Liver Cancer with Overlapping Myasthenia Gravis, Myocarditis, Seronegative Autoimmune Autonomic Ganglionopathy, and Myositis Symptoms Induced by Atezolizumab.

An 83-year-old man with hepatocellular carcinoma developed muscle weakness, ptosis, and dyspnea 3 weeks after receiving atezolizumab. Soon after, mechanical ventilation was initiated, which was followed by marked blood pressure spikes. The levels of creatine kinase and troponin-I were significantly elevated, and acetylcholine receptor antibodies were positive. The patient was diagnosed with immune checkpoint inhibitor (ICI)-induced myositis, myasthenia gravis (MG), myocarditis, and suspected autoimmune autonomic ganglionopathy (AAG). After immunotherapy, the serum markers and blood pressure normalized, and he was weaned from the ventilator after five months. To our knowledge, this is the first reported case of AAG secondary to ICI-induced myositis, MG, and myocarditis.

Successful Management of Pheochromocytoma Crisis with Cardiogenic Shock by Percutaneous Left Ventricular Assist Device.

Therapeutic strategy utilizing mechanical circulatory supports in patients with pheochromocytoma-related cardiogenic shock remains unestablished. We had a 51-year-old man with acute decompensated heart failure due to pheochromocytoma crisis. He received a percutaneous left ventricular assist device-supported alpha-blocker and intensive fluid infusion therapy, which ameliorated impaired end-organ dysfunction, maintaining hemodynamics and achieving cardiac recovery, followed by the successfully scheduled adrenalectomy. Early suspicion of pheochromocytoma and Impella-supported disease-specific medical management might be a promising bridge to surgery strategy.

The death of patients with terminal cancer: the distress experienced by their children and medical professionals who provide the children with support care.

BACKGROUND: Few studies have been conducted on the experiences of children of terminally ill patients or hospital-based medical professionals supporting such children. AIM: This study explored distress among individuals whose parents died of cancer in childhood and among hospital-based medical professionals supporting such children. DESIGN: A qualitative study. SETTING/PARTICIPANTS: The sample was 12 adults whose parents had died of cancer in childhood and 20 hospital-based medical professionals supporting children of patients' with terminal cancer. In-depth interviews were conducted, focusing on the distress experienced by the participants. The data were analysed thematically. RESULTS: Among adults whose parents died of cancer in childhood, we identified themes related to the period before death (eg, concealing the parent's illness), the time of death (eg, alienation due to isolation from the parent), soon after death (eg, fear and shock evoked by the bizarre circumstances, regrets regarding the relationship with the deceased parent before death), several years thereafter (ie, distinctive reflection during adolescence, prompted by the parent's absence) and the present time (ie, unresolved feelings regarding losing the parent). We identified seven themes among the medical professionals (eg, lack of knowledge/experience with children, the family's attempts to shield the child from the reality of death, estrangement from the family once they leave the hospital). CONCLUSIONS: An important finding of the study is that the participants' grief reaction to their parents' deaths during childhood was prolonged. Moreover, hospital medical professionals may find it difficult to directly support affected children. Comprehensive support involving organisations (eg, local communities) may be necessary for children who have lost a parent.

Effects of Trained Health Professionals' Behavioral Counseling Skills on Smoking Cessation Outcomes.

Background: There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects. Purpose: We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes. Methods: Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year. Results: On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers' characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03-1.42) and 1.26 (1.05-1.50), respectively. Conclusions: This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes.

Determinants of participation in prostate cancer screening: a simple analytical framework to account for healthy-user bias.

In Japan at present, fecal occult blood testing (FOBT) is recommended for cancer screening while routine population-based prostate-specific antigen (PSA) screening is not. In future it may be necessary to increase participation in the former and decrease it in the latter. Our objectives were to explore determinants of PSA-screening participation while simultaneously taking into account factors associated with FOBT. Data were gathered from a cross-sectional study conducted with random sampling of 6191 adults in Osaka city in 2011. Of 3244 subjects (return rate 52.4%), 936 men aged 40-64 years were analyzed using log-binomial regression to explore factors related to PSA-screening participation within 1 year. Only responders for cancer screening, defined as men who participated in either FOBT or PSA-testing, were used as main study subjects. Men who were older (prevalence ratio [PR] [95% confidence interval (CI)] = 2.17 [1.43, 3.28] for 60-64 years compared with 40-49 years), had technical or junior college education (PR [95% CI] = 1.76 [1.19, 2.59] compared with men with high school or less) and followed doctors' recommendations (PR [95% CI] = 1.50 [1.00, 2.26]) were significantly more likely to have PSA-screening after multiple variable adjustment among cancer-screening responders. Attenuation in PR of hypothesized common factors was observed among cancer-screening responders compared with the usual approach (among total subjects). Using the analytical framework to account for healthy-user bias, we found three factors related to participation in PSA-screening with attenuated association of common factors. This approach may provide a more sophisticated interpretation of participation in various screenings with different levels of recommendation.

