Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand.

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.

Growth pattern of childhood thyrotoxicosis: longitudinal follow-up to final height.

OBJECTIVE: To study the growth pattern of children affected with thyrotoxicosis. MATERIAL AND METHOD: A retrospective study of growth data of 40 patients with thyrotoxicosis diagnosed at prepuberty or at early puberty was conducted. All patients were evaluated for height and weight every 3-6 months. Height and weight were transformed to standard deviation score (SDS) to account for differences of age and sex. RESULTS: At the time of diagnosis, the patients were slightly underweight for height (weight SDS -0.27 +/- 1.24, height SDS -0.06 +/- 1.26). After 1 year of treatment, the average weight gain of the patients was 4.9 +/- 3.1 kg, resulting in becoming relatively overweight for height (weight SDS +0. 32 +/- 1.42, height SDS +0.02 +/- 1.32). At the time of reaching their final height, the patients had an appropriate weight for height (weight SDS +0.06 +/- 0.21, height SDS -0.04 +/- 1.01). The average final height SDS of the patients was -0.04 +/- 1.01. This was at the average of the general population, but was +0.57 +/- 0.48 SDS or +2.85 +/- 1.0 cm greater than their target height (p < 0.01). CONCLUSION: Growth of patients with thyrotoxicosis showed the same pattern as in the general population. The final height of thyrotoxicosis patients was averagely +0.57 SDS or +2.85 cm greater than their genetic potential. This could be from the result of secular trend in the general population rather than being the effect of thyrotoxicosis.

Thyrotoxicosis in children: treatment and outcome.

OBJECTIVES: To study the treatment modalities and the outcome of treatments of children with thyrotoxicosis or Graves' disease. MATERIAL AND METHOD: A retrospective study of 56 patients diagnosed with thyrotoxicosis from January 1992 to December 2004 was conducted. There were 44 girls and 12 boys (female to male ratio 3.7:1). The average age at diagnosis was 11.9 +/- 3.4 years. RESULTS: All patients were initially treated with antithyroid drugs, either propylthiouracil (n = 53) or methimazole (n = 3). All patients achieved euthyroidism within 8.4 +/- 3.3 weeks. Eleven patients are still on the treatment, and 45 patients have completed the treatment. Of these 45 patients, 38 (84.4%) remitted after antithyroid drug treatment of an average duration of 37.4 +/- 16.5 months (range 12-90), 4 patients (8.9%) chose radioactive iodine treatment and three patients (6.7%) underwent thyroidectomy. Of the 38 patients remitted with antithyroid drugs, eleven (28.9%) relapsed within 4-24 months. The relapsed patients remitted with a second course of antithyroid drugs in three patients, underwent radioactive iodine in seven patients, and thyroidectomy in one patient. Therefore, of the total 45 patients who had completed the treatment, 30 patients (66.7%) remitted with antithyroid drugs, eleven patients (24.4%) received radioactive iodine, and four patients (8.9%) underwent thyroidectomy. Using stepwise multivariate logistic regression, the authors could not identify any factors (including age, gender, family history of thyroid diseases, size of goiter, level of free T4, dosage and duration of antithyroid drugs) that would predict the remission of thyrotoxicosis with antithyroid drugs. CONCLUSION: Antithyroid drugs should remain the first-line therapy for treatment of thyrotoxicosis in children with a remission rate of 66.7%. The patients who are noncompliant or relapse after treatment with antithyroid drugs should be treated with radioactive iodine.

Detection of human papillomavirus in intraepithelial lesions and carcinoma of the cervix uteri in southern Thai women.

OBJECTIVE: To evaluate the prevalence of high-risk type human papillomavirus (HR-HPV) in preneoplastic lesions and invasive squamous cell carcinoma (SCC) of the cervix uteri in southern Thai women. MATERIALS AND METHODS: A total of 148 formalin-fixed, paraffin-embedded blocks of cervix tissue were retrieved from the files of the Department of Pathology, Prince of Songkla University Hospital. They were classified as negative for intraepithelial lesion (NIL) in 37 cases, low grade lesion (LGL) in 58 cases, high grade lesion (HGL) in 39 cases and SCC in 14 cases. HR-HPV DNA was tested with an Amplicor HPV (Roche Diagnostics) detection kit. RESULTS: Of the 111 cases, 42 of 58 LGLs (72.4%), 34 of 39 HGLs (87.2%) and 13 of 14 SCCs (92.9%) were positive for HR-HPV DNA. In 37 cases of histologically normal cervix, there were 15 cases that showed the presence of HR-HPV DNA. Applying the HR-HPV results for NILs to the general population, the age standardized incidence rate of HR-HPV infection in the normal Thai population was 12.8%. CONCLUSION: HR-HPV DNA can be found in all grades of intraepithelial lesions and carcinoma of the cervix uteri, even in the histologically "normal" looking cervix. These results provide strong evidence for a role in carcinogenesis of the cervix uteri and the existence of a non-productive or latent period of HPV infection.

