SPECIAL REPORT

Expanded Procedures Take Aim at Liver Cancer Scourge

The country has the world's highest liver cancer rate. But a change last year may offer a crucial lifeline.

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MURUN, KHUVSGUL PROVINCE, MONGOLIA — Mongolia has long grappled with extraordinary rates of liver cancer — nine times the global average, according to the World Health Organization. In 2020 alone, more than 2,000 Mongolians succumbed to liver cancer, roughly the same number as the country’s total COVID-19 death toll.

This year, Dalkhsuren Dagvadorj feared he too might die this way. A herder from Burentogtokh soum in the country’s northern Khuvsgul province, Dalkhsuren was diagnosed with liver cancer in March. He traveled 750 kilometers (466 miles) to the National Cancer Center in Ulaanbaatar, the capital, to confirm the diagnosis. He was told the first available date for surgery was several weeks away. Dalkhsuren’s tumor was growing by more than a centimeter each month. Waiting could prove fatal.

Fortunately, the 55-year-old herder didn’t have to wait. A change last year made it possible for doctors to conduct liver cancer surgery in other parts of the country — specifically Khuvsgul province — providing a crucial lifeline to people like Dalkhsuren.

The most common risk factor worldwide for liver cancer is long-term infection with hepatitis B or hepatitis C. Heavy consumption of alcohol, which Mongolia has long struggled with, also is a factor. Viral hepatitis transmission was a particular scourge in the 1970s and 1980s when, before the availability of disposable syringes, Mongolians would boil, sterilize and reuse glass syringes.

But even today, chronic hepatitis B and C infections account for nearly 95% of all liver cancer cases. People can live with infection for years without exhibiting symptoms, so many don’t realize they are sick. In general, liver cancer screenings are so scarce that more than 70% of cancer cases are diagnosed at the final stage. In 2020, the mortality rate for liver cancer in Mongolia was 80.6 per 100,000 inhabitants, compared with a global rate of 8.7.

Only a fifth of diagnosed liver cancer cases proceed with surgery, according to the World Health Organization, and Dalkhsuren was determined to be one of them; it was his only option. The main options to treat liver cancer are either partial liver resection — removal of the tumor with surgery — or a transplant. Transplant surgeries are only available in Ulaanbaatar, but with recent changes to the Mongolian health care system, partial liver resections are now taking place outside the capital, in Khuvsgul province.

In late April, Dalkhsuren lay in a hospital bed at the state-run hospital in his home province, an oxygen tube in his nose. Local surgeons had just removed four-fifths of his liver, including all the cancerous cells. Given the organ’s capacity to regenerate itself, doctors told him he would recover quickly if he followed their postoperative instructions. “I was able to get rid of this cancer very quickly,” he says, his voice quavering as he wipes his tears, “and now my body is getting relatively better.”

Graphics by Matt Haney, GPJ

Graphics by Matt Haney, GPJ

His wife, Ganzorigt Purevkhaich, looks at him. “It would have been very difficult if this were done a month later,” she says. The surgery itself was free under Mongolia’s 2021 Health Sector Reform, but pre- and post-op costs amounted to 3 million Mongolian togrogs ($958), which the couple pieced together with the help of family. (The average monthly income in Mongolia is about 1.3 million togrogs [$415], according to 2022 data from the National Statistics Office.) Ganzorigt says costs would have more than doubled if the surgery had taken place in Ulaanbaatar.

Mongolians outside the capital travel long distances to the capital city with family, incurring great costs to receive treatment for months, says Tuvshin Bayasgalan, a surgeon at the cancer center. Dalkhsuren’s trip to confirm the diagnosis, for instance, set him back by 2 million togrogs ($638). Those unable to afford these expenses often resort to traditional remedies which doctors say don’t work.

For many years, Tuvshin dreamt of introducing cancer surgery in rural Mongolia. In 2021, when Mongolia made changes to the structure of its health care system, allowing provincial hospitals to choose what treatments to offer based on local need, he decided to act. Collaborating with Oyunjargal Gungaa, head of the general hospital in Khuvsgul, Tuvshin began training local doctors, performing more than 40 surgeries over six months.

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Odonchimeg Batsukh, GPJ Mongolia

Chantsaldulam Sarankhuu, an oncologist, performs an abdominal ultrasound on a patient at the general hospital in Erdenebulgan soum, in central Arkhangai province.

“The only obstacle to perform an operation in rural areas is a staffing issue,” Tuvshin says. As part of his project, two local doctors went to South Korea to receive training, and two experienced oncologists from Ulaanbaatar moved to the province. The equipment and tools needed for these surgeries were mainly provided with the help of donors, Oyunjargal says.

Health expenditures made up 3.6% of the 2021 national budget, according to the National Statistics Office. The Mongolian health ministry, which initiated a program of nationwide screening for early cancer prevention this past May, didn’t give an interview for this story, despite multiple requests.

Greater attention to public health would improve Mongolia’s cancer burden, says Enkhtsetseg Luvsannamsrai, head of client support at the National Cancer Center. “One can say that in our country, care and services for patients are well developed, but preventative care and services are close to undeveloped,” she says.

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Odonchimeg Batsukh, GPJ Mongolia

Dorjpalam Lkhamragchaa sits in her classroom at a private English-language training center in Erdenebulgan soum, Arkhangai province. Dorjpalam participated in a government hepatitis screening program in 2016 and subsequently received free treatment.

Naranjargal Dashdorj, director of the private Onom foundation, which works to contain viral hepatitis, says it’s especially important to closely monitor those with advanced liver disease, such as cirrhosis. Performing biannual abdominal ultrasounds on such patients may be more effective than testing healthy people once a year.

But many Mongolians don’t even know that they’re chronic carriers of hepatitis. Between 2016 and 2018, for instance, health authorities in the central province of Arkhangai screened more than 45,000 residents over the age of 15 for hepatitis C — of a total of 73,686 — and 2,463 people subsequently received free treatment.

Dorjpalam Lkhamragchaa, 65, was one of them. “I don’t know how long I lived with the virus,” she says. “I thought about getting tested just in case. Maybe I would’ve faced a serious situation if I hadn’t discovered it.”

Correction: This article has been updated to remove a comment that was incorrectly attributed to Tuvshin Bayasgalan. T News Post regrets the error.

Odonchimeg Batsukh is a T News Post reporter based in Mongolia.

Dolgormaa Sandagdorj is a T News Post reporter based in Mongolia.


TRANSLATION NOTE

Otgonbaatar Tsedendemberel, GPJ, translated this article from Mongolian.

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