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 the 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 Situation Worldwide

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. The cancer incidence is estimated to be about 150 for every 100,000 population. The estimated number of new cases per year is approximately 40,000.

10 Principal Causes of Deaths in MOH Hospitals, Malaysia 2005

1. Septicaemia 2. Heart Diseases and Diseases of Pulmonary Circulation 3. Malignant Neoplasms 4. Cerebrovascular Diseases 5. Accidents 6. Pneumonia 7. Diseases of the Digestive System 8. Certain conditions originating in the Perinatal Period 9. Nephritis, Nephrotic Syndrome and Nephrosis 10. Ill-defined Conditions
Total Number of Deaths (39,602) Reference: Annual Report 2005, Ministry of Health, Malaysia

16.54 % 14.31 % 10.11 % 8.19 % 5.67 % 5.30 % 4.45 % 4.37 % 3.89 % 2.82 %

Based on the Report of the National Cancer Registry 2003 and government 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.

Ten most frequent cancers in males, Peninsular Malaysia 2003-2005 (unpublished)

C L RCA OO E T L L N UG NS PAYX AOHRN P O T T GA D R SAE L N LUAM E K E IA L MH M Y P O A SO AH T MC L E IV R BA D R LDE O H RS IN T E K 0

4 .7 3 .6 3 .6 3 .2 7 .8 7 .3 6 .5 6 .2 1 .2 2

1 .5 4

1 0

1 5 2 0 P rc n g o a c n e e e ta e f ll a c rs

2 5

3 0

3 5

Ten most frequent cancers in females, Peninsular Malaysia 2003-2005 (unpublished)

BES RAT C R IXU E I EV TR C L RCA OO E T L OA Y VR L UAM E K E IA L N UG L MH M Y PO A C RU UE I OPS TR T Y O GA D H R ID L N SO A H T MC 0
4 .3 3 .7 3 .6 3 .4 3 .3 3 .1 2 .7 1 .6 0 9 .9 3 .3 1

1 0

1 5 2 0 P rc n g o a c n e e e ta e f ll a c rs

2 5

3 0

3 5

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 in the country is expected to rise in light of the increasing ageing population in the country, increase in populations exposure to cancer risks with the 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 use is the single largest preventable cause of cancer in the world today and is responsible for about 30% of all cancer deaths in developed countries and this figure is increasing steadily in developing countries, particularly in women. 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 promotion, vaccination programmes, implementation of legislation and policies which are positive for human health.

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 National Pap Smear Screening Programme includes the introduction of a Call-Recall System for Pap smear screening which is scheduled to begin in 2007. Liquid-based cytology is one of the developments in screening technology and appears to have a number

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 purposes and for screening of high risk women with past history of breast disease or positive family 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 in 10 centers. Angiography facilities are available at certain major hospitals. Six tertiary hospitals (Kuala Lumpur Hospital, Selayang, Serdang, Ampang, Sungai Buloh and Pandan) have high end imaging facilities (MRI, angiography, nuclear medicine) but do not have PET CT. Penang Hospital has a full compliment of high 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 Institute 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 good supportive environment. An accurate diagnosis is the first step in cancer management. This calls for a combination of careful clinical assessment and diagnostic investigations including endoscopy, imaging, histopathology, cytology and laboratory

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 of tumour markers is not comprehensive enough for proper monitoring of cancers. There are 217 diagnostic pathologists (excluding forensic pathologists), in the country, of whom 104 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 patients, where all treatment modalities (e.g. surgery, anti-cancer drugs, radiotherapy) are considered, and 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

advanced stage is inferior compared to results in early stages. The waiting time for treatment in some centers in Malaysia is 68 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 in whom cure is not a feasible goal of treatment. This can be attained through provision of palliative care, prompt assessment and treatment of pain and 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. There are now a total of 13 palliative care units and 48 palliative care teams developed throughout the entire country. For purposes of 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.

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 and the Ministry of Health is now in the process of rectifying these issues in order to allow palliative medicine to grow further. In 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 Malaysias uniqueness. Furthermore, Malaysias 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 as to meet the criteria of the general public for their comfortable acceptance. One of the issues confronting T/CM is the difficulty in assessing the quality, safety and efficacy of herbal preparation. Hence the promotion of the usage of herbal medicine needs to be evidence-based.

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. proctoscopes, speculums, microscopes, Xray machines and ultrasonography machines must 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 be appropriate. This will resolve the problem of the lack of machines, ageing machines and poor support from privatized 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 optimally due 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 services. Pharmacists will need to be trained in the clinical therapy management of cancer patients to provide pharmaceutical care 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 through 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 programs, policies and cancer research. Appropriate resources including personnel, infrastructure 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 and NGOs should provide startups funds, leadership, guidance, and technical assistance for cancer initiatives that range from teaching school children to 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 research organizations. Among the weaknesses are that despite the money injected into research projects, only a few make it to publication. One of 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 of health and medical research remains discouraging. As research capability matures, there should be increasing funding contribution from the public 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 medicine, environmental risk factors, symptom management, imaging and screening, health disparities 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 2025, cancer will no longer be a public health problem in Malaysia, where all preventable cancers are effectively prevented, all potentially curable 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 for prevention, early detection, diagnosis, treatment, rehabilitation and palliative care of 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: Objective 2: To detect potentially cancerous lesions in the population at risk To increase the detection rate of cancers at an earlier stage of the disease

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GOAL 3: DIAGNOSIS Objective 1: Objective 2: 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 comprehensive diagnostic services to support cancer patients in all aspects of care 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

Objective 3: Objective 4:

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: TRADITIONAL AND COMPLEMENTARY MEDICINE Objective 1: Objective 2: Objective 3: Objective 4: 5.0 PRIORITIES 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

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 of risks factors for cancers in Malaysia Objective 2: To increase awareness and knowledge of the general public on the risk factors of the common cancers in Malaysia Objective 3: To strengthen the cancer risk factors intervention programmes The major challenge in controlling cancer is not only focusing on reduction in mortality but rather, in reducing the incidence. It is imperative that in the present health care system, cancer prevention activities are expanded further to include common cancers thus emphasizing the governments 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 process to provide and monitor information on cancer risks factors for common cancers among Malaysian population.

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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 human resource, infrastructure and finance were major problems faced in this initiative. In 1993, Penang launched the pilot 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) will be merged and further strengthened so as to improve data quality and validity, as well as for better management of cancer registries at 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 studies and hospital based studies. The major surveillance is the National Health and Morbidity Survey that was started in 1986 (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 2year 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 smoker to develop lung cancer is almost 20 times higher compared to nonsmoker. Smoking is rapidly becoming a serious public health problem 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 and counseling to reduce or stop smoking. To reduce exposure to environmental tobacco smoke, bans or limits on 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 of intervention activities, legislations and enforcements. In Singapore, since the start of the National Smoking 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 of 0.5% reduction per year for smoking prevalence in 9th MP period for Malaysia is considered achievable. With the availability of NHMS 2006 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 further increase the vaccination coverage in Malaysian population. The effort to prevent primary liver cancer as well as chronic hepatitis, will however 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

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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 consumption

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 from many sources that, in the developing countries, betel quid chewing is by far the most important cause of oral cancer especially with the 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 are evidentially associated with carcinogenicity in human beings. Occupational cancers 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 be carried out locally so that specific approaches related to environmental induced cancer prevention programme can be planned. 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 contraceptive use for a prolonged period by young women increases the risks of breast cancer. However, they also reduce the chance of 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 those with positive or suspicious findings, aims to reduce breast cancer mortality. 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 Cancer

Pap smear screening was initiated by the Ministry of Health in 1969. The main providers are Ministry of Health and the National Population and 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 and equipment and increasing the number of trained medical personnel. In cytology, considerable attention should be given to 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 Cancer

Screening for prostate cancer using the digital rectal examination (DRE) is often recommended, but DRE is not a sensitive screening test for early disease. Prostate 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 Cancer

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 of the most important steps in 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 of cancer, determination of cancer progression, prognosis and predictive response to treatment modalities, leading to best possible effective personalized 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 information on the nature and characteristic of each 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 various aspects of cancer assessment leads to characterization of the unique profile of each cancer, allowing determination of 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, and would encompass the upgrading of the routine anatomical pathology, chemical pathology, haematology, 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 to facilitate 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 range of 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 regional centers. These new centers should include the following locations to give enough 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 will be developed according to the Blueprint. To facilitate development, these centers will be categorized according to the level 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 and upgrading the 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. 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.

ii.

