[COLUMNIST] Breast cancer in Malaysia: Policy improvements - Part 2

AS it is, breast cancer is the most prevalent cancer for women in Malaysia with 1 in every 19 women at risk of being diagnosed (“Early Detection of Breast Cancer Can Save Lives”, CodeBlue, October 17, 2022). Given the gravity of this health condition, it’s crucial to (re)examine the policies regarding breast cancer in Malaysia to ensure that they are further improved upon to suit and accommodate the current/developing situation and needs of breast cancer patients.

Late-Stage Detection: Critical Need to Increase Awareness

The National Strategic Plan for Cancer Control Programme (NSPCCP) 2021-2025 (Ministry of Health, 2021) defines “stage” as “a measure of cancer growth and spread, with later stages having poorer outcomes. Stage at diagnosis is probably the most important determinant of survival” (pg. 3).

In EMIR Research article, “Breast Cancer in Malaysia: Policy Improvements – Part 1” (December 15, 2022), its recommended for MySalam to remove the provision of “very early cancer” as being exempted from the 45 critical illnesses list – “cancer shouldn’t be compartmentalised in this respect and including all stages is critical for the collection of staging data for diagnosis and even prognosis purposes”.

It can’t be strongly emphasised enough that excluding early cancer treatment – by denying the insurance claim – discourages early treatment which has shown to be the most effective stage for outcome as well as cost-wise.

The Malaysia National Cancer Registry has stated that breast cancer is mostly diagnosed when it has already reached the later stages.

Only 17.5% of cases were diagnosed at Stage 1, 34.5% at Stage 2, 25%. at Stage 3 and 22.8% at Stage 4 (“National Strategic Plan for Cancer Control Programme 2021-2025”, Ministry of Health, 2021).

In the early stages, the 5-year survival rate (the patient will live for at least 5-years post-diagnosis) at 99% would decrease to 26%-29% in the later stages (“Survival Rates for Breast Cancer”, American Cancer Society).

According to the Cancer Research Malaysia, breast cancer patients in Malaysia from high-income backgrounds have a 90% survival rate, far better than the 65% survival rate for those from low-income backgrounds. Low-income patients are also twice as likely to die compared to high-income patients (“Breast Cancer Survival 25% Higher for Rich than Poor Patients”, CodeBlue, October 28, 2021).

A crucial reason leading to such disparity in survival rates is the early-stage detection of breast cancer in higher-income groups compared to late-stage detection in lower-income groups. This is because breast cancer screening is more common among individuals from the higher income brackets (who tend to be more aware and, hence, pro-active) and compared to those from lower socioeconomic categories.

The PeKa B40 initiative provides the B40 community with numerous healthcare benefits including free health screening for the three main non-communicable diseases (NCD), i.e., diabetes, cardiovascular diseases, and cancer. Despite the grave importance of screening in early diagnoses, only 12.39% (737,351) of the 5,950,292 individuals eligible for PeKa B40 have undergone screening.

Research suggests that low breast cancer screening among Malaysian women was primarily due to lack or low-level of awareness about breast cancer. A research has found that Malay female respondents, for example, enjoy only limited access to breast cancer information (“Meta-synthesis Exploring Barriers to Health Seeking Behaviour among Malaysian Breast Cancer Patients", Qing Yu Foo et al., Asian Pacific Journal of Cancer Prevention, Vol. 16, Issue 1, 2015).

This suggests that the medium of delivery is an issue.

In addition to raising awareness through social media, it’s imperative to disseminate and publicise the information through other accessible methods.

Hence, EMIR Research recommends that:

• Workplaces to hold mandatory breast cancer awareness events by organising seminars and workshops once a year – which should be claimable via the Human Resource Development Fund (HRDF);

• All public and private universities to hold mandatory breast cancer awareness events for staff and students, e.g., once a year. Publicity materials such as pamphlets should be readily available at strategic outlets on campuses such as the in-house counselling and psychological services centre, student union headquarters, departmental offices, bookshop, gymnasium, etc.;

• The MOH to collaborate with the private sector (e.g., conglomerates) and non-governmental organisations (NGOs) principally with the Breast Cancer Foundation together with other partners such the Kiwanis, Rotary Club, the Lion’s Club, etc. to organise roadshows to raise awareness on breast cancer in more urban poor areas as well as rural/remote areas;

• MOH’s MaHTAS (Malaysian Health Technology Assessment) app be revamped (to further enhance user-friendliness not only in terms of providing information – but equipped with AI machine learning/ML also to allow interface for information exchange like the ChatGPT/Generative Pre-Trained Transformer) and updated (e.g., pre-existing bugs fixed) to promote awareness of and practical steps (e.g., regarding pre-emptive measures) in general on breast cancer, among other (pertinent) issues also.

The MaHTAS app (for civilian, i.e., non-MOH use) is part of the wider system of health technology assessments for decision-makers (i.e., MOH) established in 1995.

