cancer management blueprint final 27 march 2008

8/2/2019 Cancer Management Blueprint FINAL 27 MARCH 2008

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NATIONAL CANCER MANAGEMENT BLUEPRINT

MASTER PLAN: 2008 - 2015

1.0 INTRODUCTION

Cancer has become one of the most devastating diseases with more than 10 million new

cases reported each year and is the cause of 12% of all deaths worldwide. The incidence ofcancer is steadily increasing with an expected increase from 10 million in 2000 to 15million by 2020. The main factors that contribute to the projected increase are theincreasing population of the elderly, an overall decrease in deaths from communicablediseases, and the rising incidence of certain forms of cancer, notably lung cancer resultingfrom tobacco use.

Cancer represents a tremendous burden on patients, families and societies. Besides the

financial cost of disease, cancer has important psychosocial repercussions for patients andtheir families and remains, in many parts of the world, a stigmatizing disease.

Cancer is a complex group of diseases representing more than 100 distinct diseases withdifferent causes and requiring different treatment or interventions. There is no singleknown cause or cure for cancer and everyone is at risk.

There is hope as many people with cancer do survive, and much can be done to prevent,

treat and relieve cancer suffering in a country. The World Cancer Report (2003) providesclear evidence that one third of cancers are preventable, another third can be effectivelytreated given early detection and treatment, and the quality of life for the remaining thirdwith more advanced disease can be improved with pain relief and palliative care


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with more advanced disease can be improved with pain relief and palliative care

1.2 Cancer Situation in Malaysia

Like most developed and advanced developing countries, Malaysia is approaching anepidemiologic transition, where diseases related to lifestyle particularly cardiovasculardiseases and cancers have progressively become more prevalent.

Malignant neoplasm persisted as one of the five principal causes of national mortality forthe past 20 years and its trend, in terms of absolute numbers, has escalated. In 2005, cancercontributed 10.11 % of all deaths in Ministry of Health (MOH) hospitals compared with

7.37% in 1975. The cancer incidence is estimated to be about 150 for every 100,000population. The estimated number of new cases per year is approximately 40,000.

10 Principal Causes of Deaths in MOH Hospitals, Malaysia 2005

1. Septicaemia 16.54 %2. Heart Diseases and Diseases of Pulmonary Circulation 14.31 %

3. Malignant Neoplasms 10.11 %

4. Cerebrovascular Diseases 8.19 %

5. Accidents 5.67 %

6. Pneumonia 5.30 %

7. Diseases of the Digestive System 4.45 %

8. Certain conditions originating in the Perinatal Period 4.37 %

9. Nephritis, Nephrotic Syndrome and Nephrosis 3.89 %

10. Ill-defined Conditions 2.82 %


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Ten most frequent cancers in males, Peninsular Malaysia 2003-2005 (unpublished)

3.2

3.6

3.6

4.7

6.2

6.5

7.3

7.8

12.2

14.5

0 5 10 15 20 25 30 35Percentage of all cancers

OTHERSKIN

BLADDER

LIVER

STOMACH

LYMPHOMA

LEUKAEMIA

PROSTATE GLAND

NASOPHARYNX

LUNG

COLORECTAL

Ten most frequent cancers in females, Peninsular Malaysia 2003-2005 (unpublished)

36

3.7

4.3

9.9

10.6

31.3

LUNG

LEUKAEMIA

OVARY

COLORECTAL

CERVIXUTERI

BREAST


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About 60% to 80% of these cancer cases are diagnosed at the late stages of the disease. A

fairly large proportion of Malaysians are either ignorant or are intentionally ignoring thepossible signs and symptoms of early malignancies. Furthermore, for some, modernmedical and health facilities may not be their first preferred place to seek help.

2.0 ISSUES AND CHALLENGES

The incidence of cancers in the country is expected to rise in light of the increasing ageingpopulation in the country, increase in populations exposure to cancer risks with the rapidprocess of modernization and the growing adoption of unhealthy lifestyles.

In Malaysia, the cancer control activities for prevention, early detection and casemanagement are carried out quite independently by various agencies including those in thegovernment, private sector and non-government organizations. The tendency forduplication of services provided for certain aspects of cancer control does exist, whilst onthe other hand, there is lack of service availability in other areas, namely prevention,treatment, rehabilitation and palliative care. Coverage for some of these services isrestricted due to certain barriers like geographical location, economic and social factors.

2.1 Prevention

The World Cancer Report (WHO-OMS-IARC, 2003) showed that with the existing

knowledge, at least one-third of all new cases of cancer every year can be prevented.Tobacco use is the single largest preventable cause of cancer in the world today and isresponsible for about 30% of all cancer deaths in developed countries and this figure isincreasing steadily in developing countries, particularly in women. Another 30% of cancer


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The Public Health Department and the Oral Health Division of the Ministry of Health(MOH) take the lead for most of these activities. The Public Health Department consists of

the Disease Control Division, Family Health Development Division, Health EducationDivision and the Safety and Food Quality Division.

Health education and awareness activities regarding cancer risk factors, i.e. tobacco, foodand nutrition, alcohol, betel quid and sexual habits, are being carried out through the massmedia and other channels. These were intensified in 1995, through the Healthy LifestyleCampaign, where the focus was on cancer. This campaign by the MOH was done incollaboration with other government agencies, non-government organizations and the

private sector.

Hepatitis B vaccination for newborns has become a part of the country's ExpandedProgramme of Immunization (EPI) since 1989 and is an important long term strategy forprevention against hepatocellular carcinoma.This programme is further expanded to healthcare workers at risk in the Ministry of Health in 1990 and continued to be reinforced in theyear 2006. Legislation to regulate tobacco, food safety, drugs and chemicals have been putin place since 1993, 1985, 1984 and 1952 respectively. Besides these laws, other legalmeasures related to cancer control are also in the powers of other ministries like theMinistry of Human Resources, Ministry of Natural Resources and Environment, Ministryof Housing and Local Government, as well as the Ministry of Agriculture and Agro-BasedIndustry.

2.2 Screening and Early Detection

Increasing the awareness of the signs and symptoms of cancer is important to facilitateearly detection of the disease, when treatment is most effective.

There is strong evidence to support population screening for breast, cervical and colorectal


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of advantages over conventional method. However, it would involve significant capitalinvestment and running costs.

In Malaysia, the Ministry of Health has been promoting Breast Self Examination (BSE)and annual breast examination by trained health workers as part of the breast cancerawareness campaign since 1995. This was in tandem with the mass campaign on Cancerthrough Healthy Lifestyle Campaign. However, the NHMS II in 1996 showed that only34.2% women did monthly BSE, 31.1% Clinical Breast Examination (CBE) and 3.7%Mammography (MMG) (National Health Morbidity Survey II, 1996). Mammographyservices are available in the major hospitals in the Ministry of Health but are mainly for

diagnostic purposes and for screening of high risk women with past history of breastdisease or positive family history.

The Oral Health Division, Ministry of Health established the high risk strategy programme,The Primary Prevention and Early Detection of Oral Precancer and Cancer, in 1997 and ithas subsequently gained support from the World Health Organization (WHO) in 2002. Thisoutreach programme, aimed at selected population groups and augmented by opportunisticscreening of patients in dental clinics, would afford the best approach towards downstaging and reducing the incidence and prevalence of oral precancer and cancer in thecountry.

2.3 Diagnosis

Currently all state hospitals and major district hospitals are equipped with basicradiological facilities, including MRI in 10 centers. Angiography facilities are available at

certain major hospitals. Six tertiary hospitals (Kuala Lumpur Hospital, Selayang, Serdang,Ampang, Sungai Buloh and Pandan) have high end imaging facilities (MRI, angiography,nuclear medicine) but do not have PET CT. Penang Hospital has a full compliment of highend imaging facilities including PET CT, while the PET CT and Cyclotron have been


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testings. Accessible and affordable competent diagnostic facilities should be more widelyavailable.

Currently, the Ministry of Health provides pathology services at 17 tertiary hospitals, 35secondary hospitals, 72 primary hospitals, 855 health laboratories, 3 public healthlaboratories and the Institute for Medical Research. Histopathology services are availablein 14 state hospitals, 6 major district hospitals and 6 other hospitals in the Klang valley.Immunohistochemistry, which is required for proper assessment of cancers, is available instate hospitals but the range is limited. Chemistry, haematology and microbiology servicesare available in all state and district hospitals. However, the range of tumour markers is not

comprehensive enough for proper monitoring of cancers. There are 217 diagnosticpathologists (excluding forensic pathologists), in the country, of whom 104 are in theMinistry of Health, 37 in private laboratories and 76 in the universities. Together withcontract pathologists, these can be categorized into 123 histopathologists, 24 chemicalpathologists, 50 hematologists and 20 microbiologists. Of the 104 pathologists in theMinistry of Health, 61 are histopathologists, 10 chemical pathologists, 20 hematologists, 12microbiologists and 1 geneticist. In addition there are currently 20 oral medicine and oralpathologists. The pathologist: population ratio currently stands at 1:110,000. Based on atarget of 1:75,000 (one third of the Canadian norm), we are still short of 107 pathologists.However, it is important to note that Australia, whose population size is similar toMalaysia, has achieved a pathologist : population ratio of 1:15,500.

