Hutcha Sriplung

Cancer survival in Africa, Asia, and Central America: a population-based study

BACKGROUND Population-based cancer survival data, a key indicator for monitoring progress against cancer, are not widely available from countries in Africa, Asia, and Central America. The aim of this study is to describe and discuss cancer survival in these regions. METHODS Survival analysis was done for 341 658 patients diagnosed with various cancers from 1990 to 2001 and followed up to 2003, from 25 population-based cancer registries in 12 countries in sub-Saharan Africa (The Gambia, Uganda), Central America (Costa Rica), and Asia (China, India, Pakistan, Philippines, Saudi Arabia, Singapore, South Korea, Thailand, Turkey). 5-year age-standardised relative survival (ASRS) and observed survival by clinical extent of disease were determined. FINDINGS For cancers in which prognosis depends on stage at diagnosis, survival was highest in China, South Korea, Singapore, and Turkey and lowest in Uganda and The Gambia. 5-year ASRS ranged from 76-82% for breast cancer, 63-79% for cervical cancer, 71-78% for bladder cancer, and 44-60% for large-bowel cancers in China, Singapore, South Korea, and Turkey. Survival did not exceed 22% for any cancer site in The Gambia; in Uganda, survival did not exceed 13% for any cancer site except breast (46%). Variations in survival correlated with early detection initiatives and level of development of health services. INTERPRETATION The wide variation in cancer survival between regions emphasises the need for urgent investments in improving awareness, population-based cancer registration, early detection programmes, health-services infrastructure, and human resources. FUNDING Association for International Cancer Research (AICR; St Andrews, UK), Association pour la Recherche sur le Cancer (ARC, Villejuif, France), and the Bill & Melinda Gates Foundation (Seattle, USA).

Genetic and environmental determinants of risk for cholangiocarcinoma via Opisthorchis viverrini in a densely infested area in Nakhon Phanom, northeast Thailand

Infection with Opisthorchis viverrini (OV) is associated with cholangiocarcinoma. OV is common in northeast Thailand, but less than 10% of the inhabitants develop cholangiocarcinoma. Animal experiments suggest that OV infection alone does not cause cholangiocarcinoma, and thus other environmental and genetic factors may play a role in causation. We conducted a population‐based case‐control study in which sex, age and place of residence were matched individually. Polymorphisms of GSTM1 and GSTT1 alone were not associated with risk for cholangiocarcinoma, while an elevated level of antibodies against OV (ELISA) ≥0.200 was the strongest risk indicator (odds ratio as compared to that <0.200 = 27.09 [95% confidence interval (CI): 6.30–116.57]. Compared to subjects who had a normal antibody range and the wild‐type GSTM1 gene, those who had elevated antibodies had higher odds ratios of 12.32 (95% CI: 1.60–94.85) for wild‐type GSTM1 and 23.53 (95% CI: 4.25–130.31) for the null variant thereof, respectively. Past and current regular drinkers of alcohol had higher risk [odds ratio = 5.39 (95% CI: 1.11–26.06) and 4.82 (95% CI: 1.29–18.06), respectively]. Eating fermented products was an independent risk factor. Smokers or consumers of fermented fish had substantially increased risk if they were past or current drinkers. Infection with OV correlates strongly with cholangiocarcinoma, susceptibility to which may be possibly associated with GSTM1 polymorphism. Alcohol may affect metabolic pathways of endogenous and exogenous nitrosamines.

Prevalence and natural course of gastroesophageal reflux symptoms: A 1-year cohort study in Thai infants

Background Epidemiologic studies in adults suggest that the nature of gastroesophageal reflux may differ among various ethnic groups. Until recently, there has been limited information concerning the epidemiology of gastroesophageal reflux in non-Western children. The objectives of this cohort study were to investigate the prevalence of symptoms related to gastroesophageal reflux in Thai infants and to describe the clinical course of reflux regurgitation during the first year of life. Methods A cohort study was performed in 216 healthy neonates who attended the well-baby clinic of Songklanagarind Hospital between March and June 1998. All neonates were followed up, at regular well-baby clinic visits, for 1 year for reflux symptoms and clinical progress. Information concerning gastroesophageal reflux symptoms was obtained by interviewing the parents and from their diary records. An infant who regurgitated at least 1 day per week was considered to have reflux regurgitation. Results No infant with clinical features of pathologic gastroesophageal reflux or other reflux symptoms apart from regurgitation were seen during this study period. Of 145 infants in a 1-year cohort, the prevalence of reflux regurgitation peaked at 2 months at 86.9% and significantly decreased to 69.7% at 4 months, 45.5% at 6 months, and 22.8% at 8 months. At 1 year of age, only 7.6% of infants still had reflux regurgitation. Most Thai infants with gastroesophageal reflux had mild symptoms: 90% of them regurgitated only one to three times per day, and daily regurgitation was reported in a low percentage. Comparing infants with reflux regurgitation and those without, the standard deviation scores of body weight for age were similar. There was no significant difference in prevalence of reflux regurgitation between breast-fed and bottle-fed infants. Conclusions The nature of gastroesophageal reflux in Thai infants differs from that in Western infants. The prevalence of reflux regurgitation in Thai infants was very high at 1 to 2 months of age; however, many infants became symptom-free by 6 months. The type of feeding (breast milk vs. bottle milk) had no influence on the prevalence of reflux regurgitation.

