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

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

It can be said that cancer policy to date has basically focused on the equalization of care. 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 aging population and the decline in the working-age population, predicted to accelerate further in Japan—the so-called "2040 Problem"—are having a major impact on the direction of medical care.

In the discussions regarding the new regional medical vision compiled in December 2024 *2, it was 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 consolidate medical institutions. It was stated that medical institutions serving as acute care hubs should provide medical care by consolidating cases that require significant medical resources, such as surgery and emergency medicine.

The aging population 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 tolerance for treatment 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 the number of 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 Designated Cancer Hospitals and similar facilities have been established and developed nationwide. However, as of April 2024, there were 56 "blank" cancer medical districts nationwide where no Designated Cancer Hospital exists. 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 Measures, 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 consolidation based on the division of roles among Designated Cancer Hospitals and other facilities."

At the "Study Group on the 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 Measures, prefectures need to assign roles to Designated Cancer Hospitals and other facilities according to regional circumstances toward the provision of sustainable cancer care looking toward 2040 *3." The following were listed as candidates for medical services to be consolidated:

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 dispersal of medical resources

③ Medical care where the delivery system is sufficient, but because demand is low, the delivery system becomes inefficient

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.

These were cited as candidate examples.

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

Specific candidates for consolidation 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 therapy and Nuclear Medicine, and interventions that are infrequent and require specialized skills such as fertility preservation therapy (Figure 1).

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

In contrast to consolidation, the "Study Group on the State of the Cancer Care Delivery System" listed screenings, cancer rehabilitation, supportive care, and palliative care as medical services for which equalization should be promoted. It stated that for these services, it is desirable that as many medical institutions as possible, including clinics, be able to provide them from the perspectives of cancer prevention, the aging population, and coexistence with cancer. In other words, for these medical services, 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 own personal views.

Highly specialized hospitals, such as Prefectural Designated Cancer Hospitals and main university hospitals, are expected to handle cases with high difficulty and relatively low frequency (for example, esophageal or pancreatic cancer) by receiving more referrals from surrounding medical institutions than before. In order to secure internal resources (staff labor, operating room slots, etc.) to provide such care, it may become necessary to refer standard treatments that can be performed at other hospitals (for example, 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 also necessary to accept patients widely from within the prefecture. The same applies to the treatment of pediatric and rare cancers. Furthermore, for medical technologies with low frequency, such as fertility-preserving surgery, it is desirable to accept cases widely from the region.

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 treatment hospitals, such as clinics, are expected to provide palliative care, cancer rehabilitation, and screenings. For patients whose cancer treatment has stabilized, a clinical model has been presented 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 consolidation 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 together with their communities about how medical institutions should be utilized.

Note that the impact of consolidation is expected to be large in sparsely populated or declining population areas, while the impact in densely populated areas or areas where the population will continue to increase, such as urban centers, 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.