Regional Health Forum

Regional Health Forum WHO South-East Asia Region Volume 8 Number 1, 2004

Women’s Health

Geographical Distribution and Utilization of
Mammography in Thailand

By Weerasak Putthasri*, Viroj Tangcharoensathien*, Suwanna Mugem*, Wongdoen Jindawatana*

Introduction

Cancer has, from time to time, ranked as either the second or the third cause of mortality in Thailand since 1977, followed by heart diseases and accidents.(1) In 1993, the National Cancer Institute (NCI), which is responsible for cancer prevention and control, estimated some 64 000 new cases of cancer. Three of the best-known cancers occurring in men are liver, lung and colo-rectal, whereas in women, the highest-occurring cancers are cervix, breast and liver. These cancers are also a significant burden on public hospitals.

The data collection of cancer incidence rates in Thailand was passive and relied upon notification from hospitals in Bangkok, Chiangmai, Lampang, Khonkaen and Songkhla. Breast cancer was the second most frequent cancer in women, after cervical cancer.(1) The estimated incidence was 16.3 per 100 000 women, rather higher than the rate in 1990. The incidence was the highest in Bangkok, followed by Chiang mai, Lampang, Songkhla and Khonkaen, respectively. Breast cancer was very rare in Thai men. The age-specific incidence showed a rise to the maximum around the age of 50 years, with a plateau or even a small decline in risk at older ages. Changes in the population age-component and lifestyle might have led to the higher incidence of breast cancer.

Although breast cancer ranked second in Thai women and could be predicted and detected early, the concentration of treatment was on management and care systems. Breast self-examinations were and are promoted, but anecdotal observations found that Thailand performed poorly in research and prevention, including primary and secondary prevention of breast cancer. The cancer registry data revealed a high prevalence of late-stage disease at diagnosis, with 56% of patients receiving treatment at Stages III and IV.(2) Moreover, the majority of resources were allocated to curative care that required a lot of investment, and the poor return in benefits put a heavy financial burden on the public health system.

The poor outcome of breast cancer care was influenced by: the lack of people’s self-awareness resulting in their arrival at treatment facility at a late clinical stage; the scarcity of basic screening equipment, and the poor allocation of mammogram facilities. To improve breast cancer care and management in Thailand, it would be very useful to evaluate the feasibility of using mammography screening at the macrolevel.

“Breast screening” is a method of detecting breast cancer at a very early stage. There are three ways: BSE, clinical breast examinations (CBE), and mammography. The best time for BSE is about a week after the end of the period”, when breasts are not tender or swollen. If a woman’s “periods” are irregular, she performs BSE on the same day every month. A woman or her sex partner often discovers breast lumps. Most are not cancerous, but anything unusual should be reported to a clinician as soon as possible. CBE is an examination of breasts by a health care professional, such as a doctor, nurse practitioner, nurse, or a doctor’s assistant. During the CBE, it is a good time for the health care professional to teach breast self-examination to a woman who does not already know how to examine her breasts. A mammogram is an X-ray of the breast, which is taken while carefully compressing the breast. Most women find it a bit uncomfortable and a few find it painful. The mammogram can detect small changes in breast tissue, which might indicate cancers that are too small to be felt either by the woman herself or by a doctor.

An appropriate breast cancer screening programme could improve both the recent prevalence of breast cancer and improve treatment results.(3) Regular screening is an important preventive method in reducing morbidity and mortality from breast cancer. Unfortunately, only 37% of Thai breast cancer patients practise BSE, while 51% of them are aware of breast cancer(2). The majority of Thai women are unable to perform BSE from shyness. Results show that after BSE instruction, 72.27% are able to perform BSE, 1.85% are unable, and 25.95% are uncertain. Of the total participants, 49.07% practised BSE monthly and 44.44% occasionally. However, it was believed that results of the nationwide BSE programme would reflect in improvements in the 5- and 10-year survival rates of breast cancer patients in Thailand.(4) Improvement in long-term survival depends not only on improvement of the modality of treatment but also on how early the stage is at first treatment. In a retrospective study of 1,176 breast cancer patients from 1977-1985, the incidence of early stage in each of the periods: 1977-1979; 1980-1982, and 1983-1985 were: 44.65%; 46.34%; and 59.24% respectively. The increase in cases of diagnosis in early stages at first treatment reflected the results of public education on cancer and the early detection programme.(5).

This paper aims to assess the geographic distribution of mammogram facilities and their utilization among public and private institutes in Thailand. The appropriateness of human resources, basic equipment allocation and utilization of mammography in screening breast cancer are also explored.

