Osteopontin and latent-TGF ß binding-protein 2 as potential diagnostic markers for HBV-related hepatocellular carcinoma.

Chronic Hepatitis B (HB) is the main risk factor for chronic liver disease (CLD) and hepatocellular carcinoma (HCC) in many low-resource countries, where diagnosis is constrained by lack of clinical, histopathological and biomarker resources. We have used proteomics to detect plasma biomarkers that outperform α-Fetoprotein (AFP), the most widely used biomarker for HCC diagnosis in low-resource contexts. Deep-plasma proteome analysis was performed in HCC patients, patients with CLD and in HB-carrier controls from Thailand (South-East Asia) and The Gambia (West-Africa). Mass spectrometry profiling identified latent-transforming growth factor ß binding-protein 2 (LTBP2) and Osteopontin (OPN) as being significantly elevated in HCC versus CLD and controls. These two proteins were further analyzed by ELISA in a total of 684 plasma samples, including 183 HCC, 274 CLD and 227 asymptomatic controls. When combined, LTBP2 and OPN showed an area under the receiver operating curve of 0.85 in distinguishing HCC from CLD in subjects with AFP <20 ng/mL. In a prospective cohort of 115 CLD patients from Korea, increased plasma levels of LTBP2 and/or OPN were detected in plasma collected over 2 years prior to diagnosis in 21 subjects who developed HCC. Thus, the combination of LTBP2 and OPN outperformed AFP for diagnosis and prediction of HCC and may therefore improve biomarker-based detection of HBV-related HCC.

Association between TP53 R249S mutation and polymorphisms in TP53 intron 1 in hepatocellular carcinoma.

Over 100 single nucleotide polymorphisms (SNP) are validated in the TP53 tumor suppressor gene. They define haplotypes, which may differ in their activities. Therefore, mutation in cancer may occur at different rates depending upon haplotypes. However, these associations may be masked by differences in mutations types and causes of mutagenesis. We have analyzed the associations between 19 SNPs spanning the TP53 locus and a single specific aflatoxin-induced TP53 mutation (R249S) in 85 in hepatocellular carcinoma cases and 132 controls from Thailand. An association with R249S mutation (P = 0.007) was observed for a combination of two SNPs (rs17882227 and rs8064946) in a linkage disequilibrium block extending from upstream of exon 1 to the first half of intron 1. This domain contains two coding sequences overlapping with TP53 (WRAP53 and Hp53int1) suggesting that sequences in TP53 intron 1 encode transcripts that may modulate R249S mutation rate in HCC.

Factors influencing the stages of breast cancer at the time of diagnosis in Thai women.

BACKGROUND: Early diagnosis of breast cancer leads to early treatment therefore improving women's health. However, most Thai women are diagnosed at a late stage. OBJECTIVE: This cross-sectional correlational study was designed to explore factors influencing the diagnosis of early stage breast cancer in Thai women. METHOD: Thai women (n = 400) newly diagnosed breast cancer at all clinical stages from public hospitals in Bangkok Metropolitan completed a questionnaire about knowledge of breast cancer and screening. The questionnaire addressed pre-diagnosis data about: (1) health care provider's recommendations to undertake breast screening, (2) health coverage for mammography (MM) costs and (3) regularity of breast screening behaviors in terms of breast self-examination (BSE), clinical breast examination (CBE) and MM including stage breast cancer at diagnosis. Data analysis was determined by PASW Statistics version 18 as univariate and multivariate logistic regression. RESULTS: Health coverage for MM costs and all three behaviors were significantly related to and could predict the early stages breast cancer at diagnosis (p < 0.05): health coverage for MM costs (OR = 0.32, 95% confidence interval [CI], 0.17-0.63), BSE (OR = 8.08, CI 95%, 3.93-16.63), CBE (OR = 12.54, CI 95%, 2.29-68.65) and MM (OR = 5.89, CL 95%, 1.13-30.73). CONCLUSIONS: All three behaviors are essential and related to one another. CBE on a regular basis is the best predictor for early stages breast cancer at diagnosis in Thai context. Nurses should provide information and teach including re-check the woman's skills to perform BSE regularly.

Cancer prevention in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013.

