National and Subnational Population-Based Incidence of Cancer in Thailand: Assessing Cancers with the Highest Burdens

Article (PDF Available)inCancers 9(8) · August 2017with 1,056 Reads
DOI: 10.3390/cancers9080108
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Abstract
In Thailand, five cancer types-breast, cervical, colorectal, liver and lung cancer-contribute to over half of the cancer burden. The magnitude of these cancers must be quantified over time to assess previous health policies and highlight future trajectories for targeted prevention efforts. We provide a comprehensive assessment of these five cancers nationally and subnationally, with trend analysis, projections, and number of cases expected for the year 2025 using cancer registry data. We found that breast (average annual percent change (AAPC): 3.1%) and colorectal cancer (female AAPC: 3.3%, male AAPC: 4.1%) are increasing while cervical cancer (AAPC: -4.4%) is decreasing nationwide. However, liver and lung cancers exhibit disproportionately higher burdens in the northeast and north regions, respectively. Lung cancer increased significantly in northeastern and southern women, despite low smoking rates. Liver cancers are expected to increase in the northern males and females. Liver cancer increased in the south, despite the absence of the liver fluke, a known factor, in this region. Our findings are presented in the context of health policy, population dynamics and serve to provide evidence for future prevention strategies. Our subnational estimates provide a basis for understanding variations in region-specific risk factor profiles that contribute to incidence trends over time.
Cancers 2017, 9, 108; doi:10.3390/cancers9080108 www.mdpi.com/journal/cancers
Article
National and Subnational Population-Based
Incidence of Cancer in Thailand: Assessing Cancers
with the Highest Burdens
Shama Virani 1,2, Surichai Bilheem 1,Wasan Chansaard 3, Imjai Chitapanarux 4,
Karnchana Daoprasert 5, Somsak Khuanchana 6, Atit Leklob 6, Donsuk Pongnikorn 5,
Laura S. Rozek 2, Surattaya Siriarechakul 6, Krittika Suwanrungruang 7,
Sukit Tassanasunthornwong 3, Patravoot Vatanasapt 7 and Hutcha Sriplung 1,*
1 Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand;
shamav@umich.edu (S.V.); surichai.bil@gmail.com (S.B.)
2 Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109,
USA; rozekl@umich.edu
3 Cancer Registry Unit, Surat Thani Cancer Hospital, Surath Thani 84100, Thailand;
wasan1013@gmail.com (W.C); sukitsi91@gmail.com (S.T.)
4 Chiang Mai Cancer Registry, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai
University, Chiang Mai 50200, Thailand; imjai@hotmail.com (I.C.)
5 Cancer Registry Unit, Lampang Cancer Hospital, Lampang 52000, Thailand; kdaoprasert@gmail.com
(K.D.); donsukp@hotmail.com (D.P.)
6 Cancer Unit, Lopburi Cancer Center, Lopburi 15000, Thailand; s098030971@yahoo.co.th (S.K.);
s098030971@yahoo.co.th (A.L.); catsurattaya@hotmail.com (S.S.)
7 Cancer Unit, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002,
Thailand; ksuwanrungruang@gmail.com (K.S.); patvat@kku.ac.th (P.V.)
* Correspondence: hutcha.s@gmail.com; Tel.: +66-744-51-165
Academic Editor: Samuel C. Mok
Received: 5 July 2017; Accepted: 12 August 2017; Published: 17 August 2017
Abstract: In Thailand, five cancer types—breast, cervical, colorectal, liver and lung cancer—
contribute to over half of the cancer burden. The magnitude of these cancers must be quantified
over time to assess previous health policies and highlight future trajectories for targeted prevention
efforts. We provide a comprehensive assessment of these five cancers nationally and subnationally,
with trend analysis, projections, and number of cases expected for the year 2025 using cancer
registry data. We found that breast (average annual percent change (AAPC): 3.1%) and colorectal
cancer (female AAPC: 3.3%, male AAPC: 4.1%) are increasing while cervical cancer (AAPC: −4.4%)
is decreasing nationwide. However, liver and lung cancers exhibit disproportionately higher
burdens in the northeast and north regions, respectively. Lung cancer increased significantly in
northeastern and southern women, despite low smoking rates. Liver cancers are expected to
increase in the northern males and females. Liver cancer increased in the south, despite the absence
of the liver fluke, a known factor, in this region. Our findings are presented in the context of health
policy, population dynamics and serve to provide evidence for future prevention strategies. Our
subnational estimates provide a basis for understanding variations in region-specific risk factor
profiles that contribute to incidence trends over time.
