Sarawak General Hospital
Kuching, Sarawak

View of Sarawak General Hospital.

Even on the remote island of Borneo, the incidence of cancer is on the rise. According to the most recent report from the National Cancer Registry (2003-05), nearly 68,000 new cancer cases were diagnosed among the people of Malaysia, a Southeast Asian nation of nearly 28 million people.

The Sarawak General Hospital, a government hospital that offers the peninsular nation's only cancer treatment facilities, devotes about 20% of its 765 beds to cancer patients. The hospital established its Department of Radiotherapy and Oncology, along with a nuclear medicine section, in 1985. Since that time, the Department has added outpatient chemotherapy, three linear accelerator units and a high dose rate brachytherapy unit, particularly useful for treating patients with nasopharyngeal cancer as well as gynecological malignancies. Although primarily a treatment facility, the oncology department also supports epidemiological studies, early detection programs and home-based palliative care, and participates in numerous international phase 2 and 3 clinical trials.

Malaysian women have a higher incidence of cancer than men (55 percent versus 45 percent). Breast cancer is the most common cancer, followed by cancers of the large bowel and lung. In the state of Sarawak, breast cancer is the most common, followed by nasopharyngeal and cervical cancers.

Nasopharyngeal Cancer

Nasopharyngeal cancer (NPC) is fairly rare in most parts of the world. In North America, it occurs in about seven of every one million people. According to a recent epidemiological study directed by Dr. Beena Devi, a clinical oncologist at Sarawak since 1992 and now senior consultant in the Department of the Radiotherapy, Oncology and Palliative Care Unit, the Bidayuhs in Sarawak have the highest incidence of NPC in the world. "We have seen a lot of this cancer in certain families," says Dr. Devi, "particularly among the Bidayuhs, one of the ethnic groups in Sarawak." Since 2002, Dr. Devi and her colleagues have collaborated with IARC, Lyon, and the World Health Organization on a genetic epidemiology study of NPC.

Doctors at Sarawak General see about 150-170 cases of NPC a year—a number that has remained relatively constant. This type of cancer is also prevalent among certain populations in China, Vietnam, Thailand, Singapore and the Philippines. In advanced stage, patients present with neck swelling; very early symptoms include unilateral nose and ear blockage and nose bleed.

"Over the years, we've been conducting an "Early Cancer Surveillance" program emphasizing the early signs and symptoms," says Dr. Devi. "We educated our rural health personnel so they could teach the people in the village. At a June 2009 meeting in Marrakech, we presented our findings demonstrating clinical downstaging in late diagnosis of nasopharyngeal cancer from 90% to about 60%."

In a study initiated by INCTR, Sarawak's oncology department is investigating barriers to late presentation of NPC, as well as the genetic aspects of the disease.

Breast Cancer

Oncologists at Sarawak General Hospital are also seeing some progress in reaching women with breast cancer at earlier stages. Although the incidence of breast cancer is up from about 100 cases per year in 1998 to more than 250 cases per year, Dr. Devi attributes this to greater awareness of the signs and symptoms of breast cancer among rural populations. With more awareness, more women are coming forward.

"We have treated women whom I call our role models. These survivors go home to their villages and share their stories that you don't have to die of this disease."

"While Malaysia's government health care program does not support a mammography screening program — in part", Dr. Devi says, "because the disease typically strikes young, pre-menopausal women whose breasts are too dense to offer an accurate image — a strong community awareness program encourages women with early signs to go to the nearest rural clinic". Nurse personnel have been trained to refer patients to the nearest hospital; from there, they may be referred to Sarawak General.

"The population of Sarawak is pretty small for the size of our state [48,000 square miles]," notes Dr. Devi, "and the government hospitals in Malaysia will provide free treatment for Malaysian citizens who are unable to pay."

For patients traveling great distances to Sarawak, patients are treated and referred back to their respective referring doctors. Every six months, the smaller hospitals outside Kuching are asked to provide a list of patients who have come for follow-up. In cases of relapse, doctors in the peripheral hospital will arrange to refer patients back to the Sarawak's Department of Radiotherapy, Oncology and Palliative Care Unit for further treatment.

"The burden on the government is pretty high," Dr. Devi admits.

Palliative Care

With her background—Dr. Devi trained in palliative care in Australia and was a hospice doctor for Singapore Cancer Society before joining the medical staff at Sarawak General—she was quick to put a home-based palliative care program into place.

"With our initial analysis in 1994, we saw that about 70% of our patients had advanced cancer," Dr. Devi recalls. "We set out to create awareness among nurses throughout the state, emphasizing pain management and nursing care. We wanted our nurses to be able to teach family caregivers. And we wanted to make sure pain medications could be delivered to the hospital or rural clinic nearest the patient's home. We began in 1995 with a small program of home visits, and began teaching families how to care for terminally ill patients."

Training sessions were initially conducted in Sarawak General Hospital, and extended to Sibu in 1996 and Miri in 1997. The program now extends to all four reaches of the state. "We know from talking to families that their main fear is not knowing how to care for the patient," says Dr. Devi. It was also up to her to negotiate with the pharmacists and the state medical director to make sure patients in even the most remote parts of Sarawak get the drugs they need for pain relief. Terminally ill patients are provided a one-month supply. If the patient dies before the end of that month, the family returns the drugs to the local hospital or clinic.

"It did not happen overnight," Dr. Devi admits, "but now people are more accustomed to the idea that morphine does not cause addiction in cancer patients, and understand why it's important that pain should be controlled. When I first came here, the use of traditional medicine was quite rampant, but now using morphine is more acceptable. Even some hospital personnel were skeptical, but when they make the home visits and see the patient spending quality time with the family, they realize it actually works."

Institutional Resources
Total Beds	765
Beds Devoted to Cancer Care	130
Staff Physicians	30
Nurses	1,262
Dedicated Oncology Nurses	95
Pathologists	6
Clinical oncologists (trained in
radiotherapy and chemotherapy)	3
Pediatric oncologists	1
Specialized surgical oncologists	1
Oncologists in Training	2
General and Specialist Surgeons	30
CT Scanners	3
MRI Scanner	1
Cobalt Radiotherapy units	none
Linear Accelerator units	3

In September 2009, the accreditation committee of the European Society for Medical Oncology has designated Sarawak General Hospital a center of integrated oncology and palliative care.

Staff of the Department of Radiotherapy and Oncology.

Working With INCTR

One of the most important advances in cancer management in Sarawak is not a drug, but communications technology. INCTR members have been using the interactive software to share pathology slides and to consult on diagnoses and treatment management options across thousands of miles. Dr. Devi is beginning to use the iPath program at Sarawak General.

"We have very few pathologists on staff," she says, "and with some unusual cases we would like to have a second opinion. This program has been used with some success in Vietnam, where it became an excellent tool helping pathologists learn about diagnosis. If we can use iPath to improve what we are doing, I'd be thrilled."

Marcia Landskroener for INCTR