Addressing cancer management issues in Malaysia

Locations of the seven government cancer treatment centres scattered across Malaysia.

CANCER is one the major causes of mortality and morbidity worldwide, and with predictions of heavy increases in rates of incidence, the disease will be a major concern for many nations, especially poorer or developing countries where rates of most commonly seen cancers like breast cancer is set to almost double in the near future.

According to data derived from Globocan, the specialised cancer agency of the World Health Organisation (WHO), the projected cancer incidence rate is set to increase from 14.1 million recorded in 2012 to 19.3 million in 2025, while mortality rates of the disease will increase from 8.2 million to 11.4 million.

In Malaysia, the rate of cancer incidence is projected to reach a figure of 56,932 — a 38 per cent increase from reported cancer incidence figures in 2015.

The concern over this increase in developing countries like Malaysia is further amplified if we consider the divide in cancer management quality seen between the developed and developing world.

Data from Globocan estimates there are 1.3 times more new cases of cancer and 1.8 times more deaths from cancer in less developed regions compared to more developed regions.

Commenting on this figure, Dr Matin Mellor a clinical oncologist and president of the Malaysian Oncological Society (MOS), suggests this divide is most likely due issues in cancer management, and in Malaysia’s case, one of the main issues would be the lack of access to cancer care.

Comparing ASR for incidence and mortality. Adapted from Globocan 2012.

Lack of access to cancer care and manpower shortages

“In Malaysia, there are a total of 37 cancer treatment centres comprising of seven government centres, four public University medical centres and 26 private medical centres,” he says.

While our number of cancer treatment centres may seem like an adequate amount to serve our cancer patients, the reality is there is great imbalance of the spread of these centres as the majority is concentrated in more populous and developed states such as Selangor and Penang which both boast a total of 13 and eight treatment centres respectively.

And this imbalance is exacerbated when we factor in our severe shortage of oncologists.

“Ideally, there should be eight to 10 oncologists per million population and with a population of 31 million, Malaysia should ideally have 248 to 310 oncologists.

“However, we are far behind this figure as there are only 105 oncologists in Malaysia currently. We have only met one-third of the manpower needed to adequately care for cancer patients,” Dr Matin explains.

In Sarawak, the shortage of oncologists is even more concerning as the entire state only has five oncologists currently serving its 2.16 million population — three are stationed at Sarawak General Hospital’s (SGH) Radiotherapy and Oncology Unit (RTU), one at Normah Medical Specialist Centre, and one at Borneo Medical Centre.

But just addressing our shortage of oncologists is not enough to pave the way to better cancer management as Dr Matin guides that there also has to be increases in related healthcare professions as treating cancer is a team effort, requiring co-operation from surgeons, pathologists, radiologists, palliative care physicians, nurses, radiographers and many others.

Comparing Mortality Incidence Ratio. Adapted from Globocan 2012.

Lack of quality care

Besides addressing our access to cancer care, Dr Matin also highlights that it is important to figure out whether or not our cancer patients are getting the care they need.

One method of determining this is by benchmarking our results against developed nations in terms of looking at our cancer incidence and mortality, mortality incidence ratio and five-year relative survival rate for breast cancer.

From our incidence and mortality rates, it can be observed our rates are generally lower icompared to our regional developed neighbours.

Logically, it can be easily interpreted as us having low rates but Dr Matin guides that it is more likely suggestive of a shortfall in our information gathering.

“This is certainly the prevailing impression of many stakeholders in the oncology space.”

Instead our mortality to incidence ratio may paint a more accurate picture as Malaysia has a higher ratio of 58 per cent compared to Singapore (45 per cent), and a lower rate than other developing countries like Thailand (68 per cent).

Usually seen as a reflection of the over cancer care in the country, a higher ratio indicates there is more cancer mortality, putting Malaysia somewhere between its developed and developing neighbours.

Similarly, our five-year survival rate for breast cancer also suggests poorer outcomes for our cancer patients as previous studies indicate our average survival rate is only 50.5 per cent.

In comparison, our developed regional neighbours like Singapore and South Korea are reporting 79.5 and 91.5 per cent instead, indicating a large gap in terms of cancer survival between us and them.

According to Dr Matin, the reasons that contribute to our dismaying survival outcome are most likely due to a large number of cancer cases presenting at an advanced stage.