2.4 Treatment and Rehabilitation

The strategy for treatment and management is to detect cancer as early as possible and

initiate treatment in a timely fashion. Successful cancer treatment increasingly involvesmultidisciplinary management of the cancer patients, where all treatment modalities (e.g.surgery, anti-cancer drugs, radiotherapy) are considered, and optimal individual treatmentplans are designed using evidence-based guidelines and protocols.


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advanced stage is inferior compared to results in early stages. The waiting time fortreatment in some centers in Malaysia is 68 weeks compared to four weeks in the United

Kingdom. The proportion of cancer patients who seek treatment at government centers isover 50% while less than half of the clinical oncologists are in the government sector.

In an effort to meet the demand for cancer management services and to overcome the acuteshortage of facilities, the government has been buying radiotherapy services from theprivate sector in Penang (2 centers), Kuala Lumpur (1 center), Negri Sembilan (1 center),Malacca (2 centers), Selangor (1 center) and Sabah (1 center). The total number of patientswho had treatment under buying of radiotherapy services was in the region of 2000 in the

year 2006 with a contract price of RM 8 million per year.

However, definitive plans to upgrade and strengthen the existing government centers and toopen new ones, consolidate efforts at training of skilled manpower and other strategieshave been drawn up to address the great need for a more equitable and accessible cancertreatment programme.

Improvement in cooperation between health care professionals in hospitals and PublicHealth will be further strengthened especially with the introduction and implementation ofTreatment Outcome Databases and the intensification of Screening and Early Detection ofcancer, so that it can emulate the networking achieved in Maternal and Child Health,Immunization and Infectious Diseases.

2.5 Palliative Care

Improved quality of life is of paramount importance to patients with cancer including thosepatients in whom cure is not a feasible goal of treatment. This can be attained throughprovision of palliative care, prompt assessment and treatment of pain and other problemswhich may be physical, psychosocial and spiritual.


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Some common shortcomings of palliative care in the Ministry of Health include:

a) Lack of dedicated staffing of the unit. Nurses and doctors are often sentto the unit from other departments and there is no real allocation of staff forrunning these units.b) The MOH is very dependent upon the limited support of non-government hospice organizations for continued care of patients after dischargefrom hospital.

These problems have been recognized and the Ministry of Health is now in the process ofrectifying these issues in order to allow palliative medicine to grow further. In December2002, the palliative care unit of Selayang Hospital was opened. This unit was developed asthe main centre for palliative care with dedicated specialist care from which the field ofpalliative medicine was to be developed. This 12-bedded unit is run by a consultantanaesthetist and pain specialist, a clinical specialist physician, and 3 full-time medicalofficers whose daily work is in palliative care alone. The nursing staff includes a wardsister and 12 nurses. The unit has a day-care center as well as a resource center for teaching

with a small library. Following the model of the Selayang Hospital palliative care unit, theMOH plans to further develop similar models of specialized palliative medicine services inall other state hospitals.

Apart from public hospitals, non-governmental organizations also provide palliative careservices for cancer patients.

2.6 Traditional and Complementary Medicine

Malaysia has a competitive advantage in promoting traditional and complementarymedicine because of the confluence of Malay, Chinese, and Indian system of traditional


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2.7 Human Capital

In Malaysia, the development and accessibility of the cancer control programme areaffected by limitations in infrastructure and human capital.

There is lack of trained personnel in treatment and management of cancer in this country.One example is in the number of clinical oncologists in the country. Based on a norm of 8per million for clinical oncologist to the population ratio, Malaysia needs at least 200clinical oncologists, but presently there are only 39 of whom 10 are in Ministry of Health

hospitals. Moreover, more than half of cancer patients seek treatment in the governmenthospitals where the shortage of oncologists is most acute.

The lack of adequate manpower also exists in the other disciplines in cancer care such as inepidemiology, prevention, screening and early detection, diagnosis, treatment,rehabilitation, palliative care and complementary medicine. The challenge to recruit andretain these health care workers remains an urgent need in the government sector. Amongthe critical shortages in health care professions are clinical oncologists, adult

haematologists, paediatric oncologists, cancer surgeons, other ancillary care providers,pathologists, radiologists, cytopathologists, cytogeneticists, medical physicists, scientificofficers, cancer epidemiologists, radiographers, rehabilitation physicians, palliativemedicine specialists, nurses, pharmacists, medical technologists, psychologists, traineddoctors in cancer care and other supporting staff. The roles for professionals such asmedical oncologists in this country will be increasing.

The continuous training and education of the cancer health care professional workforce hasremained a challenge. Up-to-date knowledge and skills will enable health care providers toprovide excellent quality of service to cancer patients in the country. Formalized trainingwith overseas cancer centers needs to be encouraged There are also the requirements for


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these facilities in the northern, central, southern, eastern regions of the Peninsular and inSarawak and Sabah would contribute towards the accessibility of patients in these regions.

Existing facilities for cancer treatment in the Department of Radiotherapy and Oncology atKuala Lumpur Hospital and Sarawak General Hospital will need to be further upgraded.

Basic radiological cancer diagnostic services such as ultrasound, CT scans andmammogram should be extended to major district hospitals. Endoscopic facilities should beset up in all regional centers. Proven techniques such as immunohistochemistry, flowcytometry, cytogenetics and molecular biology in cancer diagnosis should be made

available in all tertiary centers.

Major hospitals should also be designated with rehabilitation medicine specialty facilities.Upgrading of current cancer rehabilitation facilities should include lymphoedema controland upperlimb function, body image, psychosocial and sexual rehabilitation for breastcancer and female-related cancers.

2.9 Equipment

Upgrading and replacement of machines in existing cancer facilities should be a priority asa significant proportion of equipment are old and beyond the normal life-span.

High-end equipments are needed for the different disciplines in cancer care. Upgrading ofendoscopes, Magnetic Resonance Imaging (MRI) equipment, Computerised Tomography(CT) scans, Positron Emission Tomograpphy (PET) scans, nuclear medicine scans andother imaging tools should be made available in tertiary centers. Provision of fundamentalequipment necessary for cancer diagnosis e.g. proctoscopes, speculums, microscopes, X-ray machines and ultrasonography machines must also be placed in primary care centers.


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Most hospitals do not have the facilities of central cytotoxic drug reconstitution. While

some newhospitals have the facility already, it is not yet being used optimallydue to poorconstruction not meeting the requirements of Good Manufacturing Practices (GMP) whichis necessary to ensure drugs reconstituted are carried out in a proper and safe manner freefrom microbial contamination for administration to patients. Considerable budget forupgrading of existing facilities and building new ones to meet the needs of hospitals havebeen approved in the 9MP to ensure all CDR are done in proper facilities and by trainedpersonnel and not in open wards as in current practice. There must be adequate training ofpharmacists and pharmacy assistants in the duties and roles that accompany expansion of

such services. Pharmacists will need to be trained in the clinical therapy management ofcancer patients to provide pharmaceutical care necessary to ensure optimal drug use andthis will complement the role of oncologists and doctors in managing drug therapy forthese patients. Improving processes in prescribing, distributing, dispensing andadministration of drugs should take into account the following: 1) identify key drugs anddemands; 2) ensure continuous supply; 3) keep track of drug development; and 4) promotelocal drug manufacture.

To explore all opportunities to improve the accessibility, affordability and availability ofchemotherapy drugs, it is advisable to build stronger partnerships with the biotechnology,biomedical engineering and pharmaceutical industries for the development of new cancerdrugs and research into the prevention, early detection and treatment of cancer. The sharingof resources and intellectual capital with both large and small companies has great potentialfor advancement of the development of novel therapeutics.

2.11 Information and ICT

All citizens should receive culturally appropriate information about ways in which theirrisks of developing and dying from cancers can be reduced and should have prompt access


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Health Outcome Measurements in the form of Treatment Outcome Databases will becomemore important and be given further development within the Ninth Malaysia Plan. This

will provide clinical data while the National Cancer Registry will continue providingpopulation based data.