Keywords: Thailand; incidence; trends; projections; health policy
1. Introduction
Approximately 60% of the cancer burden in Thailand is due to five types of cancers: breast,
cervix, colorectal, liver and lung cancers [1] (Figure 1). Excluding melanoma, these five cancers
Cancers 2017, 9, 108 2 of 27
accounted for 59.2% of incidence, 63.1% of mortality and 54.3% of 5-year prevalence in 2012 [1]. While
these national estimates are useful in highlighting important cancers on a large scale, there is clear
variability in the incidence of these cancers across the north, northeast, central and south regions [2–
7]. Effective management of these cancers and attenuation of the future burden requires subnational
estimates to determine differences in incidence by region.
Figure 1. Breast, cervix, colorectal, liver and lung cancers combined had the highest age-standardized
rates in 2012 and accounted for more than half of the incidence, prevalence and mortality in Thailand.
*excluding non-melanoma skin cancer.
There are many factors that differ by region and may contribute to region-specific cancer
incidence profiles. Each region is culturally unique and this translates into diverse lifestyles. Regions
can be generally characterized by culture, geography and diet. In the north, the culture is considered
“lanna”, a unique mix of Siamese, Laotian and Burmese culture and traditions. The geography is
mountainous and cool, offering suitable climate for agriculture of coffee, rice, and temperate-zone
fruits and plants. The cool climate serves as the rationale for the consumption of fatty dishes in the
diet, which is influenced by various minority groups including the Tai Yai, Haw Chinese, Tai Lue,
and Burmese. The diet consists of boiled vegetables, herbs and roots as found naturally in the region,
high consumption of glutinous rice and meat (mostly pork), in dishes served with mostly neutral
flavors [8,9]. In the northeast region, culture is a mix of Siamese, Laotian and Khmer. This region has
a primarily arid climate although rice cultivation is possible in some areas. Due to land infertility,
diet in this region consists of high consumption of glutinous rice, raw/fermented river fish, insects
and raw/fermented meats with very spicy, salty and sour flavors [8,9]. The culture in the central
region is influenced by many Asian/European countries, due to its long-standing role as a hub for
foreign trade. This region is situated in a fertile basin conducive to wet-rice agriculture, fruit farming
and fishing industries. Diet consists of mainly steamed rice, vegetable and meat curries with coconut
milk, distinctly combining sweet, salty, sour and spicy flavors [8,9]. Finally, the culture of the south
contains contributions from the Malays and Chinese. This region is on a peninsula linked to the Malay
Peninsula, with lots of heavy rain resulting in lush lands. Main industries include fishing, and palm,
coconut and rubber tree plantations. Southern Indian, Malaysian and Javanese influences comprise a
diet with heavy use of turmeric and capsicum, high consumption of seafood and with spicy and sour
flavors. Pork consumption is lower compared to other regions due to a Muslims subpopulation that
comprises 30% of the southern population and is the second most prevalent religion in Thailand after
Buddhism [8,9].
