NATIONAL CANCER MANAGEMENT BLUEPRINT MASTER PLAN: 2008 - 2015
1.0
INTRODUCTION
Cancer has become one of the most devastating diseases with more than 10 million new cases reported each year and is ht e cause of 12% of all deaths worldwide. The incidence of cancer is steadily increasing with an expected increase from 10 million in 2000 to 15 million by 2020. The main factors that contribute to the projected increase are the increasing population of the elderly, an overall decrease in deaths from communicable diseases, and the rising incidence of certain forms of cancer, notably lung cancer resulting from tobacco use. Cancer represents a tremendous burden on patients, families and societies. Besides the financial cost of disease, cancer has important psychosocial repercussions for patients and their families and remains, in many parts of the world, a stigmatizing disease. Cancer is a complex group of diseases representing more than 100 distinct diseases with different causes and requiring different treatment or interventions. There is no single known cause or cure for cancer and everyone is at risk. There is hope as many people with cancer do survive, and much can be done to prevent, treat and relieve cancer suffering in a country. The World Cancer Report (2003) provides clear evidence that one third of cancers are preventable, another third can be effectively treated given early detection and treatment, and the quality of life for the remaining third with more advanced disease can be improved with pain relief and palliative care. While the incidence and impact of cancer can be substantially reduced with better prevention, early detection and treatment, there is need for better integration, collaboration and coordination across government and private sectors as well as the non-governmental and professional organizations. 1.1
Cancer Si tuation W orldwide
The World Health Report (2003) indicated that non-communicable diseases (NCD) accounted for almost 60% of deaths in the world and 46% of the global burden of disease. In the year 2000, the global burden of cancer was estimated by the World Health Organization (WHO) / International Union Against Cancer (UICC) to be 10.1 million new cases (incidence), excluding non-melanocytic skin cancer (NMSC), 6.2 million cancer deaths (mortality) and 22.4 million people living with cancer (prevalence). This implied cancer killed more humans than HIV/AIDS, tuberculosis and malaria combined. This report also noted that the 5-year survival after diagnosis of cancer was 50 – 60% in developing countries, in the face of a world average of only 30 – 40%. It also predicted that 43% of cancer deaths worldwide in 2000 were attributable to tobacco, diet and infection. 1
1.2
Cancer Situation in Malaysia
Like most developed and advanced developing countries, Malaysia is approaching an epidemiologic transition, where diseases related to lifestyle particularly cardiovascular diseases and cancers have progressively become more prevalent. Malignant neoplasm persisted as one of the five principal causes of national mortality for the past 20 years and its trend, in terms of absolute numbers,has escalated. In 2005, cancer contributed 10.11 % of all deaths in Ministry of Health (MOH) hospitals compared with 7.37% in 1975. cancernumber incidence is estimated beisabout 150 for every 100,000 population. The The estimated of new cases per to year approximately 40,000.
10 Principal Causes of Deaths in MOH Hospitals, Malaysia 2005 1. Septicaemia
16.54 %
2. Heart Diseases and Diseases of Pulmonary Circulation
14.31 %
3.M alignant Neoplasms
10.11 %
4. CerebrovascularDiseases
8.19%
5. Accidents
5.67 %
6. Pneumonia
5.30 %
7. Diseases of the Digestive System
4.45 %
8. Certain conditions originating in the Perinatal Period
4.37 %
9. Nephritis,NephroticSyndromeandNephrosis
3.89%
10. Ill-defined Conditions
2.82 %
Total Number of Deaths (39,602) Reference: Annual Report 2005, Ministry of Health, Malaysia
Based on the Report of the National Cancer Registry 2003 and governm ent hospital statistics, the major cancers affecting males are cancers of the lung, nasopharyngeal (NPC), gastrointestinal tract, leukaemias and liver, while amongst females, cancers of breast, cervix, colorectum, corpus uteri, ovary and leukaemias are most prevalent. The ten most frequent cancers in Males and Females in Peninsular Malaysia as reported in the National Cancer Registry 2003-2005 (unpublished) are as tabulated.
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Ten most frequent cancers in males, Peninsular Malaysia 2003-2005 (unpublished)
COLORECTAL
14 .5
LUNG
12 .2
NASOPHARYNX
7.8
PROSTATE GLAND
7.3
LEUKA EM IA
6.5
LYMPHOMA
6.2
STOMACH
4.7
LIVE R
3.6
BLADDER
3.6
OT HE RSKIN
3.2
0
5
10
15 20 25 Percentage of l canc alers
30
35
Ten most frequent cancers in females, Peninsular Malaysia 2003-2005 (unpublished) BREAST
31.3
CE RV IXUTE RI
10 .6
COLORECTAL
9.9
4.3
OVARY LEUKA EM IA
3.7
LUNG
3.6
LYMPHOMA
3.4
COR PUS UTERI
3.3
THYR OID GLAN D
3.1
STOMACH
2.7
0
5
10
15 20 25 Percen tage foallcanc ers
30
35
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About 60% to 80% of these cancer cases are diagnosed at the late stages of the disease. A fairly large proportion of Malaysians are either ignorant or are intentionally ignoring the possible signs and symptoms of early malignancies. Furthermore, for some, modern medical and health facilities may not be their first preferred place to seek help.
2.0
ISSUES AND CHALLENGES
The incidence of cancers the country is expected exposure to rise in to light of the increasing population in the country,inincrease in population’s cancer risks with theageing rapid process of modernization and the growing adoption of unhealthy lifestyles. In Malaysia, the cancer control activities for prevention, early detection and case management are carried out quite independently by various agencies including those in the government, private sector and non-government organizations. The tendency for duplication of services provided for certain aspects of cancer control does exist, whilst on the other hand, there is lack of service availability in other areas, namely prevention, treatment, rehabilitation and palliative care. Coverage for some of these services is restricted due to certain barriers like geographical location, economic and social factors. 2.1
Prevention
The World Cancer Report (WHO-OMS-IARC, 2003) showed that with the existing knowledge, at least one-third of all new cases of cancer every year can be prevented. Tobacco usefor is the single cause of cancer in the world and is is responsible about 30%largest of all preventable cancer deaths in developed countries andtoday this figure increasing steadily in developing countries, particularly inwomen. Another 30% of cancer incidence is probably related to unhealthy nutrition from excessive caloric intake and inadequate physical activity, alcohol and obesity. There is increasing recognition of the causative role of these lifestyles factors. Alcohol use also increases the risk of cancers of oropharnynx, oesophagus, liver and breast. About 20% of cancer worldwide and about 25% in developing countries is associated with chronic infection that is potentially preventable through immunization. Vaccines against Hepatitis B virus (HBV) and Human Papilloma virus (HPV) have been produced to induce immuno-protection against the viruses associated with liver cancer and cervical cancer respectively. Knowledge of these factors can serve as a basis for cancer control and prevention strategy in the country targeting tobacco use, unhealthy nutrition, physical inactivity and alcohol abuse. The government has always been and will continue to be the main organization responsible for carrying out activities for cancer prevention. These include health education and positive promotion, vaccination programmes, implementation of legislation and policies which are for human health.
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The Public Health Department and the Oral Health Division of the Ministry of Health (MOH) take the lead for most of these activities. The Public Health Department consists of the Disease Control Division, Family Health Development Division, Health Education Division and the Safety and Food Quality Division. Health education and awareness activities regarding cancer risk factors, i.e. tobacco, food and nutrition, alcohol, betel quid and sexual habits, are being carried out through the mass media and other channels. These were intensified in 1995, through the Healthy Lifestyle Campaign, where the focus was on cancer. This campaign by the MOH was done in collaboration with other government agencies, non-government organizations and the private sector. Hepatitis B vaccination for newborns has become a part of the country's Expanded Programme of Immunization (EPI) since 1989 and is an important long term strategy for prevention against hepatocellular carcinoma. This programme is further expanded to health care workers at risk in the Ministry of Health in 1990 and continued to be reinforced in the year 2006. Legislation to regulate tobacco, food safety, drugs and chemicals have been put in place since 1993, 1985, 1984 and 1952 respectively. Besides these laws, other legal measures related to cancer control are also in the powers of other ministries like the Ministry of Human Resources, Ministry of Natural Resources and Environment, Ministry of Housing and Local Government, as well as the Ministry of Agriculture and Agro-Based Industry. 2.2
Screening and Early Detection
Increasing the awareness of the signs and symptoms of cancer is important to facilitate early detection of the disease, when treatment is most effective. There is strong evidence to support population screening for breast, cervical and colorectal cancers, and some evidence exists indicating that screening for oral cancers in selected populations is worthwhile. In addition to organized population screening programmes, public education campaigns, which demystify cancer and result in earlier diagnosis (downstaging), will benefit most cancer patients. Services for early detection of cancer are currently available only for cervical, breast and oral cancers. The Family Health Development Department of the Ministry of Health, together with the National Population and Family Development Board of the Ministry of Women, Family and Community Development are major providers of mass cytology screening. Pap smears are also available at private clinics found all over the country. In 1996, the second National Health & Morbidity Survey (NHMS II) revealed that only 26% of eligible women have been screened for cervical cancer using Pap smears. Latest efforts by the Ministry of Health to improve the coverage, efficiency and effectiveness of the Nationalfor PapPap Smear Screening includes to thebegin introduction Call-Recall System smear screeningProgramme which is scheduled in 2007.of aLiquid-based cytology is one of the developments in screening technology and appears to have a number
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of advantages over conventional method. However, it would involve significant capital investment and running costs. In Malaysia, the Ministry of Health has been promoting Breast Self Examination (BSE) and annual breast examination by trained health workers as part of the breast cancer awareness campaign since 1995. This was in tandem with the mass campaign on Cancer through Healthy Lifestyle Campaign. However, the NHMS II in 1996 showed that only 34.2% women did monthly BSE, 31.1% Clinical Breast Examination (CBE) and 3.7% Mammography (MMG) (National Health Morbidity Survey II, 1996). Mammography services are available in the major hospitals in the Ministry of Health but are mainly for diagnostic purposesfamily and for screening of high risk women with past history of breast disease or positive history. The Oral Health Division, Ministry of Health established the high risk strategy programme, ‘The Primary Prevention and Early Detection of Oral Precancer and Cancer’, in 1997 and it has subsequently gained support from the World Health Organization (WHO) in 2002. This outreach programme, aimed at selected population groups and augmented by opportunistic screening of patients in dental clinics, would afford the best approach towards down staging and reducing the incidence and prevalence of oral precancer and cancer in the country. 2.3
Diagnosis
Currently all state hospitals and major district hospitals are equipped with basic radiological facilities, including MRI in10 centers. Angiography facilities are available at certain major hospitals. Six tertiary hospitals (Kuala Lumpur Hospital, Selayang, Serdang, Ampang, Sungai Buloh have high end imaging angiography, nuclear medicine) but doand notPandan) have PET CT. Penang Hospitalfacilities has a full(MRI, compliment ofhigh end imaging facilities including PET CT, while the PET CT and Cyclotron have been recently installed at Putrajaya Hospital. The scientific advances and technology developments in genomics and proteomics have also transformed cancer diagnosis. Profiling of cancers at the molecular and cellular level is now possible using microarray and high-throughput genotyping platforms. Molecular profiling contributes to diagnosis, tailoring of treatment, prognostication as well as monitoring of residual disease. Some of the equipments and platforms are available in some academic institutions (University Malaya Medical Centre, Hospital Universiti Kebangsaan Malaysia and Hospital Universiti Sains Malaysia) as well as in the Ministry of Health (Kuala Lumpur Hospital and nI stitute for Medical Research). However the scope of the tests provided are limited and many of them are still research-based. Early detection and screening for cancer can reduce morbidity and mortality, as long as there is a goodThis supportive environment. Anofaccurate is the first and stepdiagnostic in cancer management. calls for a combination careful diagnosis clinical assessment investigations including endoscopy, imaging, histopathology, cytology and laboratory
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testings. Accessible and affordable competent diagnostic facilities should be more widely available. Currently, the Ministry of Health provides pathology services at 17 tertiary hospitals, 35 secondary hospitals, 72 primary hospitals, 855 health laboratories, 3 public health laboratories and the Institute for Medical Research. Histopathology services are available in 14 state hospitals, 6 major district hospitals and 6 other hospitals in the Klang valley. Immunohistochemistry, which is required for proper assessment of cancers, is available in state hospitals but the range is limited. Chemistry, haematology and microbiology services are available in all state and district hospitals. However, the range oftumour markers is not comprehensive enough forensic for proper monitoring inof the cancers. are 217 pathologists (excluding pathologists), country,There of whom 104 diagnostic are in the Ministry of Health, 37 in private laboratories and 76 in the universities. Together with contract pathologists, these can be categorized into 123 histopathologists, 24 chemical pathologists, 50 hematologists and 20 microbiologists. Of the 104 pathologists in the Ministry of Health, 61 are histopathologists, 10 chemical pathologists, 20 hematologists, 12 microbiologists and 1 geneticist. In addition there are currently 20 oral medicine and oral pathologists. The pathologist: population ratio currently stands at 1:110,000. Based on a target of 1:75,000 (one third of the Canadian norm), we are still short of 107 pathologists. However, it is important to note that Australia, whose population size is similar to Malaysia, has achieved a pathologist : population ratio of 1:15,500. 2.4
Treatment and Rehabilitation
The strategy for treatment and management is to detect cancer as early as possible and initiate treatment in a timely fashion. Successful cancer treatment increasingly involves multidisciplinary management of the cancer where treatment modalities (e.g. surgery, anti-cancer drugs, radiotherapy) are patients, considered, and all optimal individual treatment plans are designed using evidence-based guidelines and protocols. Treatment, whether radical or palliative, should be holistic incorporating the eradication of cancer cells as well as the alleviation of pain and subsequent rehabilitation of the patient. At present, the management of most cancer patients in this country does not incorporate all of these elements optimally and leaves much to be desired owing to the limited resources. Recognizing the need to diagnose cancers early so that prompt and adequate treatment can be instituted, a referral system from primary health clinics to various secondary and tertiary care centers was established. In Malaysia, surgery for different types of cancers as well as chemotherapy is presently available at all state hospitals and some of the larger district hospitals. These services are provided by surgeons in various surgical disciplines and physicians in consultation with oncologists. Of the estimated 40,000 new cases of cancer occurring every year, only about 12,000 are treated at radiotherapy and oncology centers in this country. Eighty per cent of these cases present at an advanced stage. It is widely known that results of treatment, e.g. survival, for
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advanced stage is inferior compared to results in early stages. The waiting time for treatment in some centers in Malaysia is 6–8 weeks compared to four weeks in the United Kingdom. The proportion of cancer patients who seek treatment at government centers is over 50% while less than half of the clinical oncologists are in the government sector. In an effort to meet the demand for cancer management services and to overcome the acute shortage of facilities, the government has been buying radiotherapy services from the private sector in Penang (2 centers), Kuala Lumpur (1 center), Negri Sembilan (1 center), Malacca (2 centers), Selangor (1 center) and Sabah (1 center). The total number of patients who had treatment under buying of radiotherapy services was in the region of 2000 in the year 2006 with a contract price of RM 8 million per year. However, definitive plans to upgrade and strengthen the existing government centers and to open new ones, consolidate efforts at training of skilled manpower and other strategies have been drawn up to address the great need for a more equitable and accessible cancer treatment programme. Improvement in cooperation between health care professionals in hospitals and Public Health will be further strengthened especially with the introduction and implementation of Treatment Outcome Databases and the intensification of Screening and Early Detection of cancer, so that it can emulate the networking achieved in Maternal and Child Health, Immunization and Infectious Diseases. 2.5
Palliative Care
Improved quality of life is of paramount importance to patients with cancer including those patients inofwhom cure care, is notprompt a feasible goal ofand treatment. This can be through provision palliative assessment treatment of pain andattained other problems which may be physical, psychosocial and spiritual. The availability and affordability of oral morphine is the single most important measure of palliative care provided by a country to relieve intolerable pain. However, there can be cultural and legislative barriers, which are usually based on erroneous beliefs about the addictive properties of morphine in cancer patients. Palliative care in Malaysia has been slowly developing since 1991 and initially involved non-government organizations (NGO's) and volunteers such as Hospis Malaysia and the Penang branch of the National Cancer Society of Malaysia. Palliative care was offered in some hospitals (e.g. Sarawak General Hospital) prior to the establishment of Palliative Care Units. In 1995 the first dedicated palliative care unit was established in Queen Elizabeth Hospital, Kota Kinabalu, Sabah. Subsequently the Ministry issued a directive that by the year 2000, all Ministry of Health Hospitals should develop palliative care units or palliative care teams.throughout There are the nowentire a total of 13 palliative careof units and 48 palliative care teams developed country. For purposes distinction, a palliative care unit (PCU) is an in-patient facility with at least 6 dedicated beds while a palliative care team (PCT) refers to a facility with at least 4 to 5 dedicated beds.
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Some common shortcomings of palliative care in the Ministry of Health include: a) Lack of dedicated staffing of the unit. Nurses and doctors are often sent to the unit from other departments and there is no real allocation of staff for running these units. b) The MOH is very dependent upon the limited support of nongovernment hospice organizations for continued care of patients after discharge from hospital. These problems have been recognized the Ministry of Health is now in the of rectifying these issues in order to allowand palliative medicine to grow further. In process December 2002, the palliative care unit of Selayang Hospital was opened. This unit was developed as the main centre for palliative care with dedicated specialist care from which the field of palliative medicine was to be developed. This 12-bedded unit is run by a consultant anaesthetist and pain specialist, a clinical specialist physician, and 3 full-time medical officers whose daily work is in palliative care alone. The nursing staff includes a ward sister and 12 nurses. The unit has a day-care center as well as a resource center for teaching with a small library. Following the model of the Selayang Hospital palliative care unit, the MOH plans to further develop similar models of specialized palliative medicine services in all other state hospitals. Apart from public hospitals, non-governmental organizations also provide palliative care services for cancer patients. 2.6 Traditional and Complementary Medicine
Malaysia has a competitive advantage in promoting traditional and complementary medicine because of the confluence of Malay, Chinese, and Indian system of traditional practices and knowledge, which is a great part of Malaysia’s uniqueness. Furthermore, Malaysia’s rain forest is rich in flora and fauna with a great potential to support long term research in the field of natural product biotechnology and phytomedicine development. In order to gain confidence from the public and western trained practitioners, research on the safety and effectiveness of traditional / complementary medicine (TCM) is mandatory. However evidence-based medicine may not be objectively possible in certain T/CM especially that based on traditional knowledge, and for such circumstances, research in T/CM will pose a challenge. The four guidelines (in conducting research in T/CM) published by the Ministry could be used as a reference. The large number of practitioners who have minimal qualifications must be encouraged to upgrade their knowledge and skills to an acceptable standard in institutions of higher learning so issues as to meet the criteria of the general publicinfor their comfortable acceptance. One of the confronting T/CM is the difficulty assessing the quality, safety and efficacy of herbal preparation. Hence the promotion of the usage of herbal medicine needs to be evidence-based.
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2.7 Human Capital
In Malaysia, the development and accessibility of the cancer control programme are affected by limitations in infrastructure and human capital. There is lack of trained personnel in treatment and management of cancer in this country. One example is in the number of clinical oncologists in the country. Based on a norm of 8 per million for clinical oncologist to the population ratio, Malaysia needs at least 200 clinical oncologists, but presently there are only 39 of whom 10 are in Ministry of Health hospitals. Moreover, more than half of cancer patients seek treatment in the government hospitals where the shortage of oncologists is most acute. The lack of adequate manpower also exists in the other disciplines in cancer care such as in epidemiology, prevention, screening and early detection, diagnosis, treatment, rehabilitation, palliative care and complementary medicine. The challenge to recruit and retain these health care workers remains an urgent need in the government sector. Among the critical shortages in health care professions are clinical oncologists, adult haematologists, paediatric oncologists, cancer surgeons, other ancillary care providers, pathologists, radiologists, cytopathologists, cytogeneticists, medical physicists, scientific officers, cancer epidemiologists, radiographers, rehabilitation physicians, palliative medicine specialists, nurses, pharmacists, medical technologists, psychologists, trained doctors in cancer care and other supporting staff. The roles for professionals such as medical oncologists in this country will be increasing. The continuous training and education of the cancer health care professional workforce has remained a challenge. Up-to-date knowledge and skills will enable health care providers to provide excellent quality of service to cancer patients in the country. Formalized training with overseas cancer centers needs to be encouraged. There are also the requirements for further consolidation of existing arrangements for training cancer care providers in their respective fields. Continuous and intensive training programmes (including Master programmes) should be emphasized. Inviting overseas consultants would further enhance the efforts to create excellent cancer care provider teams in the nation. 2.8
Facilities
At present, there are limited numbers of facilities providing radiotherapy and oncology services for the cancer patients in the country. Presently, there are 21 radiotherapy and oncology centers in the nation of which 6 are in the government and 15 in the private sector. The acute shortage of facilities for cancer management has resulted in the outsourcing radiotherapy services from selected private centers by the Government. Accessible, affordable and competent diagnostic and treatment centers are necessary, in addition to prevention, early detection, rehabilitation and palliative care. Regionalization of
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these facilities in the northern, central, southern, eastern regions of the Peninsular and in Sarawak and Sabah would contribute towards the accessibility of patients in these regions. Existing facilities for cancer treatment in the Department of Radiotherapy and Oncology at Kuala Lumpur Hospital and Sarawak General Hospital will need to be further upgraded. Basic radiological cancer diagnostic services such as ultrasound, CT scans and mammogram should be extended to major district hospitals. Endoscopic facilities should be set up in all regional centers. Proven techniques such as immunohistochemistry, flow cytometry, cytogenetics and molecular biology in cancer diagnosis should be made available in all tertiary centers. Major hospitals should also be designated with rehabilitation medicine specialty facilities. Upgrading of current cancer rehabilitation facilities should include lymphoedema control and upperlimb function, body image, psychosocial and sexual rehabilitation for breast cancer and female-related cancers. 2.9
Equipment
Upgrading and replacement of machines in existing cancer facilities should be a priority as a significant proportion of equipment are old and beyond the normal life-span. High-end equipments are needed for the different disciplines in cancer care. Upgrading of endoscopes, Magnetic Resonance Imaging (MRI) equipment, Computerised Tomography (CT) scans, Positron Emission Tomograpphy (PET) scans, nuclear medicine scans and other imaging tools should be made available in tertiary centers. Provision of fundamental equipment necessary for cancer diagnosis e.g.must proctoscopes, speculums, microscopes, Xray machines and ultrasonography machines also be placed in primary care centers. In developing surgical oncology procedures, the hospitals require a comprehensive set-up complete with purpose-built operating theatres, imaging equipment storage facilities for radioactive materials and facilities for intra-operative brachytherapy in joint facilities with clinical oncology. Plasmapheresis machines (for stem cell transplant), and photopheresis machines are major equipment needed for improvement of cancer management in the country. New cancer rehabilitation equipment should be made available to cancer patients. They include hydrotherapy, motion analysis system, electrotherapy and other related equipment. In palliative care, the appropriate equipment and vehicles fitted with special facilities will be required . As the budget for conventional purchase of equipment is too prohibitive, leasing of equipment will beand appropriate. This willprivatized resolve the problem of the lack of machines, ageing machines poor support from engineering services. 2.10
Drugs
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Most hospitals do not have the facilities of central cytotoxic drug reconstitution. While some new hospitals have the facility already, it is not yet being used optimallydue to poor construction not meeting the requirements of Good Manufacturing Practices (GMP) which is necessary to ensure drugs reconstituted are carried out in a proper and safe manner free from microbial contamination for administration to patients. Considerable budget for upgrading of existing facilities and building new ones to meet the needs of hospitals have been approved in the 9MP to ensure all CDR are done in proper facilities and by trained personnel and not in open wards as in current practice. There must be adequate training of pharmacists and pharmacy assistants in the duties and roles that accompany expansion of such will need to becare trained in the clinical therapy management of cancerservices. patients Pharmacists to provide pharmaceutical necessary to ensure optimal drug use and this will complement the role of oncologists and doctors in managing drug therapy for these patients. Improving processes in prescribing, distributing, dispensing and administration of drugs should take into account the following: 1) identify key drugs and demands; 2) ensure continuous supply; 3) keep track of drug development; and 4) promote local drug manufacture. To explore all opportunities to improve the accessibility, affordability and availability of chemotherapy drugs, it is advisable to build stronger partnerships with the biotechnology, biomedical engineering and pharmaceutical industries for the development of new cancer drugs and research into the prevention, early detection and treatment of cancer. The sharing of resources and intellectual capital with both large and small companies has great potential for advancement of the development of novel therapeutics. 2.11
Information and ICT
All citizens should receive culturally appropriate information about ways in which their risks of developing and dying from cancers can be reduced and should have prompt access to high quality information on cancer prevention, screening, diagnosis, treatment, rehabilitation, palliation and complementary medicine. The influence of the media is very wide– newspapers, television, radio, magazines, online news – however, there can be room for improvement in the accuracy of the reporting about various issues on cancer. Health care professionals are often the primary source of information for cancer risks and screening and thus must be well-trained and be active players in cancer prevention and control. They will need easy access to cancer education, such as throug h the internet, teleconferencing, and interactive educational software. These media are also valuable in providing continuing education for health care professionals who reside in rural communities or who have difficulty taking time away from their solo practices. Cancer data and information systems are important for the planning, implementing, and evaluating infrastructure programs, policies and cancer research. Appropriate resources including personnel, and funding should be made available for cancer data systems.
