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National Cancer Control Programmes in Thailand Petcharin Srivatanakul National Cancer Institute Bangkok, Thailand
National Cancer Control Programmes in Thailand
National Cancer Control Programmes
in Thailand
Petcharin Srivatanakul National Cancer Institute Bangkok, Thailand
Petcharin Srivatanakul
National Cancer Institute
Bangkok, Thailand
NCCP Thailand
NCCP Thailand
13 August 1998: 1 st National Cancer Control Committee chaired by Prime Minister of Thailand
13 August 1998:
1 st National Cancer Control Committee
chaired by Prime Minister of Thailand
17 Feb 2000:
2 nd National Cancer Control Committee meeting
chaired by Prime Minister of Thailand
2000-2001:
1 st 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
The aim of cancer control is a reduction
in both the incidence and the mortality rates
of the disease.
The objectives of cancer control :
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
NCCP Thailand
1. Cancer Informatics 2. Primary prevention 3. Secondary prevention 4. Tertiary prevention 5. Palliative care
1.
Cancer Informatics
2.
Primary prevention
3.
Secondary prevention
4. Tertiary prevention
5.
Palliative care
6.
Cancer research
Cancer Informatics
Cancer Informatics
National Policy in Cancer Registration
National Policy in Cancer
Registration
Population-based cancer registry Hospital-based cancer registry
Population-based cancer registry
Hospital-based cancer registry
Population based Cancer Registry 1998 - 2000
Population based Cancer Registry
1998 - 2000
Population based Cancer Registry 1998 - 2000 Chiang Mai Lampang 3. Nakhon Phanom 4. Udon Thani
Chiang Mai Lampang 3. Nakhon Phanom 4. Udon Thani 5. Khon Kaen 6. Bangkok 7.
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

