This document summarizes Malaysia's experience with cancer screening and control efforts. It notes that non-communicable diseases like cancer account for over 70% of deaths in Malaysia. The National Strategic Plan for Non-Communicable Diseases aims to reduce cancer morbidity, mortality, and improve quality of life through various prevention, screening, treatment, and palliative care initiatives. Specific programs are in place for cervical cancer screening via Pap smears and HPV vaccination, as well as other cancers. Challenges remain in increasing screening and treatment coverage, addressing barriers, and ensuring access. Continued efforts are needed to work towards cervical cancer elimination targets in Malaysia.
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Cancer Screening in a Middle Income Country: Malaysia's experience
1. Cancer screening in a Middle-Income
country: Malaysia’s experience
Non Communicable Disease Section
Disease Control Division
Ministry of Health Malaysia
6 January 2020
2. Burden of Disease, Malaysia (2017)
2Institute for Health Metrics and Evaluation (IHME). Health-related SDGs. Seattle, WA: IHME, University of Washington, 2017
Available from http://vizhub.healthdata.org/sdg. (Accessed 26 August 2018)
3. Determinants of Health:
Proportional contribution to premature death
3
Behavioural
patterns
40%
Environmental
conditions
5%
Social
circumstances
15%
Medical care
10%
Genetic
predisposition
30%
Our health is determined
by much more than the
health services we
receive
Determinants of Health and their contribution to premature
death (adapted from McGinnis, et al., 2002)
5. National Strategic Plan for Non-Communicable
Diseases (NSP-NCD) 2016-2025
• Approved by MOH on 10 April 2017
• In-line with Malaysia’s commitment at the global
level for NCD prevention and control
– Including Sustainable Development Goals (SDGs)
– Universal Health Coverage
• Governance: Cabinet Committee for a Health
Promoting Environment
– Chaired by Deputy Prime Minister
– Membership: 12 ministers
5
6. Implementation of NSP-NCD 2016-2025
1. National Plan of Action for Nutrition of Malaysia III 2016-2025
2. National Strategic Plan for Tobacco Control 2015-2020
3. Policy Options to Combat Obesity in Malaysia
4. Salt Reduction Strategy for Malaysia 2015-2020
5. National Strategic Plan for Active Living 2016-2025
6. Malaysia’s Alcohol Action Plan 2013-2020
7. National Strategic Plan for Cancer Control
Program 2016-2020
8. Enhanced Primary Healthcare (EnPHC) initiative
9. Komuniti Sihat, Pembina Negara (KOSPEN) initiative
6
7. National Strategic Plan for Cancer Control Program
2016-2020
Overall objective:
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
• Cross Cutting Issues:
– Communication
– Patient navigation
– Social determinants
– Genetic testing
– Decision making
– Dissemination of evidence-
based info
– Quality of cancer care
– Surveillance
– Monitoring & evaluation
7
PreventionTraditional &
Complementary Medicine
Screening &
early detection
Diagnosis
Palliative Care
Rehabilitation
Treatment
8. A selection of interventions for NCD prevention
in Malaysia (life-course approach)
8
Pregnancy
Pre-
conception
Infant/
Toddler
Pre-
School
School-
going Age
Higher
Education
Adults Elderly
Kelab Doktor
Muda
Program Siswa
Sihat (PROSIS)
KOSPEN
KOSPEN Plus
Guideline on marketing of unhealthy F&B to
children
Guideline on enforcement of sale of food
outside of school perimeters
School canteen guidelines
mQuit Services
Smoke-free areas, and other tobacco-related policies
Mass media campaigns, medical/health camps, Healthier Choice Logo (HCL)
HPV vaccination
HepB
vaccination
SSB tax
Selected cancer screenings
Early intervention
for smoking
9. Organised Screening and Early Detection programmes
in Malaysia
Breast Cancer
Cervical cancer
Oral cancer
Colorectal cancer
Opportunistic
approach
9
12. Age standardised incidence rate for ten common
cancers, by sex, 2012-2016
12Malaysia National Cancer Registry Report, 2012-2016
13. ACTION Study: Financial catastrophe at one year of being
diagnosed with cancer; Country-specific outcomes
13
Country Per capita GDP
(USD)
Age-standardized
cancer incidence
(per 100 000)
Financial
catastrophe
at 1 year
Death at 1 year
Malaysia 10,830 143.6 621/1,373 (45%) 158/1,373 (12%)
Thailand 5,561 137.5 249/1,058 (24%) 276/1,058 (26%)
Indonesia 3,515 133.5 486/1,097 (44%) 405/1,097 (37%)
Philippines 2,843 140.0 369/660 (56%) 240/660 (36%)
Vietnam 2,052 140.4 1,016/1,490 (68%) 370/1,490 (25%)
Laos 1,708 141.8 11/56 (20%) 45/56 (80%)
Myanmar 1,198 140.5 495/995 (50%) 445/995 (45%)
Cambodia 1,084 140.4 1/58 (2%) 54/58 (93%)
Source: http://business.inquirer.net/198982/cancer-costs-southeast-asia-socially-and-economically#ixzz4dI0pTBnn