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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. Provide comprehensive supportive care in collaboration with other agencies. 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. 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. Conduct research in collaboration with other agencies within the country as well as with overseas centers. Co-ordinate the network of planned regional radiotherapy and oncology centers throughout the country. The NCI shall be a facility that can be used by staff from other institutions, private sector and other countries who can provide value-added services to the patients. Monitor the implementation of Quality Assurance in all centers for Radiotherapy and Oncology in Malaysia.

b) c)

d)

e) f) g)

h)

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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 in the introduction and utilization of new and proven cancer treatment and technology. 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 time new centers for Clinical Oncology will be established by the Ministry of Health in Putrajaya (National Cancer Institute) and 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 year will need to be absorbed by the system of buying of comprehensive oncology services by the government. As the number patients being outsourced in 2006 was in 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 include consultation, prescription, delivery, monitoring and follow-up of government patients by the private centers. Efforts are in place for establishing a consensus guideline for management of common cancers. 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 the existing centers at Kuala Lumpur, Kuching and Pandan, there should be better public-private integration in 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 through, for example developing stereotactic radiosurgery for small brain lesions at the National Cancer Institute. Joint training of doctors for 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 Selayang Hospital. Surgical oncology services will continue to be developed at the various hospitals.

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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:
2008 Total cost to MOH for the country per year

Treatment site

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 There will be a snowballing effect as the duration of therapy is long.

Unit cost

2,009

2,010

Breast Ca adjuvant Traztuzumab average treatment for 1 year 8mg IV followed by 6 mg IV every 3 weeks

RM80,000 / year / pt

8,000,000

14,400,000

19,500,000

Recurrence of breast and hormone refractory prostate cancer Docetaxel inj 20mg, 80mg

RM1000 x 6 x 300 patients per year

1,800,000

2,000,000

2,500,000

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 6 cycle adjuvant after concurrent chemo radiotherapy Dose Temozolomide 200 mg/m2 every 42 days x 6 cycles Treating 50 patients per year RM2,500 per cycle so RM15,000 per patient/yr RM 1000 x 6 cycles x 100 patients per year

600,000

700,000

800,000

Temozolomide tablet 100mg, 20mg

750,000

800,000

900,000

34

Goserelin

Neoadjuvant and adjuvant for prostate cancer 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 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

RM260x 12 200 patients per year

650,000

750,000

900,000

GIST on Imatinib if histologically proven GIST with c kit positivity

Imatinib RM8,000 /mth ; =RM96,000/ year x 250 pts x0.5

12,000,000

21,000,000

25,000,000

400mg daily for 2 years

Aprepitant

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 . Of these only 50% treated in Govt hospitals & fit= 150

RM220 every cycle x 5 cycles x 500 patients per year RM2200 / 20 mg Liposomal Doxorubicin (1.7m2 x 50 mg /m2 = 80 mg)

550,000

600,000

650,000

Recurrence of ovarian cancer for average of 6 cycles at 50 mg /m2 every 21 days

5,300,000

5,300,000

5,300,000

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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. Total based on drugs that are going to be in the protocol for first time

This has been the most challenging area due to the large numbers of patients involved and the snowballing effect.

3,000,000

5,400,000

7,300,000

33,000,000

51,000,000

63,000,000

Existing Expenditure from kontrak, pharmaniaga, kpk,LPO 90 juta - 2007 and increase 15% each year Total

RM 104 M RM 137 M 2008

RM 120 M RM 171 M 2009

RM 138 M RM 201 M 2010

Hospitals with Oncology Drugs H Tuanku Fauziah, Kangar H Alor Setar H Sg Petani H Pulau Pinang H Seberang Jaya H Kepala Batas H Ipoh

Cost of Sample of Chemotherapy Drugs (RM) 7,770 341,055 116,644 821,418 772.50 3,671.50 353,888

% of Budget Given 0.09% 0.37% 1.37% 9.67% 0.01% 0.04% 4.17%

2008 (RM) 123,000 506,900 1,876,900 13,247,900 13,700 548,000 5,712,900

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H Taiping H Teluk Intan H Manjung H TAR, Klang H Selayang H Ampang HRPZ II, Kota Bharu H Sultanah Nur Zahirah (HKT) H TAA, Kuantan H Sultan Hj A.Shah, Temerloh H Tuanku Jaafar, Seremban Hospital Melaka H Sultanah Aminah H Muar H Batu Pahat H Kluang H Sultan Ismail H Queen Elizabeth H Likas H Umum Sarawak MUSN, Kuching MUSB Sri Aman MUSB Sibu MUSB Miri H Kuala Lumpur H Putrajaya TOTAL

46,049 15735 8,425 88,697 210,819 61,377.50 102,698 778,850.50 42,396 5643.50 64,373 41,913 503,404.60 50,646 19,269 1081.50 240,507.80 293,054.90 217,661 1,216,247.1 199,496 2492.5 39,385 8,250 2,574,664.20 12,950 8,491,305

0.54% 0.19% 0.10% 1.04% 2.48% 5.10% 1.21% 4.79% 0.50% 0.07% 0.76% 0.49% 5.93% 0.60% 0.23% 0.013% 2.83% 3.45% 2.56% 14.32% 2.34% 0.03% 0.46% 0.10% 30.3% 0.15% 100%

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 1,041,200 671,300 8,124,100 822,000 315,100 17,810 3,877,100 4,658,000 3,507,200 19,618,400 3,205,800 41,100 630,200 137,000 41,511,000 205,500 137,000,000

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 compulsory licensing under the grounds of Government Use authorization or non-profit use or public health emergency. For 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 must be increased and the existing centers encouraged to go full time. With more BE studies 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 BE studies 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 price negotiations to remain competitive in the pharmaceutical market. Consequently the cancer patients might 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, their families, and their rehabilitation teams work together to determine realistic goals and to develop and carry out plans to obtain optimal 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 environment will 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 function, improving nutritional status, improving physical conditioning and activities 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 quality of life of these patients by attending to their physical, psychosocial and spiritual needs Objective 3: To provide a support system for patients and families of lifethreatening cancers from diagnosis to issues of grief and 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 9th 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

40

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 such as chemotherapy. Secondly, after the pain relief 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 qualification and experience in dealing with cancer patients. There is a need for close negotiation between T/CM practitioners and medical practitioners on the treatment of 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.

41

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 9th Malaysia Plan were identified and ranked. (Appendix 3). Overall, the purpose of the cancer research framework for the 9MP is to improve understanding of the disease, evaluate program and 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 initiation. It cannot be overemphasized 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 and prevalence of cancer in the country. Cancer research and clinical trials will facilitate the development of better screening tools, new therapies and vaccines. 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 enabling environment for research instituted.. To develop active, indepth, innovative and high impact research on cancer which are at par with that of developed nations, the following strategies are proposed : 1. Set aside a National Cancer Research Grant to supplement current research funding

42

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 targeted therapy. 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

43

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 of confidential information while allowing for anonymization for research purposes. 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. Monitoring and evaluation must be put in place to determine whether the Action Plan is achieving its overall purposes, that the 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 potential responsibilities for various aspects of cancer control include agencies of 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 and updates on global cancer situation and control measures must be established. Besides 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 about RM 2.046 billion is 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 research 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 and consumables (10.3 per cent), and human capital development (10.23 per cent). Under human capital development, 2,189 new 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 programme, 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 in equipment cost can also be expected if equipment required for the various cancer 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 Structure

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 prominent. Unless positive steps are taken, Malaysia may have to face an enormous cancer burden in the near future. It is hoped that with adequate support of resources and commitment by all stakeholders, the timely 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 cancer. People with cancer will 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.