4. Udon Thani 5. Khon Kaen 6. Bangkok 7. Rayong 8. Prachuab Khiri Khan 9 Songkhla

Songkhla

Leading Cancers in Thailand, 1998-2000
Leading Cancers in Thailand, 1998-2000
Male
Male
33.4 Liver and bile duct 20.6 Bronchus, lung Colon and rectum 8.8 5.2 Oral cavity
33.4
Liver and bile duct
20.6
Bronchus, lung
Colon and rectum
8.8
5.2
Oral cavity
4.5
Non-Hodgkin lymphoma
4.2
Bladder
Oesophagus
4.1
3.9
Leukaemia
3.5
Prostate
Stomach
3.5
0
10
20
30
40
Female
Female
24. 7 Cervix uteri Breast 20. 5 Liver and bile duct 12. 3 Bronchus, lung
24. 7
Cervix uteri
Breast
20. 5
Liver and bile duct
12.
3
Bronchus, lung
9.3
Colon and rectum
7.6
5
Ovary
Oral cavity
4.6
Thyroid
4.1
Skin
3.3
Leukaemia
3.2
0
5
10
15
20
25
30
35
40
ASR (World)
ASR (World)
Leading Cancers in Chiang Mai, 1998-2000
Leading Cancers in Chiang Mai, 1998-2000
Male
Male
Bronchus, lung 29. 6 Liver and bile duct 17 Colon and rectum 9.2 6.7 Non-Hodgkin
Bronchus, lung
29. 6
Liver and bile duct
17
Colon and rectum
9.2
6.7
Non-Hodgkin lymphoma
Oral cavity
5.5
Stomach
5
Bladder
4.8
Prostate
4.6
4.1
Skin
Leukaemia
3.8
0
5
10
15
20
25
30
35
Female
Female
Cervix uteri 29. 4 Bronchus, lung 22. 3 Breast 20. 7 7.8 Colon and rectum
Cervix uteri
29. 4
Bronchus, lung
22. 3
Breast
20.
7
7.8
Colon and rectum
Ovary
5.9
Liver and bile duct
5.8
Stomach
4.4
Thyroid
4.3
4.1
Non-Hodgkin lymphoma
Oral cavity
3.9
0
5
10
15
20
25
30
35
ASR (World)
ASR (World)
Leading Cancers in Lampang, 1998-2000
Leading Cancers in Lampang, 1998-2000
Male
Male
Female
Female
Bronchus, lung 53 Liver and bile duct 32. 9 Colon and rectum 11. 7 5.4
Bronchus, lung
53
Liver and bile duct
32. 9
Colon and rectum
11. 7
5.4
Non-Hodgkin lymphoma
Prostate
5.2
Stomach
5
Leukaemia
4.6
Bladder
4.5
4.3
Skin
Nasopharynx
2.2
0
10
20
30
40
50
60
Bronchus, lung 27. 6 Cervix uteri 22. 3 Breast 20. 8 14. 7 Liver and
Bronchus, lung
27.
6
Cervix uteri
22. 3
Breast
20. 8
14.
7
Liver and bile duct
Colon and rectum
9.5
Ovary
4.6
Leukaemia
3.9
Oral cavity
3.7
3.6
Stomach
Non-Hodgkin lymphoma
3.6
0
10
20
30
40
50
60
ASR (World)
ASR (World)
Leading Cancers in Nakhon Phanom, 1998-2000
Leading Cancers in Nakhon Phanom, 1998-2000
Male
Male
Liver and bile duct 63. 5 Bronchus, lung 7 Colon and rectum 5.5 3.7 Stomach
Liver and bile duct
63. 5
Bronchus, lung
7
Colon and rectum
5.5
3.7
Stomach
Bladder
2.3
Gallbladder
1.7
Prostate
1.7
Nasopharynx
1.5
1.3
Penis
Oral cavity
1.3
0
10
20
30
40
50
60
70
Female
Female
Liver and bile duct 31. 1 Cervix uteri 11. 3 Breast 10. 1 4.9 Oral
Liver and bile duct
31. 1
Cervix uteri
11.
3
Breast
10.
1
4.9
Oral cavity
Colon and rectum
4.8
Ovary
4.7
Bronchus, lung
3.7
Corpus uteri
2.1
1.2
Uterus unspecified
Gallbladder
1.2
0
10
20
30
40
50
60
70
ASR (World)
ASR (World)
Leading Cancers in Udon Thani, 1998-2000
Leading Cancers in Udon Thani, 1998-2000
Male
Male
Liver and bile duct 113.4 Bronchus, lung 26. 3 Colon and rectum 11. 9 5.4
Liver and bile duct
113.4
Bronchus, lung
26. 3
Colon and rectum
11.
9
5.4
Leukaemia
Bladder
4.3
Stomach
4.3
Brain, nervous system
3.8
Prostate
3.8
3.3
Non-Hodgkin lymphoma
Nasopharynx
3.2
0
20
40
60
80
100
120
Female
Female
Liver and bile duct 49. 8 Cervix uteri 19. 5 Breast 13 8.5 Colon and
Liver and bile duct
49. 8
Cervix uteri
19. 5
Breast
13
8.5
Colon and rectum
Bronchus, lung
8.3
Ovary
4.5
Oral cavity
3.9
Leukaemia
3.3
2.4
Skin
Stomach
2.2
0
20
40
60
80
100
120
ASR (World)
ASR (World)
Leading Cancers in Khon Kaen, 1998-2000
Leading Cancers in Khon Kaen, 1998-2000
Male
Male
Liver and bile duct 78. 4 Bronchus, lung 20. 6 Colon and rectum 8.6 5.1
Liver and bile duct
78. 4
Bronchus, lung
20.
6
Colon and rectum
8.6
5.1
Non-Hodgkin lymphoma
Leukaemia
4.6
Skin
4.3
Bladder
4.1
Stomach
3.6
3.5
Oral cavity
Prostate
2.9
0
20
40
60
80
100
Female
Female
Liver and bile duct 33. 3 Cervix uteri 15. 9 Breast 13. 7 7.1 Bronchus,
Liver and bile duct
33. 3
Cervix uteri
15.
9
Breast
13. 7
7.1
Bronchus, lung
Colon and rectum
7
Oral cavity
6.7
Ovary
6.2
Thyroid
4.6
4.2
Skin
Leukaemia
3.1
0
20
40
60
80
100
ASR (World)
ASR (World)
Leading Cancers in Bangkok, 1998-2000
Leading Cancers in Bangkok, 1998-2000
Male
Male
Bronchus, lung 18. 4 Liver and bile duct 13. 4 Colon and rectum 12. 4
Bronchus, lung
18. 4
Liver and bile duct
13. 4
Colon and rectum
12. 4
6.7
Prostate
Bladder
5.9
Oral cavity
4.9
Non-Hodgkin lymphoma
4.6
Nasopharynx
3.6
3.6
Stomach
Skin
3.6
0
5
10
15
20
25
30
Female
Female
Breast 24. 3 Cervix uteri 19. 3 Colon and rectum 9.6 6.5 Bronchus, lung Ovary
Breast
24. 3
Cervix uteri
19. 3
Colon and rectum
9.6
6.5
Bronchus, lung
Ovary
5.1
Liver and bile duct
4.3
Thyroid
3.9
Corpus uteri
3.9
3.8
Skin
Oral cavity
3.3
0
5
10
15
20
25
30
ASR (World)
ASR (World)
Leading Cancers in Rayong, 1998-2000
Leading Cancers in Rayong, 1998-2000
Male
Male
Female
Female
25. 1 Bronchus, lung Liver and bile duct 14. 9 Oesophagus 10. 3 Oral cavity
25. 1
Bronchus, lung
Liver and bile duct
14. 9
Oesophagus
10. 3
Oral cavity
9.3
Colon and rectum
7.3
7
Bladder
Leukaemia
5
Larynx
4.2
Prostate
3.9
Oropharynx etc.
3.6
0
5
10
15
20
25
30
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4

