Barriers to cervical cancer screening and acceptability of HPV self-testing: a cross-sectional comparison between ethnic groups in Southern Thailand.

BACKGROUND: Cervical cancer rates are higher in low-resourced countries than high, partly due to lower rates of screening. Incidence in Thailand is nearly three times higher than in the USA (16.2 vs 6.5 age-standardised incidence), even with Thailand's universal health coverage, which includes screening, suggesting that alternative methods are needed to reduce the burden. We investigated barriers to screening, as well as acceptability of self-collection human papillomavirus (HPV) testing as a primary form of cervical cancer screening among Buddhist and Muslim communities in Southern Thailand. METHODS: 267 women from the Buddhist district of Ranot and Muslim district of Na Thawi, Songkhla were recruited to complete a survey assessing knowledge and risk factors of HPV and cervical cancer. Participants were offered an HPV self-collection test with a follow-up survey assessing acceptability. Samples were processed at Prince of Songkhla University and results were returned to participants. RESULTS: 267 women participated in the study (132 Buddhist, 135 Muslim), 264 (99%) self-collecting. 98% reported comfort and ease, and 70% preferred it to doctor-facilitated cytology. The main predictor of prior screening was religion (92% Buddhist vs 73% Muslim reporting prior Pap). After adjustment with multivariate logistic models, Muslim women had an OR of prior Pap of 0.30 compared with Buddhist (95% CI: 0.12 to 0.66). CONCLUSIONS: Self-collection HPV testing was highly acceptable across religious groups, suggesting that it could be beneficial for cervical cancer reduction in this region. Focus should be put into educating women from all backgrounds about the importance of screening to further improve screening rates among Thai women.

The effect of Pap smear screening on cervical cancer stage among southern Thai women.

Our study aimed to investigate the effect of Pap smear screening on stage at diagnosis of cervical cancer in a heterogeneous population of Thai women. Data was merged from the population-based cancer registry and screening registry based on unique identification numbers from 2006 to 2014. Patients being screened had lower odds to be diagnosed at late stage. After adjustment, married women had reduced risk of late stage cancer compared to single women. Muslim women had almost twice the risk of being diagnosed late stage compared to Buddhist women. The odds of being diagnosed at late stage decreased with increased number of screening. The probability of being diagnosed at late stage increased rapidly among females aged 40 to 55 years. Pap smear screening is a protective factor in diagnosis of late stage cervical cancer. Patients were more likely to be diagnosed at early stage with more frequent screening. For future screening programs, it will be beneficial to shorten screening intervals and take more concern for vulnerable population: women aged between 40 and 55 years, and women who are single or Muslim.

Trends in incidence of uterine cancer in Songkhla, Southern Thailand.

OBJECTIVE: To define the present incidence of uterine cancer and the trends of incidence in the future. Additional, subgroup analysis in religion and socio-demographic factors will be analyzed. METHODS: The data of uterine cancer from The Songkhla Cancer Registry between; 1989 and 2016, was extracted. The population denominators of Songkhla Province were referred from the information of the population censuses surveyed by the National Statistical Office. The incidence was estimate by; the age specific rate, and analyzed in trend incidence using Jointpoint and Age-period-cohort; APC regression models and trend projection in 2017-2030 using by Jointpoint, the NordPred and APC model. The comparison of incidence according to habitat and religion were unpaired t-test. RESULTS: The incidence of uterine cancer in Songkhla Province increased from 1.5, to 5.3 per 100,000 women-years in 2016, and 8 per 100,000 women-years in 2030. The incidence was more in urban areas and in Buddhists. CONCLUSION: The incidence of uterine cancer is increasing. The policy, which promotes protective factors and control risk factors, would decrease incidence of endometrial cancer, and other estrogen dependent cancers additional to chronic diseases from the cardiovascular system.

Temporal Trends and Geographic Patterns of Lung Cancer Incidence by Histology in Thailand, 1990 to 2014.

Purpose Lung cancer is one of the most common cancers worldwide and in Thailand. We characterize and forecast region-specific patterns of lung cancer incidence by histology and sex. Methods We analyzed lung cancer incidence trends in Thailand by histology (adenocarcinoma [AdC]; squamous cell carcinoma [SCC]; and large-cell, small-cell, and other carcinomas) from 1990 to 2014 in four cancer registries in three regions (north, Chiang Mai Province and Lampang Province; northeast: Khon Kaen Province; south: Songkhla Province). Annual percent change (APC) was calculated to quantify the incidence rate trends using joinpoint regression. Age-period-cohort models were used to examine the temporal trends of AdC and SCC by age, calendar year, and birth cohort. We projected the incidence of AdC and SCC up to 2030 using three independent approaches: joinpoint, age-period-cohort, and Nordpred models. Results AdC incidence significantly increased from 1990 to 2012 in Chiang Mai males (APC, 1.3%), Songkhla males from 2004 to 2014 (APC, 2.5%), Songkhla females from 1990 to 2014 (APC, 5.9%), and Khon Kaen females from 2005 to 2014 (APC, 3.1%). Conversely, SCC incidence significantly decreased from 1990 to 2012 in Chiang Mai males and females (APC, -1.2% and -4.8%, respectively), Lampang males and females from 1993 to 2014 (APC, -5.4% and -5.2%, respectively), and Songkhla females from 1990 to 2014 (APC, -2.1%). In general, trends of AdC and SCC correlated more with birth cohort than with calendar year. Three projection models suggested that incidence rates of AdC in Songkhla may continue to increase until 2030. Conclusion Temporal trends of lung cancer by histology varied among regions in Thailand. Reduction of lung cancer incidence in Thailand likely will require prevention strategies tailored to each specific region.