Cancer incidence trends in Thailand, 1989-2000.

Through 2004, five cancer registries in Thailand have collected data for more than ten years. Three-year cancer incidence in Thailand covering the years 1989-1997 has been regularly reported in three volumes of 'Cancer in Thailand. Since the data for the last decade of the 20th century have been collected, the trends in incidence of some cancer sites were analyzed. Data sources were registry data from Chiang Mai, Lampang, Khon Kaen, Bangkok, and Songkhla, which are representative of the four major geographic regions of Thailand. The data drawn in 2002 covered the years 1989 to 1997 for Bangkok, the other four registries drew data from 1989 to 2000. The population denominators were estimated from the two censuses in 1990 and 2000. Only cancers of the liver, lung, colon-rectum, female breast, uterine cervix, and all cancer sites were analyzed since cancers of these sites may have major public health impacts. Age-specific incidence rates of different 5-year age groups were projected through the period 2007-2009 using a linear regression model if the rates were increasing, and a log-linear model to prevent prediction of a negative rate if the rates were decreasing. During the past decade, colorectal and breast cancers showed a statistical significant increasing trend, while the trend was generally stable for cancer of other sites. The number of new cancer cases of all sites is expected to be approximately 125,000 by the year 2008, compared with 81,000 in 1999. However, the accuracy of projections depends very much on the quality of the cancer registries' data. The Bangkok registry significantly improved case ascertainment in recent years, while the Chiang Mai registry had a consistent drop in incidence of cancer at many sites. In-depth investigation of some cancer sites and age period cohort modeling are required for better understanding of cancer trends in Thailand.

Radium-contaminated water: a risk factor for cancer of the upper digestive tract.

There is a high incidence of oral, pharynx and esophagus cancer among males in Na Mom district in Songkhla Province in Thailand, an area where radium concentration in shallow well water is found to be higher than other areas in this province. A population-based case control study was conducted from June to November 2004 to determine the association of oral exposure to radium-contaminated water and cancer of the upper digestive tract in the district.Thirty-two confirmed cases and 128 sex and five-year birth cohort matched neighborhood controls were selected by multistage sampling from six villages in four sub-districts. All subjects were verified to have been permanent residents in the district for more than 10 years. Thirty cases were dead at the time of the study, thus their relatives were interviewed to determine their amount of water drinking, tobacco smoking, alcohol drinking, betel chewing and exposure to other potential risk factors in the past. The other two cases and all controls were directly interviewed.The concentration of radium in shallow well water at the subject's houses was estimated using a contour map of Ra-226 in the water at the location of their residence. The results showed a strong and dose-dependent associationb etween consumption of radium-contaminated shallow well water and cancer of the upper digestive tract. In multivariate analysis controlled for important risk factors of the cancer, the odds ratios for exposure to oral radium consumption 50-100 mBq/day and >100 mBq/day compared with <50 mBq/day were 2.83 (95% CI: 0.50-16.19) and 29.76 (95% CI: 4.39-201.6) respectively. The risk also increased with consumption of fresh water fish which might have been contaminated by dissolved radium in the water. This study offers the first evidence of the association between radium and cancer of the upper digestive tract to the world literature. Further studies with other methods such as area-wide correlation of radium-uranium concentration and the incidence of the cancer and case-control studies in other populations are needed to confirm the evidence.

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.

Cancer incidence in Thailand, 1995-1997.

