Patients' preferences for involvement in treatment decision making in Japan

BACKGROUND

A number of previous studies have suggested that the Japanese have few opportunities to participate in medical decision-making, as a result both of entrenched physician paternalism and national characteristics of dependency and passivity. The hypothesis that Japanese patients would wish to participate in treatment decision-making if adequate information were provided, and the decision to be made was clearly identified, was tested by interview survey.

METHODS

The subjects were diabetic patients at a single outpatient clinic in Kyoto. One of three case study vignettes (pneumonia, gangrene or cancer) was randomly assigned to each subject and, employing face-to-face interviews, the subjects were asked what their wishes would be as patients, for treatment information, participation in decision-making and family involvement.

RESULTS

134 patients participated in the study, representing a response rate of 90%. The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively. Respondents to the cancer vignette were less likely to prefer an active role and were more likely to prefer family involvement in decision-making compared to non-cancer vignette respondents. If a physician's recommendation conflicted with their own wishes, 60% of the respondents for each vignette answered that they would choose to respect the physician's opinion, while few respondents would give the family's preference primary importance.

CONCLUSIONS

Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

How can we improve the quality of health care in Japan?

The World Health Report 2000 placed Japan first for overall health system attainment: a surprising development considering that, aside from discussing excessive expenditure, health care professionals and the Health Ministry have paid little attention recently to the quality of health care. Japan's free access policy and the universal health care system have actually fostered a very relaxed attitude toward evaluation. Concerned about the possible risks to patient safety, physicians established a volunteer association to promote quality health care issues. Then in 1995, the Japan Council for Quality Health Care (JCQHC) was founded to implement the third party accreditation of hospitals. Concurrent with the formation of the JCQHC, the sharply rising costs of malpractice litigation motivated the authorities and medical facilities to work toward protecting patient safety at different levels. Despite the WHO's positive review, critics maintain that significant inequities still exist in Japanese health care. Examples include, financial inequities between private and public hospitals, and the number and quality of hospitals and physicians between rural and urban areas. To protect patient safety and improve the quality of care, every effort must be made to eliminate inequities in the health care system. JCQHC accreditation is an important tool for furthering these efforts.

Influence of length of stay on patient satisfaction with hospital care in Japan

OBJECTIVE

The objective of this study was to identify specific patient satisfaction items related to overall satisfaction by different length of stay (LOS) for patients in Japanese hospital settings.

METHODS

This cross-sectional study involved a participant sample, drawn from 77 voluntarily participating hospitals throughout Japan, of in-patients discharged to the community. Older patients and psychiatric, pediatric, obstetric and gynecologic patients were excluded. The 1050 respondents analyzed (response rate > or = 5l.1%) were divided into three groups based on their LOS: group 1, LOS < or = 1 week; group 2, LOS < or = 1 month; and group 3, LOS > 1 month. Using stepwise multiple regression analysis, we explored for each LOS group the relationship between overall patient satisfaction and satisfaction with 33 individual items, including three regarding perceived reputation of the hospital in question.

RESULTS

Some unique satisfaction items for each group (e.g. 'skill of nursing care' in group 1, 'Recovery of physical health', 'skill of nursing care', and 'respect for patients opinions and feelings' in group 2, and 'relief from pain' and 'respect for patients' opinions and feelings' in group 3) were significantly associated with overall satisfaction. In all three groups, common items (e.g. 'recovery from distress and anxiety' and 'doctor's clinical competence') also related significantly to overall satisfaction. Two items pertaining to the hospital reputation dimension (e.g. 'family member's evaluation of the hospital' and 'hospital reputation among other patients') were also significant predictors of overall satisfaction in all three groups.

CONCLUSION

The findings show that according to LOS, unique items could determine significantly the achievement of overall satisfaction, while some common predictors across all three LOS groupings also seemed to be indispensable for inpatient's assessment of hospital care. It was also confirmed in this study that a positive perception of hospital reputation might have an important role in patient satisfaction in Japan.

A first look at variations in use of breast conserving surgery at five teaching hospitals in Japan

OBJECTIVE

We assessed variations in the use of breast conserving surgery (BCS) for operable breast cancer paticnts among hospitals in Japan, and then compared the length of stay (LOS) and total charges during hospitalization between patients who received BCS and those who received mastectomy.

SETTING AND STUDY PARTICIPANTS

We used a database from the Voluntary Hospitals of Japan Quality Indicator Project that involved 10 teaching hospitals in Japan. We selected female operable breast cancer patients who were admitted to five of these hospitals from January 1996 to December 1999 (n = 614).

