Bile duct cancer (cholangiocarcinoma) is a cancer caused by abnormalities of the lining of the bile duct inside and outside the liver. Thai people die of cholangiocarcinoma and liver cancer in the number of 10,000 - 20,000 cases per year, with more than half of the population being northeastern. The World Health Organization has made liver fluke a major cause of this type of cancer. The knowledge gained from the research from Khon Kaen University has been applied to prevent and search for the first stage of cancer patients in order to accomplish curative treatment. Importantly, about 55 percent of the working-age population is a head of household between the ages of 40-60 years, which is a serious disease and causes loss of economic, social, quality of life of people in the society. Therefore, the Health System Development for Screening, Early Diagnosis and Management of Cholangiocarcinoma in Northeast, Thailand) by the support of the Health Systems Research Institute (HSRI) with the co-funding with Khon Kaen University through the Cholangiocarcinoma Screening and Care Program (CASCAP) and The National Research Council of Thailand via the Grand Challenges Thailand: Fluke Free Thailand is running the project with the aim of establishing a comprehensive program for the long-term control and elimination liver fluke infection and CCA in Thailand in all aspects. There are 11 interrelated projects running under this program in Thailand, which provide a holistic approach covering primary-, secondary-, and tertiary prevention of liver fluke and cholangiocarcinoma. The program has successfully negotiated with the Thai government to launch a 10 years strategic plan for the elimination of the liver fluke and CCA running from 2016-2026. In addition to the Ministry of Public Health, this policy involves several other ministries including the Ministry of Education, the Ministry of Agriculture, the Ministry of the Interior, the Ministry of Communication and the Ministry of Foreign Affairs. The data obtained and fed into the Isan Cohort database are being used for monitoring and evaluating the policy’s progress. In addition, there are 4 innovations have been established in order to solve liver fluke and cholangiocarcinoma problem as followings. 1. The Isan Cohort software (https://cloud.cascap.in.th/) which is an online and real-time database system used for nation-wide at risk population registration, data recording, monitoring, evaluation and reporting to the Thailand Ministry of Health as well as the general public was established. The registration and inclusion of the high-risk population takes place at primary health care hospitals. The at-risk people are then transferred for ultrasound screening to district hospitals and suspected CCA cases are referred for further investigation and treatment to super-tertiary care hospitals. Screening is performed simultaneously with at the risk members of the local population at the primary health care units. Some initial data have been published in the BMC Cancer (Khuntikeo et al. 2015) 2. An ultrasound screening system has been developed (Chamadol et al. EMSO open 2017), composed of ultrasound machines with mini-PACS, which allow the transfer of ultrasound images through the internet into the Isan Cohort database. This system also includes online-based consultation where the images can be reviewed by an expert radiologist for confirmatory diagnosis (Figure 3). In addition to increasing the screening capability, hepatobiliary ultrasonography training courses are offered for radiologists and general practitioners. 3. A new technology to detect the liver fluke antigen in urine has been developed (Worasith et al. 2015). The new method id more sensitive and specific than the
detection of parasitic eggs in feces. Interestingly, the Ov antigen detection kit is now under mass production 4. Network Hospitals for Screening, Surveillance, Diagnosis and Treatment of Liver Fluke Disease and Cholangiocarcinoma Patients. The Ministry of Public Health's service units are involved in about 3,626 health units, including the District Health Promotion Hospital, Community Hospital, General and Center hospital. Network hospitals are designated for the diagnosis and treatment of cholangiocarcinoma and for further management of the suspected CCA cases identified by ultrasound screening. This network comprises all 7 super-tertiary care hospitals in the northeast of Thailand. Moreover, hepatobiliary and pancreatic surgery training courses are provided to increase the number of the specialist surgeons available to perform potentially curative surgery Therefore, the successfully this project is an example of the results of research and development to solve the problem of the country. Importantly, the people could access services related to liver fluke and cholangiocarcinoma in all level including primary, secondary and tertiary level in timely manner with high quality.