There are five population-based cancer registries in Thailand in different regions of the country. Four of them (Chiang Mai, Khon Kaen, Bangkok, and Songkhla) have been operating since 1988 and the other (Lampang) since the early 1990s. These registries have published regular 3-year cancer incidence reports since the first in 1993 for the period 1989-1991. The objective of this article is to summarize the figures of cancer incidence in Thailand during 1995-1997. The population of Thailand in 1996, at the middle of the period, was 27 million males and 27.5 million females. Information of cancer cases residing in the five provinces was collected and abstracted from different sources. Age-standardized incidence rate (ASR) of cancer in males and females was calculated for each registry and that for the whole country was estimated using the five registries as representatives for the four geographical regions of Thailand. The estimated number of new cancer cases in 1996 for the whole country was 35,539 men and 38,476 women and the ASRs were 149.2 and 125.0 per 10(5) population in men and women respectively. Cancer incidences greatly differed from region to region. Lung cancer was the commonest in Chiang Mai and Lampang in the Northern region in both sexes. The incidence of liver cancer in Khon Kaen in the Northeastern region outnumbered all the others in both sexes; cholangiocarcinoma was the major type of liver cancer. In Bangkok, lung cancer was the most important cancer in males and breast cancer was in females. Though it was lung and cervix uteri cancer that ranked the first in men and women in Songkhla, the rate of oral and pharyngeal cancer was exceptionally higher than in other registries. The geographical variability in cancer patterns in Thailand reflects exposure of the population to different risk factors unique to the different regions. In the study as a whole, there are some methodological weak points in estimating the ASRs and number of cancer cases for the whole country, but the results are the most reliable cancer statistics from Thailand at the moment. In conclusion, both a country-wide and region-specific cancer control programmes are needed for Thailand. The national one would be for the cancers common to all regions, and the provincial-level emphasis should be on cancers which are the major problems in the area.

Clinical abnormalities, intervention program, and school attendance of Down syndrome children in southern Thailand.

BACKGROUND: Down syndrome is the most common chromosomal abnormality with an incidence of 1:700 livebirths. In southern Thailand, most Down syndrome patients are referred to Songklanagarind Hospital for surgical, medical treatment and/or stimulation intervention. OBJECTIVE: To study the clinical features and school attendance of Down syndrome children. MATERIAL AND METHOD: A total of 295 Down syndrome children attended Songklanagarind Hospital. The clinical features of Down syndrome, percentage of children receiving the stimulation intervention program, and attending school were studied. RESULTS: Congenital heart disease was found in 38.6%, gastrointestinal anomalies 16.9%, hematologic malignancy 6.1%, and thyroid disorders 11.4%. The mortality rate of Down syndrome children was 13.2%. Most children (65.6%) received the early stimulation, but only 38.9% attended the speech intervention program within the first 2 years of life. Of the total 109 Down syndrome children aged over 5 years that are still being followed, only 74 (67.9%) attended school. The school attendance was correlated with the family income, but not correlated with the level of maternal or paternal education. CONCLUSION : Congenital heart disease and gastrointestinal anomalies are commonly found in Down syndrome children. Most children received an early intervention program, but only 38.9% received speech intervention. In children aged >5 years, only 68% attended school, and school attendance was correlated with the family income.

Epidemiology of liver cancer: an overview.

The incidence of liver cancer varies widely throughout the world, with high rates in sub - Saharan Africa, eastern and southeastern Asia, and Melanesia and a low incidence in Northern and Western Europe and the Americas. Primary cancers of the liver in adults are of two main histological types: hepatocellular carcinoma, which is derived from hepatocytes, and cholangiocarcinoma, which is derived from the epithelial lining of the intrahepatic bile ducts. Hepatocellular cancer is a frequently occurring tumor in individuals in many developing countries, where several important risk factors have been demonstrated, including chronic infection with hepatitis B and C viruses and other environmental factors, such as exposure to aflatoxin, consumption of alcohol, and cigarette smoking. By contrast, cholangiocarcinoma is less common, accounting for only 7.7% of malignant tumors of the liver in the United States. However, in parts of Southeast Asia, cholangiocarcinoma occurs more frequently; it is responsible for more than 60% of liver tumors in northeastern Thailand. The geographic distribution worldwide coincides with endemic areas of the liver flukes, Opisthorchis viverrini and Clonorchis sinensis. The interaction between genes and the environment and the interplay of environmental factors, which include diet and other lifestyle parameters, illustrate the complexity underlying susceptibility.

Childhood cancer in Thailand: 1995-1997.

The incidences of childhood cancers in Thailand between 1995 and 1997 were determined from cancer registrations collected at five locations around the kingdom and compared with similar analyses performed at cancer registries in Asia, Europe and the USA. The incidence in Thailand was found to be lower than in some Asian and Western countries. Between 1988-1994 and 1995-1997, the incidence of childhood cancer rose 32.5%. As elsewhere in the world, leukemias, brain tumors and lymphomas comprised two-thirds of all childhood cancers. The age-peak for incidence was between 2 and 5 years, particularly for acute lymphoblastic leukemia. Carcinomas were rare. Several features of the cancer pattern correspond to other Asian populations, in particular the low incidence of Hodgkin s disease, Wilms tumor and Ewing s sarcoma. Neuroblastoma was more common than in neighboring Southeast Asian countries.

Histologic subtypes of hepatocellular carcinoma in the southern Thai population.

