Cancers in Northern Thailand
1 Division of Therapeutic Radiology and Oncology,
Faculty of Medicine, Chiang Mai University, Thailand
2 Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand
3 Department of Otolaryngology, Faculty of
Medicine, Chiang Mai University, Thailand
A retrospective study was undertaken to assess cancers in
northern Thailand using the Chiang Mai Cancer registry and Maharaj Nakorn Chiang Mai Hospital records from January 2001 to December 2005. Maharaj Nakorn Chiang Mai Hospital is the university hospital for the Faculty of Medicine, Chiang Mai University. There were 4,108 new cancer cases being treated at the institution. The
distribution of patients were (a) 32% from Chiang Mai, (b) 42% from nearby provinces
of Lampoon, Phayao, and Chiang Rai, (c) 20.4% from other northern provinces,
and (d) 1.2% from other parts of Thailand. Based on the data, the most common
cancers by relative frequency are cancers of the lung, cervix, liver, breast,
and non-Hodgkin's lymphoma. The current treatment options used to manage these
most common cancers are described in this article. � 2008 Biomedical
Imaging and Intervention Journal. All rights reserved.
Keywords: Cancer statistics, Thailand
Cancer is one of the major public health problems in Thailand. In 2002, cancer became the third common cause of death in the Northern part of Thailand . A retrospective analysis was undertaken to assess the cancers in Northern Thailand. The sources for this data analysis were the Chiang Mai Cancer Registry
and Maharaj Nakorn Chiang Mai Hospital, using the medical records of patients
from January 2001 to December 2005. Maharaj Nakorn Chiang Mai Hospital is the university hospital of the Faculty of Medicine, Chiang Mai University. The hospital has 1,800 beds and serves about 415,000 out-patients and 49,200
in-patients each year.
Materials And Methods
In 2005, there were 4,108 cases of new invasive cancer at Maharaj Nakorn Chiang Mai Hospital . Thirty-six percent were Chiang Mai residents, 42.0%
came from nearby provinces (Lampoon, Lampang, Phayao and Chiang Rai), 20.4%
came from the other provinces in the northern region, and only 1.2% resided
outside the northern part of Thailand (Table 1).
Age and sex
There were 1,810 male and 2,298 female cancer cases in the
year 2005, with a male-to-female ratio of 1:1.3, but 1,135 (49.4%) of the
cancers in females occurred in sex-specific sites (i.e. breast and reproductive
organs) while only 80 cases (4.4%) of sex-specific cancers (i.e. prostate,
testis, and penis cancers) occurred in males. When sex-specific sites were
excluded, the male-to-female ratio increased to 1.5:1 .
Ages ranged from below one year to 98 years. The median
age at diagnosis was 55 years, 57.3 years for males and 59 years for females.
In the age group of 25 to 59, there were more female cancer patients than
males, while in the age group above 60, there were more male cancer patients than
female cancer patients (Fig. 1). There were 100 cases of cancer in children
(below age 15), accounting for only 2.4% of all cases, but there were 1,618
cases in the old-age group (age 60 and above), accounting for 39.4% of all
There were 214 in situ patients and they were not included
in this analysis. Uterine cervical cancer in situ was the most common,
accounting for 63.6% of cases.
Stage of disease
Twenty eight percent were diagnosed at an advanced stage
(20.3% distant metastasis and 8.3% regional node metastasis), and 55.9% were
diagnosed at a localised stage and locally advanced. In 835 cases of distant
metastasis, 13.2% had multiple sites of metastasis. The most common site of
distant metastasis was lung (21.7%), followed by distant lymph nodes (21.4%), liver
(16.5%), bone (14.0%), and brain (12.6%).
Leading sites of cancer cases
Of the invasive cancer in both sexes combined, lung cancer
was the most common (14.1%), followed by cervix, liver, breast, and
non-Hodgkin�s lymphoma (Table 2). Together these five types of cancer accounted
for 51.2% of all new cancers. For males, the most common cancer was lung
cancer, accounting for 19.8% of all new cases, followed by liver cancer,
non-Hodgkin�s lymphoma, nasopharyngeal cancer and rectal cancer. For females,
the most common cancers were cervix cancer, accounting for 23.7% of all new
cases, followed by breast, lung, ovary, and liver cancer.
Approximately 24 percent of Thailand's population is
younger than 15 years old . At Maharaj Nakorn Chiang Mai Hospital, there were 100 cases of childhood cancers (ages below 1 to 14), accounting for 2.4%
of all cancer cases in 2005. The most common childhood cancer was leukaemia,
accounting for 49.0% of childhood cancers, followed by brain and nervous system
(13.0%), NHL (6.0%), bone (5.0%), and eye (5.0%). Leukaemia, brain and nervous
system were the common causes of death in childhood cancers.
In 2004, there were 18.8% of cancer patients who received
symptomatic treatment alone due to advanced disease or patient refusal. The
other 81.2% received definitive treatment . The majority of the patients
received single modality treatment and the most common primary treatment was
surgery, followed by chemotherapy, and radiation therapy (Table 3).