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Health Outcome Measurements in the form of Treatment Outcome Databases will become more important and be given further development within the Ninth Malaysia Plan. This will provide clinical data while the National Cancer Registry will continue providing population based data. 2.12
Funds
Apart from the provision of an operating budget, the Government should also allocate funds for facilities and equipment and form a body for monitoring fund utilization. The Government andfor NGO’s should provide startups leadership, guidance, and to technical assistance cancer initiatives that range funds, from teaching school children educating professionals and the public about the need to improve quality of life for all cancer survivors. All funded initiatives should focus on awareness, education, and outreach. Additional funds should be raised from public and private sources to support local and national program of pain relief and to support cancer rehabilitation programs through establishment of a system of network between collaborating agencies. A dedicated cancer research fund should be established to support research including long term cancer cohort studies and other cancer outcome studies. Currently there is insufficient funding to realize the cancer research agenda of the country. There should be more coordinated efforts to source research funds from the private, non-governmental organizations and corporations. Most cancer studies are funded by the government through the various grants from the Ministry of Science, Technology and Innovation (MOSTI) and the MOH research grant. There are some studies funded by the non- governmental organizations. Some are industry-initiated, with funding from the pharmaceutical companies or their the weaknesses are that despite money injected intoresearch researchorganizations. projects, only Among a few make it to publication. One of the the reasons is lack of skilled manpower dedicated to research, difficulty in data retrieval and poor follow-up. Funding for the proposals outlined in this plan will need to be sourced through the usual routes of DASAR BARU and through innovative approaches such as LEASING. Efforts are already undertaken by the Engineering Division of the Ministry of Health in the compilation of the list of equipment for replacement and upgrading. Stable funding is needed to sustain the National Cancer Registry and the Clinical Treatment and Outcome Database so that it can provide a cohort for long time follow-up studies and also for health outcomes. 2.13
Research and Development
Public recognition health andbemedical research remains discouraging. research capability matures, of there should increasing funding contribution from theAspublic and private sector, including the pharmaceutical industry. Making funds available for projects that feature new, interdisciplinary collaborations will stimulate interest among investigators
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and demonstrate commitment to collaborative research. Of primary importance is the need for research directions to cut across disciplines by incorporating a variety of cancer centered programmes and, where possible, promoting interactions among basic, clinical, and population scientists. In addition, targeted research directions should apply to a number of disease groups. Ongoing intra-programme retreats and meetings should showcase the many outstanding research efforts and acknowledges individuals and groups that have made significant contributions to the field of cancer research. Strategic plans should be prepared detailing how the NCI will expand its research in prevention, early detection, diagnosis, treatment, rehabilitation, palliative care, complementary risk factors, symptom management, imaging and screening, healthmedicine, disparitiesenvironmental and cancer survivorship. There is also a lack of information for survivors, their caregivers, health care professionals, and policymakers not only on late or long term effects of cancer treatment and quality of life issues, but also on prevention of second cancers and survivorship-specific concerns. Recognizing this deficit, the NCI must promote research on the health and functioning of the growing population of cancer survivors through interventions that seek to evaluate and improve the post treatment cancer experience.
3.0
VISION AND MISSION
THE VISION
By the year cancers 2025, cancer will no longer be a public health problem Malaysia, where all preventable are effectively prevented, all potentially curable in cancers are detected at the earliest stage and competently treated with optimum rehabilitation, while all terminally ill cancer patients are accorded optimum palliation. The negative impact of cancer will be reduced, by decreasing disease morbidity, mortality and improving the quality of life of cancer patients and their families.
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THE MISSION
All Malaysians must have a factual understanding of cancer, recognize its causes, know how to prevent, detect early signs and symptoms, it's treatment, rehabilitation and possible outcomes. Individuals will be empowered to choose positive lifestyles and other related personal habits. All cancer patients are cared for within a supportive and caring environment in all aspects, which includes physical, social and psychological aspects. Cost-effective, efficient and acceptable facilities and services early detection, diagnosis, treatment, rehabilitation and palliative care forofprevention, all cancers, encompassing a comprehensive range of holistic approaches, will be made available and accessible for all. Cooperation and resources from all relevant Government agencies, private sectors, nongovernment organizations, corporate bodies and the community, undertaken as a smart effective partnership will be harnessed to maximize cancer management efforts.
4.0
GOALS AND OBJECTIVES
The overall aim of the National Cancer Management Blueprint in Malaysia is to reduce the negative impact of cancer by decreasing the disease morbidity, mortality and to improve quality of life of cancer patients and their families. The seven goals outlined in the National Cancer Management Blueprint and their related objectives are:
GOAL 1: PREVENTION
Objective 1: Objective 2: Objective 3:
To reduce the prevalence of risks factors for cancers in Malaysia To increase awareness and knowledge of the general public on the risk factors of the common cancers in Malaysia To strengthen the cancer risk factors intervention programmes
GOAL 2: SCREENING AND EARLY DETECTION
Objective 1:
To detect potentially cancerous lesions in the population at risk
Objective 2:
To increase the detection rate of canc ers at an earlier stage of the disease
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GOAL 3: DIAGNOSIS
Objective 1: Objective 2:
Objective 3: Objective 4:
To improve the accuracy, efficiency, accessibility and timeliness of cancer diagnosis to all cancer patients and health care providers To streamline cancer diagnosis and research using proven state-of the-art technologies to better characterize and profile cancers, specifically in grading and staging of cancer, determination of cancer progression, prognosis and predictive response to treatment modalities, leading to best possible effective personalized treatment and outcome To provide services to support cancer patients in allcomprehensive aspects of care diagnostic including complications and secondary effects of cancer and its treatment To conduct research to improve cancer diagnosis in particular, while utilizing the diagnostic services to facilitate and support cancer research in general
GOAL 4: TREATMENT
Objective 1: Objective 2:
To enhance cancer therapy delivery and services which are timely, equitable and accessible for cancer patients throughout the country To provide a good, safe and quality state-of-the-art cancer treatment for cancer patients in the country
GOAL 5: REHABILITATION
Objective 1:
Objective 2:
To provide Cancer Rehabilitation Services (CRS) to all patients who would need and benefit from rehabilitation medicine services so as to improve their quality of life To establish effective social and public policies that will advance Cancer Rehabilitation Programme (CRP)
GOAL 6: PALLIATIVE CARE
Objective 1: Objective 2: Objective 3:
To relieve pain and suffering of cancer patients To improve the quality of life of these patients by attending to their physical, psychosocial and spiritual needs To provide a support system for patients and families of lifethreatening cancers from diagnosis to issues of grief and bereavement
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GOAL 7: TRADITIONALAND COMPLEMENTARY MEDICINE
Objective 1: Objective 2: Objective 3: Objective 4:
5.0
To relieve pain and suffering of cancer patients To improve the quality of life of cancer patients To allow cancer patients to cope better with cancer and treatment To minimize the side effects of cancer treatment
PRIORITIES
For the initial implementation of the National Cancer Management Blueprint, the following key priorities have been identified: i. Establishment of the National Cancer Institute and the setting up of the National Cancer Control Committee. The Committee shall formulate the national cancer control policies and ensure the efficient and effective implementation of all the components of cancer control priorities and strategies as outlined in the Blueprint. ii. Selected cancer for screening and early detection among populations at risk is made available and accessible. iii. Effective public health education and awareness programmes conducted in partnership with other government agencies, private sector, professional bodies and the non-government organizations. iv. Human capital development through establishment of new posts, targeted training programmes and the recruitment of foreign experts and researchers. v. Ensuring availability and accessibility of facilities and affordable treatment with a greater use of networking and outsourcing of services (e.g. from the private sector) as well as the use of generic drugs which have undergone adequate biotherapeutic equivalence procedures. vi. Upgrading of existing facilities in selected hospitals as well as the setting up of new facilities with leasing of equipment as a further option other than conventional outright purchase. vii. Optimising networking and linkages with non-government organizations, private sectors, foreign agencies and institutions. viii. Consolidating and establishing a single National Cancer Registry under the Public Health Department, Ministry of Health.
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ix. Spearheading and boosting local R&D efforts on cancer control and management. x. Strengthening current legislations and enacting new relevant legislations with effective enforcement and surveillance. xi. Developing National Standards, Guidelines, Codes of Practice on Cancer Management with professional bodies such as the Academy of Medicine Malaysia.
6.0
THE ACTION PLAN
To achieve the goals, objectives and targets of the National Cancer Management Blueprint, the following action plans are proposed.
6.1
GOAL 1:
PREVENTION
Objective 1: To reduce the prevalence ofrisks factors forcancers in Malaysia Objective 2: To increase awareness andknowledge ofthe general public on the risk factors of the common cancers in Malaysia Objective 3: To strengthen thecancer risk factors interventionprogrammes
The major challenge in controlling cancer is not only focusing on reduction in mortality but rather, in reducing the incidence. is imperative thattoin include the present health cancers care system, cancer prevention activities are Itexpanded further common thus emphasizing the government’s commitment in reducing incidence of cancers in Malaysia. Existing health education and awareness programmes on cancers will be continued and delivered effectively to the public in particular to the population who are at risk of developing cancer. Collaboration with relevant agencies including non-governmental organizations should be systematically organized and these collaborative activities must pursue the government objectives and policies on cancers. The utilization of all health facilities at primary care level that are closer to the population is needed to ensure the effectiveness of the delivery of the health services, health promotion and education activities on cancers. Monitoring the variation in the impact of cancer epidemiology is essential. Encouraging research and improving the data management on cancers are required as a continuous processMalaysian to providepopulation. and monitor information on cancer risks factors for common cancers among
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A national cancer registry is essential in providing useful information related to risk factors, identifying population at risk and thus for developing evidence-based policy, planning of cancer control and research initiatives, in particular on cancer epidemiology and treatment. The completeness and accuracy of data accumulation by the cancer registry have progressively increased. The International Agency for Research in Cancers (IARC) which plays a primary role in the establishment and accreditation of world cancer registries has given its input to our country. A population based cancer registry was first started in the country by the Public Health Department, Ministry of Health with data collection commencing in 1989. However inadequate resource, infrastructure andpilot finance were major problems faced in this initiative. human In 1993, Penang launched the Regional Cancer Registry using the variables by IARC. This registry was a success and was expanded to the whole country. However, in 2000, a decision was made that the registry would only be carried out in six selected states namely Penang, Kelantan, Pahang, Johore, Sabah and Sarawak. These states / regional registries would be representative of the ethnicity and demographic differences in Malaysia. The Penang Cancer Registry generated two 5-year composite reports, that is, in 2003 (1993 – 1999) and 2005 (1999 – 2003). The Sarawak and Kelantan Cancer Registry produced their reports in 2005 and 2006 respectively. The first National Cancer Registry (NCR) was developed in collaboration with the Clinical Research Centre (CRC), MOH in 2001. The NCR produced its first and second National Cancer Registry Report in 2003 and 2004 respectively. For the first time, national estimates of cancer burden were available. In 2007, the two cancer registry systems (namely the National Cancer Registry and the Regional Cancer Registry) be merged and further strengthened so as toatimprove data quality and validity, as wellwill as for better management of cancer registries state and national level. The Disease Control Division, MOH at Putrajaya will process and analyse the data to generate the yearly National Cancer Registry Report. To strengthen and sustain the Malaysian National Cancer Registry, a specific unit for Cancer Registry with sufficient number of staff and resources needs to be set up at every state and also at the national level where it will eventually be located at the NCI when the project is completed. The existing state epidemiological unit will be tasked to collect, verify, validate and manage the cancer data as well as to monitor the cancer trend in Malaysia. The unit will also act as the collaborating center between the Ministry of Health and the private health care providers such as private hospitals, laboratories and hospice that are providing care for cancer patients. It is also vital that there is a specific financial allocation for the operation and functioning of the National Cancer Registry in Malaysia. The risk factors prevalence in Malaysia is evidenced through various surveillance initiatives through population based andSurvey hospital studies.in 1986 The major surveillance is the National Health andstudies Morbidity thatbased was started (NHMS I) and followed by second survey in 1996 (NHMS II) which was done on a 10 year-period interval. The 2006 NHMS is not yet produced officially. However, a cross sectional
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population based study, Malaysia NCD Surveillance-1 (MyNCDS-1), produced in 2006 is the first of a population based surveillance study conducted in 2005 in all 13 states in Malaysia among the Malaysian citizens aged 25-64 years old. This surveillance is scheduled to be conducted on a 2–year interval. 6.1.1
Tobacco
In the World Cancer Report 2003, WHO has identified tobacco as the major preventable cause of death in the humankind. Boyle et al (Lung Cancer, 1995) noted smoking is the most common cause of lung cancers. The relative risk for regular to develop lung cancer is timeshealth higherproblem compared to nonsmoker.smoker Smoking is rapidly becoming a almost serious 20 public in Malaysia. The National Health and Morbidity Survey conducted in 1996 showed an overall 24.8% of those aged 18 and above were smokers, with male prevalence at 49.2% and female at 3.5%. MyNCDS-1 2005 showed that the prevalence of current smokers was 25.5%, with about 46.5% men and 3.0% women reported that they were current smokers. The National Health and Morbidity Survey conducted 2006 showed that the prevalence of current smokers was 21.5%. Effective intervention to reduce this prevalence is a great challenge. The US Centre for Disease Control and Prevention (CDCP) 2000, in systematically evaluating tobacco control interventions and health outcomes based on evidence, listed various strategies that could be taken. The strongly recommended actions on the intervention to reduce tobacco use include increasing the unit price of tobacco products and informing young people through high intensity counter-advertising campaigns. Multi-component cessation interventions to reduce tobacco use include smoker education, support tobacco and counseling reduce or stop To reduce exposure to environmental smoke, to bans or limits on smoking. tobacco smoking in workplace and public areas are strongly recommended. The amendment of Control of Tobacco Products Regulations gazetted in 2004 signifies an important milestone for legislative tobacco control in this country. Currently the final draft of Tobacco Act is well on the way as well as its regulations to further intensify and complement the current proposed Framework Convention for Tobacco Control (FCTC). Since Malaysia has already ratified the FCTC, a global treaty on control of tobacco products, a secretariat committee headed by the Ministry of Health is formed as a prerequisite in implementing the provision stated. Under FCTC, various sub-committees which will strongly emphasize on multisectoral participation, shall then assume responsibility on further actions taken under the National Tobacco Control Programme. Achievement in reduction of smoking prevalence is influenced by factors on policy, effectiveness and enforcements. In Singapore, since the startof ofintervention the Nationalactivities, Smoking legislations Control Programme in 1986, there has been an overall decrease in smoking prevalence from 20% (37% males and 3% females) in 1984 to 12.6% (21.9% males and 3.4% females) in 2004, with, achievement of
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about 0.37% reduction per year. The Cancer Council of Australia put up a target of 1% reduction of smokers prevalence per year in their National Cancer Prevention Policy 2004-2006. For Malaysia, NHMS 2006 result should be able to project the possible reduction experienced as a result of interventions that have taken place for the last 10 years. With the price increase of cigarettes every year imposed by the government, increasing places prohibited for smoking, TAK NAK campaign targeted among the school children, availability of Quit Smoking clinics and good NGO networking, it is possible for Malaysia to achieve a reasonable reduction of smoking prevalence. A maximal target ofis0.5% reduction per yearWith for smoking prevalence in 9th2006 MP period for Malaysia considered achievable. the availability of NHMS and with result from next 2-year scheduled MyNCDS survey would provide the achievement that can be the basis for review in the 9th MP mid-term review. 6.1.2
Hepatitis B
The most useful method of combating cancer as well as other afflictions induced by viral infections would be through an effective vaccine. Although some estimate that viruses could be responsible for as much as 15% of cancers, at present, the only immunization that is widely given is against hepatitis B virus (HBV). Promotion of HBV vaccination for infants became a part of the Expanded Programme of Immunization (EPI) in 1989. The implementation of HBV vaccination programme for health workers in 1990 has been consolidated in 2006 nation wide and intensified by vaccination among the Form Six schoolchildren in 2006 will furtherprimary increaseliver the vaccination coverage in Malaysian population. effort to prevent cancer as well as chronic hepatitis, will howeverThe only be apparent in 30 years. The cohort population prior to 1989 will be progressively covered with the immunization programme extended to adolescence in Malaysia. 6.1.3
Diet
Scientific evidence that some patterns of food intake may be related to cancer while other patterns protect against it, has accumulated in recent decades. Although the evidence still needs to be further substantiated with regards to the quantitative relationship, there is justification for the consideration of diet modification as a means of cancer prevention. The precise effect of diet to cancers is not clear. A combination of other factors such as sedentary lifestyle, highly calorific food rich in animal fat and protein increases the risk of colon, breast, prostate cancers. Often diet and nutrition alone is not the causative but associative risk factors to cancers. Several reviews [ from Food, nutrition and the prevention of cancers: a global perspective, by Worlf Cancer Research Fund (WCRF) and American Institute for Cancer research (AICR),1997; Diet, nutrition and the prevention of chronic
21
diseases by HO and FAO UN, 2003; Nutrition aspects of the development of cancers, UK Health Dept, 2003] have showed various conclusions on the associations of cancer protective effect of vegetable and fruits (Source: Australian National Cancer Prevention Policy 2004-2006). 6.1.4 Physical Inactivity
The research for the link between physical activity to specific cancers begin in 1980s and has been increasing since then. The IARC report in 2002 identified numerous studies on this aspect. There is growing evidence that physical inactivity has an influence in the manifestation of certain cancer types. The IARC Report (2002) and a study by Lee (2003) showed a strong evidence of association for breast cancer and colon cancer to physical activity. The promotion for physical activity in Malaysia has been launched by Ministry of Health through various mechanisms continuously especially through mass media campaigns. 6.1.5
Alcohol con sumption
Apart from the toxicity of excessive alcohol intake and the tendency of some individuals to become alcoholics, investigation has disclosed long term damage to the nervous system, liver and other organs. Moreover, liver cirrhosis is strongly associated with primary liver cancer. Accumulated evidences have also shown that heavy alcohol drinking increases the risk of cancer in the oral cavity, pharynx, larynx and oesophagus - synergistic effect with exposure to tobacco. MyNCDS-1 2005 showed the prevalence of alcohol consumption in Malaysia was 12.2 %. Twenty percent (20.0 %) of men and 3.9% of women reported they were current drinkers. It was estimated about 1.5 million adults aged 25-64 years old were current drinkers. NHMS II prevalence of alcohol intake was 38.3% among males and 7.7% females in 1996. Comparatively MyNCDS-1 showed a lower prevalence compared to NHMS II.
6.1.6
Betel Quid Chewing
There is evidence manyimportant sources that, in of theoral developing countries,with betelthe quid chewing is by far from the most cause cancer especially inclusion of areca nut and tobacco.
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In Malaysia, the habit of betel quid chewing is prevalent amongst the Indian community as well as certain indigenous groups in Sarawak, Sabah and Peninsular Malaysia. Hence, primary prevention of oral cancer should focus upon modifying the habitual use of betel quid in these target groups. 6.1.7
Occupational Exposures
Occupational exposure is associated with 5-10% of cancers. Exposure rate to wider range of carcinogens has recently accelerated with the introduction of new physical and chemical processes in the event of industrial intensification. At least 11 industrial processes and 17 chemical groups cancers are evidentially associated with carcinogenicity in human beings. Occupational often involve the lung, while other sites include the skin, urinary tract, nasal cavity and pleura. In Malaysia, the Department of Occupational Safety and Health (DOSH) is responsible for monitoring the notification of diseases related to cancer. The number of occupationally related cancers that were reported has been very low. Most are related to hydrocarbons exposure. Since the introduction of OSHA (Occupational Safety and Health Act), the regulation of cancer related substances has improved in the processes undertaken by industries. 6.1.8
Environment
Physical environment factors accounts for 1-2% of cancers that include pollution of air, water and soil. However, it is quite difficult to prove the association of cancer occurrence with environmental factors. Further research related to this association should becancer carriedprevention out locally programme so that specific to environmental induced can approaches be planned.related Asbestos is the best described environmental exposure to human related cancer. 6.1.9
Sexual and Reproductive Factors
Sexual practices and reproductive factors may affect the incidence of a number of cancers. Late age at first birth and nulliparity increases the risk of breast cancer while early age at first intercourse and multiple sexual partners are risks for cancer of cervix and AIDS (and thus of Kaposi's sarcoma and lymphomas). Treatment of menopause and post menopausal symptoms by oestrogen produced epidemics of endometrial hyperplasia and endometrial cancer, whereas the administration of diethyl-stilboestrol for treatment of threatened abortion increased the incidence of vaginal cancer in female offsprings, during the 1970s. There is good evidence that continued use of oestrogen by post menopausal women and oral for a prolonged period by young womenofincreases the risks of contraceptive breast cancer.useHowever, they also reduce the chance developing endometrial and ovarian cancer.
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6.2
GOAL 2:
SCREENING AND EARLY DETECTION
Objective 1: To detect potentially cancerous lesions in the population at risk for the selected cancers i.e. breast cancer, cervical cancer, oral cancer, liver cancer, colorectal cancer, prostate cancer and nasopharyngeal cancer Objective 2: To increase the detection rate of selected cancers at an earlier stage of the disease
If cancer can be diagnosed early in its course, treatment is generally more effective than when it is advanced. It is essential that the NCMP recognize the limitations and benefits of early diagnosis and screening to avoid "high technology" but poor cost-effective approaches, or to avoid methods which are not achieving the needed coverage of the targeted population. It is important to realize that screening programmes should not be introduced unless there is adequate manpower to perform the tests and enough facilities for diagnosis, treatment and follow- up of individuals with abnormal test results. In Malaysia, as high as 80% of relatively curable cancers are present at advanced stages. Thus, "down-staging" by increasing public awareness, combined with prompt and effective therapy, could have a major impact on the disease. 6.2.1
Breast Cancer
Systematically offering mammography to women aged 50-69 years in a population, and following-up cancer mortality. those with positive or suspicious findings, aims to reduce breast Breast Self Examination (BSE) has been part of the breast health awareness programme but more focus on Clinical Breast Examination (CBE) should be given for women over 30 years old (short term and long term strategies). Mammography is an expensive test which requires great care in its delivery and expert attention to quality control in performing and reading the test. In Malaysia, mammography is predominantly for diagnostic purpose, while its use as a community screening tool is currently still out of reach. The implementation of a national breast cancer screening programme should be started as soon as possible as part of the breast cancer control programme. 6.2.2
Cervical Ca ncer
Pap smear are screening was of initiated by and the Ministry of Health in 1969. and The main providers Ministry Health the National Population Family Development Board of the Ministry of Women, Family and Community Development. Other providers are private clinics and hospitals, university hospitals
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and army hospitals. However, the programme approach remains as opportunistic screening. The coverage of population based screening especially for women over 30 years old should be increased and made accessible for every eligible woman in the country. Cervical cancer should be down-staged i.e. from 65.1% of stages 2 – 4 presently to less than 20% in stages 2 - 4 in 2025. Efforts to organize effective cervical cancer prevention programme require collaboration and full commitment from the Government, Health Authorities, Clinicians, Pathologists, Medical Personnel, Media and the Public. This effort must be accompanied with adequate financial resources, upgrading of infrastructure equipmentattention and increasing number trained medical personnel. In cytology,and considerable should the be given to of obtaining good quality smears, staining and reporting so that a moderately high sensitivity to detect lesions is ensured. To have an impact on cervical cancer incidence and mortality, efforts must be focused on the following: increasing the awareness of women about cervical cancer and preventive health-seeking behaviour, screening all women aged 35-50 years at least once, effective treatment for high grade lesions, monitoring programme inputs and evaluating the outcomes. Although cervical cytology is a common tool used for screening of cervical cancer, there are technical, human resource and financial constraints in its implementation. Therefore there is a need to explore the other modalities of screening eg: Visual inspection with acetic acid (VIA). Human Papilloma Virus (HPV) vaccination should be considered in the future plan of the cervical cancer control programme. However despite HPV vaccination as a modality for primary prevention, cervical screening program should be continued as HPV vaccination is expected to prevent only 71% of cervical cancer. 6.2.3
Oral Cancer
The Oral Health Division, Ministry of Health had since 1999 established the National Primary Prevention and Early Detection of Oral Precancer and Cancer Programme through outreach activities and oral inspection for oral lesion provided in all its facilities throughout the nation. The programme is aimed at high-risk captive groups. Its main objective is to reduce prevalence and incidence of oral cancer in Malaysia. This programme includes primary prevention activities aimed at raising awareness of high risk habits to oral lesions and signs and symptoms associated with such lesions. The intervention strategy is via a visual examination of the oral cavity. Mouth self examination (personal skill) must be promoted especially in adult populations identified as high risk (e.g. Indian estate workers, indigenous groups, alcoholics, smokers and elderly). 6.2.4 Colorectal Cancer
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Colorectal cancer forms about 10% of all known cancers in Malaysia. At present, there is no specific programme for colorectal cancer screening. However, screening for high risk patients e.g. those with polyps is carried out at hospitals. Several techniques have been developed for early detection of colorectal cancer such as testing for occult blood in the stool and sigmoidoscopy. Future screening programme should focus on the high risk groups to improve the pick-up rate and the cost effectiveness. 6.2.5
Nasopharyngeal Cancerrcinoma
Nasopharngeal carcinoma (NPC) is a leading head and neck cancer in Malaysia. There are no specific early signs or symptoms. It can also spread to the neck without any evidence of primary growth in the nasopharynx. It is an aggressive disease which spreads to the neck very early in its course. However, it is potentially curable if detected early. Biopsy of the nasopharynx and microscopic examination of the tissue are the current methods of diagnosis. Several techniques have been developed for early detection of NPC antibody such as testing for serum IgA antibody to EBV or EBV DNA in the nasopharyngeal tissue. At present, there is no screening programme for NPC in Malaysia. High risk population screening should be started as soon as possible at the national level. However it requires careful evaluation. 6.2.6
Prostate C ancer
Screening for prostate the digital rectaltest examination (DRE) Prostate is often recommended, but DREcancer is not using a sensitive screening for early disease. specific antigen or PSA has been widely introduced as a screening test in the United States, with an initial major increase in the incidence of the diseases, and a subsequent reduction. It is not yet clear if such screening reduces the mortality from the disease. At present, there is no national screening programme for prostate cancer in Malaysia. However PSA screening is carried out at some government hospitals with urology services and some private health screening centers. Prostate awareness programmes are conducted by the Institute of Urology and Nephrology, Kuala Lumpur Hospital and Hospital Universiti Kebangsaan Malaysia. Population screening should be started as soon as possible at the national level. However, it requires careful evaluation in terms of cost effectiveness. 6.2.7
Liver C ancer
Hepatocellular carcinoma (HCC) is a highly malignant tumour with a very poor prognosis. Screening allows early detection of HCC and hence intervention may
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significantly modify the natural course, outcome and may decrease mortality. HCC is one of the top ten cancers in Malaysian male (National Cancer Registry 2003). There is already a consensus on the screening of HCC for the high risk population and its treatment. Currently there are two screening tests recommended for HCC, alpha-fetoprotein (a tumour marker) and ultrasonography of the liver.