With economic growth in Asia, cancer has become increasingly prominent as a major health problem. However, discrepancies in infrastructure, economics, and development exist within and between Asian countries. We assess means of primary and secondary prevention for cervical, breast, colorectal, and hepatocellular cancer, and offer recommendations according to resource levels. Primary prevention by health education, lifestyle modification, and avoidance of risk factors should be made available at all resource levels. When resources allow, human papillomavirus and hepatitis B vaccinations should be given to reduce the risk of cervical and hepatocellular cancer, and genetic testing should be offered to detect increased susceptibility to colorectal and breast cancer. Secondary prevention by effective yet affordable screening for precancerous lesions or by early detection of cancer should be offered, followed by appropriate treatment.

Genetic polymorphisms in folate and alcohol metabolism and breast cancer risk: a case-control study in Thai women.

Dietary folate as well as polymorphic variants in one-carbon metabolism genes may modulate risk of breast cancer through aberrant DNA methylation and altered nucleotide synthesis and repair. Alcohol is well recognized as a risk factor for breast cancer, and interactions with one-carbon metabolism has also been suggested. The purpose of this study is to test the hypothesis that genetic polymorphisms in the folate and alcohol metabolic pathway are associated with breast cancer risk. Twenty-seven single nucleotide polymorphisms (SNPs) in the MTR, MTRR, MTHFR, TYMS, ADH1C, ALDH2, GSTP1, NAT1, NAT2, CYP2E1 DRD2, DRD3, and SLC6A4 were genotyped. Five hundred and seventy patients with histopathogically confirmed breast cancer and 497 controls were included in the present study. Association of genotypes with breast cancer risk was evaluated using multivariate logistic regression to estimate odds ratios (OR) and their 95% confidence intervals (95% CI). Increased risk was observed for homozygotes at the MTR SNPs (rs1770449 and rs1050993) with the OR = 2.21 (95% CI 1.18-4.16) and OR = 2.24 (95% CI 1.19-4.22), respectively. A stratified analysis by menopausal status indicated the association between the NAT2 SNP (rs1799930) and breast cancer was mainly evident in premenopausal women (OR 2.70, 95% CI 1.20-6.07), while the MTRR SNP (rs162049) was significant in postmenopausal women (OR 1.61, 95% CI 1.07-2.44). Furthermore, SNPs of the genes that contribute to alcohol behavior, DRD3 (rs167770), DRD2 (rs10891556), and SLC6A4 (rs140701), were also associated with an increased risk of breast cancer. No gene-gene or gene-environment interactions were observed in this study. Our results suggest that genetic polymorphisms in folate and alcohol metabolic pathway influence the risk of breast cancer in Thai population.

High urinary excretion of lipid peroxidation-derived DNA damage in patients with cancer-prone liver diseases.

Chronic inflammatory processes induce oxidative and nitrative stress that trigger lipid peroxidation (LPO), whereby DNA-reactive aldehydes such as trans-4-hydroxy-2-nonenal (HNE) are generated. Miscoding etheno-modified DNA adducts including 1,N(6)-etheno-2'-deoxyadenosine (epsilondA) are formed by reaction of HNE with DNA-bases which are excreted in urine, following elimination from tissue DNA. An ultrasensitive and specific immunoprecipitation/HPLC-fluorescence detection method was developed for quantifying epsilondA excreted in urine. Levels in urine of Thai and European liver disease-free subjects were in the range of 3-6 fmol epsilondA/micromol creatinine. Subjects with inflammatory cancer-prone liver diseases caused by viral infection or alcohol abuse excreted massively increased and highly variable epsilondA-levels. Groups of Thai subjects (N=21) with chronic hepatitis, liver cirrhosis, or hepatocellular carcinoma (HCC) due to HBV infection had 20, 73 and 39 times higher urinary epsilondA levels, respectively when compared to asymptomatic HBsAg carriers. In over two thirds of European patients (N=38) with HBV-, HCV- and alcohol-related liver disease, urinary epsilondA levels were increased 7-10-fold compared to healthy controls. Based on this pilot study we conclude: (i) high urinary epsilondA-levels, reflecting massive LPO-derived DNA damage in vivo may contribute to the development of HCC; (ii) epsilondA-measurements in urine and target tissues should thus be further explored as a putative risk marker to follow malignant progression of inflammatory liver diseases in affected patients; (iii) etheno adducts may serve as biomarkers to assess the efficacy of (chemo-)preventive and therapeutic interventions.