MAIN OUTCOME MEASURES

Proportion of the use of BCS, LOS, and total charges during hospitalization.

RESULTS

Twenty-six percent of 614 subjects in the five hospitals received BCS. Proportions of the use of BCS varied from 9% to 51% across five hospitals during the 4-year period. Multiple logistic regression analysis revealed that when we selected as a reference one hospital that had the same proportion of the use of BCS (26%) as the average proportion among all hospitals, three hospitals were 0.3, 2.0, and 2.6 times more likely to use BCS than the reference (P < 0.05). LOS for BCS [mean 25.0 days, standard deviation (SD) 11.8 days] was significantly shorter than for mastectomy (mean 27.3 days, SD 8.6 days), and total charges during hospitalization for BCS (mean US$7771.5, SD 2676.7) were significantly lower than for mastectomy (mean US$8502.5, SD 2044.0). Linear mixed models confirmed that the use of BCS was significantly associated with shorter LOS (P < 0.001) and lower total charges (P < 0.001).

CONCLUSION

This preliminary description of breast cancer care in five teaching hospitals in Japan revealed variations in the use of BCS.

Functional transitions and active life expectancy for older Japanese living in a community

We examined functional transitions in both the activities of daily living (ADL), and instrumental activities of daily living (IADL), over a 1-year interval among older Japanese living in a community, then estimated their physically active life expectancy (PALE) and instrumentally active life expectancy (IALE). In 1992, all residents aged 65 or older who lived in Saku City, Nagano, Japan, were followed-up over the 1-year interval. A self-administrated questionnaire, which involved age, sex, five ADL items, and five IADL items, was used for each survey in both 1992 and 1993. Of the baseline cohort (n=10,098), we received 9533 analyzable questionnaires at the follow-up survey in 1993. During the follow-up, 92 and 87% of subjects who were initially independent in ADL and IADL remained independent, respectively. PALE for men and women were estimated to be 16.0 and 18.9 at 65 years of age, respectively. IALE for men and for women were estimated to be 12.8 and 14.6 at the age of 65, respectively. Proportions of the PALE to total life expectancy (TLE) at any age did not greatly differ between men and women; however, men had a slightly larger proportion of IALE to TLE at any given age than women.

Is Bacillus Calmette-Guerin revaccination necessary for Japanese children?

BACKGROUND

Bacillus Calmette-Guerin (BCG) revaccination has been implemented in Japan among tuberculin-negative first grade primary and first grade junior high school students for decades. Controversies regarding the effectiveness of BCG revaccination and low incidence of tuberculosis (TB) among Japanese children prompted this study.

METHODS

Cost-effectiveness and cost-benefit analyses were conducted for a cohort of schoolchildren who underwent revaccination during 1996. The study population was a hypothetical cohort comprising 1.35 million first grade primary school and 1.51 million first grade junior high school students enrolled in 1996 at locations throughout Japan. Assuming 50% vaccine efficacy for revaccination, a 10-year duration of protection, and 5% annual discount rate, we calculated the total hypothetical number of TB cases averted, the cost and number of immunizations per TB case averted, and the benefit-cost ratio for the program.

RESULTS

The revaccination program for 1996 schoolchildren cohort would prevent 296 TB cases over a 10-year period at a cost of US$ 108,378 per case averted. About 4,963 immunizations would be required to prevent one child from developing TB. The benefit-cost ratio remained at 0.13 with baseline assumptions and ranged from 0.05 to 0.29 and from 0.02 to 0.74 for one-way and two-way sensitivity analyses, respectively.

CONCLUSION

BCG revaccination among schoolchildren is not supported by available scientific and economic data. Based on the results of this study, current BCG revaccination policies in Japan and other countries should be reexamined.

Spiking properties of olfactory receptor cells in the slice preparation

The whole-cell, patch clamp [corrected] method was applied to olfactory receptor cells in slice preparations made from bullfrog olfactory epithelium. Under voltage-clamp conditions, olfactory receptor cells showed a transient inward current followed by a steady outward current in response to depolarizing voltage steps, as has been shown in the isolated preparation. The input resistance was 5.4 +/- 3.9 GOmega and capacitance 21.9 +/- 9.7 pF. Under current-clamp conditions, depolarization of cells by current injection induced action potentials. In 13 out of 20, spike generation was repetitive with a maximum frequency of 24 Hz. The frequency of the repetitive discharges increased as the injected current was increased. The relationship between the size of the injected current and firing frequency could be well fitted by the Michaelis-Menten equation, indicating that the spike generation site lacks the non-linear boosting system. The slice preparation developed here would provide a powerful tool to study the spike encoding system of the olfactory receptor cells.

