Cultural Scripts Underpinning Prostate Cancer-Literacy in Japan.

In a country where cancer has been dubbed a "national disease" (kokumin bio) that mostly affects Japanese men, this article presents a reading of the cultural scripts underneath prostate cancer-one of the "Western type of cancers" (ōbeigata no gan). The reading is grounded in an adaptation of the "sexual scripting theory," the construct of cancer-literacy, and the analysis of 3,092 newspaper reports published from 2005 to 2020, in three Japanese newspapers with the largest circulation in the country. The analysis is presented in line with three axes: cancer-self, cancer-biopedagogy, and cancer-economics to indicate that a cancer-self largely entails the subjectivity of a Westernized, married, heterosexual man who undergoes andropause, needs to understand what bladder somatics is, and depends on his family and the feminization of care to cope with cancer. The chances to prevent and/or survive the disease chiefly hinge on adopting a form of cancer-biopedagogy, which entails a composite entanglement of knowledge and health-related practices underpinned by the ethnicization of cancer through the consumption of "traditional food" (washoku) and the assumption that turning into a "healthy self" is determined by Japanese ethnic traits. Cancer-economics is concerned with costs of testing and treatments, health care insurance policies, and food and dietary supplements that serve to commodify a cancer-self who deals with prostate and urinary-related issues.

Cancer in Japan

Funds to endorse oncological research have been disbursed since 1963; nonetheless, a range of schemes aimed at a “drastic reduction in cancer morbidity and mortality” rates were launched in the 1980s, when cancer became the “leading cause of death in Japan” (Foundation for Promotion of Cancer Research, 2021, p. 5). Since 2014, the Ministry of Education, Culture, Sports, Science and Technology (MEXT), the Ministry of Health, Labour and Welfare (MHLW), and the Ministry of Economy, Trade and Industry (METI) have forged an alliance to further the prevention, treatment, and research of cancer, engage the general population in the fight against cancer, and uphold a grassroots approach that would help comfort cancer sufferers and make their concerns heard. In 2016, a restructuration of the medical system initiated, and one of its main objectives was to render the cancer grassroots approach a national strategy, which has been in line with a Basic Plan to Promote Cancer Control Programs that was implemented in 2018 (Foundation for Promotion of Cancer Research, 2021). Hereafter, a scheme to advance the quality of prevention has been specifically directed to cervical and breast cancer: Women concerned have received coupon tickets to urge screening and accelerate early detection, as well as to recommend (re)examinations, if needed. The scheme has moved in tandem with research based on the results of testing provided at workplace, and a genomic approach to testing, prevention, and treatment (Foundation for Promotion of Cancer Research, 2021).

In 2013, a major initiative to reinforce cancer control encompassed a law that required to register patients and the facilities where they were attended, to create a database aimed to improve services provided, standardize medical practices nationwide, advocate research, and overall, assure that treatments and prevention were scientifically substantiated. Key provisions in the law were to protect patients’ right to privacy, enforce informed consent, and guarantee that information collected would be used only by interested parties and for medical purposes. Furthermore, the database has helped to assess cancer-economics, which broadly refers to all financial issues related to prostate cancer including costs of individual testing and treatment, prices of products and services that supposedly prevent cancer, health care insurance policies, as well as the rational and efficient use of resources offered by the national government (Foundation for Promotion of Cancer Research, 2021).

Cancer has entered the action plan Health Japan 21, as one of the so-called “lifestyle-related diseases” (seikatsu shūkanbyō), and thus campaigns for “food and nutrition education” (shokuiku) have turned into a major cancer-preventive measure because unhealthy eating habits have been regarded as a leading cause of cancer (Ministry of Health Labour and Welfare, 2008a). Championing the consumption of nutritious food and balanced diets has then meant relentless efforts to improve population’s cancer-literacy, which entails an amalgam of knowledge and practices included in common sense, medical discourses, and public debates purporting that health problems concerning the prostate are to decrease proportionally to the “improvement of cancer education and awareness” (Foundation for Promotion of Cancer Research, 2021, p. 9). A core strategy has hinged on distributing leaflets at health care facilities; hence, “all cancer patients and their families should be able to obtain all information” (Munesue, 2010, p. 156).

From a gender perspective, the MHLW has implemented “health support measure[s] for women” (Ministry of Health Labour and Welfare, 2008b), which incorporates initiatives against cervical and breast cancer, such as the “Pink Ribbon Festival” that involves the civil society and official bodies to rise literacy levels concerning the “importance of early detection, diagnosis and treatment . . . in as many [. . .women. . .] as possible” (Japan Cancer Society, 2017, p. 4). Statistics, nonetheless, reveal that cancer has actually become an issue for men, whose probability of developing the disease throughout their lifetime is 65%, in comparison with women whose probability stands at 50.2%; one in four men and one in six women might eventually die of cancer (Kokuritsu gan kenkyū sentā, 2021).

The aging of the population might exacerbate the situation. In 2019, people aged 65 years or older entailed 28.4% of the total population, which largely means an increase in the number of men who might ultimately cope with prostate cancer (Statistics Bureau of Japan, 2020). Gastrointestinal cancers—stomach, large intestine, and liver cancer—and mortality rates are high among men aged 40 years or older; nonetheless, the rates tend to decrease among men aged 70 or older, whose lung and prostate cancer mortality rates increase gradually (Foundation for Promotion of Cancer Research, 2021). In 2016, “prostate was the most common cancer site (16%) for males” whose incidence ranks close to breast cancer (12%)—the most common cancer site for women (Foundation for Promotion of Cancer Research, 2021, p. 14). Despite cancer affecting more men than women, health policies suited specifically to men remain mostly elusive.