Methodology

We collected data on distribution of mammogram facilities from the Department of Medical Sciences (DMSc). The DMSc had compiled the data on Mammogram facilities in both public and private providers since 1988. For radiological safety reasons, both public and private medical institutions are required to register radiological medical devices with DMSc.

We also compiled the data from the Thai Medical Council database on the number of radiologists registered with the Council. At the same time, a self-administered mail questionnaire survey was launched to all public and private institutions having mammogram facilities. The questionnaire asked about human resources, staff workload, and utilization of mammo-grams for breast cancer screening for three retrospective years. The questionnaire survey was conducted from October 2001 to September 2002. Open-ended questions were allowed to depict problems in providing service and management. Finally, a work-shop among key stakeholders was held on 24-25 June 2003 to set criteria and frame guidelines for national policy on early detection of breast cancer. Baseline data were presented and a small group discussion was organized. The workshop was partici-pated by 36 experts from MoPH, National Cancer Institute, regional cancer centres, provincial hospitals and the university.

Results

1. Distribution of Mammograms and radiologists

Since 1988, 139 mammogram facilities had been installed, with 60% distributed in private hospitals and the remainder in public hospitals. The cumulative number of installed mammogram facilities increased continuously from 1988 until 1997-1998. In 1998, one year after the economic crisis, only five new machines were installed. Since 1999, how-ever, the number of mammogram facilities has risen again, though slightly.

Figure 1 Cumulative number of mammograms during 1988-2002, Thailand

The distribution of facilities was concentrated mainly in Bangkok (50.36% of total mammograms), whereas the lowest was in the north (5.04%). For every one million females aged over 35, 41.8 mammograms were performed, 2.8 in the north and 4.0 in the northeast. As a regional comparison, if an index of 1 is assigned to the lowest ratio of mammogram to million populations in the north, the discrepancy index¹ in Bangkok is 15.1. In the other words, the gap of discrepancy index in Bangkok was 15.1 times that in the north. The nation-wide index was 3.9 (Table 1).

Mammogram facilities were distributed in only 30 provinces; the other 46 provinces were not provided with a single facility. The top three ranking provinces with mammo-gram facilities were Bangkok, Chonburi and Songkhla with 70, and five machines each, respectively.

2. Equipment utilization

A structured questionnaire was distributed to all 120 hospitals where a mammogram machine was installed. The response rate was 53%; 64 hospitals returned the question-naires. Most hospitals had one mammogram machine. Only four hospitals in Bangkok had more than one mammogram machine. Lorad, GE, and Toshiba were the most common brands of mammogram machines used by hospitals; the respective percentages of utilization were: 25.7%; 22.9%, and 11.4%. The average price of 63 mammo-gram machines was 3.6 million Bahts. The average user fee for public mammography service was 1 411.04 bahts. Private hospitals charged a user fee of 1 700.31 bahts; this was higher than that charged by public hospitals (p-value=0.000).

In terms of utilization, the average case-load per annum was quite stable at 1 029, 1 022, and 1 082 cases in 1999, 2000 and 2001 respectively, with a very large range of case-loads (Table 4). The public hospital case-load was much higher than that for private hospitals.

Table 1.Mammogram diffusion in Thailand, 2002

Table 2.Price of mammogram machines installed by type of hospital, Thailand, 2002

Table 3. Mammography service fee by type of hospital, Thailand, 2002

Table 4.Average mammography utilization by hospital type, year, Thailand, 2002

*mammography shots mean number of films or positions to take radiation; users usually take four shots each.

3. Human resources

In 2002, there were 682 radiologists (403 general radiologists and 279 diagnostic radiologists) throughout the country. However, half of them worked in Bangkok. There were 63 provinces with at least one radiologist. This meant there were 13 provinces without any radiologist. The capacity of Thai postgraduate training of general and diagnostic radiologists was less than 100 per year in seven training institutes (teaching hospitals). As for main health personnel required for mammography provision including radiologists and technicians, 55 hospitals (90.2%) had full-time radiologists.2 Full-time technicians were available in 49 hospitals only because some hospitals used other personnel instead of trained technicians, such as nurses or trained assistants. Most part-time radiologists and technicians were in private hospitals.

4. National guidelines on breast cancer screenings

Finally, at the workshop held in 24-25 June 2003, the main conclusions drawn were: the BSE programme was an important strategy to increase awareness for women aged 20+; CBE was recommended annually for women aged 35+; doctors or well-trained nurses were needed at primary care unit, and mammography was recommended for women in the risk category: age 40+.

