Fighting the Big C

Tens of thousands in Malaysia die from cancer, and preventing it, diagnosing it and curing it all require the individual to be pro-actively involved.

Hopes were high when former US President Richard Nixon first declared war on cancer in 1971 through the signing of the National Cancer Act. However, 45 years later, cancer is still the major cause of death in the world. It is far from being eradicated. The WHO’s 2014 World Cancer Report projects that in the next 20 years, cancer cases will increase 75% from 2008 figures to 25 million cases per year worldwide.

Based on the database from the International Agency for Research on Cancer (IARC) GlobalCan1, there were 37,400 newly diagnosed cancer cases and 21,700 deaths in Malaysia in 2012. The age-standardised incident rate per 100,000 population per year is 143.6; however, the National Cancer Registry of Malaysia (NCR) puts an estimate of almost 10,000 unreported cases every year. If no action is taken, the number of cancer incidents could rise to 56,932 by 2025.

What is the situation in Malaysia today in the fight against cancer? To understand more, Penang Monthly speaks to Dr Thangadorai Aloysius Raj, a consultant clinical oncologist from Penang Adventist Hospital (PAH). Worryingly, according to Aloysius, early cancer has no pain, and this leads to non-diagnosis of early cancer as pain is thought to be a sign of the beginning of cancer – and it is really at the stage of pre-cancerous conditions that patients can be cured.

Most pre-cancerous conditions come from our living habits and progress on to cancer. If we practice a healthy lifestyle, then it is more likely that we will be fine,” says Aloysius. “You do not need to hike Penang Hill every day – just spending more time walking will bring health benefits.” One is strongly advised to quit smoking, to consume less meat and to take five portions (about 400g) of vegetables and fruits a day.

But there are other causes as well. “The environment we live in also plays a big role. We do not live in a pollution-free world. Certain things are out of our control, but if we keep away from certain risky and unhealthy daily lifestyle habits, the chances of getting cancer will be lower.”

Nipping the Problem in the Bud

“Prevention is better than cure” holds most truth when it comes to cancer: health screenings can indeed detect the problem early and allow the condition to be treated. There is also genetic screening, which Aloysius agrees can be useful for a “personalised treatment” tailored to the individual’s genetic profile. Genetic screening can help identify the risk for certain cancers, such as breast and ovarian cancer. The most noted example recently was the case of celebrity Angelina Jolie, who decided to undergo preventive double mastectomy to remove her breasts2. “I am with her. When you are detected with a defective BRCA1 gene and you have a family history of breast cancer, then you are in the very high risk group. After analysis of the genetic screening, you can make an informed decision to remove your breast before the cancer develops,” says Aloysius. However, the cost of the genetic screening can go up to US$5,000. This tends to put people off, but Cancer Research Malaysia (CRM) is hoping to change that by bringing new technology to reduce the cost to less than RM1,500.

Syerleena Abdul Rashid

PAH's oncology centre.

With better technology, treatment for cancer can be greatly improved. At PAH, the latest state-of-the-art machine, the linear accelerator, is available in its Oncology Centre for radiotherapy treatment. Costing about RM15mil, it uses digitised image technology to precisely map out and target only cancer-diseased cells with a margin of spread not seen by the naked eye; it then uses radiation to kill the tracked cancer cells. The machine follows the breathing pattern of the patient, calculates the movement of the tumour cells accordingly, and then “shoots” the target tumour cells at the precise location, sparing most of the other normal cells. Because the linear accelerator is so precise, it is crucial that the patient remains very relaxed and still during the treatment which lasts a few minutes.

Karen Lai

A researcher at Cancer Research Malaysia.


If we keep away from certain risky and unhealthy daily lifestyle habits, the changes of getting cancer will be lower.


Aloysius points out that nowadays, doctors tend to prescribe targeted therapy to their cancer patients, combining it with chemotherapy and immunotherapy to improve results. Drugs for targeted therapy can be in the form of tablets or injections; the cheapest drug costs about RM6,000 a month. “Cancer cells, like normal cells, need blood vessels to receive nutrients to live and grow. Some targeted therapy drugs are anti-angiogenesis, meaning that they can prevent the formation of new blood vessels; thus, the cancer cells will be starved and die.” However, Aloysius usually advises patients to take several drugs that are targeted at multiple pathways; otherwise, the cancer cells may circumvent the effects of a single target drug and survive.