At the same time, develop a separate app for individual patients with breast cancer to help them track their particular prognosis and treatment schedule. Have a telemedicine service available in the app which will allow for greater outreach to provide consultations to patients from lower socioeconomic groups wherein all data is protected under the Personal Data Protection Act (2010).

Late-Stage Detection: Critical Need to Improve the PeKa B40’s Screening Provisions

The NSPCCP (pg. 15) offers the following guidelines for breast cancer screening:

1. Clinical Breast Examination (CBE): “Woman aged 20 years and above must undergo [CBE] every three years for age between 20 to 39 years, and annually for age 40 and above”.

2. Mammogram (x-ray screening of breasts): “Woman aged 40 years and above with risk factors, are recommended to undergo mammogram every year. For women aged 50 to 74 years, mammography may be performed every two years.”

However, the PeKa B40 only offers eligible individuals a one-off screening (“Frequent Asked Questions”, ProtectHealth).

This is in direct contradiction to the NSPCCP guidelines regarding repeated cancer screenings.

Hence, EMIR Research recommends that Peka B40’s free health screening initiative be expanded to allow for multiple breast cancer screenings for the B40 community in accordance with the NSPCCP guidelines.

Oncologist Shortages

An oncologist refers to a doctor specialising in cancer.

Research suggests that for every 100,000 people in the population, having 1 oncologist is the ideal ratio (“Malaysia Has 117 Oncologists, Short of 300 Needed”, CodeBlue, February 4, 2020). Accordingly, Malaysia’s population of over 32 million should have at least 300 oncologists.

However, currently there are only 117 oncologists presiding in the country. Of this already low number of oncologists, 68 are employed in private hospitals, 35 in MoH hospitals and 14 in university hospitals (“Malaysia Has 117 Oncologists, Short of 300 Needed”, CodeBlue, February 4, 2020).

The NSPCCP has outlined numerous steps to be taken for increasing the human resource capacity such as the setting of key performance indicators (KPIs) for the training of oncologists and sub-specialists (such as radiology in breast cancer) and establishing of cancer units in government hospitals as well as the expansion of training centres (p. 9). Oncoplastic training has been incorporated in the sub-specialty training resulting in more trained breast & endocrine surgeons able to perform the procedures.

Additionally, the NSPCCP reported that in 2020, “three breast & endocrine surgeons [had] completed their sub-specialty training, with eight other trainees still undergoing training” and “seven fully trained breast & endocrine surgeons … resigned or retired. This net loss affected greatly in terms of overall manpower development and service coverage for MOH” (pg. 10).

EMIR Research recommends that the pro-active steps and measures are taken to ensure that trainees are committed to long-term employment with the MOH by, e.g., increasing the Specialist Incentive Payment.

At the same time, the Critical Service Incentive Payment (BIPK) should be restored for those employed from January 1, 2020.

Breast Cancer in Men

Breast cancer, primarily regarded as a “women-only” disease, can also happen to men.

This stems from a general lack of acknowledgement/recognition that men can contract breast cancer.

Male breast cancer has a much lower prevalence rate than female breast cancer with only around 1% of breast cancer patients being men (“One per cent of M'sian breast cancer victims are men, specialist reveals”, New Straits Times, October 22, 2017).

Due to the lack of awareness, men don’t recognise and “detect” the symptoms of breast cancer and often delay getting a diagnosis. This results in male patients usually being diagnosed when the cancer has reached a later stage and is more difficult to treat (“#HEALTH: Man up to breast cancer”, New Straits Times, November 21, 2022).

According to Dr Nik Muhd Aslan Abdullah, a clinical oncologist at Sunday Medical Centre, due to the rarity of breast cancer occurrence in males, it “can be quite isolating [sic] for those who do get the diagnosis” (“#HEALTH: Man up to breast cancer”, New Straits Times, November 21, 2022).

For instance, the National Cancer Registry’s annual reports for 2007-2011 and 2012-2016 don’t highlight statistics relating to male breast cancer in Malaysia. This is concerning given the crucial role of data and statistics in raising awareness as well as tracking and treatment.

The lack of mention could also increase the “stigma” related to male breast cancer – and ironically exacerbate the problem both at the “macro” level (i.e., of the general population of patients – albeit at a much smaller percentage) and “micro” level (i.e., of the individual patient himself re late-stage screening).

Hence, EMIR Research recommends that:

• In all campaigns regarding breast cancer such as roadshows, advertorials (print and online), public service announcements (PSAs) via radio broadcasts alongside analogue and satellite channels, etc., mention must be made regarding breast cancer in males; and

• The National Cancer Patient Registry (NCPR) to include statistics of breast cancer in males in its database.

In conclusion, EMIR Research strongly urges the government and MOH to further help improve the situation for all breast cancer patients in Malaysia.

Jason Loh and Juhi Todi are part of the research team at EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.