2.12 Funds

Apart from the provision of an operating budget, the Government should also allocatefunds for facilities and equipment and form a body for monitoring fund utilization.

The Government and NGOs should provide startups funds, leadership, guidance, andtechnical assistance for cancer initiatives that range from teaching school children toeducating professionals and the public about the need to improve quality of life for allcancer survivors. All funded initiatives should focus on awareness, education, andoutreach. Additional funds should be raised from public and private sources to supportlocal and national program of pain relief and to support cancer rehabilitation programsthrough establishment of a system of network between collaborating agencies.

A dedicated cancer research fund should be established to support research including longterm cancer cohort studies and other cancer outcome studies. Currently there is insufficientfunding to realize the cancer research agenda of the country. There should be morecoordinated efforts to source research funds from the private, non-governmentalorganizations and corporations. Most cancer studies are funded by the government throughthe various grants from the Ministry of Science, Technology and Innovation (MOSTI) andthe MOH research grant. There are some studies funded by the non-governmentalorganizations. Some are industry-initiated, with funding from the pharmaceuticalcompanies or their research organizations. Among the weaknesses are that despite themoney injected into research projects, only a few make it to publication. One of the reasonsis lack of skilled manpower dedicated to research, difficulty in data retrieval and poor


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and demonstrate commitment to collaborative research. Of primary importance is the needfor research directions to cut across disciplines by incorporating a variety of cancer

centered programmes and, where possible, promoting interactions among basic, clinical,and population scientists. In addition, targeted research directions should apply to a numberof disease groups. Ongoing intra-programme retreats and meetings should showcase themany outstanding research efforts and acknowledges individuals and groups that havemade significant contributions to the field of cancer research.

Strategic plans should be prepared detailing how the NCI will expand its research inprevention, early detection, diagnosis, treatment, rehabilitation, palliative care,

complementary medicine, environmental risk factors, symptom management, imaging andscreening, health disparities and cancer survivorship.

There is also a lack of information for survivors, their caregivers, health care professionals,and policymakers not only on late or long term effects of cancer treatment and quality oflife issues, but also on prevention of second cancers and survivorship-specific concerns.Recognizing this deficit, the NCI must promote research on the health and functioning ofthe growing population of cancer survivors through interventions that seek to evaluate and

improve the post treatment cancer experience.

3.0 VISION AND MISSION

THE VISION

By the year 2025, cancer will no longer be a public health problem in Malaysia, where allpreventable cancers are effectively prevented, all potentially curable cancers are detected atthe earliest stage and competently treated with optimum rehabilitation, while all terminally


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THE MISSION

All Malaysians must have a factual understanding of cancer, recognize its causes, knowhow to prevent, detect early signs and symptoms, it's treatment, rehabilitation andpossible outcomes. Individuals will be empowered to choose positive lifestyles and otherrelated personal habits.

All cancer patients are cared for within a supportive and caring environment in all aspects,which includes physical, social and psychological aspects.

Cost-effective, efficient and acceptable facilities and services for prevention, earlydetection, diagnosis, treatment, rehabilitation and palliative care of all cancers,encompassing a comprehensive range of holistic approaches, will be made available andaccessible for all.

Cooperation and resources from all relevant Government agencies, private sectors, non-government organizations, corporate bodies and the community, undertaken as a smarteffective partnership will be harnessed to maximize cancer management efforts.

4.0 GOALS AND OBJECTIVES

The overall aim of the National Cancer Management Blueprint in Malaysia is to reduce thenegative impact of cancer by decreasing the disease morbidity, mortality and to improvequality of life of cancer patients and their families.

The seven goals outlined in the National Cancer Management Blueprint and their relatedobjectives are:


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GOAL 3: DIAGNOSIS

Objective 1: To improve the accuracy, efficiency, accessibility and timeliness ofcancer diagnosis to all cancer patients and health care providers

Objective 2: To streamline cancer diagnosis and research using proven state-ofthe-art technologies to better characterize and profile cancers,specifically in grading and staging of cancer, determination ofcancer progression, prognosis and predictive response to treatmentmodalities, leading to best possible effective personalized treatmentand outcome

Objective 3: To provide comprehensive diagnostic services to support cancerpatients in all aspects of care including complications and secondaryeffects of cancer and its treatment

Objective 4: To conduct research to improve cancer diagnosis in particular, whileutilizing the diagnostic services to facilitate and support cancerresearch in general

GOAL 4: TREATMENT

Objective 1: To enhance cancer therapy delivery and services which are timely,equitable and accessible for cancer patients throughout the country

Objective 2: To provide a good, safe and quality state-of-the-art cancertreatment for cancer patients in the country

GOAL 5: REHABILITATION

Objective 1: To provide Cancer Rehabilitation Services (CRS) to all patients who


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GOAL 7: TRADITIONAL AND COMPLEMENTARY MEDICINE

Objective 1: To relieve pain and suffering of cancer patientsObjective 2: To improve the quality of life of cancer patientsObjective 3: To allow cancer patients to cope better with cancer and treatmentObjective 4: To minimize the side effects of cancer treatment

5.0 PRIORITIES

For the initial implementation of the National Cancer Management Blueprint, the followingkey priorities have been identified:

i. Establishment of the National Cancer Institute and the setting up of theNational Cancer Control Committee. The Committee shall formulate thenational cancer control policies and ensure the efficient and effective

implementation of all the components of cancer control priorities andstrategies as outlined in the Blueprint.

ii. Selected cancer for screening and early detection among populations atrisk is made available and accessible.

iii. Effective public health education and awareness programmes conductedin partnership with other government agencies, private sector, professional

bodies and the non-government organizations.

iv. Human capital development through establishment of new posts,targeted training programmes and the recruitment of foreign experts and


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ix. Spearheading and boosting local R&D efforts on cancer control andmanagement.

x. Strengthening current legislations and enacting new relevant legislationswith effective enforcement and surveillance.

xi. Developing National Standards, Guidelines, Codes of Practice onCancer Management with professional bodies such as the Academy ofMedicine Malaysia.

6.0 THE ACTION PLAN

To achieve the goals, objectives and targets of the National Cancer Management Blueprint,the following action plans are proposed.

6.1 GOAL 1: PREVENTION

Objective 1: To reduce the prevalence of risks factors for cancers in Malaysia

Objective 2: To increase awareness and knowledge of the general public on

the risk factors of the common cancers in Malaysia

Objective 3: To strengthen the cancer risk factors intervention programmes

The major challenge in controlling cancer is not only focusing on reduction in mortality butrather, in reducing the incidence. It is imperative that in the present health care system,cancer prevention activities are expanded further to include common cancers thusemphasizing the governments commitment in reducing incidence of cancers in Malaysia.


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A national cancer registry is essential in providing useful information related to riskfactors, identifying population at risk and thus for developing evidence-based policy,

planning of cancer control and research initiatives, in particular on cancer epidemiologyand treatment. The completeness and accuracy of data accumulation by the cancer registryhave progressively increased. The International Agency for Research in Cancers (IARC)which plays a primary role in the establishment and accreditation of world cancer registrieshas given its input to our country.

A population based cancer registry was first started in the country by the Public HealthDepartment, Ministry of Health with data collection commencing in 1989. However

inadequate human resource, infrastructure and finance were major problems faced in thisinitiative. In 1993, Penang launched the pilot Regional Cancer Registry using thevariables by IARC. This registry was a success and was expanded to the whole country.However, in 2000, a decision was made that the registry would only be carried out in sixselected states namely Penang, Kelantan, Pahang, Johore, Sabah and Sarawak. These states/ regional registries would be representative of the ethnicity and demographic differences inMalaysia. The Penang Cancer Registry generated two 5-year composite reports, that is, in2003 (1993 1999) and 2005 (1999 2003). The Sarawak and Kelantan Cancer Registry

produced their reports in 2005 and 2006 respectively.

The first National Cancer Registry (NCR) was developed in collaboration with the ClinicalResearch Centre (CRC), MOH in 2001. The NCR produced its first and second NationalCancer Registry Report in 2003 and 2004 respectively. For the first time, nationalestimates of cancer burden were available.

In 2007, the two cancer registry systems (namely the National Cancer Registry and theRegional Cancer Registry) will be merged and further strengthened so as to improve dataquality and validity, as well as for better management of cancer registries at state andnational level. The Disease Control Division, MOH at Putrajaya will process and analyse


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population based study, Malaysia NCD Surveillance-1 (MyNCDS-1), produced in 2006 isthe first of a population based surveillance study conducted in 2005 in all 13 states in

Malaysia among the Malaysian citizens aged 25-64 years old. This surveillance isscheduled to be conducted on a 2year interval.