Genetic polymorphisms of estrogen metabolizing enzyme and breast cancer risk in Thai women.

Estrogen and its metabolites are believed to play important roles in breast cancer, and its determinants include both genetic and lifestyle factors. The objective of the study is to investigate the association of breast cancer risk in Thailand with genetic polymorphisms in several genes involved in estrogen synthesis and metabolism. Five hundred and seventy patients with histopathologically confirmed breast cancer and 497 controls were included in the present study. Forty single nucleotide polymorphisms (SNPs) in the CYP1A1, CYP1A2, CYP1B1, CYP17, CYP19, CYP2C9, CYP2C19, AhR, ESR1, PGR, ERRG, COMT, HSD17B1, HSD17B2, EPHX1 and NQO1 genes were genotyped. Association of genotypes with breast cancer risk was evaluated using multivariate logistic regression, which suggested an altered risk for the following SNPs [gene, odds ratio (OR) and 95% confidence interval are shown]: heterozygote carriers of rs4917623 [CYP2C19, OR = 1.38 (1.04-1.84)], rs2066853 [AhR, OR = 1.34 (1.02-1.76)] and rs1857407 [ERRG, (OR = 0.72 (0.55-0.96)]; homozygote carriers of rs762551 [CYP1A2, OR = 2.75 (1.47-5.14)], rs4917623 [CYP2C19, OR = 1.48 (1.00-2.19) and rs945453 [ERRG, OR = 1.66 (1.04-2.65)]. In addition, a stratified analysis by menopausal status indicated that the association of the CYP1A2 (rs762551) and CYP17 (rs743572) polymorphisms with breast cancer risk were mainly evident in premenopausal, while ERRG (rs1857407) was significant in postmenopausal women. These findings suggest that CYP1A2, CYP2C19, AhR, ERRG and CYP17 polymorphisms may play an important role in estrogen metabolism and modify individual susceptibility to breast cancer in Thai women.

Colon and rectum cancer in Thailand: an overview.

Cancers of the colon and rectum are rare in developing countries, in contrast to the high incidence rates in countries of Europe, North America, Australia and Japan. Significant differences also exist within continents. Colorectal cancer mortality and incidence rates have decreased in the USA. However, the incidence in Japan and Thailand is rising, probably due to the acquisition of Western lifestyle. Incidence also increases with age: carcinomas are rare before the age of 40 years except in individuals with genetic predisposition or predisposing conditions. The incidence rate of colorectal cancer in Thailand is low when compared with other countries. It is the third in frequency in males after liver and bile duct and lung cancers, and the fifth after cancers of the cervix, breast, liver and bile duct and lung for females. The highest incidence for both sexes is seen in Bangkok. The number of cases of colorectal cancer in both sexes is increasing and will probably exceed that of lung cancer in the next decade. Thus, we are planning to have colorectal cancer screening programme. We should pay more attention on primary and secondary prevention to control colorectal cancer in Asian countries.

Cervical cancer screening in Thailand: an overview.

In Thailand, there have been no 'organized' programmes of screening for cervical cancer. For the most part, screening has been unsystematic or provided to women 'on demand'. In 2002, the Department of Medical Services of the Ministry of Public Health proposed the screening of the entire population of women in Thailand at 5-yearly intervals from the ages of 35 to 60 years. As a first step, measures to increase the capacity for obtaining and interpreting papanicolaou (Pap) smears have been put in place. Research studies have examined the effectiveness of screening with Pap smears in Thailand, and confirmed that, as elsewhere, protection is related to the number of previous tests and the time elapsed since the most recent one. Coverage of the population remains low. Other methods of screening are being investigated in Thailand, including visual inspection following acetic acid (VIA), followed by immediate treatment of observed lesions by cryotherapy ('see and treat'). Other research studies have examined the acceptability and performance of self-sampling as a means of obtaining Pap smears, and the use of mobile clinics to increase coverage of at-risk women in rural settings. Human papillomavirus (HPV) testing has been used to identify high-risk women, or to help decide which women with low-grade abnormality on cytology should undergo more intensive follow-up. Prevalence of HPV in normal women in Thailand is 9-20%, but HPV testing has not been used on any systematic basis to date. Current screening programmes in Thailand are not very effective. The national cancer control programme aims to increase the coverage of screening. The population-based cancer registry will provide an effective and economical method of evaluating the impact of early diagnosis and screening at community level.

