马学真在国外发表的论著 《中国癌症治疗现状》Cancer care in China: A general review

Available online at http://www.biij.org/2008/3/e39doi: 10.2349/biij.4.3.e39biij Biomedical Imaging and Intervention JournalREVIEW ARTICLECan

正文

Available online at http://www.biij.org/2008/3/e39
doi: 10.2349/biij.4.3.e39
biij Biomedical Imaging and Intervention Journal
REVIEW ARTICLE
Cancer care in China: A general review
XJ Ma1, MD, C Lin2, MD, W Zhen2,*, MD
1 Department of Radiation Therapy, Qingdao Tumor Hospital, Qingdao, China
2 Department of Radiation Oncology, University of Nebraska Medical Center, Omaha Nebraska, United States
Received 20 August 2008; accepted 21 August 2008
ABSTRACT
This article is to provide a general overview of cancer in China including the statistics, most common cancers, their
epidemiological characteristics and the treatments. © 2008 Biomedical Imaging and Intervention Journal. All rights
reserved.
Keywords: Cancer care, China
CANCER STATISTICS IN CHINA
The most recent epidemiological data has shown
that over 2.2 million new cancer cases (1.4 million in
men, 0.8 million in women) are diagnosed in China each
year and approximately 1.6 million of the cancers result
in mortality. Over the last 20 years, the cancer-related
mortality rate has risen by 30%, which constitutes 25-
35% of all deaths. From 2000 to 2005 alone, the total
number of new cases increased by 14.6% with the most
common sites being lung, liver and stomach in men, and
breast, lung and stomach in women primarily as a result
of population growth and aging [1]. In addition, the
rising rates of lung cancer incidence (in both sexes) and
breast cancer mean that there will be much greater
increases in the number of cases at these two sites (27%
for lung cancer in men, 38% for lung and breast cancer
in women). Cancer has become the number one cause of
death in China [2].
As of the end of 2006, there are 104.2 million
people who are 65 years or older, constituting 7.9% of
the entire population in China. At present, China also has
20% of the world’s population older than 60 years old,
which has surpassed 150 million. China has become one
of the aging countries, with the fastest growth and the
largest aging population in the world. This is one of the
major reasons for rising cancer incidence in China.
In urban populations, the leading causes of death are
as follows; cancer, cerebral vascular accidents,
cardiovascular, pulmonary, injury and poisoning,
gastrointestinal, endocrinological and metabolical,
urological, and psychiatric disorders. Although over the
last five decades the overall cancer incidence has
continued to climb, this trend is not observed in all types
of cancers. What used to be the most common cancers
such as gastric, cervical, penile, oesophageal and
nasopharyngeal cancers have declined in various degrees,
whereas lung, breast, colon, and prostate cancer rates
have increased significantly (Table 1). This kind of shift
in cancer rates is more evident in more developed coastal
cities, which likely is due to the changes in lifestyle and
diet (Table 2).
The top five most common malignancies in China
are lung, liver, gastric, oesophageal and colorectal
* Corresponding author. Present address: 987521 Nebraska Medical
Center, Omaha, NE 68918-7521, United States.
E-mail: wzhen@unmc.edu (W. Zhen).
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cancers. The mortality of lung cancer has increased every
year. For example, in Beijing, lung cancer death
constitutes one-quarter of all cancer-related mortalities.
According to the Initiative of Promoting Healthy Living
in China (Cancer 2006), the mortality rate of lung cancer
in China may exceed one million by 2025.
The main reasons for such a high lung cancer
mortality rate in China are the following:
● Lack of awareness of lung cancer
● Lack of effective screening tools for early
detection. Approximately 80% of lung cancers
in China are advanced stage disease at the
diagnosis
● Lack of access to health care
● Lack of health insurance and resources
● Lack of scientifically sound comprehensive
care. It is estimated that about one-third of lung
cancer patients may have died from inadequate
or inappropriate therapies in China.
THE CAUSE AND AETIOLOGY FOR COMMON CANCERS IN
CHINA
Lung cancer
● Tobacco use and inhalation of second hand
smoke have clearly become the main causes of
lung cancer.