14. Life Course Approach to Cervical Cancer
Prevention and Control
14
Girls 9-14 years
• HPV vaccination
Girls and boys, as appropriate
•Health information and warnings about
tobacco use
•Sexuality education tailored to age &
culture
•Condom promotion/provision for those
engaged in sexual activity
•Male circumcision
Women > 30 years of age
“Screen and treat” – single visit
approach
• Point-of-care rapid HPV testing for
high risk HPV types
• Followed by immediate treatment
• On site treatment
All women as needed
Treatment of invasive cancer at any age
and palliative care
•Ablative surgery
•Radiotherapy
•Chemotherapy
•Palliative Care
Primary Prevention Secondary Prevention Tertiary Prevention
Source: World Health Organization
15. Pap Smear Coverage for Malaysia
15
22.7 23.5
23.4
23
26.3
20
21
22
23
24
25
26
27
2013 2014 2015 2016 2017
Percentage
Source: Family Health Development Division, MOH Malaysia
16. HPV Vaccination Programme in Malaysia
16
What When, who and how
Year initiated 2010
Implementing organisation Ministry of Health
Financed by Government of Malaysia
Vaccination protocol 2 doses (0, 6 months)
Vaccination target School going 13-year old girls
Community mobilisation activities Catch-up provided in health clinics
Implementation of vaccination School Health teams
Surveillance and program monitoring Routine, Paper-based
Source: Family Health Development Division, MOH Malaysia
17. Increased coverage of HPV vaccination
17
WHO recommendations
• 2 doses to girls 9-14 years, minimum 6 months apart
• Introduce to multi-age cohort, 9-14 years (15-18 if feasible) in first year
• 3 doses for: girls 15 years and older; and for immuno-compromised individuals
Challenges
• Poor parental awareness and public confusion
• Perceived religious and cultural issues
• Financial allocation
• Logistic issues leading to delay of vaccine delivery
Accelerators
Sufficient, affordable supply of HPV vaccine
• Competitive procurement mechanism
• Concerted effort between partners and private sector to overcome vaccine supply constraints
Introduction of HPV vaccine as school based programmes
• Strong relationship with MOE
• School health services infrastructure
• Develop high quality and sustained communication and mobilisation approaches
Political will and commitment
Public trust in NIP
Effective risk communication strategy
• Addressing religious issues
18. HPV Immunisation Rates in Malaysia
18
92
93
94
95
96
97
98
99
100
2010 2011 2012 2013 2014 2015 2016 2017
Parents' Consent 95.88 97.59 98.18 98.44 98.48 98.23 98.40 98.60
First Dose 99.50 99.66 99.82 99.94 99.91 99.98 99.91 99.82
Second Dose 98.94 98.97 98.66 99.75 99.84 99.62 99.12 99.40
Third Dose 97.93 98.25 99.13 99.31 99.54
Completed Dose 98.41 98.87 99.31 99.37 99.63 99.64 99.12 99.58
Percentage
Source: Family Health Development Division, MOH Malaysia
19. Increased coverage of screening & treatment of pre-
cancer lesions
WHO recommendations
• Women aged 30-49 years be screeened at least once in their life-time for cervical cancer, and re-screened
every 5 years
• HIV positive women should be screened every 3 years
• Immediate treatment where possible
Challenges
• Patient barriers: Fear, embarrassment, perceived benefits, inconvenience (no time), negative experience, low
awareness
• Healthcare barriers: Lack of space and privacy, human resources, screening infra-structure
• Expensive and complex screen and treat technologies complicate scaling-up
• New or optimised service delivery methods required for LMIC contexts
Accelerators
• Use of self sampling HPV DNA testing
• National scale-up of screen & treat
• Simple algorithms need to be introduced for different settings
• Increased quality and coverage of service delivery
• Countries detailed implementation plans to introduce and scale-up products and delivery models
• Strengthen patient retention and linkage to treatment
19
20. 20
Eligibility Education Registration
Sample
collection
Results
0m 0.5m 2.5m 6.0m 9.5m 3 working days
• New approach to complex and
persistent problem through
human-centered research,
collective and diverse teamwork
and rapid prototyping
• ROSE is innovation that aims to
create more efficient screening,
improvement of quality and
lower total cost
Slide courtesy of Prof. Dr Woo Yin Ling, Universiti Malaya
21. A good screening program ensures every obstacle is addressed from
start to completion of the screening continuum
Slide courtesy of Prof. Dr Woo Yin Ling, Universiti Malaya
22. What else needs to be done? Increased coverage of
diagnosis, treatment and palliative care for invasive cancer
WHO recommendations
• Women diagnosed with early invasive cervical cancer can be cured with effective quality treatment