0 20 40 60 80 100 120 140 160
Others
Gallbladder
Stomach
Corpus uteri
Lip, oral cavity
Thyroid
NHL
Leukaemia
Ovary
Prostate
Colorectum
Cervix uteri
Lung
Liver
Breast
All cancers*
Age-Standardized Incidence Rate per 100,000 PY
Others
11% Gallbladder
2%
Stomach
2%
Corpus
uteri
2%
Lip,
oral
cavity
3%
Thyroid
2% NHL
3%
Leukaemia
3%
Ovary
4%
Prostate
4%
Lung,
Liver,
Breast,
Cervix,
Colorectum
64%
Others
7%
Gallbladder
1% Stomach
1%
Nasopharynx
1%
Bladder
2%
NHL
3%
Lip, oral
cavity
3%
Thyroid
3%
Corpus uteri
4%
Ovary
4%
Prostate
10%
Lung, Liver,
Breast, Cervix,
Colorectum
61%
Others
8% Brain, nervous
system
1%
Pancreas
2%
Lip, oral
cavity
2%
Oesophagus
2% Gallbladder
2%
Stomach
2%
NHL
3% Ovary
3%
Prostate
4%
Leukaemia
4%
Lung, Liver,
Breast, Cervix,
Colorectum
67%
Incidence
Prevalence
Mortality
Cancers 2017, 9, 108 3 of 27
Thailand became an upper middle income country in 2012, and rapid changes in the economy
led to changes in lifestyles and behaviors, particularly with regard to those with higher incomes
[10,11]. The shift in risk factor profiles likely plays a role in changing trends of cancer trends.
However, aside from the role of environmental and lifestyle risk factors, incidence is also shaped by
healthcare infrastructure and its ability to capture and diagnose cases when they occur. Since the
1970s, the Thai government offered insurance schemes to offset or support costs of healthcare for
various population sectors. However, in 2001, approximately 30% of the population was still
uninsured. In 2002, the Universal Health Coverage (UHC) system was introduced. Civil servants and
their dependents remained under the Civil Servant Medical Benefit Scheme (CSBMS), formal sector
employees continued to have their health-care costs paid for by the contributory Social Security
Scheme (SSS) and previously uninsured people and those covered under the Medical Welfare Scheme
and the Voluntary Health Card Scheme were covered under the Universal Coverage Scheme (UCS)
[12,13]. Upon implementation, 97% of the population was covered under the UHC system [12–15].
The success of UHC was largely dependent upon investment in healthcare infrastructure and
expansion of the healthcare workforce since the 1970s. By the time UHC was established,
infrastructure existed at every level of the administrative system, from provincial hospitals to
community healthcare centers [13]. This infrastructure improved access to health services, equity of
service utilization and prevented medical impoverishment. The success of UHC was evident in
Thailand’s achievement of the Millennium Development Goals (MDG), which were attained well
before 2015. By the early 2000s, the MDG target of halving the population living in poverty was
attained. Immunization coverage of diphtheria, tetanus and pertussis increased to 98%, prevalence
of modern contraception increased to 73%, excess child mortality decreased and rich/poor and
urban/rural gaps in maternal/child health services were reduced [16–20].
According to the Ministry of Public Health, Thailand is undergoing an epidemiological
transition. The prevalence rates of communicable diseases, which used to be significant, have
declined with the exception of the reemergence of HIV and tuberculosis. Other major and rising
causes of death include non-communicable diseases (NCDs) and accidents [10]. This increase in
NCDs could be attributed to increased life expectancy, which increased by four years between 2000
and 2012 to 72 years for males and 78 years for females, and increases in aging populations (Figure
2) [21]. Non-communicable diseases account for 71% of deaths in Thailand, of which cancer accounts
for the second largest proportion (17%) [22]. It is clear that Thailand’s epidemiologic transition will
lead to an increase in cancer, making it crucial to provide estimates and projections to offer evidence
that can be used to attenuate this burden in the future. The relatively recent introduction of UHC
makes it difficult to assess mortality, as it will likely take several more years to see these effects.
Nevertheless, we can quantify and assess cancer incidence with regard to UHC as improved access
allows for better cancer detection, better estimates off which to base projections, and gives further
weight to the fact that trends are shaped by risk factor profiles. Therefore, the aims of this research
are focused on assessment of national and subnational cancer incidence trends over time of the top
five cancers in Thailand and provide estimation for future burdens. Further, national and regional
trends will be considered in the context of health policy in Thailand.