Effects of patient demands on satisfaction with Japanese hospital care

OBJECTIVE

The objective of this study was to detect whether there was any difference among the characteristics of patient satisfaction between two patient emphasis groups: patients demanding technical elements of hospital care and patients demanding interpersonal elements.

DESIGN AND SETTING

The sample for this study was drawn from in-patients discharged from 77 voluntarily participating hospitals throughout Japan. The relationship between overall satisfaction with hospital care and patient satisfaction, and the evaluation of a hospital's reputation, was explored by stepwise multiple regression analysis of 33 variables relevant to aspects of hospital care for each patient group.

RESULTS

In the interpersonal emphasis (IE) group, 'nurse's kindness and warmth' was associated significantly with overall satisfaction, while 'skill of nursing care' and 'nurse's explanation' were significant predictors of overall satisfaction in the technical emphasis (TE) group. On the other hand, 'doctor's clinical competence', 'recovery from distress and anxiety', and items pertaining to the hospital's reputation were significantly related to overall satisfaction in both emphasis groups.

CONCLUSION

For overall patient satisfaction, it is essential to satisfy specific items related to the aspect of hospital care emphasized by the patient. Specific significant predictors of overall satisfaction (e.g. 'doctor's clinical competence') were indispensable measures of professional performance in hospital care, irrespective of the patients' emphasis. A positive perception of hospital reputation items might increase overall patient satisfaction with Japanese hospitals.

[Economics and policy of day surgery]

With advances in technology, day surgery has become more efficient and has expanded remarkably due to the policies and economic incentives in some countries. In addition, day surgery could potentially serve as a model of explicit accountability for quality assurance and institutional processes for continuous improvement. It is recommended that Japan adapt its policies and systems to facilitate day surgery after a thorough analysis of the health effects and cost structure. Cost shifts to other services and parties should be considered carefully from a long-term, comprehensive perspective. It could be socially beneficial to subsidize start-up costs for the establishment of day surgery units, since significant capital and human resources are required for quality assurance. The encouragement of day surgery could be a driving force for the improvement of clinical technology and patient quality of life. It would foster collaboration between health service providers, including during preparation and follow-up, and allow patients to participate as partners in clinical processes and decisions. To ensure constant readiness, day surgery environments should be equipped with multisite, standardized databases on clinical and economic performance. An expansion of day surgery facilities could lead to the development of a new mechanism of professional quality improvement and to a new health insurance reimbursement system based on clinical achievements and resources.

Quality of life domains in the healthy public: A trial investigation using attendants for an annual health checkup

A trial investigation of subjects gathered for annual health checkups was performed to detect domains of quality of life in the healthy public, and to explore the changes of their demographic characteristics for the possibility of engaging them in health service activities in the community. The eligible 1,096 subjects aged 30-79 years were investigated. The period of this survey was from September to December, 1997. The subjects were questioned using ten quality of life domains which were preliminarily prepared and had been assumed to be most important in the subjects' lives in relation to the order of priority, importance, and satisfaction levels. The first most important domain in both the male and female subjects' lives was personal health, followed by relationships with family, though the mean importance scores for their personal health and relationships with family were almost equivalent. The mean scores for work abruptly decreased in males over 60 years of age. Also, the first large and the second relatively small principal components were extracted through principal components analysis. The proposed ten domains of quality of life are most likely valid and reliable in terms of the results analyzed and the comparison with a referred study. Relationships with family is an effective cue for health service activities in the community, and the significance of work on quality of life in the healthy public will have to be taken into account separately, especially in males.

Effects of mailed advice on stress reduction among employees in Japan: a randomized controlled trial

We conducted a randomized controlled trial (RCT) to examine the effects of mailed advice on reducing psychological distress, blood pressure, serum lipids, and sick leave of workers employed in a manufacturing plant in Japan. Those who indicated higher psychological distress (defined as having GHQ scores of three or greater) in the baseline questionnaire survey (n = 226) were randomly assigned to an intervention group or a control group. Individualized letters were sent to the subjects of the intervention group, informing them of their stress levels and recommending an improvement in daily habits and other behaviors to reduce stress. Eighty-one and 77 subjects in the intervention and control groups, respectively, responded to the one-year follow-up survey. No significant intervention effect was observed for the GHQ scores, blood pressure, serum lipids, or sick leave (p > 0.05). The intervention effect was marginally significant for changes in regular breakfasts and daily alcohol consumption (p = 0.09). The intervention effect was marginally significant for the GHQ scores among those who initially did not eat breakfast regularly (p = 0.06). The study suggests that only sending mailed advice is not an effective measure for worksite stress reduction. Mailed advice which focuses on a particular subgroup (e.g., those who do not eat breakfast regularly) may be more effective.