4.1

3.7

3.5

3.4

4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4
4.1 3.7 3.5 3.4

4.9

4.5

7.5

6.5

22

28.

5

0

5

10

15

20

25

30

Cervix uteri

Breast

Bronchus, lung

Colon and rectum

Oral cavity

Ovary

Liver and bile duct

Thyroid

Oesophagus

Leukaemia

ASR (World)
ASR (World)

Leading Cancers in Prachuap Khiri Khan, 1998-2000

Male
Male
12. 1 Bronchus, lung Colon and rectum 7.7 Liver and bile duct 7.3 Oral cavity
12. 1
Bronchus, lung
Colon and rectum
7.7
Liver and bile duct
7.3
Oral cavity
5.7
Oesophagus
5.2
4. 1
Non-Hodgkin lymphoma
Skin
2.9
Prostate
2.6
Larynx
2.3
Penis
2.3
0
5
10
15
20
25
Female
Female
21. 2 Cervix uteri Breast 16 Colon and rectum 4.9 Oral cavity 4 .4 Bronchus,
21. 2
Cervix uteri
Breast
16
Colon and rectum
4.9
Oral cavity
4 .4
Bronchus, lung
2.8
2.6
Thyroid
Leukaemia
2.4
Liver and bile duct
2.4
Non-Hodgkin lymphoma
2.4
Skin
2.3
0
5
10
15
20
25
ASR (World)
ASR (World)
Leading Cancers in Songkhla, 1998-2000
Leading Cancers in Songkhla, 1998-2000
Male
Male
Female
Female
13. 5 Bronchus, lung Colon and rectum 10. 2 Oral cavity 9.7 Oesophagus 8.1 Liver
13. 5
Bronchus, lung
Colon and rectum
10.
2
Oral cavity
9.7
Oesophagus
8.1
Liver and bile duct
7.7
5.2
Skin
Non-Hodgkin lymphoma
5.1
Bladder
4.5
Prostate
4.1
Larynx
4
0
5
10
15
20
25
Cervix uteri 20. 6 Breast 17. 2 Colon and rectum 7.4 5.7 Thyroid Ovary 5.7
Cervix uteri
20. 6
Breast
17. 2
Colon and rectum
7.4
5.7
Thyroid
Ovary
5.7
Bronchus, lung
4.9
Leukaemia
4.5
Non-Hodgkin lymphoma
3.9
3.8
Skin
Corpus uteri
3.3
0
5
10
15
20
25
ASR (World)
ASR (World)
Table 1990 1993 1996 1999 2002 2005 2008
Table
1990
1993
1996
1999
2002
2005
2008
The four principle cancers of Thailand
The four principle cancers of Thailand
Liver Lung Cervix 42.0% of all cancers in men 54.2% of all cancers in women
Liver
Lung
Cervix
42.0% of all cancers in men
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 worldwide 1

