Knowledge, Attitude and Practice Toward Liver Cancer and Liver Cancer Screening Among HBV and HCV Patients in Vientiane, Lao People's Democratic Republic: A Cross-Sectional Study

Abstract

It is estimated that the Lao People’s Democratic Republic (PDR) has the 5th highest rate of liver cancer in the world, with approximately 22.4 cases per 100,000 population. Factors contributing to this include the high prevalence of chronic hepatitis B (CHB), lack of access to therapy, high incidence of opisthorchis infection, and rising rates of alcoholism.1Bray F. Ferlay J. Soerjomataram I. Siegel R.L. Torre L.A. Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.CA Cancer J Clin. 2018; 68: 394-424Crossref PubMed Scopus (36994) Google Scholar, 2Paboriboune P. Vial T. Chassagne F. et al.A seven-year retrospective study on the surveillance of hepatitis B in Laos.Int J Hepatol. 2018;; (April)9462475Google Scholar, 3Black A.P. Nouanthong P. Nanthavong N. et al.Hepatitis B virus in the Lao People's Democratic Republic: a cross sectional serosurvey in different cohorts.BMC Infect Dis. 2014; 14: 1-7Crossref PubMed Scopus (25) Google Scholar, 4Lao Statistics Bureau and UNICEFLao Social Indicator Survey II 2017, Survey Findings Report.2018Google Scholar There is no current surveillance program for hepatocellular carcinoma (HCC) and only limited capacity for liver biopsy and pathology assessment.2Paboriboune P. Vial T. Chassagne F. et al.A seven-year retrospective study on the surveillance of hepatitis B in Laos.Int J Hepatol. 2018;; (April)9462475Google Scholar Between April and July 2019, 302 hepatitis B and C patients were recruited while attending Centre d’Infectiologie Lao-Christophe Mérieux (n = 201) or Mittaphab hospital (6 departments: outpatient medicine, internal medicine, nephrology, mother and child, infectious disease, and cancer center; n = 101) in Vientiane Capital. Patients diagnosed with liver cancer, patients undergoing active evaluation for liver cancer, and patients who had cognitive impairment or refused to participate were excluded. A structured questionnaire was administered to determine the patients knowledge, attitude, and practice toward liver cancer. Hepatitis B had been diagnosed in most participants (232; 76.8%) and hepatitis C in 60 (19.9%), with 10 (3.3%) having hepatitis B and C coinfection (Table 1). Other risk factors for liver cancer were identified, including drinking alcohol, smoking, and eating raw fish despite high awareness of the associated risks.Table 1Sociodemographics and Knowledge, Attitude and Practice Towards Liver Cancer Among HBV/HCV Patients.VariableN (%)SexMale176 (58.3)Age group<30 years68 (22.5)30–39 years68 (22.5)40–49 years58 (19.2)50–59 years57 (18.9)≥60 years51 (16.9)EthnicityLao Loum272 (90.1)Lao Soung19 (6.3)Lao Therng11 (3.6)Marital statusSingle61 (20.2)Married230 (76.2)Divorced/widowed11 (3.6)Highest educationNo schooling6 (2)Elementary33 (10.9)High school97 (32.1)Diploma/college/post graduate166 (55.0)OccupationUnemployed8 (2.6)Housewife36 (11.9)Government worker94 (31.1)Healthcare worker2 (0.6)Farmer13 (4.3)Business/private sector/other149 (49.3)Monthly income<1,000,000 Kipa1,000,000 Kip = Approximately 107 US Dollars.43 (14.2)1,000,000–3,000,000 Kip166 (55)>3,000,000 Kip93 (30.8)Health insuranceNo insurance142 (47)Government/military insurance122 (40.4)Private insurance38 (12.5)DiagnosisHepatitis B232 (76.8)Hepatitis C60 (19.9)Co-infection B/C10 (3.3)Time since diagnosis>10 years51 (16.9)Family member diagnosed with hepatitis B/CYes105 (34.8)ComorbiditiesCirrhosis7 (2.3)Hypertension28 (8.6)Diabetes21 (7.0)Dyslipidaemia16 (5.3)Other46 (15.2)Other cancer risk factorsCurrently smoke36 (11.9)Previously smoked54 (17.9)Drink alcohol>1 per month108 (35.8)Often eat raw fish117 (38.7)Knowledge on liver cancerAlcohol is a risk factor262 (86.7)Eating raw fish is a risk factor234 (77.5)Heard of aflatoxin20 (6.6)Regular screening can increase detection295 (97.7)Early symptoms can be silent62 (20.5)Cirrhosis increases the chances of liver cancer175 (58.0)Know how often to screen164 (54.3)Testing and treatmentScreened stool for parasites158 (52.3)Liver cancer screening123 (40.7)Cost obstacle to liver cancer screening108 (35.8)Time obstacle to liver cancer screening76 (25.2)Source of liver cancer informationMedical doctor151 (50.0)Social media118 (39)Family members75 (24.8)Concerned about getting liver cancer?Yes214 (70.9)a 1,000,000 Kip = Approximately 107 US Dollars. Open table in a new tab Although most participants knew that regular screening could increase the chance to detect liver cancer,5Frenette C.T. Isaacson A.J. Bargellini I. Saab S. Singal A.G. A practical guideline for hepatocellular carcinoma screening in patients at risk.Mayo Clin Proc Innov Qual Outcomes. 2019; 3: 302-310Abstract Full Text Full Text PDF PubMed Google Scholar,6Marrero J.A. Kulik L.M. Sirlin C.B. et al.Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American association for the study of liver diseases.Hepatology. 2018; 68: 723-750Crossref PubMed Scopus (1290) Google Scholar few knew that the early symptoms of liver cancer can be silent or that cirrhosis increases the risk of liver cancer. Furthermore, many did not know how frequently they should be screened for HCC, and only less than half had had liver cancer screening. This suboptimal knowledge and screening are in line with a paucity of reliable liver cancer information provided to patients. Only half had received information from a medical doctor. Although most of the participants were concerned about getting liver cancer in the future, cost and time were significant obstacles to liver cancer screening. In conclusion, the lack of reliable information and obstacles to access hamper screening in this cohort. These data relate to Vientiane Capital, an urban area with the highest rate of access to testing and treatment nationwide. We imagine that larger barriers to access exist in rural areas of Lao PDR.4Lao Statistics Bureau and UNICEFLao Social Indicator Survey II 2017, Survey Findings Report.2018Google Scholar The development of interventions to improve knowledge of liver cancer symptoms and access to screening and treatment, including nationally subsidized liver cancer screening and hepatitis treatment program and expansion of the National Health Insurance program,7Nagpal S. Masaki E. Pambudi E.S. Jacobs B. Financial protection and equity of access to health services with the free maternal and child health initiative in Lao PDR.Health Policy Plan. 2019; 34: 14-25Crossref PubMed Scopus (3) Google Scholar are warranted. All authors have seen and approved the final version of the manuscript. The article is the authors’ original work, has not received prior publication, and is not under consideration for publication elsewhere. The authors have none to declare. We would like to thank the participants for their time in completing the survey and the staff of Insitut Pasteur du Laos, Centre d’Infectiologie Christophe Mérieux du Laos, and Mittaphab hospital for their help.