Questions/Answers

Cervical cancer is the most common cancer in Thai women since 1989. In the past, 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. There are a few types of cancer that can be screened. The World Health Organization (WHO) recommends that all countries should adopt a cervical 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 cervical cancer among Thai women, 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 cervical cancer patients as they lose their opportunity to nurture their family; (2) to expand opportunities for all Thai women, including those who are poor and in remote areas, to access cervical cancer screening services on an equitable basis without expenditure at District Health Promotion Hospital (DHPH) in their community; (3) to establish a positive and accurate attitude about cervical cancer and the screening. Most people have a misapprehension mindset that all cancer patients are believed to die. Cultural embarrassment is also a big challenge as a reproductive organ is a sensitive issue, which is considered difficult to convince women to get cervical cancer screening. Besides, Thai people understand that cervical cancer occurs among women with more sexual activities. This is a stigma for the patients since they do not want other people know when they get the cancer; 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 women to fully access the screening for cervical precancerous lesions and prior treatment to save lives. Capacity building, under the Universal Health Care (UHC) scheme, toward around 10,000 DHPH primary care units nationwide shall ensure that socioeconomic (or urban) status should not limit Thai women to access the screening. The proposed project links to “Promoting gender responsive public services to achieve the SDGs” category. Our actions likewise interlink with the WHO asking all countries to concentrate on “Elimination of cervical cancer.”

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 women achieve equitable access to cervical 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 5 (gender equality) which is considered the most important part of life. People without disease will live a happy life; they can contribute to national development. Should women comprehend the risk factors of diseases and undergo regular screening, they can avoid late-stage cervical 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.

At the beginning of the project, we focused on health literacy. Good collaboration among all stakeholders in the community to improve awareness of people to avoid risk factors and understanding the important of screening is a key factor for project sustainability. This policy has a regular budget from the government to conduct the activities. This initiative also overcomes the culture embarrassment and religion barrier. Currently, most Thai women today are willing to discuss cervical cancer as a non-taboo topic, and many Thai men recommend their wives to undergo screening.

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. Cervical screening program was provided, as opportunistic screening, in the special centerssuch as in regional cancer hospitals, university hospitals, or 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 women in remote areas to access the screening as women who live in the city do. In addition, the project also covers the ethnic minority women who do not have Thai citizen to accessthe cervical screening equally in the DHPH 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 women with low risk of cervical cancer, could cause a lower number of cervical cancers found per woman and therefore reduce its cost-effectiveness. In line with age-specific incidence data, the appropriate age group shall be 30-60 years old and screen every 5 years. However, for individual women who receive the screening at least once in their life time also gain benefit to reduce mortality of cervical cancer. Detection cervical precancerous lesions by screening asymptomatic women and treating them with simple outpatient, day care treatment (i.e. cryotherapy or loop electrosurgical excision)can prevent cervix cancer with good quality of life post-treatment. Average life expectancy for Thai women was 80.1 years. The education situation of women has improved substantially for the past two decades, faster than men. Some well-educated women have achieved to have high occupational position, making the women play an important role in driving economic growth in Thailand.

After the pilot study was evaluated in 2003, the project has been scaled up as a national program since 2005; and the target women were continuously offered cervical 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 women, aged 30-60, every 5 years instead of 1-2 years, which is recommended in most developed countries. 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, cytology smear taking in almost 10,000 primary care units, colposcopy and directed biopsies, histopathology, and treatment precancerous lesions and cervix cancer. Since 2003, 1,621 gynecologists, 1,891nurses, 1014 cytotechnicians have been trained to serve the program. In addition, 2,226 village health volunteers and 1,089 school teachers have been instructed to disseminate information of cervical cancer, screening methods and the importance of the screening to prevent cervical cancer. 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 developed Cervical Cancer Screening Program Information System. 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.

