The Day the ‘Onomichi Method’ for Pancreatic Cancer Was Published in an International Journal — Finding a Cancer That No One Can Detect Alone Through a System

Pancreatic cancer is still synonymous with the phrase “it’s too late when found.” The five-year survival rate across Japan is only 8-9% — most patients have already reached stage IV by the time they notice symptoms. In response to this, the medical community in Onomichi City, Hiroshima Prefecture, has developed an early detection system called the “Onomichi Method” over the past 20 years, which has now been published in an international academic journal.

What is noteworthy is that this achievement did not stem from a single renowned physician or an expensive piece of equipment. The essence of the Onomichi Method lies in establishing a circuit for sharing “suspicions” between local primary care physicians and core hospitals — in other words, it is fundamentally about the system that connects people.

Blueprint of the System — Separating the Roles of ‘Suspecting’ and ‘Confirming’

Why is early detection of pancreatic cancer so challenging? The reason is clear: there are almost no specific symptoms in the early stages. Abdominal discomfort, sudden fluctuations in blood sugar levels, and weight loss — all of these can easily be overlooked in routine medical practice. This is precisely why the Onomichi Method incorporates the act of “suspecting” into a community system rather than relying on individual intuition.

The specific flow is as follows:

1. Primary care physicians share criteria for recalling the “possibility of pancreatic cancer.” Several risk factors, such as new-onset or sudden worsening of diabetes, pancreatic duct dilation, and incidental discovery of pancreatic cysts, are clearly documented.
2. If there are relevant patients, the primary care physician conducts abdominal ultrasound (echo) tests. This is not an expensive test; it is a very common examination that is an extension of routine care.
3. If findings such as pancreatic duct dilation or cystic lesions are observed on the ultrasound, the patient is promptly referred to a specialist at a core hospital (such as JA Onomichi General Hospital). Here, precise examinations like EUS (endoscopic ultrasound) or MRCP (MR cholangiopancreatography) are conducted.

This three-step process forms the backbone of the Onomichi Method. The “suspecting” role is taken by the primary care physician, while the “confirming” role is handled by the specialists at the core hospital. Because the roles are separated, neither side is overburdened. Supporting this collaboration are the regular case study meetings and study sessions that have continued since the early 2000s. Dr. Takashi Hanada (JA Onomichi General Hospital) and others have been central to building a collaborative framework with over 70 local clinics.

Numbers Speak to the ‘Power of the System’

So, what kind of results has this system actually achieved?

Before the introduction of the Onomichi Method, the proportion of pancreatic cancer cases detected at stages 0-I in the Onomichi region was very low. However, in recent years, as the collaborative framework has matured, the proportion of cases detected at an early (resectable) stage has significantly exceeded the national average. The paper published in the international journal shows that the five-year survival rate for the early detection group under the Onomichi Method has greatly improved compared to the national average of about 8%.

What underlies these numbers is not a special technological innovation. It is simply that primary care physicians have the knowledge to think “this might be pancreatic cancer” and that there is a well-established pathway for immediate referral — that is all. However, maintaining “just that” across more than 70 medical institutions for 20 years is far more challenging.

Why ‘Onomichi’? — Conditions Created by the Scale of a Local City

Onomichi City has a population of approximately 128,000 (as of 2024). It is neither a large city nor a depopulated area. This “intermediate scale” is deeply related to the conditions for the establishment of the Onomichi Method.

In large cities, there are too many medical institutions, making it difficult to build “visible relationships” across the board. On the other hand, in extremely depopulated areas, access to core hospitals itself can be a barrier. Onomichi has a close physical distance between primary care physicians and core hospitals, with major medical institutions located within a range that allows for case study meetings. In other words, the distance necessary for the system to “function” was just right.

Another factor not to be overlooked is the perseverance of the promoters. Dr. Hanada and others have consistently demonstrated the results of their collaboration through numbers. They have accumulated each case of “early detection” and provided feedback to primary care physicians. Because they can see what happens to the patients they referred, primary care physicians are motivated to “refer again next time.” A positive loop has begun, where the system strengthens the system.

What the Publication in an International Journal Means — A Question of ‘Reproducibility’

Publication in an international academic journal is both a badge of honor for those involved in Onomichi and a question posed to the world: “Can this system be reproduced in your region?”

Early detection of pancreatic cancer is a global challenge, and screening studies for high-risk groups are progressing in Europe and the United States. However, many of these are based on genetic risk selection or the regular implementation of expensive imaging tests. What the Onomichi Method has shown is a more grounded approach that institutionalizes the “awareness” found within routine medical practice.

However, there are conditions for reproducibility. The primary care physician system must function to some extent, the distance to core hospitals must be realistic, and above all, someone must continue to bear the human costs necessary to maintain collaboration — managing study sessions, providing feedback on cases, and updating referral criteria. While the results published in the paper are important, what supports those results is 20 years of preparation.

Another ‘System’ Story in the Same City

Let’s shift our perspective a bit. In the same city of Onomichi, another “system” is in turmoil.

The shopping arcade in the city center has been under discussion regarding its future amid aging and declining usage. In the discussions for the 2024 fiscal year, no conclusion was reached, and the final decision has been postponed to the 2027 fiscal year. This is not only a problem of the physical structure of the arcade but also a question of how to maintain — or possibly let go of — the “system of human encounters” that the shopping district represents.

Additionally, the bid-rigging issue surrounding the Onomichi City Waterworks Bureau has shaken public trust in the systems supporting public infrastructure. If the bidding system has become a mere formality, it is nothing other than the “aging” of the system.

I do not intend to simply contrast “successful healthcare” with “failed other sectors.” Rather, what concerns me is whether the conditions that made the Onomichi Method successful — where stakeholders met face to face, shared results numerically, and continuously updated the system — function similarly in the realms of shopping districts and infrastructure. Systems deteriorate if left unattended. The Onomichi Method has lasted for 20 years because someone has maintained it for that long.

Future Points of Interest — Can the System Be ‘Exported’?

The next focus of the Onomichi Method is its expansion to other regions. Similar collaborative models are already being considered in other areas of Hiroshima Prefecture and several municipalities across the country. The Ministry of Health, Labour and Welfare is also paying attention to efforts for early detection of pancreatic cancer in the context of regional medical collaboration, and evaluations in terms of medical fees and the development of training programs for primary care physicians may become future policy issues.

However, “exporting” the system is not simply a matter of distributing a manual. What worked in Onomichi was the depth of relationships, where a physician’s face comes to mind when sitting next to them in a study session, making it possible to call them. The challenge is how to transplant that depth to another place — or replace it with another form. There are increasing technical aids, such as the establishment of information-sharing platforms through digital technology and AI-assisted image diagnostics. However, the starting point for the act of “suspecting” remains the judgment of a single physician examining the patient in front of them.

In response to one of the most difficult cancers to detect, pancreatic cancer, the healthcare providers in Onomichi thought, “If it can’t be found by one person, let’s create a system for everyone to find it together.” That system has been published in an international journal after 20 years. While the paper may span only a few dozen pages, behind it lie thousands of conversations exchanged during case study meetings at night.

A system ceases to function the moment it is left unattended. Whether the Onomichi Method truly becomes a “global standard” depends on who continues to extend their hand over the next 20 years.