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National Cancer Control Programmes

in Thailand

Petcharin Srivatanakul
National Cancer Institute
Bangkok, Thailand
NCCP Thailand
13 August 1998:
1st National Cancer Control Committee
chaired by Prime Minister of Thailand

17 Feb 2000:
2nd National Cancer Control Committee meeting
chaired by Prime Minister of Thailand

2000-2001:
1st National Cancer Control Plan was established

2001-2006:
four most common cancers- Nation-wide cancer
prevention was implemented
The aim of cancer control is a reduction
in both the incidence and the mortality rates
of the disease.
The objectives of cancer control :

. To make optimal use of limited resources


to benefit the whole population
. To achieve high coverage with early
detection and screening measures
. To ensure equality of access to cancer care
. To improve control of symptoms
NCCP Thailand

1. Cancer Informatics
2. Primary prevention
3. Secondary prevention
4. Tertiary prevention
5. Palliative care
6. Cancer research
Cancer Informatics

National Policy in Cancer


Registration

Population-based cancer registry

Hospital-based cancer registry


Population based Cancer Registry
1998 - 2000

Chiang Mai
Lampang
3. Nakhon Phanom
4. Udon Thani
Prachuab Khiri Khan 5. Khon Kaen
6. Bangkok
7. Rayong
8. Prachuab Khiri Khan
9 Songkhla
Songkhla
Leading Cancers in Thailand, 1998-2000