6.1.1 Tobacco

In the World Cancer Report 2003, WHO has identified tobacco as the majorpreventable cause of death in the humankind. Boyle et al (Lung Cancer, 1995)noted smoking is the most common cause of lung cancers. The relative risk for

regular smoker to develop lung cancer is almost 20 times higher compared to non-smoker. Smoking is rapidly becoming a serious public health problem in Malaysia.The National Health and Morbidity Survey conducted in 1996 showed an overall24.8% of those aged 18 and above were smokers, with male prevalence at 49.2%and female at 3.5%. MyNCDS-1 2005 showed that the prevalence of currentsmokers was 25.5%, with about 46.5% men and 3.0% women reported that theywere current smokers. The National Health and Morbidity Survey conducted 2006showed that the prevalence of current smokers was 21.5%.

Effective intervention to reduce this prevalence is a great challenge. The US Centrefor Disease Control and Prevention (CDCP) 2000, in systematically evaluatingtobacco control interventions and health outcomes based on evidence, listed variousstrategies that could be taken. The strongly recommended actions on theintervention to reduce tobacco use include increasing the unit price of tobaccoproducts and informing young people through high intensity counter-advertisingcampaigns. Multi-component cessation interventions to reduce tobacco use includesmoker education, support and counseling to reduce or stop smoking. To reduceexposure to environmental tobacco smoke, bans or limits on tobacco smoking inworkplace and public areas are strongly recommended.


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about 0.37% reduction per year. The Cancer Council of Australia put up a target of1% reduction of smokers prevalence per year in their National Cancer Prevention

Policy 2004-2006.

For Malaysia, NHMS 2006 result should be able to project the possible reductionexperienced as a result of interventions that have taken place for the last 10 years.With the price increase of cigarettes every year imposed by the government,increasing places prohibited for smoking, TAK NAK campaign targeted among theschool children, availability of Quit Smoking clinics and good NGO networking, itis possible for Malaysia to achieve a reasonable reduction of smoking prevalence.

A maximal target of 0.5% reduction per year for smoking prevalence in 9th MPperiod for Malaysia is considered achievable. With the availability of NHMS 2006and with result from next 2-year scheduled MyNCDS survey would provide theachievement that can be the basis for review in the 9th MP mid-term review.

6.1.2 Hepatitis B

The most useful method of combating cancer as well as other afflictions induced by

viral infections would be through an effective vaccine. Although some estimatethat viruses could be responsible for as much as 15% of cancers, at present, the onlyimmunization that is widely given is against hepatitis B virus (HBV).

Promotion of HBV vaccination for infants became a part of the ExpandedProgramme of Immunization (EPI) in 1989. The implementation of HBVvaccination programme for health workers in 1990 has been consolidated in 2006nation wide and intensified by vaccination among the Form Six schoolchildren in2006 will further increase the vaccination coverage in Malaysian population. Theeffort to prevent primary liver cancer as well as chronic hepatitis, will however onlybe apparent in 30 years. The cohort population prior to 1989 will be progressively


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diseases by HO and FAO UN, 2003; Nutrition aspects of the development of

cancers, UK Health Dept, 2003] have showed various conclusions on the

associations of cancer protective effect of vegetable and fruits (Source: AustralianNational Cancer Prevention Policy 2004-2006).

6.1.4 Physical Inactivity

The research for the link between physical activity to specific cancers begin in1980s and has been increasing since then. The IARC report in 2002 identifiednumerous studies on this aspect.

There is growing evidence that physical inactivity has an influence in themanifestation of certain cancer types. The IARC Report (2002) and a study by Lee(2003)showed a strong evidence of association for breast cancer and colon cancerto physical activity.

The promotion for physical activity in Malaysia has been launched by Ministry ofHealth through various mechanisms continuously especially through mass media

campaigns.

6.1.5 Alcohol consumption

Apart from the toxicity of excessive alcohol intake and the tendency of someindividuals to become alcoholics, investigation has disclosed long term damage tothe nervous system, liver and other organs. Moreover, liver cirrhosis is stronglyassociated with primary liver cancer.

Accumulated evidences have also shown that heavy alcohol drinking increases therisk of cancer in the oral cavity, pharynx, larynx and oesophagus - synergistic effect


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In Malaysia, the habit of betel quid chewing is prevalent amongst the Indiancommunity as well as certain indigenous groups in Sarawak, Sabah and

Peninsular Malaysia. Hence, primary prevention of oral cancer should focus uponmodifying the habitual use of betel quid in these target groups.

6.1.7 Occupational Exposures

Occupational exposure is associated with 5-10% of cancers. Exposure rate to widerrange of carcinogens has recently accelerated with the introduction of new physicaland chemical processes in the event of industrial intensification. At least 11

industrial processes and 17 chemical groups are evidentially associated withcarcinogenicity in human beings. Occupational cancers often involve the lung,while other sites include the skin, urinary tract, nasal cavity and pleura.

In Malaysia, the Department of Occupational Safety and Health (DOSH) isresponsible for monitoring the notification of diseases related to cancer. Thenumber of occupationally related cancers that were reported has been very low.Most are related to hydrocarbons exposure. Since the introduction of OSHA

(Occupational Safety and Health Act), the regulation of cancer related substanceshas improved in the processes undertaken by industries.

6.1.8 Environment

Physical environment factors accounts for 1-2% of cancers that include pollution ofair, water and soil. However, it is quite difficult to prove the association of canceroccurrence with environmental factors. Further research related to this associationshould be carried out locally so that specific approaches related to environmentalinduced cancer prevention programme can be planned. Asbestos is the bestdescribed environmental exposure to human related cancer.


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6.2 GOAL 2: SCREENING AND EARLY DETECTION

Objective 1: To detect potentially cancerous lesions in the population at risk

for the selected cancers i.e. breast cancer, cervical cancer, oral

cancer, liver cancer, colorectal cancer, prostate cancer and

nasopharyngeal cancer

Objective 2: To increase the detection rate of selected cancers at an earlier

stage of the disease

If cancer can be diagnosed early in its course, treatment is generally more effective thanwhen it is advanced. It is essential that the NCMP recognize the limitations and benefitsof early diagnosis and screening to avoid "high technology" but poor cost-effectiveapproaches, or to avoid methods which are not achieving the needed coverage of thetargeted population. It is important to realize that screening programmes should not beintroduced unless there is adequate manpower to perform the tests and enough facilities fordiagnosis, treatment and follow- up of individuals with abnormal test results.

In Malaysia, as high as 80% of relatively curable cancers are present at advanced stages.Thus, "down-staging" by increasing public awareness, combined with prompt and effectivetherapy, could have a major impact on the disease.

6.2.1 Breast Cancer

Systematically offering mammography to women aged 50-69 years in a population,and following-up those with positive or suspicious findings, aims to reduce breastcancer mortality.


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and army hospitals. However, the programme approach remains as opportunisticscreening.

The coverage of population based screening especially for women over 30 years oldshould be increased and made accessible for every eligible woman in the country.Cervical cancer should be down-staged i.e. from 65.1% of stages 2 4 presently toless than 20% in stages 2 - 4 in 2025. Efforts to organize effective cervical cancerprevention programme require collaboration and full commitment from theGovernment, Health Authorities, Clinicians, Pathologists, Medical Personnel,Media and the Public. This effort must be accompanied with adequate financial

resources, upgrading of infrastructure and equipment and increasing the number oftrained medical personnel. In cytology, considerable attention should be given toobtaining good quality smears, staining and reporting so that a moderately highsensitivity to detect lesions is ensured. To have an impact on cervical cancerincidence and mortality, efforts must be focused on the following: increasing theawareness of women about cervical cancer and preventive health-seekingbehaviour, screening all women aged 35-50 years at least once, effective treatmentfor high grade lesions, monitoring programme inputs and evaluating the outcomes.

Although cervical cytology is a common tool used for screening of cervical cancer,there are technical, human resource and financial constraints in its implementation.Therefore there is a need to explore the other modalities of screening eg: Visualinspection with acetic acid (VIA).

Human Papilloma Virus (HPV) vaccination should be considered in the future planof the cervical cancer control programme. However despite HPV vaccination as amodality for primary prevention, cervical screening program should be continuedas HPV vaccination is expected to prevent only 71% of cervical cancer.

6.2.3 Oral Cancer


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Colorectal cancer forms about 10% of all known cancers in Malaysia. At present,there is no specific programme for colorectal cancer screening. However, screening

for high risk patients e.g. those with polyps is carried out at hospitals. Severaltechniques have been developed for early detection of colorectal cancer such astesting for occult blood in the stool and sigmoidoscopy.