The Self and the Gendered Body in Japan

In exploring the cultural scripts beneath prostate cancer, a (re)view of how the body has become gendered in society is required. The body through Japanese history has been stereotypically scripted based on genital differences that have resulted in binary systems where masculinity is the antithesis of femininity, and entangle a form of “sociobiology” or “the biological basis of all social behavior” (Wilson, 1980, p. 4), where men’s and women’s conduct is meant to be determined and/or oriented by genetic differences. Accordingly, the male and the female-self represent “separate but overlapping (and often complementary)” (Wiederman, 2005, p. 496) behavioral patterns, which are ultimately expressed in distinct but paired forms of embodiment. One of these dyads revolves around the image of the “good wife and wise mother” (ryōsai kenbo) and her husband, the “house-master pillar” (daikoku bashira; Dasgupta, 2013b). The binary allegedly encompassed the gendered and sexual aspirations of Japanese couples until around the beginning of World War II. A second and probably more broadly embraced binary entwines the self of the “salaryman” (sararīman)—supposedly the epitome of “hegemonic masculinity” (R. W. Connell, 1995) in Japan, and his “professional-housewife” (sengyōshufu; Goldstein-Gidoni, 2012). Both binaries ratify that men are breadwinners and women are homemakers, and thus, a female embodiment has been mostly related to keeping the self fit, thin, and beautiful to secure “marriageability” (Boero, 2012, p. 8), contrary to a male embodiment which has mostly rested on “characteristics, action and intention” and a proper income to boost breadwinning capacities (Cook, 2016, p. 52).

The binaries mirror the “asymmetrical stratification of the sexes in relation to the historically varying institutions of patriarchal heterosexuality” (Ingraham, 1994, p. 204), where the body of Japanese men likely symbolizes a form of “medicalized masculinity” (Rosenfeld & Faircloth, 2006) connected to lifestyle-related diseases: “headaches from hangovers and a weakened liver from drinking too much, hemorrhoids and stiff shoulders from sitting at his desk for too long, stomach ulcers from irregular diet and stress” (Dasgupta, 2013a, p. 2), in addition to sleep deprivation “because . . . [of being] . . . on call around-the-clock,” which might result in karōshi—a death caused by extreme job-related exhaustion (Kawanishi, 2009, pp. 38–39). Men’s embodiment has been ruled by a range of “toxic practices” (Messerschmidt, 2018, p. 39) that would include the following: suppression of emotions, denying pain and its relevance, and failing to look for medical treatment promptly (Rosenfeld & Faircloth, 2006), which would help fathom why cancer has mostly become an issue for men.

Scholars and activists have nevertheless questioned the soundness of these dyadic systems, which are an obsolete reference to Japan, underpinned by a premodern view that does not show how gender relationships are shifting in contemporary society. In emphasizing that the gendered-self of Japanese people is fluid and plural, constructs such as “femininities” (e.g., Charlebois, 2013) have been employed to insist that the female-self and homemaking are not necessarily bonded together because the subjectivity of Japanese women is not biologically grounded and tied to genetic differences, but specific and diverse, and likely influenced by factors such as social “class, occupations, generations and regions” (Okano, 2009, p. 4). The notion of “masculinities” has been equally assisted in challenging biological determinisms and grasp how the gendered-male-self is being (re)produced in daily life (e.g., Roberson & Suzuki, 2003). Nonetheless, academic debates and the mass media have intriguingly engendered a “new” dyad enclosing the images of the “carnivorous girl” (nikushoku yoshi) versus the “grass-eating or herbivorous boy” (sōshoku danshi). Being reluctant to become professional-housewives, carnivorous girls apparently incarnate the self of a woman inclined to “adventure and career success” (Bardsley, 2011, p. 133), divorce, hedonism, and premarital sex (Muta, 2008; Okano, 2009). Conversely, herbivorous boys ostensibly epitomize the self of a man who is unwilling to come to be a breadwinner, enjoys homemaking, dislikes smoking and drinking (Bardsley, 2011), and leads a healthy life in general, and therefore, cancer should not be a “national disease” (kokumin bio) mostly affecting men (Asahi Shimbun, 2009).

Against this backdrop, this article aims to answer the following: What are the cultural scripts underpinning prostate cancer-literacy as presented in media reports in contemporary Japan? Who should be concerned about prostate cancer-literacy? How should prostate cancer be dealt with? What are the financial issues related to prostate cancer? The rest of the document includes the data and methods section, followed by the results of analysis which are sorted out in line with three concepts: cancer-self, cancer-biopedagogy, and cancer-economics.

Methods and Data

Owning to cancer being identified as a lifestyle-related disease, a cancer-self is defined here as a subjectivity who being unable to halt the occurrence of cancer in the prostate has let the self “go not only literally but also symbolically” (Lupton, 2013, p. 3). A cancer-self therefore embodies the subjectivity of Japanese men who should be cancer-literate and alerted to prostate cancer because of being at “risk” from disease, currently enduring treatment or having recovered from illness. This has largely triggered government interventions, medical action, and social movements to improve the level of cancer-literacy in the population, and thus, disentangling the scripts underneath media reports is significant. The media could increase cancer-literacy levels by conveying meanings and providing cautionary advice for laypeople and professionals alike deduce what prostate cancer involves, how prophylactic and preventive strategies operate, and what diagnosis, treatment, and prognosis imply. Media portrayals “mediate individuals’ lived experiences” and unintendedly propagate the condemnation of an ill and abject-self, who grapples with prostate cancer (Lyons, 2000, p. 349). Hence, “the media does not simply reflect the existence of social phenomena, it creates them” (Boero, 2013, p. 371). The mass media contributes to boost the power of cancer-prevention strategies by providing with cancer-biopedagogy, which paraphrasing Harwood (2009, p. 15), refers to a range of “instructions on bios” that are spelt out and offered as a form of guidance related to “how to live, how to eat, how much to eat, how to move, how much to move” to circumvent and/or survive prostate cancer. Cancer-biopedagogy is drawn from the Foucauldian notion of “biopower” (Foucault, 1990) that permits the “governance and regulation of individuals and populations through practices associated with the body” (Wright, 2009, p. 1). Cancer-biopedagogy renders “knowledge-power an agent of transformation of human life” (Foucault, 1990, p. 130), and therefore, media reports tend to endorse cancer-literacy to urge to “act responsibly” or “take control” over health to avoid cancer (Valier, 2016, p. 197).

