Japanese Journal of Clinical Oncology 32:S82-S91 (2002)
© 2002 Foundation for Promotion of Cancer Research
Cancer Control in Thailand
1Cancer Unit and 3Department of Otolaryngology, Faculty of Medicine and 2Department of Epidemiology, Faculty of Public Health, Khon Kaen University, Thailand
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Cancer in Thailand is becoming a significant health problem. It is the leading cause of death in Thailand. Several cancers can be prevented by a nationwide campaign of health education to prevent raw fish intake and an antismoking campaign. An appropriate cervical cancer and breast cancer screening program can improve the recent prevalence of both and lead to better results of treatment. Research related to the carcinogenesis mechanism of certain cancers can lead to greater understanding and a better plan of control.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Cancer has been the leading cause of death in Thailand with the age-adjusted mortality rate from the two cancer registries being 89.7 per 100 000 in males, 67.2 per 100 000 in females in Khon Kaen and 133.3 in males, 121.0 in females in Chiang Mai (1,2). The estimated age-adjusted incidence rates of cancer for all sites in Thailand were 150.4 per 100 000 for males and 123.0 for females (3), which are not that significant when compared with earlier data (149.6 for males and 125.2 for females) (4). The incidence rates are comparable to those in Asian countries but about half of those in Western countries (Fig. 1).
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Thailand is divided into four major regions, the North, Northeast, Central and South. There is a representative population-based cancer registry in each region, namely Chiang Mai for the North, Khon Kaen for the Northeast, Songkhla for the South and Bangkok, the capital city of the central area. The Bangkok data were obtained by a cross-sectional survey. The data from each registry show different cancer sites as most prevalent. Liver cancer, especially cholangiocarcinoma, is first in Khon Kaen, whereas lung cancer predominates in the North and esophageal cancer is significantly high in the South (Figs 2 and 3).
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CANCER INCIDENCE |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Liver Cancer
Liver cancer is the most common cancer in men [age-standardized incidence rate (ASR) = 37.4/105] and the third most common in women (ASR = 16.3/105) (3). Hepatocellular carcinoma, which is associated with hepatitis B virus, is a major problem in all regions of Thailand, with the exception of Khon Kaen and the Northeast. Liver flukes [Opisthorchis viverrini (OV)], related to cholangiocarcinoma, account for about 89% of all liver cancers in Khon Kaen, which has the highest incidence rate of liver cancer in the world (97.4/105 in males and 39.0/105 in females) (4,5) (Figs 4 and 5) (6).
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Cholangiocarcinoma is a rare tumor comprising only 18.3% (males) to 29.8% (females) of liver cancers in the USA (6). High rates in Thailand have been found related to liver fluke OV infestation (7). The habit of eating uncooked cyprinoid fish which are infected with OV is the source of the high prevalence in northeastern Thailand (8,9): this dietary custom is sometimes practiced in the north but not at all in the south. There is an association of high intensity of OV in stool (>10 000 eggs/g) prevalence and a high incidence of cholangiocarcinoma at the local (district) level in Khon Kaen (10). In a recent case-control study of subjects from northeastern Thailand, OV infection, as measured by an elevated titer of anti-OV antibodies, was strongly associated (OR, 5.0) (Table 1) with cholangiocarcinoma (11). The percentage of cases attributable to opisthorchiasis was 72% in males and 62% in females. Haswell-Elkins et al. (12) found the dose–response of high OV eggs in the stool associated with the high risk of cholangiocarcinoma; various carcinogenic mechanisms of liver fluke infestation were cellular proliferation in response to tissue damage, the induction of nitric oxide synthase by inflammatory cells and increased activity of certain carcinogen-metabolizing cytochromes of the P450 group (7).
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Chronic carriers of the hepatitis B surface antigen were found to be the risk factor [odds ratio (OR) for hepatocellular carcinoma 15.2] in a case control study in Northeast Thailand (Table 1) (13). Hepatitis C infection appears to be rare (14).
The direct measurement of aflatoxin–albumin adducts in sera from human subjects suggests that aflatoxin intake is relatively low (15). This corresponds with the findings of a low prevalence of G to T mutations at codon 249 of the p53 gene in sera and liver tissues from Thai patients with hepatocellular carcinoma (16).
