covered by public insurance.

However, there are points to be cautious about. Recently, advanced medical treatments such as robot-assisted surgery and particle beam therapy have been spreading at an accelerated pace, but these treatment technologies are not superior for all diseases. It is important to determine the evaluation for medical fees according to the benefits the patient receives.

In other words, if using a robot results in better treatment outcomes and greater benefits for the patient, it should be evaluated with a high medical fee. However, if that is not the case, even if a robot is used, the medical fee should be the same as a normal surgery. To maintain the medical insurance system in the future, I believe such tuning of policies based on scientific evidence is important.

Also, a system for cost-effectiveness evaluation of pharmaceuticals has been introduced, and I believe this is also a non-negotiable system.

In other countries, there seems to be a way of thinking that draws a line on the treatments one can receive based on age, but would that not be well-received in Japan?

I don't think it would be well-received. However, for future healthcare providers, the perspective of looking at the patient's "life" rather than just the "disease" will become even more important. About 60% of people aged 85 and over require long-term care, and the number of elderly people with dementia or living alone will increase.

It is important to temporarily take off the stiff armor of being a "healthcare provider" and decide on treatment plans while thinking about the "life" that continues even after treatment.

I don't think a uniform age-based approach would suit Japan, and I think it would be difficult, but I believe that we must think about the choice and withholding of treatment for people of any age in the future, not just as a matter of medical costs.

The concept of ACP (Advance Care Planning) is becoming widespread. We doctors are taught in medical education to focus on curing, but I think it is important not just to think about curing, but to value each individual's values.

So it's about deciding while listening more to the patient's voice regarding their own values and what they prioritize in their life.

For example, even if a person says they do not want dialysis anymore, withholding medical care when we know it could prolong their life is ethically very painful for us. I don't know if establishing laws is the answer, but I hope Japan as a whole becomes a society where such things can be considered on a daily basis.

Listening to the talk about palliative care earlier, I wished I had met a doctor like Dr. Takeuchi back then. At that time, I couldn't sleep because I thought if I went to sleep today, I might not wake up in this world tomorrow, and I was terrified. There is an image that palliative care exists to take away pain in the final stages of life, and I think there is still a lack of awareness that it is something that can be received from the stage when cancer is discovered early.

When thinking about palliative care, two things come to mind. One is that, of course, palliative care in the terminal stage is important, but as you mentioned, because palliative care is too closely linked to the terminal stage, there is a problem that the idea of palliative care starting from diagnosis, which is what is supposed to be said, does not easily take root.

I feel like conversations are being exchanged where if someone says, "I want to receive palliative care," the response is, "No, no, it's not that time yet."

At the time of my treatment, I also had the image that palliative care equals the terminal stage.

When diagnosed, some people have physical pain and others don't, but everyone experiences at least some mental shock. So, one thing is that I want the importance of palliative care from the time of diagnosis to be clearly communicated.

On the other hand, when people hear "terminal stage," they tend to think nothing more can be done, but if the terminal stage is defined as roughly six months before death, one can still work normally during that period. A senior colleague at my company came to work energetically until about a month before he passed away. Therefore, along with palliative care, I would like many people to know that even in the terminal stage, one can live in their own way.

I want people to know more that it's not that nothing can be done, but that medical care can be provided to alleviate symptoms.

The government has intended to promote palliative care from the time of diagnosis for quite a long time, but does the image that palliative care means the terminal stage still remain strong on the ground?

The stigma among medical professionals is quite different from when I first entered palliative care. But it took time to get here. There were doctors who said, "You're still undergoing treatment, so you don't need to see palliative care."

Also, when a primary care physician refers a patient saying, "It's very painful, so let's have a specialist see you," and I go to meet them in the ward, the patient sometimes says, "It's not time for palliative care yet." I explain carefully and say, "I didn't come because it's the end," but palliative care from an early stage still has difficult aspects.

Furthermore, palliative care from an early stage is not only done by those who specialize in palliative care. I think there are things that can be resolved through interaction with the primary care physician, so I hope there is no misunderstanding there, or rather, that the term doesn't take on a life of its own.

Time has passed so quickly. If there is anything left to say, please go ahead.

There is the word survivorship, and I think it's about the way of living and being, where each individual lives in their own way with cancer or after experiencing cancer. What supports that is, after all, staying close to each individual.