Effect of the national screening program on malignancy status of cervical cancer in Northern Thailand.

OBJECTIVES: Cervical cancer has posed a serious problem in Thailand for decades. In 2002, a systematic screening program was implemented under universal healthcare coverage for all Thai women. However, there has been little research on how screening affected particular aspects of cervical cancer, such as stage distribution. This screening program has a target group; therefore, it is necessary to assess stage and incidence trends by age of those within and outside the screening target group. METHODS: Using trend analysis, we assess in situ and malignant cervical cancers in Northern Thailand to measure changes after implementation of the national screening program. RESULTS: While incidence of malignant cancers is decreasing and incidence of in situ tumors is increasing across all age groups, women above age 60 still experience a high incidence of malignant tumors. CONCLUSIONS: The screening program is successful in the target group at downshifting the stage distribution of malignant tumors and reducing incidence of malignant tumors with in situ cases being captured. However, the high incidence of malignant tumors in women over age 60 will continue to be clinically relevant for cervical cancer management until younger generations undergoing screening enter this age group.

Trends in Incidence of Two Major Subtypes of Liver and Bile Duct Cancer: Hepatocellular Carcinoma and Cholangiocarcinoma in Songkhla, Southern Thailand, 1989-2030.

BACKGROUND: The incidence of liver and bile duct cancer continues to rise, especially in Thailand. We aimed to project the trends in incidence of this rare but lethal cancer in southern Thailand in order to determine its future disease burden. METHODS: Gender-specific trends in age-standardized incidence rates per 100,000 person-years for hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) cases in Songkhla province of southern Thailand diagnosed between 1989 and 2013 were estimated and projected up to year 2030 using three different modeling techniques: a joinpoint model, an age-period-cohort model, and a modified age-period-cohort model. RESULTS: Of 2,676 liver and bile duct (LBD) cancer cases identified, 73% were males, 51% were aged between 50 and 69 years, and HCC (44.4%) was slightly more common than CCA (38.1%). The models all predicted an increase in the incidence rate of CCA up to 2025 for both sexes whereas the incidence of HCC is expected to decrease among males and stabilize among females. The incidence rates of HCC and CCA among males in 2030 could reach 6.7 and 9.4 per 100,000 person-years, respectively, whereas the expected rates of HCC and CCA among females are expected to be around 1.5 and 3.9 per 100,000 person-years, respectively. CONCLUSIONS: The incidence of cholangiocarcinoma is expected to increase in Songkhla and will contribute a larger proportion of LBD cancers in the future. Future public health efforts and research studies should focus on this increasing trend.

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

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.

Trends in Female Breast Cancer by Age Group in the Chiang Mai Population

Objectives: This study was conducted to determine incidence trends of female breast cancer according to age groups and to predict future change in Chiang Mai women through 2028. Method: Data were collected from all hospitals in Chiang Mai in northern Thailand, from 1989 through 2013, and used to investigate effects of age, year of diagnosis (period) and year of birth (cohort) on female breast cancer incidences using an age-period-cohort model. This model features geometric cut trends to predict change by young (<40 years), middle-aged (40-59) and elderly (≥60) age groups. Result: Of 5, 417 female breast cancer patients with a median age of 50 years (interquartile range: 43 to 59 years), 15%, 61% and 24% were young, middle-aged and elderly, respectively. Seventy nine percent of cancer cases in this study were detected at advanced stage. The trend in stage classification showed an increase in percentage of early stage and a decrease in metastatic cancers. Linear trends for cohort and period were not found in young females but were observed in middle-aged and elderly groups. Age-standardized rates (ASR) can be expected to remain stable around 6.8 per 100,000 women-years in young females. In the other age groups, the ASR trends were calculated to increase and reach peaks in 2024 of 120.2 and 138.2 per 100,000 women-years, respectively. Conclusion: Cohort effects or generation-specific effects, such as life style factors and the year of diagnosis (period) might have impacted on increased incidence in women aged over 40 years but not those under 40 years. A budget should be provided for treatment facilities and strategies to detect early stage cancers. The cost effectiveness of screening measures i.e. mammographic screening may need to be reconsidered for women age over 40 years.

Estimation of the Incidence of Hepatocellular Carcinoma and Cholangiocarcinoma in Songkhla, Thailand, 1989-2013, Using Multiple Imputation Method.

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.

The use of a multiple imputation method to investigate the trends in Histologic types of lung cancer in Songkhla province, Thailand, 1989-2013.