Similar to Jackson and Scott (2010), the concepts of the self and subjectivity are used synonymously in this article, to express a nuance of multiplicity and diversity, that the concept of identity lacks. Subjectivity and the self are two constructs that transmit the meanings embedded in our own individual actual existence together with our internal desires, ambitions, prospects, and determinations. “The self is essentially a social process going on” (Mead, 2015, p. 188, emphasis added) that preserves a sense of continuity amid irregularities and disagreements. Subjectivity carries multiple levels of the self that cannot be grasped by the concepts of identity or identities; “subjectivity is produced, negotiated and reshaped via discourse and practice” (Lupton, 1998, p. 26). Nonetheless, a Japanese-self has been traditionally scripted through the “Theories of the Japanese” (nihonjinron) to sustain “ethno-essentialisms of the self ” (Castro-Vázquez, 2021), because in contrast to a “Western society” that is allegedly “polyracial and heterogenous,” the Japanese society is supposedly “homogenous and uniracial in its composition,” and with a “racially exclusive national culture,” which could be understood only if “one is born a Japanese” (Yoshino, 2001, p. 23). Ethno-essentialisms of the self could serve to justify that prostate cancer is ontologically linked to ethnic differences grounded in a dialectical opposition: a Japanese versus a Western subjectivity.

The “sexual scripting theory” of Gagnon and Simon (2005) was adapted to examine the cultural construction of prostate cancer in contemporary Japan. The theory has been affiliated with the philosophical tradition of pragmatism where “human action” is key to understanding why and how “subjectivity, meaning, and consciousness do not exist prior to experience, but are emergent in action and interaction” (Waskul & Vannini, 2006, pp. 2–3). How Japanese people know about prostate cancer is, therefore, “culturally and historically situated” because knowledge or knowing is always connected to how they construct and experience reality (Shapiro, 2005, pp. 3–4). Scripts entail fluid mental improvisations that permit ongoing processes of signification and interpretation (Gagnon & Simon, 2005) related to how the male-self, the prostate, and cancer become embodied and entangled at three separated but intersected dimensions of scripting: the cultural, the interpersonal, and the intrapsychic (Gagnon, 2004). The cultural entails a general scenario underpinned by public and clinical debates, as well as common sense embedded in the meanings attached to prostate cancer in Japan, to urge early detection and prevention, as well as effective means to cope with treatment and prognosis. The interpersonal encompasses a series of common dispositions that facilitate interaction concerning two or more cancer-selves, which could help them to adapt or (re)write partially cultural scripts (Simon, 1996). Eventually, the intrapsychic refers to the ability of the self to engage in an internal conversation to filter interpersonal and cultural scripting, by answering the following: What kind of subjectivity am I? What kind of subjectivity do I want to be? (Simon, 1996).

Scripts underneath prostate cancer-literacy in contemporary Japan were investigated through a textual analysis of 3,092 media reports included in three Japanese newspapers: Asahi Shimbun, Mainichi Shimbun, and Yomiuri Shimbun. Newspaper databases were used to gather editorials, news articles, and opinion pieces, but letters to the editor. Prostate cancer was the keyword to create a sample data of reports from 2005 to 2020. Once the articles including the keyword were identified, an inductive thematic analysis (De Brún et al., 2013) was conducted, which started by listing the reports but not quantifying them. Subsequently, data were classified in line with a number of tentative concepts created to scrutinize the contents presented. This generated codes and subsidiary codes that were attached to the reports, and presented through a map of systemic networks (Bliss et al., 1983). In ensuring that the networks remained an effective and valid heuristic tool, an interactive process of induction-deduction took place. As presented in Figure 1, the networks incorporated three concepts: cancer-self, cancer-biopedagogy, and cancer-economics, which included three subsidiary concepts such as ethno-essentialisms of the self, cancer-treatments, and bladder somatics, that is defined here, as the understanding of the (in)ability of passing urine, which largely implicates the embodiment of the moral and cultural scripts underneath prostatic and “intimate health” in both urinary and sexual terms (Valier, 2016, p. 6). The three concepts and subsidiary concepts are justified in the analysis, as they assisted in answering the questions grounding this article.

Figure 1

Cancer-Literacy

In reporting the outcomes of analysis, the articles were translated into English, and some excerpts are presented verbatim to facilitate explanation and a comparative perspective. Excerpts have been revised only to avoid repetition or changed to communicate fully their meaning; in this case, ellipses have been included. Overall, the analysis was oriented by the standpoint that cancer-literacy presented through “representations or other communicative forms, do not provoke a ‘response’ in any behaviorist sense, but may produce ‘a predisposition to act’” (Jensen, 1995, p. 11, emphasis added); representations “are symptoms, not portraits” (Goffman, 1976, p. 8). Consequently, readers do not necessarily decode cancer-literacy in accordance with media producers’ objectives; “[a] range of responses to media texts may eventuate, including acceptance of the intended meanings but also active negotiation or rejection of them” (Lupton, 1999, p. 261). The analysis was conducted by a scholar in his mid-50s, who has done Japanese studies for more than 20 years, and whose main teaching and research areas are medical sociology, gender, sexuality, and education.