Figure 2. Population distribution for each region and nationally in 2012 and the expected population
distribution in 2025.
Cancers 2017, 9, 108 4 of 27
2. Results
2.1. National Trends, Projected Rates and Numbers
National cancer incidence rates were available from 2000 to 2012. Average annual percent
changes (AAPCs) were calculated to provide a summary measure of change over the entire the time
period. In females, incidence of all cancers combined remained constant over this time likely due to
the combination of the increase in breast (AAPC: 3.1, 95% CI: 2.1, 4.1) and colorectal (AAPC: 3.3, 95%
CI: 1.9, 4.8) cancers with the decrease in cervical cancer (AAPC: −4.4, 95% CI: −6.2, −2.6) (Figure 3).
Projections were based on observed data using age-period-cohort models (Methods, Section 4.4).
Breast cancer had the highest incidence of female cancers in 2012 and is expected to remain the
highest in 2025. Colorectal cancer is expected to increase in incidence at the same rate as breast cancer
from 2012 to 2025 and by 2025, both cancers combined will account for 63% of female cancer cases.
Cervical cancer had the largest projected decline in incidence and is expected to account for only 7%
of female cancers in 2025 (Table 1).
In males, incidence of all cancers declined from 2000 to 2012 (AAPC: −0.8, 95% CI: −1.5, −0.1),
likely due to the significant decrease in lung cancer (AAPC: −1.3, 95% CI: −1.9, −0.7) (Figure 3). Liver
cancer had the highest incidence of male cancers in 2012 and is projected to remain the highest in
2025. In 2012, liver and lung cancers contributed 80% of male cancer cases. While incidences of these
are expected to decrease, colorectal cancer incidence is projected to increase, accounting for 29% of
male cancer cases, while liver and lung cancers account for 71% of cases in 2025 (Table 1).
Figure 3. National and subnational average annual percent changes (AAPC) of each cancer from 2000
to 2012 for females and males. Significant AAPC are denoted with an asterisk (*). Significance was
achieved at α = 0.05.
Cancers 2017, 9, 108 5 of 27
Table 1. Subnational and National Age-standardized Incidence Rates for Cancers and Estimated New Cases, 2025, by Region.
Females
Age-Standardized Incidence Rate (ASR)
(Per 100,000 Person-Years) Cases
Change
2000–2012
Change
2012–2025 Change
2000–2012
Regional
Proportion in
2012
Change
2012–2025
Regional
Proportion in
2025
National Proportion
200
0 2012 2025 ΔASR ΔASR 2000 2012 2025 ΔCases % All Cases ΔCases % All Cases 2012 2025% Δ
North
All Sites 93.4 88.9 81.8 −5% −8% 6104.0 8362.4 9470.4 37% 100% 13% 100% 25% 21% −3%
Breast 21.8 27.9 30.3 28% 9% 1475.6 2535.2 3102.5 72% 30% 22% 33%
Cervix 17.5 13.5 6.8 −23% −50% 1883.0 1208.6 562.2 −36% 14% −53% 6%
CRC 8.4 11.9 13.6 42% 14% 535.9 1120.3 1819.0 109% 13% 62% 19%
Liver 10.0 14.1 14.3 41% 1% 625.9 1366.0 1901.7 118% 16% 39% 20%
Lung 25.4 21.4 15.5 −16% −28% 1583.6 2132.3 2085.0 35% 25% −2% 22%
Northeast
All Sites 71.1 67.9 67.3 −5% −1% 7335.2 9711.8 12,393.8 32% 100% 28% 100% 29% 28% −1%
Breast 14.5 24.0 34.7 66% 45% 1606.8 3260.1 5076.9 103% 34% 56% 41%
