Mongolia's struggle with liver cancer

[Guest guest]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960448-0/fu\

lltext?elsca1=TL-010411 & elsca2=email & elsca3=segment

The Lancet, Volume 377, Issue 9772, Pages 1139 - 1140, 2 April 2011

doi:10.1016/S0140-6736(11)60448-0

Mongolia's struggle with liver cancer

Ted Alcorn

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.

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 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 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 non-communicable

diseases, including liver disease, at the primary health-care 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 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.

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.

[Guest guest]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960448-0/fu\

lltext?elsca1=TL-010411 & elsca2=email & elsca3=segment

The Lancet, Volume 377, Issue 9772, Pages 1139 - 1140, 2 April 2011

doi:10.1016/S0140-6736(11)60448-0

Mongolia's struggle with liver cancer

Ted Alcorn

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.

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 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 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 non-communicable

diseases, including liver disease, at the primary health-care 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 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.

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.

[Guest guest]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960448-0/fu\

lltext?elsca1=TL-010411 & elsca2=email & elsca3=segment

The Lancet, Volume 377, Issue 9772, Pages 1139 - 1140, 2 April 2011

doi:10.1016/S0140-6736(11)60448-0

Mongolia's struggle with liver cancer

Ted Alcorn

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.

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 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 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 non-communicable

diseases, including liver disease, at the primary health-care 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 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.

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.

[Guest guest]

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960448-0/fu\

lltext?elsca1=TL-010411 & elsca2=email & elsca3=segment

The Lancet, Volume 377, Issue 9772, Pages 1139 - 1140, 2 April 2011

doi:10.1016/S0140-6736(11)60448-0

Mongolia's struggle with liver cancer

Ted Alcorn

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.

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 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 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 non-communicable

diseases, including liver disease, at the primary health-care 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 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.

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.