This retrospective study shows that lung cancer and cancer
of the cervix are the two most common cancers in Northern Thailand. A
comprehensive report on the characteristics, diagnosis and staging, and
treatment is presented in the management of these diseases.
Lung cancer is defined as one of the major health problems
in Thailand and has been the most common cause of death since 1999 . Lung
cancer in Thailand is the second most common cancer in males after liver cancer
and the fourth in females after cervix, breast and liver cancers. There is a
higher incidence rate of lung cancer in northern Thailand than other areas .
In 2005, there were 535 new cases of lung cancer diagnosed in 2005 (326 males,
209 females) (Figure 2 and 3) in Northern Thailand. This constituted 25.6% of
all cancers in males and 14.9% of those in females. The age-standardised
incidence rates were 38.0 for males and 21.7 for females. Lung cancer has
ranked first for new male cancers in Chiang Mai since the first
population-based registration in 1983 until 2005 in this report. For females, lung
cancer ranked third in 2005 after breast and cervix cancers. The incidence
rates increased with age in both sexes, with the rates in males increasing
sharply after the age of 45 years and exceeding those in females. The
cumulative rate percent to age 75 were 4.9% for males and 2.7% for females. The
risk of men developing lung cancer by the age of 75 years was 10 in 205 for men
and 10 in 376 for women.
Among the 534 deaths from lung cancer, 327 were males
(28.9% of all male cancer deaths) and 207 were females (24.0% of all female
cancer deaths). The age-standardised mortality rates were 38.5 for males and
21.9 for females, and these rates were increased in both sexes (Figure 4). The
mortality rates increased with age in both sexes, with rates in males increasing
sharply after the age of 45 years and exceeding those in females (Figure 5).
Among lung cancer deaths, 375 cases (70.2%) died within
one year of diagnosis and 116 cases (21.7%) died in the second year.
Diagnosis and stage of lung cancer
Fifty percent of cases were diagnosed in advanced stage
(36.6% had distant metastasis, 13.1% had regional nodes metastasis). The most
common metastasis site was distant lymph nodes, followed by brain (Table 4).
One hundred and thirty cases (40.7%) were diagnosed by clinical diagnosis and
85 cases were diagnosed by death certificate only. The common cell types were
adenocarcinoma (30.1%) and squamous cell carcinoma (15.7%).
In terms of diagnosis and staging for lung cancer, plain
film chest radiography and computed tomography (CT) of the chest and upper
abdomen including the liver and adrenal glands are necessary. For endobronchial
lesions, pathologic diagnosis can be obtained from bronchoscopic biopsy or
CT-guided needle biopsy. Mediastinoscopy and biopsy of mediastinal nodes are
commonly performed during preoperative assessment of patients with resectable
lung cancer. Pulmonary function tests are utilised to identify patients at high
risk of surgical complications. At present, the routine screening for lung
cancer in heavy smokers using CT scans is not implemented.
Treatment of Lung Cancer
Various platinum-based chemotherapy regimens have been
utilised in combination with radiotherapy. Cisplatin-based chemotherapy
regimens such as cisplatin plus etoposide are commonly used. Other regimens
including carboplatin/cisplatin plus paclitaxel, Cisplatin/carboplatin plus
gemcitabine and Cisplatin plus vinorelbine have also been utilised.
Palliative thoracic radiotherapy is commonly used for
relieving symptoms caused by advanced disease. Various total dose and fraction
arrangements were considered for controlling symptoms: 13 Gy given in 2
fractions, or 8 Gy single-fraction, or 20 Gy over 5 fractions are commonly
used. Whole brain radiation is usually indicated for stage IV non-small cell
lung cancer with intracranial metastases. Prophylactic cranial irradiation is
recommended for small cell lung cancer patients with good response from the
primary treatment. Palliative radiotherapy for bone pain and prevention of
fractures in weight-bearing bones among patients with bone metastasis is
There were 234 new cases of cervix cancer diagnosed in
2005. This was 10.3% of all cancers in females. The age-standardised incidence
rates were 22.7 and tend to be slightly decreased (Fig 7). Cervix cancer was
one of the three most common cancers in females. In 2005, cervix cancer ranked
second after breast cancer. The incidence rates increased sharply after the age
of 25 and were more common than breast and lung cancers in the age group 15-44
years. The mean age at diagnosis was 50.4 years and the median age at diagnosis
was 48 years. The cumulative rate percent to age 75 were 2.3%, representing a 1
in 44 risk for women developing cervix cancer by the age of 75 years.
Screening for cervical cancer uses the Pap test to detect
the presence of premalignant or malignant cells of the uterine cervix. Although
human papilloma virus (HPV) is a major risk factor for uterine cervical cancer,
testing for HPV deoxyribonucleic acid (DNA) is not a component in the routine
screening of cervical cancer in Northern Thailand.