Site of cancer 2

Prevention

Early

diagnosis

Curative 3

therapy

Pain relief and

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
Primary prevention
• minimizing or eliminating exposure to carcinogenic agents
• minimizing or eliminating
exposure to carcinogenic agents
• reducing individual susceptibility to the effect of carcinogenic agents
• reducing individual susceptibility
to the effect of carcinogenic agents
NCCP Thailand Strategies for Primary Prevention Liver and Lung Cancers
NCCP Thailand
Strategies for Primary Prevention
Liver and Lung Cancers
Cancer in Thailand Vol. IV 2007

Cancer in Thailand Vol. IV 2007

Cancer in Thailand Vol. IV 2007

Cancer in Thailand Vol. IV 2007

Vaccination against hepatitis B

virus infection
virus infection
Vaccination against hepatitis B virus infection Major risk factors for HCC: Hepatitis B Virus Hepatocellular carcinoma

Major risk factors for HCC:

Hepatitis B Virus

against hepatitis B virus infection Major risk factors for HCC: Hepatitis B Virus Hepatocellular carcinoma (HCC)

Hepatocellular carcinoma (HCC)

Major risk factor for CCA in Thailand

- Opisthorchis viverrini (OV)
- Opisthorchis viverrini (OV)
Life cycle of Opisthorchis viverrini
Life cycle of Opisthorchis viverrini
factor for CCA in Thailand - Opisthorchis viverrini (OV) Life cycle of Opisthorchis viverrini Cholangiocarcinoma (CCA)

Cholangiocarcinoma (CCA)

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

M 38.8 M 21.5 Sakhon F 18.0 F 13.2 Laos Nakhon M 27.9 F 11.3
M 38.8
M 21.5
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
F 43.7
M 136.5
Mukdahan
F 54.3
M 59.4
F 28.1

Srivatanakul et al. 2004

Upatham et al. (1994)
Upatham et al. (1994)
Upatham et al. (1994) Prevalence Intensity of infection with Opisthorchis viverrini in an area of high

Prevalence

Intensity

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

VOLATILE N-NITROSAMINES IN FERMENTED THAI FOOD

NDMA

VOLATILE N-NITROSAMINES IN FERMENTED THAI FOOD NDMA NPIP NPYR Food No. of Mean Range No.of Mean

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

Fish 1

15

3.8+7.3

0-25.5

8

2.3+6.4

0-23.0

3

2.1+46.6

0-177

8

Pork 2

9

1.2+2.0

0-6.5

6

5.7

1

2.9+7.0

0-21.4

4

Vegetable 3

4

0-0.5

2

0-62

2

1 Pla-ra, pla-chom, pla-som (fermented fish) 2 Nam, Thai sausage 3 Puk - dong

Srivatanakul et al. 1991

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

No tumor

No tumor

hamster(NDMA) 25 mg/L in drinking water No tumor No tumor hamster Dimethyl nitrosamine Opisthorchis viverrini hamster

hamster(NDMA) 25 mg/L in drinking water No tumor No tumor hamster Dimethyl nitrosamine Opisthorchis viverrini hamster

Dimethyl

nitrosaminein drinking water No tumor No tumor hamster hamster Dimethyl Opisthorchis viverrini hamster Cholangiocarcinoma Thamavit