Future screening programme should focus on the high risk groups to improve thepick-up rate and the cost effectiveness.

6.2.5 Nasopharyngeal Cancerrcinoma

Nasopharngeal carcinoma (NPC) is a leading head and neck cancer in Malaysia.There are no specific early signs or symptoms. It can also spread to the neckwithout any evidence of primary growth in the nasopharynx. It is an aggressivedisease which spreads to the neck very early in its course. However, it is potentiallycurable if detected early.

Biopsy of the nasopharynx and microscopic examination of the tissue are the

current methods of diagnosis. Several techniques have been developed for earlydetection of NPC antibody such as testing for serum IgA antibody to EBV or EBVDNA in the nasopharyngeal tissue. At present, there is no screening programme forNPC in Malaysia. High risk population screening should be started as soon aspossible at the national level. However it requires careful evaluation.

6.2.6 Prostate Cancer

Screening for prostate cancer using the digital rectal examination (DRE) is oftenrecommended, but DRE is not a sensitive screening test for early disease. Prostatespecific antigen or PSA has been widely introduced as a screening test in the United


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significantly modify the natural course, outcome and may decrease mortality. HCCis one of the top ten cancers in Malaysian male (National Cancer Registry 2003).

There is already a consensus on the screening of HCC for the high risk populationand its treatment. Currently there are two screening tests recommended for HCC,alpha-fetoprotein (a tumour marker) and ultrasonography of the liver.

6.3 GOAL 3: DIAGNOSIS

Objective 1: To improve the accuracy, efficiency, accessibility and timeliness

of cancer diagnosis to all cancer patients and health careproviders

Objective 2: To streamline cancer diagnosis and research using proven state-

of the-art technologies to better characterize and profile

cancers, specifically in grading and staging of cancer,

determination of cancer progression, prognosis and predictive

response to treatment modalities, leading to best possible

effective personalized treatment and outcome

Objective 3: To provide comprehensive diagnostic services to support cancerpatients in all aspects of care including complications and

secondary effects of cancer and its treatment

Objective 4: To conduct research to improve cancer diagnosis in particular,

while utilizing the diagnostic services to facilitate and support

cancer research in general

Objective 1: To improve the accuracy, efficiency, accessibility and timeliness of

cancer diagnosis to all cancer patients and health care providers

The diagnosis of cancer is one of the most important steps in the management of cancer. It


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It should also be recognized that the diagnosis of cancer is not merely the detection of thepresence of cancer. In line with advancements in therapeutic options, there is increasing

demand for more information on the nature and characteristic of each cancer detected. Thescope of cancer diagnosis therefore extends to (1) identification of aetiological agents andtheir linkages to the development of precancer and cancer (with impact on policydevelopment, cancer prevention and treatment), (2) determination of cancer biology andpathogenesis (impact on cancer prevention, treatment strategies and product development),(3) accuracy, sensitivity and specificity in detection, monitoring and classification ofcancer (impact on efficiency and cost-effectiveness of cancer diagnosis), and (4)determination of prognostic and predictive parameters (impact of treatment strategies).

The combination of all these various aspects of cancer assessment leads to characterizationof the unique profile of each cancer, allowing determination of the most appropriatetreatment modality for each patient (personalized treatment) and prediction of outcome.

Objective 3: To provide comprehensive diagnostic services to support cancer

patients in all aspects of care including complications and secondary effects of cancer

and its treatment

The morbidity suffered by cancer patients are often related to secondary effects of thecancer rather than the cancer itself (such as deep vein thrombosis, infections,paraneoplastic syndromes, hormonal and electrolyte imbalances, etc). Furthermore, cancertreatment itself also induces physiological changes, side-effects and complications whichcan lead to considerable morbidity and even mortality. Hence, good cancer managementrequire comprehensive diagnostic services with the capability and capacity to detect andmonitor all kinds of secondary effects and complications of cancer as well as treatment.These diagnostic services would extend beyond the detection of the mere presence ofcancer, and would encompass the upgrading of the routine anatomical pathology, chemicalpathology, haematology, immunology, microbiology and radiological facilities to meet theneeds of cancer care.


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Objective 1: To enhance cancer therapy delivery and services which are

timely, equitable and accessible for cancer patients throughoutthe country

Objective 2: To provide a good, safe and quality state-of-the-art cancer

treatment for cancer patients in the country

For both the objectives above, a more comprehensive treatment strategy will be plannedaccording to the needs and requirements of the population. The major part of this strategyis to increase the number of new cancer treatment centers in the country through the

development of several regional centers. These new centers should include the followinglocations to give enough coverage nationwide.

National Cancer Institute, PutrajayaLikas Hospital, SabahPenang Hospital

In the first three years of development, Likas Hospital should have a dedicated Oncology

Unit to begin or continue the treatment of patients using chemotherapy and other drugtherapy. The development of the radiotherapy component should be started immediately sothat by the end of the RMK-9 period, a comprehensive cancer treatment center can beestablished. The installation of radiotherapy facilities at Penang Hospital will begin inRMK-10.

Together with the existing cancer treatment centers already functioning at the KualaLumpur Hospital, Sarawak General Hospital and Sultan Ismail Hospital, these new centerswill be developed according to the Blueprint. To facilitate development, these centers willbe categorized according to the level of sophistication required at the various centers.


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Other MOH General Hospitals will deliver simpler chemotherapy regimes and supportedby Surgical and/or Medical Units with resident Consultants, Oncology Nurses, Pharmacists

and Cytotoxic Drug Reconstitution Facilities (CDR).

With this stratification, chemotherapy funding and costs can be planned carefully by thevarious hospitals and in the long run, provide better access to treatment which will also bemore cost-effective.

To overcome the shortcomings in cancer treatment, the following strategies will beadopted:

i. Strengthening and upgrading the present system of radiotherapy andoncology services and palliative care services. This would be done with theestablishment of a national cancer centre, namely the National CancerInstitute and the strengthening of a network of regional centers during theperiod of the 9th Malaysia Plan. All of these together would constitute anational network of clinical oncology.

ii. Upgrading of Haematology Centers

Haematology will be upgraded as follows:a) Ampang Hospital (2006-2010)(National Haematology Referral + Adult Stem Cell Transplant Center)

b) Penang Hospital (2008-2010)(New Bone Marrow Transplant services second center)

c) Upgrading of facilities in Sultanah Aminah Hospital, Johor Bahru,Tengku Ampuan Rahimah Hospital, Klang, Ipoh Hospital and Kota


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iv. Upgrading of Oral Oncology

Upgrading existing facilities and services in oral oncology at identifiedregional centers (Kuala Lumpur Hospital, Tengku Ampuan RahimahHospital, Sultanah Aminah Hospital, Johor Bahru, Sarawak GeneralHospital, Queen Elizabeth Hospital Kota Kinabalu, Kuala TerengganuHospital, Alor Star Hospital).

v. Continuing and expanding the existing Ministry of Health and private sectorpartnership through the outsourcing of a certain proportion of the treatment.

National Cancer Institute (NCI)

The role of the NCI will be as follows:

a) Provide state-of-the-art facilities for cancer management with the NCI beingthe main referral center for clinical oncology focusing on the treatment ofcases requiring sophisticated techniques, especially stereotactic

radiosurgery for various sites in the body and sophisticated brachytherapy.

b) Provide comprehensive supportive care in collaboration with otheragencies.

c) Establish and regularly monitor and review national guidelines, standardoperating procedures and other documents for appropriate clinical practicesusing multidisciplinary approaches in treating all cancer patients.

d) Provide training for doctors and allied health personnel specializing incancer management and treatment. This includes training for pharmacists


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i) Develop and sustain the Clinical Treatment and Outcome Database.

Regional Centers

The National Network of Clinical Oncology will have the following roles andobjectives:

i. To provide a minimum standard of quality medical care and treatmentfor cancer patients by following good clinical practice guidelines (to havemeasurable objectives on health outcomes (e.g. survival).

ii. To lead in the introduction and utilization of new and proven cancertreatment and technology.iii. To encourage and provide a conducive environment for thedevelopment of cancer research.iv. To provide training of oncology related supporting personnel includingphysicists, radiographers, nurses, pharmacists, palliative care physicians,counselors, etc.v. To provide education and current information on research in oncology

and breakthroughs in the field.vi. To facilitate the development of palliative and supportive care includingcontinued provision of care at home.

The development of clinical oncology at Kuantan in the eastern region could be ledby the Ministry of Higher Education, in collaboration with the Ministry of Health.