Lung Cancer
A high incidence of lung cancer was found in women in northern Thailand (Fig. 3) with a high proportion of adenocarcinomas. In a case control study in Chiang Mai (17), the smoking of cigarettes and Khiyoh (long, indigenous cigars) was found to be associated with non-significant elevated risks in both sexes, while the chewing of miang (fermented wild tea leaves) was associated with an increased risk of lung cancer in women (OR, 2.02) (Table 1). The percentage of smoking prevalence in female is high in the north (Table 2) (18). The percentage of consumption of tobacco has declined for the past few years owing to strong antismoking campaigns.
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Cervical Cancer
The incidence of cervical cancer in Thailand (23.4/100 000) (Fig. 6) (19) is relatively high in comparison with other developing countries in southern and southeastern Asia. Wangsuphachart et al. (20) found trends of increasing risk in young women related to age at first intercourse and number of sexual partners (Table 1). Women with high parity were at higher risk than nulliparous women, but there was no significant trend related to number of children (20,21). Women whose husbands have been exposed to prostitutes have a higher risk of cervical cancer (21) (Table 1). Human papilloma virus type 16 (3.08%) and type 18 (3.85%) were found in cervical cancer survey of the northeast (22).
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Breast Cancer
The incidence of breast cancer in Thailand is low, with an age-specific rate similar to those in developing countries (Fig. 7). There have been no studies of breast cancer epidemiology in Thailand. The low risk may be a consequence of previously high frequency of fertility and low caloric intake. However, the incidence rate of breast cancer seems to have been increasing gradually over the past 5–10 years, which may be related to the change of lifestyle and diet.
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Oral Cavity Cancer
Cancer of the oral cavity is common in Thailand with similar rates in both sexes. Females seem to have a higher rate (6.2/105) than males (2.7/105) in Khon Kaen but vice versa in Songkhla (females 3.5/105, males 9.7/105). In Chiang Mai (North) and Khon Kaen (Northeast), betel quid chewing remains relatively common among female villagers. Two case control studies in Thailand have shown this to be the significant risk factor in both sexes (Table 3) (17,23). In 1992, the reported incidence rate of lip cancer in females in Khon Kaen was the highest recorded in the world, but is relatively rare elsewhere (24). Thus far, this remains unexplained. In males, the highest incidence is observed in Songkhla, which also has the highest rates for cancer of the pharynx and esophagus; these cancers share common risk factors (tobacco and alcohol) with oral cancer.
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Nasopharyngeal Cancer
The incidence of nasopharyngeal cancer is intermediate between the very high rates observed in southern China and those of European populations (Fig. 8). A case control study by Sriamporn et al. (25) found that the consumption of sea-salted fish was a risk factor (OR, 2.5) in the population of northeast Thailand, as were agricultural occupations and wood-cutting (OR, 8.0) (Table 3).
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Esophageal Cancer
The incidence of esophageal cancer is low in Thailand (3.7/105 in males and 1.3/105 in females), except for Songkhla in the south (9.7/105 in males and 3.1/105 in females), where the rates in both sexes are moderately high (Figs 2 and 3). Chongsuvivatwong (26) found that tobacco smoking alone was not associated with a significantly elevated risk, but the risk for non-smoking alcohol drinkers was 4.7. Subjects who both smoked and consumed alcohol were at a significantly higher risk (5.7) than abstainers. In another case control study (27), past consumption of two species of bean, Archidendron jiringa (Luk Niengh) and Parkia timoriana (Luk Riengh), was found to increase risk; in contrast, the consumption of the raw beans of Parkia speciosa (Satawh) was found to be protective (Table 3).
Gastrointestinal Cancers
The incidence of other gastrointestinal cancers, stomach and colorectal, is low among the Thai population (Figs 2 and 3). These have not been the subject of any epidemiological studies. Rates of colon cancer have increased in Chiang Mai in the last decade (28), possibly related to the increasing consumption of meat and fat and the decreasing consumption of vegetables over the last 20 years (29).
Thyroid Cancer
The incidence of thyroid cancer is highest in females in the northeast (Fig. 3). Papillary carcinoma is two to four times more frequent than the follicular type in Singapore, the Philippines and in other parts of Thailand (30). The opposite ratio is found in Khon Kaen (Fig. 9), which may be related to a low iodine intake in the northeast where, in a recent survey, 10–50% of children were found to have thyroid goiters.