Lifestyle habits and genetic susceptibility and the risk of esophageal cancer in the Thai population

The association of lifestyle habits and polymorphism of ADH2 and ALDH2 genes with the risk of esophageal cancer in Thai population was investigated in a hospital-based case-control study: 202 cases and 261 controls. The results of multivariate logistic analysis showed that alcohol consumption >60g/day, smoking >10 cigarettes/day and chewing betel >or=10 quids/day significantly increased risk (odds ratio (OR) 5.84, 95% confidence interval (CI) 3.15-10.83; 4.65, 95% CI 1.99-10.84; and 4.68, 95% CI 2.05-10.72, respectively). ADH2*1/*1 also increased the risk significantly (OR 1.56, 95% CI 1.01-2.39) while ALDH2 did not (OR of ALDH2*1/*2 1.57, 95% CI 0.89-2.76). However, the combined at risk genotypes, ADH2*1/*1 and ALDH2*1/*2 increased risk to four-fold. In addition, significant gene-environment interaction was found. Heavy drinkers >60g/d harboring ADH2*1/*1 or ALDH2*1/*2 had about an 11-fold increased risk.

Factors related to delay in diagnosis of oral squamous cell carcinoma in southern Thailand.

The factors related to patient, professional and total delay in 161 oral squamous cell carcinoma (OSCC) patients attending for treatment at a university hospital in southern Thailand were investigated. About 42 and 20% of these patients had a patient delay of more than 1 month and 3 months, respectively. About half of the patients received proper management from health care professionals (HCPs) on their first consultation. Traditional herbal medication use was significantly associated with prolonged patient delay (hazard ratio [HR] 0.46, 95% C.I. 0.28-0.76). None of the variables investigated had a significant association with professional delay. Traditional herbal medication use also significantly prolonged total delay (HR 0.45, 95% C.I. 0.27-0.74). Buddhists had shorter total delay than Muslims (HR 0.68, 95% C.I. 0.49-0.95). The present study indicates that both patients and HCPs are responsible for the diagnostic delay. A health education campaign about OSCC and the use of traditional herbal medication is recommended to shorten patient delay. Continuing education on oral cancer and precancer for HCPs and clarification of the referral system are needed to effect a major reduction in professional delay.

Delay in breast cancer care: a study in Thai women.

BACKGROUND Breast cancer is the second most common cause of cancer death in Thai women. Cancer registry data reveal a high prevalence of late-stage disease at diagnosis. The factors resulting in delay in Thailand have not yet been investigated. OBJECTIVES To determine the extent of, and the factors contributing to, delay in breast cancer care. DESIGN Women with breast cancer who were first treated at Songklanagarind Hospital between June 1994 and June 1996 were interviewed with retrospective chart audits of care. MEASURES Dependent variables included patient delay (symptom recognition to first care) and system delay (first care to treatment). Independent variables tested included demographic factors, help-seeking behavior, and cancer knowledge. Nonparametric rank sum tests were used for univariate analysis, and Cox regression was used for multivariate analysis. RESULTS Ninety-four cases were included in the study. The median patient and system delays were 4 weeks; 26.6% and 24.4% of patients, respectively, experienced patient and system delay >12 weeks. Only marital status (unmarried compared with married women) was significantly associated with patient delay (hazard ratio [HR] 2.78, 95% CI 1.23-6.25). Contacting a provincial hospital instead of a university hospital as first medical care (hazard ratio 2.50, 1.23-5.26), being given a diagnosis rather than being told nothing (HR 2.04, 1.14-3.57) and being given treatment rather than being immediately referred (HR 4.55, 2.22-9.09) were associated with system delay. CONCLUSIONS Patient delay and system delay in breast cancer care are important weaknesses of disease control in Thailand. Educational programs should target unmarried women, who are at higher risk of delay. System delay in hospitals outside the university needs to be improved by a good referral system.