This network should be realized by the end of the Ninth Malaysia Plan, during

which time new centers for Clinical Oncology will be established by the Ministryof Health in Putrajaya (National Cancer Institute) and Sabah and services upgradedat Kuala Lumpur Hospital, Sarawak General Hospital and Sultan Ismail Hospital,


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Health is already outsourcing services from include the Mount Miriam Hospital,Sabah Medical Centre, Mahkota Medical Centre, Pantai Ayer Keroh Hospital,

Pantai Mutiara Hospital, NCI Cancer Hospital and Sabah Medical Centre. Newprivate centers will be opened, upgraded or planned in Kuala Lumpur, Penang,Ipoh, Sarawak and Malacca in the foreseeable future.

A greater level of outsourcing will be appropriate until the manpower and facilitiesin the Government sector are able to achieve an equitable and accessible level ofcancer services in the country. While comprehensive planning is needed indeveloping the new cancer centers for the whole country such as at Likas and

Penang, as well as in consolidating the existing centers at Kuala Lumpur, Kuchingand Pandan, there should be better public-private integration in the setting up ofnew centers.

The Ministry of Health centers will treat cases that meet certain criteria ofcomplexity while other cases will be referred and treated by selected centers in theprivate sector. The purchasing of radiotherapy services in the future may becomemore comprehensive, i.e. not just machine time, but the holistic management of

patients by the private sector oncologists. Efforts at establishing a consensusguideline for management of common cancers are already underway so thatnetworking between various cancer centers will be closer.

The issue of human resource especially for oncologists must be addressed. Thereshall be more widespread adoption of double appointments where doctors at onecenter may be able help see patients in other centers, or to be attached to bothservice and research institutions. The location of subspecialities needs to be

carefully thought through, for example developing stereotactic radiosurgery forsmall brain lesions at the National Cancer Institute. Joint training of doctors for theMaster in Clinical Oncology shall be given continued support. While waiting for


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Surgical oncology procedures requiring brachytherapy will be developed at theNational Cancer Institute which will provide a comprehensive set-up complete with

purpose-built operating theatres, imaging equipment, storage facilities forradioactive materials and facilities for intra-operative brachytherapy.

Oncology Drugs

The following new drugs have been proposed to be included into the MOHSystemic Therapy of Cancer 2nd Edition after the Chemotherapy protocol meeting atPutrajaya in November 2007. The suggested budget requirements for new drugs

are as follows:

Treatment siteNo. of MOH patients (pt) in

Malaysia to be treatedUnit cost

2008 Total

cost to

MOH for

the country

per year

2,009 2,010

Breast Ca adjuvantTraztuzumabaverage treatmentfor 1 year 8mg IVfollowed by 6 mgIV every 3 weeks

Incidence of breast cancer 4,000/yr, 50% are stage 1 & 2, =2,000 pts ;

of this 20% ie 400 are HER2 + andof this only 50% are high risk node+ve ie 200 pts but only 100 aretreated in public hospitals+C2

RM80,000 /year / pt

8,000,000 14,400,000 19,500,000

There will be a snowballing effectas the duration of therapy is long.

Docetaxel inj

Recurrence of breast and hormonerefractory prostate cancer

RM1000 x 6 x300 patientsper year

1,800,000 2,000,000 2,500,000


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GoserelinNeoadjuvant and adjuvant forprostate cancer

RM260x 12200 patientsper year

650,000 750,000 900,000

GIST on Imatinib ifhistologicallyproven GIST with ckit positivity

Incidence of GIST & CML 250/year. 500 patients on treatmentnow. May treat additional 100pts /year in Govt hospitals. 250patients estimate to need treatmentcurrently

ImatinibRM8,000 /mth; =RM96,000/year x 250 ptsx0.5

12,000,000 21,000,000 25,000,000

400mg daily for 2years There will be a snowballing effect

as the duration of therapy is long.*see tx for 2 yrs average

Half cost borned by Novartisthrough MYPAP

estimated 25% death per year

AprepitantAntiemetic for level 3 and 4Day 1 : 125 mg, D2 and D3 : 80mg

RM220 everycycle x 5cycles x 500patients peryear

550,000 600,000 650,000

Recurrence ofovarian cancer for

average of 6 cyclesat 50 mg /m2 every21 days

Incidence of ovarian cancer=533 /year; 70% are epithelial

ovarian cancer = usually 80%relapse = 373 . Of these only 50%treated in Govt hospitals & fit=150

RM2200 / 20mg Liposomal

Doxorubicin(1.7m2 x 50 mg/m2 = 80 mg)

5,300,000 5,300,000 5,300,000


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Extended adjuvanthormonal treatment

for breast cancer

Incidence of breast cancer per year= 4000. Post menopausalestimated to be 2000. Thosepatients who are node positive andoestrogen receptor positiveestimated to be 1000. Estimatedthat 500 patients per year willcomplete 5 years of tamoxifenwithout recurrence, thus makingthem eligible for extendedadjuvant therapy. This will

SNOWBALL into at least 900patients the following year (ie 500plus 400, assuming some of thepatients will develop recurrenceand thus not be eligible foradjuvant therapy as stated above).This number will be increasingyear to year, thus making thebudget more and more challenging.

This has beenthe mostchallengingarea due to thelarge numbersof patients

involved andthesnowballingeffect.

3,000,000 5,400,000 7,300,000

Total based on drugs that aregoing to be in the protocol for

first time

33,000,000 51,000,000 63,000,000

Existing Expenditure from kontrak, pharmaniaga, kpk,LPO RM 104 M RM 120 M RM 138 M

90 juta - 2007 and increase 15% each year

Total RM 137 M RM 171 M RM 201 M

2008 2009 2010


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Lumpur consumed 30.3% of the budget, Hospital Umum Sarawak 14.32%,Hospital Pulau Pinang 9.67%, Hospital Ampang 5.10%, Hospital Kuala Trengganu

4.79% and Hospital Sultanah Aminah 5.93%, Hospital Ipoh 4.17% and HospitalQueen Elizabeth 3.45%.

Generic Drugs

Access to oncology drugs is a major concern in the treatment of cancer patientsbecause of the impact of patents on the costs of the drugs. To facilitate access toaffordable medicine, there is a need to look into the import of generic versions of

antineoplastic drugs through compulsory licensing under the grounds ofGovernment Use authorization or non-profit use or public health emergency. Forthe long term, local manufacturing of generic drugs is an option to consider as afurther cost reduction measure. Efforts must be taken to make appropriateprovisions in the legislation to enable access to medicines for all especially thepoor. Legislation is also needed to ensure that the companies marketing genericdrugs invest in bioequivalence (BE) studies to ensure quality drugs for goodoutcomes in patients. Bioequivalence or therapeutic equivalence data shall be a

requirement for all generic anticancer drugs before being approved for use in thecountry. Bioequivalence should be done at the Federal level where the regulatoryauthority requires drugs to be of a minimum standard before they are marketed.Bioequivalence may be assigned at the time they are listed on the Ministry ofHealth Drug Formulary (Blue Book).

However there are few BE centers in the country. Of the BE centers providing BEstudies for the pharmaceutical industry, only a minority are doing full time. The

number of laboratories in the country for BE studies must be increased and theexisting centers encouraged to go full time. With more BE studies centersfunctioning in the country, more generic drugs can be handled for the registration


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With compulsory licensing for Government use of generic drugs while these novel

drugs are still patented would enable cancer medicine to be practiced at enhancedlevel rather than at limited level now. This would lead to greater cost reduction intreatment of cancer and hence provide equity of access to affordable life savinganti-cancer medicines for all cancer patients in the near future. However legislationfor the use of generic drugs has to be accompanied by legislation for quality controlof generic drugs which is essentially implementation of bioequivalence ortherapeutic equivalence testing and reporting to ensure efficacious and safemedicine. Following these moves, the patented drug companies would eventually

enter into price negotiations to remain competitive in the pharmaceutical market.Consequently the cancer patients might get treated with patented drugs instead.

6.5 GOAL 5: REHABILITATION

Objective 1: To provide Cancer Rehabilitation Services (CRS) to all patients

who would need and benefit from rehabilitation medicine

services so as to improve their quality of life

Objective 2: To establish effective social and public policies that will advance

Cancer Rehabilitation Programme (CRP)

Rehabilitation is the process of helping a person to reach the fullest physical,psychological, social, vocational, and educational potential consistent with his or herphysiologic or anatomic impairment, environmental limitations, and desires and life plans.

Patients, their families, and their rehabilitation teams work together to determine realisticgoals and to develop and carry out plans to obtain optimal function despite residualdisability, even if the impairment is caused by a pathologic process that cannot be reversed.