Opisthorchis

viverriniwater No tumor No tumor hamster hamster Dimethyl nitrosamine Opisthorchis hamster Cholangiocarcinoma Thamavit et al, 1978

tumor No tumor hamster hamster Dimethyl nitrosamine Opisthorchis viverrini hamster Cholangiocarcinoma Thamavit et al, 1978

hamster

Cholangiocarcinoma

Thamavit et al, 1978

Life cycle of liver flukes A: DEFINITIVE HOST, HUMAN B: ADULT LIVER FLUKES IN BILE
Life cycle of liver flukes
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

Control of infection has been achieved in some areas by a combination of chemotherapy, health education and improved sanitationand also leads to reversal of biliary tract abnormalities. IARC monographs on the evaluation of carcinogenic

Conceptual Frame of Liver Fluke Control
Conceptual Frame of Liver Fluke Control

Ministry of Public Health, Thailand

Urinary level of NPRO in relation to evidence of OV infestation
Urinary level of NPRO in relation to
evidence of OV infestation

20

15 10 5 g / 12h )NPRO (
15
10
5
g / 12h )NPRO
(

0

evidence of OV infestation 20 15 10 5 g / 12h )NPRO ( 0 + PRO

+ PRO

n = 23

n = 18

n = 18

n = 18
n = 18
n = 18
n = 18
n = 18
n = 18
n = 18
n = 18

ANTI - OV

)NPRO ( 0 + PRO n = 23 n = 18 A N T I -

+ PRO & ASCORBIC ACID

30

20 10 g / 12h )NPRO (
20
10
g / 12h )NPRO
(

0

n = 5

n = 36
n = 36
n = 36
n = 36

n = 36

n = 36
n = 36
n = 36
n = 36
n = 36
n = 36
n = 36
n = 36
n = 36
n = 36

-

PRESENCE OF OV EGGS

Srivatanakul et Al. 1991

Chronic infection by viruses/bacteria/parasites Toxins
Chronic infection by viruses/bacteria/parasites Toxins

antioxidants

infection by viruses/bacteria/parasites Toxins antioxidants Inflammation Cox-2 inhibitors e.g. Aspirin, NSAIDS Free

Inflammation

Cox-2 inhibitors e.g. Aspirin, NSAIDS

Inflammation Cox-2 inhibitors e.g. Aspirin, NSAIDS Free radicals DNA and tissue damage Altered signalling

Free radicals

DNA and tissue damage

Altered signalling pathways (prostaglandins, cytokines)

Altered signalling pathways (prostaglandins, cytokines) Modulation of gene expression and protein function Increased

Modulation of gene expression and protein function

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

Increased cell division Decreased DNA repairModulation of gene expression and protein function Mutation Carcinogenesis Chronic inflammation leads to

Mutation

Increased cell division Decreased DNA repair Mutation Carcinogenesis Chronic inflammation leads to prolonged

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:

for primary prevention to control Liver Cancer in Thailand:  Vaccination against hepatitis B virus infection

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
Behavioral interventions

Having important advantages for population level prevention, a low risk of side effects

level prevention, a low risk of side – effects Do not smoke or chew tobacco Have
level prevention, a low risk of side – effects Do not smoke or chew tobacco Have

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
Public Education
Public Education Physical Exercise
Public Education Physical Exercise
Public Education Physical Exercise
Public Education Physical Exercise
Public Education Physical Exercise

Physical Exercise

Promoting dietary modification to achieve a healthier diet

(or preventing change of diet to

more hazardous pattern).
more hazardous pattern).
LESS CONSUMPTION
LESS CONSUMPTION
Alcoholic drinks
Alcoholic drinks
Fatty food
Fatty food
Fry food Grill food Charred food
Fry food
Grill food
Charred food
drinks Fatty food Fry food Grill food Charred food Fermented food Salted food Red meat Cured
Fermented food Salted food Red meat Cured and smoked meat
Fermented food
Salted food
Red meat
Cured and smoked meat
Food preservation (nitrate,nitrite)
Food preservation (nitrate,nitrite)
Grill food Charred food Fermented food Salted food Red meat Cured and smoked meat Food preservation
Grill food Charred food Fermented food Salted food Red meat Cured and smoked meat Food preservation
Grill food Charred food Fermented food Salted food Red meat Cured and smoked meat Food preservation
MORE CONSUMPTION
MORE CONSUMPTION
MORE CONSUMPTION Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam

Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin)

Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs
Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs

Boil food, Steam food Herbs and Spices

Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs
Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs
Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs
Vegetables, Fruits and other Plant-based Foods Fish, Poultry (remove the skin) Boil food, Steam food Herbs

Half vegetables & Fruits

Liver Fluke Control Behavioral Intervention

Chemoprevention
Chemoprevention

Early Detection

vitamin c antioxidants Preventive cox-2 inhibitors Interventions e.g. Aspirin, NSAIDS EARLY ALTERED BIOLOGICAL
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 exposure

O.V

Nitrosamine

Nitrate

Biomarkers

for carcinogen

exposure

DNA adducts Protein adducts

Gene mutation

Oncogene activation

Tumor suppressor gene activation

Microsatellite instability

Lack of protective (dietary) factors

Tumor suppressor gene activation Microsatellite instability Lack of protective (dietary) factors SUSCEPTIBILITY FACTORS
Tumor suppressor gene activation Microsatellite instability Lack of protective (dietary) factors SUSCEPTIBILITY FACTORS

SUSCEPTIBILITY

FACTORS

Lung cancer in different regions 1998 - 2000
Lung cancer in different regions
1998 - 2000
9.3 Thailand 20.6 22.3 Chiang Mai 29.6 27.6 Lampang 53 3.7 Nakhon Phanom 7 8
9.3
Thailand
20.6
22.3
Chiang Mai
29.6
27.6
Lampang
53
3.7
Nakhon Phanom
7
8
.3
Udon Thani
26.3
Female
7.1
Male
Khon Kaen
20.6
6.5
Bangkok
18.4
7.5
Rayong
25.1
2.8
Prachuap Khiri Khan
12.1
4.9
Songkhla
13.5
0
10
20
30
40
50
60
ASR (World)
ASR (World)
Anti – smoking campaigns
Anti – smoking campaigns
Government organizations : Institute of Tobacco Consumption Control
Government organizations :
Institute of Tobacco Consumption Control
Non- Government organizations : Action on Smoking and Health Foundation
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
Anti – smoking campaigns
•Forbade - tobacco sales to young people under • Restricts demonstration of smokers in movies,
•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:
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
• 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
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 Cardiovascular Respiratory Riskfactor Cancer disease1
Risk factors common to major
noncommunicable diseases
Cardiovascular
Respiratory
Riskfactor
Cancer
disease1
Diabetes
disease2

tobaccouse

tobaccouse
tobaccouse
tobaccouse
tobaccouse

Alcohol

Alcohol
Alcohol

Unhealthdiet

Unhealthdiet
Unhealthdiet
Unhealthdiet
Unhealthdiet

Physical inactivity

Physical inactivity
Physical inactivity
Physical inactivity
Physical inactivity

Obesity

Obesity
Obesity
Obesity
Obesity

Raisedbloodpressure

Raisedbloodpressure
1 Including heart disease, stroke, and hypertension 2 Including chronic-obstructive pulmonary disease and asthma
1 Including heart disease, stroke, and
hypertension
2 Including chronic-obstructive
pulmonary disease and asthma

NCCP 2nd Edition WHO 2002

Secondary Prevention
Secondary Prevention
Programmes for screening and early detection of cervical cancer
Programmes for screening and
early detection of cervical cancer
Programmes for screening and early detection of breast 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
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)
Estimated Cervical Cancers (thousands)
Developing Developed
Developing
Developed

IARC / WHO

Age-specific incidence rates of cervical cancer
Age-specific incidence rates of cervical cancer