Male Female
Liver and bile duct 33.4 Cervix uteri 24.7

Bronchus, lung 20.6 Breast 20.5

Colon and rectum 8.8 Liver and bile duct 12.3

Oral cavity 5.2 Bronchus, lung 9.3

Non-Hodgkin lymphoma 4.5 Colon and rectum 7.6

Bladder 4.2 Ovary 5

Oesophagus 4.1 Oral cavity 4.6

Leukaemia 3.9 Thyroid 4.1

Prostate 3.5
Skin 3.3

Stomach 3.5 Leukaemia 3.2

0 10 20 30 40 0 5 10 15 20 25 30 35 40

ASR (World)
Leading Cancers in Chiang Mai, 1998-2000

Male Female
Bronchus, lung 29.6 Cervix uteri 29.4

Liver and bile duct 17 Bronchus, lung 22.3

Colon and rectum 9.2 Breast 20.7

Non-Hodgkin lymphoma 6.7 Colon and rectum 7.8

Oral cavity 5.5 Ovary 5.9

Stomach 5 Liver and bile duct 5.8

Bladder 4.8 Stomach 4.4

Prostate 4.6 Thyroid 4.3

Skin 4.1 Non-Hodgkin lymphoma 4.1

Leukaemia 3.8 Oral cavity 3.9

0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35

ASR (World)
Leading Cancers in Lampang, 1998-2000

Male Female
Bronchus, lung 53 Bronchus, lung 27.6

Liver and bile duct 32.9 Cervix uteri 22.3

Colon and rectum 11.7 Breast 20.8

Non-Hodgkin lymphoma 5.4 Liver and bile duct 14.7

Prostate 5.2 Colon and rectum 9.5

Stomach 5 Ovary 4.6

Leukaemia 4.6 Leukaemia 3.9

Bladder 4.5 Oral cavity 3.7

Skin 4.3 Stomach 3.6

Nasopharynx 2.2 Non-Hodgkin lymphoma 3.6

0 10 20 30 40 50 60 0 10 20 30 40 50 60

ASR (World)
Leading Cancers in Nakhon Phanom, 1998-2000

Male Female
Liver and bile duct 63.5 Liver and bile duct 31.1

Bronchus, lung 7 Cervix uteri 11.3

Colon and rectum 5.5 Breast 10.1

Stomach 3.7 Oral cavity 4.9

Bladder 2.3 Colon and rectum 4.8

Gallbladder 1.7 Ovary 4.7

Prostate 1.7 Bronchus, lung 3.7

Nasopharynx 1.5 Corpus uteri 2.1

Penis 1.3 Uterus unspecified 1.2

Oral cavity 1.3 Gallbladder 1.2

0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70

ASR (World)
Leading Cancers in Udon Thani, 1998-2000

Male Female
Liver and bile duct 113.4 Liver and bile duct 49.8

Bronchus, lung 26.3 Cervix uteri 19.5

Colon and rectum 11.9 Breast 13

Leukaemia 5.4 Colon and rectum 8.5

Bladder 4.3 Bronchus, lung 8.3

Stomach 4.3 Ovary 4.5

Brain, nervous system 3.8 Oral cavity 3.9

Prostate 3.8 Leukaemia 3.3

Non-Hodgkin lymphoma 3.3 Skin 2.4

Nasopharynx 3.2 Stomach 2.2

0 20 40 60 80 100 120 0 20 40 60 80 100 120

ASR (World)
Leading Cancers in Khon Kaen, 1998-2000

Male Female
Liver and bile duct 78.4 Liver and bile duct 33.3

Bronchus, lung 20.6 Cervix uteri 15.9

Colon and rectum 8.6 Breast 13.7

Non-Hodgkin lymphoma 5.1 Bronchus, lung 7.1

Leukaemia 4.6 Colon and rectum 7

Skin 4.3 Oral cavity 6.7

Bladder 4.1 Ovary 6.2

Stomach 3.6 Thyroid 4.6

Oral cavity 3.5 Skin 4.2

Prostate 2.9 Leukaemia 3.1

0 20 40 60 80 100 0 20 40 60 80 100

ASR (World)
Leading Cancers in Bangkok, 1998-2000

Male Female
Bronchus, lung 18.4 Breast 24.3

Liver and bile duct 13.4 Cervix uteri 19.3

Colon and rectum 12.4 Colon and rectum 9.6

Prostate 6.7 Bronchus, lung 6.5

Bladder 5.9 Ovary 5.1

Oral cavity 4.9 Liver and bile duct 4.3

Non-Hodgkin lymphoma 4.6 Thyroid 3.9

Nasopharynx 3.6 Corpus uteri 3.9

Stomach 3.6 Skin 3.8

Skin 3.6 Oral cavity 3.3

0 5 10 15 20 25 30 0 5 10 15 20 25 30

ASR (World)
Leading Cancers in Rayong, 1998-2000

Male Female
Bronchus, lung 25.1 Cervix uteri 28.5

Liver and bile duct 14.9 Breast 22

Oesophagus 10.3 Bronchus, lung 7.5

Oral cavity 9.3 Colon and rectum 6.5

Colon and rectum 7.3 Oral cavity 4.9

Bladder 7 Ovary 4.5

Leukaemia 5 Liver and bile duct 4.1

Larynx 4.2 Thyroid 3.7

Prostate 3.9 Oesophagus 3.5