Cervix 17.3 9.2 11.7 −47% 27% 1508.3 1251.0 1613.2 −17% 13% 29% 13%
CRC 7.7 8.9 12.0 16% 35% 773.0 1306.7 2555.3 69% 13% 96% 21%
Liver 28.2 17.7 8.5 −37% −52% 2779.2 2704.4 1762.3 −3% 28% −35% 14%
Lung 6.7 8.0 7.4 19% −8% 667.9 1189.6 1386.1 78% 12% 17% 11%
Central
All Sites 68.7 72.9 75.1 6% 3% 7677.8 12,977.2 19,569.4 69% 100% 51% 100% 38% 44% 6%
Breast 20.7 29.4 33.7 42% 15% 2443.7 5335.2 8568.7 118% 41% 61% 44%
Cervix 21.5 13.4 6.8 −38% −49% 2417.6 2428.6 1368.7 0% 19% −44% 7%
CRC 9.2 11.4 17.5 24% 54% 925.0 1879.5 4839.2 103% 14% 157% 25%
Liver 9.5 10.2 9.6 7% −6% 1030.1 1796.7 2725.1 74% 14% 52% 14%
Lung 7.9 8.5 7.9 8% −7% 861.4 1537.2 2067.7 78% 12% 35% 11%
South
All Sites 57.5 52.0 66.4 −10% 28% 2267.3 2955.6 5566.0 30% 100% 88% 100% 9% 13% 4%
Breast 19.8 23.6 35.0 19% 48% 806.7 1298.3 2407.9 61% 44% 85% 43%
Cervix 21.7 9.5 5.9 −56% −38% 845.5 531.6 390.2 −37% 18% −27% 7%
CRC 8.5 7.9 13.3 −7% 68% 325.7 458.0 1105.2 41% 15% 141% 20%
Liver 3.3 3.8 7.2 15% 89% 132.3 233.6 677.6 77% 8% 190% 12%
Lung 4.1 7.2 10.9 76% 51% 157.1 434.1 985.1 176% 15% 127% 18%
Thailand
All Sites 82.7 83.6 71.1 1% −15% 23,384.4 34,007.2 44,061.1 45% 100% 30% 100% 100% 100% 1%
Breast 19.2 26.2 33.9 36% 29% 6332.8 12,428.8 18,286.8 96% 37% 47% 42%
Cervix 21.2 14.4 6.8 −32% −53% 6654.3 5419.9 3264.8 −19% 16% −40% 7%
CRC 8.4 10.0 12.9 19% 29% 2559.7 4764.6 9125.2 86% 14% 92% 21%
Liver 12.8 11.5 9.1 −10% −21% 4567.6 6100.7 6462.5 34% 18% 6% 15%
Lung 11.0 11.3 9.7 3% −14% 3270.0 5293.2 6921.8 62% 16% 31% 16%

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    Background The age at menarche in the Thai population has not been determined since 1997. This study recruited adolescents in Bangkok Metropolis to determine the age at menarche and its associations with health and socioeconomic status. Methods This cross-sectional study used a two-step stratified sampling strategy to recruit 1,020 female students, aged 10–16 years, from schools in Dusit district, Bangkok, Thailand. Self-reported data on age at menarche and social determinants of health were collected from participants and their parents. A trained research nurse collected anthropometric data. ResultsMean age at menarche was 11.8 ± 1.0 years, and age at menarche was significantly correlated with year of birth (r = −0.4, p < 0.001). Students from schools that are part of Bangkok Metropolis had the lowest mean age at menarche. Participants born in 2000–2003 having their first period at < 11.8 years numbered 5.5 times (95% CI: 3.80–8.18) and 5.0 times (95% CI: 3.6–8.0) greater than those born in 1997–1999 by univariate and multivariate analysis, respectively. Year of birth significantly associated with age at menarche in univariate and multivariate analysis (p = 0.001). Conclusion The mean age at menarche among female adolescents in Bangkok Metropolis was occurring earlier and was inversely associated with year of birth in this cohort. Only year of birth were associated with age at menarche in the multivariate regression models to adjust for potential confounders.