The present state and perception of young women with breast cancer towards breast reconstructive surgery.

PURPOSE: This study was conducted to identify factors influencing patients' decisions to undergo breast reconstruction, and to identify the influences of breast reconstruction on patient behavior and psychological well-being. METHODS: Data were collected from January to June 2011, using a questionnaire distributed to women ≤45 years old with breast cancer, at five medical institutes across Japan. RESULTS: Completed questionnaires were collected from 316 women (mean age: 39.46 ± 4.4 years, range: 27-45 years). Overall, 174 patients received breast-conserving surgery, 101 received mastectomy, 31 received subcutaneous mastectomy, 3 patients received none, and 49 were unreported). The data indicated a reconstruction rate of 36.7 % in women who underwent mastectomy. The most prevalent reason for not undergoing breast reconstruction was the fear of cancer relapse. Other factors mentioned were to avoid additional distress on the body from surgery, financial reasons, and a belief that breast reconstruction is unnecessary. The main factor that influenced the decision not to undergo delayed breast reconstruction, specifically, was the expense. Women who had completed breast reconstruction showed higher self-evaluations of physical attractiveness and were more active in comparison to those who did not. However, regardless of having undergone breast reconstruction or not, women who reported higher levels of self-consciousness over the treated areas showed more restrictions on activity and higher chances of a decline in psychological well-being. CONCLUSION: Regardless of deciding to undergo breast reconstruction or not, the results of this study suggested the need for cognitive interventions to avoid patients fixating on self-consciousness over treated areas.

Predictors of lapse and relapse to smoking in successful quitters in a varenicline post hoc analysis in Japanese smokers.

BACKGROUND: The efficacy of the smoking-cessation agent varenicline has been reported in Asian smokers; however, few studies have investigated factors that contribute to lapse and relapse. OBJECTIVE: This post hoc analysis aimed to identify predictors of smoking lapse and relapse. METHODS: This was a post-hoc analysis based on a double-blind, placebo-controlled, randomized, parallel-group study in which Japanese smokers (aged 20-75 years) who smoked ≥ 10 cigarettes/day and were motivated to quit were randomized to receive varenicline (0.25 mg twice daily [BID], 0.5 mg BID, 1 mg BID) or placebo for 12 weeks followed by a 40-week non-treatment follow-up. For inclusion in this analysis, participants must have been nicotine dependent (Tobacco Dependence Screener score ≥ 5) and must have successfully quit smoking continuously for 4 weeks (weeks 9-12). Lapse was defined by answering yes to ≥ 1 question in the Nicotine Use Inventory. Relapse was defined by participants having smoked for ≥ 7 days during follow-up measured by the Nicotine Use Inventory. RESULTS: Of the 619 randomized individuals, 515 had a Tobacco Dependence Screener score of ≥ 5, and 277 quit smoking continuously from weeks 9 to 12. Approximately 75% were male, with a mean (SD) BMI of 23.0 (3.0) kg/m(2). Maximum length of continuous abstinence (CA) during treatment and age (both P < 0.0001) were significant predictors of lapse. Maximum CA (P < 0.0001), age (P = 0.0002), Minnesota Nicotine Withdrawal Scale (MNWS) score for urge to smoke (P = 0.0019), and having made ≥ 1 serious quit attempt (P = 0.0063) were significant predictors of relapse. For participants with a maximum CA of 4 to 6 weeks versus those with a maximum CA of 10 to 11 weeks, the ORs for lapse and relapse were 4.649 (95% CI, 2.071-10.434) and 3.337 (95% CI, 1.538-7.239), respectively. In participants aged 21-34 years versus those aged 47-72 years, the ORs for lapse and relapse were 3.453 (95% CI 1.851, 6.441) and 3.442 (95% CI 1.795, 6.597), respectively. Participants with a MNWS urge to smoke score of 2 to 4 versus 0 had an OR for relapse of 3.175 (95% CI, 1.166-8.644). Participants having made ≥ 1 versus no serious quit attempts had an OR for relapse of 2.108 (95% CI, 1.168-3.805). CONCLUSION: Shorter maximum CA and younger age at quit attempt were associated with increased risk of lapse and relapse. Higher MNWS urge to smoke score and having made ≥ 1 serious quit attempt were associated with increased relapse risk. ClinicalTrials.gov identifier: NCT00139750.