• Cervical cancer diagnosis must be confirmed by histopathological examination
• Cancer surgery and radiotherapy are major primary treatment modalities
• Palliative care is an essential element of cervical cancer control
• Reducing delays in access to diagnosis and treatment can improve survival of women with cervical cancer
Challenges
• About 40% of cervical cancer is detected in late stages
• Treatment is often associated with catastrophic health expenditure
• Access to palliative care is poor
Accelerators
• Access to quality pathology, cancer surgery and radiotherapy
• Reducing cost of equipment and cancer medicines
• Sufficiently trained health workforce
• Implemented protocols and care pathways
• Timely diagnosis, staging, treatment, and referral of patients
• Increased access to palliative care
• Ensured financial access to treatment
• Integrated into UHC or other social support programs
22
23. Towards Cervical Cancer Elimination in Malaysia
• Malaysia is well positioned for cervical elimination targets
• Must retain vaccine uptake among adolescents to 90% and above
• It is necessary to transition from pap smear to HPV test
• It is necessary for monitoring and surveillance to achieve 70%
screening targets with 90% of abnormal screens being followed up
• Cross ministry and cross sector collaboration is necessary for
organised screening and surveillance
• International collaboration is an accelerator
23
A paper by McGinnis in 2002 examined the contributions of various factors to premature mortality.
Their paper found that medical care only contribute 10% - meaning that our health is determined by much more than the health services that we receive.
The National Strategic Plan for Non-Communicable Diseases (or NSP-NCD) provides the overall framework for Malaysia’s response to the increasing burden of NCDs.
This Strategic Plan is in-line with Malaysia’s commitment at the global level, including the SDGs.
To support the implementation of the NSP-NCD, there is a Cabinet level committee called the JK Kabinet bagi Persekitaran Hidup yang Sihat or JKPHS
This Committee is chaired by the Deputy Prime Minister and membership consisted of 12 ministers.
Under the NSP-NCD, these are the various Strategic Plans that addresses the various NCDs and NCD risk factors.
This shows a selection of interventions for NCD prevention – depicted graphically along the life-course approach.
We have implemented many interventions, targeting the school-going children and adults.
Unfortunately, we are still not doing enough
528,000 new cases with 266,000 deaths
90 % of the deaths in LMICs
Cervical cancer is an unacceptable disease and the burden is still far too high in many countries, principally in middle and low income countries, reflecting the many inequities across the world in terms of access to services.
High income countries have addressed the burden with organized screening programmes and now the low cx ca incidence can be maintained by the introduction of vaccines
Cervical cancer is a completely preventable disease, yet it remains the leading cause of cancer-related death and morbidity among women in the developing world, with approximately 85 percent of the disease burden occurring in low- and middle-income countries. To address this challenge, countries need to use testing as part of population-based screening for human papillomavirus (HPV), which is the principal cause of cervical cancer.
The strategic direction 2, highlights the 3 key WHO recommendations to be implemented at scale in countries based on a life course approach, as represented on this figure:
- HPV vaccination;
- Screening and treatment;
- Treatment of cancer and access to palliative care.
For vaccination, the vaccine group in WHO is currently looking at new evidence available to update the recommendation if needed, and to present findings to the next SAGE meeting
For screening and treatment: new recommendations are going to be published on thermal ablation and screening amog HIV positive women. The strategy will focus on the extensive implementation of one of the recommended algorithm: HPV testing followed by immediate treatment for women tested positive in a single visit approach
As more cancer will be identified in the context of an intensive screening campain, strengthen access to reatment and palliative care is essential
1969- Introduced of Pap Smear in few clinics as package for family planning acceptors
1995- Expansion of pap smear screening to eligible women – opportunistic screening
2010 - Introduction of School Based HPV vaccination to 13 yrs old girls
Why HPV vaccination?
Low smear uptake
Delay in seeking treatment
WHO endorsement
Presentation of cervical cancer
Stage 1 – 24%
Stage 2 – 38%
Stage 3 – 21%
Stage 4 – 17%