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REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. The New Zealand Cancer Control Strategy: Action Plan 2005 2010. Cancer Control Taskforce, 2005. Texas Cancer Plan 2005. Annual Report 2004, Ministry of Health, Malaysia. World Cancer Report, 2003. International Agency for Research on Cancer, World Health Organization. World Health Report, 2003 shaping the future. World Health Organization. Key Statistics 2003. Jabatan Statistik Malaysia.(http://www.statistics.gov.my ) Zarihah MZ, Mohd Yusoff H, Devaraj T, et al. Penang Cancer Registry Report 1994-1998. Penang: Penang Cancer Registry, 2003. Narimah A, Rugayah B, Tahir A, et al. Cervical Cancer Screening. Paps 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 9. GCC Lim, Y Halimah (Eds). Second Report of the National Cancer Registry. Cancer Incidence in Malaysia 2003. National Cancer Registry. Kuala Lumpur 2004. 10. 11. 12. 13. 14. 15. 16. 17. National Cancer Control Programmes. Policies and Managerial Guidelines. World Health Organization. 2002 Malaysias Health 2002. Ministry of Health, Malaysia. Health Facts 2005. Planning & Development Division, MOH. Manual on the Prevention and Control of Common Cancers. World Health Organization 1998. National Health Morbidity Survey 1996. Ministry of Health, Malaysia. National Cancer Control Programme. Policies and Managerial Guidelines. World Health Organization. 1995 Malaysia NCD Surveillance 2005/2006: NCD Risk Factors in Malaysia. Disease Control Division, MOH, 2007 National Cancer Prevention Policy 2004-2006, The Cancer Council Australian.

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18. 19. 20. 21. 22.

Cancer Awareness, Prevention and Control: Strategies for South East Asia, UICC 2006 An American Cancer Society Report, The Worldwide Cancer Burden, 2006 Boyle P, Maisonneuve P. 1995, Lung cancer and tobacco smoking, Lung Cancer, 12:167-181 Lee IM. 2003. Physical activity and Cancer prevention-data from epidemiologic studies. Med Sci Sports Exerc 35(11) Cancer Control Opportunities in low- and middle-income countries. Committee on Cancer Control in Low- and Middle-Income Countries, Frank A. Sloan and Hellen Gelband, Editors, 2004 National Academy of Sciences.

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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 and knowledge of the general public on the risk factors of the common 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 awareness on selected cancers and their risk factors, the early warning signs and ensuring accessibility to 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 AND EARLY 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 at MOH clinics screened for Nasopharyngeal cancer 7. Prostate Cancer 100 % of high risk population identified at MOH 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 Cancer a. 15% 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 of stage 1 disease (male) from 15.8% to 25% (13.5% in Penang Cancer Registry 1994-1998, 15.8% in Penang Cancer Registry 1999-2003)

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III

STRATEGIC ACTION PLANS SCREENING & EARLY DETECTION Below are the screening modalities and target groups for the selected cancers Selected cancers Breast Cancer Cervical Cancer Oral Cancer Screening modalities (accepted/proposed) Mammogram Clinical Breast Examination (CBE) Pap smear Visual examination Targeted population (proposed) Women 50 to 69 years Women 35 to 49 years - Women 20 to 65 years old with sexual history High risk population - Age more 20 years - Indians - Indigenous population - Specific behaviour 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 High risk group: - Men > 50 years - Family history High risk : - Chinese - Age > 40 years - Family history

Hepatocellular Carcinoma

Serum Alpha- feto protein Transabdominal ultrasound

Colorectal cancer Prostate Cancer

Fecal occult blood

Prostate Specific Antigen (PSA) Epstein-Barr Virus (EBV) Serological Markers

Nasopharyngeal Cancer

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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 - Strengthen screening programme for high risk patients for Hepatocellular Carcinoma (HCC) in major hospitals 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 Human resource development - 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 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 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

2.

3.

4.

5.

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 Development or update of protocols/guidelines/standards/targets - Develop or update the documents on selected cancers through establishment of technical working groups and consultancy from experts on specific cancers 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) Research and development - Evaluate the screening modalities through Health Technology Assessment on test accuracy (sensitivity and specificity), safety, cost effectiveness, acceptability for PSA, Fecal 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

7.

8.

9.

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

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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 Health Promotion - Continuous public education and awareness campaign on screening programmes to ensure optimal programme coverage. - Review and strengthen the approach and mechanisms of information dissemination on screening programmes 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 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 of screening facilities and laboratory services for other selected cancers Outsourcing of services to other agencies - Continue and review outsourcing services including identify other possible areas for outsourcing Quality assurance programme - Continue quality assurance programme in screening procedures, laboratory and radiology Development or update of protocols/guidelines/standards/targets - Continue develop or review or update the relevant documents on selected cancers Strengthening of surveillance and evaluation system - Evaluate and strengthen the existing monitoring mechanism

2.

3.

4.

5.

6.

7.

8.

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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 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

10.

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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

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4. To continually upgrade diagnostic facilities in existence and those newly established according to state-of-art technology and evidence-based practice 5. To progressively equip all radiology 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. To provide services that will support cancer research and development in order to improve cancer diagnosis and treatment III STRATEGIC ACTION PLANS - DIAGNOSIS 20068 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 in all national, regional and state hospitals to provide total support for cancer patients including a full range of tumour markers, utilization 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

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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 flow of information between the two 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 in all district hospitals with radiologists to include general radiography, fluoroscopy, 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

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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 20068 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 Radiation Protection Committees in all Radiotherapy Centers and implementing all radiation protection policies immediately 2011 2015 1. Set up new Radiotherapy cancer treatment centers at Eastern Region Kuantan Hospital Northern Zone Penang Hospital 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

2.

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. 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)

2.

II

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 and strengthen after care service and human resource training to cancer survivors and their family of those who need cancer rehabilitation

III

STRATEGIC ACTION PLANS REHABILITATION 20068-2010 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 communication through a system of networking with support group in the 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 service centers

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NATIONAL CANCER MANAGEMENT BLUEPRINT 10 - YEAR MASTER PLAN GOAL 6: PALLIATIVE CARE I OBJECTIVES 1. To relieve pain and suffering of cancer patients

2. To improve the quality of life of these patients by attending to their physical, psychosocial and 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 2008-2010 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. 4. 5. To integrate palliative care in nurse training programs To develop cancer pain management Clinical Practice Guideline (CPG) 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

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5. III

To develop a local training programme : Master of Palliative Medicine

STRATEGIC ACTION PLANS PALLIATIVE CARE 2008 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

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. 9. 10. To integrate palliative care in nurse training programs To develop cancer pain management Clinical Practice Guideline (CPG) 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

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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 Guanganmen 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 Cancer Institute - Sultan Ismail Hospital, Johor Bahru - 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 - meditation - yoga b. Benchmark the current T/CM services in Cancer Management 3. 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 services through road shows, publishing or promoting guidelines as well 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 Oncology a. Kuala 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

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APPENDIX 2

1st National Conference on Cancer Research Coordination, April 2004

EXECUTIVE SUMMARY
The main agenda of the conference was to help formulate effective strategies for future cancer research in the country, identify priority needs and new frontiers in cancer research, 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 for cancer prevention and/or early 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. national surveillance function for cancer monitoring 5. 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
The 1st 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

