Oncology in Cambodia Free

Cambodia, located in Southeast Asia, is a country of 14 million inhabitants. Since 1975, during the Khmer Rouge period and thereafter, several tragedies have occurred within the population and more than 2 million people died. All structures of care were abandoned and looted. All doctors and nurses – except for fewer than 30 of them – were killed. At the end of the 1990s, hope came again with peace. First level of care and training of new doctors were the priorities of the authorities. Because of the increase in chronic diseases, especially cancer due to the increase in life expectancy and carcinogenic exposure, the Government of Cambodia became interested in the fight against cancer. Before 1975, there was a department of radiotherapy functioning with a Khmer doctor trained in France, the former colonizing country. The department, located in the Khmer-Soviet Friendship Hospital in Phnom Penh, the capital of Cambodia, was equipped with a cobalt unit machine and brachytherapy equipment. The department was the only one of its kind in Cambodia. After the Khmer Rouge period, the radiotherapy department was looted, only walls remained. The cobalt machine disappeared, as did the cobalt radioactive source and the other radioactive source used for brachytherapy. In 2005, the radioactive sources were discovered by chance, buried underground, close to the radiotherapy department. It was possible to extract the radioactive needles but the cobalt source could not be extracted and is now protected by layers of lead and concrete (fig. 1).

Cambodia has neither a cancer registry nor correct mortality statistics. Epidemiologic data about Cambodia are known due to the GLOBOCAN program from IARC (International Agency for Research on Cancer) [1], which estimates incidence and mortality from closer countries and Cambodian hospital statistics (fig. 2). Cancer incidence is approximately 153/100,000 for males and 123/100,000 for females. For men, liver cancer ranks first (20% of all male cancers), followed by lung cancer (18%), gastric cancer (11%), colorectal cancer (9%) and lymphoma (6%). For women, cancer of the cervix uteri ranks first (25% of all female cancers), followed by breast cancer (19%), lung (7%) and liver cancer (6%). The incidence of cervical cancer is one of the highest in the world (27.4/100,000), with an incidence/mortality ratio of 0.55. Cancers are seen at stage 3 or 4 in 70% of patients.

The radiotherapy department, located in one of the three main public hospitals (fig. 3), was rehabilitated in 2003 by the Ministry of Health of Cambodia with the help of three French Non-Governmental Organizations (NGO), Physicien Médical Sans Frontières (Medical Physicist Without Borders), Cancérologues Sans Frontières (Oncologists Without Borders) and Energie Sans Frontières (Energy Without Borders), which received an important grant from the French Ministry of Foreign Affairs (USD 400,000). The local French cooperation in Phnom Penh was involved in the project. Refurbished second-hand machines (cobalt unit, X-rays simulator and 2D dosimetry systems) and a new remote afterloading brachytherapy machine were brought from France. Six doctors (radiation oncologists, medical oncologists and one surgeon) and two physicists were trained in France for 1 year. Nurses and radiographers were trained on site by numerous missions done by French doctors and physicists who also performed quality control on the treatments and on the machines. The radiotherapy department is the only one in Cambodia which treats patients by radiotherapy and chemotherapy. This department is a public one; there are no other private hospitals treating patients with radiotherapy or chemotherapy. Surgery is performed in public and in private hospitals. Very few surgeons are specialized in oncology; they have been trained in France and in Belgium. There is no thoracic surgery in Cambodia. Until now, there is no hematology department, high-dose chemotherapy cannot be performed and, for instance, lymphoma patients can be treated only by low-dose chemotherapy. There is no oncopediatric unit. A new national cancer center will be built in the near future (2013) in another public hospital in Phnom Penh. This center will be a teaching hospital and will be equipped with two linacs, a high dose brachytherapy system, and a medical and a hematology department. At this moment, imaging machines for diagnosis are scarce. There are only eight CT scanners, two MRI machines and four mammography machines in all of Cambodia. There is no nuclear medicine department; one is planned for the future National Cancer Center. There are only 8 pathology centers in all of Cambodia. There is no biology center specialized in hematology and solid tumors. There is no palliative care unit.

The priorities of the Cambodian Ministry of Health are mother and child care and the fight against communicable diseases, especially AIDS. There is not any organization against chronic diseases, especially cancer, and no cancer plan. All the care – diagnostic imaging and treatment – must be paid for by patients. There is no health insurance; some tests are underway using microcredit for poor people to allow them to receive basic care.

