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Mongolia's struggle with liver cancer
World Report
Mongolia’s struggle with liver cancer High rates of hepatitis C and B infection along with widespread alcohol use have left Mongolia with a burden of liver cancer that it is ill-equipped to handle. Ted Alcorn reports from Ulaanbaatar.
www.thelancet.com Vol 377 April 2, 2011
the promise of eliminating the virus in the country’s next generation. But what distinguishes Mongolia from the rest of Asia is the additional burden of hepatitis C, for which no vaccine currently exists. Although
“...dying in a peaceful place and free of pain might be the most that Mongolian patients with HCC can hope for.” unsafe surgical procedures and dental practices are thought to play a part, much remains unclear about the origins of the virus in the country and the mechanisms of its continuing transmission. In the absence of a solid understanding of this epidemiology, the country’s hepatitis C prevalence continues to rise. Alcohol use, which hastens progression to cirrhosis for those with concurrent viral infection, is also widespread in Mongolia, compounding the epidemic. Chronic carriers of either virus are usually asymptomatic for decades but face a great risk of developing cirrhosis and HCC over their lifetimes. So even if new cases of hepatitis in Mongolia are curtailed, the high proportion of people already carrying the viruses portends a sustained increase in the burden of liver disease. “This won’t just last 5 more years”, asserts Tsiiregzen Enkhamgalan, one of a handful of the country’s hepatobiliary surgeons tasked with treating these patients. “We expect 40 more years to face the same conditions.” The global health community has given little attention to liver disease relative to other public health issues, and Mongolia’s experience is no exception. “The utmost priority is given to HIV, TB, and infectious diseases such as avian influenza”, commented Zolbayar Ganbold, an officer in the ministry
of health’s division of international cooperation. “Viral hepatitis and liver disease are very much less targeted.” UN agencies support a set of burgeoning HIV programmes in Mongolia although, as of 2009, the cumulative total of AIDS cases was just 62. And the US Millennium Challenge Account has recently begun supplying substantial funding for non-communicable diseases, but their compact focuses on breast and cervical cancer and makes no mention of HCC. Still poor by global standards, Mongolia is thus in the challenging position of dealing with a heavy burden of non-communicable disease that is more typical of the developed world, and which demands a rich country’s resources and functioning health system. The Mongolian Government is making organisational and strategic changes to improve the early detection and control of noncommunicable diseases, including liver disease, at the primary healthcare level, according to Gombodorj Tsetsegdary, a senior officer in the ministry of health. But such changes will be a challenge, and the extensiveness of the Mongolian countryside is daunting. It is the least densely populated independent
Ted Alcorn
In Mongolia’s National Cancer Centre, an imposing cement structure in the capital Ulaanbaatar, Chantsal was recovering from surgery. A retired radiology technician, it was chance that had brought him in for screening. “It was my children’s vacation so I took them there for a dental checkup, and I just thought that I should do an ultrasound check.” The examination showed a large tumour on his liver. Mongolia has the world’s highest rate of liver cancer mortality—six times the global average—and the number is increasing (figure). Chantsal was a fortunate case; by the time most Mongolians with hepatocellular carcinoma (HCC) are diagnosed, their disease is already inoperable. This was the case for Chantsal’s brother when he developed liver cancer 2 years ago. “He was working in the countryside at that time and the only doctors he had were the soum [district] doctors and then he just died”, Chantsal recalls. The surgeons at the National Cancer Centre, where nearly all the country’s cases are referred after diagnosis, estimate that only 10% of Mongolians diagnosed with HCC are identified early enough to be eligible for surgery. According to WHO, one of every ten deaths in the country is due to HCC or its frequent precursor, cirrhosis. In turn, nearly all Mongolians with liver disease are carriers of hepatitis B or C viruses or both, and researchers agree that those infections are the main causes of liver disease in the country. More than a quarter of Mongolians are chronic carriers of at least one of the viruses, and almost none are aware of their status. Asia has historically been burdened with a high prevalence of hepatitis B, so Mongolia is not an outlier in this respect. A national childhood vaccination campaign, initiated in 1991, has protected younger cohorts and holds
A patient with liver cancer at Mongolia’s National Cancer Centre in Ulaanbaartar
1139
World Report
HCC deaths per 100 000 people
70
World average
63·2
60 50 40 31·6
30·9
30
29·2
28·9
27·2
20
23·5
22·1
21·0
20·4
10
eg al Se n
Ch in a M ald ive s Ca m er oo n
an Jap
Ko re a
bi a lic ub Re p
Th
eG
of
am
an d
qu e bi
ail Th
am oz M
M
on
go lia
0
Figure: Top ten countries with the highest annual mortality rate from hepatocellular carcinoma (HCC) Source: WHO.