Since there has been no report on histologic subtypes of hepatocellular carcinoma (HCC) and its significance in the Thai population, the present study was conducted to elucidate the situation through appraisal of histologic and laboratory records. A total of 180 archived microscopic slides of HCC in Sonklanagarind Hospital from 1991 to 1998 were of good enough quality with sufficient tissue to be reviewed. The reclassified histologic subtypes were correlated with microscopic features and laboratory data. Of the 180 cases, 147 were males and hepatitis B was the main etiologic factor. The histologic subtypes of HCC were trabecular 63.3%, compact 15.6%, scirrhous 7.8%, pseudoglandular 5%, and fibrolamellar 0.6%. There was no correlation between histologic subtypes and morphological findings, as well as HBV, HCV, and cirrhotic status. A correlation between AFP levels and the AST/ALT ratio was evident.

The p53 codon 72 polymorphism and risk of oral cancer in Southern Thailand.

The codon 72 polymorphism of the p53 tumor suppressor gene has been investigated extensively for its association with various cancers around the world. However, its influence has not been elucidated in the Thai population. Therefore, a case-control study with 97 patients and 97 matched controls was conducted to elucidate the association between the polymorphic p53 and oral cancer risk in a Southern Thai population. The frequencies of the Arg/Arg, Arg/Pro, and Pro/Pro genotypes were 36%, 35%, and 29%, respectively in the controls and 33%, 45% and 22%, respectively in the patients. This study shows that there was no significant association between the p53 codon 72 polymorphism and oral cancer risk. There was also no link with respect to smoking or drinking habits. However, our data suggest that for individuals who were younger than 65 years old, the Pro/Pro genotype may offer some protection against oral cancer (OR = 0.13, 95%CI 0.04-1.10). This is the first report on p53 polymorphism and oral cancer in Thailand.

Etiologies of central diabetes insipidus in children : 15 years experience in Songklanagarind hospital, Thailand.

Central diabetes insipidus (DI) is a rare disease in children. The authors retrospectively reviewed the records of children with central DI identified at Songklanagarind Hospital from 1985 to 2000. Of the total 29 patients identified, 16 patients were males and 13 were females. All patients received computed tomography or magnetic resonance imaging of the brain to differentiate the etiologies of central DI. The median age at diagnosis was 6.6 years (range 1.5-14.9). The etiologies of central DI were intracranial tumors in 7 patients (24.1%), histiocytosis in 3 patients (10.3%), septooptic dysplasia in 1 patient (3.5%), empty-sella syndrome in 1 patient (3.5%), pituitary abscess in 1 patient (3.5%), and idiopathic in 16 patients (55.1%). All patients with idiopathic central DI were followed-up for a median duration of 4.5 years (range 1.3-15.5). Three of 16 patients (18.8%) were found to have intracranial tumors at 1.3, 2.3, and 3.5 years of follow-up. It was also observed that the patients whose age at presentation was less than 5 years (histiocytosis was excluded) were less likely to have intracranial tumors than those older than 5 years, (0% vs 55%), with significant statistical difference (p<0.01). It is concluded that: 1) the common etiologies of central DI are intracranial tumor and idiopathic, 2) patients initially diagnosed with idiopathic central DI need to have long-term follow-up by magnetic resonance imaging to identify any occult intracerebral tumor.

Comparative study of the efficacy of the Songkla uterine manipulator and the Hulka controlling tenaculum in laparoscopic tubal ligation.

OBJECTIVE: To compare the efficacy of the Songkla uterine manipulator (SUM) and the Hulka controlling tenaculum for manipulation of the uterus for laparoscopy. METHOD: Forty women scheduled for laparoscopic tubal ligation were randomized to the SUM group (n=20) or the Hulka group (n=20) as uterine manipulator. Laparoscopic evidence of antevertion and lateral uterine movements and organ exposure was video recorded. Assessment of organ exposure and degree of lateral uterine deviation were subsequently evaluated. RESULTS: The characteristics of the women were similar in both groups. Right, left and range of lateral uterine motion were greater in the SUM group than the Hulka group (59 vs 42 degrees, 60 vs 47 degrees, and 118 vs 89 degrees, respectively, p<0.0001). The SUM group had 2.4 times better cul-de-sac exposure than the Hulka controlling tenaculum (95% CI: 0.51-11.51, p= 0.475). The SUM exposed fallopian tubes better than the Hulka tenaculum (p=0.022) but other structures were not significantly better visualized. There were no complications in the SUM group but two had cervical bleeding in the Hulka group. CONCLUSION: The SUM has advantages over the Hulka controlling tenaculum in giving a wider angle of lateral uterine deviation and better exposure of the fallopian tubes.