Oropharynx etc. 3.6 Leukaemia 3.4

0 5 10 15 20 25 30 0 5 10 15 20 25 30

ASR (World)
Leading Cancers in Prachuap Khiri Khan, 1998-2000

Male Female
Bronchus, lung 12.1 Cervix uteri 21.2

Colon and rectum 7.7 Breast 16

Liver and bile duct 7.3 Colon and rectum 4.9

Oral cavity 5.7 Oral cavity 4.4

Oesophagus 5.2 Bronchus, lung 2.8

Non-Hodgkin lymphoma 4.1 Thyroid 2.6

Skin 2.9 Leukaemia 2.4

Prostate 2.6 Liver and bile duct 2.4

Larynx 2.3 Non-Hodgkin lymphoma 2.4

Penis 2.3 Skin 2.3

0 5 10 15 20 25 0 5 10 15 20 25

ASR (World)
Leading Cancers in Songkhla, 1998-2000

Male Female
Bronchus, lung 13.5 Cervix uteri 20.6

Colon and rectum 10.2 Breast 17.2

Oral cavity 9.7 Colon and rectum 7.4

Oesophagus 8.1 Thyroid 5.7

Liver and bile duct 7.7 Ovary 5.7

Skin 5.2 Bronchus, lung 4.9

Non-Hodgkin lymphoma 5.1 Leukaemia 4.5

Bladder 4.5 Non-Hodgkin lymphoma 3.9

Prostate 4.1 Skin 3.8

Larynx 4 Corpus uteri 3.3

0 5 10 15 20 25 0 5 10 15 20 25

ASR (World)
Table
1990 1993 1996 1999 2002 2005 2008
The four principle cancers of Thailand
Liver
Lung 42.0% of all cancers in men
Cervix 54.2% of all cancers in women
Breast
National Cancer Control Programmes(NCCP) of Thailand
in the year 2000

Prevention
Early diagnosis
Treatment
Palliative Care
CANCER CONTROL
Priorities and strategies for the eight most common cancer worldwide1
Site of cancer2 Prevention Early Curative3 Pain relief and
diagnosis therapy palliative care

Liver ++ - - ++
Lung ++ - - ++
Cervix + ++ ++ ++
Breast + ++ ++ ++
Stomach + - - ++
Colon / rectum + - + ++
Mouth / pharynx ++ + ++ ++
Oesophagus + - - ++

1 Adapted from reference 4.


2 Listed in order of global prevalence
3 For the majority of cases,provided that there is early diagnosis
++ effective + partly effective - ineffective
Primary prevention

• minimizing or eliminating
exposure to carcinogenic agents

• reducing individual susceptibility


to the effect of carcinogenic agents
NCCP Thailand
Strategies for Primary Prevention
Liver and Lung Cancers
Cancer in Thailand Vol. IV 2007
Cancer in Thailand Vol. IV 2007
Vaccination against hepatitis B
virus infection

Major risk factors for HCC: Hepatocellular carcinoma (HCC)


Hepatitis B Virus
Major risk factor for CCA in Thailand
- Opisthorchis viverrini (OV)

Life cycle of Opisthorchis viverrini


Cholangiocarcinoma (CCA)
Liver Cancer in Nakhon Phanom 1997-2001 (1999)
ASR (World)

M 21.5 M 38.8
Sakhon F 18.0 F 13.2
Laos
Nakhon
M 27.9
F 11.3
M 73.2 Kong river
F 43.9
M 67.7 M 24.9
F 34.6 F 15.6

M 63.4
F 31.0
Plapak
M 200.1
M 200.1
F 104.1
F 104.1
M 106.0
F 53.2
M 79.9
M 136.5 F 43.7
Mukdahan F 54.3
M 59.4
F 28.1

Srivatanakul et al. 2004


Upatham et al. (1994)

Prevalence Intensity
of infection with Opisthorchis viverrini
in an area of high intensity in Thailand

IARC monographs on the evaluation of carcinogenic risks to humans, Vol. 61


VOLATILE N-NITROSAMINES IN FERMENTED THAI FOOD

NDMA NPIP NPYR


Food No. of Mean Range No.of Mean Range No.of Mean Range No.of
item samples + SD (ug/kg) positive + SD (ug/kg) positive + SD (ug/kg) positive
(ug/kg) sample (ug/kg) sample (ug/kg) sample

Fish1 15 3.8+7.3 0-25.5 8 2.3+6.4 0-23.0 3 2.1+46.6 0-177 8


Pork2 9 1.2+2.0 0-6.5 6 5.7 1 2.9+7.0 0-21.4 4
Vegetable3 4 0-0.5 2 0-62 2

1Pla-ra,pla-chom, pla-som (fermented fish)


2Nam, Thai sausage
3Puk - dong

Srivatanakul et al. 1991


Infection with o. viverrini 100 metacercariae by intragastric intubation
in combination with N-Nitrosodimethylamine (NDMA) 25 mg/L in drinking water