In the context of medical care, I think that staying close to each individual is done on the hardware side by, for example, genomic medicine, and on the software side by consultation support and palliative care. To put it bluntly, the former is evidence-based, and I think narrative-based is also important for the latter.

When you think about it, this narrative-based approach is not just a story about medical care, but an absolutely necessary attitude in interacting with people in the society we live in.

In our busy daily lives, we have become problem-solving oriented, collecting information and solving problems as quickly as possible when they arise. So I think it's important to set aside that problem-solving orientation and see how much time we can take, even for a short while, to accept others and empathize.

Whether not only medical professionals but each of us can take this attitude. Since we are in an era where there are people with various circumstances, not just cancer, I think such things will become important for the future state of society.

That's true. Due to the nature of my work, I tend to become problem-solving oriented, but listening to your talk made me want to carefully re-examine my relationships with people.

I want to make sure not to forget the professional perspective as a medical practitioner and the attitude of facing patients as a human being. Since medical sciences also have a scientific aspect, it is important to act according to evidence. However, I want to be a medical professional and a hospital that can provide medical care aligned with the values of what that person needs.

There is also the term shared decision-making, but is that something derived from dialogue?

Yes. Since the protagonist is the patient, how medical professionals share that together is a concept that is now being taught in medical education. I hope it becomes the norm.

Now, Mr. Furumoto, what do you think?

Speaking a bit from a policy standpoint, at the risk of being misunderstood, I believe that cancer control is a very privileged system. Even looking at the national Basic Plan for Promotion of Cancer Control Programs, it is evolving very healthily.

In the first phase of the plan, the weight of the medical provision side, such as core hospitals, was large. However, from the second phase, childhood, rare cancers, and coexistence were added; from the third phase, the AYA generation, elderly response, and ACP were added; and in the recently formulated fourth phase, phrases like "inclusion" and "leaving no one behind" were also incorporated. It has achieved a very healthy evolution, to an extent rarely seen elsewhere.

We believe that such evolution has been realized because, above all, many stakeholders such as patients and the media participate in policy planning. It is precisely because everyone has sat at the same table and moved forward while understanding each other that this level of evolution has been achieved.

Using these cancer control measures as a model case, for example, measures for stroke and cardiovascular diseases are now also progressing. I think it is very important to connect this to other diseases as well.

Come to think of it, cancer was the first disease to have a basic law named after it, wasn't it?

That's right. Also, another good thing about the Basic Plan for Promotion of Cancer Control Programs is that it is a cabinet decision. In other words, the Minister of Finance has also signed off on it. This makes it easier to secure a budget. In this way, I think it is a privileged system with a well-made frame.

The Cancer Control Act also has a history where the late Mr. Takashi Yamamoto, who was a member of the House of Councillors at the time, revealed that he was a patient himself, appealed for the importance of passing the bill, and it was passed unanimously. Considering that, there is also an aspect that patients have participated in creating the system from the beginning.

I got cancer in 2008, which was the first phase of the Basic Plan for Promotion of Cancer Control Programs. In the dozen or so years since then, in addition to pharmaceuticals and medical devices, I feel from both the perspective of having experienced cancer and the perspective of supporting others that the society and policies surrounding cancer have truly evolved.

Therefore, Japan's cancer control is by no means bad, and I believe that by everyone discussing the challenges of each period and doing what they can, it has evolved to this point. I believe that if we evolve it further from here, we can truly create a society where people can live long, in their own way, even if they get cancer.

Since people who have cancer might read this roundtable discussion, the last thing I want to convey is that "you are definitely not alone; there are companions." There are many companions who have experienced cancer, and Japan is full of people who are moving to support from various positions. I have met many such people.

When I got cancer, I suffered greatly from the thought, "Why only me...?" But I want to convey from the bottom of my heart that there are companions, and I want to collaborate with those companions and once again do what I can from my position.

I also fell ill with Stage IVB cancer in 2008. At that time, I was frantic in the midst of shock and confusion, but precisely because I got cancer, my perspective broadened, or rather, I was able to notice things I hadn't noticed before.

I think the fact that I am luckily living like this now is thanks to our predecessors creating good systems and evolving medical care and care. As someone living now as a survivor who experienced cancer, I want to do what I can for the next generation as well. I hope to do what needs to be done by joining hands with many companions, medical professionals, and policy planners.

I hope this roundtable discussion will be an opportunity for everyone facing cancer to have hope. Thank you very much for your time today despite your busy schedules.