[A case of postencephalitic intractable partial epilepsy with multiple brain lesions demonstrated by MRI]

We encountered a case of focal encephalitis. A 5-year-old boy developed high fever and he was admitted to our hospital on the third day with generalized tonic-clonic convulsions. Cerebrospinal fluid showed slight pleocytosis. CT showed diffuse low-density area in the left temporal, parietal and occipital regions. T2 weighed MRI showed swelling and hyperintense regions in the left temporal, parietal and occipital cortex. With the disappearance of generalized convulsion, the cortical swelling improved. But aphasia and intractable complex partial seizures appeared. On MRI, the atrophic findings of the left hippocampus and temporal lesion became developed. We considered this case corresponds to focal encephalitis related to "a peculiar type of post-encephalitic/encephalopathic epilepsy" reported by Awaya et al.

Factor VIII gene analysis in Japanese CRM-positive and CRM-reduced haemophilia A patients by single-strand conformation polymorphism

Haemophilia A is the most common X-linked blood coagulation disorder; it is caused by deficiency of factor VIII activity (FVIII:C). Half of the affected patients do not have detectable levels of FVIII protein in their plasma, whereas about 5% have normal levels of the FVIII antigen (FVIII:Ag) (> 50 u/dl), and are called cross-reacting material (CRM) positive (CRM+ or A+). About 45% of patients have reduced levels of the FVIII:Ag (1-50 u/dl), classified as CRM reduced (CRM[R] or A[R]). We screened the FVIII gene of 13 Japanese patients (five CRM+ and eight CRM[R]) by single-strand conformation polymorphism, and identified 11 different mutations in 13 patients by analysing all 26 exons (Trp255Cys, Tyr473Cys, Gly479Arg, Arg531His, Thr667Arg, Arg1689Cys, Arg1941Gln, Arg2150His, Arg2159Cys, Thr2245Ala and Gly2285Val). Seven mutations were identified in the A domains (four in the A2 domain). All the mutations are point mutations resulting in missense codons. Four mutations (Trp255Cys, Thr667Arg, Thr2245Ala and Gly2285Val) have not been described previously.

Genetic characterization of protein C deficiency in Japanese subjects using a rapid and nonradioactive method for single-stand conformational polymorphism analysis and a model building

We studied the molecular basis of protein C deficiency in 28 Japanese families including 4 asymptomatic families. Two showed a decreased level of function with a normal antigen concentration consistent with type II protein C deficiency and the remaining 26 showed type I deficiency with decreases in both function and antigen level. All the exons and intron/exon junctions of the protein C gene were studied using a strategy combining polymerase chain reaction (PCR) amplification and rapid nonradioactive single-strand conformational polymorphism (SSCP) analysis. The PCR-amplified fragments with aberrant migration on SSCP analysis were sequenced. We identified 11 missense mutations, 1 nonsense mutation, 2 neutral polymorphisms, 1 frameshift deletion, 1 inframe deletion, and 1 splice site mutation. We also identified two different rare mutations in the 5'-untranslated region in the protein C gene that may be responsible for the phenotype. Of these molecular defects, ten were novel. From the results of genetic analysis of 47 Japanese families with protein C deficiency reported in this and previous studies, Phe139Val and Met364Ile substitutions and a G8857 deletion were only found in Japanese subjects and seem to be a founder effect. In contrast, Arg169Trp and Val297Met substitutions, both occurring at CG dinucleotides, were commonly observed in not only Japanese but also Western populations, indicating that these are hot spots for mutation in the protein C gene. These molecular defects were found in 22 families in total, accounting for 47% of Japanese families with protein C deficiency. The structural models of the second EGF and protease domains of activated wild-type and mutant human protein C suggest a possible substrate binding exosite on two loops; one from amino acid position 349 to 357 and the other from position 385 to 388, both of which are close to each other in the three-dimensional model.

Patient judgment of the quality of ambulatory care in a Japanese setting

OBJECTIVE

To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service.

DESIGN

A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service.