Cancers

P u rp o se
Perceptions and behaviour Needs for health care & support

Improve Understanding

Improve Effectiveness

Develop new modalities

Clinical management

Diagnosis, treatment

Disease pattern, risk factors, economic burden Determinants of treatment outcomes

Health care & supportive services Information, health promotion & empowerment

Source : National Conference on Research Priorities in the Health Sector for 9MP, July 2006

81

CANCER: RESEARCH PRIORITIES

Purpose Scope of research Suggested focus of Research Topic(s)
A 1.1 Studies on measures and strategies to empower cancer patients and survivors A 1. Empowerment and perceptions for self care A 1.2 Elucidate patients and families' perception of self-care in order to recommend strategies to promote self care 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 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 1

Relative rank

A. Understand perceptions, behaviour, & empowerment & evaluate promotion activities

A 2. Impact of health promotion activities (Healthy Life Style)

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

B 1. Evaluate prevention programmes

B 1.1 Evaluate the cost effectiveness of prevention programmes such as FCTC implementation, National Tobacco Control Programme, National Hepatitis B vaccination programme, etc. B 1.2 Evaluate the effectiveness of vaccination and chemo-prevention for specific cancers

B. Evaluate Public Health Programmes B 2. Evaluate screening programmes

B 2.1 Evaluate impact of screening programmes on specific cancer incidence, morbidity, mortality and survival rate

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

Purpose

Scope of research

Suggested focus of Research Topic(s)

C 1.1 Evaluation of cost effectiveness of molecular detection in cancer diagnosis

Relative rank

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 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 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 chemotherapy in 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 5.1 Evaluate the effectiveness of use of Guidelines in the management of cancer pain 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 D 2.1 Development of clinically relevant molecular classifications of selected cancers 7 1

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

C 5. Effectiveness of current protocols (cont.) D. New Modalities diagnosis & treatment D 1. To discover new biomarkers for diagnosis and monitoring of cancers (from research to development for commercialization) D 2. Profiling of cancers using new technologies for better classification

83

Purpose

Scope of research
and prognostication of cancers

Suggested focus of Research Topic(s)

Relative rank

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 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 4.1 Priority items for study would include (a) Pharmaceutical products, (b) Immunotherapy. (c) Targeted therapy, (d) Cell based therapies (e)Others 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 7.1 Investigate and analyse conditions for optimization of biospecimen collection, processing and archiving 6

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 7. Research on biospecimens and biobanking

84

Purpose

Scope of research

Suggested focus of Research Topic(s)

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 E 2.1 Determine life expectancies of cancer patients compared with normal population

Relative rank

E 1. Studies to identify important risk factors in Malaysia

E. Understand disease pattern, risk factors and determinants

E 2. Studies on health status and needs and factors contributing to short and long term survival of cancer patients

E 2.2 Identify prognostic factors for survival of cancer patients E 2.3 Quality of life of patients with specific cancers (e.g. breast, cervix, lung etc) E 2.4 Functional impairments in cancer patients and survivors E 2.5 Assessment of rehabilitative needs and unmet needs of persons with cancer 3

E 3. Correlation of clinical outcomes of specific cancers with genomics and epidemiology

E 3.1 Emphasis on: (a) Breast cancer, (b) Cervix, (c) Adult Leukaemia & Lymphoma, (d) Paediatric cancers, (e) Liver cancers, (f) nasopharyngeal carcinoma

85

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities 1. Create posts for support staff AMRO N17 (2 per 8 new State Cancer Registries - total 16 post), Clerk N17 (1 post for NCR) AMRO N17 ( 2 post for NCR) This is to strengthen and maintain Cancer Registry at MOH and at state level

GOAL 1 : PREVENTION
Cost TimeFrame 2008-2010 Agency/Person Remarks

0.76M

MOH/ HRD

18 AMRO (N17) 1 Clerk (N17) RM753,289.2 (Emolument)

2.

Facilities

1. District Cancer Resource Center

RM 1.0 M

2008-2015

MOH (Public Health Programme /HECC

86

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. 3. Elements Equipment Activities -

GOAL 1 : PREVENTION
Cost TimeFrame Agency/Person Remarks

4.

Drugs (Vaccine)

1. National Human Papilloma Virus (HPV) immunization programme for cervical cancer prevention

RM 319.0 M

2008-2010

MOH

In accordance with the policy developed Price of the vaccine is subject to price reduction strategy by the drug company.

87

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. 5. Elements Health Education Activities Intensive media campaign for selected cancer identified in the National Cancer Management (other than Tak Nak & Healthy Life Styles) 1.Develop health education materials 2. Divide workload among media 3. Organize continuous media coverage 4. development of cancer portal (MyHealth Portal) 6. Outsourcing & Consumables . 7. Research & Development -

GOAL 1 : PREVENTION
Cost RM 10.0 M TimeFrame 2008-2010 Agency/Person Public Health Programme / Oral Health Division Remarks Allocation already existing : RM 10 mil for Tak Nak campaign RM 10 mil for Healthy Life Style Campaign

1. 1.. Study related to cancer

prevention and behavioural modification 2. 3. 2. Establish a central body to collect, collate and review all scientific papers on cancer research.

RM 1.0 M

2008-2015

To be determined

88

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. Elements 4. 3. Activities Establish database 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 cancer survival statistic. 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). Establish on-line cancer reporting through MOHs Health Information Centre

GOAL 1 : PREVENTION
Cost TimeFrame Agency/Person Remarks

5. 8. Information Communication Technology and Networks 1. RM 0.3 M 2008-2015 MOH / Pubic Health Department Budget needed for data management and report printing

Operating Budget

2008-2015

MOH

89

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 1 : PREVENTION
Cost TimeFrame Agency/Person Remarks

9.

NGOs / Corporations

1. Strengthen networking with

related agencies at all levels.

RM 0.1 M

2008-2015

10.

Institutions / Organization

1. Establish and maintain Cancer Registry Unit at all State Health Departments 2. Establish and maintain National Cancer Registry Unit at MOH

(Emolument under human resource) (Emolument under human resource)

2006-2015

Public Health Programme Public Health Programme

2006-2015

11.

Standards / Guidelines / Codes of Practice

Guideline on the implementation of prevention activities.

0.1 M

90

APPENDIX 4

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 1 : PREVENTION
Cost TimeFrame Agency/Person Remarks

12. 13.

Quality Assurance Legislation 1.

Establish consultative mechanism to improve compliance by relevant authorised bodies to the existing standards provided by existing law and regulations To develop regulation for mandatory cancer reporting through the existing legislations (included in element no 5 2008-2015 Public Health Programme

2.

(existing operational budget) - (0.05 M)

2008-2010

MOH (Public Health Programme)

TOTAL: PREVENTION

RM 332.26 M

91

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities

GOAL 2 : SCREENING AND EARLY DETECTION

Cost RM 1.08 M Time-Frame 2008-2010 Agency/Person ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Oral Health ) Division / ) Research & ) Technical ) Support ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Oral Health Division/ Medical Division ) ) ) ) ) Public Health Medical Development Division / Planning & Remarks

1.Training of supporting staffCytotechnicians, radiographers, sonographers, nurses, MAs, others

2.Establish posts and employ the following personnel: Cytotechnicians (240), Radiographers (62), Sonographers (21), Nurses(62), Clerks (4)

RM 19.21 M (Emolument)

2008-2010

2.

Facilities

1. Set up infrastructure for

2 breast screening centers (RM 2 million per center) 12 cytology laboratories (RM 2.5 million)

RM 6.5 M

2008-2010

92

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 2 : SCREENING AND EARLY DETECTION

Cost Time-Frame ) ) ) ) Agency/Person Development Division / Engineering Division Remarks

3.