Conclusions and discussion

The first mammogram machine was introduced and installed in 1968 at the National Cancer Institute. The number of machines rose significantly between 1995 and 1997.(6) After 1997, the rate of increase of mammogram machines temporary slowed down as a result of the economic crisis, but recovered a few years later. Consequently, the rate of increase in the public sector was higher than in the private sector.(6) Of the total 139 mammogram machines in Thailand, their distribution was concentrated in Bangkok, 50.4 percent, which changed slightly from 1999 with 112 mammograms, 54.5% in Bangkok.(7) The discrepancy index in Bangkok was 15.1 times that in the north. The nationwide index was 3.9. Such indices showed the inequity of technology distribution. However, the data on number and distribution of mammogram machines and radiologists were collected from secondary sources. The study validity depended on official reports, which however could not indicate exactly the number of machines which were still in use or out of order.

It was quite clear that the distribution of both machines and personnel was poor. In addition, problems highlighted by radiologists or heads of mammogram units who responded to our questionnaire indicated that a well-organized system of specialized and regular maintenance of machines was required to maintain the quality of output. All categories of personnel needed continuous training to keep abreast of techniques and medical advancements. High demand for screening and limited services resulted in a long waiting time especially in the public sector, whereas most private providers seemed underutilized because of the high cost of their services, and because they are seldom covered by insurance schemes.

The Civil Servant Medical Benefit Scheme, for instance, is considered one of the most generous health benefit and insurance schemes in the country but does not cover mammography.(8) As a result, unit costs might be high and cost recovery points would not be met. On the other hand, the observed number of shots per patient was much higher in public than in private hospitals; this might reflect the quality of services. On issues of case-load, overload and underutilization, regulations on import and distribution of machines should be implemented in both public and private sectors to encourage efficiency at the macro level. As for policy issues, it is not clear if mammography can decrease mortality rates of breast cancer since diagnosis depends on the processing of mammography and interpretation of images. Further study and randomized clinical trials to determine effectiveness and costs in are needed.

In addition, the barriers to access to mammography should be studied from the patient’s point of view, such as awareness and mammography fees, as well as psychological and cultural barriers, such as fear of cancer, fatalistic views on cancer, and culturally-based embarrassment.(9) Positive cues to undergo screening include physicians recommendation, community outreach programmes with the use of lay health leaders and use of culture-specific media.(9) From the provider’s side, such issues as overloaded capacity in some providers but underutilization in other providers and break-even point of services should also be explored.

It is not very difficult to rapidly improve the maldistribution of mammogram machines to match the provincial prevalence. A group of neighbouring provinces could share one mammogram machine through efficient referrals. However, it is quite difficult to re-allocate human resources especially radiologists. This requires long-term human resource planning. We recommend improving the current under-utilization of private mammogram facilities, through the purchase of services by public insurance schemes. Increase in public awareness on breast cancer would promote BSE and CBE and ensure early detection and better outcome of breast cancer treatment.

Acknowledgements

The country office of the World Health Organization (WHO), in Thailand and Thailand Research Fund (TRF) supported this study. We are grateful for the cooperation received by us from many hospitals, the Ministry of Public Health and the Thai Medical Council. We also appreciate the help of officials who provided us with special data that were most helpful, including directors and officers of all hospitals who provided the cost and utilization data. We are very grateful to Dr Somkiat Phothisat and Dr Busanee Wibulpolprasert who provided helpful suggestions. Finally, the writers also appreciate the hard work put in by the members of the study team.

References

1.      Deerasamee S. Cancer in Thailand Vol. II, 1992-1994: Cancer Research Foundation for Cancer Institute, Thailand; 1999.

2.      Thongsuksai P, Chongsuvivatwong V, Sriplung H. Delay in breast cancer care: a study in Thai women. Med Care 2000;38(1):108-14.

3.      Vatanasapt V, Sriamporn S, Vatanasapt P. Cancer control in Thailand. Jpn J Clin Oncol 2002;32 Suppl:S82-91.

4.      Runkasiri P. Evaluation of the Breast Self-Examination Instruction among Thai Women. Thai Cancer J 1986;12:112-117.

5.      Thanapoom W. The Association between Incidence of Breast Cancer and Period of Time at Siriraj Hospital. the Thai J of Radiology 1991;28:87-93.

6.      Jindawatana W. Utilization and Cost Recovery of Mammography at National Cancer Institute, Thailand: Faculty of Economics, Chulalongkorn University; 1999.

7.      Wibulpolprasert S. Thailand Health Profile 1999-2000. 1 ed. Nonthaburi: Printing Press, Express Transportation Organization; 2002.

8.      Pramualratana P. WS. Health Insurance System in Thailand. 1 ed. Nonthaburi: Health System Research Institute; 2002.

9.      Austin LT, Ahmad F, McNally MJ, Stewart DE. Breast and cervical cancer screening in Hispanic women: a literature review using the health belief model. Women's Health Issues 2002;12(3):122-8.