Dimethyl
No tumor hamster nitrosamine

hamster

Opisthorchis
No tumor hamster viverrini

Cholangiocarcinoma
Thamavit et al, 1978
Life cycle of liver flukes

A: DEFINITIVE HOST, HUMAN

B: ADULT LIVER FLUKES IN BILE DUCT,


Clonorchis sinensis (b1),
Opisthorchis viverrini (b2)

C: embryonated egg;

D: first intermediate host, Bithynia sp.;

E: intramolluscan stages, miracidium (e1),


sporocyst (e2), mother redia (e3),
daughter redia (e4);

F: cercaria;

G: second intemediate host (cyprinoid


fish), metacercaria in fish muscle (g1);

H: reservoir host, dog and cat

IARC monographs on the evaluation of


carcinogenic risks to humans, Vol. 61
Treatment with praziquantel is highly effective
and also leads to reversal of biliary tract
abnormalities.

Control of infection has been achieved in some


areas by a combination of chemotherapy, health
education and improved sanitation

IARC monographs on the evaluation of carcinogenic risks to humans, Vol. 61


Conceptual Frame of Liver Fluke Control

Ministry of Public Health, Thailand


Urinary level of NPRO in relation to
evidence of OV infestation

+ PRO + PRO & ASCORBIC ACID


20 30

NPRO ( g / 12h )
NPRO ( g / 12h )

15 n = 23 n=5
20

10
10
n = 18 n = 36
5

0 0
-
ANTI - OV PRESENCE OF OV EGGS
Srivatanakul et Al. 1991
Chronic infection by viruses/bacteria/parasites Toxins
Cox-2 inhibitors
antioxidants
e.g. Aspirin, NSAIDS
Inflammation

Free radicals Altered signalling pathways


(prostaglandins, cytokines)

DNA and tissue damage


Modulation of gene expression and
Increased cell division
Decreased DNA repair protein function

Mutation

Carcinogenesis
Chronic inflammation leads to prolonged exposure of tissues to cancer-
causing agents produced within the body in response to infection or toxins

IARC
Strategies for primary prevention to control
Liver Cancer in Thailand:

 Vaccination against hepatitis B virus infection


 Prevention and control of Opisthorchis viverrini
infection
 Controlling alcohol consumption
 Promoting dietary modification to achieve a healthier
diet (or preventing change of diet to a more hazardous
pattern).
 More vegetables and fruits Consumption
Behavioral interventions
Having important advantages for population level prevention,
a low risk of side – effects

Do not smoke or chew tobacco


Have a healthy diet
Do not eat raw fish
Be physically active and avoid obesity
Reduce alcohol consumption

Avoid smoke from cooking


Public Education

Physical Exercise
Promoting dietary modification
to achieve a healthier diet
(or preventing change of diet to
more hazardous pattern).
LESS CONSUMPTION

Alcoholic drinks
Fatty food
Fry food
Grill food
Charred food
Fermented food
Salted food
Red meat
Cured and smoked meat
Food preservation (nitrate,nitrite)
MORE CONSUMPTION

Vegetables, Fruits and other Plant-based Foods

Fish, Poultry (remove the skin)

Boil food, Steam food

Herbs and Spices


Half vegetables & Fruits
Liver Fluke Control
Behavioral Intervention Early Detection
Chemoprevention
vitamin c
antioxidants Preventive
cox-2 inhibitors Interventions
e.g. Aspirin, NSAIDS

EARLY ALTERED
BIOLOGICAL
INTERNAL BIOLOGICAL STRUCTURE/ CANCER
EXPOSURE EFFECTIVE
DOSE EFFECT FUNCTION
DOSE
High carcinogen Biomarkers DNA adducts Gene mutation
exposure for carcinogen Protein adducts
exposure Oncogene activation
O.V
Nitrosamine Tumor suppressor gene activation
Nitrate
Microsatellite instability
Lack of protective
(dietary) factors

SUSCEPTIBILITY
FACTORS
Lung cancer in different regions
1998 - 2000
Thailand 9.3
20.6
22.3
Chiang Mai 29.6