Equipment

1. Radiology equipment (mammogram, ultrasound, mammotome equivalent, viewers, computers etc) for breast cancer screening centers 2. Related equipment/facilities for call-recall activities in population based breast cancer screening programme (software, computer, office equipment, training,) for 2 centers 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 22.6 M

2008-2010

2008-2010 RM 1 M

) ) Public Health, ) Medical ) Division / ) Engineering ) Division/ Oral Health Division ) ) )

RM 7.2 M

93

ACTION PLANS: ACTIVITIES

No. Elements Activities 4. Pap smear taking facilities at primary care centers and outreach services 5. Ultrasound machine in major hospitals RM500,000 /machine 4. 5. Drugs Health Education Not applicable Develop health education materials / teaching aids

GOAL 2 : SCREENING AND EARLY DETECTION

Cost RM 6 M Time-Frame Agency/Person Remarks

RM 10.5 M

RM 2 M

Not applicable Public Health Dept / Oral Health Division / Medical Division 2008 - 2010 Public Health Dept / Oral Health Division / Medical Division

6.

Outsourcing & Consumables

1. Consumables for cytology laboratories (RM200,000/center/year) 2. Breast and cervical cancer screening activities (including mailing services for call-recall activities (RM500,000/center/year) 3. Outsourcing radiological services 4. Alpha-feto protein (AFP) testing

RM 7.2 M

RM 3 M

RM 1 M RM 0.14 M

94

ACTION PLANS: ACTIVITIES

No. Elements Activities 5. Epstein Barr Virus serological markers 6. Prostate Specific Antigen Test 7. Consumables such as examination glove, disposable mouth mirror, disposable tray, disposable twizer, paper towel, gauze etc 7. Research & Development 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

GOAL 2 : SCREENING AND EARLY DETECTION

Cost RM 0.12 M RM 0.13 M RM 1 M Time-Frame Agency/Person Remarks

RM 1 M

2008 - 2010

Public Health Dept/ Oral Health Division

8.

Information Communication Technology and Networks

95

ACTION PLANS: ACTIVITIES

No. 9. 10. 11. Elements NGOs / Corporations Institutions / Organizations Standards / Guidelines / Codes of Practice Quality Assurance Activities

GOAL 2 : SCREENING AND EARLY DETECTION

Cost Time-Frame Agency/Person Remarks

Circulate Standards/Guideline (To develop / update the consensus on the screening of selected cancers) External QA in cytology & radiology Preparation of accreditation by Department of Standards Malaysia (RM40,000 x 12 cyto-laboratories)

RM 0.6 M

2008 - 2010

Public Health Dept / Oral Health Division / Medical Division Public Health )Dept /Oral Health Division/ Medical Division

12.

RM 0.04 M RM 0.48 M

2008 - 2010

13.

Legislation

TOTAL: SCREENING AND EARLY DETECTION

RM 90.8 M

96

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities A. PATHOLOGY SERVICES 1. Training of subspecialty pathologists in fields of soft tissue, bone, respiratory, ocular, lymphoproliferative & urological cancers, cytogenetics & molecular pathology

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

RM 0.7 M

20086 - 2010

MOH/ HRD/PSD

RM100,000 / person

2. Overseas training of subspecialty

in HLA typing in Sg Buloh Hosp for 1 Pathologist, 1 Scientific Officer, 2 MLT 3. Training in adult haematooncology to support the centre of excellence in Ampang Hospital 4. Training in stem cell and cord blood transplantation to support paediatric haemato-oncology 5. Short courses training oversea/seminar in various subspecialty for i. Anatomical pathologist -1 candidate per year

RM 0.75 M

20087

MOH/HRD/PSD

RM 250,000/person RM 50,000/MLT RM100,000 / person RM100,000 / person RM 40,000 / person

RM 0.5 M

20086-2010

MOH/HRD/PSD

RM 0.2 M

20086-2010

MOH/HRD/PSD

RM 0.24 M

20068-2010

MOH/HRD/PSD

97

ACTION PLANS: ACTIVITIES

No. Elements Activities ii. MLT-1 candidate per year 6. Short training for leukemia/ lymphoma immunophenotyping x6

GOAL 3 : DIAGNOSIS
Cost RM 0.12 M RM 1 M Time-Frame 20086 2010 20086-2010 MOH/HRD/PSD RM100,000 / person RM100,000 /person RM100,000 /person In line with current training projections Agency/Person Remarks

7. Training of cytogenetic scientists

(Master in Cytogenetics Australia), X 10

8. To engage short term consultancies

in expression array and bioinformatics-2 persons (US)

RM 0.2 M

20086-2010

MOH/HRD/PSD

9.

Training in Bioinformatics (2 Scientists/Researchers)

RM 0.2 M RM 0.525 M

20086-2010 200862010

MOH/HRD/PSD MOH/HRD/PSD

10. To train diagnostic pathologists (Master of Pathology): histopathologists (20), haematologists (5), chemical pathologists (5), medical microbiologists (5)
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

RM 20,000/year for 11a-11c

98

ACTION PLANS: ACTIVITIES

No. Elements Activities 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: a)2 Anatomical Pathologists from each center b) 1 MLT from AP lab of each hospital 14. Overseas conferences of various subspecialty or related conferences/ workshops/ seminars/courses at least 5 candidates per year 15.

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

RM 0.1509 M

20086-2010

RM 30,000/year

RM 10.6 M

20086-2010

RM 0.475 M

M 17.296 M

2006-2010

MOH/HRD/PSD

HRD to employ

99

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

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
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 0.57 M

20086-2010

MOH/HRD/PSD

RM 100,000 / person 7 subspecialty radiologist each phase

RM 0.61 M RM 0.61 M RM 01.2 M RM 0.46 M

20086-2010

MOH/HRD/PSD

RM 40,000 per person

2. To train diagnostic radiologists:

(Master of Radiology): 40 Master

20086-2010

100

ACTION PLANS: ACTIVITIES

No. Elements students Activities

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person MOH/HRD/PSD Remarks In line with current training projections

3.

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 Oversea conferences of various subspecialty or related conferences/ workshops/ seminars/courses at least 10 candidates per year Post basic courses for radiographers-CT, MRI, Angio, MMG Post basic courses for radiology nurse (probably to start in phase 2)

RM 12.5 M

RM 35 M

4.

RM 0.35 M

5.

RM 0.35 M

6.

RM 76.855 M

20086-2010

101

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost (Emolument) Time-Frame Agency/Person MOH/HRD/PSD Remarks HRD to employ

7.

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

ACTION PLANS: ACTIVITIES

No. Elements Activities 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. C. NUCLEAR MEDICINE

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

20086-2010 1. Training of Personnel a. Clinical Nuclear Medicine Specialists (25 trainees) RM 1.075 M MOH/HRD/PSD

4 local trainees/yr (RM25,000 /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)

RM 4.52.7 M b. Nuclear Medicine Technologists (30 trainees) 20081120105 MOH/HRD/PSD

RM 31.8 M c. Medical Physicists (Nuclear

103

ACTION PLANS: ACTIVITIES

No. Elements Activities Medicine) (10 trainees) d. Nuclear Medicine Nurses (25 trainees)

GOAL 3 : DIAGNOSIS
Cost RM 0.1225 M 2008-2010 RM 3 1.8 M Time-Frame 20086202510 Agency/Person MOH/HRD/PSD Remarks 4 locals/yr (RM10,000 /person) 3 locals/yr (RM20,000 /person) 1 overseas/year (RM100,000 /person) 2 local/ year (RM 10,000/person) MOHE/MOH/PSD/ HRD RM 0.36 M 2008-2010 2006-2010 RM 0.6 1 M MOHE/MOH/PSD/ HRD MOH, ALL NM Centers 1 per year from 2007 (RM 100,000 per person) 1 overseas/year (RM 100,000/person)

e. Nuclear Medicine Physicists (15 trainees) 2008-2010 2006-2010 RM 0.53 M f. Scientist: Nuclear Medicine Biochemist (5 trainees) MOHE/MOH/PSD/ HRD

g. Pharmacist: Nuclear Medicine (10 trainees)

2. CME and CPD activities for attending conferences, seminars and attachments

2008-2010 RM 0.24 M 2006-2010

104

ACTION PLANS: ACTIVITIES

No. Elements Activities 23. Recruit 3 new expatriates in Nuclear Medicine

GOAL 3 : DIAGNOSIS
Cost Time-Frame 2008-2010 2006-2010 2008-2010 2006-2010 Agency/Person MOH/PSD/HRD Remarks

2.