Results

A Cancer-Self

Some articles admit that the media could rise cancer-literacy levels by offering “basic knowledge of prostate cancer” (zenritsusen gan no kisochishiki) which might have a preventive impact (Asahi Shimbun, 2007b). The first part of the analysis aims to answer the following: Who should be concerned about prostate cancer-literacy? To unravel the profile of a cancer-self. Cultural scripts related to a cancer-self mostly describe a subjectivity entwined with bladder somatics, which is understood here as an embodied experience that permits to comprehend how “urine travels through the body” (nyō no tōri michi; Mainichi Shimbun, 2013), and how a male-self becomes attached to the mechanics of urine, which largely refers to “urinary troubles [that] are [almost always] in the course of life” (hainyō toraburu jinsei no shukumei; Asahi Shimbun, 2011b). The mechanics of urine imply a “leaky abject [male] body” (Waskul & van der Riet, 2002, p. 509, original emphasis) that is subject to detailed monitoring of the amount, flow-direction, and frequency of urine excreted per day, as well as the presence of hematuria or dysuria—blood or pain when urinating. A leaky male body might indicate prostate cancer, as well as a feminized-self because “leakage and seepage” or the propensity to leak have been used to identify the “otherness” of the female body (Gatrell, 2008, p. 10).

Following Featherstone and Hepworth (2001, p. 372), bladder somatics suggest the so-called “panopticon society,” or the “institutionalisation of the life course” that elicits well-defined biosocially structured stages connected to chronological age, and “orderly sequences of psychosocial ‘growth’ and development” that render a male aging body susceptible to urinary and prostatic abnormality. A leaky male body at risk of prostate cancer is almost always a matter of age, being 50 years old a marker that could leave a younger subjectivity cancer-unconcerned.

Among cancer patients in the urology department, prostate cancer is the most common; 80 per cent of the cases. The chances of developing this form of cancer increase with age; in general, men aged 50 or older should get tested, but men older than 40 with a family member who has suffered from prostate cancer are at higher risk and should be tested too. (Yomiuri Shimbun, 2012c, p. 31)

Similar to the MHLW’s genomic approach, newspaper reports mention that “genes could easily provoke the onset of prostate cancer” (zenritsusengan wo hasshōshiyasukunaru idenshi; Mainichi Shimbun, 2010c, p. 3): a cancer-self could stem from hereditary factors. Nonetheless, the media tends to emphasize the influence of the so-called “aging society phenomenon” (kōreika shakai) that makes the self prone to cancer (Yomiuri Shimbun, 2009). Aging society is actually acknowledged as one of the two core factors contributing to the increase of prostate cancer in the population (Yomiuri Shimbun, 2012c). Aging and the susceptibility to disease translate into flesh when looking at a self who encounters “andropause” (dansei kōnenki).

. . . a 59-year-old Japanese man in Sapporo with a low testosterone level was diagnosed with an early onset of andropause . . . a decrease in male hormones is seen as a cause of andropause, and the Japanese Urologist Association has recommended . . . injecting male hormones to maintain the level of testosterone . . . 40 percent of men in their 60’s experience dropping levels of testosterone. (Yomiuri Shimbun, 2007b, p. 16)

“Hormone therapy” (horumon chiryō) or testosterone replacement therapy entails a recurrent option to ease the symptoms of andropause, yet its side-effects should be thoroughly considered: “If there is no symptom, hormone therapy is not needed” (shōjō ga nakeraba, horumon chiryō ha hitsuyō nai; Yomiuri Shimbun, 2007b, p. 16). The therapy could cause prostate tissue growth and eventually trigger prostate cancer. A cancer-self might hence involve an andropausal subjectivity who underwent testosterone replacement therapy.

Many cultural references to aging linked to a cancer-self become apparent via the image of World War II “atomic bomb survivors” (hibakusha) from Hiroshima and Nagasaki, who having been exposed to nuclear radiation through the so-called “black rain” (kuroi ame) have wrestled with different forms of cancer through their life, and currently cope with prostate cancer as their body ages (Mainichi Shimbun, 2015). The persona of the former emperor Akihito, likewise, plays an important role in (re)asserting the relevance of an age-graded subjectivity in the construction of a cancer-self. After the emperor underwent a prostate cancer surgery, his condition is critical: “his age and health are a concern” (tennō no nenrei ya kenkō ni hairyoshite no koto da; Mainichi Shimbun, 2009c, p. 5).

Despite the Foundation for Promotion of Cancer Research (2021) insisting that data regarding a cancer-self should be treated confidentially, details related to diagnosis and treatment of the emperor are regularly reported, as the well-being and physical condition of the father of the nation could be a national preoccupation (Mainichi Shimbun, 2009a). The emperor’s circumstances are not unique, however. Aging and fatherhood become interwoven and a number of newspaper articles locate a cancer-self at the heart of a family who is worried about the father who grapples with prostate cancer. Through the articles, the ideology of familialism might be grounding the provision of care for a cancer-self.

I read carefully the mail till the end, holding my breath. For about six months from today, my father is going to the hospital for prostate cancer treatment. As they found it early, his recovery rate is 100 percent. But still, I can’t help worrying . . . I want to do something for my father who is receiving treatment alone . . . I answered his mail with shaky hands: “. . . do your best. I love you”. (Mainichi Shimbun, 2008a, p. 4)

Nonetheless, taking care of a cancer-self is likely to be a matter for the women in the household. A number of reports portray the image of wives or daughters tending and nursing a cancer-self which largely elicits the feminization of care. As a 64-year-old wife from Hyogo prefecture elaborates,

For my child half of a bowl of rice, for my husband even less, I’m told. When he gets back from the field, before changing his clothes, he weighs himself. My husband is 76 years old, since he recovered from a prostate cancer surgery last year, he got motivated to lead an independent life as much as possible . . . I make an effort to get him back to his normal weight little by little . . . I simmer rice together with chopped sweet potato, potato, carrot and turnip . . . For breakfast, I sometimes serve him green tea and for seasoning, I use less sodium miso paste . . . mixing red and black rice changes his appetite a bit. (Yomiuri Shimbun, 2006a, p. 18)

Consistent with the MHLW, the media insists that a “healthy diet” constitutes cancer-prevention. The second core factor contributing to Japanese prostate cancer, therefore, relates to the “Westernisation of eating habits” (shokuseikatsu no ōbeika). Cultural scripting appears simplified and expressed in the formula: aging society + Westernization of eating habits = prostate cancer (Yomiuri Shimbun, 2012c). A cancer-self might imply a Westernized subjectivity connected to the consumption of Western food, which leads to the second part of analysis: a cancer-biopedagogical project that could help minimize the impact of prostate cancer.