LOXL2 expression is associated with invasiveness and negatively influences survival in breast cancer patients.

Lysyl oxidase-like 2 (LOXL2) is associated with invasiveness and metastasis in breast cancer. We analyzed the prognostic impact of LOXL2 for breast cancer patients and investigated the role of LOXL2 in breast cancer cell lines. Immunohistochemical study of LOXL2 expression was done in samples from 309 patients. Survival analysis was performed using log-rank test and Cox regression hazard model. After identification of LOXL2 expression in breast cancer cell lines, we performed matrigel invasion and wound-healing assays with LOXL2-silenced cell lines. In the human study, LOXL2 was expressed in 16.2 % of patients. Comparing the LOXL2-positive versus negative groups, there was a significantly higher proportion of estrogen receptor-negative patients (54.0 vs. 37.0 %, respectively; p = 0.029) and triple-negative patients (34.0 vs. 18.0 %; p = 0.022) in the positive group. In multivariate analysis for overall survival and metastasis-free survival, positive LOXL2 was demonstrated as a poor prognostic factor (HR 2.27 and 2.10, respectively). In vitro study indicated that LOXL2 silencing induces a mesenchymal-epithelial transition-like process in basal cell lines (MDA-MB-231 and BT549) associated with decreased invasive and migratory properties. These clinical and preclinical data confirm that higher LOXL2 expression is associated with invasiveness of basal-like breast cancer cells and lower survival of breast cancer patients. Our results suggest the clinical value of LOXL2 as a therapeutic target in breast cancer.

Modeling the effect of disseminating brief intervention for smoking cessation at medical facilities in Japan: a simulation study.

PURPOSE: The Japanese male smoking prevalence is still high. Underlying causes are the low quit attempt rate (QAR) and lack of pharmacotherapy (PT) use. Though health checkups are widely and systematically performed in Japan, this setting has not been utilized for intervention to smokers. We aimed to estimate the population effect of disseminating brief intervention (BI) at health checkup facilities combined with encouraging PT utilization. METHODS: The annual population quit rate (PQR) was modeled as a product of three components: the QAR, utilization of PT, and effectiveness of PT. A policy to disseminate effective BI at health checkup facilities was then incorporated into the PQR model as means to increase the QAR and/or PT utilization. Japanese male smokers aged 40-74 years were the target population, and the baseline year was set at 2005. The PQR and the number of smokers who successfully quit were compared with the baseline to evaluate the BI policy. RESULTS: The BI policy was estimated to increase the PQR from 4.3 to 5.7 % (rate ratio: 1.34) in a scenario where 75 % of smokers having an annual health checkup received BI and 60 % of BI-induced quit attempts were supported by PT, resulting in 177,000 new successful quitters on an annual basis and 3,000 avoidable cancer deaths in 10 years. Comparisons of different scenarios revealed that increasing QAR and encouraging PT were both essential to maximize the effect of BI policy. CONCLUSION: The dissemination of BI at health checkup facilities encouraging PT utilization is an effective tobacco control policy in Japan.

Burden on oncologists when communicating the discontinuation of anticancer treatment.

OBJECTIVE: Communicating the discontinuation of anticancer treatment to patients is a difficult task. The primary aim of this study was to clarify the level of oncologist-reported burden when communicating about discontinuation of an anticancer treatment. The secondary aims were (i) to identify the sources of burden contributing to their levels and (ii) to explore the useful strategies to alleviate their burden. METHODS: A multicenter nationwide questionnaire survey was conducted on 620 oncologists across Japan (response rate, 67%). RESULTS: High levels of perceived burden were reported by 47% of respondents, and 17% reported that they sometimes, often or always wanted to stop oncology work because of this burden. There was a significant association between high levels of burden and: a feeling that breaking bad news would deprive the patient of hope; concern that the patient's family would blame the oncologist; concern that the patient may lose self-control; and a feeling that there was not enough time to break the bad news. Strategies perceived to be useful by oncologists included training in how to effectively communicate to patients discontinuation of anticancer treatment, a reduction in total workload to allow sufficient time to break bad news, and development of a multidisciplinary model to facilitate cooperation with other professionals and facilities. CONCLUSIONS: Many oncologists reported high levels of burden relating to communication of discontinuation of anticancer treatment. A specific communication skills training program, sufficient time for communication and development of a multidisciplinary model could help alleviate the burden on oncologists.