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    Background: The national cervical cancer screening program in Thailand has been successful in reducing overall burden from this disease. However, evaluation on spatial and temporal scales is needed to assess the efficacy of this program in smaller regions. Here, we geographically assess incidence in a province with a uniquely heterogeneous distribution of lifestyle factors associated with religiosity. Methods: Cervical cancer cases were extracted from the provincial cancer registry from 1989 to 2013. Age-adjusted incidence rates were calculated using population statistics from the census bureau and adjusted to the Segi world standard population. Bayesian hierarchical modelling was employed to spatiotemporally map cervical cancer incidence trends in Songkhla province in 5-year period. Results: Overall, the incidence of cervical cancer decreased in Songkhla province. The three districts with a Muslim population of greater than 70% had consistently lower cervical cancer rates from 1989 to 2013 compared with the rest of the predominantly Buddhist districts. Hotspots of incidence were identified in Sadao, Hat Yai and the juncture of Mueang Songkhla and Singhanakhon in each 5-year period. Conclusions: Distinct cervical cancer incidence trends by religion over time indicate differences in sexual habits, lifestyle and religion-associated culture between Muslims and Buddhists, and suggest divergent risk factor profiles for these groups. The high incidence rates in Sadao and Hat Yai is likely explained by the main road to Malaysia, which runs across these two areas and has frequent commercial sex trade. Female sex workers should be targeted as a vulnerable population for screening efforts to address this continuing burden of cervical cancer.
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    Background: The incidence of lung cancer in many parts of the country as shown in cancer registry statistics is not decreasing. The incidence of adenocarcinoma (ADCA) in Songkhla is now higher than that of squamous cell carcinoma (SCC) in both sexes. The percentage of the unknown histologic type of lung cancer in Songkhla is around 30 %. The objective of this study is to estimate trends in incidence of the two major histologic types of lung cancer: SCC and ADCA, in Songkhla province of Thailand from 1989 to 2013. Methods: Age-standardized incidence rates (ASR) were used to compare and described the trends in both major types of cancers. Multinomial logistic regression models were used to impute unknown histological cancer types using a multiple imputation (MI) method to account for the high percentage of unknown histology. Results: The multinomial predictive model for major types of lung cancer in Songkhla consisted of sex, age, year of diagnosis, and place of residence. After MI, the number of cases with both SCC and ADCA in both sexes increased by one-third of the number of cases with originally known histology. The increasing trends were observed in ADCA in both sexes while SCC in males was stable and in females was decreasing. Conclusions: A rapid increase in the incidence of ADCA was found while the incidence of SCC in males showed no significant change and it was declining in females. These results warrant an investigation into risk factors other than cigarette smoking. The number of cases has limited use when the age structure of the population under study is changing. Year of diagnosis was one of the predictors in the MI model.
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    Background: Testing for high-risk human papillomavirus DNA (HPV test) has gained increasing acceptance as an alternative method to cytology in cervical cancer screening. Compared to cytology, HPV test has a higher sensitivity for the detection of histologic high-grade squamous intraepithelial lesion or worse (HSIL+), but this could lead to a large colposcopy burden. Genotyping for HPV16/18 has been recommended in triaging HPV-positive women. This study was aimed to evaluate the screening performance of HPV testing and the role of genotyping triage in Northern Thailand. Methods: A population-based cervical screening program was performed in Chiang Mai (Northern Thailand) using cytology (conventional Pap test) and HPV test (Hybrid Capture 2). Women who had abnormal cytology or were HPV-positive were referred for colposcopy. Cervical samples from these women were genotyped using the Linear Array assay. Results: Of 5,456 women, 2.0% had abnormal Pap test results and 6.5% tested positive with Hybrid Capture 2. Of 5,433 women eligible for analysis, 355 with any positive test had histologic confirmation and 57 of these had histologic HSIL+. The sensitivity for histologic HSIL+ detection was 64.9% for Pap test and 100% for Hybrid Capture 2, but the ratio of colposcopy per detection of each HSIL+ was more than two-fold higher with Hybrid Capture 2 than Pap test (5.9 versus 2.8). Genotyping results were available in 316 samples. HPV52, HPV16, and HPV58 were the three most common genotypes among women with histologic HSIL+. Performance of genotyping triage using HPV16/18/52/58 was superior to that of HPV16/18, with a higher sensitivity (85.7% versus 28.6%) and negative predictive value (94.2% versus 83.9%). Conclusions: In Northern Thailand, HPV testing with genotyping triage shows better screening performance than cervical cytology alone. In this region, the addition of genotyping for HPV52/58 to HPV16/18 is deemed necessary in triaging women with positive HPV test.