● Rapid growth of aging population
● Rapid industrialisation and westernisation of
cities
● Rapid urbanisation of rural communities
● Worsening pollution, especially air and water
pollution
● Unhealthy lifestyles
The risk factors of lung cancer in China:
Smoking: China is the largest producer of tobacco
products in the world; 2.5 times more than that of the
United States, which is the second largest producer.
China is also the largest consumer of tobacco in the
world. The smoker population in China is estimated to be
over 350 million. As many as 540 million Chinese are
exposed to second-hand smoke, of which 180 million are
under the age of 15 years, according to a national
tobacco control report released on May 29, 2007 by the
Ministry of Health of China. Women and children are
most vulnerable to second-hand smoke with the smoking
rate among men reaching 57%. Ninety percent of the
women are exposed to second-hand smoke at home.
There has been no collective effort to curtail the use of
tobacco products. In 2005, cigarette sales generated
US$32.5 billion in taxes and profits in China,
approximately 7.6% of the government's total revenue
[3]. It is suggested that close to 90% of lung cancer
mortality is due to cigarette smoking or inhalation of
second-hand smoke. The link is even stronger in elderly
smokers. The chance of dying from lung cancer in male
smokers is eight- to 20-fold that of non-smokers. The
risk of lung cancer is directly proportionate to the
amount of cigarettes consumed. The incidence of lung
cancer is 75 in 10,000 people who smoke less than 14
cigarettes daily, but this number increases dramatically
to 227 in smokers who smoke more than 25 cigarettes a
day. Similarly, the duration of cigarette use also
proportionately correlates with the risk of developing
lung cancer. It is an extremely difficult task to control the
use of cigarettes and to prevent lung cancer in China.
China has been hit the hardest by tobacco industries with
more than one million people dying annually of tobaccorelated
health problems. If this trend continues, it is
estimated that over two million people by 2030 and
possibly three million people by mid-century may die of
tobacco-related illnesses. By eliminating smoking, it is
estimated that the total mortality could be reduced by
10.0% among men and by 3.5% among women in China
[3].
Air pollution: China is facing a serious
environmental crisis due to widespread pollution. Air
pollution contributes to the high incidence of respiratory
ailments and lung cancers. The main sources for air
pollution in China are industrial exhaust and dust,
automobile exhaust, coal burning for energy, etc., which
are present mostly in major cities [4, 5].
Environmental and occupational exposures:
Occupational exposure to asbestos, silicon, chromium,
nickel and their by-products are known to cause lung
cancer. Workers who work at charcoal mills and in the
mining industries also have a higher risk of lung cancer
due to chronic exposure to the dust which contains
silicon, arsenic and radon gas.
Genetic susceptibility
Table 1 The Leading Sites of New Cancer Cases in China over
the last 30 years.
1970s 1990s 2000s
Stomach Stomach Lung
Oesophagus Liver Liver
Liver Lung Stomach
Lung Oesophagus Oesophagus
Cervix Colorectal Colorectal
Table 2 The percentage of change in annual mortality rates
among urban and rural areas.
Type of Cancer Annual mortality Rate (%)
Urban Rural
Cervix -27.5 -17.3
Lung +29.4 +47.7
Liver +13.0 +17.1
Colorectal +31.2 +17.5
Breast +38.9 +39.4
Bladder +23.5 +19.9
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Liver Cancer-Hepatocellular Carcinoma (HCC)
The risk factors for liver cancer in China:
Hepatitis B viral (HBV) infection: Hepatitis B is an
endemic in China. A national survey in 2002 showed a
9% rate of hepatitis B surface antigen (HbsAg) in the
general population [6]. Around 130 million people in
China are carriers of hepatitis B virus (HBV) (almost a
third of the people infected with HBV worldwide); 30
million people in China are chronically infected [7].
Every year, 300,000 people die from HBV-related
diseases in China, including 180,000 patients with HCC
[8]. The incidence of hepatitis B is still increasing from
21.9 in 100,000 people in 1990 to 53.3 in 100,000 in
2003 [9]. That increase has occurred despite a
vaccination program for newborn babies since the 1990s.
By 2006, China has successfully immunised 11.1 million
children living in the country's poorest provinces against
hepatitis B according to the Chinese health ministry, and
the Global Alliance for Vaccines and Immunization
(GAVI).