Cancer-Biopedagogy

The concept of cancer-biopedagogy as a valid heuristic tool to disentangle cultural scripts linked to prostate cancer relies upon the viewpoint that cancer is a lifestyle-related disease. In this light, rather than “genetics” (iden), health care professionals, academics, and politicians should be fretted about the presumed “cancer in the family line” (gan kakei), which refers to eating habits and “unhealthy” practices that could provoke cancer in the household. When doctor Nakagawa is asked “whether there is cancer genetic predisposition” (gan taishitsu ha identiki no yōso ga aru ka to iu), he responds the following:

Basically, no. Cancer genetic predisposition is very low. There are many cancers that are gotten at home. If the father smokes, children smoke too. Everyone eats the same food at home, and if they eat meat only, it is easy to get colon cancer or prostate cancer. This could be explained by what has been thought of as cancer in the family line. (Mainichi Shimbun, 2008b, p. 25)

Cancer-biopedagogy becomes rather concrete and “applicable” instruction when reports highlight the risk factor that red meat entails. Clearly, a cancer-self is most likely a Westernized-self, who is an avid meat eater and thus adopting vegetarianism or reducing meat ingestion could be a means to prevent prostate cancer. This moves in tandem with research that stresses eating patterns to convey that higher prostate cancer incidence in the “West” is strongly associated with “high in energy, meat, and fat” diets, in opposition to “Asian” lower incidence which is due to “rich in vegetables and legumes” diets (Mróz et al., 2011b, p. 177). Such cancer-biopedagogy seemingly sustains a form of essentialism of the self, similar to the traditional perspective purported in the Theories of the Japanese, where a Western subjectivity could be ontologically “unhealthy” in opposition to a Japanese one, who might personify an archetype of “healthiness.” Ingesting red meat is indeed a Western influence; nevertheless, “the consumption of beef . . . in the form of . . . a dish now internationally known as sukiyaki” has been in the Japanese diet of the upper middle classes since the 1870s, and eating meat was already a general population habit by the “late nineteenth or early twentieth centuries” (Bestor, 2011, p. 281). Substantiating cause–effect relationships in current Japanese society is challenging, yet some newspaper reports underscore that an increase in the consumption of red meat stimulates the secretion of sexual hormones, which has been linked to the occurrence of “Western type of cancers” (ōbeigata no gan): breast and prostate cancer (Yomiuri Shimbun, 2010, p. 29).

Milk was introduced during the Asuka Period (592–710), and Meiji authorities (1868–1912) advocated the consumption of meat and milk as an element of the “modernization push” (Japan Dairy Association, 2020, p. 2). Nevertheless, another factor of the assumed recent Westernization of eating practices that might be triggering prostate cancer entails the intake of dairy products.

“Drinking too much milk means a risk factor for prostate cancer.” . . . The MHLW has found in a survey that the risk is about 50 per cent higher among those who drink 150 millilitres of milk every day, in opposition to those who barely drink it. The risk seems to be related to “saturated fat acids” (hōwa shibō san) and calcium contained in dairy products. If the risk of cancer becomes higher, it is not unusual to conclude that it is better to avoid dairy products. However, in a recent MHLW survey, it was found that the risk of colon cancer in men who take calcium from dairy products decreases by 40 per cent. Depending on cancer type the risk increases or decreases. (Asahi Shimbun, 2008, p. 7)

Through the newspapers, the meaning of cancer-risk and cancer-prevention turns unclear, and renders cancer-biopedagogy puzzling. In relieving anxiety and abating confusion, some reports provide succinct, straightforward, and rather realistic cancer-biopedagogy: to espouse “a diet centred on Japanese traditional food to prevent” cancer (washoku chūshin nado de yobō) (Yomiuri Shimbun, 2012a, p. 30). As Dr. Fukaya at a general hospital in the city of Koriyama explains,

There is a growing tendency of patients whose urological cancer has its origin in smoking, psychological stress and the so-called Westernisation of eating habits: a high-fat diet [. . . that includes . . .] red meat and dairy products. In our hospital there are more than 100 people with prostate cancer a year, about twice as much as ten years ago. Although it is known as an ageing men disease, the number of patients in their 40s and 50s is increasing . . . Obviously, prevention is the most important thing before cancer starts . . . I want [men] to reconsider daily life, drinking alcohol and smoking in moderation, and “eating habits centre in traditional Japanese food” (washoku chūshin no shokuseikatsu) [which means] eating a lot of beans, cereals and vegetables. (Yomiuri Shimbun, 2012a, p. 30)

Cancer-biopedagogy thus emerges at the heart of a fairly rigid dichotomy between the “unhealthy” Westernization of eating habits and the “healthy” consumption of traditional Japanese food—a plausible cancer-prevention strategy. Ohnuki-Tierney (1993, pp. 129–130) contends that Japanese food has become a sign of “self-identity” via the symbolism embedded in food consumption, which mainly elicits that Japanizing the male-self could be the “best” preventive scheme against cancer of the prostate. Comprehending what traditional Japanese food involves is therefore key to articulating cancer-biopedagogy. The well-known Japanese “multi-course haute cuisine” (kaiseki ryōri) as well as “dishes prepared for particular occasions such as the celebration of New Year’s Day” (osechi ryōri) have been conventionally acknowledged as traditional Japanese food. Yet, the Ministry of Agriculture, Forestry and Fisheries (MAFF) conveys the following:

[t]ypical washoku at home is usually comprised of cooked rice, miso soup, some main and side dishes and pickles. A set menu of grilled fish at a downtown diner is also a type of washoku. Recipes using cooked rice as the main ingredient such as curry and rice or sushi should also be considered as a type of washoku. Of course, washoku includes some noodle and mochi dishes. The world of traditional washoku is extensive. (Ministry of Agriculture, Forestry and Fisheries [MAFF], 2013, p. 1)

Owning to the extensiveness of traditional Japanese food, grasping how exactly Japanese eating habits could preclude prostate cancer remains problematic. Rather than cancer-prevention, media’s open endorsement of traditional cuisines might denote the romanticization of foodstuffs amid “the rapid advancement of globalization,” which has prompted chauvinism via “banal nationalism in food” (Ichijo & Ranta, 2016, p. 6). Sanctioning traditional Japanese food does not encompass a “value free, symbolically-neutral source of nutrition that has come haphazardly into being” (O’Connor, 2011, p. 157), and might magnify the power of cancer-niche markets, which in this article refers to an element of cancer-economics that entails a range of services, foods, products, dietary supplements, and alternative treatments that could serve as prevention strategies or palliative-care practices for a cancer-self. Examples of these are “healthy foodstuffs” (kenkō shokuzai) that are meant to keep prostate cancer at bay (Asahi Shimbun, 2010a, p. 34). Eating soybeans—a legume native to East Asia containing “isoflavones” (isofurabon)—could be the basis of a sound cancer-biopedagogy, due to an estrogenic and antioxidant effect on the body. Some newspaper reports maintain that drinking “soy milk” (tōnyū) and consuming “soybean products” (daizu seihin), in general, epitomize a strong cancer-preventive strategy (Asahi Shimbun, 2010c).

The image of soybeans as “healthy foodstuffs” is strong. In reality, how effective are they? . . . Isoflavones’ structure is similar to female hormones or oestrogen. Since they have the same effect on the body as oestrogens, it is expected that they somewhat would have a preventive effect against breast cancer and prostate cancer. There is a risk that they could also cause cancer or provoke cancer relapse. That is why it is recommended not take them to excess; about 30 milligrams every day is a standard intake. (Asahi Shimbun, 2010a, p. 34)

Healthy foodstuffs with cancer-preventive value include also green tea—one of the quintessential components of Japanese culinary traditions, whose “curative” force circulates around its high occurrence of catechin that acts as an “antioxidant” in the body (MAFF, 2013, p. 30). Some newspaper reports highlight that men who drink more than five cups of green tea every day could reduce by half the risk of prostate cancer progression (Mainichi Shimbun, 2012). Flourishing cancer-niche markets intimate that rising cancer-literacy levels could have limited impact on disease rates, if a cancer-self’s capacity for buying services and products to grapple with prostate cancer is not considered. This leads to cancer-economics as a category to analyze cultural scripting beneath prostate cancer.

Cancer-Economics

The analysis reveals that obituaries heavily populating the newspaper reports likely deliver a reminder that although treatable, prostate cancer could mean a death sentence (eg. Mainichi Shimbun, 2005a). “When I was hospitalised, it was a great shock [to know that] three men with a metastasised prostate cancer died” (Mainichi Shimbun, 2005b, p. 6). The profitability of cancer-niche markets might be directly proportional to “fear of death” and cancer-testing results’ inaccuracy. Investing money in foodstuffs with healing power, as well as any form of testing that could serve to identify cancer at an early stage expose an aspect of current cancer-economics. A reading of the body through bladder somatics is the first step to recognize any “irregularity” in the mechanics of urine that could indicate prostate cancer. Prostate-specific antigen (PSA) testing could dispel doubt, and thus, some articles strongly advocate examination once a year for those aged 50 years or older. However,

PSA does not only indicate the presence of cancer cells, “benign prostatic hyperplasia” (zenritsusen hidaishō) also increases [a PSA level]. A PSA level could be very high when suffering from cystitis [inflammation of the urinary bladder] or urethritis [inflammation of the urethra], or after taking medicine for cold when urinating could be very difficult . . . If cancer progresses the PSA level becomes higher . . . In a scale from four to ten, cancer has been detected in one in five men with a PSA level of four. Two in three men have cancer, if their level is higher than 20, and the probability of suffering cancer is mostly 99 per cent, if the level is 50 or over. But a PSA level could be the same when having cancer at early stage, benign prostatic hyperplasia or prostatitis. As long as a biopsy is not done, cancer cannot be diagnosed. (Mainichi Shimbun, 2006a, p. 21)

This encompasses an additional layer to cancer-literacy: a cancer-self should be arithmetically literate to read the body through the parameters of PSA testing and prostate biopsies—a test that “requires anaesthesia and lasts for about 30 minutes” where “a tool is inserted through the anus” to obtain a sample tissue from the prostate, which begets a new sense of embodied normality in the structuring of bladder somatics (Asahi Shimbun, 2013b, p. 30). Furthermore, the analysis of cancer-economics shows that the health care insurance system, which unlikely covers regular (re)testing, is closely related to the profits of cancer-niche markets. A number of articles underscore how prostate cancer was discovered only after a self-pay, “complete medical check-up” (ningen dokku) was practiced. PSA testing is unlikely included in a routine “company-subsidised check-up” (shokuba no kenkō shindan; Asahi Shimbun, 2005a, p. 21), and consequently testing might be culturally scripted as a dispensable procedure that depends on a cancer-self financial situation. In the event, civil society organizations have collaborated with medical facilities to hold public events and brace initiatives that would enhance the social visibility of prostate cancer, and accelerate early detection through PSA testing (Mainichi Shimbun, 2010b). Some of these organizations propose to institute the “blue clove” (burū kurōbā) day, similar to “the pink ribbon” (pinku ribon) day, to raise social awareness of prostate cancer (Asahi Shimbun, 2013a).

