Transforming Cancer Outcomes -  Malaysia's Diagnostic Challenge

Opening the lecture, SONODA Shigeto asked students to reflect on the previous two lectures, provided by Dr. Murallitharan (Lecture 2) and Dr. Adams and Mr. Sakano (Lecture 3).

A student noted that Lecture 2 had provided an opportunity to learn about how a particular country is tackling universal health care (UHC), and that Lecture 3 had provided an introduction to the activities of the Union for International Cancer Control (UICC) and how it is bringing people together to tackle cancer. Lecture 3 had also covered the importance of telemedicine and utilizing the latest remote and portable technologies to provide medical care.

 Another student noted that Lecture 2 had provided an overview to the cancer issues facing Malaysia and the challenges facing hospitals. Lecture 3 had set out the goals and activities of UICC, together with the activities of Allm, Inc., a company that is deploying telemedicine in doctor-to-doctor support measures, including the use of devices such as smartphones. 

KAWAHARA Norie noted that in this lecture students would explore the efforts made towards achieving UHC in cancer care in Malaysia. Cancer care involves a series of steps, from screening to diagnosis and treatment. Even if a screening test finds something abnormal without a previous diagnosis, proper treatment cannot begin. Healthcare systems vary significantly across countries as do the challenges they face. She noted that two experts from Malaysia will be explaining the reality of cancer diagnosis in Malaysia.

BJJ ABDULLAH noted that he serves as an interventional radiologist and that he also engages in diagnostic procedures. He noted that he would be taking a look at how imaging in developing countries fits into the overall paradigm and treatment processes for patients who have cancer.

Health is not a static state, but actually a series of dynamic transitions during the course of a life. Health depends greatly on a person’s socioeconomic status. Health is also about well-being, and well-being is about the reason one wishes to be alive. Those reasons matter, not just at the end of life or when debility comes, but all along the way. It is necessary to have broader perspective of what is important in people's life and what wellbeing actually is. 

In the context of cancer, cancer presents several challenges, in that it affects a diverse population, treatment is often expensive, resource intensive and potentially detrimental to wellbeing, and it is a continuum from early disease with long-lasting effects on overall health to chronic, and sometimes life-threatening disease that defines the remainder of a person's life.

On the individual level, patients who have cancer experience significant but dynamic physical, psychosocial, and financial challenges. The evolution of these patients from diagnosis, treatment, survivorship, and at the end of life requires a full circle approach, where health is defined by what is important and meaningful to patients with cancer.

Screening programs are very effective if done properly. A recent study based on the International Early Lung Cancer Action Program (I-ELCAP) has shown that the survival benefits of a screening lung program extend to 20 years. There is therefore no question about screening programs being effective if they are done well. In developing countries, however, many patients present with advanced stage cancer, and these patients could have been diagnosed earlier if a screening program had been in place. There are also lots of new cancer markers coming in that are changing the way treatment is being offered.

My work is to look into how diagnostic imaging fits into the broader spectrum of care. Looking more broadly at the cancer care continuum, the enter continuum is comprised of cancer prevention, screening, diagnosis, treatment, survivorship and end-of-life care. It is important to navigate the patient along all of these complicated pathways.

Another way of looking at the cancer care continuum is in terms of prevention, in which imaging does not have a large role to play. Prevention is largely focused on education and awareness raising. Imaging has a critical role in diagnosis, staging, restaging, and looking for complications.

The cancer care continuum is a complex interplay of numerous human, social, political, economic, and technological channels, and data collection and monitoring systems are vital. Unfortunately in Malaysia there is not a coherent system in place at the current time. The healthcare system is more focused on the secondary care of patients who already come in with disease. Furthermore, Malaysia does not have a national health insurance scheme which can collect data, engage in monitoring and make adjustments, meaning that it is not possible to have timely and efficient decision making. 

Cancer care is therefore about cross cutting strategies across the continuum of care that focuses on measures to prevent disease, identify and treat asymptomatic patients who have already developed risk factors or preclinical disease, and restore function. It is also important to minimize the negative effects of disease, and prevent other physical, psychosocial, and economic disease-related complications. 

It is increasingly recognized that improving the quality of cancer care requires systematic understanding of the factors that influence health outcomes. There is evidence that some countries have successfully achieved similarly favorable breast cancer stage distributions in the absence of population-wide mammographic screening. 

Figure 1: Framework for improving the quality of cancer care 

Soo Tze HUI noted that she is a clinical radiologist and medical lecturer serving in University Putra, Malaysia. She also noted that her lecture would focus on the situation for breast cancer in Malaysia.

Breast cancer is a frequent cause of cancer death in Malaysian women as well as worldwide. The overall age standardized incident rate is 47 women per 100,000 population with a total of 7,500 new cases reported in 2018. More than 80 percent of cancers are diagnosed in stage 2, 3, 4, and between 2012 to 2016, the percentage diagnosed at stage 3 and 4 increased to approximately 50%.