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.

Breast Cancer in Surat Thani, a Province in Southern Thailand: Analysis of 2004-2012 Incidence and Future Trends.

BACKGROUND: With the recent epidemiologic transition in Thailand, featuring decreasing incidences of infectious diseases along with increasing rates of chronic conditions, cancer is becoming a serious problem for the country. Breast cancer has the highest incidence rates among females, not only in the southern regions, but throughout Thailand. Surat Thani is a province in the upper part of Southern Thailand. A study was needed to identify the current burden, and the future trends of breast cancer. MATERIALS AND METHODS: Here we used cancer incidence data from the Surat Thani Cancer Registry to characterize the incidences of breast cancer. Joinpoint analysis was used to investigate the incidences in the province from 2004 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 Southern Thailand increased from 35.1 to 59.2 cases per 100,000 female population, which is equivalent to an annual percentage change of 4.5-4.8%. Linear drift effects played a role in shaping the increase of incidence. Joinpoint projection suggested that incidence rates would continue to increase in the future with incidence for women aged 50 and above, 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.

Breast Cancer in Lampang, a Province in Northern Thailand: Analysis of 1993-2012 Incidence Data and Future Trends.

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.

Breast Cancer in Lopburi, a Province in Central Thailand: Analysis of 2001-2010 Incidence and Future Trends.

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.

Success of a cervical cancer screening program: trends in incidence in songkhla, southern Thailand, 1989-2010, and prediction of future incidences to 2030.

BACKGROUND: Cervical cancer has been a leading female cancer in Thailand for decades, and has been second to breast cancer after 2007. The Ministry of Public Health (MoPH) has provided opportunistic screening with Pap smears for more than 30 years. In 2002, the MoPH and the National Health Security Office provided countrywide systematic screening of cervical cancer to all Thai women aged 35-60 years under universal health care coverage insurance scheme at 5-year intervals. OBJECTIVES: This study characterized the cervical cancer incidence trends in Songkhla in southern Thailand using joinpoint and age period cohort (APC) analysis to observe the effect of cervical cancer screening activities in the past decades, and to project cervical cancer rates in the province, to 2030. MATERIALS AND METHODS: Invasive and in situ cervical cancer cases were extracted from the Songkhla Cancer Registry from 1990 through 2010. Age standardized incidence rates were estimated. Trends in incidences were evaluated by joinpoint and APC regression models. The Norpred package was modified for R and was used to project the future trends to 2030 using the power of 5 function and cut trend method. RESULTS: Cervical cancer incidence in Songkhla peaked around 1998-2000 and then dropped by -4.7% per year. APC analysis demonstrated that in situ tumors caused an increase in incidence in early ages, younger cohorts, and in later years of diagnosis. CONCLUSIONS: Both joinpoint and APC analysis give the same conclusion in continuation of a declining trend of cervical cancer to 2030 but with different rates and the predicted goal of ASR below 10 or even 5 per 100,000 women by 2030 would be achieved. Thus, maintenance and improvement of the screening program should be continued. Other population based cancer registries in Thailand should analyze their data to confirm the success of cervical cancer screening policy of Thailand.

Differences in cancer incidence among predominantly Muslim and Buddhist subpopulations in Songkhla.

BACKGROUND: The population of Songkhla, a province in Southern Thailand, can be divided into a predominantly Muslim subpopulation (PMSP, approximately 70% Muslim) and a predominantly Buddhist subpopulation (PBSP, around 14% Muslim). OBJECTIVES: This study was conducted to 1) describe the incidence of various cancers in both PMSP and PBSP, and 2) compare the incidence of various cancers between the two subpopulations. MATERIALS AND METHODS: Cancer cases diagnosed between 1990 and 2010 were drawn from the database of Songkhla Cancer Registry. Population denominators were estimated from the 3 population censuses surveyed by the National Statistical Office of Thailand in 1990, 2000, and 2010. RESULTS: The age-standardized incidence rates (ASR) of the 5 commonest male cancers among both subpopulations were calculated. In females, a lower incidence of cancers of the cervix and breast in PMSP compared to PBSP, with odds ratios of 0.54 (95% CI: 0.45-0.64) and 0.51 (95% CI: 0.43-0.60) respectively, was observed. In males, the incidence of cancers of the lung, liver, colon-rectum, and some other cancers were significantly different between the two populations in the past, but only prostate cancer showed a lower incidence among males in PMSP in recent years. Independent of sex and year of diagnosis, the incidence of lung, liver, NHL, and colorectal cancers was lower in MPSP compared to BPSP, with odds ratios of 0.75 (95% CI: 0.65-0.85), 0.74 (95% CI: 0.62-0.88), 0.74 (95% CI: 0.60-0.91), and 0.67 (95% CI: 0.56-0.78) respectively. CONCLUSIONS: The differences in incidence of some cancers and religion- related culture between the two subpopulations need 2 sets of cancer-control plans and goals to fit the unique population context in deep Southern Thailand. This plan can be used in the 3 southernmost provinces of Thailand where the percentage of Muslims is over 85%.