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National Cancer Control Programmes in Thailand - Petcharin Srivatanakul - National Cancer Institute, Bangkok, Thailand
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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.
. 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
The objectives of cancer control :
NCCP Thailand
1. Cancer Informatics
2. Primary prevention
3. Secondary prevention
4. Tertiary prevention
5. Palliative care
6. Cancer research
National Policy in Cancer
Registration
Cancer Informatics
Population-based cancer registry
Hospital-based cancer registry
Population based Cancer Registry
1998 - 2000
Chiang Mai
Lampang
3. Nakhon Phanom
4. Udon Thani
5. Khon Kaen
6. Bangkok
7. Rayong
8. Prachuab Khiri Khan
9 Songkhla
Prachuab Khiri Khan
Songkhla
3.5
3.5
3.9
4.1
4.2
4.5
5.2
8.8
20.6
33.4
0 10 20 30 40
Stomach
Prostate
Leukaemia
Oesophagus
Bladder
Non-Hodgkin lymphoma
Oral cavity
Colon and rectum
Bronchus, lung
Liver and bile duct
Leading Cancers in Thailand, 1998-2000
ASR (World)
3.2
3.3
4.1
4.6
5
7.6
9.3
12.3
20.5
24.7
0 5 10 15 20 25 30 35 40
Leukaemia
Skin
Thyroid
Oral cavity
Ovary
Colon and rectum
Bronchus, lung
Liver and bile duct
Breast
Cervix uteri
Male Female
3.8
4.1
4.6
4.8
5
5.5
6.7
9.2
17
29.6
0 5 10 15 20 25 30 35
Leukaemia
Skin
Prostate
Bladder
Stomach
Oral cavity
Non-Hodgkin lymphoma
Colon and rectum
Liver and bile duct
Bronchus, lung
Leading Cancers in Chiang Mai, 1998-2000
ASR (World)
3.9
4.1
4.3
4.4
5.8
5.9
7.8
20.7
22.3
29.4
0 5 10 15 20 25 30 35
Oral cavity
Non-Hodgkin lymphoma
Thyroid
Stomach
Liver and bile duct
Ovary
Colon and rectum
Breast
Bronchus, lung
Cervix uteri
Male Female
2.2
4.3
4.5
4.6
5
5.2
5.4
11.7
32.9
53
0 10 20 30 40 50 60
Nasopharynx
Skin
Bladder
Leukaemia
Stomach
Prostate
Non-Hodgkin lymphoma
Colon and rectum
Liver and bile duct
Bronchus, lung
Leading Cancers in Lampang, 1998-2000
3.6
3.6
3.7
3.9
4.6
9.5
14.7
20.8
22.3
27.6
0 10 20 30 40 50 60
Non-Hodgkin lymphoma
Stomach
Oral cavity
Leukaemia
Ovary
Colon and rectum
Liver and bile duct
Breast
Cervix uteri
Bronchus, lung
ASR (World)
Male Female
1.3
1.3
1.5
1.7
1.7
2.3
3.7
5.5
7
63.5
0 10 20 30 40 50 60 70
Oral cavity
Penis
Nasopharynx
Prostate
Gallbladder
Bladder
Stomach
Colon and rectum
Bronchus, lung
Liver and bile duct
Leading Cancers in Nakhon Phanom, 1998-2000
1.2
1.2
2.1
3.7
4.7
4.8
4.9
10.1
11.3
31.1
0 10 20 30 40 50 60 70
Gallbladder
Uterus unspecified
Corpus uteri
Bronchus, lung
Ovary
Colon and rectum
Oral cavity
Breast
Cervix uteri
Liver and bile duct
ASR (World)
Male Female
3.2
3.3
3.8
3.8
4.3
4.3
5.4
11.9
26.3
113.4
0 20 40 60 80 100 120
Nasopharynx
Non-Hodgkin lymphoma
Prostate
Brain, nervous system
Stomach
Bladder
Leukaemia
Colon and rectum
Bronchus, lung
Liver and bile duct
Leading Cancers in Udon Thani, 1998-2000
2.2
2.4
3.3
3.9
4.5
8.3
8.5
13
19.5
49.8
0 20 40 60 80 100 120
Stomach
Skin
Leukaemia
Oral cavity
Ovary
Bronchus, lung