The high incidence of liver cancer is linked to viral infection by hepatitis virus B and C. Among a sample of the Cambodian population with high levels of transaminases, the prevalence of the virus, measured by the level of antibodies, is 41% for hepatitis B and 39% for hepatitis C. Virus B infection is more frequent among the young population; virus C infection is more frequent in the older population [2]. A national vaccination program against hepatitis B for the newborns was established in 2006. Smoking prevalence is high, especially in the male population. Even though the Cambodian State has signed the WHO chart against tobacco, few actions have been taken. There is no restriction of publicity imposed on tobacco companies. Despite the very high incidence of cervical cancer, there is no organized screening. Some pilot studies with Papanicolaou tests have been done with no clear results. A new pilot study is under discussion with Cambodian doctors and international experts. Visual inspection with acetic acid was the technique chosen since there are no cytotechnicians and numerous logistic problems (transportation of slides after the Papanicolaou test/providing information on test results to the women). Cervical cancer prevention by vaccination will show interesting findings. An unpublished study shows that HPV 16 prevalence is about 70% among cervical cancer. In Thailand, which is on the border of Cambodia, the HPV 16 and 18 prevalence is 73.8% [3]. We can imagine that a vaccination correctly administered would prevent 70% of cervical cancer. Some occasional vaccination campaigns for small selected populations have been done (young girls and children from the staff of public hospitals in Phnom Penh). There is no breast cancer screening but the Ministry of Health is trying to inform women about self-palpation and to see a doctor or a midwife at the local hospital in case of abnormalities.

A multidisciplinary approach for gynecologic, gastrointestinal (GI), thoracic, head-and-neck and neurologic tumors have been organized but attendance of meetings to discuss each case is irregular due to busy doctor schedules. Guidelines were discussed and written for cervical cancer, breast cancer, some digestive cancers, head-and-neck cancers and lymphoma. Nevertheless, it is difficult to know if the guidelines are in application. The difficulties for cancer care are due to the lack of good hospitals, equipment, specialized doctors (only five oncologists, very few surgeons trained in oncology and few doctors in any other kind of specialty), other cancer centers, and limited knowledge of cancer treatment among general practitioners and fear of cancer among the general population. Costs of imaging, biology and treatment are also a difficulty for the majority of the population, which is poor (earns less than USD 2 per day). CT scans cost USD 150, a mastectomy costs USD 250, a radiotherapy treatment costs USD 240–300 (USD 12 per session), chemotherapy costs USD 20 plus cost of drugs (e.g. Cytoxan 500 mg costs USD 10 and cisplatin USD 13). Antimitotics and hormonal treatments are more often generic products made in India. These costs are limiting the access to new drugs, especially targeted drugs. Poor people have difficulty obtaining treatment even though the NGO pays for them and, ethically, the oncology department should spare 10% of their resources to take care of very poor patients. Because of the lack of good hospitals and equipment, rich patients go to Thailand or Vietnam to be treated. Presently, the Oncology Department at the Marie Curie Oncologic Center treats about 60 patients per day with radiotherapy and 20 with chemotherapy.

The first oncologist was first trained in Vietnam and thereafter in France. Because of the lack of any medical specialty taught in Cambodia, a university diploma was organized in 2006 at the public University of Phnom Penh, which offered a 2-year program whereby general practitioners could obtain a degree in oncology. The program was supported by two French professors from Strasbourg University, who came on site during several 5-day periods. Five oncologists received training, including a 1-year residency program abroad at French comprehensive cancer centers and university hospitals. They also attended courses at French universities. Other missions were completed by French oncologists and physicists in the Cambodian oncology department from 2003 to 2012 to train local doctors and nurses and do quality control in clinical oncology and treatment administration. Surgeons were trained in France (gynecology, head and neck and GI tract) and in Belgium, especially for GI cancer surgery at the Gent University. Two engineers were trained as physicists during 1 year in medical physics and radioprotection in France. Other specialists (pathology/radiologic imaging) were trained in France and in Belgium. In 2010, some medical specializations were created to train on site at the University of Phnom Penh, among them oncology, which is recognized as a full specialty due to the needs of the country. A position for a full professor in oncology was created and occupied by the first author of this article. The new oncology specialization which began in 2011 will take 5 years, among them 1 year in a foreign country. Cooperation with foreign countries, especially France, has established. Contacts have been made with Vietnamese oncologists. Furthermore, some Cambodian oncologists attend international meetings, especially in Southeast Asia and the Far East. Palliative care teaching is performed at two hospitals and at the University by a French NGO, Douleur Sans Frontières (Pain Without Borders).

Future development in oncology is linked to the economic development of Cambodia, increase in the standard of living of all populations and the launching of a health insurance program to cover basic needs in medical care. The future National Cancer Center in Phnom Penh will be the place to train oncologists who will subsequently work at new centers in other parts of the country. The development of other medical specialties linked to oncology is mandatory: for instance, there is only one young surgeon able to perform surgery for head-and-neck tumors. The development of modern hospitals is necessary because, until now, the conditions of operating rooms and wards in and outside of Phnom Penh have been poor. Foreign resources are necessary for training, medical structures and organization. Prevention and screening must be developed. The same goes for epidemiology with the creation of a population cancer registry in a defined area for example. Psychosocial oncology must not be forgotten: as a first step, volunteers, e.g. Cambodian psychologists who went abroad before the Khmer Rouge period and are now pensioned, can come home to help until the local training of sociopsychologists could be completed.

After the Khmer Rouge period, Cambodia had neither doctors nor oncology facilities. It was necessary to build a new medical system, especially in oncology, with corresponding structures, well-trained medical staff and an educational program in all fields of oncology. This is occurring slowly due to the shortage of money for Cambodian institutions and the lay public. Foreign aid will be necessary to help the Cambodians reach the goal of proper oncology care.

The authors have no conflict of interest.