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CANCER TREATMENT |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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The facilities for cancer treatment in Thailand are fairly good. Most of the provincial hospitals can handle the primary treatment, especially the surgical care, but the university hospital in each region continues to be the center of referral for cancer care. The numbers and percentages of new cancer cases in university hospitals, such as Khon Kaen University, were 9.8 or 9.5% of all new patients annually (31,32) and in Chiang Mai were 4.4 or 4.3% (33,34). These relatively high proportions of new cancer cases to all new other cases in the university hospital have been shown to be due not only to the preference of individual patients but also the availability of more intensive cancer facilities, e.g. a radiation therapy unit. The Ministry of Health has set up six cancer centers to improve this tertiary care coverage of cancer treatment in each region of Thailand. The remaining problems are the systematic referral system and the acceptable established standard treatment plan for each type of cancer in all centers.
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CANCER PAIN |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Cancer pain has been an unrecognized problem in Thailand, because the oncologist’s main aim with cancer treatment is to reduce the size of the tumor and improve the results of laboratory testing. Cancer pain occurs mostly in the later stages of many cancers. Cancer specialists, therefore, have neglected cancer pain. A survey of the prevalence of cancer pain in all sites of those cancer patients admitted was approximately 62% (35). The statistics from Khon Kaen regarding cancer pain were comparable to those in other countries. We also found that ~21 645 cancer cases in Thailand had not received adequate pain care. The prescription of morphine, which is the best pain medicine, has been a significant problem in many of the hospitals (36).
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CANCER CONTROL |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Several attempts to initiate a National Cancer Control Program have been made in the past. Part of the plan is to set up the six cancer centers in all the regions in Thailand, especially in provinces in which there are no university hospitals.
Recently, a new National Committee has been appointed to review the National Cancer Control Plan. There are several subcommittees, including the Cancer Informatics Subcommittee, Primary Prevention of Cancer Subcommittee, Secondary Prevention of Cancer Subcommittee, Cancer Treatment and Hospice Care Subcommittee and Cancer Control Research Subcommittee. Several activities have been planned. For example, the Cancer Informatics Center plans to control major cancers in Thailand such as liver cancer, lung cancer, cervical cancer, oral cancer and breast cancer through a nationwide campaign. Alternative medicine as a treatment for cancer has been brought to attention by research groups. The late presentation of cancer patients at the hospital resulted in poor survival and high mortality rates. Improving the referral system of cancer patients and setting up the optimum cancer treatment plan are the two most important goals to enhance better care of cancer patients. The treatment plan should not only set the standard treatment of each individual cancer but also look into pain control and hospice care.
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ASIA PACIFIC NETWORKING OF SHIZUOKA FORUM |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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There are gaps in knowledge among different countries in this region. To improve the care of cancer patients and to control the disease better, researchers from these countries must provide and share information, technology, material, etc., to set up multicenter research projects. In doing this, it will become possible to answer several research questions quicker. The Shizuoka plan of joining together regional researchers is to be commended, with hopes for a continuation and growth of this excellent initiative.
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FOOTNOTES |
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+ For reprints and all correspondence: Vanchai Vatanasapt, Cancer Unit, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand. E-mail: vanchai@kku.ac.th
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCANCER INCIDENCECANCER TREATMENTCANCER PAINCANCER CONTROLASIA PACIFIC NETWORKING OF...REFERENCES |
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Thomas DB, Ray RM, Pardthaisong T, Chutivongse S, Koetsawang S, Silpisornkosol S, et al. Prostitution, condom use, and invasive squamous cell cervical cancer in Thailand. Am J Epidemiol 1996;143:779–86.
22 Vatanasapt V, Peonthong J, Ekaluksananant T, Pengsaa P, Charoensiri DC, Kongyinyong B, et al. Human Papillomavirus Detection in Cervical Scraped Cells by Polymerase Chain Reaction. Khon Kaen: Faculty of Medicine, Khon Kaen University 1998;26.
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24 Vatanasapt V, Martin N, Sriplyng K, Chindavijak K, Sontipong S, Sriamporn S, et al. Cancer Incidence in Thailand, 1988–1991. Cancer Epidemiol Biomarkers Prev 1995;4:475–83.[Abstract]
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36 Vatanasapt V, Areemit P. Problems in analgesic usage in cancer pain (Thai Chapter). Pain News 1992;3:6–7.
Received February 13, 2001; accepted September 6, 2001.
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