6.3
GOAL 3:
DIAGNOSIS
Objective 1: To improve the accuracy, efficiency, accessibility and timeliness of cancer diagnosis to all cancer patients and health care providers Objective 2: To streamline cancer diagnosis and research using proven stateof the-art technologies to better characterize and profile cancers, specifically in grading and staging of cancer, determination of cancer progression, prognosis and predictive response to treatment modalities, leading to best possible effective personalized treatment and outcome Objective 3: To provide comprehensive diagnostic services to support cancer patients in all aspects of care including complications and secondary effects of cancer and its treatment Objective 4: To conduct research to improve cancer diagnosis in particular, while utilizing the diagnostic services to facilitate and support cancer research in general Objective 1: To improve the accuracy, efficiency, accessibility and timeliness of cancer diagnosis to all cancer patients and health care providers
The diagnosis of cancer is one ofthe most important steps ni the management of cancer. It is well appreciated that an inaccurate or substandard diagnosis would lead to wrong or delayed treatment and perhaps even the loss of life. For the diagnostic services to have a meaningful positive impact for cancer patients, it is imperative that the various categories of professionals who deliver the diagnostic services be competent (appropriately trained and qualified) and undertake continuing professional development to keep up-to-date with new diagnostic developments. There should also be sufficient diagnostic facilities, strategically distributed to ensure availability to patients in all parts of the country. The workload of the diagnostic facilities should be optimal, so that results can be delivered efficiently and without undue delay.
Objective 2: To streamline cancer diagnosis and research using proven state-of theart technologies to better characterize and profile cancers, specifically in grading and staging er, deter min ation can cer to pro gressposs ion,ible prognos and pred ve resp onseoftocanc trea tmen t mo daliti es,oflead ing best effecis tive pers onaicti lized treatment and outcome
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It should also be recognized that the diagnosis of cancer is not merely the detection of the presence of cancer. In line with advancements in therapeutic options, there is increasing demand for more informationon the nature and characteristic ofeach cancer detected. The scope of cancer diagnosis therefore extends to (1) identification of aetiological agents and their linkages to the development of precancer and cancer (with impact on policy development, cancer prevention and treatment), (2) determination of cancer biology and pathogenesis (impact on cancer prevention, treatment strategies and product development), (3) accuracy, sensitivity and specificity in detection, monitoring and classification of cancer (impact on efficiency and cost-effectiveness of cancer diagnosis), and (4) determination of prognostic and predictive parameters (impact of treatment strategies). The combination of all these aspects of cancer assessment to characterization of the unique profil e of eachvarious cancer, allowing determination of leads the most appropriate treatment modality for each patient (personalized treatment) and prediction of outcome. Objective 3: To provide comprehensive diagnostic services to support cancer patients in all aspects of care including complications and secondary effects of cancer and its treatment
The morbidity suffered by cancer patients are often related to secondary effects of the cancer rather than the cancer itself (such as deep vein thrombosis, infections, paraneoplastic syndromes, hormonal and electrolyte imbalances, etc). Furthermore, cancer treatment itself also induces physiological changes, side-effects and complications which can lead to considerable morbidity and even mortality. Hence, good cancer management require comprehensive diagnostic services with the capability and capacity to detect and monitor all kinds of secondary effects and complications of cancer as well as treatment. These diagnostic services would extend beyond the detection of the mere presence of cancer, andhaematology, would encompass the upgrading of the routine anatomical pathology, chemical pathology, immunology, microbiology and radiological facilities to meet the needs of cancer care. Objective 4: To conduct research to improve cancer diagnosis in particular, while utilizing the diagnostic services tofacilitate and support cancer research in general
To improve the various facets in the diagnosis and assessment of cancer patients, scientific knowledge in the form of new findings, methods and technologies must be effectively translated into clinical practice. As such, research programmes must be undertaken with renewed vigour to facilitate development of better diagnostic clinical tests to further improve assessment of cancer. Because of the wide rangeof scientific technologies as well as the rich supply of cancer material (archived or otherwise) available in the diagnostic laboratory it is also in a unique position to support both basic research into cancer biology as well as clinical research. The collection of high quality biospecimens and ethically conducted cancer research and development programmes should be encouraged as the future of the battle against cancer rests heavily in this arena. 6.4
GOAL 4:
TREATMENT
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Objective 1: To enhance cancer therapy delivery and services which are timely, equitable and accessible for cancer patients throughout the country Objective 2: To provide a good, safe and quality state-of-the-art cancer treatment for cancer patients in the country
For both the objectives above, a more comprehensive treatment strategy will be planned according to the needs and requirements of the population. The major part of this strategy is to increase the number of new cancer treatment centers in the country through the development of several centers. These new centers should include the following locations to give enoughregional coverage nationwide. National Cancer Institute, Putrajaya Likas Hospital, Sabah Penang Hospital In the first three years of development, Likas Hospital should have a dedicated Oncology Unit to begin or continue the treatment of patients using chemotherapy and other drug therapy. The development of the radiotherapy component should be started immediately so that by the end of the RMK-9 period, a comprehensive cancer treatment center can be established. The installation of radiotherapy facilities at Penang Hospital will begin in RMK-10. Together with the existing cancer treatment centers already functioning at the Kuala Lumpur Hospital, Sarawak General Hospital and Sultan Ismail Hospital, these new centers willcategorized be developed according to level the Blueprint. To facilitate development, these centers will be according to the of sophistication required at the various centers. With regards to chemotherapy treatment, all General Hospitals and major District Hospitals should be able to deliver this service either fully or partially. Identification of such hospitals should be made through the implementation of a National Chemotherapy Protocol and stratification of such hospitals. Dedicated cancer treatment centers will provide all forms of chemotherapy regimes and treatment combinations including chemo/irradiation, pre and post-operative chemotherapy. These centers will be supported by Oncologists, Oncology Nurses, Pharmacists dedicated to Oncology and Cytotoxic Drug Reconstitution Facilities (CDR). Cytotoxic drugs are known to be potentially genotoxic, carcinogenic and teratogenic. As such they pose a danger to the staff who prepares them. Due to the hazardous nature of cytotoxic drugs, the staff who prepares the drugs need to be protected with personal protective equipment and facilities which include a cytotoxic cabinet in a negative pressure cleanroom after having undergone specialized training in cytotoxic drugs reconstitution (CDR).
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Other MOH General Hospitals will deliver simpler chemotherapy regimes and supported by Surgical and/or Medical Units with resident Consultants, Oncology Nurses, Pharmacists and Cytotoxic Drug Reconstitution Facilities (CDR). With this stratification, chemotherapy funding and costs can be planned carefully by the various hospitals and in the long run, provide better access to treatment which will also be more cost-effective. To overcome the shortcomings in cancer treatment, the following strategies will be adopted: i.
Strengthening an d upgrading th e present system of radiotherapy and oncology services and palliative care services. This would be done with the establishment of a national cancer centre, namely the National Cancer Institute and the strengthening of a network of regional centers during the period of the 9th Malaysia Plan. All of these together would constitute a national network of clinical oncology.
ii.
Upgrading of Haematology Centers Haematology will be upgraded as follows: a) Ampang Hospital (2006-2010) (National Haematology Referral + Adult Stem Cell Transplant Center) b) Penang Hospital (2008-2010) (New Bone Marrow Transplant services – second center) c) Upgrading of facilities in Sultanah Aminah Hospital, Johor Bahru, Tengku Ampuan Rahimah Hospital, Klang, Ipoh Hospital and Kota Kinabalu Hospital (2008-2010) d) Upgrading of facilities in Malacca Hospital, Kuantan Hospital, Kuching Hospital (2008-2010)
iii.
Upgrading of Paediatric Oncology Paediatric Institute, Kuala Lumpur Hospital (National Referral Center for Paediatric Hematology-Oncology and Paediatric Stem Cell Transplant Center) Upgrading of existing facilities and services in Sarawak General Hospital, Sabah and Penang. Setting up new services in Kuantan.
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iv.
Upgrading of Oral Oncology Upgrading existing facilities and services in oral oncology at identified regional centers (Kuala Lumpur Hospital, Tengku Ampuan Rahimah Hospital, Sultanah Aminah Hospital, Johor Bahru, Sarawak General Hospital, Queen Elizabeth Hospital Kota Kinabalu, Kuala Terengganu Hospital, Alor Star Hospital).
v.
Continuing and expanding the existing Ministry of Health and private sector partnership through the outsourcing of a certain proportion of the treatment.
National Cancer Institute (NCI)
The role of the NCI will be as follows: a)
Provide state-of-the-art facilities for cancer management with the NCI being the main referral center for clinical oncology focusing on the treatment of cases requiring sophisticated techniques, especially stereotactic radiosurgery for various sites in the body and sophisticated brachytherapy.
b)
Provide comprehensive supportive care in collaboration with other agencies.
c)
Establish and regularly monitor and review national guidelines, standard operating procedures and other documents for appropriate clinical practices using multidisciplinary approaches in treating all cancer patients.
d)
Provide training for doctors and allied health personnel specializing in cancer management and treatment. This includes training for pharmacists in monitoring and reviewing pharmacotherapy of cancer patients and reconstituting cytotoxic drugs that are in accordance with the Chemotherapy Protocol of Ministry of Health.
e)
Conduct research in collaboration with other agencies within the country as well as with overseas centers.
f)
Co-ordinate the network of planned regional radiotherapy and oncology centers throughout the country.
g)
The NCI shall be a fa cility that can be used by staff from other institutions, private sector and other countries who can provide value-added services to the patients.
h)
Monitor the implementation of Quality Assurance in all centers for Radiotherapy and Oncology in Malaysia.
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i)
Develop and sustain the Clinical Treatment and Outcome Database.
Regional Centers
The National Network of Clinical Oncology will have the following roles and objectives: i. To provide a minimum standard of quality medical care and treatment for cancer patients by following good clinical practice guidelines (to have measurable objectives on health outcomes (e.g. survival). ii. To lead intechnology. the intr oduction and uti lization of new and pro ven cancer treatment and iii. To encourage and provide a conducive environment for the development of cancer research. iv. To provide training of oncology related supporting personnel including physicists, radiographers, nurses, pharmacists, palliative care physicians, counselors, etc. v. To provide education and current information on research in oncology and breakthroughs in the field. vi. To facilitate the development of palliative and supportive care including continued provision of care at home. The development of clinical oncology at Kuantan in the eastern region could be led by the Ministry of Higher Education, in collaboration with the Ministry of Health. This network should be realized by the end of the Ninth Malaysia Plan, during which timeinnew centers(National for Clinical Oncology willand be established by the Ministry of Health Putrajaya Cancer Institute) Sabah and services upgraded at Kuala Lumpur Hospital, Sarawak General Hospital and Sultan Ismail Hospital, Johore.
Outsourcing of Oncology Services
Of the approximately 8,000 patients per year that are not seen by radiotherapy and oncology departments, 1,000 per year will be seen at the NCI, 2000 per year by the various existing government centers and another 1000 per year by the existing system of buying of radiotherapy services. Hence, another 4000 per yearwill need to be absorbed by the system of buying of comprehensive oncology services by the government. As the number patients being outsourced in 2006 wasin the region of 2000, the rate of buying of radiotherapy services has to be doubled. This can be achieved with the outsourcing of such services to existing and the new private centers. Outsourcing of radiotherapy services will includepatients consultation, prescription, delivery, monitoring and follow-up of government by the private centers. Efforts are in place for establishing a consensus guideline for management of common canc ers. Private centers from which the Ministry of
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Health is already outsourcing services from include the Mount Miriam Hospital, Sabah Medical Centre, Mahkota Medical Centre, Pantai Ayer Keroh Hospital, Pantai Mutiara Hospital, NCI Cancer Hospital and Sabah Medical Centre. New private centers will be opened, upgraded or planned in Kuala Lumpur, Penang, Ipoh, Sarawak and Malacca in the foreseeable future. A greater level of outsourcing will be appropriate until the manpower and facilities in the Government sector are able to achieve an equitable and accessible level of cancer services in the country. While comprehensive planning is needed in developing the new cancer centers for the whole country such as at Likas and Penang, as well as in consolidating existing centers at Kuala Kuching and Pandan, there should be better the public-private integration inLumpur, the setting up of new centers. The Ministry of Health centers will treat cases that meet certain criteria of complexity while other cases will be referred and treated by selected centers in the private sector. The purchasing of radiotherapy services in the future may become more comprehensive, i.e. not just machine time, but the holistic management of patients by the private sector oncologists. Efforts at establishing a consensus guideline for management of common cancers are already underway so that networking between various cancer centers will be closer. The issue of human resource especially for oncologists must be addressed. There shall be more widespread adoption of double appointments where doctors at one center may be able help see patients in other centers, or to be attached to both service and research institutions. The location of subspecialities needs to be carefully thought for example stereotactic small brain lesionsthrough, atthe National Cancerdeveloping Institute. Joint training radiosurgery of doctors forfor the Master in Clinical Oncology shall be given continued support. While waiting for Malaysians to qualify, there is an urgent need to facilitate the recruitment of overseas expatriate specialists. With these strategies, the waiting time for cancer patients from diagnosis to treatment can be effectively shortened to 2 – 4 weeks by 2015. There shall be greater input from Outcome Measurements in guiding the development of treatment strategies and policies in the country. Surgical Oncology
Surgical Oncology services will continue to be provided at the state hospitals and large district hospitals as well as hospitals specializing in specific areas such as Breast and Endocrine Surgery services at Putrajaya Hospital and Hepato-biliary surgery at atSelayang Hospital. Surgical oncology services will continue to be developed the various hospitals.
33
Surgical oncology procedures requiring brachytherapy will be developed at the National Cancer Institute which will provide a comprehensive set-up complete with purpose-built operating theatres, imaging equipment, storage facilities for radioactive materials and facilities for intra-operative brachytherapy. Oncology Drugs
The following new drugs have been proposed to be included into the MOH Systemic Therapy of Cancer 2nd Edition after the Chemotherapy protocol meeting at Putrajaya in November 2007. The suggested budget requirements for new drugs are as follows:
Treatment site
Breast Ca adjuvant Traztuzumab average treatment for 1 year 8mg IV followed by 6 mg IV every 3 weeks
No. of MOH patients (pt) in Malaysia to be treated
Incidence of breast cancer 4,000/yr , 50% are stage 1 & 2, =2,000 pts ; of this 20% ie 400 are HER2 + and of this only 50% are high risk node +ve ie 200 pts but only 100 are treated in public hospitals+C2
RM80,000 / year / pt
8,000,000
2,009
2,010
14,400,000
19,500,000
There will be a snowballing effect as the duration of therapy is long.
Recurrence of breast and hormone refractory prostate cancer Docetaxel inj 20mg, 80mg
Unit cost
2008 Total cost to MOH for the country per year
RM1000 x6x 300 patients per year
1,800,000
2,000,000
2,500,000
RM 1000 x 6 cycles x 100 patients per year
600,000
700,000
800,000
RM2,500 per cycle so RM15,000 per patient/yr
750,000
800,000
900,000
Recurrence of Breast Cancer :Docetaxel 75 mg/m2 D1 every 21 days x 6 cycles Hormone refractory prostate cancer:Docetaxel 75mg/ m2 D1 Every 21 days Glioblastoma multiforme
Temozolomide tablet 100mg, 20mg
6 cycle adjuvant after concurrent chemo radiotherapy Dose Temozolomide 200 mg/m2 every 42 days x 6 cycles Treating 50 patients per year
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Goserelin
Neoadjuvant and adjuvant for prostate cancer
RM260x 12 200 patients per year
GIST on Imatinib if histologically proven GIST with c kit positivity
Incidence of GIST & CML 250 /year. 500 patients on treatment now. May treat additional 100 pts /year in Govt hospitals. 250 patients estimate to need treatment currently
Imatinib RM8,000 /mth ; =RM96,000/ year x 250 pts x0.5
400mg daily for 2 years
650,000
750,000
900,000
12,000,000
21,000,000
25,000,000
550,000
600,000
650,000
5,300,000
5,300,000
5,300,000
There will be a snowballing effect as the duration of therapy is long. *see tx for 2 yrs average Half cost borned by Novartis through MYPAP estimated 25% death per year
Aprepitant
Recurrence of ovarian cancer for average of 6 cycles at 50 mg /m2 every 21 days
Antiemetic for level 3 and 4 Day 1 : 125 mg, D2 and D3 : 80 mg Incidence of ovarian cancer =533 /year; 70% are epithelial ovarian cancer = usually 80% relapse = 373 these only 50% treated in Govt. Of hospitals & fit= 150
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RM220 every cycle x 5 cycles x 500 patients per year RM2200 / 20 mg Liposomal Doxorubicin (1.7m2 x 50 mg /m2 = 80 mg)
Extended adjuvant hormonal treatment for breast cancer
Incidence of breast cancer per year = 4000. Post menopausal estimated to be 2000. Those patients who are node positive and oestrogen receptor positive estimated to be 1000. Estimated that 500 patients per year will complete 5 years of tamoxifen without recurrence, thus making them eligible for extended adjuvant therapy. This will SNOWBALL into at least 900 patients the following year (ie 500 plus 400, assuming some of the patients will develop recurrence and thus not be eligible for adjuvant therapy as stated above). This number will be increasing year to year, thus making the budget more and more challenging.
This has been the most challenging area due to the large numbers of patients
3,000,000
5,400,000
7,300,000
33,000,000
51,000,000
63,000,000
involved and the snowballing effect.
Total based on drugs that are going to be in the protocol for first time
Existing Expenditure from kontrak, pharmaniaga, kpk,LPO 90 juta - 2007 and increase 15% each year Total
RM 104 M RM 137 M
RM 120 M
RM 138 M
RM 171 M
RM 201 M
2008
Hospitals with Oncology Drugs
Cost of Sample of Chemotherapy Drugs (RM)
% of Budget Given
2009
2008 (RM)
HTuankuFauziah,Kangar
7,770
0.09%
123,000
HAlorSetar
341,055
0.37%
506,900
HSgPetani
116,644
1.37%
1,876,900
HPulauPinang
821,418
9.67%
13,247,900
HSeberangJaya HKepalaBatas
772.50 3,671.50
0.01% 0.04%
13,700 548,000
353,888
4.17%
H Ipoh
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5,712,900
2010
H Taiping HTelukIntan H Manjung HTAR,Klang
46,049 15735 8,425
210,819
HAmpang
61,377.50
H Sultanah Nur Zahirah (HKT) HTAA,Kuantan H Sultan Hj A.Shah, Temerloh HTuankuJaafar,Seremban
0.19% 0.10%
88,697
HSelayang
HRPZII,KotaBharu
0.54%
1.04% 2.48% 5.10%
102,698
1.21%
778,850.50
4.79%
42,396
0.50%
5643.50
0.07%
64,373
0.76%
739,800 260,300 137,000 1,424,800 3,397,600 6,986,400 1,657,700 6,562,900 685,000 95,900 1,041,200
HospitalMelaka
41,913
0.49%
671,300
HSultanahAminah
503,404.60
5.93%
8,124,100
H Muar
50,646
HBatuPahat
0.60%
19,269
0.23%
822,000 315,100
H Kluang
1081.50
0.013%
17,810
HSultanIsmail HQueenElizabeth
240,507.80 293,054.90
2.83% 3.45%
3,877,100 4,658,000
H Likas
217,661
2.56%
3,507,200
HUmumSarawak
1,216,247.1
14.32%
19,618,400
MUSN,Kuching
199,496
2.34%
3,205,800
MUSBSriAman
2492.5
0.03%
41,100
MUSB Sibu
39,385
0.46%
630,200
MUSB Miri
8,250
0.10%
137,000
HKualaLumpur
2,574,664.20
30.3%
41,511,000
HPutrajaya
12,950
0.15%
205,500
TOTAL
8,491,305
100%
137,000,000
In summary, the total cost of a sample of chemotherapy drugs (Gemcitabine inj 200mg, Gosorelin, Etoposide inj, Irinotecan 10mg inj, 40 mg inj, Daunoribicin inj and Mitoxantrone inj) was RM 8,491,305. From these figures, Hospital Kuala 37
Lumpur consumed 30.3% of the budget, Hospital Umum Sarawak 14.32%, Hospital Pulau Pinang 9.67%,Hospital Ampang 5.10%,Hospital Kuala Trengganu 4.79% and Hospital Sultanah Aminah 5.93%, Hospital Ipoh 4.17% and Hospital Queen Elizabeth 3.45%. Generic Drugs
Access to oncology drugs is a major concern in the treatment of cancer patients because of the impact of patents on the costs of the drugs. To facilitate access to affordable medicine, there is a need to look into the import of generic versions of antineoplastic drugs through orcompulsory licensing grounds For of Government Use authorization non-profit use or publicunder healththe emergency. the long term, local manufacturing of generic drugs is an option to consider as a further cost reduction measure. Efforts must be taken to make appropriate provisions in the legislation to enable access to medicines for all especially the poor. Legislation is also needed to ensure that the companies marketing generic drugs invest in bioequivalence (BE) studies to ensure quality drugs for good outcomes in patients. Bioequivalence or therapeutic equivalence data shall be a requirement for all generic anticancer drugs before being approved for use in the country. Bioequivalence should be done at the Federal level where the regulatory authority requires drugs to be of a minimum standard before they are marketed. Bioequivalence may be assigned at the time they are listed on the Ministry of Health Drug Formulary (Blue Book). However there are few BE centers in the country. Of the BE centers providing BE studies for the pharmaceutical industry, only a minority are doing full time. The number of laboratories in the country for BE studies increased the existing centers encouraged to go full time. Withmust morebeBE studiesand centers functioning in the country, more generic drugs can be handled for the registration thus ensuring that only reputable generic companies enter the market with quality drugs. Use of generics after bioequivalence studies would foster the confidence of doctors and patients in using these much cheaper and similarly efficacious drugs. This would cut down costs tremendously and hence with the same budget a greater number of patients can be treated. Outsourcing from the neighbouring countries like Thailand, Indonesia and the Philippines for BEstudies may be an option. For a start, the Malaysian National Pharmaceutical Control Bureau has received reports for imported products whereby the bioequivalent studies were conducted in a neighbouring country.
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With compulsory licensing for Government use of generic drugs while these novel drugs are still patented would enable cancer medicine to be practiced at enhanced level rather than at limited level now. This would lead to greater cost reduction in treatment of cancer and hence provide equity of access to affordable life saving anti-cancer medicines for all cancer patients in the near future. However legislation for the use of generic drugs has to be accompanied by legislation for quality control of generic drugs which is essentially implementation of bioequivalence or therapeutic equivalence testing and reporting to ensure efficacious and safe medicine. Following these moves, the patented drug companies would eventually enter into pricethe negotiations to remain in the pharmaceutical market. Consequently cancer patients mightcompetitive get treated with patented drugs instead.
6.5
GOAL 5:
REHABILITATION
Objective 1: To provide Cancer Rehabilitation Services (CRS) to all patients who would need and benefit from rehabilitation medicine services so as to improve their quality of life Objective 2: To establish effective social and public policies that will advance Cancer Rehabilitation Programme (CRP)
Rehabilitation is the process of helping a person to reach the fullest physical, psychological, social, vocational, and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations, and desires and life plans. Patients, families,and andcarry their out rehabilitation teams optimal work together to determine realistic goals andtheir to develop plans to obtain function despite residual disability, even if the impairment is caused by a pathologic process that cannot be reversed. Rehabilitation is a concept that should permeate the entire health-care system. It should be comprehensive and include prevention and early recognition, as well as outpatient, inpatient, and extended care programmes. The outcomes include increased independence, a shortened length of stay, the most efficient use of evolving health-care systems, and an improved quality of life. Rehabilitation should focus on cancer patients for whom rehabilitation medicine services would be appropriate. The Cancer Rehabilitation Programme (CRP) in Malaysia for the next 10 years will be based on a holistic and comprehensive approach to medical care, using the combined expertise of multiple caregivers. The health-care team responsible to ensure the smooth running of the 10-year CRP includes the following: Oncologists, Therapy Radiographers, Rehabilitation Physicians, Surgeons, Oral Surgeons, Physicians, Physiotherapists, Occupational Therapists, Clinical Psychologists, Neuropsychologists, Speech Pathologists and Therapists, Counsellors, Dieticians, Dental Technologists, Prosthetists, Orthotists, Vocational Rehabilitation Personnel and Cancer Rehabilitation Nurses.
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To facilitate accessibility to rehabilitation medicine services while enabling delivery as close to home of patients, the plan is to evolve basic services in all general hospitals and district hospitals, while networking with the Family Medicine services in the Health Clinics. The Cheras Rehabilitation Hospital with 50-bed facility for multidisciplinary cases including cancer rehabilitation cases should lead and be at the cutting edge of rehabilitation. Care within a supportive and caring environmentwill need standards and credentialing, as well as audit of services to ensure that this objective is attained and maintained. The issues that need to be addressed by the service include managing pain, improving bowel and bladder improving nutritional status, improving physical conditioning and activitiesfunction, of daily living, improving social/cognitive/emotional status that also addresses stress/anxiety/depression management, reducing hospitalizations, and improving vocational status. There is need for cost effective, efficient and acceptable facilities and services for cancer rehabilitation that is comprehensive and holistic. Standards for benchmarking and clinical audit need to be in place to ensure appropriate service delivery. Cooperation, networking and smart partnership with other agencies are important and need to be further enhanced.
6.6
GOAL 6:
PALLIATIVE CARE
Objective 1: To relieve pain and suffering of cancer patients Objective 2: To improve the qua lity of life of thes e patients by attending to their physical, psychosocial and spiritual needs Objective 3: To pp tem fornopat and threprov atenide ing acasu nc eror s t frsys om diag sis ien tots is suesfami of lie grsieof f lifeand bereavement
With the success of the Palliative Care Unit in Selayang Hospital, the Ministry of Health has now approved the development of the field of Palliative Medicine as a clinical specialty of its own. Palliative care services will initially (over the first 2 years of the 9 th MP) be further developed regionally at 6 hospitals, namely at Penang Hospital, Selayang Hospital, Sultanah Aminah Hospital, Johor Bahru, Raja Perempuan Zainab II Hospital, Kota Bahru, Sarawak General Hospital, Kuching and Queen Elizabeth Hospital, Kota Kinabalu. This will be followed by the development of palliative care services in all state hospitals over the next 5-10 years and each hospital should have a separate unit which is managed and administered by a Palliative Medicine specialist, doctors trained specifically in the field of palliative medicine with recognized and accredited training. Simultaneously, efforts must be made to establish good homecare services within the public health set up and via networking with NGOs so as to create a seamless palliative care service from hospital to the community and back again. The field of palliative medicine can truly grow and flourish with legal support to ensure adequate use and supply of oral morphine to all patients who warrant it, and also with
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sufficient skilled personnel to carry out the duties. Due recognition can be achieved when there are fully trained and accredited palliative medicine physicians. Hence, the ministry is now in the process of identifying individuals who are interested in training as palliative care physicians.
