AS it is, breast cancer is the most prevalent cancer for women in Malaysia, with one in every 19 women at risk of being diagnosed (“Early Detection of Breast Cancer Can Save Lives”, CodeBlue, Oct 17, 2022). Given the gravity of this health condition, it is crucial to re-examine the policies regarding breast cancer in Malaysia to ensure that they are further improved 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 (Health Ministry, 2021) defines “stage” as “a measure of cancer growth and spread, with later stages having poorer outcomes. Stage diagnosis is probably the most important determinant of survival”.
Emir Research, in an article titled “Breast Cancer in Malaysia: Policy Improvements – Part 1” (Dec 15, 2022), recommended for MySalam to remove the provision of “very early cancer” as being an exemption from the 45 critical illnesses list – as “cancer should not be compartmentalised in this respect, and should include all stages as critical for the collection of data for diagnosis and even prognosis purposes”.
It cannot be strongly emphasised that excluding early cancer treatment – by denying 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 One, 34.5% at Stage Two, 25% at Stage Three and 22.8% at Stage Four (“National Strategic Plan for Cancer Control Programme 2021-2025”, Health Ministry, 2021).
In the early stages, the five-year survival rate (a patient will live for at least five 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 with high-income patients (“Breast Cancer Survival 25% Higher for Rich than Poor Patients”, CodeBlue, Oct 28, 2021).
The reason for such disparity is the early-stage detection of breast cancer in higher-income groups compared with late-stage detection in lower-income groups. This is because breast cancer screening is more common among individuals from the higher income bracket (who tend to be more aware and, hence, pro-active) compared with 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, i.e. diabetes, cardiovascular diseases and cancer. Despite the grave importance of screening for 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, 2015). This suggests that the medium of delivery is an issue.
In addition to raising awareness through social media, it is imperative to disseminate and publicise the information through other accessible methods. Hence, Emir Research recommends that:
-> Workplaces hold mandatory breast cancer awareness events by organising seminars and workshops once a year – which should be claimable via the Human Resource Development Fund;
-> All public and private universities 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, bookshops, gymnasiums, etc.;
-> The health ministry collaborates with the private sector (e.g. conglomerates) and NGO, principally with the Breast Cancer Foundation and other partners such as the Kiwanis, Rotary Club, the Lion’s Club, etc. to organise roadshows to raise awareness in more urban poor areas as well as rural/remote areas;
-> The health ministry’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 issues.
The MaHTAS app is part of the wider system of health technology assessments for decision-makers, established in 1995.
At the same time, develop a separate app for individual patients with breast cancer to help them track their 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 PeKa B40’s screening provisions
The NSPCCP offers the following guidelines for breast cancer screening:
1. Clinical Breast Examination (CBE): Women aged 20 years and above must undergo CBE every three years, and annually for ages 40 and above.
2. Mammogram (x-ray screening of breasts): Women 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 multiple breast cancer screenings for the B40 community.
An oncologist refers to a doctor specialising in cancer. Research suggests that for every 100,000 people in the population, having one oncologist is the ideal ratio (“Malaysia has 117 oncologists, short of 300”, CodeBlue, Feb 4, 2020). Accordingly, Malaysia’s population of over 32 million should have at least 300 oncologists. However, currently there are only 117 oncologists. Of these, 68 are employed in private hospitals, 35 in public hospitals and 14 in university hospitals.
The NSPCCP has outlined numerous steps to be taken to increase the capacity such as the setting of key performance indicators for the training of oncologists and sub-specialists, such as in radiology of breast cancer, and establishing of cancer units in government hospitals as well as the expansion of training centres.
Oncoplastic training has been incorporated in the sub-specialty training, resulting in more trained breast and endocrine surgeons able to perform the procedures.
Additionally, the NSPCCP reported that in 2020, “three breast and endocrine surgeons had completed their sub-specialty training, with eight other trainees still undergoing training” and “seven fully trained surgeons ... resigned or retired. This net loss has greatly affected the overall manpower and services of the health ministry”.
Emir Research recommends that pro-active steps and measures be taken to ensure that trainees are committed to long-term employment with the health ministry by, e.g. increasing the specialist incentive payment.
At the same time, the Critical Service Incentive Payment should be restored for those employed from Jan 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 (“1% of Malaysian breast cancer victims are men, specialist reveals”, New Straits Times, Oct 22, 2017).
Due to the lack of awareness, men do not 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, Nov 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 for those who do get diagnosed”.
For instance, the National Cancer Registry’s annual reports for 2007-2011 and 2012-2016 do not 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 patient at late-stage screening).
Hence, Emir Research recommends that:
-> In all campaigns regarding breast cancer such as roadshows, advertorials (print and online), public service announcements via radio broadcasts alongside analogue and satellite channels etc., mention must be made regarding breast cancer in males; and
-> The National Cancer Patient Registry include statistics of breast cancer in males in its database.
In conclusion, Emir Research strongly urges the government and health ministry to further help improve the situation of 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.