“This can be caused by a multitude of reasons such as patients seeking alternative therapies before radio and chemotherapy and patients not understanding the signs of cancers such as breast lumps; logistic issues of providing care all around Malaysia; delay in the diagnosis and finally a defeatist attitude that is widespread locally, causing patients to avoid or delay their treatments due to fear,” he explains.

Moreover, he notes that our lower survival outcome could also be due to the treatment our patients have received in that they have not had received either the necessary or optimal treatment needed or the treatment was received but not timely.

“Our healthcare system is under-performing as far as cancer care is concerned. We certainly need to improve to better serve our patients’ needs and aspirations,” he asserts.

Comparing five-year relative survival of breast cancer in developing and developed countries. Adapted from the Economist Intelligence Unit, Breast Cancer in Asia the challenge and response 2016.

Improving cancer management

In saying that however, we are left with a clear dilemma — how do we go about improving our cancer care and cancer management?

According to the Asean Cost in Oncology (Action) study, up to 50 per cent of patients experience financial catastrophe in the first year after diagnosis.

What this means is up to 50 per cent of patients found themselves in strained financial situations because their out-of-pocket healthcare expenditure in 12 months has exceeded 30 per cent of their entire household, leading them to experience secondary outcomes like illness-induced poverty, lower quality of life, psychological duress, economic hardship, poorer survival and disease status.

Suggesting methods to rectify this, the study went on to highlight that screening for early detection maybe the best avenue to favourably influence economic and disease outcomes in cancer patients of the low and middle-classes.

It explained that down-staging would not only help improve survival rates for cancer patients but also allow for more patients to qualify for cheaper curative treatment options such as surgery as their cancer may not have yet spread to other parts of the body.

Additionally, the process of screening for early detection could also be delegated to other healthcare professionals such as general practitioners who are in the front-line of healthcare, allowing for earlier detections and also better distribution of man power in oncology.

Prompt administration of affordable treatments of cancer should also be practised to help potentially reduce financial loss and premature deaths.

Besides that, other recommendations of the study suggested that enhancing cancer registration and increased innovation in developing awareness about cancer could also be helpful in the long run.

Projection of cancer incidence in Malaysia.

Politics and awareness

On the topic of developing awareness, Dr Matin shares that the latest George Institute for global health policy roundtable titled “Turning Action Results into Policy on Southeast Asia 2015” had identified several points centred on how to mobilise society to establish an effective cancer control programme.

The key points are to create a common message of cancer and communicate that message across all media platforms available and directed towards politicians, healthcare professionals and the public at large.

Politicians should be especially emphasised on as according to the roundtable findings, political support is necessary to ensure that support and enactment of appropriate legislation that is beneficial to the prevention of cancer, can come to fruition.

For example, regulation on tobacco control and legislation on vaccination programmes can help curb tobacco and virus-induced cancer rates on a large scale.

Following that, better resource allocations for national cancer control programmes can also be achieved by highlighting that cancer is not just a health issue but also a societal and economical issue.

For healthcare professionals and the general public, Dr Matin says the message is equally important as it can dispel some of the common myths of cancer being a death sentence and help patients get over their defeatist attitude and accept treatment earlier.

“Overall, the way forward is to collaborate with many stakeholders, both in private and public, to spread the message. And to do this, we need generous support from the government, talented and willing individuals as well as citizen groups.”

And an organisation to champion this cause is the MOS which will be holding its Annual Scientific Congress 2017 (Ascomos) for the very first time in Sarawak from Dec 8 to 10.

The two-day conference with the tagline “Pushing the boundaries of cancer — together” will focus on talks and discussions on cancer and give special focus to issues affecting cancer patients with particular interest to patients in Sarawak itself.

Some of the topics to be discussed are truths and myths of cancer, the essence of palliative care, breast cancer, colon cancer, lung cancer, Malaysia’s cancer statistics and more.

Dr Matin Mellor

About Dr Matin Mellor

Dr Matin is the current president of the MOS and a clinical oncologist at the cancer and radiosurgery centre in Subang Jaya medical centre.

Outside of his work, Dr Matin is a staunch believer that Malaysia’s cancer management needs to be continually improved on to do more and better for our cancer patients.

He believes this can be done through empowerment of the public and conducting forums regularly to help educate the public on cancer and help arm them with the knowledge to make informed decisions.

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