6.7
GOAL 7:
TRADITIONAL AND COMPLEMENTARY MEDICINE
Objective 1: To relieve pain and suffering of cancer patients Objective 2: To improve the quality of life of cancer patients Objective 3: To allow cancer patients to cope better with cancer and treatment Objective 4: To minimize the side effects of cancer treatment
The objective of traditional and complementary medicine is to relieve pain and suffering by acupuncture, massage, meditation, yoga or the use of herbal preparations that have undergone clinical trial testing. By doing so, the quality of life of both the patient and relatives will be improved. This may enhance their confidence on receiving or continuing further conventional treatment suchas chemotherapy. Secondly, after the painrelief by the Traditional and Complementary Medicine (T/CM) practices, patients may be able to cope better with the subsequent conventional treatment. In addition the Acupuncture and Herbal preparations may be able to minimize the side effects of conventional treatment of the cancer. The establishment of T/CM services shall be done by working closely with all the practitioner bodies to ensure the selection and recruitment of T/CM practitioners with high qualificationbetween and experience in dealing with patients. There isona the needtreatment for close of negotiation T/CM practitioners andcancer medical practitioners difficult or rare cancer cases so as to further enhance the safety and efficacy of the service for cancer patients. In addition, incident reporting and a monitoring system need to be considered in setting up a safety T/CM services for cancer patients.
7.0
RESEARCH AND DEVELOPMENT
Cancer research in Malaysia is still at an infancy stage.Research needs to be intensified to search for new knowledge and understanding of cancer, and for the development of new and innovative approaches to not only diagnose and treat the disease but also to prevent the initiation and progression of the disease. Although cancer research conducted over the years has contributed to a better understanding of the disease as well as their improved management, there still remain large gaps in knowledge in certain areas. Research is needed to increase our knowledge on local cancers, particularly cancers which are more common in the region (Asian cancers) but rare elsewhere. Research should also be conducted to investigate if research findings from other countries are applicable to our local population.
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The battle against cancer is an essential and multi-faceted one, bearing in mind the needs relevant to our local population and the constraints of limited resources. Focus must be given on cancers of high prevalence, which are unique to our community and posing specific clinical problems. To address this need, seven research working groups, namely on epidemiology, prevention, diagnosis, treatment, rehabilitation, palliative care and herbal medicine, were formed in 2004 to formulate strategies and approaches for integrating cancer research in these areas ( Appendix 2). The cancer research agenda was further articulated in the recently concluded national health research priority setting exercise in which the Framework for Research Priorities for Cancer was drafted. Scopes and focus of cancer research for the country in the 9 th Malaysia Plan were identified and ranked. Appendix 3). Overall,ofthe (improve the cancer research for the 9MP is to understanding thepurpose disease,ofevaluate program andframework management effectiveness, and to formulate new modality such as for diagnosis and treatment.
Cancer research can be very expensive and its research outcomes and benefits may not be realized immediately, and can be tangible or intangible in nature. It is important to recognize that research can take a long time to complete and that the output from in-depth research can only be expected many years after its ini tiation. It cannot be ove remphasized that research is essential and that research findings have contributed significantly to the improvement in health care. Research findings can and will influence decisions at many levels ranging from developing practice guidelines, in developing prevention and health promotion strategies, in developing policy, in designing educational programmes, in patient care and clinical audit. Epidemiological data and knowledge gained from studies on multiple risk factors in carcinogenesis will enable the formulation of effective strategies to reduce the incidence anddevelopment prevalence ofofcancer the country. researchand andvaccines. clinical trials will facilitate the better in screening tools,Cancer new therapies Recent advances in genomics, proteomics and nanotechnology will enable, in the very near future, the development of innovative imaging technology that will make diagnosis and treatment more accurate and minimally invasive. Molecularly targeted diagnosis and treatment will be a reality, producing fewer side effects while reducing morbidity and mortality and improving the quality of life of cancer patients. Evidence-based management, rehabilitation and palliative care will address more effectively the other needs of the individuals and community burdened by cancer. Complementary and alternative medicine involving biopharmacologic and herbal approaches will be given due recognition in the management of cancer in Malaysia. Concerted effort through a multidisciplinary approach, involving scientists and researchers, public health workers, healthcare providers, patients-advocates and policymakers is needed to defeat cancer. For cancer research to make a real impact to the country, a paradigm shift in research is greatly needed and an enablingenvironment for research instituted.. To develop active, indepth, innovative high impact research on cancer: which are at par with that of developed nations, and the following strategies are proposed 1. Set aside a National Cancer Research Grant to supplement current research funding
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2. Develop a National Cancer Research Consortium to increase research cooperation and collaboration between research institutes and universities from the public and private sector as well as to enhance international networks and partnerships 3. Establish a National Biospecimen Banking Network that will focus on collection of specimens on nasopharyngeal carcinoma, breast cancer, colorectal carcinoma, liver and other major cancers. Specimens will also be collected from newly enrolled and long term patients undergoing targetedtherapy. A National Research Coordination Centre, manned by permanent staff, will be set up to provide secretariat support and coordinate the activities and functions of the Network and Consortium. 4. Build up a critical mass of cancer researchers within the Ministry of Health through creation of new posts at the National Cancer Institute and the Cancer Research Centre at the Institute for Medical Research, provision of targeted skills training and post-graduate education 5. Upgrade cancer research facility and equipment at the Cancer Research Centre, Institute for Medical Research including communication facilities so as to encourage and facilitate collaborative projects between local and international research teams 6. Set up a cancer advisory board comprising local and international experts who will advise on the development of cancer research programs in the country to ensure research excellence and relevance National Cancer Research Consortium
A National Cancer Research Consortium is proposed aimed at promoting cooperation and collaboration between individuals, groups and institutes / organizations for cancer research. The final goal is to develop a strong network of research teams in cancer which are fully competent to carry out cutting edge research in all the various aspects of cancer, particularly relevant to the major cancers in the country. The creation of a National Cancer Research Consortium could also further enhance sharing of facilities and equipment as well as exchange of materials for cancer research. Institutes involved in cancer research would be invited to form the National Cancer Research Consortium. The Consortium will be advised by an Advisory board / Governance Board. The Advisory Board / Governance Board will elect a steering committee and subcommittees will be formed based on research interest groups / types of cancers. The Cancer Research Centre of the Institute for Medical Research (IMR) can play a central role in the establishment of the National Cancer Research Consortium and serve as the coordinator of the network. Cancer Biospecimen Banking Network
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A major activity of the National Cancer Research Consortium is the collection of biospecimens for cancer research from a network of banking sites throughout the country. A network for biospecimen collection from sites around the country has the added advantage compared with single site collection of a series of cases. These advantages include a wider spectrum of specimen source such as from indigenous communities, a high number of cases obtained in a shorter period of time as well as an adequate collection of less common cancers to make research viable and with adequate statistical power. Biospecimen banking also allows the storage of a ready source of material for future studies. It is important that the Network is supported by a system for recording high quality clinical data, including outcome data associated with biospecimens, equipped with features ensuring secure handling anonymization for research purposes. of confidential information while allowing for Within the Ministry of Health, the Network of Clinical Research Centres (CRC), which are set up within major public hospitals within the country could play a role in this activity. Proposal for a Research Division in NCI
As a long term goal, a national level institute for cancer research should be set up within the Ministry of Health. In the interim period, it is proposed that a Research Division be established in the National Cancer Institute (NCI) to support and complement clinical research. Studies such as molecular epidemiology, pharmacogenetics as well as biomarker profiling can be pursued to aid patient management and stratification in clinical trials and risk assessment. As the national focal point for cancer management, the NCI will manage the information related to treatment and clinical outcomes of major cancers. Besides research, the research division shall conduct training courses and provide research attachments for post doctoral candidates. The Institute for Medical Research will actively collaborate with the NCI in its research activities through the setting up of a satellite IMR Cancer Research Centre within the premise of NCI.
8.0
IMPLEMENTION, EVALUATION AND MONITORING
The implementation and success of the National Cancer Blueprint will require an integrated approach with close working partnerships across sectors and will involve a wide range of organizations and health care providers. To ensure an effective and efficient implementation, there must be competent management and strong leadership to identify priorities and resources, and to organize and coordinate those resources to meet the planned objectives and strategic action plans. and evaluation must that be put place to determine whether the Action Plan is Monitoring achieving its overall purposes, the in various activities identified are meeting their respective outcomes and attaining the milestones that have been set. Periodic review of the implementation is important to ensure that actions
44
are achieving the desired effects, and if necessary, modifications or new objectives can be added. Development of cancer management measures should be an integral part of a comprehensive National Health Plan. The Malaysian National Cancer Management Programme should be integrated with the existing health care systems at the hospitals, primary care and public health level. The components of NCMP include Primary Prevention, Screening, Early Detection, Diagnosis, Treatment, Palliative Care, Rehabilitation, Traditional and Complementary Medicine. However, the NCMP should take into consideration the epidemiological and economical aspects.
8.1
Network and Linkages
Since cancer involves many sectors namely socio-economic, educational and political, the control of cancer requires a broad community approach. Cancer experts alone will not suffice. Intersectoral collaboration is thus a crucial requisite for a cost-effective NCMP. Those concerned with cancer control must work with authorities in agriculture, commerce, communications, education, industry and law in order to achieve success. Establishing effective network with supportive elements in the society deserves high priority. In cultivating a communication strategy a wide range of functional coalition should be established, with representation from relevant stakeholders. Stakeholders with interest and responsibilities for various aspects of cancer control include agencies of potential the government (Ministries of Health, Welfare, Education, Human Resources, Agriculture, Science, Technology and Innovations, Finance etc.), private sectors which provide medical and health related services, and appropriate non-government organizations (National Cancer Council - MAKNA, National Cancer Society of Malaysia, CancerLink Foundation, Malaysian Medical Association, Hospis Malaysia and other bodies with interest in health, welfare, anti-tobacco, the environment etc.). NGOs can often perform roles in cancer control that are not open to government because of fiscal or political restraints. NGOs should be consulted in the development of the NCMP and their collaboration in the process secured. They need to work within the NCMP, and avoid promoting measures that are suitable in other countries but impractical or not feasible in Malaysia. International linkages should be strengthened and maintained. Two-way communication channels for information exchange Besides and updates on global cancer situation and control measures must be established. the WHO, UICC and other relevant international bodies, the NCMP in Malaysia should also link-up with
45
authorities of similar programmes in other countries, essentially those who are members of ASEAN. 8.2
Financing
Based on current situation, the government will still continue to be the principal provider and financial supporter of the NCMP, even though the trend now is moving towards privatization, outsourcing, public private partnership and leasing of equipment as innovative means of financing. The Action Plan in Appendix 4 identifies the elements, activities, timeframe and agencies needed for implementation of the NCMP and the stakeholders involved. A total allocation of aboutRM 2.046 billionis needed during the second half of the Ninth Malaysia Plan for implementing the first phase of the National Cancer Management Blueprint Master Plan. The summary of the financial implications for the whole spectrum of cancer related activities in the 9MP including research and development is as listed in Appendix 5. Strategic action plans proposed under Treatment alone account for 50.33 per cent of the total budget estimated, followed by 22.49 per cent for Diagnosis, 16.24 per cent for Prevention, 4.44 per cent for Screening and Early Detection as well as 3.95 per cent for cancer r esearch and strengthening. The budget for Treatment is high because it involves the use of expensive equipment and drugs. Overall, procurement of drugs for treatment as well as HPV vaccines accounts for the largest portion of the total budget requested (49.43 per cent). This is followed by purchase of equipment (for treatment, diagnostic and screening purposes) (21.1 per cent), outsourcing per cent), and 2,189 humannew capital development (10.23 per and cent).consumables Under human(10.3 capital development, posts are proposed for the recruitment of medical and allied health care professionals including specialists, doctors, scientists, researchers, therapists, nurses, and other support staff. Emolument alone constitutes 8.06 per cent of the total budget while training of key personnel and recruitment of foreign experts another 2.17 per cent. Upgrading and setting up of new or improved facilities constitute another 5.05 per cent of the budget. As the financial requirement indicates, the implementation of a national cancer management programme is expensive. Although the overall estimated budget is about RM 2.046 billion, this amount may be reduced to RM 1.692 billion with the implementation of the Replacement and Upgrading of Medical Equipment Programme of the MOH for the 9MP. Under this pro gramme, most of the equipment proposed for Treatment and Diagnosis may be acquired through leasing, be it technology leasing or financial leasing. This will reduce the high capital outlay incurred by these equipments. Further reduction equipment cost can also be expected if equipment required for the various cancer in screening programmes are also acquired through leasing.
46
The import of generic drugs for cancer treatment can be another effective measure that can bring down the high cost of cancer management in the country. Special Allocation for Cancer Drugs and Research Activities
Of the total estimated budget of RM 2.046 billion for implementation of the cancer blueprint master plan in the second half of the 9MP, 61 per cent of the budget shall be sourced through the existing financing mechanism within the Ministry of Health. The various requests can be made through the Modified Budgeting System at Program level, Dasar Baru and the Training Budget. Of utmost importance and immediate concern, is the need for new federal government funding for improving cancer treatment and strengthening cancer research in the country. This will require an additional allocation of RM 700.27 million for 2008 - 2010 , comprising RM 619.53 million for the purchase of cancer drugs to accomodate the increased demand for cancer treatment and its ensuing escalated costs, and RM 80.735 million for implementing the various strategies of the cancer research agenda.
8.3
Organizational St ructure
It is most essential to provide strong and effective leadership from an early stage in the establishment of a NCMP. Since ideal leadership qualities may not be found in one person, a team may be the more appropriate solution. Individuals should be sought with the qualifications that equip them to induce changes. In recognition of the enormous and ongoing task, it is recommended that the National Cancer Control Committee be established to oversee and provide the leadership to steer the National Cancer Management Programme, to monitor and review its implementation and to foster collaboration and coordination across the sectors. A national cancer control programme policy should also be formulated to provide a solid platform for its implementation and to maintain its momentum. The National Cancer Control Committee (NCCC) will be managed by a team that constitutes the National Advisory Committee on Cancer Control. This team will be led by the Director General of Health Malaysia and will include Directors of all the relevant divisions. Organization of the NCCC at the national level will be broadly divided into two, i.e. the coordination and the technical arms. The National Coordinating Committee on Cancer Control will function as a consultative body for government and non-government agencies involved in cancer prevention and control, as well as management of the NCMP in the country. Technical matters will be handled by the National Technical Committee on Cancer Control, under which are working committees to address the different
47
identified areas of cancer control. Ad-hoc committees can be formed as and when necessary, should matters outside the terms of reference of these committees arise.
9.0
CONCLUSION
Cancer, which is presently the third major cause of deaths in MOH hospitals in the country will continue to become more and more promin ent. Unless positive steps are taken, Malaysia may have to face an enormous cancer burdenbyinall thestakeholders, near future. Itthe is timely hoped that with adequate support of resources and commitment and effective implementation of the strategic action plans outlined in the National Cancer Management Blueprint (Master Plan) will reduce the negative impact of cancer, by decreasing disease morbidity, mortality and improving the quality of life of cancer patients and their families. The Blueprint provides the framework for all levels of government to work together to reduce the risks of developing cancer, improve cancer care through better screening, treatment, access to services and quality of life and reduce the risk of dying from cancer. Implementing the Strategies of the Blueprint means fewer Malaysian will get cancer and fewer Malaysians will die from cance r. People with cancer wil l have access to highquality, timely treatment and care, no matter where they live. When cancer cannot be cured, patients will receive high-quality, compassionate end-of-life care, close to family and friends, without enduring unnecessary pain. Duplication in the current cancer system shall be decreased and cancer trends will be reliably tracked to help the country monitor how it is doing compared to the rest of the world. Most primary prevention strategies and cancer monitoring and surveillance activities will remain the prerogative and responsibility of the government. However, early detection, cancer treatment, rehabilitation, palliation, training and research, can be a shared obligation. Meanwhile, NGOs must maintain fund raising efforts to improve their pool of accessible reserves. Cooperation between Government and NGOs who have similar goals but access to different resources can and must be given further encouragement in order to expedite the progress in the various objectives of the National Cancer Blueprint. In future, when the NCMP has developed a firm sense of common purpose, there may also be opportunities for reallocation of resources for priority aspects of cancer control, especially in areas of cancer prevention.
48
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1.
The New Zealand Cancer Control Strategy: Action Plan 2005 – 2010. Cancer Control Taskforce, 2005.
2.
Texas Cancer Plan 2005.
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Annual Report 2004, Ministry of Health, Malaysia.
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World Cancer Report, 2003. International Agency for Research on Cancer, World Health Organization.
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World Health Report, 2003 – shaping the future.World Health Organization.
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Key Statistics 2003. Jabatan Statistik Malaysia.(http://www.statistics.gov.my)
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Zarihah MZ, Mohd Yusoff H, Devaraj T, et al. Penang Cancer Registry Report 1994-1998. Penang: Penang Cancer Registry, 2003.
8.
Narimah A, Rugayah B, Tahir A, et al. Cervical Cancer Screening. Pap’s smear examination. Public Health Institute, Ministry of Health of Malaysia. National Health and Morbidity Survey 1996. Vol. 19. Kuala Lumpur: Ministry of Health, 1999:16
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GCC Lim, Y Halimah (Eds). Second Report of the National Cancer Registry. Cancer Incidence in Malaysia 2003. National Cancer Registry. Kuala Lumpur 2004.
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National Cancer Control Programmes. Policies and Managerial Guidelines.
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Malaysia’s Health 2002. Ministry of Health, Malaysia.
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Health Facts 2005. Planning & Development Division,MOH.
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Manual on the Prevention and Control of Common Cancers. World Health
World Health Organization. 2002
Organization 1998. 14.
National Health Morbidity Survey 1996. Ministry of Health, Malaysia.
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National Cancer Control Programme. Policies and Managerial Guidelines. World Health Organization. 1995
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Malaysia NCD Surveillance 2005/2006: NCD Risk Factors in Malaysia. Disease Control Division, MOH, 2007
17.
National Cancer Prevention Policy 2004-2006, The Cancer Council Australian.
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Cancer Awareness, Prevention and Control: Strategies for South East Asia, UICC 2006
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An American Cancer Society Report, The Worldwide Cancer Burden, 2006
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Boyle P, Maisonneuve P. 19 95, Lung ca ncer an d tobacco smoking, Cancer, 12:167-181
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Lee IM. 2003. Physical activity and Cancer prevention-data from epidemiologic studies. Med Sci Sports Exerc 35(11)
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Cancer Control Opportunities in low- and middle-income countries. Committee
Lung
on Cancer Control in Low- and Middle-Income Countries, Frank A. Sloan and Hellen Gelband, Editors, 2004 National Academy of Sciences.
50
APPENDIX 1 NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 1: PREVENTION
I
OBJECTIVES
1. To reduce the prevalence of risks factors for cancers in Malaysia 2. To increase awareness knowledge of the general public on the risk factors of the commonand cancers in Malaysia 3. To strengthen the cancer risk factors intervention programmes
II
TARGETS
1. Decrease prevalence of identified modifiable cancer risk factors: a. Decrease smoking prevalence from 21.5% in 2006 (NHMS III) to 16.5% by 2015 (24.8% in MHMS II) b. Increase prevalence of physical activity among adult aged 18 year and above from 56.3% (NHMS III) to 80% by 2015 (11.6% in NHMS) c. Reduce prevalence of alcohol consumption from 12.2% in 2005 (MyNCDS-1) to 7.2% by 2015 2. 75% of general public has knowledge on the risk factors and 7 early warning signs of common cancers in Malaysia (NHMS III 46.9% - health information) by 2015 3. Introduce and implement the National HPV immunization programme by 2010. 4. Attain 95% hepatitis B vaccination coverage for population under 1 year by 2015
III
STRATEGIC ACTION PLANS - PREVENTION 2008 to 2010
1. Increase on selected cancers and risk factors, the early warning awareness signs and ensuring accessibility totheir promotive & preventive activities and services
51
2. Compliance to existing law and standards related to cancer prevention and control 3. Increase human resource for cancer registries 4. Cancer prevention through immunization programme 5. Efficient and timely reporting of cancer cases 6. Study related to cancer prevention and behavioural modification 7. Collaboration / networking with related agencies at all level
2011 to 2015
1. Evaluate Post phase I programmes 2. Strengthen the National Hepatitis B and HPV immunization programmes 3. Further strengthen cancer prevention programmes and activities based on post phase I evaluation 4. Continue health education on cancer risk factors and prevention through community mobilization 5. Continue and strengthen compliance to legislations related to cancer control
52
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 2: SCREENING ANDEARLY DETECTION
I
OBJECTIVES
1. To detect potentially cancerous lesions in the population at risk for the selected cancers i.e. breast cancer, cervical cancer, oral cancer, liver cancer, colorectal cancer, prostate cancer and nasopharyngeal cancer 2. To increase the detection rate of selected cancers at an earlier stage of the disease
II
TARGETS 2008 – 2010
1. Cervical Cancer 60% of women aged 20-65 years had done pap smear (26% in NHMS II, 43.7% in NHMS III) 2.
Breast Cancer 100% of women aged 35-49 years attending MOH facilities had Clinical
Breast Examination 3. Oral Cancer To increase the detection rate of stage 1 disease from 26% (Penang Cancer Registry 1999-2003) to 30% ( National Oral Health Plan Goal for 2010) 4.
Colorectal cancer 100% of high risk population identified at MOH clinics screened for colorectal cancer
5. Liver Cancer 100% of high risk patients screened for Hepatocellular Carcinoma (HCC) 6. Nasopharyngeal Cancer (NPC) 100 % of high risk population identified atMOH clinics screened for Nasopharyngeal cancer 7. Prostate Cancer 100 % of high risk population identified atMOH clinics screened for prostate cancer
53
2011 – 2015
1. Cervical Cancer a. 80% of women aged 20-65 years had done pap smear (26% in NHMS II, 43.7% in NHMS III) b. To increase the detection rate of stage 1 disease from 29.3% to 50%. (34.9% in Penang Cancer Registry 1994-1998, 29.3% in Penang Cancer Registry 1999-2003) 2. Breast a. 15%Cancer of women aged 50-69 years had mammography examination (10.7% in NHMS III) b. 80% of women aged 35-49 years in general population had Clinical Breast Examination (63% in NHMS III) c. To increase the detection rate of stage 1 disease from 20.5% to 40% (15.4% in Penang Cancer Registry 1994-1998, 20.5% in Penang Cancer Registry 1999-2003) 3. Oral Cancer To increase the number of cases detected at stage 1 by another 10% based on 2010 achievement 4. Colorectal cancer To increase the detection rate of stage 1 disease (male) from 5.4% to 11% (9.3% in Penang Cancer Registry 1994-1998, 5.4% in Penang Cancer Registry 1999-2003) 5. Liver Cancer To increase the detection rate of stage 1 disease (male) from 19% to 45% (9.1% in Penang Cancer Registry 1994-1998, 19% in Penang Cancer Registry 1999-2003) 6. Nasopharyngeal Cancer To increase the detection rate of stage 1 disease (male) from 12.2% to 20% (11.1% in Penang Cancer Registry 1994-1998, 12.2% in Penang Cancer Registry 1999-2003) 7. Prostate Cancer To increase the detection rate ofstage 1 disease (male) from 15.8% to 25% (13.5% in Penang Cancer Registry 1994-1998, 15.8% in Penang Cancer Registry 1999-2003)
54
III
STRATEGIC ACTION PLANS – SCREENING & EARLY DETECTION
Below are the screening modalities and target groups for the selected cancers Selected cancers
Breast Cancer
CervicalCancer
Screening modalities (accepted/proposed)
Targeted population (proposed)
Mammogram Women 50 to 69 years Clinical Breast Examination Women 35 to 49 years (CBE) Papsmear - Women20to65yearsold with sexual history
Oral Cancer
Visual examination
High risk population - Age more 20 years - Indians - Indigenous population - Specific behaviour
Hepatocellular Carcinoma
Serum Alpha- feto protein Transabdominal ultrasound
Colorectal cancer
Fecal occult blood
Prostate Cancer
Prostate Specific Antigen (PSA)
High risk group: - Men > 50 years - Family history
Nasopharyngeal Cancer
Epstein-Barr Virus (EBV) Serological Markers
High risk : - Chinese - Age > 40 years - Family history
High risk patients: - All cirrhotics - Hep.B Carriers more than 40 years old - Hep.B Carriers less than 40 years old with at least 2 risk factors - HCV sero-positive individuals more than 40 years old High risk: - Age more than 50 years old - Family history
55
2008 – 2010
1.
Development or strengthening of screening programme for selected cancers - Reorganise existing screening programme to population based screening programme for cervical and breast cancers - Strengthen opportunistic screening programme for identified high risk population for oral, colorectal, prostate and nasopharygeal (NPC) cancers at primary health care services
for high risk patients for Hepatocellular - Strengthen Carcinoma screening (HCC) in programme major hospitals 2.
Health Promotion - Public education and awareness campaign on screening programmes eg: pap smear, mammogram, mouth self-examination, family history, prostate and breast awareness - Develop health education materials on screening programmes
3.
Human resource dev elopment - Develop, review and update training modules on screening for in-service, basic or post basic training, particularly for procedure and counseling - Increase the number of trained and credentialed staffs :primary health care providers cytoscreeners (15-20 per cytology centre), radiographers (30 per breast screening centre)and sonographers • •
•
relevant laboratory personnel
4.
Strengthening of screening facilities and laboratory services - Integration of screening services in existing facilities for cervical, oral, colorectal, prostate, NPC and HCC - Set up infrastructures and facilities for 2 breast cancer screening centres in Malacca and Pahang - Strengthen centralisation of cytology services in MOH – 12 hospital-based laboratory screening centres - Strengthen and expand relevant laboratory services for screening tests – fecal occult blood, Prostate Specific Antigen (PSA), serum Alpha-feto protein, Epstein-Barr Virus (EBV) Serological Markers
5.
