In 2020, data from Globocan showed that more than 27,000 patients in Thailand are found to have liver cancer each year, making it the most-frequently diagnosed cancer in the country [1]. Due to gaps in surveillance, diagnostic and treatment services, many patients only discover their condition at advanced stages when the only available option is palliative care.

Hepatocellular carcinoma (HCC) and cholangiocarcinoma are the dominant histological subtypes of primary liver cancer found in the country, albeit for very different reasons. Historically, higher incidences of cholangiocarcinoma were found in Northeast regions such as Esan and were linked to the ingestion of liver fluke parasites during the consumption of fermented river fish. As Northern Thais travelled in search of employment, this incidence and disease risk gradually spread throughout the country. In recent years, alcohol consumption has also become an emerging risk factor for liver disease and cancer in Thailand as well.

As managing liver disease continues to be a serious challenge for the Thai Ministry of Public Health (MoPH), the Lab Insights team spoke with Dr Terachai Songkiatkawin, a surgical oncologist and co-president of the MoPH’s cancer service plan, to learn more about the policy trends and strategies for improving liver cancer care in the country.

How has Thailand’s universal healthcare scheme (UCS) improved cancer outcomes?

In the decade since it was implemented, the UCS has improved medical advances, patient outcomes, and lifespan longevity, while relieving the burden of expenses and accelerating access to lifesaving services. In breast, colon and cervical cancers, the UCS has provided nationwide access to screening programmes and therapies, even in rural areas.

Can you describe the available screening programmes for liver cancer?

Thailand currently has a trend of late-stage liver disease diagnosis and management, mainly because there are no liver cancer screening programmes to raise awareness or identify patients early, even though the UCS should cover cancer care expenditures, from screening to treatment. Preliminary discussions are underway on providing rural areas with interventional radiology equipment, but interventions and MoPH policies have not been implemented yet for the various Thai provinces.

Screening or surveillance are only implemented if both prove to be clinically and financially effective and efficient. While cervical cancer screening is available by Pap smears and human papillomavirus tests, and colon cancer screening is provided with faecal immunochemical tests, there are no equivalent diagnostic tools for liver cancers, for which diagnosis still relies on CT and MRI scans.

How do Thai MoPH policies address the differences in healthcare resources and risk factors between provinces?

Factors that contribute to the high incidence of new cases and mortality in liver cancer include an unequal distribution of health care specialists and infrastructure in rural areas, with caseloads being far higher in government hospitals managed by the MoPH. To address this, the MoPH is improving coverage planning, but until then, specialists like hepatosurgeons, or resources and facilities like interventional radiology equipment, are available mostly in large cities, at Centres of Excellence, and tertiary care or large hospitals, many of which are difficult to access for poor, rural patients.

Currently, the MoPH works with healthcare practitioners at the hospital level to roll out health service plans and reduce unequal access to care. For advanced HCC patients who need more effective treatments, it is beneficial to adopt interventional radiology treatments. Thailand’s hepatitis surveillance and vaccination programme has been successful in lowering HCC risks, showing how important it is to target high-risk patients and focus on engaging them.

What health plans or social welfare schemes are currently in place to help Thais manage the financial burden of liver cancer, whether they are diagnosed early or late?

Ironically, given the late-disease stage at which most Thais find out they have liver cancer, only minimal treatment is needed, and they therefore have no financial burden. To improve the trajectory of the disease, interventional radiology treatments are needed, but this tool and certain drugs cannot be reimbursed yet and remains unaffordable for most Thais.

This is a challenge for future planning by the MoPH, as the UCS currently only reimburses basic or core treatments, not advanced treatments. Patients are therefore still reliant on welfare schemes, social security and voluntary health care. With increasing annual treatment costs, especially in cancer, the MoPH hopes to launch policies to increase public awareness of cancer prevention or early screening for liver cancer.

Crucially, investigations and tests are needed but funding such programmes is an obstacle for the government. Comprehensive health economics data may provide a better understanding of the situation and exactly what types of interventions or tools must be included in nationwide UCS policies. The MoPH can then combine existing tools, national guidelines and health economics data to allocate budgets for the screening and prevention of liver disease at all hospitals, even those in rural areas.

Are there digital tools or monitoring apps used in healthcare centres to manage liver disease and to connect doctors, patients and healthcare systems?

Digital applications do exist for COVID monitoring in Thailand but not for liver cancer or disease. Even though doctors want digital tools for the general public, their use is limited by who will benefit from these tools. Further planning and pilot studies on the use of such applications for liver disease are needed before they can be launched nationwide.

What does the future of liver cancer screening in Thailand look like to you?

Collaborations between Thailand’s MoPH and healthcare practitioners will be needed in the future to ensure an equitable standard of care. In fact, updated medical guidelines now recommend using primary detection of a biomarker (alpha fetoprotein) plus ultrasonography for HCC surveillance in high-risk groups, as current systems are not sensitive enough, and more sensitive HCC screening or surveillance tools are difficult to find. Doctors have suggested using newer biomarkers (e.g. AFP-L3) and scoring systems (GALAD) for early screening, and such suggestions may change future guidelines in Thailand.

The MoPH understands that raising public awareness is an important health strategy and has adopted digital and mobile apps for breast cancer self-assessment and COVID-19 disease tracking. These user-friendly tools have effectively driven health awareness of those diseases and can do the same for liver cancer and HCC, but their true benefits and cost-efficacy will need to be validated first.

References:

[1] WHO International Agency for Research on Cancer Thailand Fact Sheet