100

10

1

0.1

Age 20 25 30 35 40 45 50 55 60 65 70+ Bangkok Chiang Mai
Age
20
25
30
35
40
45
50
55
60
65
70+
Bangkok
Chiang Mai
Khon Kaen
Lampang
Songkhla
Cervical Cancer
Cervical Cancer
percentage distribution of microscopically verified cases by histological type
percentage distribution of microscopically verified cases by histological type
Cervical Cancer percentage distribution of microscopically verified cases by histological type
Survival from cervical cancer by clinical extent of disease
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
1
0.75
0.5
0.25
0
0
12
24
36
48
60

Survival time in months

localizedChiang Mai 1 0.75 0.5 0.25 0 0 12 24 36 48 60 Survival time in

distant metastasisof disease Chiang Mai 1 0.75 0.5 0.25 0 0 12 24 36 48 60 Survival

regionalChiang Mai 1 0.75 0.5 0.25 0 0 12 24 36 48 60 Survival time in

unknownChiang Mai 1 0.75 0.5 0.25 0 0 12 24 36 48 60 Survival time in

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.

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.

Low-grade Cervical Dysplasia

High-grade Cervical Dysplasia

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.

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.

dysplasia or, in some cases, directly from HPV infection. • Management: Low-grade dysplasia generally should be
•
or, in some cases, directly from HPV infection. • Management: Low-grade dysplasia generally should be
or, in some cases, directly from HPV infection. • Management: Low-grade dysplasia generally should be

Management:

Low-grade dysplasia generally should be monitored rather than treated since most lesions regress or do

not progress.

Management:

High-grade dysplasia should be treated, as a significant proportion progresses to cancer.

treated, as a significant proportion progresses to cancer. Invasive cancer Characteristics: • Women with high-grade

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.

Table 1 Reduction in the cumulative rate of invasive cervical cancer for women aged 35-64
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 sensitive test
(a) Assuming 100% complance and a highly
sensitive test
(b) After correcting for lesser compliance (80%) and reduced sensitivity in practice
(b) After correcting for lesser compliance
(80%) and reduced sensitivity in practice

Frequency of Percentage reduction No. of

Frequency of Percentage reduction No. of

Screening

in cumulative rate

tests

Screening

in cumulative rate

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

3

10-yearly

42

3

3
Source: Miller AB. (1992) Cervical cancer screening programmes: managerial guidelines. Geneva, World health Organization.
Source: Miller AB. (1992) Cervical cancer screening programmes:
managerial guidelines. Geneva, World health Organization.
NCCP 2nd Edition WHO 2002
NCCP 2nd Edition WHO 2002
Table. Comparison of Two Screening Strategies in Chile
Table.
Comparison of Two Screening Strategies in Chile
Program 1 Program 2
Program 1
Program 2
Age Frequency of screening Coverage Reduction in mortality Cost per case detected 30 - 35
Age
Frequency of screening
Coverage
Reduction in mortality
Cost per case detected
30 - 35 years
3 years
30 - 50 years
10 years
30%
90%
15%
44%
US$2,522
US$556
Source: Eddy, D 1986, as described in Miller, Cervical Cancer Screening Programmes, Managerial Guidelines. Geneva
Source: Eddy, D 1986, as described in Miller, Cervical Cancer Screening
Programmes, Managerial Guidelines. Geneva : WHO (1992)
Objectives
Objectives
General :
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.
• To treat preinvasive lesions.
• To manage invasive lesions.
Objectives
Objectives
Specific:
Specific:

To evaluate reduction in incidence and mortality rates from cervical cancer in the

by means of an organised low

province

intensity cervical cytology programme.
intensity cervical cytology programme.
programme implementation.
programme implementation.