Facilities

A. PATHOLOGY SERVICES 1. Reorganisation of 12 histo/cytopathology centers - Infrastructural facilities (lab renovations) - Establish Laboratory Information System (LIS) 2. Upgrade of existing pathology facilities (14 centers) Upgrade/establish LIS 3. Molecular profiling and cancer 20058-2010 RM 1.2 M RM 2.4 M RM 2 M MOH - Finance RM100,000 /center x 12 RM200,00 /center x 12 RM100,000 /center/yr RM500,000

RM 0.5M

105

ACTION PLANS: ACTIVITIES

No. Elements Activities genetics infrastructure in one centers (IMR) 4. Biobanking infrastructure (1 center) 5. Establishing stem cell laboratory in Penang (2008)and KK (2010) 6. Establishing cancer cytogenetics laboratory in Penang(2008) and KK (2010) B. RADIOLOGY SERVICES 1. Radiology information systems in 4 centers 2. Establishing RIS and PACS in NCI (see NCI project proposal) 3. Upgrading of existing RIS and PACS in HPJ to support and communicate with RIS / PACS in NCI

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks /center RM500,000 /center

RM 0.5 M RM 1 M RM 1 M

RM 1.2 M

20086-2010

MOH- Finance /Planning & Development MOH- Finance /Planning & Development MOH- Finance /Planning & Development

RM 300,000 / system x 4

RM 10 M

20086-2010

RM 4 M

20086-2010

106

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost RM 10 M Time-Frame 20068-2010 Agency/Person MOH- Finance /Planning & Development Remarks

4. Radiology department renovations

and new sites (infrastructural facilities) in various hospitals for conversion to CR system, upgrading and installation of new equipment

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) Nuclear Medicine Department in Sabah (Likas) ( Nuclear Medicine Department with Hot Lab for conventional NM and radioiodine preparation. Radioiodine wards with 12 rooms) ) RM 7 M 2008-2010 2006-2010 MOH Finance /Planning & Development

RM 7 M 2008-2010 2006-2010

107

ACTION PLANS: ACTIVITIES

No. Elements Activities 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) 2. Replacement and upgrading of the facilities and equipment at

GOAL 3 : DIAGNOSIS
Cost RM 14 M Time-Frame 2008-2010 2006-2010 Agency/Person MOH Finance /Planning & Development Remarks

Penang Hospital
In Vivo laboratory with equipment (RM 2 M) Radioiodine ward with 14 rooms (RM 6 M)

RM 8 M 2008-2010 2006-2010

MOH Finance /Planning & Development

Kuala Lumpur Hospital

In Vivo laboratory with equipment (RM 2 M)

RM 2 M

MOH- Finance/ Planning /Development 2008-2010

Sarawak General Hospital

RM 8 M

MOH Finance /Planning & Development

108

ACTION PLANS: ACTIVITIES

No. Elements Activities In Vivo laboratory with equipment (RM 2 M) Radioiodine ward with 14 rooms (RM 6 M)

GOAL 3 : DIAGNOSIS
Cost Time-Frame 2008-2010 2006-2010 Agency/Person Remarks

3.

Equipment

A. PATHOLOGY SERVICES 1. Reorganization of 12 histo/cytopathology centers: Immunohistochemistry autostainers 2. HLA typing laboratory equipment - PCR & serology 3. 4. 5. Molecular profiling (1 center) Biobanking equipment (1 center) Directed Cord Blood Bank Equipment for paediatric haemato-oncology RM 2.2 M 2008-2010 2006-2010 MOH-Finance RM 18,000/ autoimmuniserstainer x 12

RM 1.2 M 20087 RM 4 M RM 1.5 M RM 1 M 20068-2010 20068-2010 20068-2010

MOH - Finance RM4,000,000 / center RM1,500,000 /center

109

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost RM 0.5 M RM 4 M RM 5 M RM 1 M RM 2,000,000 each x 7 hosp RM 3,000,000 each x 7 hosp RM 2,000,000 each x 4 hosp RM 250,000 each x7 RM 750,000 each x5 20086-2010 RM 18 M 20086-2010 RM 8 M 2006-2010 RM 1.75 M 20086-2010 Time-Frame 20086-2010 Agency/Person Remarks

6. Upgrading of existing stem cell

transplant laboratory

7. Stem cell laboratory in Penang

(2008)and Kota Kinabalu (2010) 8. Cancer cytogenetics laboratory in Penang (2008)and KK (2010)

9. Upgrading Haematology
laboratory with flow cytometry in Kuching (2008)and Malacca (2010) B. RADIOLOGY SERVICES Expansion and upgrading of Radiology services: Phase 1 a) 4 slice CT Scan x 7 hosp b) 16 slice CT Scan x 6 hosp c) Digital Mammography x 4 hosp. d) Ultrasound x 7 hospitals ed) Fluoroscopy (nil. Recent c-arm already acquired for few hosp)

RM 14 M

110

ACTION PLANS: ACTIVITIES

No. Elements 5 plain x-ray Activities

GOAL 3 : DIAGNOSIS
Cost RM 3.75 M Time-Frame 20086-2010 Agency/Person Remarks

MRI (2 states) Angiography (4 regional centers) CR System e) Dry laser printer (Note this is excluding Likas Hospital as it 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

RM 10 M RM 16 M

RM 9 M RM 38 M

2008-2010 2006-2010 2008-2010

111

ACTION PLANS: ACTIVITIES

No. 4. Drugs Elements Activities Non ionic contrast media Iso-osmolar contrast media MRI contrast media Thrombolytic drug RM 13 M/yr

GOAL 3 : DIAGNOSIS
Cost RM 65 M Time-Frame 20068-2010 Agency/Person MOH /Hospital Division Remarks State hospital RM0.5 M HKL, regional and tertiary hospital RM1M

5.

Health Education

6.