Immunohistochemical expression of mismatch repair genes: a screening tool for predicting mutator phenotype in liver fluke infection-associated intrahepatic cholangiocarcinoma.

AIM: To clarify possible contributions of DNA mismatch repair (MMR) system in carcinogenesis of liver fluke infection-associated intrahepatic cholangiocarcinoma (ICC) by using immunohistochemical assay. METHODS: A total of 29 ICC samples, which had been assessed for genomic instability by a PCR-based method, were used for study. They were examined immunohistochemically to demonstrate protein expression of two MMR genes, hMSH2 and hMLH1. Results obtained were compared with their mutator phenotype assessed previously. RESULTS: Either hMSH2 or hMLH1 protein was obviously expressed in 28 of 29 (96.6%) ICC samples. Positive nuclear localization of hMSH2 or hMLH1 protein was observed in 86.2% (25/29) or 93.1% (27/29) ICC cases, respectively, while their negative nuclear reactivity was only detected in 13.8% (4/29) or 6.9% (2/29) ICC cases analyzed, respectively. CONCLUSION: Our study, probably for the first time, showed through immunohistochemical detection of hMSH2 and hMLH1 gene that DNA MMR system does not play a prominent role in liver fluke infection-associated cholangiocarcinogenesis. These results confirm previous findings on mutational status of these genes assessed through a PCR-based method. The immunohistochemical analysis has proven to be an effective and sensitive approach for screening MMR deficiency regardless of somatic inactivation or promoter hypermethylation of hMSH2 and/or hMLH1 gene. Furthermore, immunohistochemistry is more advantageous compared to mutator phenotyping assay in terms of simplicity, less time consuming and cost effectiveness for screening possible involvements of target MMR genes in tumorigenesis.

Prognostic improvement of patients with advanced liver cancer after active hexose correlated compound (AHCC) treatment.

Most patients with liver cancer are diagnosed when they are not suitable for resection. Although some palliative approaches can be applied to these patients, the overall survival rate remains unsatisfactory. Active hexose correlated compound (AHCC), a newly developed functional food, has been shown to act as a potent biological response modifier in in vitro experiments. Recently, AHCC was found to improve the prognosis of hepatocellular carcinoma patients following surgical treatment. We investigated whether AHCC could prolong survival and improve the prognosis of patients with advanced liver cancer. A prospective cohort study was performed with 44 patients with histologically confirmed liver cancer. All of the patients underwent supportive care. Survival time, quality of life, clinical and immunological parameters related to liver function, cellular immunity, and patient status were determined. Of the 44 patients, 34 and 10 received AHCC and placebo (control) orally, respectively. Patients in the AHCC treated-group had a significantly prolonged survival when compared to the control group by Mann-Whitney test (95% CI, p = 0.000). Quality of life in terms of mental stability, general physical health status, and ability to have normal activities were significantly improved after 3 months of AHCC treatment when tested using the Wilcoxon signed-rank test (on one-sided test, p = 0.028, 0.037, and 0.040, respectively). The apparent different clinical parameters between the two groups were the levels of albumin and percentage of lymphocytes with p-values of 0.000 and 0.026 at 1 and 2 months after treatment, respectively. Unlike the control patients, AHCC treated-patients with longer survival time had the tendency of better outcomes since the levels of AST and ALT had not increased rapidly from their baselines at follow-up. In addition, the levels of total IL-12 and neopterin were slightly increased in AHCC treated-patients. This study suggests that AHCC intake could prolong the survival and improve the prognosis of patients with advanced liver cancer and delay the gradual decline of their physiological status.

Diagnosis of liver cancer from blood sera using FTIR microspectroscopy: a preliminary study.

FTIR microspectroscopy was applied for studying macromolecular changes in human serum samples from patients with healthy livers, and those diagnosed with liver cirrhosis or hepatocellular carcinoma (HCC). Our study demonstrated that the serum samples from HCC and cirrhotic patients could readily be discriminated from those from healthy controls based on macromolecular differences related to their lipid and protein structure. Spectral changes appeared to indicate that the secondary structure of protein from HCC sample groups contained a more distinctive ß -sheet structure and a lower lipid content compared to samples from the healthy and cirrhosis group. This was correlated with measurements of large decreases in albumin levels in serum from diseased patients. We argue that this technique shows potential as a simple, rapid, inexpensive, and non-subjective methodology for the screening patients suspected of liver disease.