Factors related to advanced stage oral squamous cell carcinoma in southern Thailand

A critical factor that indicates a poor prognosis of oral squamous cell carcinoma (OSCC) is advanced stage disease. This study, therefore, aimed to identify the factors related to advanced stage (TNM staging III, IV) OSCC in Thailand. There were 161 patients with squamous cell carcinoma of the oral cavity and lip (ICD-9 140, 141, 143-5), included in the study. Sixty-two per cent of the patients presented with advanced stage disease. Information on demographic characteristics, risk habits, health-seeking behaviour prior to health care professional (HCP) consultation, tumour characteristics and patient and professional delay was obtained by questionnaire-based interview of the patients. These variables were included as initial variables in a logistic regression to calculate the odds ratio (OR) of advanced versus early stage OSCC. Having traditional herbal medication before HCP consultation significantly increased the risk of advanced stage OSCC (OR 5.77; 95% C.I. 1.25-26.62). Floor of mouth location of tumour was associated with a lower risk of advanced stage disease (OR 0.27; 95% C.I. 0.09-0.82) as was having an ulcer (OR 0.43, 95% C.I. 0.02-0.89). The findings indicate that having traditional herbal medication before HCP consultation increased the risk of advanced stage disease. The lower risk of advanced stage OSCC associated with ulcerative tumours and those on the floor of the mouth may be due to their being more readily detected by the patients.

The clinical course of Hashimoto's thryoiditis in children and adolescents: 6 years longitudinal follow-up.

Forty-six children and adolescents with Hashimotos thyroiditis were followed up for 5.9 +/- 0.3 years. The mean age at diagnosis was 12.4 +/- 1.7 years (range 9-15.4 yr). The patients were divided into three groups according to thyroid function: group 1 (n = 28) included patients who had normal concentrations of free thyroxine (FT4) and thyrotropin (TSH); group 2 (n = 8) included patients who had normal FT4 and elevated TSH, consistent with compensated hypothyroidism; group 3 (n = 10) included patients who had low FT4 and elevated TSH consistent with overt hypothyroidism. After 5.9 years of follow-up, four out of eight patients with compensated hypothyroidism had normal thyroid function and the other four patients developed overt hypothyroidism. Thyroxine therapy was administered in patients with overt hypothyroidism including the four patients with compensated hypothyroidism who later presented with overt hypothyroidism. All patients in both euthyroid and hypothyroid groups had normal growth and puberty. Final adult height was 0.43 +/- 0.80 SDS which was 1.58 +/- 3.03 cm above mid-parental height. The mean age at menarche (n = 43) was 12.4 +/- 1.1 years, which was not different from normal children. The goiter remained the same size in most of the patients with euthyroidism without thyroxine therapy, but decreased in patients with overt hypothyroidism after thyroxine therapy.

Disclosure of a cancer diagnosis in Thai patients treated with radiotherapy

Although radiotherapy usually implies a cancer diagnosis, no available study has been reported as to what proportion of Thai patients treated with radiotherapy know their diagnosis and how they want related information revealed. We questioned 106 patients in order to determine the proportion who knew their cancer diagnosis, and interviewed patients who knew the diagnosis and relatives of patients both who knew and did not know it with semi-structured questionnaires concerning how they wanted to be told. Sixty-seven patients (63.2%) knew their cancer diagnosis. Multivariate analysis showed that the patients with the following characteristics were inclined to know their diagnosis: younger than 70 years old, head and neck or gynecological cancer, no previous treatment before radiotherapy, no accompanying relatives during the treatment, and patients with relatives who wanted to disclose the information. 97.0% of patients who knew the diagnosis indicated that they had really wanted to know, 89.5% and 73.3%, respectively of relatives who accompanied patients who knew and did not know it expressed the same wish. No demographic factors could predict who wanted to be told the diagnosis. The majority of patients and relatives who wanted the diagnosis disclosed wanted to know all related information before treatment. They wanted to hear this directly from the doctor in the presence of their relatives.

Maternal iodine status and neonatal thyroid-stimulating hormone concentration: a community survey in Songkhla, southern Thailand

OBJECTIVE To determine iodine intake and urinary iodine excretion (UIE) in a group of pregnant Thai women and the concentration of thyroid-stimulating hormone (TSH) in their neonates. DESIGN A prospective cohort study. SETTING Three districts of Songkhla, southern Thailand. SUBJECTS Two hundred and thirty-six pregnant women. RESULTS A quarter of the participants lacked knowledge of iodine and the prevention of iodine deficiency, although 70 % used iodized salt. Those who did not use iodized salt stated that they had no knowledge about iodine (57 %) and no iodized salt was sold in their village (36 %). The median iodine intake in the three districts was 205-240 microg/d, with 53-74 % of pregnant women having iodine intake <250 microg/d. The median UIE in the three districts was 51-106 microg/l, with 24-35 % having UIE < 50 microg/l. The mean neonatal TSH was 2.40 (sd 1.56) mU/l, with 8.9 % of neonates having TSH > 5 mU/l. CONCLUSIONS The studied women and their fetuses were at risk of mild iodine deficiency. About a quarter of the participants lacked knowledge of the importance of iodine. Education regarding the importance of iodine supplements and the promotion of iodized salt should be added to national health-care policies in order to prevent iodine-deficiency disorders, diseases that are subclinical but have long-term sequelae.