country on earth, and 60% of the population resides outside the capital. Even if diagnostics improve, it is not clear what treatments will be readily available. Ideally, carriers of viral hepatitis would be identified and treated long before the infection damaged their livers irreparably. But neither antiviral treatment for hepatitis B nor interferon-based therapy for hepatitis C are presently covered by the national health system, and their high price puts them well out of the reach of most Mongolians. “Treatment is very, very costly”, Tsetsegdari says. “That’s why we don’t have [them].” Even for services that the public system covers, much of the financial burden ultimately falls on patients. In regards to surgery at the National Cancer Centre, Enkhamgalan explains: “the government says...that all costs related to cancer care come from the government. But the government doesn’t give a sufficient amount of money to pay for them.” He estimates that patients must defray about 80% of the cost of imaging tests, surgical equipment, and sutures. Perversely, non-surgical treatments such as radiofrequency ablation or transcatheter arterial chemoembolisation are rarely used because those procedures are not covered by insurance, even though they are less invasive than surgery and are associated with better outcomes for some patients. 1140
In wealthier countries, all these treatments serve primarily as bridges to liver transplantation, but, in Mongolia, they are themselves the last recourse. Some Mongolian doctors dream of beginning a transplant programme in the country, but most acknowledge that it is not realistic in the short term. “[Transplantation] is like the diamond in the crown”, says Voluntary Services Overseas country director Indermohan Narula, who has been a technical adviser to the ministry of health since 1995. “It’s just decorative; it’s too expensive to actually manage.” By necessity, then, Mongolia has turned to palliative care as a final but valuable service for its terminal cancer patients, and with noteworthy success. The National Cancer Centre established a palliative care wing in 2000, but additional policy changes were needed to make the necessary drugs and manpower available. Tserendorj Gantuya, now its chief palliative care physician, began working on the wing 8 years ago. “I always remember how before 2006 it was so difficult, how my job made me so nervous. Every day we received patients with really, really severe pain and we didn’t have any painkillers and the doctors didn’t know how to relieve the pain. And the patient’s caregiver was so nervous because the patient had severe pain and the doctor couldn’t do anything.” Local advocates have managed to integrate palliative care into the national health system with support from outside groups such as the Open Society Institute. In 2005, importation quotas for injectable and oral morphine formulations were greatly increased, and national standards for their use were issued. Reformers also added palliative care to undergraduate medical education and initiated a 4-year course for social workers. The workload of the palliative care wing has expanded, as has their staff. “In 2003, we received only 100 patients a year”, recalls Gantuya. “Now in the inpatient unit alone we see 700 patients, and in the ambulatory
service we see another 14 patients every day.” Where once they employed just two doctors and six nurses, the staff now includes three doctors, 11 nurses, a dietician, a pharmacist, and a social worker. Several private hospices have also sprung up in Ulaanbaatar, mostly run by missionary groups. But these services are few compared with the scale of the country’s needs. Palliative care is not yet widely available outside the capital, so patients often travel great distances for treatment. At Hope Hospice, one such family hovered anxiously around the ashen figure of their father, who was dying of HCC. Herders by trade, they had journeyed more than 1000 km to bring him to Ulaanbaatar for care. Advocates of palliative care hope to soon close some of those gaps. Mongolia’s health insurance law was recently revised to begin reimbursing district hospitals for palliative services so that patients can obtain care closer to home. Cancer Free Mongolia, an organisation founded by first lady Bolormaa Khajidsuren, has since established a model palliative care facility in one of Mongolia’s six districts, and the health ministry has promised to set up similar services in the others soon. And, in March, physicians across the country participated in a formal training on pain management. “Family doctors can prescribe morphine, but they don’t know how to use it so they are anxious”, Gantuya opines. “After the training, I hope they will have more confidence.” For now, though, needy patients outnumber spaces and the palliative care wing must restrict inpatient stays to 10 days. HCC cases fill two-thirds of their beds and, barring a breakthrough in the way that viral hepatitis is diagnosed or treated, conditions are likely to remain this way. For the foreseeable future, then, dying in a peaceful place and free of pain might be the most that Mongolian patients with HCC can hope for.