Colon and rectum
Breast
Cervix uteri
Liver and bile duct
ASR (World)
Male Female
2.9
3.5
3.6
4.1
4.3
4.6
5.1
8.6
20.6
78.4
0 20 40 60 80 100
Prostate
Oral cavity
Stomach
Bladder
Skin
Leukaemia
Non-Hodgkin lymphoma
Colon and rectum
Bronchus, lung
Liver and bile duct
Leading Cancers in Khon Kaen, 1998-2000
3.1
4.2
4.6
6.2
6.7
7
7.1
13.7
15.9
33.3
0 20 40 60 80 100
Leukaemia
Skin
Thyroid
Ovary
Oral cavity
Colon and rectum
Bronchus, lung
Breast
Cervix uteri
Liver and bile duct
ASR (World)
Male Female
3.6
3.6
3.6
4.6
4.9
5.9
6.7
12.4
13.4
18.4
0 5 10 15 20 25 30
Skin
Stomach
Nasopharynx
Non-Hodgkin lymphoma
Oral cavity
Bladder
Prostate
Colon and rectum
Liver and bile duct
Bronchus, lung
Leading Cancers in Bangkok, 1998-2000
3.3
3.8
3.9
3.9
4.3
5.1
6.5
9.6
19.3
24.3
0 5 10 15 20 25 30
Oral cavity
Skin
Corpus uteri
Thyroid
Liver and bile duct
Ovary
Bronchus, lung
Colon and rectum
Cervix uteri
Breast
ASR (World)
Male Female
3.6
3.9
4.2
5
7
7.3
9.3
10.3
14.9
25.1
0 5 10 15 20 25 30
Oropharynx etc.
Prostate
Larynx
Leukaemia
Bladder
Colon and rectum
Oral cavity
Oesophagus
Liver and bile duct
Bronchus, lung
Leading Cancers in Rayong, 1998-2000
3.4
3.5
3.7
4.1
4.5
4.9
6.5
7.5
22
28.5
0 5 10 15 20 25 30
Leukaemia
Oesophagus
Thyroid
Liver and bile duct
Ovary
Oral cavity
Colon and rectum
Bronchus, lung
Breast
Cervix uteri
ASR (World)
Male Female
2.3
2.3
2.6
2.9
4.1
5.2
5.7
7.3
7.7
12.1
0 5 10 15 20 25
Penis
Larynx
Prostate
Skin
Non-Hodgkin lymphoma
Oesophagus
Oral cavity
Liver and bile duct
Colon and rectum
Bronchus, lung
Leading Cancers in Prachuap Khiri Khan, 1998-2000
2.3
2.4
2.4
2.4
2.6
2.8
4.4
4.9
16
21.2
0 5 10 15 20 25
Skin
Non-Hodgkin lymphoma
Liver and bile duct
Leukaemia
Thyroid
Bronchus, lung
Oral cavity
Colon and rectum
Breast
Cervix uteri
ASR (World)
Male Female
4
4.1
4.5
5.1
5.2
7.7
8.1
9.7
10.2
13.5
0 5 10 15 20 25
Larynx
Prostate
Bladder
Non-Hodgkin lymphoma
Skin
Liver and bile duct
Oesophagus
Oral cavity
Colon and rectum
Bronchus, lung
Leading Cancers in Songkhla, 1998-2000
3.3
3.8
3.9
4.5
4.9
5.7
5.7
7.4
17.2
20.6
0 5 10 15 20 25
Corpus uteri
Skin
Non-Hodgkin lymphoma
Leukaemia
Bronchus, lung
Ovary
Thyroid
Colon and rectum
Breast
Cervix uteri
ASR (World)
Male Female
Table
1990 1993 1996 1999 2002 2005 2008
Prevention
Early diagnosis
Treatment
Palliative Care
The four principle cancers of Thailand
Liver
Lung
Cervix
Breast
42.0% of all cancers in men
54.2% of all cancers in women
National Cancer Control Programmes(NCCP) of Thailand
in the year 2000
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 prevalence3 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:
Hepatitis B Virus
Hepatocellular carcinoma (HCC)
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)
Srivatanakul et al. 2004
M 38.8M 21.5
M 27.9
M 73.2
M 67.7 M 24.9
M 63.4
M 200.1
M 106.0
M 136.5
M 79.9
M 59.4
F 18.0 F 13.2
F 11.3
F 43.9
F 34.6 F 15.6
F 31.0
F 104.1
F 53.2
F 54.3
F 43.7
F 28.1
Kong river
Laos
Mukdahan
Sakhon
Nakhon
M 200.1