Cirrhosis: During a five-year period, 10–20% of
patients with chronic hepatitis developed cirrhosis, and
20–23% of the cases with compensated cirrhosis
progressed to decompensated cirrhosis. Six to 15% of the
people with cirrhosis and chronic hepatitis progressed to
HCC. The five-year survival for compensated cirrhosis is
55%, for decompensated cirrhosis is 14%, and for HCC
is less than 5%. Approximately 85% of liver cancer
patients also suffer from cirrhosis, typically nodular type.
In recent years, hepatitis C related cirrhosis has become
as prevalent as that of hepatitis B associated cirrhosis.
Afflatoxins: Afflatoxins B1 (AFB1) is a well-known
carcinogen for liver cancer. These toxins are made by
fungus that contaminates peanuts and corn. Once
ingested, these toxins can cause liver cancer directly or
enhance the risk from hepatitis B infection.
Contamination of drinking water: A strong
association exists between the incidence of liver cancer
and the consumption of polluted water in rural areas of
China.
Alcohol consumption: Excessive drinking of alcohol
remains a risk factor for HCC. Some studies have also
shown an increased risk of HCC in those that use alcohol
and tobacco due to an additive effect.
Parasite infection: A parasitic worm, commonly
known as a fluke, infests rivers in rural parts of China.
Flukes can stimulate proliferation in the epithelium of
the biliary duct during feeding and migration, which in
turn can induce cholangiobiliary carcinoma.
Genetic susceptibility and hereditary
Gastric cancer and its risk factors
Dietary: Unhealthy diets and food preparations can
introduce carcinogens for gastric cancer. The most wellknown
substances are nitrates and nitric acid, nitrous
acid, complex aromatic hydrocarbon and its byproducts.
These may contaminate the food or can be produced
during processing of the food, and has been shown to
increase the risk for stomach cancer as demonstrated in
some regions in China where smoked fish and meat are
frequently consumed. There is some evidence to suggest
a correlation of stomach cancer with diets high in sodium.
The deficiency in certain nutrients such as animal
proteins, vitamins and antioxidants may also play a role
in the development of gastric cancer.
Infections: Helicobacter pylori is a well-known
cause for certain stomach cancers.
Genetics: A positive family history also increases
the risk for gastric cancer.
Oesophageal cancer and its risk factors:
Chemicals and environmental factors, including
N-nitrites, mould-infected foods, toxins produced by
fungi, a deficiency in minerals, infectious processes such
as fungal and human papilloma virus (HPV), genetic
susceptibility and an unhealthy lifestyle including the use
of tobacco and alcohol all increase the risk for
oesophageal cancer. The use of pesticides, chemical
fertilisers, and the consumption of contaminated water
has been linked to the development of oesophageal
cancer.
Colorectal cancer and its common risk factors:
Dietary: There is a strong association between colon
cancer and nutritional, hereditary and environmental
factors. The effect of carcinogens and familial hypersusceptibility
can induce gene mutation leading to cancer
development. With the marked improvement of living
standards in China, the Chinese are no longer faced with
starvation; instead they have an abundance of choices for
nutrition. There is a significant change in the diet in
China; high calories, high fat, high protein and less fibre
now comprise the typical Chinese diet. The unhealthy
diet and more westernised lifestyle may have contributed
to the increase of colorectal cancer in China.
Genetics: Hereditary factor plays a very important
role in colorectal cancer. It is estimated that 5 to 20% of
colon cancers may be due to hereditary conditions such
as hereditary non-polyposis colon cancer (HNPCC), and
familial adenomatous polyposis (FAP).
Certain gastrointestinal ailments can also increase
the risk for colon cancer such as ulcerative colitis,
Crohn’s disease, and adenomatous polyposis, all of
which have increased in China.
THE MANAGEMENT OF LUNG AND BREAST CANCERS IN
CHINA
The strategies in the prevention and treatment of lung
cancer
1. Prevention: The single most effective measure
to reduce lung cancer in China is smoking
cessation and the elimination of all tobacco
products in China. This has proven to be
extremely difficult to accomplish due to various
historical, cultural, social and economic
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influences. A concerted effort has not been
established by the government to ban smoking.
2. Early diagnosis and intervention: Early
diagnosis and intervention can improve the
treatment outcome for lung cancer.