Syerleena Abdul Rashid

Prof Dr Teo Soo Hwang.

Immunotherapy is a different kind of treatment – it helps patients develop their own immunity against cancer cells. Combined with chemotherapy, immunotherapy can safeguard the bone marrow, which is prone to the negative effects of chemotherapy.

When doctors have the liberty to prescribe different combinations of therapies, normally they would reduce the dose for each component of treatment. This reduces the side effects of individual treatments and keeps the benefits.

Knowing One’s Enemy to Fight it

There are several non-profit organisations that have joined the battle against cancer. One of these is CRM, which was established in 2000 to conduct research to find better ways of preventing, diagnosing and treating cancers, especially cancers which are common in Malaysia and Asia. However, lack of funding for research is a major obstacle. According to Prof Dr Teo Soo Hwang, chief executive at CRM, Malaysia spends 4.5% of GDP on health, and only 0.8% to one per cent of GDP on all research activities. The current difficult economic situation in Malaysia is definitely tough – even the Ministry of Health’s budget has contracted.

Besides funding, the challenge for Malaysia is finding talented people. “It is not only about how much one can pay to persuade them to do research, but also about the research environment and the people surrounding them, the deliverables and expectations, and the career development prospect,” explains Teo. “

At CRM, we have built a small but impactful team who are already making key discoveries in breast, oral and nasopharyngeal cancer.

We have developed new ways of studying oral and nasopharyngeal cancer, and using these new methods to develop a new immunotherapy for head and neck cancer patients. We have also developed new ways for testing the BRCA1 and BRCA2 genes and are now able to increase access to services by reducing the cost to less than RM1,500 per test. We would love to expand and to work on other cancers, and are on constantly looking for funding and talented Malaysians to join our cause.”

The linear accelerator at PAH.

Syerleena Abdul Rashid

The dedicated team at CRM.

Changes are needed from increased funding for research to awareness at the individual level in the form of a healthier lifestyle. “We urgently need to do more in the fight against cancer. For example, in Korea and Singapore, the average size at presentation for breast cancer is less than 1.5cm, but in Malaysia, it is more than 5cm. This contributes to poorer survival in Malaysia.” Teo mentions the efforts of the federal and some state governments to heavily subsidise or even provide free mammogram services for early detection of cancer. However, offering free early detection services is not enough. “In Malaysia, some people are scared of or misunderstand mammograms, so even if the public can have it for free, the uptake rate is going to be very poor.” According to the National Health and Morbidity Survey, the current uptake rate is 10.6% of all women. On average, a woman should have 12 mammograms during her lifetime, and at the moment, many women in Malaysia record only one to two mammograms in their lifetimes.

Public awareness is just one part of the strategy to make people change their behaviour. For a successful behavioural change campaign to promote health, policymakers should know their target groups, the right strategies for achieving their aim and how to evaluate the impact of their campaign. Teo firmly believes that proper research studies can guide the policies with confidence. “

"We need to have more community-based research. Fortunately, CRM and some universities in Malaysia are doing this research."

Syerleena Abdul Rashid

Aloysius with Chief Minister Lim Guan Eng (second from left) at the opening of the PAH oncology centre.


Perhaps most urgent – and most challenging – is to change the mindset of Malaysians towards cancer. “At the moment, many Malaysians believe that cancer equals to death. We believe that we should reverse that mindset – cancer research can bring new hope and enable us to build a future free of the fear of cancer,” Teo quips.

1 Population Fact Sheets: Malaysia, IARC GlobalCan 2012 (URL: http://globocan.iarc.fr/Pages/fact_ sheets_population.aspx).

2 Angelina Jolie, “My medical choice”, The New York Times, May 14, 2013.

 

Lim Chee Han received his PhD in Infection Biology from Hannover Medical School, Germany. He is currently a senior analyst in the economics section at Penang Institute.



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