F 104.1
Plapak
IARC monographs on the evaluation of carcinogenic risks to humans, Vol. 61
Prevalence Intensity
of infection with Opisthorchis viverrini
in an area of high intensity in Thailand
Upatham et al. (1994)
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 sausage3Puk - dong
Srivatanakul et al. 1991
No tumor hamster
Dimethyl
nitrosamine
No tumor hamster
Opisthorchis
viverrini
hamster
Cholangiocarcinoma
Infection with o. viverrini 100 metacercariae by intragastric intubation
in combination with N-Nitrosodimethylamine (NDMA) 25 mg/L in drinking water
Thamavit et al, 1978
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
Life cycle of liver flukes
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
0
5
10
15
20
0
10
20
30
+ PRO + PRO & ASCORBIC ACID
n = 23
n = 18
n = 5
n = 36
PRESENCE OF OV EGGSANTI - OV
NP
RO
(g
/ 1
2h
)
NP
RO
(g
/ 1
2h
)
-
Srivatanakul et Al. 1991
Chronic infection by viruses/bacteria/parasites Toxins
Chronic inflammation leads to prolonged exposure of tissues to cancer-
causing agents produced within the body in response to infection or toxins
IARC
Inflammation
Free radicals Altered signalling pathways
(prostaglandins, cytokines)
DNA and tissue damage
Mutation
Modulation of gene expression and
protein function
Carcinogenesis
Increased cell division
Decreased DNA repair
antioxidantsCox-2 inhibitors
e.g. Aspirin, NSAIDS
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
Strategies for primary prevention to control
Liver Cancer in Thailand:
Having important advantages for population level prevention,
a low risk of side – effects
Behavioral interventions
Have a healthy diet
Be physically active and avoid obesity
Reduce alcohol consumption
Do not smoke or chew tobacco
Do not eat raw fish
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
Red meat
Fatty food
Fry food
Grill food
Charred food
Salted food
Cured and smoked meat
Food preservation (nitrate,nitrite)
Fermented food
MORE CONSUMPTION
Vegetables, Fruits and other Plant-based Foods
Fish, Poultry (remove the skin)
Boil food, Steam food
Herbs and Spices
Half vegetables & Fruits
CANCERBIOLOGICAL
EFFECTIVE
DOSE
EARLY
BIOLOGICAL
EFFECT
Preventive
Interventions
EXPOSUREINTERNAL
DOSE
High carcinogen exposure
O.VNitrosamineNitrate
Biomarkersfor carcinogen exposure
DNA adductsProtein adducts
Gene mutation
Oncogene activation
Tumor suppressor gene activation
Microsatellite instability
ALTERED
STRUCTURE/
FUNCTION
SUSCEPTIBILITY
FACTORS
vitamin c
antioxidants
cox-2 inhibitors
e.g. Aspirin, NSAIDS
Chemoprevention
Behavioral Intervention
Liver Fluke ControlEarly Detection
Lack of protective
(dietary) factors
13.5
12.1
25.1
18.4
20.6
26.3
7
53
29.6
20.6
4.9
2.8
7.5
6.5
7.1
8.3
3.7
27.6
22.3
9.3
0 10 20 30 40 50 60
Songkhla
Prachuap Khiri Khan
Rayong
Bangkok
Khon Kaen
Udon Thani
Nakhon Phanom
Lampang
Chiang Mai
Thailand
Female
Male
Lung cancer in different regions
1998 - 2000
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).