Unfortunately, effective and practical measures
to screen for lung cancer in China are not
available. (Or not established?)
3. Treatments:
a. Minimum invasive treatments such as
video-assisted thoracoscopy and
thoracotomy surgery (VATS) and
radiofrequency ablation (RFA) can be used
in early stages or highly-selected patients.
b. Comprehensive multi-modality therapy
with a combination of local and systemic
therapy can maximise the treatment
outcome for more advanced stage lung
cancers. Systemic therapy includes
chemotherapy, targeted therapy and
rehabilitation.
c. Effective health care policy: It is necessary
to increase governmental funding for the
prevention, diagnosis and treatment of lung
cancer. The main focus should be
curtailing the use of tobacco in China.
The practice guidelines of lung cancer
The main treatment modalities for lung cancer are
surgery, radiation therapy and chemotherapy. More
recently bio-molecular targeted therapy has been
incorporated into the comprehensive strategies of lung
cancer management. In China, there are 58 Positron
Emission Tomography-Computed Tomography (PET-CT)
scanners which have played an important role in
improving lung cancer staging and radiation treatment
planning.
Surgery remains the main treatment modality for
early stage (I-IIb) non-small cell lung cancer (NSCLC).
Over the last decade there have been significant
advancements in minimum invasive surgery in China.
This reduces the risk of surgery in elderly patients and
those with significant co-morbidities such as chronic
obstructive pulmonary disease (COPD). Adjuvant
radiation therapy and/or chemotherapy are used in
selected patients. For advanced stage NSCLC,
chemotherapy or supportive care are the treatments of
choice (table 3).
Radiation therapy for NSCLC
Conventional radiation therapy
The treatment volumes cover the primary with a
margin of 1.5 – 2cm and ipsilateral hilar and mediastinal
lymph nodes. The standard treatment has generally been
1.8 -2 Gy per fraction, one fraction per day, five days per
week, for a total dose of 40 Gy to 66 Gy. The initial
volume is treated to a dose of 40 Gy, and then the area of
residual disease detected on a repeat CT scan will be
boosted to a total dose of 66 Gy.
Intensity modulated radiation therapy (IMRT)
The treatment volume is defined according to ICRU
50. Gross target volume (GTV) is defined as the known
volume of the primary tumour and its regional nodal
metastases clinically and radiologically. GTV will be
contoured on the lung window of the CT scan. Clinical
Table 3 Chemotherapy regimens for non-small cell lung cancer
NSCLC.
First line
NP-vinorelbine-vavelbin & platinum
Platinum 80 mg/m2 IV gtt on day 1
Vinorelbine 25 mg/m2 IV gtt on day 1,8
Repeat every 3 weeks
GP-gemcitabine & platinum
Platinum 75 mg/m2 IV gtt on day 2
Gemcitabine 1250 mg/m2 IV gtt on day 1,8
Repeat every 3 weeks
EP-etoposide (VP-16)& platinum
Platinum 75 mg/m2 IV gtt on day 1
VP-16 120 mg/m2 IV gtt on day 1,2,3
Repeat every 3 weeks
PT-platinum & Paclitaexel
Paclitaxel 175 mg/m2 IV gtt day 1
Platinum 75 mg/m2 IV gtt on day 1
Repeat every 3 weeks
PD-platinum and docetaxel
Platinum 75 mg/m2 IV gtt on day 1
Docetaxel 75 mg/m2 IV gtt on day 2
Repeat every 3 weeks
CPT-11/DDP
Platinum 60 mg/m2 IV gtt on day 1
CPT-11 60 mg/m2 IV gtt on day 1,8,15
Repeat every 3 weeks
PC-paclitaxel & carboplatin (CBP)
CBP AUC5 IV gtt on day 1
Paclitaxel 175 mg/m2 IV gtt on day 1
Repeat every 3 weeks
Second line chemotherapy
Docetaxel 75 mg/m2 IV gtt on day 1
Repeat every 3 weeks
Pemetrexed 500 mg/m2 IV gtt on day 1
Repeat every 3 weeks
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target volume (CTV) is defined as GTV plus 1cm margin
to include surrounding subclinical disease and the area at
risk for microscopic involvement. The radiologists,
radiation oncologists and physicists work together to
define the CTV. Planning target volume (PTV) is CTV
plus 1.5 cm. PTV is covered by 90% isodose line. Lung
V20 ≤ 20%. Dose to oesophagus ≤ 40 Gy and to heart
≤ 30 Gy. Median dose is 64.8 Gy (60 Gy to 72 Gy), 1.8 –
2 Gy per fraction, one fraction per day and 5 fractions
per week.