SETTING AND PATIENTS

All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis.

RESULTS

Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non-physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants.

Identification of two novel mutations in non-Jewish factor XI deficiency

We have studied two heterozygous unrelated CRM- non-Jewish FXI-deficient patients. Neither of the patients carries a previously described mutation. Their FXI genes were screened by SSCP analysis following PCR amplification of each exon and the flanking intronic sequences. DNA fragments showing aberrant mobility were cloned and sequenced. The following mutations were identified: in case 1, a T to G transition in exon 12 results in the substitution of Phe-442 by Val (FXI-F442V); in case 2 a C to A transition in exon 5 results in the substitution of Cys-128 by a nonsense codon (FXI-C128X). The missense mutation results in a substitution within the protease domain of FXI. Molecular modelling locates this residue in a structurally conserved region of the protease domain and the amino acid substitution may therefore interfere with either chain folding and subsequent secretion or the stability of the protein in plasma. We conclude that the mutations which we have identified are responsible for the inherited abnormality in these patients.

[Spinal canal bleeding in hemophilia A]

Case 1: Sensory and motor paralysis below the L3 level developed in a moderate hemophilia A due to spinal epidural bleeding following lumbar anesthesia for the resection of retro-peritoneal hematoma. By the treatment with cryoprecipitates, the patient recovered to walk with sticks after laminectomy. Case 2: the patient had severe hemophilia A with 220 Bethesda units/ml of inhibitor. The patient suffered from epidural and intramedullary spinal bleeding from C3 to C7 and developed tetraplegia. Since the inhibitor titer was high, infusion therapy with FEIBA was performed. Paralysis gradually reduced to the T5 level, but the patient had both sensory and motor paralysis of the extremities. It is required that an effective hemostastic treatment for spinal canal bleeding in hemophilia A with high-responder inhibitor is established.

High-level production of human blood coagulation factors VII and XI using a new mammalian expression vector

Recombinant human proteins are generally recovered in low yields from mammalian tissue culture following transfection with commercially available vectors. We have constructed a novel vector containing both the neomycin-resistance-encoding gene (neo) as a dominant selectable marker, and the dihydrofolate reductase-encoding gene (DHFR) to enable amplification of transfected DNA followed by stable expression in mammalian cell lines. Levels of 5 micrograms/ml of the coagulation proteins, factor VII (FVII) and factor XI (FXI), have been achieved in serum-free media. N-terminal sequencing of the purified proteins, and of their separated chains after proteolytic activation, demonstrated correct processing of the recombinant products. In addition, the ratios of clotting activity to antigen for each are close to unity, and the recombinant and plasma-derived proteins had identical mobilities upon electrophoresis in the presence of SDS. The vector described will be of use for the synthesis of recombinant proteins, both wild-type and variants produced by site-directed mutagenesis, especially where complex post-translational modification of the protein makes it essential to use mammalian cells.

[Determinants of patient satisfaction and intention to continue service utilization: analysis of a survey of outpatients at general hospital]

The patient-perceived quality of hospital ambulatory service and its relationship to patient satisfaction and intention to continue utilization of the service were assessed using a questionnaire which was mailed to 1,695 outpatients of a general hospital in Tokyo (response rate, 77.2%). Patient satisfaction and satisfaction and intention of continuing service utilization were each assessed and both for physicians and for the hospital. The quality of hospital outpatient service was evaluated for 36 items, and 9 patient evaluation scales were extracted by factor analysis: i.e., "treatment results", "physician competence and explanation", "physician warmth and commitment", "reputation of hospital and physician", "services by nurses and non-clerical staff", "services by clerical staff", "medical costs and barriers", "hospital environment" and "accessibility to medical care". These scales, with the exception of "accessibility of medical care", had high internal consistency. Accessibility was then decomposed into 4 independent scales-"waiting time", "outpatient clinic hours", "availability of services when needed" and "transportation convenience". The effects of a total of 23 variables, consisting of 12 patient evaluation scales, sex, age, education, income, clinical departments (4 dummy variables), "frequency of service utilization", "perceived severity of disease" and perceived necessity for medical care intervention" on patient satisfaction and patient intention to continue utilization of services were assessed by multiple regression analysis (forced entry method). The results indicated that patient assessment of "treatment results", "physician competence and explanation", "physician warmth and commitment" and "reputation of hospital and physician are important determinants of patients satisfaction and intention to continue using hospital outpatient service.