•Forbade - tobacco sales to young
people under
• Restricts demonstration of smokers
in movies, TV programs etc.
• Increase tobacco taxes
Anti – smoking campaigns
• restricting smoking in public places,
workplaces,hospitals
• ban on tobacco advertising
• stigmatizing cigarette packs
Anti – smoking campaigns
Tobacco Control Legislation, Tobacco Law
for Improvement of Health through:
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 diseases
NCCP 2nd Edition WHO 2002
1 Including heart disease, stroke, and hypertension2 Including chronic-obstructive pulmonary disease and asthma
Cardiovascular Respiratory
Risk factor Cancer disease1 Diabetes disease2
tobacco use
Alcohol
Unhealth diet
Physical inactivity
Obesity
Raised blood pressure
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)
IARC / WHO
Developing
Developed
Age-specific incidence rates of cervical cancer
0.1
1
10
100
20 25 30 35 40 45 50 55 60 65 70+
Bangkok Chiang Mai Khon Kaen Lampang Songkhla
Age
percentage distribution of microscopically verified cases by histological type
Cervical Cancer
Survival from cervical cancer by clinical extent of disease
0
0.25
0.5
0.75
1
0 12 24 36 48 60
localized regional
distant metastasis unknown
Survival time in months
Chiang Mai
Natural History of Cervical Cancer and Program lmplications
HPV
Infection
Characteristics:
• HPV infection
extremely common
among women of
reproductive age.
• HPV infection can
remain stable, lead to
dysplasia,or become
undetectable.
Low-grade
Cervical Dysplasia
Management:
• While genital warts
resulting from
HPV infection may be
treated, there is no
treatment that
eradicates HPV.
• Primary prevention
through use of ondoms
offers some protection.
Characteristics:
• Low-grade dysplasia
usually is temporary
and disappears over
time.
• Some cases, however,
progress to high-grade
dysplasia.
• It is not unusual for
HPV to cause low-grade
dysplasia within months
or years of infection.
Management:
Low-grade dysplasia
generally should be
monitored rather than
treated since most
lesions regress or do
not progress.
High-grade
Cervical Dysplasia
Characteristics:
• High-grade dysplasia,
the precursor to cervical
cancer, is significantly
less common than
low-grade dysplasia.
• High-grade dysplasia
can progress from low-
grade dysplasia or, in
some cases, directly
from HPV infection.
Management:
High-grade dysplasia
should be treated, as a
significant proportion
progresses to cancer.
Invasive
cancer
Characteristics:
• Women with high-grade
dysplasia are at risk of
developing invasive
cancer,; this generally
occurs slowly, over a
period of several years.
Management:
Treatment of invasive
cancer ishospital-based,
expensive, and often
not effective.
NCCP 2nd Edition WHO 2002
Frequency of Percentage reduction No. of
Screening in cumulative rate tests
Yearly 93 30
2-yearly 93 15
3-yearly 91 10
5-yearly 84 6
10-yearly 64 3
Frequency of Percentage reduction No. of
Screening in cumulative rate tests
Yearly 61 30
2-yearly 61 15
3-yearly 60 10
5-yearly 55 6
10-yearly 42 3
(a) Assuming 100% complance and a highly
sensitive test
(b) After correcting for lesser compliance
(80%) and reduced sensitivity in practice
Source: Miller AB. (1992) Cervical cancer screening programmes:
managerial guidelines. Geneva, World health Organization.
Table 1 Reduction in the cumulative rate of invasive cervical
cancer for women aged 35-64 years, with different
frequencies of screening
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
Table. Comparison of Two Screening Strategies in Chile
Source: Eddy, D 1986, as described in Miller, Cervical Cancer Screening
Programmes, Managerial Guidelines. Geneva : WHO (1992)
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.
Objectives
Considerations for Low-Resource Settings
when to initiate screening
how often to screen
when to recommend treatment
and/or follow-up
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.
Program Goal
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.
Cervix Cancer Screening
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
Screening for cervical cancer will be evaluated.
