Questions/Answers

Colorectal cancer is increasing overtime among Thai people both men and women. Patients often came to see the doctor at very advanced stages when treatment is often ineffective with poor prospects of long-term survival and cure. The World Health Organization (WHO) recommends that all countries should adopt a colorectal cancer screening policy based on the country's existing public health infrastructure and available resources. The key objectives of The National Cancer Screening Program are as follows: (1) to reduce the incidence and mortality rate of colorectal cancer among Thai people, which leads to a decrease in premature death of the population. Not only does the cancer cause economic loss and social problems to the country, it also creates an obstacle to a family with colorectal cancer patients as they lose their opportunity to nurture their family; (2) to expand opportunities for all Thai people, including those who are poor and in remote areas, to access colorectal screening services on an equitable basis without expenditure at Health Promotion Hospital (HPH) in their community; (3) to establish a positive and accurate attitude about colorectal cancer and the screening. As many people generally assume that they are healthy and misapprehension mindset that all cancer patients are believed to die, it is unnecessary to go screening; and (4) to establish a multidisciplinary network with interactions among medical personnel and village health volunteers to strengthen capacity for cancer screening.

We recognize the rights of all Thai people to fully access the screening for colorectal precancerous lesions and prior treatment to save lives. Capacity building, under the Universal Health Care (UHC) scheme, toward around 10,000 HPH nationwide shall ensure that socioeconomic (or urban) status should not limit Thai people to access the screening. The proposed project links to “Fostering innovation to deliver inclusive and equitable services for all including through digital transformation” category.

This project aligned with Goal 3 (good health and well-being) of the UN sustainable development stated in the 2030 agenda, ensuring that all Thai people achieve equitable access to colorectal cancer screening services and be improved public awareness and knowledge of cancer screening to acquire good health and well-being. It also contributes to Goal 8 (decent work and economic growth) which is considered the impact on employment. People without disease will live a happy life; they can contribute to national development. Should people comprehend the risk factors of diseases and undergo regular screening, they can avoid late-stage colorectal cancer. Since early-stage lesions are curable, treated patients can return to workforce and maintain a good quality of life, which reflects the economic growth of the country.

One of the most successful aspects was improved awareness of the importance of avoiding risk factors and understanding of colorectal cancer screening among Thai people. Good collaboration of all stakeholders, particularly community health care workers as well as patients alliance, is also proved to be key factor for project sustainability. With all networking parties, we promote colorectal awareness using new mass media since age of colorectal cancer diagnosis in Thailand slightly shift to younger people.

Once cancer was diagnosed, the patient may require medical treatment and special care for months, and often years. The principle modes of the therapy are surgery, radiotherapy, and chemotherapy. Some patients may receive all three modalities of treatment. Our government spent a big budget for cancer treatment yearly and the cost is increasing gradually. Access to the treatment is also a major challenge since a number of comprehensive cancer centers are few and mostly located in Bangkok and other major urban sites. Delay of diagnosis and treatment may affect the staging of disease. Although the treatment expense is covered by the UHC or other health insurance schemes, the patients still have to wait for a long period and spend travelling and other expenses by themselves. Some families experience financial hardship due to this chronic illness and give up continuing the treatment. Some patients, additionally, seek alternative treatments though no obvious evidence of efficacy exists. The project should change attitudes to the treatment modalities as well as raise awareness of plausible cure.

Before this initiative was implemented. Colorectal cancer screening program was provided, as opportunistic screening, in the special centers such as regional cancer hospitals, university hospitals, private hospitals. The project improved the capacity building of health personnel and service system, particularly in the rural area. As a result, it allows Thai people in remote areas to access the screening as Thai people who live in the city do. In addition, the project also covers the ethnic minority people who do not have Thai citizen to access the colorectal screening equally in the HPH in their community with free of charge.

To conduct the organized screening program, consideration of the targeted age group is very important. Targeting the wrong age group, such as younger people with low risk of colorectal cancer, could cause a lower number of colorectal cancers found per all Thai people, therefore reduce its cost-effectiveness. In line with age-specific incidence data, the appropriate age group shall be 50-70 years old and screen every 2 years. Detection colorectal precancerous lesions by screening asymptomatic people and treating them with simple outpatient, day care treatment can prevent colorectal cancer with good quality of life post-treatment.

After the pilot study was done and the outcome of the project was evaluated for economic evaluation, the project has been scaled up as a national program since 2018; and the target population were continuously offered colorectal screening since then. Stakeholders from a wide range of sectors consulted and exchanged views to develop the screening policy and its implementation. At the same time, screening and treatment infrastructure, as well as referral systems for diagnosis and treatment, were developed in each health area. In accordance with the available resources of budget and manpower, our program aims to screen Thai people, aged 50-70, every 2 years. Also, the manpower needs, expected additional workload, and operating expenses of the program were taken into account before the program initiated. The National Cancer Institute (NCI) together with professional medical societies conducted several training courses to generate trained human resources for awareness creation in almost 10,000 HPH. Since 2018, 55 medical physicians, 134 nurses, 728 health personnel in HPH have been trained to serve the program. NCI and its affiliates prepared and disseminated various educational materials to each area through the district health promotion officers, the village health volunteers; and the lay public can be provided with information on the effective screening. To monitor the progress and to evaluate the outcomes of the program, NCI has developed guidelines how to record the code for screening results, colonoscopy results and send the data to Ministry of Public Health (MOPH) to link the data and show the report on website of MOPH. This information system allowed documentation of the screening, diagnosis and treatment data at the national, provincial and district levels, which everyone can assess on the website.