Targeted therapy
Several new bio-molecular targeted therapy agents,
such as gefitinib, erlotinib and bevacizumab, have
become available in China.
Small cell lung cancer (SCLC)
The treatment of small cell lung cancer mainly
involves chemotherapy. Table 4 shows the most common
regimens that are used in China.
Management of Breast Cancer
Table 5 shows the chemotherapy regimens for breast
cancer.
Post-mastectomy radiation therapy
The radiation target volume post-radical or modified
radical mastectomy includes chest wall and regional
lymph nodes. The indication of radiation and the
identification of target volume are dictated by the stage
of the primary tumour and regional lymph nodes.
Chest wall: The upper border is the thoracic
entrance or to match the lower border of the
supraclavicular field (half-beam block). The lower
border is 1-2 cm inferior to the breast tissue. The medial
border is placed just medial to the inner breast tissue or
the midline of sternum. The lateral border is the midline
of axilla. The chest wall post-modified radical
mastectomy is irradiated using 4 -6 MV x-ray via
standard tangent fields with wedges and bolus. The chest
wall post-radical mastectomy is irradiated en-face using
electrons. The energy of the electrons is selected
according to the thickness of the chest wall. Bolus is
used to increase the skin dose to ≥ 85%. The total dose
will be 45 Gy to 50 Gy.
Supraclavicular lymphatic drainage: The upper
border extends laterally across the neck and the trapezius
to the acromial process. The lower border is at the first or
Table 4 Most common treatments for small cell lung cancer
(SCLC) used in China.
Chemotherapy:
EP: Etoposide (VP-16) & cisplatin (CDDP)
CDDP 75 mg/m2 IV gtt on day 1
VP-16 100-120 mg/m2 IV gtt on day 1, 2, 3
Repeat every 3 weeks
Other regimens include:
EC: Etoposide & carboplatin (CBP)
Repeat every 3 weeks
CDDP & CPT-11
Repeat every 4 weeks
Radiation therapy (RT):
Thoracic RT: 40-50 Gy/4-5 weeks
Prophylactic whole brain irradiation:
30-36 Gy/10-12 fractions/2-2.5 weeks
Table 5 Chemotherapy regimens for breast cancer.
CMF
Cyclophosphomide (CTX) 100 mg/m2, po, day 1-14
Methotrexate (MTX) 40 mg/m2, IV gtt, on day 1, 8
5-Fu 600 mg/m2, IV gtt, on day 1, 8
Every 28 days/cycle
FAC
5-Fu 500 mg/m2, IV gtt, on day 1, 8
Adriamycin (ADM) 50 mg/m2, IV on day 1
CTX 500 mg/m2 IV on day 1
Every 21 days/cycle
AC
ADM 60 mg/m2, IV, on day 1
CTX 600 mg/m2, IV, on day 1
Every 21 days/cycle
TAC
TXT 75 mg/m2, IV gtt, on day 1
ADM 50 mg/m2, IV gtt, on day 1
CTX 500 mg/m2, IV, on day 1
Every 21 days/cycle
AC->T
ADM 60 mg/m2, IV, on day 1
CTX 600 mg/m2, IV, on day 1
Every 21 days/cycle x 4 cycles
Paclitaxel 175 mg/m2 IV gtt, on day 1
Every 21 days/cycle x 4 cycles
FEC
5-Fu 400 mg/m2, IV gtt, on day 1, 8
EPI 50 mg/m2, IV, on day 1, 8
CTX 500 mg/m2, IV, on day 1, 8
Every 28 days/cycle
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second intercostal space. The medial border is the
midline of the sternum or 1 cm beyond. The lateral
border is the anterior line of axilla. The dose covers a
depth of 3-4 cm. The mixed beams of photons (60Co or
4-6 MV x-ray) and electrons (12 MeV) are used to
deliver 45 – 50 Gy in conventional fractionation.