Ted Alcorn www.thelancet.com Vol 377 April 2, 2011
Mongolia’s struggle with liver cancer High rates of hepatitis C and B infection along with widespread alcohol use have left Mongolia with a burden of liver cancer that it is ill-equipped to handle. Ted Alcorn reports from Ulaanbaatar.
www.thelancet.com Vol 377 April 2, 2011
the promise of eliminating the virus in the country’s next generation. But what distinguishes Mongolia from the rest of Asia is the additional burden of hepatitis C, for which no vaccine currently exists. Although
“...dying in a peaceful place and free of pain might be the most that Mongolian patients with HCC can hope for.” unsafe surgical procedures and dental practices are thought to play a part, much remains unclear about the origins of the virus in the country and the mechanisms of its continuing transmission. In the absence of a solid understanding of this epidemiology, the country’s hepatitis C prevalence continues to rise. Alcohol use, which hastens progression to cirrhosis for those with concurrent viral infection, is also widespread in Mongolia, compounding the epidemic. Chronic carriers of either virus are usually asymptomatic for decades but face a great risk of developing cirrhosis and HCC over their lifetimes. So even if new cases of hepatitis in Mongolia are curtailed, the high proportion of people already carrying the viruses portends a sustained increase in the burden of liver disease. “This won’t just last 5 more years”, asserts Tsiiregzen Enkhamgalan, one of a handful of the country’s hepatobiliary surgeons tasked with treating these patients. “We expect 40 more years to face the same conditions.” The global health community has given little attention to liver disease relative to other public health issues, and Mongolia’s experience is no exception. “The utmost priority is given to HIV, TB, and infectious diseases such as avian influenza”, commented Zolbayar Ganbold, an officer in the ministry
of health’s division of international cooperation. “Viral hepatitis and liver disease are very much less targeted.” UN agencies support a set of burgeoning HIV programmes in Mongolia although, as of 2009, the cumulative total of AIDS cases was just 62. And the US Millennium Challenge Account has recently begun supplying substantial funding for non-communicable diseases, but their compact focuses on breast and cervical cancer and makes no mention of HCC. Still poor by global standards, Mongolia is thus in the challenging position of dealing with a heavy burden of non-communicable disease that is more typical of the developed world, and which demands a rich country’s resources and functioning health system. The Mongolian Government is making organisational and strategic changes to improve the early detection and control of noncommunicable diseases, including liver disease, at the primary healthcare level, according to Gombodorj Tsetsegdary, a senior officer in the ministry of health. But such changes will be a challenge, and the extensiveness of the Mongolian countryside is daunting. It is the least densely populated independent
Ted Alcorn
In Mongolia’s National Cancer Centre, an imposing cement structure in the capital Ulaanbaatar, Chantsal was recovering from surgery. A retired radiology technician, it was chance that had brought him in for screening. “It was my children’s vacation so I took them there for a dental checkup, and I just thought that I should do an ultrasound check.” The examination showed a large tumour on his liver. Mongolia has the world’s highest rate of liver cancer mortality—six times the global average—and the number is increasing (figure). Chantsal was a fortunate case; by the time most Mongolians with hepatocellular carcinoma (HCC) are diagnosed, their disease is already inoperable. This was the case for Chantsal’s brother when he developed liver cancer 2 years ago. “He was working in the countryside at that time and the only doctors he had were the soum [district] doctors and then he just died”, Chantsal recalls. The surgeons at the National Cancer Centre, where nearly all the country’s cases are referred after diagnosis, estimate that only 10% of Mongolians diagnosed with HCC are identified early enough to be eligible for surgery. According to WHO, one of every ten deaths in the country is due to HCC or its frequent precursor, cirrhosis. In turn, nearly all Mongolians with liver disease are carriers of hepatitis B or C viruses or both, and researchers agree that those infections are the main causes of liver disease in the country. More than a quarter of Mongolians are chronic carriers of at least one of the viruses, and almost none are aware of their status. Asia has historically been burdened with a high prevalence of hepatitis B, so Mongolia is not an outlier in this respect. A national childhood vaccination campaign, initiated in 1991, has protected younger cohorts and holds
A patient with liver cancer at Mongolia’s National Cancer Centre in Ulaanbaartar
1139
World Report
HCC deaths per 100 000 people
70
World average
63·2
60 50 40 31·6
30·9
30
29·2
28·9
27·2
20
23·5
22·1
21·0
20·4
10
eg al Se n
Ch in a M ald ive s Ca m er oo n
an Jap
Ko re a
bi a lic ub Re p
Th
eG
of
am
an d
qu e bi
ail Th
am oz M
M
on
go lia
0
Figure: Top ten countries with the highest annual mortality rate from hepatocellular carcinoma (HCC) Source: WHO.