Lampang 27.6
53
3.7
Nakhon Phanom 7
8.3
Udon Thani 26.3 Female

Khon Kaen 7.1 Male


20.6
6.5
Bangkok 18.4
Rayong 7.5
25.1
2.8
Prachuap Khiri Khan 12.1
4.9
Songkhla 13.5

0 10 20 30 40 50 60

ASR (World)
Anti – smoking campaigns

Government organizations :
Institute of Tobacco Consumption Control

Non- Government organizations :


Action on Smoking and Health Foundation
 1990 –Setting up of Tobacco Control
Office in MOPH (Secretariat of NCCTU)

 Thailand has ratified WHO Framework


Convention on Tobacco Control (WHO
FCTC) in 2005
Tobacco Products Control
Act, B.E. 2535 (1992)

- Total ban of advertising and sponsorship


- Notification of the composition of Tobacco products
- Vending machines is not permitted
- Health Warning
- Prohibition of sale to minor etc.

Non-smoker’s Health Protection Act, B.E.


2535 (1992) (names and types of Non-
smoking areas).
Anti – smoking campaigns

•Forbade - tobacco sales to young


people under
• Restricts demonstration of smokers
in movies, TV programs etc.
• Increase tobacco taxes
Anti – smoking campaigns

Tobacco Control Legislation, Tobacco Law


for Improvement of Health through:
• restricting smoking in public places,
workplaces,hospitals
• ban on tobacco advertising
• stigmatizing cigarette packs
Behavioral intervention can reduce
exposure to carcinogenic agents and
increase the protective factors.

Community intervention in high risk


areas should be the most cost-effective,
safe and long-lasting approach to cancer
control.
Risk factors common to major
noncommunicable
Cardiovascular diseases
Respiratory
Risk factor Cancer disease1 Diabetes disease2
tobacco use
Alcohol
Unhealth diet
Physical inactivity
Obesity
Raised blood pressure
1 Including heart disease, stroke, and
hypertension
2 Including chronic-obstructive
pulmonary disease and asthma
NCCP 2nd Edition
Secondary Prevention

Programmes for screening and


early detection of cervical cancer

Programmes for screening and


early detection of breast cancer.
Prevention and Early detection of Cervical Cancer:
A Model Demonstration Project for the Control
of Cervical Cancer in Nakhon Phanom Province,
Thailand

Somyos Deerasamee, Petcharin Srivatanakul, Penkae Pitakpraiwan,


National Cancer Institute, Bangkok, Thailand
Hutcha Sriplung, Faculty of Medicine, Prince of Songkla University
Somkiat Nilvachararung, Utai Tansuwan, Nakhon Phanom Provincial Hospital
Phisit Nimnakorn, Nakhon Phanom Provinvial Health Office
Pratap Singhasivanon, Jaranit Kaewkungwal,
Faculty of Tropical Medicine, Mahidol University
Rengaswamy Sankaranarayanan, International Agency for Research on Cancer,
Lyon, France

Asian Pacific J Cancer Prev, 2007; 8: 547-556


Estimated Cervical Cancers (thousands)

Developing
Developed

IARC / WHO
Age-specific incidence rates of cervical cancer

100

10

0.1 Age
20 25 30 35 40 45 50 55 60 65 70+

Bangkok Chiang Mai Khon Kaen Lampang Songkhla


Cervical Cancer
percentage distribution of microscopically verified cases by histological type
Survival from cervical cancer by clinical extent of disease

Chiang Mai
1

0.75

0.5

0.25

0
0 12 24 36 48 60
Survival time in months

localized regional

distant metastasis unknown


Natural History of Cervical Cancer and Program lmplications
HPV Low-grade High-grade Invasive
Infection Cervical Dysplasia Cervical Dysplasia cancer

Characteristics: Characteristics: Characteristics: Characteristics:


• HPV infection • Low-grade dysplasia • High-grade dysplasia, • Women with high-grade
extremely common usually is temporary the precursor to cervical dysplasia are at risk of
among women of and disappears over cancer, is significantly developing invasive
reproductive age. time. less common than cancer,; this generally
low-grade dysplasia.
occurs slowly, over a
• HPV infection can • Some cases, however,
• High-grade dysplasia period of several years.
remain stable, lead to progress to high-grade
can progress from low-
dysplasia,or become dysplasia.
grade dysplasia or, in
undetectable. • It is not unusual for some cases, directly
HPV to cause low-grade from HPV infection.
Management: dysplasia within months
• While genital warts or years of infection.
resulting from
HPV infection may be
Management: Management: Management:
treated, there is no
Low-grade dysplasia High-grade dysplasia Treatment of invasive
treatment that
generally should be should be treated, as a cancer ishospital-based,
eradicates HPV.
monitored rather than significant proportion expensive, and often
• Primary prevention treated since most progresses to cancer. not effective.
through use of ondoms lesions regress or do
offers some protection. not progress.
Table 1 Reduction in the cumulative rate of invasive cervical
cancer for women aged 35-64 years, with different
frequencies of screening
(a) Assuming 100% complance and a highly (b) After correcting for lesser compliance
sensitive test (80%) and reduced sensitivity in practice

Frequencyof Percentagereduction No. of Frequencyof Percentagereduction No. of


Screening incumulativerate tests Screening incumulativerate tests
Yearly 93 30 Yearly 61 30
2-yearly 93 15 2-yearly 61 15
3-yearly 91 10 3-yearly 60 10
5-yearly 84 6 5-yearly 55 6
10-yearly 64 3 10-yearly 42 3

Source: Miller AB. (1992) Cervical cancer screening programmes:


managerial guidelines. Geneva, World health Organization.

NCCP 2nd Edition WHO 2002


Table. Comparison of Two Screening Strategies in Chile

Program 1 Program 2

Age 30 - 35 years 30 - 50 years


Frequency of screening 3 years 10 years
Coverage 30% 90%
Reduction in mortality 15% 44%
Cost per case detected US$2,522 US$556

Source: Eddy, D 1986, as described in Miller, Cervical Cancer Screening


Programmes, Managerial Guidelines. Geneva : WHO (1992)
Objectives
General :
• To implement a model demonstration
programme of cervical cancer screening with
cytology as the principal screening test.
• To treat preinvasive lesions.
• To manage invasive lesions.
Objectives

Specific:
 To evaluate reduction in incidence and
mortality rates from cervical cancer in the
province by means of an organised low
intensity cervical cytology programme.
 To demonstrate the different aspects of the
programme implementation.
Considerations for Low-Resource Settings

 when to initiate screening

 how often to screen

 when to recommend treatment

and/or follow-up
Program Goal

 Increase awareness of cervical cancer, emphasizing


the need for cervical cancer screening among
women aged 35 to 54.
 Screen all women aged 35 to 54
once in 5 year-intervals by Pap smear.
 Treat women with high-grade dysplasia.
 Refer those with invasive disease to Cancer Centers.
 Provide palliative care for women with advanced cancer.
 Monitoring and evaluation of program activities and
outputs.
Cervix Cancer Screening

 Population based, organized


 Register target population
 Education, Training
 Quality Assurance System
 Team-work, further investigation and treatment
 Pap Smear Results Registry (PAPREG PROGRAM)
 Cancer Registry (CANREG PROGRAM)
 Monitoring and Evaluation
Cervix Cancer Screening

 The screening activities are integrated in


the health care system.

 Attending organized screening for women


at target population (age 35-54 years) is free
of charge.
Cervix Cancer Screening

 Sample taking is done by trained nurses


(midwives) and Primary Health Care
Personnals in the local health care centers.

 The sample quality is under continuous


control done by the cytology laboratories.
Confirmation and treatment is integrated into
the normal health care routines.
Cervix Cancer Screening

The screening results of the programme,


including histologically confirmed diagnosis,
are registered at the National Cancer Institute
by using Pap Reg Programme and Can Reg 4
Programme.
Screening for cervical cancer will be evaluated.