Outsourcing & Consumables

A. PATHOLOGY SERVICES 1. Tumour marker reagents 2. Antibody markers and detection kit for IHC

RM 4.2 M7 M RM 1.31.5 M

2008-2010 2008-2010

RM100,000/ center/yr RM 200,000/ center/yr x 11 centers RM200,000/ year for referral center (Lembah Kelang)

RM100,000 /center/yr

3. Flowcytometry reagents
(leukaemia immunophenotyping ) x 6 centers (RM 2M / yr) 4. Leukaemia/lymphoma markers studies for Ampang Hospital 5. HLA Typing reagent PCR & Serology 6. Molecular profiling reagents

RM 610 M RM 3.52.1 M RM 10.6 M

2008-2010 2008-2010 2008-2010

RM9,000 /patient x 1500

RM6,000 /100 patient

112

ACTION PLANS: ACTIVITIES

No. Elements Activities Breast tumor profiling, reagents & consumables Two cycle cDNA synthesis kit Oligonucleotide array Real time PCR validation Array CGH 7. 8. Directed Cord Blood Bank RM 0.3 M/yr Stem cell transplantation RM 0.4 M / yr (2008)and Kota Kinabalu (2010)

GOAL 3 : DIAGNOSIS
Cost RM 47.5 M RM 13.58.1 M RM 0.0954 M RM 0.549M RM 1.50.9 M RM 1.2 M RM 6 M RM 4 M RM 0.2 M/yr RM 0.6 M Time-Frame 2008-2010 Agency/Person Remarks RM3000 /patient x 300

9. Stem cell laboratory in Penang 10. Cancer cytogenetics

laboratory in Penang (2008)and KK (2010) 11. Flow immunophenotyping in Kuching and Penang - (2008-2010) B. RADIOLOGY SERVICES Need additional 50% of current

Current operating expenditure: Film cost: RM 500,000.00 for all GH & RM

113

ACTION PLANS: ACTIVITIES

No. Elements Activities consumables budget to support cancer management 1. Films 2. Processing chemicals

GOAL 3 : DIAGNOSIS
Cost RM 230 M Time-Frame Agency/Person Remarks 800,000.00 for regional and referral centers Angio/interventio nal consumables: RM 1 M for HKL, Selayang, JB, Kuching, Sg Buloh. Other GH RM 300,000.00 each. RM 50,000 for each new service.

RM 22.514 M

3.

Angiography and interventional disposable interventional items

a)

increment of 20% annual budget for upgrading of existing services in respective hosp. 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.

b)

7.

Research & Development

A. PATHOLOGY SERVICES 1. Studies related to molecular defects of paediatric leukemia / lymphoma . RM 0.2 M 2008-2010

114

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

20086-2010 B. RADIOLOGY SERVICES RM 5 M 1. Conduct pilot project for population based, breast screening 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. Baseline T-Z score for Malaysian women 4. BOLD (functional ) imaging in functional brain surgery

115

ACTION PLANS: ACTIVITIES

No. 8. Elements Information Communication Technology and Networks Activities 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) 4. Integration of PACS by region / 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 C. NUCLEAR MEDICINE Connectivity of PET-CT between Putrajaya Hospital, Sultan Ismail (Pandan) Hospital and Penang Hospital

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

20068-2010 20086-2010 2011-2015 2011-2025 20086-2010

RM 0.02 M

RM 2.1 M

20086-2007

MOH-FINANCE /DEVELOPMENT

Connectivity software and hardware

116

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks RM 700,000 for the 3 centersres

9.

NGOs / Corporation

To work with breast screen center

10.

Institutions / Organizations

To work with College of Radiology/Academy of Medicine

11.

Standards / Guidelines / Codes of Practice

A. PATHOLOGY SERVICES 1. Establish cancer profiling and biobanking guidelines RM250,000 per guideline 2. Performa of Histopathology diagnosis B. RADIOLOGY SERVICES 1. Review / update Breast Cancer Screening guidelines (probably after completion of breast (RM 0.1M) 2011-2015 RM 0.5 M 20086 - 2025 MOH / Academy of Medicine Malaysia

RM 0.05 M

117

ACTION PLANS: ACTIVITIES

No. Elements Activities screening pilot project) 2. Reporting format on mammogram and other radiology examination or procedures 3. Risk Management in Radiology -Protocols / Guideline on radiological examination and procedures

GOAL 3 : DIAGNOSIS
Cost RM 0.1 M Time-Frame 20086-2010 Agency/Person Remarks

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. 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 RM 0.01 M 20086-2010

PUU, Training Division, College of Radiology, AMM, Engineering Division (MOH) PUU, Training Division, College of Radiology, AMM, Engineering Division (MOH)

RM 0.02 M

20086-2010

118

ACTION PLANS: ACTIVITIES

No. Elements Activities in Medical Use of Radiation in Radiology, Radiotherapy, Nuclear Medicine, Dentistry and Veterinary services and its enforcement.

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

12.

Quality Assurance

A. PATHOLOGY SERVICE 1. External QA activities in Anatomical Pathology 2. External QAP for leukemia / lymphoma immunophenotyping x 6 RM 24,000/year

RM 1.08 M RM 0.12072 M

2008-2010

RM 15,000 per center /year for 12 centers

3. External QAP for molecular tests

for haematology for 1 center RM 5,000/year B. RADIOLOGY SERVICES

RM 0.015 M

QA activities and programmes in

Radiology Risk management / Audit / NIA C. NUCLEAR MEDICINE

RM 0.25 M

2008-2010

20068-2010

All Nuclear Medicine Centers,

119

ACTION PLANS: ACTIVITIES

No. Elements

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Medical Development / Engineering Division (MOH)
All Nuclear Medicine Centers, Medical Development / Engineering Division MOH) / PUU, College of Radiology

1.

Activities Identify National Indicator for Nuclear Medicine Treatment Centers

Remarks Establish and adapt National Indicator

2. Implement QAP in MOH Cancer

Radiation Protection Committees Committees in all hospitals with Nuclear Medicine Facilities RM 0.1 M

20068-2010 20068-2010

RM 20,000/year

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

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 3 : DIAGNOSIS
Cost Time-Frame Agency/Person Remarks

TOTAL: DIAGNOSIS

RM 516.635460.071 M

121

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities 1. Training of basic personnel a. Clinical Oncologists (25 trainees)

GOAL 4 : TREATMENT
Cost RM 1.8 M Time-Frame 2008-2010 Agency/Person MOHE/MOH/PSD/ HRD Remarks 4 local trainees/yr (RM25,000/ person) 1 overseas/yr (RM500,000/ person) 3 overseas/yr (RM300,000/ person) 2 overseas/yr (RM300,000/ person) 3 overseas/yr (RM300,000/ person) 2 locals/yr (RM10,000/ person) 20 locals/yr (RM10,000/ person)

b. Haematologists (15 trainees) c. Paediatric Oncologists (10 trainees) d. Cancer Surgeons (15 trainees) e. Medical Physicists (10 trainees) f. Therapy Radiographers (100 trainees)

RM 2.7 M

2008-2010

MOHE/MOH/PSD/ HRD

RM 1.8 M

2008-2010

RM 2.7 M

2008-2010

RM 0.06 M

2008-2010

RM 0.6 M

2008-2010

122

ACTION PLANS: ACTIVITIES

No. Elements Activities g. Oncology Nurses h. Hematology Nurses

GOAL 4 : TREATMENT
Cost RM 0.06 M RM 0.2 M Time-Frame 2008-2010 2008-2010 Agency/Person Remarks (RM10,000/ person) x 2 2 overseas/year (RM30,000/ person) 1 overseas/year (RM100,000/ person) 4 overseas (2009/ 2010) at RM30,000/ person = RM120,000 4 local ( 2009/ 2010) RM2,000/person = RM8,000 12 local (2009/2010) RM 1,400/person = 16, 800

i.