Outsourcing of services to overcome long waiting time, shortage of manpower and inadequate equipment - Outsourcing the services to other agencies for :• • •
Cytology services Radiological services eg: mammogram, ultrasound Laboratory services for fecal occult blood, Prostate Specific Antigen (PSA), serum Alpha-feto protein, Epstein-Barr Virus
56
•
(EBV) Serological Markers Trainings – eg: post basic for cytology in HUKM, Breast Ca Management for nurses in UMMC
6.
Establishment and strengthening of quality assurance programme - Quality assurance programme in screening procedures - External /internal quality assurance programme in laboratory and radiology
7.
Development or update of protocols/guidelines/standards/targets
or update the documents selected through - Develop establishment of technical workingongroups andcancers consultancy from experts on specific cancers 8.
Development or strengthening of surveillance and evaluation system - Establish or review indicators for :Epidemiology (eg: coverage, acceptance rate) Clinical (eg: positivity rate, results) Impact (eg: staging, morbidity, mortality) - Development and strengthening of monitoring mechanism eg: Oral Health Clinical Information System, Sistem Informasi Program Pap Smear (webbased software application for population-based pap smear screening programme) • • •
9.
Research and development - Evaluate the screening modalities through Health Technology Assessment
on test accuracy specificity), safety, cost effectiveness, acceptability for (sensitivity PSA, Fecal and Occult Blood, EBV serological markers and Serum AFP eg: Feasibility study on population based colorectal cancer screening (on going study) - Evaluate existing screening programmes for cervical cancer and oral cancer - Develop model for screening eg: risk management for oral cancer - New or alternative modalities for screening eg: Demonstration project on Visual Inspection with Acetic Acid (VIA) as alternative to pap smear Indirect Nasopharyngoscopy for NPC •
•
10. Intersectoral cooperation and collaboration - Collaborate with other department and agencies on advocacy, health promotion, screening activities, training, research and development,
laboratory and radiology services, reporting system
57
2011 – 2015 1.
Strengthening of screening programme for selected cancers - Expand the population based screening programme for cervical and breast cancers in other regions - Strengthen screening programmes for high risk population for other selected cancers - Hepatocellular Carcinoma (HCC), oral, colorectal, prostate and nasopharygeal (NPC) cancers
2.
Health Promotion
education awareness campaign on screening - Continuous programmespublic to ensure optimaland programme coverage. - Review and strengthen the approach and mechanisms of information dissemination on screening programmes 3.
Human resource development - Develop and review training modules on screening for in-service, basic or post basic training - Create posts and provide training for primary health care providers, cytoscreeners, radiographers, sonographers and relevant laboratory personnel
4.
Strengthening of screening facilities and laboratory services - Expand breast cancer screening centres in other regions - Further strengthen centralisation of cytology services and establish more laboratory screening centres in MOH
Further strengthening and expansion - services for other selected cancers of screening facilities andlaboratory 5.
Outsourcing of services to other agencies - Continue and review outsourcing services including identify other possible areas for outsourcing
6.
Quality assurance programme - Continue quality assurance programme in screening procedures, laboratory and radiology
7.
Development or update of protocols/guidelines/standards/targets - Continue develop or review or update the relevant documents on selected cancers
8.
Strengthening of surveillance and evaluation system
- Evaluate and strengthen the existing monitoring mechanism
58
9.
Research and development - Evaluate screening programmes for breast , Hepatocellular Carcinoma (HCC), oral, colorectal, prostate and nasopharygeal (NPC) cancers - New or alternative modalities for screening
10.
Intersectoral cooperation and collaboration - Continue to collaborate with other department and agencies on advocacy, health promotion, screening activities, training, research and development, laboratory and radiology services, reporting system
59
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 3: DIAGNOSIS
I
OBJECTIVES
1.
To improve the accuracy, efficiency, accessibility and timeliness
of cancer diagnosis to all cancer patients and health care providers 2. To streamline cancer diagnosis and research using proven state-of the-art technologies to better characterize and profile cancers, specifically in grading and staging of cancer, determination of cancer progression, prognosis and predictive response to treatment modalities, leading to best possible effective personalized treatment and outcome 3. To provide comprehensive diagnostic services to support cancer patients in all aspects of care including complications and secondary effects of cancer and its treatment 4. To conduct research to improve cancer diagnosis in particular, while utilizing the diagnostic services to facilitate and support cancer research in general
II
TARGETS
1. To provide histopathology, cytopathology and radiological services for diagnosis and monitoring of all cancer patients, and to be delivered in a timely manner by appropriately qualified and trained medical professionals by 2010 2. To provide molecular profiling and cancer genetics services for the 10 most common cancers in Malaysia by 2010, and to be extended progressively till available for all cancers by 2025 3. To provide high end imaging facilities (PET scan, angiogram, MRI and nuclear medicine) to support cancer management and treatment in main regional centers by 2010 and to be extended progressively until available for all cancer patients by 2025
60
4. Tocontinuallyupgradediagnostic facilities in existence and those newly established according to state-of-art technology and evidence-based practice 5. Toprogressivelyequipallradiology department with RIS/PACS system to ensure efficient and lossless transfer of diagnostic imaging information. This will be done in phases initially with state hospitals and subsequently to all hospitals with radiologists by 2025. (Towards digital imaging community and service) 6. Toprovideservicesthatwillsupport cancer research and development in order to improve cancer diagnosis and treatment
III
STRATEGIC ACTION PLANS - DI AGNOSIS 200 6 8 – 2010
1. Re-organize the histopathology diagnostic services into 12 comprehensive regional centers with complete routine cancer tissue diagnostic services such as immunohistochemistry, supported by a network of laboratory information systems 2.
Upgrade the scope and efficiency of existing laboratory diagnostic
services inpatients all national, regional and stateofhospitals provideutilization total support for cancer including a full range tumour to markers, of automation and data management through laboratory information systems 3. Establish flowcytometry for leukaemia profiling in at least 3 regional centres 4. Establish molecular profiling and cancer genetics services in at least 2 MOH regional centers 5. Train subspeciality pathologists in soft tissue, bone, respiratory, ocular, lymphoproliferative, urological cancers, cytogenetics and molecular pathology
61
6. Train professional, scientific and technical staff to support upgraded and newly established pathology and radiological services 7. Establish biobanking facilities in at least 1 regional center (preferably the National Cancer Institute) 8.Establish guidelines on cancer profiling and biobanking (to be jointly developed with professional bodies such as the Academy of Medicine of Malaysia) 9. Form research clusters at regional centers focusing on the 10 most common cancers in Malaysia 10. Establish Radiology Information systems (RIS) and PACS in the National Cancer Institute (NCI) and upgrade existing PACS at the Putrajaya Hospital to ensure seamless flowof information between thetwo centers 11. Establish RIS and / or PACS to regional centers ( Penang Hospital, Kuantan Hospital , Sultan Ismail Hospital) 12. Extend RIS and / or PACS to other regional centers or state hospitals in phases. Phase 1: HKL, HSA JB, Kuching, Queen Elizabeth and Malacca. 13.
Expand, upgrade and / or replace basic radiological cancer
diagnostic services influoroscopy, all district hospitals with radiologists to include general radiography, mammography, ultrasonography and MSCT. The expansion of services will be done in phases. a. Digital fluoroscopy unit for Hospitals Sandakan, Keningau, Labuan, Kuala Terengganu, Kuala Pilah. b. Ultrasonography for Hospitals Seri Manjung, Bintulu, Kuala Krai, Muar, Selayang , HAS JB and Putrajaya. c. 4 slice MSCT Scan for Hospitals Sibu, Keningau, Miri, Labuan, Batu Pahat. 14.
Upgrade existing radiological facilities in all state hospitals. a. 16 slice MSCT Scan for Hosp. Ipoh, Melaka, Seremban, HSA JB. b. Digital Mammography for state and tertiary hospitals in phases – Hosp. Selayang, Queen Elizabeth KK, Penang, HSA JB, Seremban c. Replacements and upgrading of Ultrasound, MRI, angiography / c-arm fluoroscopy units initially in tertiary, state hospitals and priority areas. This will be done in stages from 2006 – 62
d. Upgrading of PACS system in existing hospitals to accommodate new modalities and latest software. This will be ongoing from 2006 – 2025. e. Upgrading and replacement of radiology equipment in Hospital Likas which is to be the regional cancer treatment centre for Sabah. 15. Train subspecialty radiologists in breast imaging, interventional radiology, paediatrics, musculoskeletal, neuroradiology, urology, hepatobiliary and gastro-intestinal radiology 16. Provide short courses training for radiologist, radiographer and radiology nurses to fill in the need for trained personnel 17. Create additional posts for radiologists, radiographers, sonographers 18. Create posts and training for radiology nurses and information and image managers.
2011 – 2015
1. Establish at least 3 additional regional centers for molecular profiling and cancer genetics (at least 1 in East Malaysia) 2. Establish biobanking facilities in 2 additional regional centers 3. Establish proteomic facilities in at least 1 regional center 4. Provide additional subspeciality training of pathologists and radiologists to fulfill needs as identified 5. Upgrade pathology and radiology facilities in accordance with state-of-art technology 6. Establish high end imaging facilities (PET scan, angiogram, MRI and nuclear medicine) in 3 additional regional centers (Eastern region, East Malaysia and Southern region) 7. Provide ongoing installation of RIS and / or PACS to regional, state and tertiary hospitals. 8. Provide ongoing upgrading and replacement of equipment (general x-ray, digital fluoroscopy, US, digital mammography MSCT, MRI, Angiography) in hospitals
63
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 4: TREATMENT
I
OBJECTIVES
1. To enhance cancer therapy delivery and services which are timely, equitable and accessible for cancer patients throughout the country 2. To provide a good, safe and quality state-of-the-art cancer treatment for cancer patients in the country
II
TARGETS
1. To improve accessibility and distribution of cancer treatment services with the aim to treat at least 80% of newly diagnosed cancer patients per year by 2010 and 100% by 2015 2. To reduce the overall waiting time from the time of diagnosis to receiving Oncological Treatment within 2 to 4 weeks by 2015
III
STRATEGIC ACTION PLANS – TREATMENT 200 6 8 – 2010
1.
Set up new radiotherapy treatment centers at Putrajaya – National Cancer Institute Sabah – Likas Hospital
2. Set up new Hematology and Bone Marrow Transplant Centers in Ampang Hospital (Pusat Rujukan Nasional) and Penang 3.
Set up new Paediatric Oncological services in Kuantan
4. Improve and strengthen the current existing Radiotherapy cancer treatment centers in Kuala Lumpur Hospital, Sarawak General Hospital and Pandan Hospital, Johore by upgrading and replacing old equipment and facilities 5. Improve and strengthen the current existing Hematology centers in Ipoh, Johor Bahru, Kota Kinabalu and Klang 6. Improve and strengthen the current existing Paediatric Haematology-Oncology and Stem Cell transplant services in the Paediatric Institute, HKL 64
7. Increase human resource in tandem with the setting up of the above new centers in particular Oncologists, Medical Physicists, Therapy Radiographers and Oncology Nurses 8. Outsourcing and buying of oncology services to be further developed 9. Improve the Oncology referral system nationally through a system of networking and National Referral Guideline for Oncology 10. Establish effective planning and budgeting system for chemotherapeutic and Oncology related drugs to ensure its availability at the appropriate treatment centers 11. Establish comprehensive and multidisciplinary care for 4 cancers, namely Breast, Head & Neck, Colorectal and Gynaecological cancers at all cancer centers 12. Confirm the National Indicators for Radiotherapy Treatment and consolidate Quality Assurance Programmes 13. Complete the development and implementation of minimum criteria for credentialing of oncology related personnel and cancer treatment procedures 14. Establish Radiationall Protection in all Radiotherapy Centers and implementing radiationCommittees protection policies immediately
2011 – 2015
1.
Set up new Radiotherapy cancer treatment centers at Eastern Region – Kuantan Hospital Northern Zone – Penang Hospital
2.
Set up new Hematology services in Kuantan, Kuching and Malacca 3. Improve and strengthen the current existing cancer treatment centers by upgrading and replacing old equipment and facilities 4.
Establish comprehensive and multidisciplinary care for two
additional cancers, namely lung and musculo-skeletal tumours 5. Form a National Tumour Advisory Board to serve as Policymakers and Planners for management of the respective cancers: For Breast Cancer and Colorectal Cancer 65
6. Implement standard national Quality Assurance Program in all cancer centers 7.
Strengthen the credentialing criteria through enforcement and licensing
66
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 5: REHABILITATION
I
OBJECTIVES
1.
ToprovideCancerRehabilitationServices(CRS) to all patients who would need and benefit from rehabilitation medicine services so as to improve their qualityof life
2.
II
Toestablisheffectivesocialandpublicpolicies that will advance Cancer Rehabilitation Programme (CRP)
TARGETS
1. To improve accessibility of Cancer patient to Cancer Rehabilitation services with the aim to treat 80% by 2010 and 100% by year 2015 2. To strengthen the existing Interdisciplinary Rehabilitation team in managing cancer patient by year 2010 3. To improve strengthen service and human resource training to cancerand survivors andafter theircare family of those who need cancer rehabilitation
III
STRATEGIC ACTION PLANS – REHABILITATION 200 6 8 -2010
1. Strengthen Cancer Rehabilitation Team in line with the cancer treatment centers such as Putrajaya - National Cancer Institute Sabah - Likas Hospital Northern Zone - Penang Hospital 2.
Improve and strengthen cancer Rehabilitation Service by upgrading the
facilities and equipment 3. Increase human resource in line with the above newly set up cancer centers
67
4. Improve the referral services through a system of networking and establish a national guideline for Cancer Rehabilitation Service 5. Complete the development of minimum criteria for credentialing of Cancer Rehabilitation team in relation with the rehabilitation procedures applications and their implementation 6. Establish effective planning and through a system of networking with support group in thecommunication community with regards to aftercare service
2011-2015
1. Set up a Cancer Rehabilitation Team in a newly set up Cancer Treatment Center in the Eastern region - Kuantan 2. Improve and strengthen the current existing Cancer Rehabilitation Service by upgrading and replacing old equipment and facilities 3. Enhance the cancer rehabilitation team further in managing various common cancers namely. Breast, Head and Neck, Colorectal and Gynecological Cancer at all cancer centers 4. Set up Standard National Quality Assurance Programme in all established cancer rehabilitation servicecenters
68
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 6: PALLIATIVE CARE
I
OBJECTIVES
1.
To relieve pain and suffering of cancer patients
2. improve theand quality of life of these patients by attending to their physical,To psychosocial spiritual needs 3. To provide a support system for patients and families of life-threatening cancers from diagnosis to issues of grief and bereavement
II
TARGETS 200 8 -2010
1. To set up specialized palliative care services in 6 regional hospitals with palliative medicine and pain specialists 2. To include palliative care education at the undergraduate and postgraduate levels at all medical schools 3.
To integrate palliative care in nurse training programs
4.
To develop cancer pain management Clinical Practice Guideline (CPG)
5.
To network with other palliative care service providers within each region
2011 – 2015
1.
50% of patients with cancer pain receive oral morphine
2. More than 70% of cancer patients and their relatives informed that relief of cancer pain is possible 3.
25% of medical practitioners informed about cancer pain relief guidelines
4. To set up specialized Palliative Care Units in more than 50% of state hospitals
69
5. III
To develop a local training programme : Master of Palliative Medicine
STRATEGIC ACTION PLANS – PALLIATIVE CARE 200 8 – 2010
1. Set up Specialized Palliative Medicine Services in 6 regional centers Penang Hospital, Selayang Hospital, Johore Bahru Hospital, Kota Bharu Hospital, Kuching Hospital, Queen Elizabeth Hospital, Kota Kinabalu 2. Set up specialist consultative palliative medicine service in the National Cancer Institute 3.
Identify and train 8 specialists in palliative medicine
4. Identify and train other healthcare professionals and support staff in palliative medicine (pharmacists, nurses, physiotherapists, social workers, clinical psychologists) 5. Network and lobby with all accredited medical schools to provide undergraduate and postgraduate palliative care curriculum 6. Network and lobby with all accredited universities and government nursing colleges to provide palliative care components in nursing curriculum 7.
Develop a post-basic palliative care nursing course
8. Conduct basic CME programmes in palliative medicine for doctors and nurses throughout the country 2011 – 2015
1.
Include palliative care curriculum as part of cancer training programme
2. Develop specialized palliative medicine services in 6 more state hospitals. (Alor Star, Kuantan, Melaka, Ipoh, Kuala Terengganu, Klang) 3. Network with anesthesia division to develop advanced pain management services alongside palliative care services in the 12 state hospitals 4.
Conduct research and audit on cancer pain relief
5. Set up a Department of Palliative Medicine in at least one of the teaching medical universities 6.
Provide more supportive resources (including funds, training,
70
leadership) to accredited community palliative care providers
I
OBJECTIVES
4.
To relieve pain and suffering of cancer patients and their families
5. To improve the quality of life of these patients by attending to their physical, psychosocial and spiritual needs 6. To provide a support system for patients and families of life-threatening cancers from diagnosis to issues of grief and bereavement
II
TARGETS 2006-2010
6. To set up specialized palliative care services in 6 regional hospitals with palliative medicine and pain specialists 7. To include palliative care education at the undergraduate and postgraduate levels at all medical schools 8.
To integrate palliative care in nurse training programs
9.
To develop cancer pain management Clinical Practice Guideline (CPG)
10.
To network with other palliative care service providers within each region
2011 – 2015
6.
50% of patients with cancer pain receive oral morphine
7. More than 70% of cancer patients and their relatives informed that relief of cancer pain is possible 8.
25% of medical practitioners informed about cancer pain relief guidelines
9.
To set up specialized Palliative Care Units in more than 50% of state
hospitals 10.
To develop a local training programme : Master of Palliative Medicine
71
III
STRATEGIC ACTION PLANS – PALLIATIVE CARE 2006 – 2010
9. Set up Specialized Palliative Medicine Services in 6 regional centers Penang Hospital, Selayang Hospital, Johore Bahru Hospital, Kota Bharu Hospital, Kuching Hospital, Queen Elizabeth Hospital, Kota Kinabalu 10. Set up specialist consultative palliative medicine service in the National Cancer Institute 11.
Identify and train 8 specialists in palliative medicine
12. Identify and train other healthcare professionals and support staff in palliative medicine (pharmacists, nurses, physiotherapists, social workers, clinical psychologists) 13. Network and lobby with all accredited medical schools to provide undergraduate and postgraduate palliative care curriculum 14. Network and lobby with all accredited universities and government nursing colleges to provide palliative care components in nursing curriculum 15.
Develop a post-basic palliative care nursing course
16.
Conduct basic CME programmes in palliative medicine for doctors and
nurses throughout the country 2011 – 2015
7.
Include palliative care curriculum as part of cancer training programme
8. Develop specialized palliative medicine services in 6 more state hospitals. (Alor Star, Kuantan, Melaka, Ipoh, Kuala Terengganu, Klang) 9. Network with anesthesia division to develop advanced pain management services alongside palliative care services in the 12 state hospitals 10.
Conduct research and audit on cancer pain relief
11. Set up a Department of Palliative Medicine in at least one of the teaching medical universities 12. Provide more supportive resources (including funds, training, leadership) to accredited community palliative care providers
72
NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 7: TRADITIONAL AND COMPLEMENTARY MEDICINE
I
OBJECTIVES
1. To relieve pain and suffering of cancer patients 2. To improve the quality of life of cancer patients 3. To allow cancer patients to cope better with cancer and treatment 4. To minimize the side effects of cancer treatment
II
TARGETS
1. To establish standards and guidelines of T/CM used for cancer patients 2. To establish T/CM facilities and services for cancer patients in centers in line with integrated hospital concept – to be carried out in 2 phases (RMK-9 & RMK-10) 3. To introduce quality and standardized herbal preparation/products and Complementary Therapy practices such as acupuncture, manual therapy (massage), spiritual therapy (meditation) and exercise as an adjunct therapy in the treatment of cancer patients 4. To facilitate basic training in primary health care for Traditional and Complementary practitioners 5. To identify and collaborate research for local medicinal plants which can help to minimize side effects of cancer treatment
III
STRATEGIC ACTION PLANS – TRADITIONAL AND COMPLEMENTARY MEDICINE 2008 – 2010
1. Introduce herbal preparation (for adjunct therapy), acupuncture and rehabilitation massage in a pilot project at the integrated hospitals. The
73
project will start with the 3-month attachment posting for 3 Oncology specialists from the Traditional Chinese Medicine Guang’anmen Hospital, Beijing and 3 professors from the University of Traditional Chinese Medicine Beijing, Shanghai and Nanjing. The locations for the attachment will be at: University Beijing - Putrajaya Hospital University Shanghai - Kepala Batas Hospital, Penang University Nanjing - Sultan Ismail Hospital, Johor Bahru. 2. Establish Complementary Therapy services at the following hospitals: --
Putrajaya Hospital / National Sultan Ismail Hospital, Johor Cancer Bahru Institute Kepala Batas Hospital, Penang Likas Hospital, Kota Kinabalu
3. Establish standards and guidelines of Complementary Therapy for cancer patients a. Develop a manual for standards and guidelines in – i. Acupuncture Therapy - cater to relief and manage post chemotherapy symptoms/ side effect, such as pain, nausea, vomiting and post chemotherapy fatigue. ii. Aromatherapy Massage post chemotherapy fatigue relievers iii. Mind, Body and Soul wellness - spiritual wellness
b. 3.
meditation -- yoga Benchmark the current T/CM services in Cancer Management
Identify T/CM modalities for pain management in cancer patients a. Identify types of cancer suitable for T/CM modalities through consultation with international T/CM experts
4. Facilitate training for T/CM Practitioners in Oncology fields a. Collaborate with international agencies for training and sharing valuable experiences in cancer management b. Establish and strengthen strategic partnerships with other stakeholders c. Establish T/CM unit in Oncology Department 5. Initiate awareness of T/CM through road shows, publishing or promoting guidelines as wellservices as through the T/CM Act. Active participation by primary health care providers is encouraged through provision of basic training on T/CM
74
6. Initiate research on T/CM treatment for cancer cases and to identify local medicinal plants for development as a product for cancer treatment
2011 – 2015
1. Establish T/CM services at other centers that provide Chemotherapy for Clinical a. KualaOncology Lumpur Hospital b. Sarawak General Hospital c. Penang Hospital d. Kuantan Hospital e. Ipoh Hospital f. Malacca Hospital g. Kota Bharu Hospital h. Kuala Terengganu Hospital
75
APPENDIX 2
1st National Conference on Cancer Research Coordination, April 2004
EXECUTIVE SUMMARY
The main agenda conference waspriority to helpneeds formulate effective strategies for research, future cancer research in of thethe country, identify and new frontiers in cancer and to foster networking and research collaboration.
Conference Objectives Participants in this conference were asked to identify a concrete set of priorities to address cancer research in Malaysia that were consistent with the research theme developed by the conference organizing committee for each of the seven participating working groups. They were to: 1. Identify promising scientific areas that could be pursued in cancer centers given their unique resources and expertise. 2. Recommend opportunities in cancer research that will advance medical progress in the country. Each working group was asked to select their research priorities. 3. Suggest various strategies and approaches for integrating cancer research. The focus designated by the conference organizing committee was future directions in cancer research in Malaysia. Participants were encouraged to make recommendations for research implementation and research barriers as well.
Conference Design and Participants The conference was held at the Institute for Medical Research, Kuala Lumpur, 27-28 April 2004. Six plenary sessions (held in the Ungku Omar Auditorium) and the seven working groups (convened in the various meeting rooms at the IMR) provided the forum and setting for brainstorming and the exchange of ideas and insights from participants. Each working group was chaired by the representative from the various cancer groups who were selected by the National Cancer Research Committee. Seven scientific presentations on cancer research from the epidemiology, prevention, diagnosis, treatment, rehabilitation, palliative care and herbal medicine working groups were incorporated into each plenary session to orient participants for their breakout group discussions. Breakout group reports were presented at the end of the second day of the conference.
76
There were 157 participants comprising medical oncologists, pathologists, surgeons, paediatricians, physicians, basic scientists, social scientists, epidemiologists and other health professionals. Four overseas plenary speakers were invited: Dr. Lawrence Piro, Cancer Institute Medical Group, California; Professor Dr. Soo Khee Chee, Director, National Cancer Centre, Singapore; Professor Lee Hin Peng, Chairman, Singapore Cancer Registry and Dr. Cynthia Goh, Chairman, Singapore Hospice Council. Dr. Lye Munn Sann, Director, IMR, welcomed the participants. The keynote presentation was delivered by Datuk Dr. Hj Mohd Ismail Merican, Deputy Director General of Health (Research & Technical Support), Ministry of Health Malaysia. He also chaired the presentation of the breakout groups.
Research Themes and Priorities Identified Many valuable suggestions were derived from the plenary and breakout group discussions. The full report identifies the domain of research issues and concerns that cut across institutes, disciplinary and professional boundaries and calls for the coordination of cancer research. The Working Group Chairpersons, speakers, and themes are identified and abbreviated versions of the research priorities are indicated below.
Group I: Cancer Research on Epidemiology [research on cancer causation, mechanisms of carcinogenesis, prevention, and survivorship including descriptive, analytical, biochemical, and molecular epidemiology; the use of biomarkers to study the neoplastic and preneoplastic processes in humans; chemoprevention and other types of prevention trials; and the role of behavioural factors in cancer aetiology and prevention] Chairperson: Dr Lim Teck Onn Clinical Research Centre, Hospital Kuala Lumpur Research Priorities: 1. Cancer incidence and prevalence, secular trend, and distribution by age, sex and ethnic groups 2. Cancer mapping - small area variation in cancer incidence e.g. for stomach cancer, nasopharyngeal cancer 3. Short and long term cancer patient survival; life expectancy with cancer compared with normal population 4. Prognostic factors for cancer patient survival 5. Genetic and molecular epidemiology 6. Economics studies: Cost of disease burden
Group II: Cancer Research on Prevention [cancer causation, risk reduction, intervention and evaluation impact of the preventive measures; understanding causes of
77
cancer providing opportunity forcancer prevention and/orearly detection; external factors categorized as physical, chemical and biological] Chairperson: Dr Zarihah Mohd. Zain Disease Control Division, Ministry of Health Malaysia Research Priorities: 1. environmental and occupational carcinogenic contaminants 2. advocate screening programmes and early diagnosis 3. establish systematic evaluation of screening programmes for impact assessment 4. surveillance function for cancer monitoring 5. national provide baseline for comparisons between intervention methods, geographical and time trends.