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    Purpose Histological specimens are not required for diagnosis of liver and bile duct (LBD) cancer, resulting in a high percentage of unknown histologies. We compared estimates of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) incidences by imputing these unknown histologies. Materials and Methods A retrospective study was conducted using data from the Songkhla Cancer Registry, southern Thailand, from 1989 to 2013. Multivariate imputation by chained equations (mice) was used in re-classification of the unknown histologies. Age-standardized rates (ASR) of HCC and CCA by sex were calculated and the trends were compared. Results Of 2,387 LBD cases, 61% had unknown histology. After imputation, the ASR of HCC in males during 1989 to 2007 increased from 4 to 10 per 100,000 and then decreased after 2007. The ASR of CCA increased from 2 to 5.5 per 100,000, and the ASR of HCC in females decreased from 1.5 in 2009 to 1.3 in 2013 and that of CCA increased from less than 1 to 1.9 per 100,000 by 2013. Results of complete case analysis showed somewhat similar, although less dramatic, trends. Conclusion In Songkhla, the incidence of CCA appears to be stable after increasing for 20 years whereas the incidence of HCC is now declining. The decline in incidence of HCC among males since 2007 is probably due to implementation of the hepatitis B virus vaccine in the 1990s. The rise in incidence of CCA is a concern and highlights the need for case control studies to elucidate the risk factors.
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    Hepatitis B vaccination for newborns was introduced in two provinces in 1988 as part of Thailand’s Expanded Program on Immunization (EPI), and extended to the whole country in 1992. Our previous studies showed that children and adolescents who were born after the implementation of this program had a carrier rate of less than 1%, compared with 5–6% before implementation. In 2014 we performed hepatitis B serosurveys among 5964 subjects in the different geographic regions of the country to evaluate the long-term immunogenicity and impact of universal hepatitis B vaccination in newborns as part of the 22-year EPI program, by assessing HBsAg, anti-HBc and anti-HBs seropositivity status. The number of HB virus (HBV) carriers, both children and young adults, who were born after universal HB vaccination was markedly reduced. The carrier rates among the age groups 6 months to 5 years, 5–10, 11–20, 21–30, 31–40, 41–50 and >50 years were respectively 0.1, 0.29, 0.69, 3.12, 3.78, 4.67 and 5.99%. The seropositivity rate for HBsAg in the post-EPI group was 0.6%, whereas in the pre-EPI group it was as high as 4.5% (p<0.001). HBV infection by means of detectable anti-HBc had also drastically declined in the population born after the HB vaccine was integrated into the EPI program. We estimated that the total number of HBV carriers amounted to 2.22 million, or 3.48% of the total population, most of whom are adults. The HB vaccine is the first vaccine shown to be effective in preventing the occurrence of chronic liver disease and hepatocellular carcinoma. Universal vaccination campaign will contribute to the eventual eradication of HBV-associated disease.