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To facilitate accessibility to rehabilitation medicine services while enabling delivery asclose to home of patients, the plan is to evolve basic services in all general hospitals and

district hospitals, while networking with the Family Medicine services in the HealthClinics. The Cheras Rehabilitation Hospital with 50-bed facility for multidisciplinary casesincluding cancer rehabilitation cases should lead and be at the cutting edge ofrehabilitation.

Care within a supportive and caring environmentwill need standards and credentialing, aswell as audit of services to ensure that this objective is attained and maintained. The issuesthat need to be addressed by the service include managing pain, improving bowel and

bladder function, improving nutritional status, improving physical conditioning andactivities of daily living, improving social/cognitive/emotional status that also addressesstress/anxiety/depression management, reducing hospitalizations, and improving vocationalstatus.

There is need for cost effective, efficient and acceptable facilities and services for cancerrehabilitation that is comprehensive and holistic. Standards for benchmarking and clinicalaudit need to be in place to ensure appropriate service delivery. Cooperation, networking

and smart partnership with other agencies are important and need to be further enhanced.

6.6 GOAL 6: PALLIATIVE CARE

Objective 1: To relieve pain and suffering of cancer patients

Objective 2: To improve the quality of life of these patients by attending to

their physical, psychosocial and spiritual needs

Objective 3: To provide a support system for patients and families of life-threatening cancers from diagnosis to issues of grief and

bereavement


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sufficient skilled personnel to carry out the duties. Due recognition can be achieved whenthere are fully trained and accredited palliative medicine physicians. Hence, the ministry is

now in the process of identifying individuals who are interested in training as palliativecare physicians.

6.7 GOAL 7: TRADITIONAL AND COMPLEMENTARY MEDICINE

Objective 1: To relieve pain and suffering of cancer patients

Objective 2: To improve the quality of life of cancer patients

Objective 3: To allow cancer patients to cope better with cancer andtreatment

Objective 4: To minimize the side effects of cancer treatment

The objective of traditional and complementary medicine is to relieve pain and suffering byacupuncture, massage, meditation, yoga or the use of herbal preparations that haveundergone clinical trial testing. By doing so, the quality of life of both the patient andrelatives will be improved. This may enhance their confidence on receiving or continuing

further conventional treatment such as chemotherapy. Secondly, after the pain relief by theTraditional and Complementary Medicine (T/CM) practices, patients may be able to copebetter with the subsequent conventional treatment. In addition the Acupuncture and Herbalpreparations may be able to minimize the side effects of conventional treatment of thecancer.

The establishment of T/CM services shall be done by working closely with all thepractitioner bodies to ensure the selection and recruitment of T/CM practitioners with high

qualification and experience in dealing with cancer patients. There is a need for closenegotiation between T/CM practitioners and medical practitioners on the treatment ofdifficult or rare cancer cases so as to further enhance the safety and efficacy of the service


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The battle against cancer is an essential and multi-faceted one, bearing in mind the needsrelevant to our local population and the constraints of limited resources. Focus must be

given on cancers of high prevalence, which are unique to our community and posingspecific clinical problems. To address this need, seven research working groups, namelyon epidemiology, prevention, diagnosis, treatment, rehabilitation, palliative care and herbalmedicine, were formed in 2004 to formulate strategies and approaches for integratingcancer research in these areas (Appendix 2). The cancer research agenda was furtherarticulated in the recently concluded national health research priority setting exercise inwhich the Framework for Research Priorities for Cancer was drafted. Scopes and focus ofcancer research for the country in the 9th Malaysia Plan were identified and ranked.

(Appendix 3). Overall, the purpose of the cancer research framework for the 9MP is toimprove understanding of the disease, evaluate program and management effectiveness,and to formulate new modality such as for diagnosis and treatment.

Cancer research can be very expensive and its research outcomes and benefits may not berealized immediately, and can be tangible or intangible in nature. It is important torecognize that research can take a long time to complete and that the output from in-depthresearch can only be expected many years after its initiation. It cannot be over-

emphasized that research is essential and that research findings have contributedsignificantly to the improvement in health care. Research findings can and will influencedecisions at many levels ranging from developing practice guidelines, in developingprevention and health promotion strategies, in developing policy, in designing educationalprogrammes, in patient care and clinical audit.

Epidemiological data and knowledge gained from studies on multiple risk factors incarcinogenesis will enable the formulation of effective strategies to reduce the incidence

and prevalence of cancer in the country. Cancer research and clinical trials will facilitatethe development of better screening tools, new therapies and vaccines. Recent advances ingenomics, proteomics and nanotechnology will enable, in the very near future, the


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2. Develop a National Cancer Research Consortium to increase research cooperation

and collaboration between research institutes and universities from the public andprivate sector as well as to enhance international networks and partnerships

3. Establish a National Biospecimen Banking Network that will focus on collection ofspecimens on nasopharyngeal carcinoma, breast cancer, colorectal carcinoma, liverand other major cancers. Specimens will also be collected from newly enrolled andlong term patients undergoing targeted therapy. A National Research CoordinationCentre, manned by permanent staff, will be set up to provide secretariat support and

coordinate the activities and functions of the Network and Consortium.

4. Build up a critical mass of cancer researchers within the Ministry of Health throughcreation of new posts at the National Cancer Institute and the Cancer ResearchCentre at the Institute for Medical Research, provision of targeted skills trainingand post-graduate education

5. Upgrade cancer research facility and equipment at the Cancer Research Centre,

Institute for Medical Research including communication facilities so as toencourage and facilitate collaborative projects between local and internationalresearch teams

6. Set up a cancer advisory board comprising local and international experts who willadvise on the development of cancer research programs in the country to ensureresearch excellence and relevance

National Cancer Research Consortium

A National Cancer Research Consortium is proposed aimed at promoting cooperation and


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A major activity of the National Cancer Research Consortium is the collection ofbiospecimens for cancer research from a network of banking sites throughout the country.

A network for biospecimen collection from sites around the country has the addedadvantage compared with single site collection of a series of cases. These advantagesinclude a wider spectrum of specimen source such as from indigenous communities, a highnumber of cases obtained in a shorter period of time as well as an adequate collection ofless common cancers to make research viable and with adequate statistical power.Biospecimen banking also allows the storage of a ready source of material for futurestudies. It is important that the Network is supported by a system for recording highquality clinical data, including outcome data associated with biospecimens, equipped with

features ensuring secure handling of confidential information while allowing foranonymization for research purposes.

Within the Ministry of Health, the Network of Clinical Research Centres (CRC), which areset up within major public hospitals within the country could play a role in this activity.

Proposal for a Research Division in NCI

As a long term goal, a national level institute for cancer research should be set up withinthe Ministry of Health.

In the interim period, it is proposed that a Research Division be established in the NationalCancer Institute (NCI) to support and complement clinical research. Studies such asmolecular epidemiology, pharmacogenetics as well as biomarker profiling can be pursuedto aid patient management and stratification in clinical trials and risk assessment. As thenational focal point for cancer management, the NCI will manage the information related to

treatment and clinical outcomes of major cancers.

Besides research, the research division shall conduct training courses and provide research


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are achieving the desired effects, and if necessary, modifications or new objectives can beadded.

Development of cancer management measures should be an integral part of acomprehensive National Health Plan. The Malaysian National Cancer ManagementProgramme should be integrated with the existing health care systems at the hospitals,primary care and public health level. The components of NCMP include PrimaryPrevention, Screening, Early Detection, Diagnosis, Treatment, Palliative Care,Rehabilitation, Traditional and Complementary Medicine. However, the NCMP shouldtake into consideration the epidemiological and economical aspects.

8.1 Network and Linkages

Since cancer involves many sectors namely socio-economic, educational andpolitical, the control of cancer requires a broad community approach. Cancerexperts alone will not suffice.

Intersectoral collaboration is thus a crucial requisite for a cost-effective NCMP.Those concerned with cancer control must work with authorities in agriculture,commerce, communications, education, industry and law in order to achievesuccess. Establishing effective network with supportive elements in the societydeserves high priority.

In cultivating a communication strategy a wide range of functional coalition shouldbe established, with representation from relevant stakeholders. Stakeholders with

interest and potential responsibilities for various aspects of cancer control includeagencies of the government (Ministries of Health, Welfare, Education, HumanResources, Agriculture, Science, Technology and Innovations, Finance etc.),


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authorities of similar programmes in other countries, essentially those who aremembers of ASEAN.