A gene expression signature of acquired chemoresistance to cisplatin and fluorouracil combination chemotherapy in gastric cancer patients.

BACKGROUND: We initiated a prospective trial to identify transcriptional alterations associated with acquired chemotherapy resistance from pre- and post-biopsy samples from the same patient and uncover potential molecular pathways involved in treatment failure to help guide therapeutic alternatives. METHODOLOGY/PRINCIPAL FINDINGS: A prospective, high-throughput transcriptional profiling study was performed using endoscopic biopsy samples from 123 metastatic gastric cancer patients prior to cisplatin and fluorouracil (CF) combination chemotherapy. 22 patients who initially responded to CF were re-biopsied after they developed resistance to CF. An acquired chemotherapy resistance signature was identified by analyzing the gene expression profiles from the matched pre- and post-CF treated samples. The acquired resistance signature was able to segregate a separate cohort of 101 newly-diagnosed gastric cancer patients according to the time to progression after CF. Hierarchical clustering using a 633-gene acquired resistance signature (feature selection at P<0.01) separated the 101 pretreatment patient samples into two groups with significantly different times to progression (2.5 vs. 4.7 months). This 633-gene signature included the upregulation of AKT1, EIF4B, and RPS6 (mTOR pathway), DNA repair and drug metabolism genes, and was enriched for genes overexpressed in embryonic stem cell signatures. A 72-gene acquired resistance signature (a subset of the 633 gene signature also identified in ES cell-related gene sets) was an independent predictor for time to progression (adjusted P = 0.011) and survival (adjusted P = 0.034) of these 101 patients. CONCLUSION/SIGNIFICANCE: This signature may offer new insights into identifying new targets and therapies required to overcome the acquired resistance of gastric cancer to CF.

Projected cancer mortality among Japanese males under different smoking prevalence scenarios: evidence for tobacco control goal setting.

OBJECTIVE: Male smoking prevalence is still high in Japan, and quantitative information for tobacco control is scarce. The aim of the present study was to project cancer mortality among Japanese males under different future scenarios of smoking prevalence. METHODS: The target population comprised Japanese males aged 40-79 years in 2007, whose smoking prevalence was 35%. On the basis of the pooled data from three large-scale cohort studies in Japan, the effects of age, years of smoking and years after smoking cessation on the time to all-cancer or lung cancer death were estimated by an accelerated failure time model. The parameter estimates were used to project the annual number of deaths from all cancers and lung cancer by running simulations for different future scenarios of smoking prevalence. Each scenario was evaluated by the cumulative number of avoided deaths when compared with the status quo and by the percent change (from the baseline year) in age-standardized rate of mortality. RESULTS: Reducing the smoking prevalence from 35% in 2007 to 0% in 2017 was estimated to avoid 333 900 all-cancer deaths and 171 100 lung cancer deaths in 20 years. Even when we shortened the projection period to 10 years, these numbers of avoided deaths would be 81 100 and 38 800, respectively. The age-standardized rate of all-cancer mortality was estimated to decrease by 9.6% in 10 years and 18.1% in 20 years. CONCLUSIONS: Reducing the prevalence of smoking among males would be effective in reducing the cancer burden even within 10 years in countries with a high male smoking prevalence.

Gastric cancer-specific protein profile identified using endoscopic biopsy samples via MALDI mass spectrometry.