Selected Evaluation Indicators


- percentage of women aged to screened in the past four
years

- percentage of women with positive for high grade lesions or

cancer

- percentage of diagnosed women with positive screening results

- Incidence of cancer (Stage distribution)

- Invasive cancers : screening history

Effect of Cervix Cancer Screening


- decreased in incidence and mortality rates
Figure1 Nakhon Phanom population and Health care Services

Nakhon Phanom Province


Population
Total
Male

Female
Target Women 80,000 in yrs
( - yrs) 6,000 in yr

Health Care Services


Provincial Health Office
Provincial Hospital
Community Hospitals
District Health Offices

48 Primary Health Care Centers


Table 2 Number of target women having Pap test in 1999 - 2002

Total Target Number of Women Percentage of


District
Women Having Pap Test Coverage
Muang 13,660 5,879 43.0
Na Kae 7,688 3,639 47.3
Tha Uthen 4,723 2,295 48.6
That Phanom 7,703 3,210 41.7
Si Songkhram 6,166 2,848 46.2
Renu Nakhon 4,359 2,173 49.8
Na Wa 4,382 2,350 53.6
Ban Phaeng 2,872 1,754 61.1
Phon Sawan 4,352 3,544 81.4
Pla Pak 4,818 3,485 72.3
Na Thom 1,958 899 45.9
Wang Yang 1,270 556 43.8
Nakhon Phanom 63,951 32,632 51.0
Province
Table 4 Target female population of Nakhon Phanom
in the year 2000

Age group (years)

35-39 40-44 45-49 50-54 Total

female population in 2000 24464 21921 18388 15166 79939

pop at risk 19571 17537 14710 12133 63951


(4/5 of population in 2000)

non-screened population 8036 8651 7774 6858 31319

screened population 11535 8886 6936 5275 32632


Table 9 Risk and risk ratio of getting precancerous and cancerous
lesions in non-screened and screened target woman

Cumul
35-39 40-44 45-49 50-54 Total Cumul. Crude Risk Lower Upper
risk risk ratio lim. lim.

non-screened CIN I 0 0 3 0 3 0.0004 0.0001 1.0

CIN II 1 0 0 0 1 0.0001 0.0000 1.0

CIN III 5 1 4 0 10 0.0013 0.0003 1.0

cervix cancer 9 11 13 9 42 0.0054 0.0013 1.0

screened CIN I 46 29 25 9 109 0.0125 0.0033 34.9 11.6 172.3

CIN II 12 18 15 6 51 0.0063 0.0016 48.9 5.3 81.7

CIN III 21 19 21 11 72 0.0090 0.0022 6.9 3.5 15.0

cervix cancer 5 10 22 11 48 0.0068 0.0015 1.1 0.7 1.7


Table 10 Stage distribution of cervix cancer cases before (1997-1998)
and during (1999-2002) screening periods in screened and non-
screened populations.
A. excluding in situ cases
1997-1998 1999-2002
Non-screened Screened
Cases Percent Cases Percent Cases Percent
Localized 16 23.9 23 24.0 14 31.1
Regional 34 50.7 52 54.1 13 28.9
Metastasis 3 4.5 4 4.2 1 2.2
Unknown 14 20.9 17 17.7 17 37.8

B. including in situ cases


1997-1998 1999-2002
Non-screened Screened
Cases Percent Cases Percent Cases Percent
In situ 3 4.3 14 12.7 72 61.5
Localized 16 22.8 23 20.9 14 12.0
Regional 34 48.6 52 47.3 13 11.1
Metastasis 3 4.3 4 3.6 1 0.9
Unknown 14 20.0 17 15.5 17 14.5
Table 11 Stage distribution of cervix cancer cases aged 35-54 before
(1997-1998) and during (1999-2002) screening periods in screened
non-screened target groups
A. excluding in situ cases
1997-1998 1999-2002
Non-screened Screened
Cases Percent Cases Percent Cases Percent
Localized 11 26.2 9 20.0 14 31.1
Regional 22 52.4 27 60.0 13 28.9
Metastasis 2 4.8 3 6.7 1 2.2
Unknown 7 16.6 6 13.3 17 37.8