8.2 Financing

Based on current situation, the government will still continue to be the principalprovider and financial supporter of the NCMP, even though the trend now ismoving towards privatization, outsourcing, public private partnership and leasing ofequipment as innovative means of financing. The Action Plan in Appendix 4identifies the elements, activities, timeframe and agencies needed for

implementation of the NCMP and the stakeholders involved.

A total allocation of about RM 2.046 billion is needed during the second half of theNinth Malaysia Plan for implementing the first phase of the National CancerManagement Blueprint Master Plan. The summary of the financial implications forthe whole spectrum of cancer related activities in the 9MP including research anddevelopment is as listed in Appendix 5. Strategic action plans proposed underTreatment alone account for 50.33 per cent of the total budget estimated, followed

by 22.49 per cent for Diagnosis, 16.24 per cent for Prevention, 4.44 per cent forScreening and Early Detection as well as 3.95 per cent for cancer research andstrengthening. The budget for Treatment is high because it involves the use ofexpensive equipment and drugs.

Overall, procurement of drugs for treatment as well as HPV vaccines accounts forthe largest portion of the total budget requested (49.43 per cent). This is followedby purchase of equipment (for treatment, diagnostic and screening purposes) (21.1

per cent), outsourcing and consumables (10.3 per cent), and human capitaldevelopment (10.23 per cent). Under human capital development, 2,189 new postsare proposed for the recruitment of medical and allied health care professionals


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The import of generic drugs for cancer treatment can be another effective measurethat can bring down the high cost of cancer management in the country.

Special Allocation for Cancer Drugs and Research Activities

Of the total estimated budget of RM 2.046 billion for implementation of the cancerblueprint master plan in the second half of the 9MP, 61 per cent of the budget shallbe sourced through the existing financing mechanism within the Ministry of Health.The various requests can be made through the Modified Budgeting System atProgram level, Dasar Baru and the Training Budget.

Of utmost importance and immediate concern, is the need for new federalgovernment funding for improving cancer treatment and strengthening cancerresearch in the country. This will require an additional allocation ofRM 700.27million for 2008 - 2010, comprising RM 619.53 million for the purchase ofcancer drugs to accomodate the increased demand for cancer treatment and itsensuing escalated costs, and RM 80.735 million for implementing the variousstrategies of the cancer research agenda.

8.3 Organizational Structure

It is most essential to provide strong and effective leadership from an early stage inthe establishment of a NCMP. Since ideal leadership qualities may not be found inone person, a team may be the more appropriate solution. Individuals should besought with the qualifications that equip them to induce changes.

In recognition of the enormous and ongoing task, it is recommended that theNational Cancer Control Committee be established to oversee and provide the


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identified areas of cancer control. Ad-hoc committees can be formed as and whennecessary, should matters outside the terms of reference of these committees arise.

9.0 CONCLUSION

Cancer, which is presently the third major cause of deaths in MOH hospitals in the countrywill continue to become more and more prominent. Unless positive steps are taken,

Malaysia may have to face an enormous cancer burden in the near future. It is hoped thatwith adequate support of resources and commitment by all stakeholders, the timely andeffective implementation of the strategic action plans outlined in the National CancerManagement Blueprint (Master Plan) will reduce the negative impact of cancer, bydecreasing disease morbidity, mortality and improving the quality of life of cancer patientsand their families.

The Blueprint provides the framework for all levels of government to work together to

reduce the risks of developing cancer, improve cancer care through better screening,treatment, access to services and quality of life and reduce the risk of dying from cancer.

Implementing the Strategies of the Blueprint means fewer Malaysian will get cancer andfewer Malaysians will die from cancer. People with cancer will have access to high-quality, timely treatment and care, no matter where they live. When cancer cannot becured, patients will receive high-quality, compassionate end-of-life care, close to familyand friends, without enduring unnecessary pain. Duplication in the current cancer system

shall be decreased and cancer trends will be reliably tracked to help the country monitorhow it is doing compared to the rest of the world.


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of Health, 1999:16

9. GCC Lim, Y Halimah (Eds). Second Report of the National Cancer Registry.

Cancer Incidence in Malaysia 2003. National Cancer Registry. Kuala Lumpur2004.

10 National Cancer Control Programmes Policies and Managerial Guidelines
http://www.statistics.gov.my/http://www.statistics.gov.my/


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10 - YEAR MASTER PLAN

GOAL 1: PREVENTION

I OBJECTIVES

1. To reduce the prevalence of risks factors for cancers in Malaysia

2. To increase awareness and knowledge of the general public on the riskfactors of the common cancers in Malaysia

3. To strengthen the cancer risk factors intervention programmes

II TARGETS

1. Decrease prevalence of identified modifiable cancer risk factors:a. Decrease smoking prevalence from 21.5% in 2006 (NHMS III) to

16.5% by 2015 (24.8% in MHMS II)b. Increase prevalence of physical activity among adult aged 18 year and

above from 56.3% (NHMS III) to 80% by 2015 (11.6% in NHMS)c. Reduce prevalence of alcohol consumption from 12.2% in 2005

(MyNCDS-1) to 7.2% by 2015

2. 75% of general public has knowledge on the risk factors and 7 earlywarning signs of common cancers in Malaysia (NHMS III 46.9% - health

APPENDIX 1


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10 - YEAR MASTER PLAN

GOAL 2: SCREENING AND EARLY DETECTION

I OBJECTIVES

1. To detect potentially cancerous lesions in the population at risk forthe selected cancers i.e. breast cancer, cervical cancer, oral cancer, liver

cancer, colorectal cancer, prostate cancer and nasopharyngeal cancer

2. To increase the detection rate of selected cancers at an earlier stageof the disease

II TARGETS

2008 2010

1. Cervical Cancer60% of women aged 20-65 years had done pap smear (26% in NHMS II,43.7% in NHMS III)

2. Breast Cancer100% of women aged 35-49 years attending MOH facilities had Clinical

Breast Examination

3. Oral Cancer


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2011 2015

1. Cervical Cancera. 80% of women aged 20-65 years had done pap smear (26% in NHMS II,

43.7% in NHMS III)b. To increase the detection rate of stage 1 disease from 29.3% to 50%.

(34.9% in Penang Cancer Registry 1994-1998, 29.3% in Penang CancerRegistry 1999-2003)

2. Breast Cancera. 15% of women aged 50-69 years had mammography examination (10.7%in NHMS III)

b. 80% of women aged 35-49 years in general population had ClinicalBreast Examination (63% in NHMS III)

c. To increase the detection rate of stage 1 disease from 20.5% to 40%(15.4% in Penang Cancer Registry 1994-1998, 20.5% in Penang CancerRegistry 1999-2003)

3. Oral CancerTo increase the number of cases detected at stage 1 by another 10% based on2010 achievement

4. Colorectal cancerTo increase the detection rate of stage 1 disease (male) from 5.4% to 11%(9.3% in Penang Cancer Registry 1994-1998, 5.4% in Penang Cancer

Registry 1999-2003)

5. Liver Cancer


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III STRATEGIC ACTION PLANS SCREENING & EARLY DETECTION

Below are the screening modalities and target groups for the selected cancers

Selected

cancers

Screening modalities

(accepted/proposed)

Targeted population

(proposed)

Breast Cancer MammogramClinical Breast Examination(CBE)

Women 50 to 69 yearsWomen 35 to 49 years

Cervical Cancer Pap smear - Women 20 to 65 years oldwith sexual history

Oral Cancer Visual examination High risk population- Age more 20 years- Indians- Indigenous population- Specific behaviour

HepatocellularCarcinoma

Serum Alpha- feto proteinTransabdominal ultrasound

High risk patients:- All cirrhotics- Hep.B Carriers more than

40 years old- Hep.B Carriers less than 40

years old with at least 2 risk

factors- HCV sero-positiveindividuals more than 40years old


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2008 2010

1. Development or strengthening of screening programme for selected

cancers

- Reorganise existing screening programme to population based screeningprogramme for cervical and breast cancers

- Strengthen opportunistic screening programme for identified high riskpopulation for oral, colorectal, prostate and nasopharygeal (NPC) cancersat primary health care services

- Strengthen screening programme for high risk patients for HepatocellularCarcinoma (HCC) in major hospitals

2. Health Promotion

- Public education and awareness campaign on screening programmes eg:pap smear, mammogram, mouth self-examination, family history, prostateand breast awareness

- Develop health education materials on screening programmes

3. Human resource development

- Develop, review and update training modules on screening for in-service,basic or post basic training, particularly for procedure and counseling

- Increase the number of trained and credentialed staffs :- primary health care providers cytoscreeners (15-20 per cytology centre), radiographers (30 per

breast screenin

cancer management blueprint final 27 march 2008

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