Figure 4: Trends in breast cancer incidence in Malaysia 

In terms of patient-related factors contributing to diagnostic challenges, one of the first challenges is to respond to social cultural perceptions and strong beliefs in traditional medicine. This belief in traditional medicine leads to late diagnosis. 

Another patient factor is poverty, and the challenges the patient experiences with medical bills and medical-related costs (such as transportation and accommodation, etc.). 

A third factor is low health literacy among patients, which is also related to a lack of awareness about mammography due to a lack of information. 

Another factor is a lack of time among patients and the perceived fear of mammography and mastectomy surgery, etc. There is also shame associated with exposing breasts to a medical practitioner. 

In terms of the medical care factors impacting screening, the most significant factor is long appointment waiting times and unavailability of healthcare services in rural areas in particular. There is also a shortage of resources and specialists, coupled with an overall shortage of qualified manpower. 

In terms of take-home messages from today’s lecture, the first message is to underscore the need to conduct widespread breast cancer awareness campaigns, providing financial support for the underprivileged and creating a culturally sensitive healthcare environment would be a step towards earlier detection with better outcomes. Collaboration between government, NGOs and primary healthcare providers to address this barrier effectively is also critically important.

SUGIMURA Haruhiko (Director, Sasaki Institute) asked the number of rural patients who come to the hospitals of Dr. Abdullah and Dr. Hui for consultation or screening and how far these patients are prepared to come and how they receive a referral to a major hospital. 

Dr. Hui noted that some patients will fly into Kuala Lumpur in order to get a diagnosis or treatment. She noted that some rural patients are recommended to visit general hospitals for diagnosis and treatment. Some patients present very late due to a belief in traditional medicine. 

Dr. Sugimura asked whether patients have the means to pay for western medicine after relying on traditional medicine and remedies. Dr. Hui responded that the costs of treatment, both western and traditional medicine, impose a financial burden on patients. 

Dr. Sugimura asked whether logistics in Malaysia is improving and helping patients gain better access to medical care. Dr. Hui responded that compared to ten years ago the situation is very much improved, but mainly in urban areas. The situation is still very challenging in rural areas. 

Dr. Sonoda noted that Dr. Abdullah had pointed out the lack of coherence in the system in Malaysia. He asked whether the situation is more coherent in Japan and if the structures are more integrated. Dr. Sugimura responded that the Japanese health system focuses on early detection for gastric and lung cancers. This has resulted in a body of knowledge in Japan about early stage cancers, which is not the case in western countries. 

In terms of what makes Japan different from other parts of the world, endoscopy is very popular in Japan. Gastric and colorectal endoscopy is available even in rural areas in Japan, which is unusual in other countries. Japan is also fortunate in that there are a number of medical device manufacturers that encourage medical practitioners to use their devices. 

Dr. Sugimura asked whether stomach cancer is common in Malaysia. Dr. Hui responded that there is no national insurance system in Malaysia, and although gastric cancer is relatively common in Malaysia, most people only present once they have symptoms, which is very often too late. There is also some difference between the different ethnic populations of Malaysia, with the ethnic Chinese population being better mentally prepared and more aware than other ethnic groups. Ethnic Chinese are also more open to submitting for screening. 

In terms of breast cancer, there is no genetic counselling or clustering in Malaysia, and the genetic tests are generally very expensive and would have to be paid out-of-pocket by patients.

With regard to ethnic differences in Malaysia when it comes to breast cancer, Dr. Hui responded that ethnic Chinese are more inclined to visit a doctor earlier, and therefore receive an earlier diagnosis, leading to improved outcomes. 

Dr. Hui noted that there are many programs with NGOs in Malaysia to promote awareness about breast cancer. Buses are also provided to bring people into the cities for screening. Notwithstanding these activities awareness is still very low and take-up of screening opportunities remains low. It is a challenge to transform mindsets in Malaysia. 

With regard to the use of AI, Dr. Hui responded that although efforts are being made to look into the potential for utilizing AI and its benefits, the costs are still high and it would require concerted action from all stakeholders, including policymakers and device manufacturers, etc. It is standard practice for a mammogram to be read by two medical doctors, but due to time and resource constraints in Malaysia very often a mammogram is only read by one person. AI could help to solve such issues and it is hoped that it could be used in the future. 

Dr. Sugimura asked whether there are any regions in Malaysia that have elevated levels of particular cancers. Dr. Hui responded that this is not the case, to her knowledge.

In terms of safety of lab experiments regarding cancer, Dr. Sugimura noted that it is important to exercise caution and use clean rooms when dealing with carcinogenic agents in a lab environment. In industry and manufacturing there are previous examples, such as in the dyeing industry, where accidents have led to cancer incidences. These are now in the past and due to increased safety protocols measures are in place to guard against such incidence in the future.

Dr. Kawahara thanked the lecturers, noting that the lectures had provided an opportunity to delve deeply into the reality of cancer care in Malaysia. As Japan and Malaysia have completely different health care systems, we aim to continue our cooperation in the future and seek out new areas for collaboration.