B. including in situ cases


1997-1998 1999-2002
Non-screened Screened
Cases Percent Cases Percent Cases Percent
In situ 3 6.7 3 6.3 72 61.5
Localized 11 24.4 9 18.7 14 12.0
Regional 22 48.9 27 56.3 13 11.1
Metastasis 2 4.4 3 6.2 1 0.9
Unknown 7 15.6 6 12.5 17 14.5
Figure 2 Age-standardized incidence rates of cervical cancer and
precancerous lesions before (1997-1998) and during (1999-2002)
screening periods.
Figure 5 Survival from Cervix Cancer: Nakhon Phanom,
1997 – 1998 and 1999 -2002
Conclusion
 This organized low intensity cervical cytology
programme showed a considerable increase in
early carcinoma in situ and CIN II – III cases and
should be reduce cervical cancer incidence in
Nakhon Phanom province in the future.

 Screening with the Papanicolaou smear plus


adequate follow-up diagnosis and therapy can
achieve major reductions in both incidence and
mortality rates.

 At present, we have national policy to perform


Pap test in the women at age 35, 40, 45, 50, 55
and 60 years in all of the primary health care
centers and hospitals with free of charge.
National Policy

Programmes for screening and


early detection of cervical cancer
Cervix Cancer Screening

National Policy

 Population based, organized


 All Women in Thailand,
Ages: 35,40,45,50,55 and 60 years
Test : Pap Smear
Cervix Cancer Screening
Public Education

Education andTraining
• Nurses, PHC Personnels for
Pap smear taking
• Re-training cytotechnicians

Quality Assurance System


Cervical Cancer Screening in
76 provinces of Thailand, 2005
by National Health Security office
and Ministry of Public Health

Department of Medical Services (National Cancer Institute)


is responsible for cervical cancer screening by Pap Smear
Target Population : Women at age : 35,40,45,50,55 and 60 in
76 provinces

Department of Health is responsible for cervical cancer


screening by Visual Inspection With Acetic Acid (VIA)
Target Population : women at age 30 – 34 , 36 – 39 , 41 – 44
years in 9 provinces : Roi – Et , Nong Kai , Umnatcharoen ,
Yasothorn , Surat Thani , Uttaradit , Chiang Mai , Nakorn
Srithamnarat , Nan and one Amphur in Pisanulok Province
Programmes for screening
and early detection of breast cancer
Breast cancer in different regions
1998 - 2000
20.5
Thailand 0.2
20.7
Chiang Mai 0.3
20.8
Lampang 0
10.1
Nakhon Phanom 0.3
13
Udon Thani 0.3 Female
13.7 Male
Khon Kaen 0.1
24.3
Bangkok 0.2
22
Rayong 0
16
Prachuap Khiri Khan 0.3
17.2
Songkhla 0.4

0 5 10 15 20 25 30

ASR (World)
Campaigns for early detection of breast cancer

Public awareness

Breast self examination


• Clinical breast examinat
• Mammogram
• Appropriate diagnosis an
Tertiary prevention

• National Cancer Institute and Regional


Cancer center network(7 centers)

• Regional Referral Cancer Center Network


(30 centers)
Tertiary Prevention

• guidelines for cancer treatment

Surgery
Radiotherapy
Chemotherapy
Hormonal Therapy
Combination Treatment
Palliative Care
Incurable cancer, palliative care deserves
high priority in cancer therapy

• Guidelines for palliative care


• Palliative care clinic
• Hospices
• Home care
Cancer Research

Priorities of cancer research in Thailand

We emphasize to do cancer research on


the five most common cancer:
Liver, Lung, Cervix, Breast and Colorectal
cancers.
Thank you