We are aware of problems and challenges in scaling up and implementing the program. There are poor coverage areas; quality of screening and diagnosis and treatment of positive people, lack of physicians performing colonoscopy as well as infrastructure and adequacy of trained service providers. NCI in collaboration with The Gastroenterological Association of Thailand help physicians in several hospitals to perform colonoscopy for 650 FIT positive in different areas. Moreover, we reported the outcomes to provincial health promotion office every month. The staffs in those provinces have discussed, identify the gap, and find the solution to fill the gap.

In the past, patients with an advanced-stage disease had to be present at a hospital. To overcome this problem, a proactive policy emphasizing prevention and screening was established. This screening program is supported by Thai government for Thai people throughout the country, providing free access by utilizing existing public health infrastructure. The project also features the systematic record of performance to monitor and evaluate outcomes.

Population-based colorectal cancer screening programs have been available in developed countries for several decades. Most people in such countries acquired health insurance and are well-aware of benefits. Our project is an organized screening program that provides all Thai people access to information and services systematically on an equitable basis. Project initiative to introduce people to screen FIT test by themselves.

The MOPH constructed the clinical and health database which called "43 file" and asked all hospitals send the data files to Health Data Center (HDC). This system will allow each health unit that use different Hospital Information System to send the data to HDC using the same standard data set. Standard code assignments are made to enable the data to be linked and share nationally.

Thailand is the first country to implement a populated-based colorectal cancer screening policy among low- and middle-income countries (LMICs). This projected initiative started as a pilot in “Lampang” province during 2010-2012. The outcome of this project was evaluated by the Health Technology Assessment Policy and found that the project is cost-effective and worth investing in national scaling up in the country.

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The project operates under the existing public health infrastructure, from the primary to tertiary care. The budget is funded by National Health Security Office who oversees the UHC, including cancer treatment, for all Thai people. The NCI and its affiliated organizations prepare and disseminate various educational materials so that HPH officers, village health volunteers, and the lay public group can be provided with information to effective screening. Having become a national policy for more than 3 years, the project is exposed to be sustainable.

This project has created a strong, multidisciplinary network and interaction among doctors, nurses, public health specialists, medical personnel, and village health volunteers in the Thai Government health services. Most importantly, the movement of people and private sector have significant impact to make project sustainable. Several institutes organized the events and launched several cancer campaigns about colorectal cancer. New information was also disseminated by different social media progressively.

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To monitor progress and to evaluate outcomes, NCI has developed the data system. This allows documentation of screening, diagnosis and treatment processes at national, provincial and district levels. The screening information send to MOPH to monitor and evaluate about the screening performance in each area.

The MOPH sets the Key Performance Index of number involving Thai people who were screened for the diseases and those with abnormalities who were referred for diagnostic assessment and treatment. Since 2018, approximately 55.9% of the targeted population (around 1,807,337 people) were screened. There were 692 cases of suspected cancer. The results can be compared with health regions and provinces, allowing a focus on locations where implementation is optimal. Problems can be investigated; and appropriate measures can be introduced for their solution.

The average of FIT test positive of the country was around 5%, they were people who do not have any sign and symptoms. The project allow this people to have further investigate to confirm the disease. If we look carefully the outcomes in each province, the coverage of screening vary from 1.2-100% of targeted population. There are many factors behind to make project success or fail, these are; infrastructure and resources and good collaboration of net working in each area.

Cancer is the leading cause of death among Thai population since 2000. In response to this challenge, NCI in collaboration with other bodies has developed and promoted the National Cancer Control Program (NCCP) to provide appropriated policies and practices for the prevention, early detection, treatment of cancer, and palliative care. In 2013, the MOPH implemented a new policy, called Service Plan Policy, a collaborative effort among every department within the MOPH at every level from community-based units from primary to super tertiary care level, to strengthen the public health care system. As per this policy, Thailand is divided into 12 health areas and the Bangkok area. Each health area covers 4-8 provinces and have around 3 to 6 million people. As a result, access to health services has become widespread with equal allocation of healthcare resources in order to better respond to existing and emerging public health care challenges. Our institute proposed to implement NCCP to regional and community level. Colorectal cancer screening program is one of the activities to decrease the incidence and mortality of the disease. NCI plays a key role to facilitate and provide recommendation to health region and community work.

Stakeholders from a wide range of sectors were consulted with exchange of views to develop the screening policy and its implementation. At the same time, elements of screening, treatment infrastructure as well as referral systems were developed for each health region. Further aspects, such as manpower needs, expected additional workload, and operating expenses of the program, had been considered before the program initiated. National Health Security Office (NHSO) allocated funds through MOPH for the screening, monitoring, and evaluation of the program. To achieve goals, NCI is responsible for coordination of all efforts and annual report submission to MOPH. Additionally, our institute together with professional medical societies and provincial hospitals conducted several training courses to generate human resources, implement guidelines, and monitor quality of the program. Field work within a community with a support from village health volunteers and local administrative organizations are considered as the important aspect to ensure continuous operation. As a matter of fact, we have approximately 1,000,000 volunteers across the country involving in this project. In addition, with collaboration of private sectors, regular exhibitions are organized in March as a colorectal cancer awareness month.

Implementation of the program provided valuable experiences to all of us. Overall the project outcomes were rated satisfactory even the coverage ware varies in individual areas. We overcame many difficulties and took time to initiate the project. This project is not successful without the commitment of all parties, from government to community. Though there are several areas where poor coverage and quality of screening have to be improved, more efforts are on their way to educate people about the important of screening.