Having had detected prostate cancer does not inevitably indicate speedy medical intervention. Commonsensical cancer-literacy indicates that “cancer early detection decreases mortality rates, but the progression of many prostate cancers is slow,” and thus, “it is unclear, if mortality rates would decrease in men without noticeable symptoms” (Yomiuri Shimbun, 2007c, p. 1). In the case of breast cancer, watchful waiting has been recommended as an alternative to opt out of “traditional surgery and treatment” (Fink, 2021). Nonetheless, newspaper reports indicate that “watchful wating” (keika kansatsu) could be a recurrent course of action in the case of prostate cancer, because

every treatment has pros and cons, . . . [therefore it is recommended to] listen to medic’s explanation carefully to choose treatment . . . “prostate cancer grows slowly in general, there are instances when non-immediate treatment is required, watchful waiting is recommended without immediate treatment”. (Yomiuri Shimbun, 2012b, p. 31)

In cancer-literacy terms, a cancer-self should be able to read the body in line with the “ABCD prostate cancer staging system” (ABCD no 4 dankai), where A and B stages refer to cancer tumors confined to the prostate, C means cancer cells growing out of the prostate but not reaching lymph nodes or other parts of the body, and D stage denotes cancer tumors present in lymph nodes and other parts of the body (Mainichi Shimbun, 2006b, p. 21). Watchful waiting, in addition, evinces another angle on cancer-economics, which is related to the niche market of “complementary and alternative medicine” (hokan daitaiiryō) and “Japanese traditional medicine” (kampo yaku). Monitoring how prostate cancer progresses via watchful waiting and regular testing might make a cancer-self a potential and eager consumer of complementary and alternative medicine. Ito and colleagues have found that medics are willing to prescribe Japanese traditional medicine because this form of “treatment is well accepted by patients too” (Ito et al., 2012, p. 5), which chiefly symbolizes a socio-economic process where a cancer-self becomes commodified. Newspaper reports alert to the “dangers” of looking for alternatives to thwart cancer because

. . . herbs that are said to be “effective against prostate cancer” are not. In Japan, shark cartilage is supposed to be “effective against cancer” [but] research is in progress and thus it is unknow how effective it is . . . (Asahi Shimbun, 2005b, p. 23)

After corroborating that watchful waiting is not a viable option, a cancer-self usually faces the difficult conundrum of deciding medical treatment, as it requires a higher cancer-literacy level or a clearer and deeper understanding of the impact of treatment side-effects and cancer-economics because not all treatments can be covered by the National Health Care Insurance. Newspaper reports underscore how major breakthroughs in cancer-research have brought about improvements in the “quality of life” (seikatsu no shitsu) of a cancer-self through the use of less invasive treatments (Yomiuri Shimbun, 2006b), where the gendered-self, the sexual-self, and the cancer-self become entangled. Reports stress that less invasive treatments are grounded in “male’s feelings” (dansei no kimochi; Mainichi Shimbun, 2009b) to help preserve “male’s pride” (jisonshin; Asahi Shimbun, 2011a), as well as “male’s functions” (dansei kinō; Yomiuri Shimbun, 2007a). Opting for less advanced treatments might result in a leaky-feminized male body that suffers from “incontinence” (hainyō shōgai; Asahi Shimbun, 2007a), and struggles with “decreased libido” (seishoku gentai; Asahi Shimbun, 2010b), or the most feared male condition: “erectile dysfunction” (bokki fuzen; Asahi Shimbun, 2010b). Japan certainly boasts top-notch medical technologies that a cancer-self could avail to avoid treatment side-effects. The so-called “advanced treatments” (kōdo iryō, senshin iryō) are largely nonaggressive medical procedures that have less repercussions for the body, and include the use of “robots” (robotto; Yomiuri Shimbun, 2011, p. 25), “heavy ion radiotherapy” (jūryūshisenchiryō; Asahi Shimbun, 2013c, p. 31), or “proton therapy” (yōshisenchiryō; Mainichi Shimbun, 2007, p. 26). Yet, accessing them could be restricted by the financial capacity of a cancer-self because their costs might be only partially covered by the health care insurance.

The power of cancer-economics is clearer when looking at how some articles outline the outcomes of surveys to evince how the lack of financial means has become an obstacle to accessing cancer-treatments (Mainichi Shimbun, 2010a). The case of Mr. Yoshida aged 72 years from Tokyo illustrates how cancer-literacy and cancer-economics might be intertwined in current cultural scripting of prostate cancer in Japan.

I have chosen heavy ion radiotherapy as prostate cancer treatment. The reasons are “I hate pain. I am busy with work. Treatment finishes soon” . . . So far, there’s no relapse. “It is good that I got treated. But, in terms of lifestyle, treatment was not the best option, also many doctors say that their treatment is the best option. I felt that getting a second opinion and getting informed by my own was important” . . . Heavy ion radiotherapy’s impact on the body is low, . . . But, the heavy ion radiotherapy that the MHLW acknowledges as “advanced treatment” (senshin iryō) means a self-pay treatment of about 3,000,000 JPY. . .[which is] difficult to afford. (Asahi Shimbun, 2011c, p. 25)

Conclusion

In view of cancer being a national disease that affects more Japanese men than women, and prostate cancer “the second most common cancer in men worldwide” (Soerjomataram & Bray, 2020, p. 28), this article has explored how mass media reports have contributed to propagating the cultural construction of prostate cancer in Japan. An adaptation of the “sexual scripting theory” (Gagnon & Simon, 2005) along with the concept of cancer-literacy was instrumental to delve up and dismantle how newspaper reports (re)create signification and interpretation processes concerning a condition that has been classified as a lifestyle-related disease whose social, economic, and political impact could be diminished by disseminating knowledge concerning prevention, diagnosis, treatment, and prognosis, as the occurrence of prostate cancer might essentially hinge on the “volitional act” of changing lifestyle.