Population
Total
Male
Female
Health Care Services
Provincial Health Office
Provincial Hospital
Community Hospitals
District Health Offices
48 Primary Health Care Centers
Target Women 80,000 in yrs
( - yrs) 6,000 in yr
Nakhon Phanom Province
Figure1 Nakhon Phanom population and Health care Services
Table 2 Number of target women having Pap test in 1999 - 2002
Nakhon Phanom
Province
43.85561,270Wang Yang
45.98991,958Na Thom
72.33,4854,818Pla Pak
81.43,5444,352Phon Sawan
61.11,7542,872Ban Phaeng
53.62,3504,382Na Wa
49.82,1734,359Renu Nakhon
46.22,8486,166Si Songkhram
41.73,2107,703That Phanom
48.62,2954,723Tha Uthen
47.33,6397,688Na Kae
43.05,87913,660Muang
Percentage of
Coverage
Number of Women
Having Pap Test
Total Target
Women
63,951 32,632 51.0
District
Table 4 Target female population of Nakhon Phanom
in the year 2000
326325275888611535screened population
313196858777486518036non-screened population
6395112133147101753719571pop at risk
(4/5 of population in 2000)
Total50-5445-4940-4435-39
female population in 2000 7993915166183882192124464
Age group (years)
6936
Table 9 Risk and risk ratio of getting precancerous and cancerous
lesions in non-screened and screened target woman
1.70.71.10.00150.0068481122105cancercervix
15.03.56.90.00220.00907211211921CIN III
81.75.348.90.00160.0063516151812CIN II
172.311.634.90.00330.01251099252946CIN Iscreened
1.00.00130.005442913119cancercervix
1.00.00030.0013100415CIN III
1.00.00000.000110001CIN II
1.00.00010.000430300CIN Inon-screened
Upper
lim.
Lower
lim.
Cumul
Risk
ratio
Crude
risk
Cumul.
risk
Total50-5445-4940-4435-39
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
37.81717.71720.914Unknown
2.214.244.53Metastasis
28.91354.15250.734Regional
31.11424.02323.916Localized
PercentCasesPercentCasesPercentCases
ScreenedNon-screened
1999-20021997-1998
B. including in situ cases
14.51715.51720.014Unknown
0.913.644.33Metastasis
11.11347.35248.634Regional
12.01420.92322.816Localized
61.57212.7144.33In situ
PercentCasesPercentCasesPercentCases
ScreenedNon-screened
1999-20021997-1998
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 groupsA. excluding in situ cases
37.81713.3616.67Unknown
2.216.734.82Metastasis
28.91360.02752.422Regional
31.11420.0926.211Localized
PercentCasesPercentCasesPercentCases
ScreenedNon-screened
1999-20021997-1998
B. including in situ cases
14.51712.5615.67Unknown
0.916.234.42Metastasis
11.11356.32748.922Regional
12.01418.7924.411Localized
61.5726.336.73In situ
PercentCasesPercentCasesPercentCases
ScreenedNon-screened
1999-20021997-1998
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
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.
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.
Programmes for screening and
early detection of cervical cancer
National Policy
Population based, organized
All Women in Thailand,
Ages: 35,40,45,50,55 and 60 years
Cervix Cancer Screening
National Policy
Test : Pap Smear
Public Education
Cervix Cancer Screening
Quality Assurance System
• Nurses, PHC Personnels for
Pap smear taking
• Re-training cytotechnicians
Education andTraining
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
0.4
0.3
0
0.2
0.1
0.3
0.3
0
0.3
0.2
17.2
16
22
24.3
13.7
13
10.1
20.8
20.7
20.5
0 5 10 15 20 25 30
Songkhla
Prachuap Khiri Khan
Rayong
Bangkok
Khon Kaen
Udon Thani
Nakhon Phanom
Lampang
Chiang Mai
Thailand
Female
Male
Breast cancer in different regions
1998 - 2000
ASR (World)
Breast self examination
Campaigns for early detection of breast cancer
Public awareness
• Clinical breast examination• Mammogram • Appropriate diagnosis and therapy
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
Incurable cancer, palliative care deserves
high priority in cancer therapy
Palliative Care
• Palliative care clinic
• Hospices
• Home care
• Guidelines for palliative 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
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