To date, proteomic analyses on gastrointestinal cancer tissue samples have been performed using surgical specimens only, which are obtained after a diagnosis is made. To determine if a proteomic signature obtained from endoscopic biopsy samples could be found to assist with diagnosis, frozen endoscopic biopsy samples collected from 63 gastric cancer patients and 43 healthy volunteers were analyzed using matrix-assisted laser desorption/ionization (MALDI) mass spectrometry. A statistical classification model was developed to distinguish tumor from normal tissues using half the samples and validated with the other half. A protein profile was discovered consisting of 73 signals that could classify 32 cancer and 22 normal samples in the validation set with high predictive values (positive and negative predictive values for cancer, 96.8% and 91.3%; sensitivity, 93.8%; specificity, 95.5%). Signals overexpressed in tumors were identified as alpha-defensin-1, alpha-defensin-2, calgranulin A, and calgranulin B. A protein profile was also found to distinguish pathologic stage Ia (pT1N0M0) samples (n = 10) from more advanced stage (Ib or higher) tumors (n = 48). Thus, protein profiles obtained from endoscopic biopsy samples may be useful in assisting with the diagnosis of gastric cancer and, possibly, in identifying early stage disease.

Diagnostic validity of high-density barium sulfate in gastric cancer screening: follow-up of screenees by record linkage with the Osaka Cancer Registry.

BACKGROUND: The use of high-density barium sulfate was recommended by the Japan Society of Gastroenterological Cancer Screening (JSGCS) in 2004. We evaluated the diagnostic validity of gastric cancer screening that used high-density barium sulfate. METHODS: The study subjects were 171 833 residents of Osaka, Japan who underwent gastric cancer screening tests at the Osaka Cancer Prevention and Detection Center during the period from 1 January 2000 through 31 December 2001. Screening was conducted using either high-density barium sulfate (n = 48 336) or moderate-density barium sulfate (n = 123 497). The subjects were followed up and their medical records were linked to those of the Osaka Cancer Registry through 31 December 2002. The results of follow-up during 1 year were defined as the gold standard, and test performance values were calculated. RESULTS: The sensitivity and specificity of the screening test using moderate-density barium sulfate were 92.3% and 91.0%, respectively, while the sensitivity and specificity of the high-density barium test were 91.8% and 91.4%, respectively. The results of area under receiver-operating-characteristic (ROC) curve analysis revealed no significant difference between the 2 screening tests. CONCLUSIONS: Screening tests using high- and moderate-density barium sulfate had similar validity, as determined by sensitivity, specificity, and ROC curve analysis.

Transient tumor-fibroblast interactions increase tumor cell malignancy by a TGF-Beta mediated mechanism in a mouse xenograft model of breast cancer.

Carcinoma are complex societies of mutually interacting cells in which there is a progressive failure of normal homeostatic mechanisms, causing the parenchymal component to expand inappropriately and ultimately to disseminate to distant sites. When a cancer cell metastasizes, it first will be exposed to cancer associated fibroblasts in the immediate tumor microenvironment and then to normal fibroblasts as it traverses the underlying connective tissue towards the bloodstream. The interaction of tumor cells with stromal fibroblasts influences tumor biology by mechanisms that are not yet fully understood. Here, we report a role for normal stroma fibroblasts in the progression of invasive tumors to metastatic tumors. Using a coculture system of human metastatic breast cancer cells (MCF10CA1a) and normal murine dermal fibroblasts, we found that medium conditioned by cocultures of the two cell types (CoCM) increased migration and scattering of MCF10CA1a cells in vitro, whereas medium conditioned by homotypic cultures had little effect. Transient treatment of MCF10CA1a cells with CoCM in vitro accelerated tumor growth at orthotopic sites in vivo, and resulted in an expanded pattern of metastatic engraftment. The effects of CoCM on MCF10CA1a cells were dependent on small amounts of active TGF-beta1 secreted by fibroblasts under the influence of the tumor cells, and required intact ALK5-, p38-, and JNK signaling in the tumor cells. In conclusion, these results demonstrate that transient interactions between tumor cells and normal fibroblasts can modify the acellular component of the local microenvironment such that it induces long-lasting increases in tumorigenicity and alters the metastatic pattern of the cancer cells in vivo. TGF-beta appears to be a key player in this process, providing further rationale for the development of anti-cancer therapeutics that target the TGF-beta pathway.

A qualitative study of decision-making by breast cancer patients about telling their children about their illness.