To demonstrate the different aspects of the

Considerations for Low-Resource Settings  when to initiate screening  how often to screen when

Considerations for Low-Resource Settings

 when to initiate screening
 when to initiate screening


how often to screen when to recommend treatment


and/or follow-up
and/or follow-up

Program Goal

 Increase awareness of cervical cancer, emphasizing the need for cervical cancer screening among women
 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
 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
Cervix Cancer Screening
 The screening activities are integrated in the health care system.
 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
 Attending organized screening for women
at target population (age 35-54 years) is free
of charge.
Cervix Cancer Screening
Cervix Cancer Screening
 Sample taking is done by trained nurses (midwives) and Primary Health Care Personnals in
 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
 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
Cervix Cancer Screening
The screening results of the programme, including histologically confirmed diagnosis, are registered at the National
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.
Screening for cervical cancer will be evaluated.
Selected Evaluation Indicators - percentage of women aged years to screened in the past four
Selected Evaluation Indicators
- percentage of women aged
years
to
screened in the past four
- percentage of women with positive for high grade lesions or
- percentage of women with positive for high grade lesions or
cancer
cancer
- percentage of diagnosed women with positive screening results
- percentage of diagnosed women with positive screening results
- Incidence of cancer (Stage distribution)
- Incidence of cancer (Stage distribution)
- Invasive cancers : screening history
- Invasive cancers : screening history
Effect of Cervix Cancer Screening - decreased in incidence and mortality rates
Effect of Cervix Cancer Screening
- decreased in incidence and mortality rates
Figure1 Nakhon Phanom population and Health care Services
Figure1 Nakhon Phanom population and Health care Services
Figure1 Nakhon Phanom population and Health care Services Nakhon Phanom Province Population Total Male Female Target

Nakhon Phanom Province

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

District

Total Target Women

Number of Women Having Pap Test

Percentage of 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 Province

63,951

32,632

51.0

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.

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

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 Polic Programmes for screening and early detection of cervical cancer

National Polic

Programmes for screening and

early detection of cervical cancer

Cervix Cancer Screening
Cervix Cancer Screening

National Policy

Cervix Cancer Screening National Policy  Population based, organized  All Women in Thailand, Ages: 35,40,45,50,55

Population based, organized

All Women in Thailand,

Ages: 35,40,45,50,55 and 60 years

Screening National Policy  Population based, organized  All Women in Thailand, Ages: 35,40,45,50,55 and 60

Test : Pap Smear

Test : Pap Smear
Test : Pap Smear
Test : Pap Smear

Cervix Cancer Screening

Public Education

Education andTraining

Nurses, PHC Personnels for Pap smear taking

Re-training cytotechnicians

andTraining • Nurses, PHC Personnels for Pap smear taking • Re-training cytotechnicians Quality Assurance System
andTraining • Nurses, PHC Personnels for Pap smear taking • Re-training cytotechnicians Quality Assurance System
andTraining • Nurses, PHC Personnels for Pap smear taking • Re-training cytotechnicians Quality Assurance System

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
Programmes for screening
and early detection of breast cancer
Breast cancer in different regions 1998 - 2000
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
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)
ASR (World)
Campaigns for early detection of breast cancer
Campaigns for early detection of breast cancer
Public awareness Breast self examination
Public awareness
Breast self examination
• Mammogram • Clinical breast examinat • Appropriate diagnosis a
• Mammogram
• Mammogram

Clinical breast examinat

Appropriate diagnosis a

Tertiary prevention
Tertiary prevention
• National Cancer Institute and Regional Cancer center network(7 centers) • Regional Referral Cancer Center
• National Cancer Institute and Regional
Cancer center network(7 centers)
• Regional Referral Cancer Center Network
(30 centers)
Tertiary Prevention
Tertiary Prevention
• guidelines for cancer treatment
• guidelines for cancer treatment
Surgery Radiotherapy Chemotherapy Hormonal Therapy Combination Treatment
Surgery
Radiotherapy
Chemotherapy
Hormonal Therapy
Combination Treatment
Palliative Care Incurable cancer, palliative care deserves high priority in cancer therapy • Guidelines for
Palliative Care
Incurable cancer, palliative care deserves
high priority in cancer therapy
• Guidelines for palliative care
• Palliative care clinic
• Hospices
• Home care
Cancer Research
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
Thank
you