Internal mammary chain: The upper border is at the
medial head of clavicle or to match the lower border of
the supraclavicular field. The lower border is in the
fourth intercostal space. For a primary tumour located at
the inner lower quadrant, the lower border is at the sixth
intercostal space. The medial border is the midline of
sternum or 1 cm beyond. The lateral border is 5 cm from
the midline of sternum to the ipsilateral chest wall. The
dose covers a depth of 3-5 cm. Electrons with
appropriate energy are used to deliver 45 – 50 Gy in
conventional fractionation.
Axillary lymphatic drainage: The upper border is at
the clavicle. The lower border is at the second intercostal
space. The medial border is 1-1.5 cm lateral to the chest
wall. The lateral border is at the posterior line of the
axilla. The 4-6 MV x-ray is used to deliver 45 – 50 Gy in
conventional fractionation.
Post-lumpectomy radiation therapy
Tangential fields and boost fields: The borders of
the tangential fields are usually defined as follows:
medial border is midline of the sternum (or 3 cm beyond
midline to include the internal mammary chain); lateral
border is mid-axillary; inferior border is 1-2 cm below
the breast; superior border is the thoracic entrance or to
match the inferior border of the supraclavicular field.
The total dose is 45-50 Gy at 1.8 -2 Gy per fraction,
5 fractions a week.
Accelerated partial breast irradiation: There are
many ways to deliver partial breast irradiation either with
brachytherapy including; interstitial brachytherapy,
intracavitary brachytherapy or an external beam radiation
therapy system such as a 3D Conformal radiotherapy or
IMRT and intraoperative radiotherapy (IORT).
Hormone therapy for breast cancer
Hormone therapy is commonly used for patients
with breast cancer that stain positive for oestrogen
receptor (ER) and progestron receptors (PR). Targeted
therapy such as trastuzumab is used for Her2 receptor
positive patients respectively.
CURRENT STATUS OF RADIATION ONCOLOGY IN CHINA
Radiotherapy Equipment in China
There is a significant shortage in radiotherapy
equipment to meet the increasing needs in China. As of
September 2006, there were 952 radiation therapy
centers that were equipped with 918 linear accelerators,
472 60Co machines, 146 ortho-voltage x-ray machines,
827 fluoroscoopy simulators, and 400 brachytherapy
units including 21 252Cf neutron remote afterloading
brachytherapy units. There were 851 treatment planning
systems and 467 ion-chambers [10]. In comparison to the
1997 survey, there has been a 321% increase in linear
accelerators and 481% increase in treatment planning
systems. As of 2006, there were 214 CT simulators, 149
Gamma Knives (74 for head only, 75 for both head and
body), and 467 X-Knife machines. Despite the
significant growth in radiation oncology equipment,
there is less than 1 (0.7) accelerator per million people.
Even considering both 60Co machines and linear
accelerators combined, there are only 1.06 machines per
one million population, which is short of meeting the
minimum requirements of the World Health
Organization of two linear accelerators per million
population. The radiotherapy equipment is also unevenly
distributed throughout the country. In the major cities or
provinces such as Beijing, Shanghai, and Shandong,
there are at least two machines per million people,
whereas in more remote regions of China such as deep
inland and the western part of the country, there is
limited accessibility to radiotherapy equipment.
Radiation Technique
The majority of radiation centers in China are
equipped and capable of performing basic three
dimensional conformal radiotherapy (3D-CRT) as
reported by the 2006 survey [10]. Among 952 registered
radiation centers in China, 579 centres (60%) were
practising three-dimensional conformal radiotherapy, but
only 115 (12%) were delivering intensity-modulated
radiotherapy (IMRT). Approximately 8% of centres were
capable of doing stereotactic radiosurgery [10].
Radiation Oncologists and Radiation Physicists in China
There are 18,992 healthcare workers that are
involved in providing radiation therapy in China. Among
them, 5,247 are radiation oncologists (including 2,110
residents), 4,559 radiation therapists, 6,864 nurses, 1,181
medical physicists, and 1,141 are maintenance engineers.
Clearly there is a severe shortage in medical physicists.