OBJECTIVE: Many breast cancer patients are troubled about telling their school-age children about their illness. However, little attention has been paid to the factors that encourage or discourage them from revealing the illness. This study explored decision-making by breast cancer patients about telling their children about their illness. METHODS: Participants were 30 breast cancer patients recruited from a regional cancer institution in Japan. Semi-structured interviews were conducted and content analysis was performed. RESULTS: Six preparatory stages of decision-making by Japanese breast cancer patients about telling their children about their illness were identified as follows: contemplation, preparation, action-hospitalization and surgery, action-adjuvant therapy, action-diagnosis, and action-prognosis. We also identified 11 categories of positive aspects and ten categories of negative aspects about revealing their illness to children. The categories of negative aspects with higher frequency were similar to those found by previous research, but categories of positive aspects were unique. The rate of reference to negative aspects in total reduces gradually as the preparatory stage advances, and in action-diagnosis and action-prognosis stages the balance between positive and negative aspects becomes about half and half. CONCLUSIONS: Patients, especially in action-hospitalization and surgery, can be expected to tell their children about their illness although they find negative aspects much more compelling than positive aspects and experience great distress. These patients have special needs for support from others.

Smoking cessation patterns and predictors of quitting smoking among the Japanese general population: a 1-year follow-up study.

AIM: To examine the percentage of Japanese adult smokers who make quit attempts and succeed in smoking cessation over a 1-year period, and to identify predictors of attempts to stop and successful smoking cessation. DESIGN AND SETTING: This study used Ipsos JSR Company's access panel, whose sampling framework is based on the Basic Resident Register in Japan. We tracked and monitored a selected sample of smokers who were at least 20 years of age through a baseline postal questionnaire survey in 2005 and a follow-up survey 1 year later. PARTICIPANTS: The original response rate was 72.1% (1874 of 2600 smokers). There were 1627 current smokers in the baseline survey, and of those, 1358 were followed-up 1 year later. FINDINGS: Among the current smokers, 23.0% reported that they had attempted to quit smoking at least once in the past year. Of those who made quit attempts, 25.6% had achieved 1-week abstinence successfully and 13.5% reported having achieved sustained 6-month abstinence successfully at the time of the follow-up survey. The predictors associated with quit attempts were non-daily smoker, higher motivation to quit and previous attempts to stop smoking. Among smokers who made quit attempts, only 13.5% used nicotine replacement therapy. Higher nicotine dependence was associated with lower probability of success in quitting. CONCLUSIONS: Japanese smokers attempt to quit at a lower rate than smokers in the United Kingdom and United States, but factors that predict attempts (primarily markers of motivation) and success of attempts (primarily dependence) are similar to those found in western samples.

Hospital procedure volume and prognosis with respect to testicular cancer patients: a population-based study in Osaka, Japan.

Establishment of gold-standard chemotherapy and the subsequent development of salvage therapy have much improved the prognosis of patients with testicular germ cell cancer. However, not all patients with this disease get the best possible outcome in Osaka, Japan. A population-based study of testicular cancer cases diagnosed during 1993-1999 was performed using the Osaka Cancer Registry database to verify changes in prognosis and to examine their relationship with hospital procedure volume. Patients' referrals to hospitals during 1990-2001 were also examined to evaluate the degree of centralization. The 5-year relative survival rate of testicular cancer as well as testicular germ cell cancer in Osaka during 1993-1999 was markedly improved compared with that of previous periods (1975-1992); but remained lower than those reported in the EUROCARE-4 and Surveillance Epidemiology and End Results program. There appeared to be a significant association between survival and hospital procedure volume, even with adjustment made for clinical stage, age and histology. Centralization of referrals had not progressed during the past 12 years. In conclusion, the prognosis of testicular cancer in Osaka has improved remarkably, but nevertheless has remained lower than in the EU and/or the USA. Little progress has been made in centralization of hospital referrals.

Smoking behavior and attitudes toward smoking cessation among members of the Japanese Cancer Association in 2004 and 2006.

We analyzed the postal surveys conducted by Japanese Cancer Association (JCA) in 2004 and 2006. This survey aimed to assess JCA members' behavior and their attitudes toward patients who are smokers, smoking cessation, and their responsibilities. In the 2006 version, questions were added about hope for various approaches related to smoking and health and the attitudes as medical experts when treating patients. JCA members' smoking rate was 5.9% in 2004 and 9.0% in 2006. Current smokers were significantly more likely than never or former smokers to disagree or have no opinion with most activities about smoking control such as 'raising the price of tobacco' and 'labeling health warnings describing the harmful effects of tobacco in large letters with clarity for easier reading', while most members including smokers agree to ban smoking while walking, to educate general people about tobacco and health, to provide an environment where children cannot get tobacco and the information about tobacco and health. Smoking rate among JCA members were less than that of general populations, and most of them are in favor of promoting tobacco control activities.