Group III: Cancer Research on Diagnosis [detection of presence of malignancy (aetiological & tissue diagnosis, imaging), information needed for typing and classification of cancer, choice of treatment and monitoring of cancer (protein & molecular expression profiles, prognostic & predictive indicators, tumour markers)] Chairperson: Professor Dr. Looi Lai Meng President, College of Pathologists, Academy of Medicine, Malaysia Research Priorities: 1. identification of aetiological agents and linkages to precancer and cancer 2. cancer biology and pathogenesis 3. improvements in accuracy, sensitivity and specificity in cancer detection, monitoring and classification 4. prognostic and predictive parameters
Group IV: Cancer Research on Treatment[to ascertain the burden of cancer in our society as baseline data as well as to find innovative ways in the treatment of cancer] Chairperson: Dr Gerard Lim Chin Chye Institute of Radiotherapy and Oncology, Hospital Kuala Lumpur Research Priorities: 1. register and coordinate all parties involved in cancer research study 2. creation of adequate clinical practice guidelines for cancers to facilitate audit and retrospective analysis 3. newly introduced modalities to undergo clinical trials and audit process 4. facilitate the networking between disciplines and government hospitals that may facilitate research 5. develop teleconsultation
78
6. establish teams with liaison officers for oncology in various hospitals to facilitate follow up of cancer patients
Group V: Cancer Research on Rehabilitation[process of helping a person with cancer to help himself obtain maximum physical, social, psychological, vocational and recreational functioning within the limits imposed by the disease and its treatment aiming at attaining functional status and quality of life] Chairperson: Associate Professor Dato’ Dr Zaliha Omar Department of Allied Sciences, Faculty of Medicine, University of Malaya Research Priorities: 1. include data on survivors & functional status and epidemiological profile of cancer survivors/database in the National Cancer Registry 2. situations where rehabilitation process can make a difference to quality of life (QOL) of people with cancer 3. respite care 4. manpower needs for holistic and comprehensive rehabilitation process 5. overcoming burden of care 6. impact of immediate post-treatment rehabilitation
Group VI: Cancer Research on Palliative Care [an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual] Chairperson: Co-Chairperson:
Dr Mary Cardosa, Selayang Hospital Dr Ednin Hamzah, Hospis Malaysia
Research Priorities: 1. burden of care 2. pain and symptoms management 3. communication issues 4. audit and establishment of standards
Group VII: Cancer Research on Herbal Medicine [investigate the use of medicinal plants’ extracts and screened for their anti-cancer properties; continuing search for effective substances that can augment/replace imported preparation; and ensuring the quality, safety and efficacy of herbal preparation through preclinical and clinical studies] Chairperson: Dr Nor Shahidah Khairullah National Institute for Natural Products,Vaccines & Biologicals
79
Research Priorities: 1. Setting up of a multi-disciplinary programme on bioprospecting of local herbs for potential anti-tumour activities. 2. use of platform technologies if available to replace conventional high throughput screening to decrease the time to product discovery.
Conclusion st
The 1 National Conference on Cancer Research Coordination is an important step forward in the research planning and programme development for cancer research in Malaysia. Creative ideas stemming from the working groups which included medical practitioners and scientists from diverse disciplines and professions, have the potential to produce research programmes that facilitate collaborative studies to integrate cancer research. The conference priorities encourage scientific productivity in critical areas for the benefit of our people.
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APPENDIX 3
Cancer Research Priorities in the Health Sector for the 9th Malaysia Plan
Cancer: Framework for Research Priorities
Priority research area
P u rpo s
Cancers
Improve Effectiveness
Improve Understanding
Perceptions and behaviour
Clinical management
Develop new modalities
Diagnosis, treatment
Needs for health care & support
Disease pattern, risk factors, economic burden
Determinants of treatment outcomes
Health care & supportive services Information, health promotion & empowerment
Source : National Conferenceon Research Priorities in the Health Sector for9MP, July 2006
81
CANCER: RESEARCH PRIORITIES
Purpose
Suggested focus of Research Topic(s)
Scope o f r esearch
Relative rank
A 1.1 Studies on measures and strategies to empower cancer patients and survivors A 1. Empowerment and perceptions for self care
A. Understand perceptions, behaviour, & empowerment & evaluate promotion activities
A 1.2 Elucidate patient’s and families' perception of self-care in order to recommend strategies to promote self care
A 2. Impact of health promotion activities (Healthy Life Style)
A 2.1 Evaluate impact of national healthy lifestyle campaigns in particular with reference to tobacco use, food & nutrition, alcohol use, physical activity, mental health, sexual health
A 3. Elucidate perception and behaviour of (a) the community, and (b) health care providers, on the influence and impact on cancer and its management of various modalities
A3.1 Priority items for study would include (a) Traditional / Complementary medicine, (b) Genomics, (c)Vaccines, (d) Screening programmes, (e) Risk factors, (f) Palliative care (g) Others
B 1. Evaluate prevention programmes
B. Evaluate Public Health Programmes
1
2
4
B 1.1 Evaluate the cost effectiveness of prevention programmes such as FCTC implementation, National Tobacco Control Programme, National Hepatitis B vaccination programme, etc.
1
B 1.2 Evaluate the effectiveness of vaccination and chemo-prevention for specific cancers
2
B 2.1 Evaluate impact of screening programmes on specific cancer incidence, morbidity, mortality and survival rate 3
B 2. Evaluate screening programmes B 2.2 Evaluate effectiveness of screening guidelines and level of compliance by healthcare personnel B 3. Evaluate programmes to reduce environment factors
B 3.1 Evaluate effectiveness of various measures to control / regulate presence of carcinogens in foods, environment, etc
82
7
Purpose
Suggested focus of Research Topic(s)
Scope o f r esearch
Relative rank
C 1.1 Evaluation of cost effectiveness of molecular detection in cancer diagnosis C 1. Cost effectiveness of selected diagnosis and clinical management modalities
C 1.2 Evaluate the cost-effectiveness of current treatment modalities C 1.3 Cost-benefit analysis of providing palliative care (inpatient and home care) in a community
C. Evaluate clinical management
C 2. Use and effectiveness of treatment protocols & selected interventions
C 3. Development of matrix of quality assurance in cancer care
C 4. Financial cost and economic burden of cancer
D. New Modalities diagnosis & treatment
C 2.1 Evaluation of the use and outcomes of treatment protocols of major cancers. Emphasis on Breast, Cervix, Lung, Colorectal, Prostate, Hepatoma, Leukaemia & Lymphoma, Paediatric cancers
1
C 2.2 Evaluate effectiveness of current interventions: (include manpower) such as Physiotherapy, Occupational Therapy, Swallowing therapy, Orthotics and prosthetics, Psychotherapy, Counseling, Social rehabilitation, Holistic cancer rehabilitation programmes C 3.1 Development of matrix of quality assurance for chemotherapyin cancer care 5 C 3.2 Development of matrix of quality assurance for radiotherapy in cancer care C 4.1 Determine the total cost of providing public sector Cancer health services C 4.2 Determine economic burden of cancer for individuals, community and nation
C 5. Effectiveness of current protocols (cont.)
C 5.1 Evaluate the effectiveness of use of Guidelines in the management of cancer pain
D 1. To discover new biomarkers for diagnosis and monitoring of cancers (from research to development for
D 1.1 Study the molecular mechanisms of selected cancers with the purpose of identifying new approaches and developing new assays for diagnosis and monitoring of selected cancers
7
1
commercialization) D 2. Profiling of cancers using new technologies for better classification
D 2.1 Development of clinically relevant molecular classifications of selected cancers
83
2
Purpose
Suggested focus of Research Topic(s)
Scope o f r esearch
Relative rank
and prognostication of cancers D 3.1 Evaluate the effectiveness of vaccination and chemo-prevention for specific cancers D 3. Vaccination & chemoprevention
D 3.2 Development of vaccines and chemoprevention for specific cancers
2
D 3.3 Study the initiation and progression of selected cancers with the purpose of identifying new potential vaccines and chemotherapeutic agents for cancer prevention and control
D 4. Development and evaluation of new therapeutic products and modalities, and existing traditional / complementary therapies
D 5. Multidisciplinary programme in bioprospecting of local herbs for potential anti-cancer activities (from discovery to development of product)
D 4.1 Priority items for study would include (a) Pharmaceutical products, (b) Immunotherapy. (c) Targeted therapy, (d) Cell based therapies (e)Others
5
D 4.2 Identify critical cellular pathways in selected cancers which can be targeted for new therapeutic modalities D 5.1 High throughput screening of compounds for effect on cellular signaling pathways relevant for cancer development and progression D 5.2 Development of bio-assays for product/efficacy testing 6
D 6. Molecular and genetic basis for selected cancers
To study the fundamental mechanisms of cancer to further our understanding of the biology of the diseases D 6.1 Association of liver cancer with hepatitis B. D 6.2 Association of stomach cancer with Helicobacter pylori.
D 7. Research on biospecimens and biobanking
D 7.1 Investigate and analyse conditions for optimization of biospecimen collection, processing and archiving
84
6
Purpose
Suggested focus of Research Topic(s)
Scope o f r esearch
E 1. Studies to identify important risk factors in Malaysia
E 1.1 (a) environmental factors, (b) occupational factors, (c) infective, (d) gene - environment interaction (molecular epidemiology), ( e) co-factors for cancer development in individuals who are at risk of cancer (e.g. factors increasing the risk of liver cancer in Hepatitis B chronic carriers), (f) Others
Relative rank
2
E 2.1 Determine life expectancies of cancer patients compared with normal population E. Understand disease pattern, risk factors and determinants
E 2.2 Identify prognostic factors for survival of cancer patients E 2. Studies on health status and needs and E 2.3 Quality of life of patients with specific factors contributing to cancers (e.g. breast, cervix, lung etc) short and long term survival of cancer patients E 2.4 Functional impairmentsin cancer patients and survivors
3
E 2.5 Assessment of rehabilitative needs and unmet needs of persons with cancer E 3. Correlation of clinical outcomes of specific
E 3.1 Emphasis on: (a) Breast cancer, (b) Cervix, (c) Adult Leukaemia & Lymphoma,
cancers with genomics and epidemiology
(d) Paediatric cancers, (e) Liver cancers, (f) nasopharyngeal carcinoma
85
5
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
1.
E lem e n t s
Human Capital
GOAL 1 : PREVENTION
A ct iv it ie s
1. Create posts for support staff AMRON17(2 per 8 new State Cancer Registries - total 16 post), ClerkN17(1 post for NCR) AMRON17(2 post for NCR)
Cost
Tim e Frame
0.76M
2008-2010
A g e n cy / P e rso n
MOH/ HRD
18 AMRO (N17) 1 Clerk (N17)
RM753,289.2 (Emolument)
This is to strengthen and maintain Cancer Registry at MOH and at state level
2.
Facilities
R e m a rk s
1. District Cancer Resource Center
RM 1.0 M
86
2008-2015
MOH (Public Health Programme /HECC
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
3.
Equipment
4.
Drugs (Vaccine)
GOAL 1 : PREVENTION
A ct iv it ie s
Cost
Tim e Frame
A g e n cy / P e rso n
R e m a rk s
-
1. National Human Papilloma Virus (HPV) immunization programme for cervical cancer prevention
RM 319.0 M
2008-2010
MOH
Inaccordancewith the policy developed Price of isthesubject vaccine to price reduction strategy by the drug company.
87
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
5.
E lem e n t s
Health Education
GOAL 1 : PREVENTION
A ct iv it ie s
Cost
Intensive media campaign for selected cancer identified in the National Cancer Management (other than Tak Nak & Healthy Life Styles)
RM 10.0 M
Tim e Frame
2008-2010
A g e n cy / P e rso n
Public Health Programme / Oral Health Division
1.Develop health education materials 2. Divide workload among media
4. development of cancer portal (MyHealth Portal)
Outsourcing & Consumables
7.
Research & Development
-
.
1. 1.. Study related to cancer
RM 1.0 M
prevention and behavioural modification 2. 3. 2.
Allocation already existing : RM 10 mil for Tak Nak campaign RM 10 mil for Healthy Life Style Campaign •
•
3. Organize coverage continuous media
6.
R e m a rk s
Establish a central body to collect, collate and review all scientific papers on cancer research.
88
2008-2015
To be determined
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
8.
E lem e n t s
Information Communication Technology and Networks
GOAL 1 : PREVENTION
A ct iv it ie s
4. 3.
Establishdatabase linkages so that important cancer outcome data can be provided e.g. linkage of mortality data (from National Registration Department) with cancer data (from the National Cancer Registry) to obtain national
5.
cancer survival statistic. 1.
Cost
Efficient and timely reporting of cancer cases Strengthen the National Cancer Registry through effective and comprehensive collaboration with all stakeholders (government and private health care sectors including NGOs).
Tim e Frame
RM 0.3 M
2008-2015
MOH / Pubic Health Department
Operating Budget
2008-2015
MOH
•
•
Establish on-line cancer reporting through MOH’s Health Information Centre
89
A g e n cy / P e rso n
R e m a rk s
Budget needed for data management and report printing
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
9.
E lem e n t s
NGO’s / Corporations
GOAL 1 : PREVENTION
A ct iv it ie s
Cost
1. Strengthen networking with
RM 0.1 M
Tim e Frame
A g e n cy / P e rso n
2008-2015
related agencies at all levels.
10.
11.
Institutions / Organization
Standards / Guidelines / Codes of Practice
1. Establish and maintain Cancer Registry Unit at all State Health Departments
(Emolument under human resource)
2006-2015
Public Health Programme
2. Establish and maintain National Cancer Registry Unit at MOH
(Emolument under human resource)
2006-2015
Public Health Programme
Guideline on the implementation of prevention activities.
0.1 M
90
R e m a rk s
APPENDIX 4
ACTION PLANS: ACTIVITIES N o.
12.
13.
E lem e n t s
A ct iv it ie s
QualityAssurance
Legislation
GOAL 1 : PREVENTION Cost
Tim e Frame
A g e n cy / P e rso n
-
1.
Establishconsultative mechanism to improve compliance by relevant authorised bodies to the existing standards provided by existing law and regulations
2.
TOTAL: PREVENTION
To develop regulation for mandatory cancer reporting through the existing legislations
-
2008-2015
Public Health Programme
2008-2010
MOH (Public Health Programme)
(included in element no 5
(existing operational budget)
- (0.05 M)
RM332.26M
91
R e m a rk s
ACTION PLANS: ACTIVITIES N o.
1.
E lem e n t s
Human Capital
GOAL 2 : SCREENING AND EARLY DETECTION
A ct iv it ie s
C o st
1.Training of supporting staffCytotechnicians, radiographers, sonographers, nurses, MAs, others
RM 1.08 M
T im e - F r a m e
2008-2010
A g e n cy / P e r s o n
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Oral Health ) Division / ) Research & )) Technical Support
2.Establish posts and employ the following personnel: Cytotechnicians (240), Radiographers (62), Sonographers (21), Nurses(62), Clerks (4)
2.
Facilities
RM 19.21 M
1. Set up infrastructure for −
−
2008-2010
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Oral Health Division/ Medical Division
2008-2010
) Public Health ) Medical ) Development ) Division / ) Planning &
(Emolument)
RM 6.5 M
2 breast screening centers (RM 2 million per center) 12 cytology laboratories (RM 2.5 million)
92
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 2 : SCREENING AND EARLY DETECTION
A ct iv it ie s
C o st
T im e - F r a m e
) ) ) )
3.
Equipment
1. Radiologyequipment (mammogram, ultrasound,
RM 22.6 M
mammotome equivalent, computers etc) for breast viewers, cancer screening centers
2008-2010
2008-2010
2. Related equipment/facilities for call-recall activities in population based breast cancer screening programme (software, computer, office equipment, training,) for 2 centers
RM 1 M
3. Cytology laboratory equipment (Automatic slide stainer, Lab refrigerator, Slide filing cabinet, Automated cover slipping etc) for 15-20 cytoscreeners per center (80,000 – 100,000 slides) (12 centers –RM 600,000/center)
RM 7.2 M
) ) Public Health, )) Medical Division / ) Engineering ) Division/ Oral Health Division ) ) )
93
A g e n cy / P e r s o n
Development Division / Engineering Division
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 2 : SCREENING AND EARLY DETECTION
A ct iv it ie s
C o st RM 6 M
4. Pap smear taking facilities at primary care centers and outreach services 5. Ultrasound machine in major hospitals – RM500,000 /machine
4.
Drugs
5.
Health Education
Develop health education materials / teaching aids
6.
Outsourcing & Consumables
1. Consumables for cytology laboratories (RM200,000/center/year)
T im e - F r a m e
A g e n cy / P e r s o n
RM 10.5 M
Not applicable
-
Not applicable Public Health Dept / Oral Health Division / Medical Division
RM 2 M
RM 7.2 M
2. Breast and cervical cancer screening activities (including mailing services for call-recall activities (RM500,000/center/year)
RM 3 M
3. Outsourcing radiological services
RM 1 M
4. Alpha-feto protein (AFP) testing
RM 0.14 M
94
2008 - 2010
Public Health Dept / Oral Health Division / Medical Division
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
7.
Research & Development
8.
Information Communication Technology and Networks
GOAL 2 : SCREENING AND EARLY DETECTION
A ct iv it ie s
C o st
5. Epstein Barr Virus serological markers
RM 0.12 M
6. Prostate Specific Antigen Test
RM 0.13 M
7. Consumables such as examination glove, disposable mouthmirror, disposable tray, disposable twizer, paper towel, gauze etc
RM 1 M
1. Evaluate the screening modalities 2. Evaluate existing screening programmes for cervical cancer and oral cancer 3. Develop model for screening eg: risk management for oral cancer 4. New or alternative modalities for screening eg: Demonstration project of VIA for cervical cancer and Indirect Nasopharyngoscopy for NPC
RM 1 M
-
95
T im e - F r a m e
2008 - 2010
A g e n cy / P e r s o n
Public Health Dept/ Oral Health Division
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 2 : SCREENING AND EARLY DETECTION
A ct iv it ie s
C o st
T im e - F r a m e
9.
NGO’s Corporations /
10.
Institutions / Organizations
11.
Standards / Guidelines / Codes of Practice
Circulate Standards/Guideline (To develop / update the consensus on the screening of selected cancers)
RM 0.6 M
2008 - 2010
12.
Quality Assurance
External QA in cytology & r adiology
RM 0.04 M
2008 - 2010
-
Preparation of accreditation by Department of Standards Malaysia (RM40,000 x 12 cyto-laboratories)
13.
A g e n cy / P e r s o n
-
RM 0.48 M
Legislation
TOTAL: SCREENING AND EARLY DETECTION
RM 90.8 M
96
Public Health Dept / Oral Health Division / Medical Division Public Health )Dept /Oral Health Division/ Medical Division
R em a rk s
ACTION PLANS: ACTIVITIES N o.
1.
E lem e n t s
Human Capital
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
A. PATHOLOGY SERVICES
1. Training of subspecialty pathologists in fields of soft tissue, bone, respiratory, ocular, lymphoproliferative & urological cancers, cytogenetics & molecular pathology
RM 0.7 M
20086 - 2010
MOH/ HRD/PSD
RM100,000 / person
2. Overseas training of subspecialty
RM 0.75 M
20087
MOH/HRD/PSD
RM 250,000/person RM 50,000/MLT
3. Training in adult haematooncology to support the centre of excellence in Ampang Hospital
RM 0.5 M
20086-2010
MOH/HRD/PSD
RM100,000 / person
4. Training in stem cell and cord blood transplantation to support paediatric haemato-oncology
RM 0.2 M
20086-2010
MOH/HRD/PSD
RM100,000 / person
5. Short courses training oversea/seminar in various subspecialty for i. Anatomical pathologist-1 candidate per year
RM 0.24 M
20068-2010
MOH/HRD/PSD
RM 40,000 / person
in HLA typing in Sg Buloh Hosp for 1 Pathologist, 1 Scientific Officer, 2 MLT
97
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
ii. MLT-1 candidate per year 6. Short training for leukemia/ lymphoma immunophenotyping x6
7. Training of cytogenetic scientists
RM 0.12 M
20086 – 2010
RM 1 M
20086-2010
MOH/HRD/PSD
RM100,000 / person
RM 0.2 M
20086-2010
MOH/HRD/PSD
RM100,000
(Master in Cytogenetics Australia), X 10
8. To engage short term consultancies in expression array and (US) bioinformatics-2 persons
9.
/person RM 0.2 M
20086-2010
MOH/HRD/PSD
RM100,000 /person
10. To train diagnostic pathologists (Master of Pathology): histopathologists (20), haematologists (5), chemical pathologists (5), medical microbiologists (5)
RM 0.525 M
20086–2010
MOH/HRD/PSD
In line with current training projections
11. Local Conferences/ workshops/ seminars/ courses– at least 1 per year for: a) 1 haematologist from each of 6 regional hospitals
RM 0.061 M
20086-2010
Training in Bioinformatics (2 Scientists/Researchers)
98
RM 20,000/year for 11a-11c
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
b) 1 scientific officer (haematology) from each of 6 regional hospitals c) 1 MLT ( haematology) from each of 6 regional hospitals 12. Overseas conferences of various subspecialty or related conferences/ workshops/ seminars/courses – at least 1 haematology candidates per year 13. Local Conferences/ workshops /seminars/ courses– at least 1 per year for:
RM 0.1509 M
20086-2010
RM 10.6 M
20086-2010
RM 30,000/year
a)2 Anatomical Pathologists from each center b) 1 MLT from AP lab of each hospital RM 0.475 M
14. Overseas conferences of various subspecialty or related conferences/ workshops/ seminars/courses – at least 5 candidates per year 15.
M 17.296 M
99
2006-2010
MOH/HRD/PSD
HRD to employ
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
16. Establish posts and employ the following personnel: Research officers (4), Scientific officers - BBioMedSc. or equivalent (100); Medical Laboratory Technologists (200) B. RADIOLOGY SERVICES
1. a. Training of subspecialty
RM 0.57 M
radiologists in fields of breast imaging, interventional radiology, paediatric, musculoskeletal, neuroradiology, urology, hepatobiliary & gastrointestinal radiology (7 subspecialties) b. Short courses training oversea/seminar in various subspecialty for i. radiologist -5 candidates per year ii. radiographer-5 candidates per year iii. radiology nurse – 5 candidates per phase
RM 0.61 M RM 0.61 M
20086-2010
20086-2010
RM 01.2 M
RM 0.46 M
2. To train diagnostic radiologists:
20086-2010
(Master of Radiology): 40 Master
100
MOH/HRD/PSD
RM 100,000 / person 7 subspecialty radiologist each phase
MOH/HRD/PSD
RM 40,000 per person
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
students
3.
RM 12.5 M
Local Conferences/ workshops/ seminars/ courses– at least 3 – 5 per year for: a) 1 radiologist from each hospital b) additional 2 radiologists from larger hospital c) 1 radiographer from each hospital
RM 35 M
4.
Oversea conferences of various subspecialty or related conferences/ workshops/ seminars/courses – at least 10 candidates per year
5.
Post basic courses for radiographers-CT, MRI, Angio, MMG
6.
Post basic courses for radiology nurse (probably to start in phase 2)
A g e n cy / P e r s o n
MOH/HRD/PSD
RM 0.35 M
RM 0.35 M
RM 76.855 M
101
20086-2010
R em a rk s
In line with current training projections
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
MOH/HRD/PSD
7.
(Emolument)
Establish posts and employ the following personnel: Pathology Services Research officers (4), Scientific officers - BBioMedSc. Or equivalent (100); Medical Laboratory Technologists (200)
Radiology Services Radiologists (80); Medical Officers (40); Physicists (14); Radiographers and Ultrasonographers (160); Nurses (244); Image and Information Managers (19) Radiology nurses - 6 posts each for all state hospitals (14), 10 for Hospital Selayang, Kuching, Penang, KK and 12 for HKL, HAS JB, Sg Buloh hospital in Phase 1 - Additional 3 nurses for each state hospitals (14 hospitals) and 3
102
R em a rk s
HRD to employ
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
nurses for district hospitals with radiologists in Phase 2. Information and image managerAt least 1 post in each hospital with PACS system in phase 1 and expand in phases. 4 local trainees/yr (RM25,000
C. NUCLEAR MEDICINE
20086-2010 RM 1.075 M
1. Training of Personnel a. Clinical Nuclear Medicine
MOH/HRD/PSD
Specialists (25 trainees)
RM 4.52.7 M
20081120105
b. Nuclear Medicine Technologists (30 trainees)
RM 31.8 M
c. Medical Physicists (Nuclear
103
MOH/HRD/PSD
/person) 1 overseas/yr (RM250,000 /person) 3 overseas/yr (RM300,000 /person) Note: NM technologist come from a pool of MLT, radiographer or Medical Assistant 2 overseas/yr (RM300,000 /person)
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
Medicine) (10 trainees)
T im e - F r a m e
20086202510
A g e n cy / P e r s o n
MOH/HRD/PSD
RM 0.1225 M
d. Nuclear Medicine Nurses (25 trainees)
R em a rk s
4 locals/yr (RM10,000 /person) 3 locals/yr (RM20,000 /person)
2008-2010 RM 3 1.8 M
e. Nuclear Medicine Physicists (15 trainees)
1 overseas/year (RM100,000 2008-2010
MOHE/MOH/PSD/ HRD
2006-2010
/person) 2 local/ year (RM 10,000/person)
RM 0.53 M
f.
Scientist: Nuclear Medicine Biochemist (5 trainees)
MOHE/MOH/PSD/ HRD
1 overseas/year (RM 100,000/person)
RM 0.36 M
g. Pharmacist: Nuclear Medicine (10 trainees)
2008-2010 2006-2010
MOHE/MOH/PSD/ HRD
RM 0.6 1 M
2. CME and CPD activities for attending conferences, seminars and attachments
2008-2010 RM 0.24 M
104
2006-2010
MOH, ALL NM Centers
1 per year from 2007 (RM 100,000 per person)
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
23. Recruit 3 new expatriates in Nuclear Medicine
A g e n cy / P e r s o n
R em a rk s
MOH/PSD/HRD 2008-2010 2006-2010
2008-2010 2006-2010
2.