Radiation Therapy Funding in China
In China, there is a significant lack of funding and
reimbursement to maintain costly radiotherapy
equipment and meet the demands. A national health
insurance system in China has not been developed. The
reimbursement rates for cancer treatment are set by the
local governments and vary widely due to the differences
in the financial situations of each district. For example,
in City of Qingdao the municipal healthcare agency
reimburses 80% for IMRT treatment. However, at the
same time they also set a fixed reimbursement rate of
250 Chinese yuan (equivalent to approximately $40) for
each IMRT beam, 80% of which will be reimbursed. The
government will only pay 70% of the radiation treatment
planning cost. The rest of the expense has to be paid by
the patients. For 3D-CRT the local government has set
the maximum reimbursement rate of 1,100 yuan
(equivalent to approximately $150). Therefore, a
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significant portion of the expense will have to be paid by
the patients or they have to accept substandard or no
treatment at all. The same situation also applies to
chemotherapy treatments. The government will pay the
full amount of money, but only for the basic drug
regimen. However, the newer or more expensive
chemotherapy drugs (which may be more effective) will
get little or no reimbursement. Furthermore, 60% of the
Chinese population have no medical insurance or
coverage at all. Unfortunately for those patients, they
either have to pay completely out-of-pocket (which very
few can afford), or settle for less service, which
oftentimes results in inadequate healthcare. As most
people either have no healthcare insurance or have an
insurance coverage with low reimbursement rates, it is
very difficult, if not impossible, for them to receive
comprehensive or long-term care. There is also a
profound disparity of healthcare within China. In eastern
regions of China, especially large coastal cities, medical
care is more advanced and relatively accessible than that
in remote areas such as many western provinces.
UNIQUE CANCER THERAPY IN CHINA
China has a long history of using its traditional
Chinese medicine for various ailments, including
malignancies. Clinical and experimental research have
shown that Chinese medicine may have positive effects
on cancer and cancer therapy. The potential benefits of
traditional Chinese medicine are believed to be as
follows:
1. Reducing the toxic side-effects of
chemotherapy and radiation therapy.
2. Improving human immune systems and its
functions.
3. Improving haematopoiesis in bone marrow.
4. Improving endocrine function and body
metabolism
5. Re-establishing homeostasis to promote the
human body’s recovery.
6. Enhancing the treatment effects which may lead
to a prolonged survival.
Qigong
Qigong (an ancient Chinese exercise system of deep
breathing) is also believed to improve a patient’s overall
well-being by adjusting each organ’s function. It further
improves the patient’s immune system and boosts one’s
confidence. Qigong may also perk up a patient’s
emotional and psychological state of health leading to a
better tolerance of cancer therapy and a faster recovery.
Incorporating Chinese medicine into a
comprehensive cancer treatment program may enhance
the overall treatment outcomes. In recent years, the
Chinese government has approved the use of some
Chinese herbal remedies that may improve the immune
function of cancer patients and also may have additive
effects to conventional cancer therapy.
Chinese Herbal Medicine
Chinese herbal medicine has existed and been
practised in cancer therapy in China for ages. It is
administered based on the underlying physio-pathologic
processes of the malignancies, including the type and
stage of the malignancy, the patients’ overall state of
health and nutritional status. Chinese medicine remedies
also take other treatment modalities into consideration
such as the side-effects from the treatment (e.g.
chemotherapy or radiation) and clinical symptoms. It is
believed that Chinese herbal medicine may lessen the
patient’s clinical symptoms, decrease toxic side-effects
from conventional western approaches and result in
favourable therapeutic ratios. The use of Chinese herbal
medicine is a very complicated process that contains the
art and science of medicine as well as human experiences,
wisdom, and knowledge that have been accumulated and
passed on for generations in China. The combination of
conventional western medicine and traditional Chinese
medicine may be complementary to each other and may
ultimately improve the cancer care in China.