Organised colorectal cancer screening in Lampang Province, Thailand: preliminary results from a pilot implementation programme.

OBJECTIVE: Colorectal cancer (CRC) is the third-most and fifth-most common cancer in men and women, in Thailand. The increasing CRC incidence and mortality can be reduced by screening and treating adenomas and early cancers. A pilot CRC screening programme using immunochemical faecal occult blood testing (iFOBT) and colonoscopy for test-positives were implemented through the routine Government Health Services in Lampang Province, to inform the acceptability, feasibility and scaling-up of screening in Thailand. This report describes the implementation, coverage and performance indicators of this project. DESIGN: A target population aged 50-65 years was informed about and invited face to face to undergo CRC screening by community health workers (HWs). The HWs provided faecal sample collection kits and participants brought their samples to one of the primary health units or community hospitals where nurses performed iFOBT. iFOBT-positive persons were referred for colonoscopy at the Lampang cancer hospital, and endoscopic polypectomy/biopsies were performed according to the colonoscopic findings. Those with confirmed CRC received appropriate treatment. RESULTS: Of the 127 301 target population, 62.9% were screened using iFOBT between April 2011 and November 2012. Participation was higher among women (67.8%) than men (57.8%) and lower in 50-54 year-old persons than in 60-65-year-olds. Of those screened, 873 (1.1%) were found positive; positivity was higher in men (1.2%) than in women (1.0%). To date 627 (72.0%) iFOBT-positive persons have had colonoscopy in which 3.7% had CRC and 30.6% had adenomas. CONCLUSIONS: The successful implementation of the pilot CRC screening with satisfactory process measures indicate the feasibility of scaling-up organised CRC screening through existing health services in Thailand.

Genetic and environmental determinants of risk for cholangiocarcinoma in Thailand.

Cholangiocarcinoma (CCA) is a difficult cancer to diagnose in the early stage and to treat by curative resection. The incidence of CCA in the northeast of Thailand is the highest in the world. To make progress in detecting a high risk group and in the prevention and detection of CCA, we have been analyzing the risk factors for CCA. Although liver fluke infection is known to be a risk factor, there are patients who are not infected with the liver fluke and not all people infected with the liver fluke will suffer from the disease. Therefore, it is of the utmost importance to analyze the risk factors and the mechanism to prevent the disease and also to detect the disease in its early stage to save patients' lives. Through collaboration among Thai and Japanese researchers, we analyzed the genetic and environmental determinants of risks for CCA. Also, we have been trying to develop methods to detect the disease in a non-invasive way. Without repeating findings reported in various reviews on CCA, we will first discuss the environmental and genetic determinants of the risks for CCA. Second, we will discuss the properties of CCA, including the etiological agents and the mechanism of cholangiocarcinogenesis, and finally, we will discuss future approaches to prevent and cure CCA from the standpoint of evidence-based medicine. We will discuss these points by including the data from our laboratories. We would like to emphasize the importance of the genetic data, especially whole genome approaches, to understand the properties of CCA, to find a high risk population for CCA and to develop effective preventative methods to stop the carcinogenic steps toward CCA in the near future. In addition, it is of the upmost importance to develop a non-invasive, specific and sensitive method to detect CCA in its early stage for the application of modern medical approaches to help patients with CCA.

Analysis of new biomarkers for cholangiocarcinoma.

Cholangiocarcinoma is one of the most serious diseases in northeast Thailand, where its incidence is reported to be the highest in the world. We tried to develop a new method to detect cholangiocarcinoma in the early stages using serum proteins. We found that after fluorescent labeling of the sugar moiety of serum proteins, a new peak was identified, which might be a promising marker for cholangiocarcinoma.

Association between HBX status, aflatoxin-induced R249S TP53 mutation and risk of hepatocellular carcinoma in a case-control study from Thailand.