Facilities
A. PATHOLOGY SERVICES
1. Reorganisation of 12 histo/cytopathology centers - Infrastructural facilities (lab renovations)
20058-2010
MOH - Finance
RM 1.2 M
RM100,000 /center x 12
RM 2.4 M
RM200,00 /center x 12
2. Upgrade of existing pathology facilities (14 centers) Upgrade/establish LIS
RM 2 M
RM100,000 /center/yr
3. Molecular profiling and cancer
RM 0.5M
RM500,000
- Establish Laboratory Information System (LIS)
105
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
genetics infrastructure in one centers (IMR)
R em a rk s
/center
4. Biobanking infrastructure (1 center)
RM500,000 /center
RM 0.5 M
5. Establishing stem cell laboratory in Penang (2008)and KK (2010)
RM 1 M
6. Establishing cancer cytogenetics
RM 1 M
laboratory KK (2010)in Penang(2008) and
B. RADIOLOGY SERVICES
1. Radiology information systems in 4 centers
RM 1.2 M
20086-2010
MOH- Finance /Planning & Development
2. Establishing RIS and PACS in NCI (see NCI project proposal)
RM 10 M
20086-2010
MOH- Finance /Planning & Development
3. Upgrading of existing RIS and PACS in HPJ to support and communicate with RIS / PACS in NCI
RM 4 M
20086-2010
MOH- Finance /Planning & Development
106
RM 300,000 / system x 4
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st RM 10 M
4. Radiology department renovations
T im e - F r a m e
20068-2010
and new sites (infrastructural facilities) in various hospitals for conversion to CR system, upgrading and installation of new equipment
A g e n cy / P e r s o n
MOH- Finance /Planning & Development
C. NUCLEAR MEDICINE 1. New Nuclear Medicine Centers •Sultan Ismail Hospital, Pandan, Johor (Nuclear Medicine Department with Hot Lab for conventional NM and radioiodine preparation. Radioiodine wards with 12 rooms)
RM 7 M
2008-2010 2006-2010
RM 7 M
Nuclear Medicine Department in Sabah (Likas) ( Nuclear Medicine Department with Hot Lab for conventional NM and radioiodine preparation. Radioiodine wards with 12 rooms) ) •
2008-2010 2006-2010
107
MOH – Finance /Planning & Development
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st RM 14 M
National Cancer Institute (refer to National Cancer Institute Paper) ( Nuclear Medicine Department with Hot Lab for conventional NM and radioiodine preparation. Radioiodine wards with 24 rooms) •
T im e - F r a m e
2008-2010
A g e n cy / P e r s o n
MOH – Finance /Planning & Development
2006-2010
2. Replacement and upgrading of the facilities and equipment at •
MOH – Finance /Planning & Development
RM 8 M
Penang Hospital In Vivo laboratory with equipment (RM 2 M)
2008-2010 2006-2010
Radioiodine ward with 14 rooms (RM 6 M) •
In Vivo laboratory with equipment (RM 2 M)
•
MOH- Finance/ Planning /Development
RM 2 M
Kuala Lumpur Hospital
2008-2010 RM 8 M
Sarawak General Hospital
108
MOH – Finance /Planning & Development
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
In Vivo laboratory with equipment (RM 2 M)
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
2008-2010 2006-2010
Radioiodine ward with 14 rooms (RM 6 M)
3.
Equipment
A. PATHOLOGY SERVICES
1. Reorganization of 12 histo/cytopathology centers: Immunohistochemistry autostainers
RM 2.2 M
2. HLA typing laboratory equipment - PCR & serology
RM 1.2 M
3.
Molecular profiling (1 center)
4.
Biobanking equipment (1 center)
2008-2010 2006-2010
MOH-Finance
RM 18,000/ autoimmuniserstainer x 12
MOH - Finance 20087 RM4,000,000 / center
RM 4 M
20068-2010 RM 1.5 M
20068-2010 5.
RM 1 M
Directed Cor d Blood Bank Equipment for paediatric haemato-oncology
20068-2010
109
RM1,500,000 /center
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st RM 0.5 M
6. Upgrading of existing stem cell
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
20086-2010
transplant laboratory RM 4 M
7. Stem cell laboratory in Penang (2008)and Kota Kinabalu (2010) 8. Cancer cytogenetics laboratory in Penang (2008)and KK (2010)
RM 5 M
9. Upgrading Haematology
RM 1 M
RM 2,000,000 each x 7 hosp
laboratory with flow cytometry in Kuching (2008)and Malacca (2010)
RM 3,000,000 each x 7 hosp RM 2,000,000 each x 4 hosp RM 250,000 each x7
B. RADIOLOGY SERVICES
Expansion and upgrading of Radiology services: Phase 1
a) 4 slice CT Scan x 7 hosp
RM 14 M
b) 16 slice CT Scan x 6 hosp
RM 18 M
c) Digital Mammography x 4 hosp.
RM 8 M
RM 750,000 each x5 20086-2010 20086-2010 2006-2010
RM 1.75 M
d) Ultrasound x 7 hospitals
20086-2010
ed) Fluoroscopy – (nil. Recent c-arm already acquired for few hosp)
110
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
5 plain x-ray RM 3.75 M
20086-2010
MRI (2 states) RM 10 M
Angiography (4 regional centers) RM 16 M
CR System e)
Dry laser printer
(Note thisasisitexcluding Likas Hospital is under different project) C. NUCLEAR MEDICINE PET-CT Sultan Ismail Hospital Gamma Camera 1. Sultan Ismail Hospital (3) 2. Sabah (2) 3. NCI (4) 4. HKL (2) 5. HPP (1) In Vitro Laboratory : HPJ, HPP, HIS, HUS
111
RM 9 M
2008-2010 2006-2010
RM 38 M
2008-2010
A g e n cy / P e r s o n
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
4.
Drugs
5.
Health Education
6.
Outsourcing & Consumables
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
Nonioniccontrastmedia Iso-osmolar contrast media MRI contrast media Thrombolytic drug RM 13 M/yr
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
RM 65 M
20068-2010
MOH /Hospital Division
State hospital RM0.5 M HKL, regional and tertiary hospital RM1M
1. Tumour marker reagents
RM 4.2 M7 M
2008-2010
RM100,000/ center/yr
RM100,000 /center/yr
2. Antibody markers and detection kit for IHC
RM 1.31.5 M
2008-2010
RM 200,000/ center/yr x 11 centers
RM 610 M
2008-2010
RM200,000/ year for referral center (Lembah Kelang)
4. Leukaemia/lymphoma markers studies for Ampang Hospital
RM 3.52.1 M
2008-2010
5. HLA Typing reagent – PCR & Serology
RM 10.6 M
2008-2010
A. PATHOLOGY SERVICES
3. Flowcytometry reagents (leukaemia immunophenotyping ) x 6 centers (RM 2M / yr)
RM9,000 /patient x 1500
RM6,000 /100 patient
6. Molecular profiling reagents
112
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st RM 47.5 M
Breast tumor profiling, reagents & consumables Two cycle cDNA synthesis kit Oligonucleotide array Real time PCR validation Array CGH •
T im e - F r a m e
2008-2010
A g e n cy / P e r s o n
R em a rk s
RM3000 /patient x 300
•
RM 13.58.1 M RM 0.0954 M RM 0.549M
• • •
7.
Directed Cord Blood Bank RM 0.3 M/yr
8.
Stem cell transplantation RM 0.4 M / yr
RM 1.50.9 M
RM 1.2 M
RM 6 M
9. Stem cell laboratory in Penang (2008)and Kota Kinabalu (2010)
RM 4 M
10. Cancer cytogenetics laboratory in Penang (2008)and KK (2010)
RM 0.2 M/yr RM 0.6 M
11. Flow immunophenotyping in Kuching and Penang - (2008-2010) Current operating expenditure: Film cost: RM 500,000.00 for all GH & RM
B. RADIOLOGY SERVICES
Need additional 50% of current
113
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st RM 230 M
consumables budget to support cancer management 1. Films 2.
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
800,000.00 for regional and referral centers
Processing chemicals
Angio/interventio nal consumables: RM 1 M for HKL, Selayang, JB, Kuching, Sg Buloh.
RM 22.514 M
3.
Angiography and interventional disposable interventional items
Other GH RM 300,000.00 each.
7.
Research & Development
a)
increment of 20% annual budget for upgrading of existing services in respective hosp.
b)
new allocation for new service e.g. digital mammography or new CT Scan
Additional 20 % to radiology services operating budget for each hospital with upgrading of service.
RM 50,000 for each new service.
A. PATHOLOGY SERVICES
1. Studies related to molecular defects of paediatric leukemia / lymphoma .
RM 0.2 M
114
2008-2010
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
20086-2010 B. RADIOLOGY SERVICES RM 5 M
1. Conduct pilot project forscreening population based, breast programme in 1 center (Please refer to Goal 2: Screening and Detection activities) RM 0.5M
2. Radiology based research facility in NCI / HPJ. To include on-line journals, computers etc
3. 4.
Baseline T-Z score for Malaysian women BOLD (functional ) imaging in functional brain surgery
115
A g e n cy / P e r s o n
R em a rk s
ACTION PLANS: ACTIVITIES N o.
8.
E lem e n t s
Information Communication Technology and Networks
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
A. PATHOLOGY SERVICES Integrated pathology linkage nationwide B. RADIOLOGY SERVICES
1. RIS for 4 hospitals in phase 1 2. RIS & PACS for 8 hospitals 3. RIS & PACS for other state hospitals (phase 2)
20068-2010
4. Integration of PACS by re gion / nationwide (phase 2- phase 4) 5. On-line reporting of cancer patients to National Cancer Registry to be available in all hospitals with radiologist 6. Fax machine in radiology department for all state hospitals and tertiary center to expedite sending of forms etc
20086-2010 2011-2015 2011-2025 20086-2010
RM 0.02 M
C. NUCLEAR MEDICINE
Connectivity of PET-CT between Putrajaya Hospital, Sultan Ismail (Pandan) Hospital and Penang Hospital
RM 2.1 M
116
20086-2007
MOH-FINANCE /DEVELOPMENT
Connectivity software and hardware
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
RM 700,000 for the 3 centersres
9.
NGO’s / Corporation
10.
Institutions /
To work with College of
Organizations
Radiology/Academy of Medicine
Standards / Guidelines / Codes of Practice
A. PATHOLOGY SERVICES
11.
To work with breast screen center
1. Establish cancer profiling and biobanking guidelines RM250,000 per guideline
RM 0.5 M
2. Performa of Histopathology diagnosis
RM 0.05 M
20086 - 2025
B. RADIOLOGY SERVICES
1. Review / update Breast Cancer Screening guidelines (probably after completion of breast
(RM 0.1M)
117
2011-2015
MOH / Academy of Medicine Malaysia
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
screening pilot project) 2. Reporting format on mammog ram and other radiology examination or procedures
RM 0.1 M
20086-2010
3. Risk Management in Radiology -Protocols / Guideline on radiological examination and procedures
RM 0.2 M
20086-2015
C. NUCLEAR MEDICINE
Credentialing of personnel and facilities Establish minimum criteria for Nuclear Medicine Specialist in the National Specialist Criteria.
RM 0.01 M
20086-2010
RM 0.02 M
20086-2010
•
•
Introduction of latest Regulations in Medical Use of Radiation in Radiology, Radiotherapy, Nuclear Medicine, Dentistry and Veterinary services and its enforcement. Introduction of latest Regulations
118
PUU, Training Division, College of Radiology, AMM, Engineering Division (MOH) PUU, Training Division, College of Radiology, AMM, Engineering Division (MOH)
R em a rk s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
in Medical Use of Radiation in Radiology, Radiotherapy, Nuclear Medicine, Dentistry and Veterinary services and its enforcement.
12.
Quality Assurance
A. PATHOLOGY SERVICE
1. External QA activities in Anatomical Pathology
RM 1.08 M
2. External QAP for leukemia / lymphoma immunophenotyping x 6 RM 24,000/year
RM 15,000 per center /year for
2008-2010
12 centers RM 0.12072 M
•
RM 0.015 M
3. External QAP for molecular tests for haematology for 1 center RM 5,000/year B. RADIOLOGY SERVICES
RM 0.25 M
QA activities and programmes in Radiology Risk management / Audit / NIA •
2008-2010
C. NUCLEAR MEDICINE
20068-2010
119
All Nuclear Medicine Centers,
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 3 : DIAGNOSIS
A ct iv it ie s
1.
C o st
T im e - F r a m e
Identify National I ndicator for Nuclear Medicine 20068-2010
2. Implement QAP in MOH Cancer Treatment Centers RM 0.1 M
Radiation Protection Committees Committees in all hospitals with Nuclear Medicine Facilities
20068-2010
A g e n cy / P e r s o n
Medical Development / Engineering Division (MOH)
All Nuclear Medicine Centers, Medical Development / RM 20,000/year Engineering Division MOH) / PUU, College of Radiology
13.
Legislation
A. RADIOLOGY SERVICES
Code and Standard of Practice MS 838 Akta 304 Regulation
1. Basic Safety Standards 2. Licensing 3. Use of ionizing radiation in medicine , dental and veterinary
B. NUCLEAR MEDICINE
Radiation Protection Committees
120
R em a rk s
Establish and adapt National Indicator
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
TOTALD : IAGNOSIS
GOAL 3 : DIAGNOSIS
A ct iv it ie s
C o st
RM 516.635460.071 M
121
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
ACTION PLANS: ACTIVITIES No.
1.
E le m e n ts
Human Capital
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Tim e- F ra m e
A g e ncy /P e rso n
R e m a rk s
1. Training of b asic personnel a. Clinical Oncologists (25 trainees)
RM 1.8 M
2008-2010
MOHE/MOH/PSD/ HRD
4 local trainees/yr (RM25,000/ person) 1 overseas/yr (RM500,000/ person)
b. Haematologists (15 trainees)
RM 2.7 M
2008-2010
MOHE/MOH/PSD/ HRD
3 overseas/yr (RM300,000/
c. Paediatric Oncologists (10 trainees)
RM 1.8 M
2008-2010
2 overseas/yr (RM300,000/ person)
d. Cancer Surgeons (15 trainees)
RM 2.7 M
2008-2010
3 overseas/yr (RM300,000/ person)
e. Medical Physicists (10 trainees)
RM 0.06 M
2008-2010
2 locals/yr (RM10,000/ person)
f.
RM 0.6 M
2008-2010
20 locals/yr (RM10,000/ person)
person)
Therapy Radiographers (100 trainees)
122
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Tim e- F ra m e
A g e ncy /P e rso n
R e m a rk s
g. Oncology Nurses
RM 0.06 M
2008-2010
(RM10,000/ person) x 2
h. Hematology Nurses
RM 0.2 M
2008-2010
2 overseas/year (RM30,000/ person)
i.
RM 0.3 M
2008-2010
1 overseas/year (RM100,000/
RM 0.384 M
2008-2010
4 overseas (2009/ 2010) at RM30,000/ person = RM120,000
RM 0.0504 M
2008-2010
4 local ( 2009/ 2010) RM2,000/person = RM8,000
Scientists
person) j . Pharmacists (Oncology)
k. Pharmacy Assistant (CDR)
12 local (2009/2010) RM 1,400/person = 16, 800
123
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
l. Laboratory Technicians (MLT)
RM 0.2 M
Tim e- F ra m e
2008-2010
A g e ncy /P e rso n
R e m a rk s
2 per year (RM30k per person)
2. Training of subspecialty Clinical Oncologists: Paediatric Radiation Oncology Brachytherapy Stereotactic Radiosurgery
RM 0.18 M
3. Recruit 3 new expatriates in Oncology
RM 1.5 M
2008-2010
RM500,000 per year
4. CME and CPD activities for attending conferences, seminars and attachments
RM 1 M
2008-2010
RM300,000/year
5. Establish posts and employ the following personnel: Clinical oncologists (25), Haematologists (15), Paediatric Oncologists (10), Cancer Surgeons (15), Medical Physicists (10), Therapy Radiographers (100), Oncology Nurses (100), Hematology Nurses (50), Scientists (10), Pharmacist Oncology (10), MLT (10)
RM 39.894 M
2008 2009 2010
(Emolument)
124
RM60,000 per person
ACTION PLANS: ACTIVITIES No.
2.
E le m e n ts
Facilities
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Tim e- F ra m e
A g e ncy /P e rso n
R e m a rk s
Paediatric Oncology
Set up new services in Kuantan
RM 0.2 M
Haematology
Upgrading of centers at: JB , Klang, Ipoh, KK
RM 1.2 M
Upgrading of new centers at: Melaka, Kuantan, Kuching
RM 1.0 M
Cytotoxic Drug Reconstitution (DCR) Sterile Preparation Rooms Paediatric Oncology– RM 1.2 M
Build new facility at HTAA Kuantan) (room 1)
2010
Haematology–
Build new facility at : HSA JB* Hospital Ipoh ** Hospital Melaka HTAA Kuantan (room 2)
RM 1.2 M RM 1.5 M RM 0.45 M RM 0.45 M
Upgrade existing facility at : HTAR Klang Hospital Queen Elizabeth, KK Hospital Umum Sarawak, Kuching
RM 0.37 M RM 0.45 M RM 0.1 M
125
2010
2008
Project approved under RMK-9 *Cost for the whole sterile complex (including TPN, IV admixture) for HAS JB = RM 2 M **Project approved under RMK-9 ***Project has been finished, still require additional works to comply with GMP Standards
ACTION PLANS: ACTIVITIES No.
3.
E le m e n ts
Equipment
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Tim e- F ra m e
Clinical Oncology
1. New Oncology Centers: National Cancer Institute
RM 71.4 M
2008-2010
RM 27.1 M
2008-2010
•
A g e ncy /P e rso n
R e m a rk s
5 LINACS 2 CT Sim 6 TPS2 HDR 1 CT Scan 2 U/s Machine 1 MRI 2 Mobile C-arm 1 Radiation Beam Analysing System CDR Facilities
•
Likas Chemotherapy services from 2006 then add Radiotherapy facilities (2008-2010)
2 LINACs 1 CT sim 2 TPS 1 Oncology Data and Record Information System
1 HDR CDR •
After 2011:
Penang Chemotherapy services from 2006 then add Radiotherapy facilities after 2011 (RM 27.1 M)
(2 LINACs 1 CT sim,2 TPS 1 Oncology Data and Record Information System 1 HDR, CDR)
126
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
2. Replacement and upgrading of equipment at Kuala Lumpur Hospital
RM 52.6 M
Tim e- F ra m e
2008-2010
•
A g e ncy /P e rso n
R e m a rk s
5 LINACS 1 CT Simulator 1 CT scanner 6 TPS 1 SRS System 1 Oncology Data and Record Information System
1 HDR 1 Diagnostic Xray 1 Mobile X ray 1 Mobile C-arm 1 Radiation Beam Analysing System CDR •
RM 36.35 M
Sarawak General Hospital
2008-2010
2 LINACS 1 CT Simulator 1 CT scanner 2 TPS 1 Oncology Data and Record Information System
1 C-arm 1 HDR 1 Radiation Beam Analysing System CDR
127
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
•
Co st RM 14 M
Sultan Ismail Hospital JB
Tim e- F ra m e
2008-2010
A g e ncy /P e rso n
R e m a rk s
1LINACS 1 CT Simulator 1 CT Scan 2 TPS 1 Oncology Data and Record Information System
1 mobile C-arm 1 HDR Surgical Oncology RM 6 M
Upgrading of : Robotic Surgery Laparoscopic Surgery • •
Paediatric Oncology RM 10 M
Stem cell transplant Apharesis machines Photopheresis machines Stem cell/graft engineering • • •
128
(estimated RM10 million asset and renovations in Ampang for both paeds and adults)
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Tim e- F ra m e
A g e ncy /P e rso n
R e m a rk s
Hematology centers RM 3 M RM 1 M
Ampang Penang Hospital Oral Oncology
Upgrading existing facilities and services at Kuala Lumpur Hospital, Tengku Ampuan Rahimah Hospital, Sultanah Aminah Hospital, Johor Bahru, Sarawak General Hospital, Queen Elizabeth Hospital Kota Kinabalu, Kuala Terengganu Hospital and Alor Star Hospital 4.
Drugs
RM 1.2 M
Clinical Oncology • • • • • • • •
RM 509 M
Kuala Lumpur Hospital Sarawak General Hospital Johor Bahru Penang Kuantan Kota Kinabalu Ipoh Malacca
2008-2010 2008 = RM137M 2009 RM171M
2010 -
129
Medical Development Division, Bahagian Perolehan
RM 104M + 120 M + 138M (estimated use in 2008, 2009, 2010) add estimated cost of new drugs based on revised protocol of
33M, 51M,63M
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
• •
Co st
Tim e- F ra m e
RM 201M
Kota Bharu Kuala Terengganu
A g e ncy /P e rso n
R e m a rk s for the first, second and third consecutive years
Hematology RM 39 M
2008-2010
RM 12 M
2008-2010
RM 30 M
2008-2010
RM 18 M
2008-2010
1. Ampang Hospital (National
RM10M+RM3M = RM13M/yr
Haematology ReferralCenter) & Adult Stem Cell Transplant 2. Penang Hospital
3. Sultanah Aminah Hospital JB Tengku Ampuan Rahimah Hospital Ipoh Hospital Queen Elizabeth Hospital, KK 4. Malacca Hospital Kuantan Hospital Sarawak General Hospital
Paediatric Oncology
130
RM3+1M = RM4M/yr RM10M/yr for 4 hospitals
RM6M/yr for 3 hospitals
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st RM 7.5 M
Tim e- F ra m e
RM 2.1 M
• •
R e m a rk s
RM 1.5M for drugs and RM 1.0 M for consumables 2008-2010
2. Upgrading of existing facilities and services for Paediatric Oncology in the 3 regional centers •
A g e ncy /P e rso n
2008-2010
1. Pediatrics Institute, KLH (National Referral centre for Paediatric Hematology-Oncology and Paediatric Stem cell transplant Center). RM 1.5M per year
RM 1M per year per center (RM 0.7 M for drugs,
Sarawak General Hospital Likas Hospital, Sabah Penang Hospital
RM 0.3 M for = consumables) RM3 M per year RM 1.9 M
2008-2010
3. New services in Kuantan (RM 0.5 M for 1 st year and RM 0.7M per year for subsequent years) Stratification of Chemotherapy Delivery National Chemotherapy Protocol Conference Implement Stratified Chemotherapy Delivery in MOH Hospitals
RM 0.03 M
•
2008 2009-2010
•
131
1st year: RM 0.3M for renovation, RM -0.5M for drugs and RM 0.2M for consumables 2nd year onwards: RM 0.7M for drugs, RM 0.3M for consumables
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
5.
Health Education
1. Develop health education materials/ teaching aids
RM 0.5 M
6.
Outsourcing & Consumables
Clinical Oncology
RM 80 M
Tim e- F ra m e
2008 - 2010
2008 – 2010
Malacca Johore Kuala Lumpur Penang Ipoh Sabah Sarawak
A g e ncy /P e rso n
R e m a rk s
Oral Health Division Medical Development Division, Bahagian Perolehan
Outsourcing
20M per year
Haematology
Ampang Pulau Pinang JB, Klang, Ipoh, KK
RM 30 M RM 1.5 M
2008 – 2010 2008 – 2010
RM10M/year RM0.5M/year
RM 3 M
2008 – 2010
Laboratory consumables RM0.25M/year
RM 2.25 M
New Centers in: Melaka, Kuantan, Kuching
2008 - 2010
Laboratory consumables RM0.25M/year
Paediatric Oncology
Consumables 1. Pediatrics Institute, KLH (RM 1.0 M per year)
RM 3 M
RM 3 M
2. 3 regional centers
132
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 4 : TREATMENT A ct iv it ie s
Co st
Sarawak General Hospital Likas Hospital, Sabah Penang Hospital (RM 0.3M per year)
Tim e- F ra m e
A g e ncy /P e rso n
• • •
RM 1 M
3. New services in Kuantan (RM 0.2 M for 1 st year and RM 0.3 M per year for subsequent years)
7.
Research & Development
8.
Information Communication Technology and Networks
Establishment and Development of Treatment Outcome Database Cancer Registration to be made mandatory through laws and regulations. Enhance networking between Public Health, Hospitals, relevant agencies in cancer programme through cooperation in cancer registries and treatment outcome database
RM 0.8 M
133
2008-2015
Public He alth Department, Department of Radiotherapy and Oncology, CRC, PUU, Professional societies
R e m a rk s
ACTION PLANS: ACTIVITIES No.
E le m e n ts
9.
NGO’s / Corporations
10.
Institutions / Organizations
11.
Standards / Guidelines / Codes of Practice
GOAL 4 : TREATMENT A ct iv it ie s
Co st
1. Radiation Protection Committees Committees in all hospitals starting with Radiotherapy facilities 2. Comprehensive multidisciplinary care addressing common cancer diseases Establishment of 4 Combined and Joint Clinics in all Radiotherapy centers (breast, colorectal, head & neck, Gynaecology) Establishment total of 6 Combined and Joint Clinics in all Radiotherapy centers (breast, colorectal, head & neck, Gynaecology, Musculoskeletal, Lung) Formation of National Tumor Board for Breast and Colorectal Cancer
RM 0.25 M
Tim e- F ra m e
2008-2015
•
2008-2010
•
•
134
2011-2015
2011-2015
A g e ncy /P e rso n
PUU, College of Radiology, Engineering Division, MOH
R e m a rk s
ACTION PLANS: ACTIVITIES No.
E le m e n ts
12.
QualityAssurance
13.
Legislation
GOAL 4 : TREATMENT A ct iv it ie s
Co st
1.
IdentifyNational Indicator for Quality Assurance in Radiotherapy Applications 2. ImplementQAPin MOH Cancer Treatment Centers
RM 0.25 M
Credentialing of personnel and facilities. Establish minimum criteria for
RM 0.25 M
2008
2009
Oncologists.inIntroduction Regulations Medical Useofoflatest Radiation in Radiology, Radiotherapy, Nuclear Medicine, Dentistry and Veterinary services and its enforcement.