252Cf neutron remote afterloading brachytherapy
China has a relatively large number of remote
afterloading neutron brachytherapy units using
Californium-252 (252Cf) nuclide which is a source of
gamma neutron radiation. 252Cf generated by nuclear
reactions produces fast neutrons which offer high-LET
radiation and potentially a more effective cell kill effect
than photons. The indication and technique of 252Cf are
similar to those that are used with 192Ir for treating intracavitary/
intra-luminal or body surface tumours such as
oesophageal and cervical cancer. 252Cf is, at least
theoretically, equal to or more effective than photons
generated by 192Ir. Because of its high-LET radiation 252C
may offer more favourable treatment outcomes for
tumours that have large hypoxic cell population or
tumours that did not respond to conventional photon
radiation. For difficult or recurrent tumours with hypoxic
cells, 252Cf neutron therapy may also produce a faster
tumour response compared to that of photon beam.
Dendritic Cell Immunotherapy
China has a very active program in basic and
clinical research on dendritic cell immunotherapy. A new
and more efficient way to culture LAK cells was
developed in China. This allowed a more efficient way to
produce LAK cells for possible clinical use. This new
approach was used in a clinical trial using cultured
CD3AK cells in 1999. This therapy has the following
advantages: 1) it can be used for a wide range of
malignancies, 2) it has significant effects on both
primary tumours and metastases, 3) it may be more
effective than conventional chemotherapy in adjuvant
setting, and 4) the side effects are mild (only low-grade
fevers). Based on early clinical evidence, this new
modality appeared to be more efficacious when
combined with chemotherapy to treat advanced stage
cancers. The tumour response rate has been reported to
XJ Ma et al. Biomed Imaging Interv J 2008; 4(3):e39 8
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be as high as 60%. It was the first time that the DC +
CIK was combined with chemotherapy to treat late stage
lung cancer and combined with neutron knife to treat
colon cancer in clinical trials conducted in China. Further
research and larger clinical trials are being done in this
area.
THE HEALTHCARE POLICIES
China is experiencing a rapid growth in the aging
population and cancer incidence. In the past, the
government health agencies were focused more on
cancer treatment than its prevention. Recently the
Chinese government has started to attribute more
attention towards cancer prevention and cancer therapy
rehabilitation. Fortunately, the basic needs for surgical
oncology equipment have been met and many radiation
therapy facilities have been developed in the last
20 years. More and more linear accelerators and 60Co
machines have been installed nationwide. But it is far
from meeting the basic needs in China. Chemotherapy is
also advancing and has adopted the international
standards in many parts of China. The concept and
practice of terminal care have also been introduced into
more families, healthcare institutions and social welfare
organisations in today’s practice. The government has
also allowed more use of narcotics for pain control for
terminal cancer patients. As an example, the city of
Qingdao was one of the first cities in the nation to start
an education centre for cancer patients which is
supported by the local government. The centre is open to
the public. It provides guidance and assistance on a wide
range of issues in cancer care and cancer therapy
rehabilitation. The centre also provides telephone
hotlines for psychological counseling for cancer patients.
Patient support groups meet regularly to discuss the
variety of issues that they are facing, including cancer
therapy, the coping process and rehabilitation.
Oncologists are invited to give lectures and advice to the
participating groups.
The central government has realised that the cost of
cancer treatment is overwhelming and will continue to
grow exponentially in the foreseeable future. The best
way to curtail the cost in cancer care is cancer prevention.
The current health insurance system provided by the
local government does not provide funding for
preventive measures, which has been a major obstacle to
the implementation of preventive medicine. Since 2004,
the Chinese government has made efforts to increase
funding for cancer prevention and early detection which
are important to reducing cancer-related deaths in China.
Multidisciplinary management has become the principle
of cancer treatment, and efforts to practise the standard
of care have been implemented. However, there remains
a large number of Chinese people who do not have
health insurance or have coverage that is inadequate as
the cost extends beyond their financial ability to even
afford the co-pay. Therefore, cancer patients are facing
heavy financial burdens which may prevent them from
obtaining little, if any, cancer therapy. These problems
are much more profound in the rural areas of China.
THE FUTURE CHALLENGES
Cancer care is a complicated process that requires an
enormous effort and resources from the government,
healthcare workers and cancer researchers. It is estimated
that 80% of cancers are preventable; therefore, it is
essential to control environmental pollution and to
advocate a healthy lifestyle and diet. An increase in the
awareness of cancer prevention and early detection
through educating the public has become paramount. It is
absolutely necessary for both the central and local
governments to greatly increase the funding for cancer
care and to improve the distribution of the resources
throughout China.
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