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    Background: Thailand has come to an epidemiologic transition with decreasing infectious diseases and increasing burden of chronic conditions, including cancer. Breast cancer has the highest incidence rates among females throughout Thailand. This study aimed to identify the current burden and the future trends of breast cancer of Lopburi, a province in the Central Thailand. Materials and methods: We used cancer incidence data from the Lopburi Cancer Registry to characterize and analyze the incidence of breast cancer in Central Thailand. With joinpoint and age-period-cohort analyses, the incidence of breast cancer in the province from 2001 to 2010 and project future trends from 2011 to 2030 was investigated. Results: Age-adjusted incidence rates of breast cancer in Lopburi increased from 23.4 to 34.3 cases per 100,000 female population during the period, equivalent to an annual percentage change of 4.3% per year. Both period and cohort effects played a role in shaping the increase in incidence. Joinpoint projection suggested that incidence rates would continue to increase in the future with incidence for women ages 50 years and above increasing at a higher rate than for women below the age of 50. Conclusions: The current situation where early detection measures are being promoted could increase detection rates of the disease. Preparation of sufficient budget for treatment facilities and human resources, both in surgical and medical oncology, is essential for future medical care.
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    Background: The recent epidemiologic transition in Thailand, with decreasing incidence of infectious diseases along with increasing rates of chronic conditions, including cancer, is a serious problem for the country. Breast cancer has the highest incidence rates among females throughout Thailand. Lampang is a province in the upper part of Northern Thailand. A study was needed to identify the current burden, and the future trends of breast cancer in upper Northern Thai women. Materials and methods: Here we used cancer incidence data from the Lampang Cancer Registry to characterize and analyze the local incidence of breast cancer. Joinpoint analysis, age period cohort model and Nordpred package were used to investigate the incidences of breast cancer in the province from 1993 to 2012 and to project future trends from 2013 to 2030. Results: Age-standardized incidence rates (world) of breast cancer in the upper parts of Northern Thailand increased from 16.7 to 26.3 cases per 100,000 female population which is equivalent to an annual percentage change of 2.0-2.8%, according to the method used. Linear drift effects played a role in shaping the increase of incidence. The three projection method suggested that incidence rates would continue to increase in the future with incidence for women aged 50 and above, increasing at a higher rate than for women below the age of 50. Conclusions: The current early detection measures increase detection rates of early disease. Preparation of a budget for treatment facilities and human resources, both in surgical and medical oncology, is essential.
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    Background: Heavy alcohol consumption is an established risk factor for non-communicable diseases (NCDs) but few studies have investigated drinking and disease risk in middle income, non-western countries. We report on the relationship between alcohol consumption and NCDs in Thailand. Methods: A nationwide cross sectional survey was conducted of 87,151 Thai adult open university students aged 15 to 87 years (mean age 30.5 years) who were recruited into the Thai Cohort Study. Participants were categorized as never having drunk alcohol (n = 22,527), as being occasional drinkers who drank infrequently but heavily (4+ glasses/occasion - occasional heavy drinkers, n = 24,152) or drank infrequently and less heavily (<4 glasses/occasion - occasional light drinkers, n = 26,861). Current regular drinkers were subdivided into those who either drank heavily (4 + glasses per occasion - regular heavy drinkers, n = 3,675) or those who drank less (<4 glasses/occasion -regular light drinkers, n = 490). There were 7,548 ex-drinkers in the study. Outcomes were lifetime diagnoses of self-reported NCDs and obesity (body mass index ≥ 25). Results: Most women were never drinkers (40 % among females) or occasional light drinkers (39 %), in contrast to men (11 % and 22 %, respectively). Alcohol consumption was associated with urban in-migration and other recognized risks for NCDs (sedentary lifestyle and poor diet). After adjustment for these factors the odds ratios (ORs) for several NCDs outcomes - high cholesterol, hypertension, and liver disease - were significantly elevated among both occasional heavy drinkers (1.2 to 1.5) and regular heavy drinkers (1.5 to 2.0) relative to never drinkers. Conclusions: Heavy alcohol consumption of 4 or more glasses per occasion, even if the occasions were infrequent, was associated with elevated risk of NCDs in Thailand. These results highlight the need for strategies in Thailand to reduce the quantity of alcohol consumed to prevent alcohol-related disease. Thailand is fortunate that most of the female population is culturally protected from drinking and this national public good should be endorsed and supported.