Effects of patient health beliefs and satisfaction on compliance with medication regimens in ambulatory care at general hospitals

Patient non-compliance with therapeutic regimens in ambulatory care settings is prevalent. This study was conducted to clarify the effects of patient health beliefs and satisfaction on compliance behavior. The results of multiple logistic regression analysis for the data of 650 outpatients in 7 general hospitals indicated that self-efficacy regarding compliance behavior, perceived threat to health, patient satisfaction with care, severity of illness scored by the physician, sex and age had significant effects on medication compliance. It is suggested that patient compliance is influenced not only by rationalistic decision making in relevance to health and behavior but also by patient satisfaction with health care, particularly with communication with providers.

Comorbidity and its impact on disability

Older people often suffer from comorbidity, or several chronic conditions simultaneously. Disability rises rapidly as the number of chronic conditions grows, although very ill people who acquire another condition experience attenuated increases. High prevalence conditions such as arthritis tend to have a low or occasionally moderate impact for community residents, while low prevalence ones such as osteoporosis have a high impact; paired conditions sometimes give extra propulsion to disability, as when cerebrovascular disease and hip fracture co-occur. Further research is needed to pin-point combinations of conditions posing great risks and to identify demographic segments in which comorbidity has elevated effects.

[Breast cancer: the significance of parasternal node dissection, with reference to the lymph flow of the breast]

The clinical significance of dissection of the parasternal lymph nodes (Ps) as a means for treating breast cancer has been re-evaluated through a lymph-flow study, which involved 58 cases of breast cancer patients and the use of CH 44. Initially, 1 ml of CH 44 was injected about the breast tumor immediately prior to the mastectomy. Later, the percentage of metastasis in the dissected lymph nodes, stained black by the CH 44, was studied. It was found that the originating site of the cancer had no impact on the parasternal nodes that stained black (inner and central, 76.7%; outer, 53.6%). Even in patients with an outer site tumor, cases with a metastasis to the axillary lymph nodes (Ax) showed a Ps staining as high as 75%. Thus, through not only a prognostic study but also through this lymph flow study, it has been clarified that for breast cancer, both the Ps and Ax are located at the same level as the primary lymph nodes.

A study on the correlation between estrogen receptor, progesterone receptor and tamoxifen binding sites in human breast cancer tissues

In order to examine the clinical significance of the tamoxifen binding site, correlations between the concentration of the tamoxifen binding site and either the estrogen receptor (ER) or progesterone receptor (PgR) were studied. A saturable high-affinity tamoxifen binding site was detected in human breast cancer tissues. The concentration of the tamoxifen binding sites in 12,000 g supernatant of ER positive tumors was 122.3 +/- 186.8 (mean +/- SD) fmol/mg protein, and that of ER negative tumors was 68.38 +/- 82.97 fmol/mg protein. The concentration of the tamoxifen binding sites in 12,000 g supernatant of PgR positive tumors was 103.7 +/- 137.3 fmol/mg protein, and that in the 12,000 g supernatant of PgR negative tumors was 90.29 +/- 159.0 fmol/mg protein. There was no significant difference between the concentration of the tamoxifen binding sites in the 12,000 g supernatant of ER positive tumors and ER negative tumors, and there was no significant difference between the concentration of the tamoxifen binding sites in the 12,000 g supernatant of PgR positive tumors and PgR negative tumors. The concentration of the tamoxifen binding sites in the cytosol of PgR positive tumors was 90.55 +/- 103.5 fmol/mg protein, and that in the cytosol of PgR negative tumors was 29.13 +/- 42.22 fmol/mg protein. There was a significant difference between them (p less than 0.05). The concentration of tamoxifen binding sites in 12,000 g supernatant had no correlation with the values of ER and PgR. Only the content of tamoxifen binding sites in cytosol, and the PgR value had a significant correlation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Efficacy of extrapleural internal mammary node dissection in breast cancer]

The results of extended radical mastectomy for breast cancer in 180 randomized patients treated at this department between 1965 and 1984 are reported. About 18% of the women with breast cancer had internal mammary lymph node metastasis. The incidence of metastasis in internal mammary lymph nodes increased from 9.5% when the tumor was locate in the outer half to 24.7% when it was in the center or inner half. The increase in the number of axillary lymph node metastasis was correlated with the increase in the incidence of internal mammary lymph node metastasis. The five-year survival rate of patients with no internal mammary lymph node involvement was better than that of involvement (81% versus 47%). But when the internal mammary nodes alone were involved without axillary lymph node metastasis, 83% of the patients survived for five years.