Hepatocellular carcinoma (HCC) is associated with hepatitis B virus (HBV) chronicity and dietary exposure to aflatoxin, a mutagen targeting codon 249 of tumor suppressor TP53 (R249S mutation). Based on a case-control in Thailand, we have measured R249S and the status of HBX gene in plasma DNA of 176 cases and 133 referents. Detection of HBX complete sequences was associated with R249S in HCC with no documented prior cirrhosis but not in HCC developing in a context of cirrhosis or in non-cancer chronic liver diseases. Thus, R249S may specifically cooperate with HBX in a pathway to HCC that bypasses cirrhosis.

Evaluation of health status of a population underwent routine medical check up at the high risk screening clinic in National Cancer Institute.

The objective of the study was to evaluate the efficacy of a health check-up program among Thai people at the National Cancer Institute in the years 2008-2009. The program included history taking, physical examination, chest X-ray, EKG, and laboratory tests. A total of 28,240 women and 9,665 men were included in the study, with mean ages of 44.5 and 46.9 years, respectively. The study showed that obesity, as assessed by a BMI over 25.0 kg/m2, in men and women was present in 41.4% and 30%, respectively. Biochemical study revealed that anemia was prevalent in 21.6% of men and 20.1% of women. High plasma glucose level (>115 mg/dL), cholesterol level (>200 mg/dL), triglyceride level (>190 mg/dL) in men was 13.8%, 63.8%, 22.6% and 7.7%, 61.1%, 8.9% in women. Hepatitis B virus infection was found 7.5% in men and 4.1% in women. In this study, 177 new cancer cases were detected, of which 35 were breast, 19 were cervical and 26 were colorectal, most of these cancers being detected at early stage. In addition, precancerous states was also found including 718 cases of benign and 99 cases of adenoma in situ. In conclusion, an annual check up may detect abnormalities that have no obvious clinical symptoms of disease. Early detection of asymptomatic neoplasms and precursor lesions should contribute to a prompt provision of treatment and further decline of death from cancer.

Organization and evolution of organized cervical cytology screening in Thailand.

OBJECTIVE: To describe phase 1 of an organized cytology screening project initiated in Thailand by the Ministry of Public Health and the National Health Security Office. METHODS: Women aged 35-60 years were encouraged to undergo cervical screening in primary care units and hospitals through awareness programs. Papanicolaou smears were processed and reported at district or provincial cytology laboratories. Women with normal test results were advised to undergo repeat screening after 5 years, while those with precancerous and cancerous lesions were referred for colposcopy, biopsy, and treatment. Information on screening, referral, investigations, and therapy were logged in a computer database. RESULTS: Between 2005 and 2009, 69.2% of the 4030833 targeted women were screened. In all, 20991 women had inadequate smears; 27253 had low-grade squamous intraepithelial lesions; 15706 had high-grade squamous intraepithelial lesions; and 2920 had invasive cancers. Information on the management of precancerous lesions was available for only 17.4% of women referred for colposcopy. CONCLUSION: Although follow-up data on women with positive test results were inadequately documented, the present findings indicate that provision of cytology services through the existing healthcare system is feasible.

Socioeconomic impact of cancer in member countries of the Association of Southeast Asian Nations (ASEAN): the ACTION study protocol.

Cancer can be a major cause of poverty. This may be due either to the costs of treating and managing the illness as well as its impact upon people's ability to work. This is a concern that particularly affects countries that lack comprehensive social health insurance systems and other types of social safety nets. The ACTION study is a longitudinal cohort study of 10,000 hospital patients with a first time diagnosis of cancer. It aims to assess the impact of cancer on the economic circumstances of patients and their households, patients' quality of life, costs of treatment and survival. Patients will be followed throughout the first year after their cancer diagnosis, with interviews conducted at baseline (after diagnosis), three and 12 months. A cross-section of public and private hospitals as well as cancer centers across eight member countries of the Association of Southeast Asian Nations (ASEAN) will invite patients to participate. The primary outcome is incidence of financial catastrophe following treatment for cancer, defined as out-of-pocket health care expenditure at 12 months exceeding 30% of household income. Secondary outcomes include illness induced poverty, quality of life, psychological distress, economic hardship, survival and disease status. The findings can raise awareness of the extent of the cancer problem in South East Asia and its breadth in terms of its implications for households and the communities in which cancer patients live, identify priorities for further research and catalyze political action to put in place effective cancer control policies.