In grasping how prostate cancer constitutes an embodied experience that transforms the self and turns the male body into a form of “abject embodiment” where “coherent bodily boundaries erode” (Waskul & van der Riet, 2002, p. 487), the concepts of the self and subjectivity were employed synonymously. This served to express the sociality of the self as a “process going on” (Mead, 2015, p. 188), and largely challenged any form of essentialisms of the self contending that a Japanese identity encompasses an “expression of a timeless national essence” (Martin, 2015, p. 35), framed by a binary implying that a Western and a Japanese subjectivity are ontologically different.

The inductive thematic analysis elicited that cancer-self was the first concept to examine the meanings embedded in a male subjectivity who is likely to endure prostate cancer. The male-self gets intertwined with bladder somatics through the mechanics of urine, which would be the first step to detect prostate cancer: “a disease that is after all overwhelmingly a disease of older men” (Valier, 2016, p. 195) because a Japanese cancer-self was depicted as an aging subjectivity struggling with andropause, whose gendered-self was chiefly located within the grids of “patriarchal heterosexuality” (Ingraham, 1994, p. 204). Care for a cancer-self was underpinned by the ideology of familialism and the feminization of care, and thus, the viewpoint that contemporary Japanese gender relationships are fluid and plural might be “an energetic celebration of diversity [that does not disrupt] familiar gender categories” (R. Connell & Pearse, 2015, p. 84). Such cultural scripting appeared rather in line with Canadian couples who “positioned women as natural leaders in family food, nutrition and health” when dealing with prostate cancer in the household (Mróz et al., 2011a, p. 1501). Furthermore, the profile of a cancer-self intimated the prevalence of ethno-essentialisms of the self because the occurrence of prostate cancer was entangled with “unhealthy” Westernized eating habits.

Rebbeck (2020, p. 425) has argued that “limited convincing evidence for associations of . . . dietary exposures with risk prostate cancer makes it difficult to identify . . . prevention strategies.” Nonetheless, some newspaper reports straightforwardly maintained that aging society + Westernization of eating habits = prostate cancer. This helped to simplify cancer-literacy and led to the second category of analysis: cancer-biopedagogy, to refer to a concoction of knowledge and health-related practices that could serve to ward off disease, and largely portrayed prostate cancer as an ethnicized-disease, or one of the “Western type of cancers” (ōbeigata no gan). Consequently, the best prevention strategy could rely on the Japanization of eating habits and by extension the Japanization of the self, through the consumption of “traditional food” (washoku). Such cultural scripting chiefly mirrored academic and medical perspectives contending that the so-called “Asian diet . . . [might] . . . inhibit prostate cancer cell growth” (Sonn et al., 2005, p. 304). Ethnicizing prostate cancer denoted, nonetheless, two unintended consequences: fostering a false sense of embodied-disease-impregnability of the Japanese-self, and creating profitable niche markets linked to a range of “healthy foodstuffs” (kenkō shokuzai) with alleged cancer-preventive or curative power.

Associated with the understanding of niche markets, the third concept to analyze cancer-literacy was concerned with finances and expenses related to prostate cancer: cancer-economics. Given that prostate cancer has been profusely scripted as an ethnicized ailment, PSA testing might have been unlikely an element of routine health checkups or covered by the National Health Care Insurance, which has made early detection unessential, and largely hanging on self-pay testing or as Valier (2016, p. 11) puts it, prostate cancer encompasses “a ‘neglected’ disease.” In keeping with Skyring and colleagues (2021, p. 1), the analysis hinted that decision-making concerning “treatment options are complex and difficult.” This seemed mostly linked to the watchful waiting stage that a cancer-self usually endures. Such stage seemingly resulted in a reading of the prostate cancer staging system as an embodied experience that transforms a cancer-self, and shed some light on a different view of cancer-economics: alternative treatments and traditional Japanese medicine as a niche market available to a cancer-self who monitors how prostate cancer progresses. The last aspect of cancer-economics stemmed from “prostate cancer diagnosis and treatment side-effects [that] can [. . . threaten] men’s financial security” (Yu Ko et al., 2020, p. 1). A number of newspapers indicated that advanced and less invasive interventions that could represent post-treatment improved quality of life were partially or uncovered by the health care insurance. A cancer-self unable to afford such interventions might compromise his sexual and gendered-self. Similar to Valier (2016, p. 194), the analysis of cancer-economics illustrated how ethnicized prostate cancer might have emerged as a “promised market” due to the persistent efforts of the medical industry and the enthusiasm of a cancer-self willing to preserve “male’s pride” (jisonshin) intact.

Discussion

The analysis of cancer-literacy through Japanese newspaper reports helps to add another layer to the understanding of prostate cancer through the use of the concepts of cancer-self, cancer-biopedagogy, and cancer-economics. In the analysis of data, the construct of ethno-essentialisms of the self is particularly relevant, as it largely serves to justify the existence of the so-called Western type of cancers. Such justification is mostly underpinned by the assumption that a Japanese ethnicity renders the self “healthy” in opposition to a Western-self, which seems to be ontologically “unhealthy.” Considering prostate cancer as an ailment of “the West” suggests that improvements in health care policy-making and early detection, as well as advances in cancer-research are dispensable in a “non-Western” context. This could result in boosted-profits and revenues of cancer-niche markets offering traditional food as “the best” form of cancer-biopedagogy to prevent and cope with ailment. In managing prostate cancer, Japanese clinicians are therefore to sustain a critical view concerning a disease that affects the male-self regardless of ethnic backgrounds. Future medicosociological research should shed some light on how ethnicizing prostate cancer has an impact on actual medical practice and the lived-experiences of a cancer-self who might be enduring the impact of treatments’ side-effects that compromise his gendered and sexual-self, and might contradict his comprehension of what a Japanese ethnicity entails. Taking into account the apparent salience of ethnic factors in the sociomedical assessment of prostate cancer, the outcomes of analysis presented here should be compared and/or contrasted with research conducted at different “non-Western” and “Western” contexts.