national cancer control programmes in thailand

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


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


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


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


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


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


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


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


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


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


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


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

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


• restricting smoking in public places,

workplaces,hospitals

• ban on tobacco advertising

• stigmatizing cigarette packs


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


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.


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.


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.


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


11.11347.35248.634Regional

12.01420.92322.816Localized

61.57212.7144.33In situ



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


28.91360.02752.422Regional

31.11420.0926.211Localized



1999-20021997-1998

B. including in situ cases

14.51712.5615.67Unknown


11.11356.32748.922Regional

12.01418.7924.411Localized

61.5726.336.73In situ



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.


early detection of cervical cancer

National Policy

Population based, organized

All Women in Thailand,

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


National Policy

Test : Pap Smear

Public Education


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

national cancer control programmes in thailand

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