country on earth, and 60% of the population resides outside the capital. Even if diagnostics improve, it is not clear what treatments will be readily available. Ideally, carriers of viral hepatitis would be identified and treated long before the infection damaged their livers irreparably. But neither antiviral treatment for hepatitis B nor interferon-based therapy for hepatitis C are presently covered by the national health system, and their high price puts them well out of the reach of most Mongolians. “Treatment is very, very costly”, Tsetsegdari says. “That’s why we don’t have [them].” Even for services that the public system covers, much of the financial burden ultimately falls on patients. In regards to surgery at the National Cancer Centre, Enkhamgalan explains: “the government says...that all costs related to cancer care come from the government. But the government doesn’t give a sufficient amount of money to pay for them.” He estimates that patients must defray about 80% of the cost of imaging tests, surgical equipment, and sutures. Perversely, non-surgical treatments such as radiofrequency ablation or transcatheter arterial chemoembolisation are rarely used because those procedures are not covered by insurance, even though they are less invasive than surgery and are associated with better outcomes for some patients. 1140
In wealthier countries, all these treatments serve primarily as bridges to liver transplantation, but, in Mongolia, they are themselves the last recourse. Some Mongolian doctors dream of beginning a transplant programme in the country, but most acknowledge that it is not realistic in the short term. “[Transplantation] is like the diamond in the crown”, says Voluntary Services Overseas country director Indermohan Narula, who has been a technical adviser to the ministry of health since 1995. “It’s just decorative; it’s too expensive to actually manage.” By necessity, then, Mongolia has turned to palliative care as a final but valuable service for its terminal cancer patients, and with noteworthy success. The National Cancer Centre established a palliative care wing in 2000, but additional policy changes were needed to make the necessary drugs and manpower available. Tserendorj Gantuya, now its chief palliative care physician, began working on the wing 8 years ago. “I always remember how before 2006 it was so difficult, how my job made me so nervous. Every day we received patients with really, really severe pain and we didn’t have any painkillers and the doctors didn’t know how to relieve the pain. And the patient’s caregiver was so nervous because the patient had severe pain and the doctor couldn’t do anything.” Local advocates have managed to integrate palliative care into the national health system with support from outside groups such as the Open Society Institute. In 2005, importation quotas for injectable and oral morphine formulations were greatly increased, and national standards for their use were issued. Reformers also added palliative care to undergraduate medical education and initiated a 4-year course for social workers. The workload of the palliative care wing has expanded, as has their staff. “In 2003, we received only 100 patients a year”, recalls Gantuya. “Now in the inpatient unit alone we see 700 patients, and in the ambulatory
service we see another 14 patients every day.” Where once they employed just two doctors and six nurses, the staff now includes three doctors, 11 nurses, a dietician, a pharmacist, and a social worker. Several private hospices have also sprung up in Ulaanbaatar, mostly run by missionary groups. But these services are few compared with the scale of the country’s needs. Palliative care is not yet widely available outside the capital, so patients often travel great distances for treatment. At Hope Hospice, one such family hovered anxiously around the ashen figure of their father, who was dying of HCC. Herders by trade, they had journeyed more than 1000 km to bring him to Ulaanbaatar for care. Advocates of palliative care hope to soon close some of those gaps. Mongolia’s health insurance law was recently revised to begin reimbursing district hospitals for palliative services so that patients can obtain care closer to home. Cancer Free Mongolia, an organisation founded by first lady Bolormaa Khajidsuren, has since established a model palliative care facility in one of Mongolia’s six districts, and the health ministry has promised to set up similar services in the others soon. And, in March, physicians across the country participated in a formal training on pain management. “Family doctors can prescribe morphine, but they don’t know how to use it so they are anxious”, Gantuya opines. “After the training, I hope they will have more confidence.” For now, though, needy patients outnumber spaces and the palliative care wing must restrict inpatient stays to 10 days. HCC cases fill two-thirds of their beds and, barring a breakthrough in the way that viral hepatitis is diagnosed or treated, conditions are likely to remain this way. For the foreseeable future, then, dying in a peaceful place and free of pain might be the most that Mongolian patients with HCC can hope for.
Ted Alcorn www.thelancet.com Vol 377 April 2, 2011