Background

This year, 30,000 Malaysians will be diagnosed with cancer. Breast cancer is the most common cancer in Malaysia, with 1 in 3 cancers in women being breast cancer. Breast cancer affects 40 out of 100,000 women in Malaysia, but this number is set to rise.

In the 2016 edition of the Economist’s War on Cancer, Malaysia is estimated to record a 49% increase in breast cancer cases between 2012 to 2025. This is worrying as Malaysia recorded the lowest rate of five-year survivorship rate as well as the highest rate of mortality and incident rates in the region.

While Malaysia ranks highly on awareness of cancer, much still needs to be done. Some of the challenges in Malaysia involving cancer in women include fatalistic thinking, late presentation, lack of systematic screenings, treatment access, treatment adherence, survivorship support, palliative care and data for control planning.

 

Main pillars of improving cancer care and survivorship in Malaysia

• Improved prevention: 30-50% of cancers, mostly lung, liver and cervical cancers are preventable. While hormonal cancers like breast cancer cannot be controlled, there are possible preventative measures. Women who have inherited the BRCA1 or BRCA2 alterations in their genetic code can opt to remove and reconstruct their breasts. However, this procedure is highly invasive.

Tamoxifen can also reduce risk for women who have a higher risk of developing breast cancer. However, it is found to increase the risk of uterus cancer.

Research by Cancer Research Malaysia has found that breastfeeding, regular physical activity and soy intake can reduce the risk of breast cancer. Soy however remains controversial as a lifetime exposure to soy is associated with a higher risk of cancer. Research is currently being conducted into this.

• Improved early detection: More than 50% of breast cancer cases are diagnosed in women below 50 years of age. Screening criteria must change from age-based to risk-based in order to improve efficiency in detection and reduce wastage of resources.

While risk factors are poor predictors of cancer, genetic testing has shown much promise in precisely stratifying risk, allowing for highly effective, personalised prevention strategies for various forms of cancer. This will increase early cancer detection rates, which will drastically increase survivorship and significantly reduce suffering and cost of treatment. As such, genetic testing and counselling should be accessible in Malaysia.

However, only 10% of women aged 50 and above attend breast cancer screening, and about 50% of rural women who are discovered by mobile cancer screening buses to potentially have lumps in their breasts do not show up for further screening and treatment in hospitals. As such, screening will have very little impact unless health-seeking behaviours are changed.

• Improved treatment: Cancer therapy has advanced significantly in the past 40 years. Surgery and radiotherapy have improved to make it easier to remove and kill cancer cells more precisely with reduced damage to the surrounding healthy tissue. It is also now easier to control the side effects from chemotherapy, and even determine which individuals may not benefit from chemotherapy through genomics.

Targeted therapy, used to control the growth of cancer cells, and immunotherapy, which boosts the patient’s immune system, can also be applied with these treatments to improve outcomes. Immunotherapy should be explored for Asian breast cancers.

• Improved survivorship support: Research has found that there are many factors that impede women in accessing cancer care. This includes fear, belief in alternatives to medicine and the inability to make decisions, either from the social subjugation of women, the cost of treatment or poor basic health knowledge.

The cancer narrative must change from a death sentence to a curable or manageable chronic condition like diabetes in order to increase early detection and reduce treatment defaults.

Early supportive care has been shown to improve outcomes for cancer patients in terms of better survivability, higher quality of life and less usage of chemotherapy.

The Patient Navigation Programme is a critical determinant of improved outcomes. In the Harlem model, early stage cancer detection increased from 6% to 41% and survival improved from 39% to 70%. In Malaysia, the Patient Navigation Programme aims to increase completion of late stage breast cancer treatment from 70% to more than 85% and reduce default rates from 8-12% to less than 5% by the year 2020.

This nurse-led patient navigation program was piloted by the Pink Ribbon Centre at Hospital Tengku Ampuan Rahimah in Klang, Selangor. Due to the success of the pilot in reducing the default rate, the program will be expanded to cover the whole state of Selangor.