TOTAL : TREATMENT
Tim e- F ra m e
2011-2015 RM10,000
A g e ncy /P e rso n
MOH/Engineering/ All Cancer Treatment Centers All MOH Cancer Treatment Centers PUU, College of Radiology, Engineering Division (MOH)
RM 1029.528 M
135
R e m a rk s
Establish and adapt National Indicator
ACTION PLANS: ACTIVITIES N o.
1.
E lem e n t s
Human Capital
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
1. To train various professionals in rehabilitation team Rehabilitation specialists 52 – 52 years RM 0.5 2 M
RM 13.6 M
T im e - F r a m e
20086-2010
Speech therapists 21 – 52 years RM 0.21 M Occupational therapists 126 -52 years RM 0.65 M
5 years
Physiotherapists 126 – 52 years RM 0.65 M Clinical psychologists 21 – 52 years RM 0.21 M Specialist nurses 3012 – 52 years RM 1.50.6 M
2. Establish posts and employ the following personnel: Rehabilitation Medicine Physician (6), Medical Officers (6), Rehabilitation Nurses (102), Physiotherapists (18), Occupational Therapists (18),
RM 11.896 M (Emolument)
136
A g e n cy / P e r s o n
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support
Re m a r k s
For second five year triple all categories such that each of the 6 regions will have a core CR team and community CR extended service
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
Re m a r k s
Speech Therapists (6), Clinical Psychologists (6)
2.
Facilities
Develops pecialist-based Rehabilitation care service in 6 cancer centers (20068 -2010) •
RM 31.2 M
20068-2010
NCI – Putrajaya
•
Kuantan Hospital Penang Hospital Sultan Ismail Hospital Sarawak General Hospital Likas Hospital Sabah
) ) ) ) )
Medical Development Division / Planning & Development
)) Engineering Division / ) Division
• •
Existing facilities renovation RM 0.15 M for each hospital per year in 5 years for 2 years
•
•
3.
Equipment
Latestavailable technology Decide on number and type needed • Purchase all needed equipments
RM 66 M
•
Equipment: RM 1M per center Equipment : RM 1M per center
20068-2010
) ) ) )
Pharmacy Division / Engineering Division
2011-2015 easten regionsKuantan NCI + 5 Regional Hospitals 2011-2015 Easten regions-
137
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
Re m a r k s
Kuantan
4.
Drugs
1. Identifykeydrugscommonlyused for rehabilitation purposes e.g
RM 7.53.0 M
20086 –2010
those related bladder & bowel training, pain,tospasticity, depression, anxiety 2. Arrange bulk long term supply in rehabilitation activities 3. Keep track of drug development used to enhance rehabilitation activities
RM 1.5 M Per year for 6 ) Pharmacy ) Division
hospital 2011-2015 RM 2 M Per year for 6 hospital Total :RM12M
for 5 years
5.
Health Education
1. Develop health education materials
RM 2.51 M
on cancer rehabilitation e.g. Health, wellness & fitness promotion Increase awareness on CR among health professionals
138
20068-2010
HECC / IHP
RM 0.5M for local training Per year.
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
Re m a r k s
Organize seminar or workshops Booklet for rehabilitation 8 categories of CR education pamphlets per year e.g. bowel management, skin, speech physiotherapy, Diet, Nursing OT counseling 2. Awareness campaign to improve quality of life 3. Study effects of public education on CR 6.
Outsourcing & Consumables
7.
Research & Development
1. Prioritize Cancer Rehabilitation
RM 0.112 M
20086-2010
NIH
Research First 5-yr evaluation of needs Subsequently quality of life assessment of cancer survivors and patients Top five cancer in Malaysia NIH NIH NIH NIH
139
Outsource private consultancy to implement until such time that CR division have enough resources to do so. 1 research asst: RM2,500/m RM30,000/yr x 52 = RM15 60,000 Equipment =
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
Re m a r k s
RM50,000
8.
Information Communication Technology and Networks
9.
NGO’s / Corporations
10.
Institutions / Organizations
1. Establish Malaysian Cancer Portal with CR section 2. Strengthen the National Cancer Registry, Malaysia including survivors and those who are disabled by cancer 3. Link with International Networks
Telehealth
on CR e-learning on Cancer 4. Develop Rehabilitation 5. Establish Teleconsultation with leading CR Centers
Telehealth
MOH
To develop RMK10 onwards 2011-2015 =RM 1.0 M
Telehealth Telehealth
1. Network all existing NGO’s dealing with CR 2. Designate roles for specific CR by NGO’s 3. Establish Consultative Forum including a division on CR
) ) ) MOH / NGO ) ) )
1. Establish Cancer Rehabilitation Management Units in all General and District Hospitals 2. Establish Cancer Rehabilitation
2011-2015
140
) Medical ) Development ) Division / ) Planning &
In collaboration with MSC Need to establish a Cancer Registry Unit
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
supportandcommunityCenters
11.
12.
13.
Standards / Guidelines / Codes of Practice
1. Establish SOP Cancer Rehabilitation. 2. Organize Training Program 3. Widely Circulate Standards/Guidelines
Quality Assurance
1. Establish key performance indicators for Cancer Rehabilitation Management 2. Establish reporting and monitoring mechanism 3. Review and Revise Ind icators 4. Establish Benchmarks with other countries
Legislation
Reviewp resenti nsurancepolicies which discriminate against cancer survivors who need rehabilitation to ensure good quality of life
T im e - F r a m e
A g e n cy / P e r s o n
)Development ) Division RM 0.2 M
2011-2015 (RM 0.2 M)
) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc
RM 0.2510 M
2008-20105 years
) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health / ) Research & ) Technical ) Support
Attorney General Office
141
Re m a r k s
ACTION PLANS: ACTIVITIES N o.
E lem e n t s
TOTAL:REHABILITATION
GOAL 5 : REHABILITATION A ct iv it ie s
C o st
RM 35.14624.906 M
142
T im e - F r a m e
A g e n cy / P e r s o n
Re m a r k s
ACTION PLANS: ACTIVITIES No.
1.
E le m e n ts
Human Capital
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
1. Recruit foreign palliative care experts Overseas expert: RM 250,000/yr 1 expert – for 1 year : RM 250,000
RM 2.2 M
2. Arrange counterparts for training: Recruit clinical specialists U48/54 Recruit nurses : specialist palliative care nurses (1 in each regional center) 72 staff nurses to undergo post basic training in Palliative Care (6 per center) Clinical Psychologists •
T im e - F r a m e
2008-2010
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support ) ) )
•
•
Trainee doctors: RM 100,000/yr 6 doctors: RM 600,000 Specialist nurses: RM75,000/yr 1 nurse: RM75,000 Nurses (post-basic): 6,250/nurse 12 Nurses/unit: RM 75,000/unit 6 units: RM 450,000 Clinical psychologists: RM75,000/yr 1 psychologist: RM75,000
A g e n cy / P e r s o n
R em a rk s
Utilise existing supportive staff eg dieticians, physiotherapists 2011-2015: For 6 State hospitals: 6 Trainee doctors: RM 600,000 6 specialist nurses:RM450,0 00 72 Nurses: RM 450,000 Total for second 5-year: RM 1.5M
143
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
3. Establish new posts and recruit the following personnel:
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
RM 11.376 M (Emolument)
Clinical specialists (12), Medical Officers (12), Matrons (6), Nurses (72), Palliative Care staff (6), Attendants (24)
2.
Facilities
RM 0.6 M
Development of palliative care centers: i. Develop specialist-based palliative care services in 6 general hospitals regionally in Malaysia (20082010). ii. Set up in each state hospital a Palliative Care Unit which is managed and administrated by a Palliative Medicine and a Pain Specialist by 2020. iii. Establish good home care services within the public health set up and the NGOs so as to create a seamless palliative care service to the
144
2008-2010
) Medical ) Development ) Division / ) Planning & ) Development ) Division / ) Engineering ) Division
Existing facilities renovation: RM 100,000/ unit.for 6 PC Units
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
community level iv. Implementati on of effective Quality System in all areas of cancer management (palliative care) v. Upgradeand renovate existing facilities.
3.
Equipment
1. Study latest available technology 2. Decide on number and type needed 3. Purchase all needed equipment: Electric beds, ripple mattress, wheelchairs, syringe drivers, patient transport van, etc. 4. Arrange needed training 5. Arrange up-to-date maintenance
RM 1.08 M
145
2008-2010
) ) ) ) ) ) ) ) )
Pharmacy Division / Engineering Division
Equipment: RM 100,000 /unit(State) Patient transport van: RM 80,000/unit 200 8 -2010: 6 Regional hospitals: Equipment: RM 600,000 Vehicle: RM 480,000
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
4.
Drugs
1.I dentifykeydrugs&demands 2. Arrange bulk long term supply 3. Keep track of drug development 4. Promote local drug manufacture
RM 3.6 M
5.
Health Education
Develop palliative care education materials, for: The general public Post-basic Palliative Care Nursing programme Community General Practitioners’ (GP) short-term clinical attachment Continuing Medical/Health Education programme Volunteers in palliative care/home care services
RM 0.45 M
T im e - F r a m e
2008-2010
2008-2010
A g e n cy / P e r s o n
) ) ) ) Pharmacy ) Division ) ) )
Special drugs & consumables: RM 200,000/unit/year 200 8 -2010: 6 Regional hospitals: 6 x 3 years x RM 200,000
HECC / IHP
General Public awareness: RM100,000
HECC
•
R em a rk s
•
HECC
•
IHSR / HECC / IHP
Post-basic nursing: RM100,000 Community GP training: RM100,000
•
•
CME : RM100,000 Volunteer training: RM 50,000
146
ACTION PLANS: ACTIVITIES No.
E le m e n ts
6.
Outsourcing & Consumables
7.
Research & Development
8.
Information Communication Technology and Networks
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
-
-
1. Prioritize Cancer Rese arch 2. Divide research priorities among institutions 3. Monitor research progress 4. Publicize research findings 5. Document & track all research
RM 0.2 M
1. 2. 3. 4.
Establish Malaysian Cancer Portal Link with International Networks Develop e-learning on Cancer Establish Tele-consultation with leading Centers for teaching, training and consultation. 5. High-speed Internet connection in all hospitals /palliative care centers for information search and research.
2008-2010
To develop RMK-10 onwards
NIH NIH
Preliminary data research:
NIH NIH NIH
1 research asst.: RM2,500/month RM30,000/yr x 5 =RM150,000 Other equipment and facilities: RM 50,000
Telehealth
In collaboration with MSC Need to establish a Cancer Registry Unit To connect with Peter McCallum and Royal Adelaide Hospital in Australia.
MOH Telehealth Telehealth Telehealth
147
ACTION PLANS: ACTIVITIES No.
9.
E le m e n ts
NGO’s / Corporations
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
1. Network all existing NGO’s 2. Designate roles for existing NGO’s 3. Establish Consultative Forum 4. Enhance collaboration with NGO’s
RM 0.3 M
T im e - F r a m e
2008-2010
A g e n cy / P e r s o n
R em a rk s
NGO ) ) ) MOH / NGO ) ) )
Grants for NGOs: RM100,000 per year After 2011, Grants for running cost of accredited NGO palliative homecare services - 30-40% of running costs for NGO (Estimated RM2-3M / yr)
10.
Institutions / Organizations
11.
Standards / Guidelines / Codes of Practice
1. Identify key experts in specified field 2. Analyze guidelines established in other centers 3. Panel to develop guidelines in accordance to local conditions 4. Publish guidelines 5. Create awareness and promotion of guidelines
RM 0.05 M
148
2008-2010
) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc
Cancer Pain Management Clinical Practice Guidelines (CPG) 2011-2015: RM 100,000
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
6. Review every 5 years and audit adoption of guidelines
12.
13.
Quality Assurance
Legislation
1. Establish accreditation criteria f or specialty of palliative medicine. 2. Establish key performance indicators for Cancer Management 3. Establish reporting and monitoring mechanism 4. Review and revise Indicators 5. Establish benchmarks with other countries
) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health
1. All accredited Malaysian Universities must have a palliative care component in the undergraduate medical curriculum. 2. All Postgraduate programmes in oncology and family medicine must have a palliative care clinical attachment. 3. All Nursing college curriculum must have palliative care nursing
NA
149
Audit of Cancer pain incidence & relief to begin in RMK-10: 2011-2015: RM 500,000
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
A g e n cy / P e r s o n
R em a rk s
curriculum. 4. All hospitals with Cancer treatment facilities must also make provision for palliative care services. 5. Quality of life act
TOTAL: PALLIATIVECARE
RM19.856M
ACTION PLANS: ACTIVITIES No.
1.
E le m e n ts
Human Capital
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
4.
C o st
Recruit foreign palliative care experts Overseas expert: RM 250,000/yr 1 expert – for 1 year : RM 250,000
RM 1.45 M
5. Arrange counterparts for training: • Recruit clinical specialists U48/54 • Recruit nurses : sp ecialist
150
T im e - F r a m e
2006-2010
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support )
Utilise existing supportive staff eg dieticians, physiotherapists 2011-2015: For 6 State hospitals:
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
•
C o st
T im e - F r a m e
palliative care nurses (1 in each regional center) 72 staff nurses to undergo post basic training in Palliative Care (6 per center) Clinical Psychologists
A g e n cy / P e r s o n
) )
Trainee doctors: RM 100,000/yr 6 doctors: RM 600,000 Specialist nurses: RM75,000/yr
Total for second
1 nurse: RM75,000 Nurses (post-basic): 6,250/nurse 12 Nurses/unit: RM 75,000/unit 6 units: RM 450,000 Clinical psychologists: RM75,000/yr 1 psychologist: RM75,000
6.
R em a rk s
6 Trainee doctors: RM 600,000 6 specialist nurses:RM450,0 00 72 Nurses: RM 450,000
5-year: RM 1.5M
RM 11.376 M (Emolument)
Establish new posts and recruit the following personnel: Clinical specialists (12), Medical Officers (12), Matrons (6), Nurses (72), Palliative Care staff (6), Attendants (24)
2.
Facilities
RM 0.6 M
Development of palliative care
151
2006-2010
) Medical ) Development
Existing facilities
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
centers: vi. Develop specialist-based palliative care services in 6 general hospitals regionally in Malaysia (20062010). vii. Set up in each state hospital a Palliative Care Unit which is managed and administrated by a Palliative Medicine and a Pain Specialist by 2020. viii. Establish good home care services within the public health set up and the NGOs so as to create a seamless palliative care service to the community level ix. Implementati on of effective Quality System in all areas of cancer management (palliative care) x. Upgradeand renovate existing facilities.
T im e - F r a m e
) ) ) ) ) )
152
A g e n cy / P e r s o n
Division / Planning & Development Division / Engineering Division
R em a rk s
renovation: RM 100,000/ unit.for 6 PC Units
ACTION PLANS: ACTIVITIES No.
3.
E le m e n ts
Equipment
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
6.
Studylatestavailable technology 7. Decide on number and type needed
RM 1.08 M
T im e - F r a m e
2006-2010
8.
Purchase all needed equipment: Electric beds, ripple mattress, wheelchairs, syringe drivers, patient transport van, etc. 9. Arrange needed training 10. Arrange up-to-date maintenance
4.
Drugs
) ) ) ) ) ) ) ) )
A g e n cy / P e r s o n
Pharmacy Division / Engineering Division
R em a rk s
Equipment: RM 100,000 /unit(State) Patient transport van: RM 80,000/unit 2006-2010: 6 Regional hospitals: Equipment: RM 600,000 Vehicle: RM 480,000
5.
Identifykeydrugs& demands Arrange bulk long term supply 7. Keep track of drug development 8. Promote local drug manufacture
RM 6 M
6.
153
2006-2010
) ) ) ) Pharmacy ) Division ) ) )
Special drugs & consumables: RM 200,000/unit/year 2006-2010: 6 Regional hospitals: 6 x 5 years x RM 200,000
ACTION PLANS: ACTIVITIES No.
5.
E le m e n ts
Health Education
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
Develop palliative care education materials, for: The general public •Post-basic Palliative Care Nursing programme •Community General Practitioners’ (GP) short-term clinical attachment Continuing Medical/Health Education programme •Volunteers in palliative care/home care services
RM 0.45 M
HECC IHSR / HECC / IHP
R em a rk s
General Public awareness: RM100,000 Post-basic nursing: RM100,000 Community GP training:
•
Outsourcing & Consumables
A g e n cy / P e r s o n
HECC / IHP HECC
•
6.
T im e - F r a m e
2006-2010
RM100,000 CME : RM100,000 Volunteer training: RM 50,000 -
-
154
ACTION PLANS: ACTIVITIES No.
7.
E le m e n ts
Research & Development
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
6.
RM 0.2 M
Prioritize Cancer Research Divide research priorities among institutions 8. Monitor research progress 9. Publicize research findings 10. Document & track all research
T im e - F r a m e
2006-2010
7.
A g e n cy / P e r s o n
R em a rk s
NIH NIH
Preliminary data research:
NIH NIH NIH
1 research asst.: RM2,500/month RM30,000/yr x 5 =RM150,000 Other equipment and facilities: RM 50,000
8.
Information Communication Technology and Networks
6. Establish Malaysian Cancer Portal 7. Link with International Networks 8. Develop e-learning on Cancer
To develop RMK-10 onwards
Telehealth MOH
9. Establish Tele-consultation with leading Centers for teaching, training and consultation.
Telehealth
10.
High-speed Internet connection in all hospitals /palliative care centers for information search and research.
Telehealth Telehealth
155
In collaboration with MSC Need to establish a Cancer Registry Unit To connect with Peter McCallum and Royal Adelaide Hospital in Australia.
ACTION PLANS: ACTIVITIES No.
9.
E le m e n ts
NGO’s / Corporations
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
5. 6.
Network all existing NGO’s Designate roles for existing NGO’s 7. Establish Consultative Forum 8. Enhance collaboration with NGO’s
RM 0.5 M
T im e - F r a m e
2006-2010
A g e n cy / P e r s o n
R em a rk s
NGO ) ) ) MOH / NGO ) ) )
Grants for NGOs: RM100,000 per year After 2011, Grants for running cost of accredited NGO palliative homecare services - 30-40% of running costs for NGO (Estimated RM2-3M / yr)
10.
Institutions / Organization
11.
Standards / Guidelines / Codes of Practice
7.
Identify key experts in specified field 8. Analyze guidelines established in other centers 9. Panel to develop guidelines in accordance to local conditions
RM 0.05 M
156
2006-2010
) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc
Cancer Pain Management Clinical Practice Guidelines (CPG) 2011-2015: RM 100,000
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
10. Publish guidelines 11. Create awareness and promotion of guidelines 12. Review every 5 years and audit adoption of guidelines
12.
Quality Assurance
6.
Establish key performance indicators for Cancer Management 7. Establish reporting and monitoring mechanism 8. Review and revise Indicators 9. Establish benchmarks with other countries
13.
Legislation
1.
) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health
Allaccredited Malaysian Universities must have a palliative care component in the undergraduate medical curriculum. 2. AllPostgraduate programmes in oncology and family medicine must have a palliative care clinical attachment. 3. All Nursing college curriculum
NA
157
Audit of Cancer pain incidence & relief to begin in RMK-10: 2011-2015: RM 500,000
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 6 : PALLIATIVE CARE A ct iv it ie s
C o st
must have palliative care nursing curriculum.
4.
Allhospitalswith Cancer treatment facilities must also make provision for palliative care services. Quality of life act
TOTAL: PALLIATIVECARE
RM21.706M
158
T im e - F r a m e
A g e n cy / P e r s o n
R em a rk s
ACTION PLANS: ACTIVITIES No.
1.
E le m e n ts
HumanCapital
GOAL 7 : TRADITIONAL AND COMPLEMENTARYMEDICINE A ct iv it ie s
1. 2. 3. 4.
C o st
T/CMpractitioners outsourcing. Recruiting T/CM practitioners Formulating Training Plan Identify candidates for training
RM 0.8 M
RM 2.2 M
T im e - F r a m e
20067-2010
) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support )) )
Outsource team / hospital consists of a. TCMpractitioner -3 b. Acupuncturists -3 c. TraditionalMasseur -3
New budget allocation
Advanced training in cancer management for one month China (2x$30,000/person) England (1x$50,000/person) • •
*Outsource professional consultation group (3 professors & 3 TCM oncology specialists) at 3 pilot integrated hospitals
159
A g e n cy / P e r s o n
R em a rk s
ACTION PLANS: ACTIVITIES No.
2.
E le m e n ts
Facilities
GOAL 7 : TRADITIONAL AND COMPLEMENTARYMEDICINE A ct iv it ie s
C o st
1. Constructthefacilities The regional hospitals will plan to
RM 0.6 M
T im e - F r a m e
20068-2010
use 0.6M for the construction of its facilities.
RM 0.2 M
The cost for the maintenance is about the 20-30% of the main cost of the building construction.
3.
Equipment
Plan for T/CM practitioners outsourcing
4.
Drugs
Herbalmedicine • Introduce end product of herbal preparation which is commonly used to minimize the side effect of chemo / radiotherapy as an adjunct therapy
160
-
2006 -2010
RM 1 M
20086-2010
R em a rk s
) T/CM/Medical ) Development ) ) ) ) ) )
2. Maintain the facilities.
A g e n cy / P e r s o n
Division / Planning & Development Division / Engineering Division
.
) ) ) ) Pharmacy ) Division )
ACTION PLANS: ACTIVITIES No.
E le m e n ts
A ct iv it ie s •
5.
Health Education
GOAL 7 : TRADITIONAL AND COMPLEMENTARYMEDICINE C o st
T im e - F r a m e
A g e n cy / P e r s o n
1. Develop health education materials 2. Divide workload among media 3. Organize continuous media coverage 4. Study effects of public education 5. Awareness program
RM 0.4 M
20068-2010
HECC / IHP HECC HECC IHSR / HECC / IHP
6.
R em a rk s
) )
The usage of the Herbal Medicine (Malay, Chinese and India) is depending on the preference of T/CM practitioners which undergo proper research. The main objective is to minimize side effect of cancer treatment. (Chemotherapy, Radiotherapy etc). It is about $200,000/year for each hospital.
Outsourcing & Consumables
-
161
RM400,000/year for each hospital for preparation of public speech, T/CM information leaflets, campaign and in house training.
ACTION PLANS: ACTIVITIES No.
E le m e n ts
7.
Research & Development
8.
Information Communication Technology and Networks
9.
NGO’s / Corporations
GOAL 7 : TRADITIONAL AND COMPLEMENTARYMEDICINE A ct iv it ie s
C o st
Research on the T/CM practice
1. Establishing T/CM registration and licensing 2. Maintenance 3. Enhance T/CM registration and licensing 4. Maintenance
Institutions / Organizations
1. Establish National Cancer Advisory Council – to include representative from the T/CM Division
11.
Standards / Guidelines / Codes of Practice
1. 2. 3.
A g e n cy / P e r s o n
R em a rk s
NIH
20066-2010 -
1. Network all existing NGO’s 2. Designate roles for existing NGO’s 3. Establish Consultative Forum
10.
T im e - F r a m e
RM 3.8 M
NGO ) ) MOH / NGO
-
-
Establish Cancer Management Standards Organize Training Program Established
RM 0.5 M
162
Practitioner bodies need to obtain funding from the operating budget.
NIH Secretariat ) Medical ) Development ) Division /
20086-2010
In collaboration with practitioner bodies.
ACTION PLANS: ACTIVITIES No.
E le m e n ts
GOAL 7 : TRADITIONAL AND COMPLEMENTARYMEDICINE A ct iv it ie s
C o st
T im e - F r a m e
A g e n cy / P e r s o n
Standards/Guidelines
12.
Quality Assurance
1. Establish key performance indicators for Cancer Management 2. Establish reporting and monitoring mechanism
-
IHSR )NIH // ) Medical ) Development ) Division /
3. Review Revise Indicators 4. Establishand Benchmarks with other countries
13.
Legislation
Health )) Public Research & / ) Technical ) Support
1.T/CMActandRegulation
-
TOTAL: TRADITIONAL AND COMPLEMENTARY MEDICINE
RM 9.5 M
163
2006-2010
R em a rk s
APPENDIX 5 ACTION PLANS : SUMMARY OF BUDGET REQUIRED (2008 – 2010) PREVENT ION
ELEMENTS
SCREENIN G AND EARLY DETECTION
D I A G N O S IS
T R EA T M EN T
RE HA B I LI TATION
PALLIATIVE CARE
TC M
R&D
TO TA L
%
COSTS (RM ‘000,000)
1.
Human Capital - Training
1 .0 8
- Emolument
1 1 .2 1 5 0 .7 6 1 .0 5
2.
Facilities
3.
Equipment
4.
Drugs
5.
Health Education
6.
Outsourcing & Consumables
7.
Research & Development
8.
ICT and Networks
0. 31
9.
NGOs / Corporations
0.1 4
10.
Institutions / O rganizations
11. 12.
Standards / Gu idelines Codes of Practice QualityA ssurance
13.
Legislation
T O T A L BU DG ET
231 9 (Vaccines) 2 10
0. 12
13. 53 44
1 3 0.9
2 2 2 .6 5
6
1 .0 8
65
6 1 9 .5 3
3
3. 6
1
0.5
1
0. 45
0 .4
1
0 .1 1
0.2
3 .8
0. 6
0.88
0.25
1 .51 7
0.25
0. 05 0.1
0.25
90.8 (4.44%)
460.071 1203.788 (22.49%) (50.33%)
164
0 .5
10.23 2.6( 17 ) ( 1 6 4 .8 0 6 ) 8.05() 1 0 3 .2 1 5.05
4 31 .66 1 0 1 1 .1 3 1 4 .3 5
2
0. 3
1
2 0. 83 3 2. 26 (16.24%)
23.7 3
0.8
0.5 2
4 .8 1 5 5.1 9
0 .8
1 2 3 .7 5
5.7 2.12
1 1 .3 7 6 0.6
209.2254 ( 44.41 9 4 )
3
4 7.3
7 4 .2 9 4
1 1.896 1.2
2 .2
7 6.855 79.8
2 .0
39.89 4 8.12
1.6
19.2 1 6.5
12 .59 1
2 3 .0 0 5
2 1 0 .6 3 4 45
56.81
19.856 (0.97%)
4 9 .4 3 0.7 10.3 2.78
3. 22
0.16
0 .4
0.052
2. 38
0.12
2 .3 8 7
0.12
1.2 5 0.2 5
24.906 (1.22%)
21.1
9.5 80.735 2,045.6564 (0.46%) (3.95%)
0.01
165