The obstacles were different in each region. In the Northern part, the prevalence of HIV and cervical cancer are higher than other parts. Health education is important, therefore health personnel and volunteers work very hard to assure that all women know and understand the project. In the Southern part, there are more Muslim women, health personnel ask assistance from Sheikh to explain to husbands and encourage their wife for screening, whereas, in the Northeastern, the DHPH provides a mobile unit to serve in the rice field working areas for women who don’t have time to go for screening.

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 program is Thailand’s first government-supported screening project for women throughout the country, providing free access by utilizing existing public health infrastructure. The project also features thesystematic record of performance to monitor and evaluate outcomes and as such could be a model for other screening programs, such as colorectal cancer and other NCDs. In addition, the research project to develop AI for cervical cancer screening and diagnosis are in progress.

Population-based cervical 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 women access to information and services systematically on an equitable basis. We also organize the meeting where health personnel could share the experiences about the successful and unsuccessful stories. New innovations such as mobile units, after-hour services, use of facial masks, privacy for pelvic examination, and selection of female DPHP staff to minimize embarrassment, are featured to increase the coverage of screening.

There were an estimated number of 569,847 cervical cancer cases globally in 2018; 85% of the cases occurred in developing countries. Thailand is the first country to implement a populated-based cervical cancer screening policy among low- and middle-income countries (LMICs). This projected initiative started as a pilot in “Nakhon Phanom” province during 1999-2002. 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. Several countries are interested in learning from our experience—how to plan and implement the program. Thai NCI with a collaboration of domestic and international societies has organized many training programs for gynecologists and nurses about the screening program and how to manage screen-positive women. Since 2010, 352 gynecologists and 78 nurses from ASEAN countries have been participating in the training programs.

-

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 district health promotion 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 15 years, the project is exposed to be sustainable.

This project has created a strong, multidisciplinary network and interaction among doctors, nurses, cytologists, 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 institutesorganized the events and launched several cancer campaigns about cervical cancer.New information was also disseminated by different social media progressively.

Yes

The NCI monitored the progress, evaluated outcomes, and reported to Ministry of Public Health (MoPH) and the NHSO. In 2010, a national survey indicated that 67.4% of women were screened for cervical cancer in the past 5 years (either by our program or by their own screening). Prior to the implementation of the national program, only 25% of Thai women underwent screening. It can be concluded that Thai women are now more likely to receive cervical cancer screening voluntarily, so do women in developed countries.This year, we received a reward from Office of the Public Sector Development Commission.

The MoPH sets the Key Performance Indexof number involving women who were screened for the diseases and those with abnormalities who were referred for diagnostic assessment and treatment. Since 2005, approximately 53% of the targeted women (around 15,894,608 women during 2005-2019) were screened. There were 6,589 cases of suspected cancer and 66,957 of High-Grade Squamous Intraepithelial Lesions. 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 National Cervical Cancer Screening Program has been lightening cervical cancer burden in Thailand progressively. It was revealed that the cervical cancer incidence rate was 23.4 per 100,000 women (ranked 1st among cancers in female) in 1989 then was declined to 11.7 (ranked 3rd) in 2014, which is 50% fall over 25 years. However, compared to developed countries, the incidence was still high with 2,193 fatalities from cervical cancer and more than 6,000 cases annually (or 16.5 cases per day). Each year, the government spends enormous amount of budget for therapeutic measures. If we observe the outcomes in each province carefully, the coverage of screening varies from 26-92% of targeted women. There are many factors behind to make project success or fail, for instance, policy maker commitment, infrastructure and resources, and good collaboration of networking in each area.In general, shortage of human resources is one of the main problems for any kind of health activities; however, in some health areas, they shared the resources together and ask assistance from professional society. Another important thing that could help resolve the problem is to create networking with private and social sectors within the community.

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 level. Cervical 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 allocated funds through MoPH and NHSO 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 January as a cervical cancer awareness month.

The project outcomes were rated satisfactory.We overcame many difficulties and put an effor to initiate the project. This project would not be 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 women who do not realize the importance or still embrace of the screening.We continue to propose new technology of screening using HPV DNA test with higher sensitivity, reduce workload, and could be do a self-collection of specimens in case of apprehensive women.