There were 89 deaths from cervix cancer, accounting for
10.3% of all female cancer deaths. The age-standardised mortality rates were
9.3 and tend to be decreased after 1998 (Fig. 8). The mortality rates increased
with age, and increased sharply after the age of 55 years (Fig 9).
Among cervix cancer deaths, 24 cases (27.0%) survived more
than five years, 34 cases (38.2%) survived more than three years and 15 cases
(16.9%) survived less than one year.
Diagnosis and stage of cancer
There were 223 cases of carcinoma in situ of cervix uteri
which were not included in this analysis. The most widely accepted staging
system for cervical cancer is the FIGO (International Federation of Gynecology
and Obstetrics) system. Among the invasive cancers, 112 cases (47.9%) were
diagnosed in localised stage and 6 cases had distant metastasis. The most
common metastasis site was intra-peritoneum seedling. Ninety-eight percent were
histologically diagnosed and the common cell types were squamous cell carcinoma
(79.1%) and adenocarcinoma (17.1%) (table 5).
The patient is staged by physical examination including a
bimanual pelvic examination with attention to parametria and pelvic side walls,
rectovaginal examination, as well as examination of regional lymph nodes.
Imaging studies recommended include chest radiography, intravenous pyelography
(IVP) and computed tomography (CT). In some situations magnetic resonance
imaging (MRI) will help to identify local involvement of the disease, as well
as evidence of metastatic spreading. Cystoscopy or proctoscopy is indicated in
advanced diseases in which bladder and /or rectal involvement are suspected.
Treatment of Cervical Cancer
Surgery alone can be utilised for carcinoma in situ (CIS),
stage IA1-2 and IB1. Primary surgery is often chosen for younger patients to
preserve ovarian function. Surgery is commonly used in conjunction with
chemotherapy and radiation therapy for patients with bulky disease.
Radiotherapy alone can also be used for CIS, stage IA1-2 ,
and IB1 disease but is often chosen for older patients to avoid surgical risks.
Radiation can be delivered with external beam and/or intracavitary approaches.
Postoperative radiotherapy is recommended in patients whose disease exhibits
high-risk features including bulky tumours, lymphovascular invasion, deep
cervical stromal invasion, positive lymph nodes, and positive margins.
Radiation therapy is delivered with concurrent chemotherapy for patients with
stage IB, II, III and IVA cancers.
Current chemotherapy recommendations are platinum-based
regimens. Cisplatin-based chemotherapy concurrent with radiotherapy affords
improved locoregional control and survival and is the standard of care in Northern Thailand.
This study referred to only the northern part of Thailand, However, the data and findings are important for the planning and delivery of the
most appropriate and effective health services for the regional population. The
authors recommended that cancer registry is one of the best methods for
handling cancer problems in Thailand in terms of serving and guiding the health
The authors wish to thank the Chiang Mai Cancer Registry
and Medical records and Hospital statistic section, Maharaj Nakorn Chiang Mai Hospital for their assistance in data preparation.
Figure 1 Age distribution of new cancer cases in Maharaj Nakorn Chiang Mai Hospital, 2005.
Figure 2 Number of new cases of lung cancer by sex, 1996-2005.
Figure 3 Incidence rates of new cases of lung cancer by sex, 1996-2005.
Figure 4 Mortality rate of lung cancer by sex, Chiang Mai, 1996-2005.
Figure 5 Age-specific mortality rate of lung cancer, Chiang Mai, 2005.
Figure 6 Number of new cases of cervix cancer by sex, 1996-2005.
Figure 7 Incidence rates of new cases of cervix cancer by sex, 1996-2005.
Figure 8 Mortality rate of cervix cancer by sex, Chiang Mai, 1996-2005.
Figure 9 Age-specific mortality rate of cervix cancer, Chiang Mai, 2005.
Table 1 Locations of the invasive cancer cases.
Table 2 The 10 leading malignancies in Maharaj Nakorn Chiang Mai Hospital, 2005.
Table 3 Type of Primary Treatment for Cancers in 2004.
Table 4 Histological Cell type and Staging of Lung Cancer
Table 5 Histological Cell type and Staging of Lung Cancer
Chiang Mai Cancer Registry, Annual Report 2004. Volume 24.
Chiang Mai Cancer Registry, Annual Report 2005.
National Statistical Office, Thailand. 2002.
Public Health Statistics A.D.2003 Nonthaburi. Ministry of Public Health, Thailand, 2004.
Sriplung H, Sontipong S, Martin N. Cancer in Thailand 1995-1997. Vol. III. Bangkok: Bangkok Medical Publisher, 2003.
|Received 29 December 2008; received in revised form 21
January 2009, accepted 4 February 2009
Correspondence: Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chiang Mai University, Thailand. . E-mail: firstname.lastname@example.org (Pimkhuan Kamnerdsupaphon).
Please cite as: Kamnerdsupaphon P, Srisukho S, Sumitsawan Y, Lorvidhaya V, Sukthomya V,
Cancers in Northern Thailand, Biomed Imaging Interv J 2008; 4(3):e46