Scientists

RM 0.3 M

2008-2010

j . Pharmacists (Oncology)

RM 0.384 M

2008-2010

k. Pharmacy Assistant (CDR)

RM 0.0504 M

2008-2010

123

ACTION PLANS: ACTIVITIES

No. Elements Activities l. Laboratory Technicians (MLT) 2. Training of subspecialty Clinical Oncologists: Paediatric Radiation Oncology Brachytherapy Stereotactic Radiosurgery 3. Recruit 3 new expatriates in Oncology

GOAL 4 : TREATMENT
Cost RM 0.2 M RM 0.18 M 2008 2009 2010 RM 1.5 M RM 1 M 2008-2010 2008-2010 RM60,000 per person Time-Frame 2008-2010 Agency/Person Remarks 2 per year (RM30k per person)

RM500,000 per year RM300,000/year

4. CME and CPD activities for attending conferences, seminars and attachments 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

(Emolument)

124

ACTION PLANS: ACTIVITIES

No. 2. Elements Facilities Activities Paediatric Oncology Set up new services in Kuantan Haematology Upgrading of centers at: JB , Klang, Ipoh, KK Upgrading of new centers at: Melaka, Kuantan, Kuching Cytotoxic Drug Reconstitution (DCR) Sterile Preparation Rooms Paediatric Oncology Build new facility at HTAA Kuantan) (room 1) Haematology Build new facility at : HSA JB* Hospital Ipoh ** Hospital Melaka HTAA Kuantan (room 2)

GOAL 4 : TREATMENT
Cost RM 0.2 M Time-Frame Agency/Person Remarks

RM 1.2 M RM 1.0 M

RM 1.2 M

2010

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

RM 1.2 M RM 1.5 M RM 0.45 M RM 0.45 M RM 0.37 M RM 0.45 M RM 0.1 M

2010

Upgrade existing facility at : HTAR Klang Hospital Queen Elizabeth, KK Hospital Umum Sarawak, Kuching

2008

125

ACTION PLANS: ACTIVITIES

No. 3. Elements Equipment Activities Clinical Oncology 1. New Oncology Centers: National Cancer Institute

GOAL 4 : TREATMENT
Cost Time-Frame Agency/Person Remarks 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 2 LINACs 1 CT sim 2 TPS 1 Oncology Data
and Record Information System

RM 71.4 M

2008-2010

Likas Chemotherapy services from 2006 then add Radiotherapy facilities (2008-2010)

RM 27.1 M

2008-2010

1 HDR CDR Penang Chemotherapy services from 2006 then add Radiotherapy facilities after 2011 (RM 27.1 M) After 2011:
(2 LINACs 1 CT sim,2 TPS 1 Oncology Data and Record Information System 1 HDR, CDR)

126

ACTION PLANS: ACTIVITIES

No. Elements Activities 2. Replacement and upgrading of equipment at Kuala Lumpur Hospital

GOAL 4 : TREATMENT
Cost RM 52.6 M Time-Frame 2008-2010 Agency/Person Remarks 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 Sarawak General Hospital RM 36.35 M 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. Elements Activities Sultan Ismail Hospital JB

GOAL 4 : TREATMENT
Cost RM 14 M Time-Frame 2008-2010 Agency/Person Remarks 1 LINACS 1 CT Simulator 1 CT Scan 2 TPS
1 Oncology Data and Record Information System

1 mobile C-arm 1 HDR Surgical Oncology Upgrading of : Robotic Surgery Laparoscopic Surgery RM 6 M

Paediatric Oncology Stem cell transplant Apharesis machines Photopheresis machines Stem cell/graft engineering RM 10 M (estimated RM10 million asset and renovations in Ampang for both paeds and adults)

128

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 4 : TREATMENT
Cost Time-Frame Agency/Person Remarks

Hematology centers 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 Clinical Oncology Kuala Lumpur Hospital Sarawak General Hospital Johor Bahru Penang Kuantan Kota Kinabalu Ipoh Malacca

RM 3 M RM 1 M

RM 1.2 M

RM 509 M

2008-2010 2008 = RM137M 2009 RM171M

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

2010 -

33M, 51M,63M

129

ACTION PLANS: ACTIVITIES

No. Elements Activities Kota Bharu Kuala Terengganu

GOAL 4 : TREATMENT
Cost Time-Frame RM 201M Agency/Person Remarks
for the first, second and third consecutive years

Hematology 1. Ampang Hospital (National Haematology Referral & Adult Stem Cell Transplant Center) 2. Penang Hospital

RM 39 M

2008-2010

RM10M+RM3M = RM13M/yr RM3+1M = RM4M/yr RM10M/yr for 4 hospitals

RM 12 M RM 30 M

2008-2010 2008-2010

3. Sultanah Aminah Hospital JB Tengku Ampuan Rahimah Hospital Ipoh Hospital Queen Elizabeth Hospital, KK 4. Malacca Hospital Kuantan Hospital Sarawak General Hospital

RM 18 M

2008-2010

RM6M/yr for 3 hospitals

Paediatric Oncology

130

ACTION PLANS: ACTIVITIES

No. Elements Activities 1. Pediatrics Institute, KLH (National Referral centre for Paediatric Hematology-Oncology and Paediatric Stem cell transplant Center). RM 1.5M per year

GOAL 4 : TREATMENT
Cost RM 7.5 M Time-Frame 2008-2010 Agency/Person Remarks RM 1.5M for drugs and RM 1.0 M for consumables RM 2.1 M 2008-2010 RM 1M per year per center (RM 0.7 M for drugs, RM 0.3 M for consumables) = RM3 M per year RM 1.9 M 2008-2010 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

2. Upgrading of existing facilities and services for Paediatric Oncology in the 3 regional centers Sarawak General Hospital Likas Hospital, Sabah Penang Hospital 3. New services in Kuantan (RM 0.5 M for 1st 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

ACTION PLANS: ACTIVITIES

No. 5. 6. Elements Health Education Outsourcing & Consumables Activities

GOAL 4 : TREATMENT
Cost RM 0.5 M RM 80 M Time-Frame 2008 - 2010 2008 2010 Agency/Person Oral Health Division Medical Development Division, Bahagian Perolehan Outsourcing 20M per year Remarks

1. Develop health education materials/ teaching aids Clinical Oncology Malacca Johore Kuala Lumpur Penang Ipoh Sabah Sarawak Haematology

Ampang Pulau Pinang JB, Klang, Ipoh, KK New Centers in: Melaka, Kuantan, Kuching
Paediatric Oncology Consumables 1. Pediatrics Institute, KLH (RM 1.0 M per year) 2. 3 regional centers

RM 30 M RM 1.5 M RM 3 M RM 2.25 M

2008 2010 2008 2010 2008 2010 2008 - 2010

RM10M/year RM0.5M/year Laboratory consumables RM0.25M/year Laboratory consumables RM0.25M/year

RM 3 M RM 3 M

132

ACTION PLANS: ACTIVITIES

No. Elements Activities Sarawak General Hospital Likas Hospital, Sabah Penang Hospital (RM 0.3M per year) 3. New services in Kuantan (RM 0.2 M for 1st year and RM 0.3 M per year for subsequent years) 7. Research & Development 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

GOAL 4 : TREATMENT
Cost Time-Frame Agency/Person Remarks

RM 1 M

8.

RM 0.8 M

2008-2015

Public Health Department, Department of Radiotherapy and Oncology, CRC, PUU, Professional societies

133

ACTION PLANS: ACTIVITIES

No. 9. 10. 11. Elements NGOs / Corporations Institutions / Organizations Standards / Guidelines / Codes of Practice Activities

GOAL 4 : TREATMENT
Cost Time-Frame Agency/Person Remarks

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

2008-2015

PUU, College of Radiology, Engineering Division, MOH

2008-2010

2011-2015

2011-2015

134

ACTION PLANS: ACTIVITIES

No. 12. Elements Quality Assurance 1. Activities Identify National Indicator for Quality Assurance in Radiotherapy Applications 2. Implement QAP in MOH Cancer Treatment Centers

GOAL 4 : TREATMENT
Cost RM 0.25 M Time-Frame 2008 Agency/Person MOH/Engineering/ All Cancer Treatment Centers All MOH Cancer Treatment Centers PUU, College of Radiology, Engineering Division (MOH) Remarks Establish and adapt National Indicator

2009 RM 0.25 M 2011-2015 RM10,000

13.

Legislation

Credentialing of personnel and facilities. Establish minimum criteria for Oncologists. Introduction of latest Regulations in Medical Use of Radiation in Radiology, Radiotherapy, Nuclear Medicine, Dentistry and Veterinary services and its enforcement.

TOTAL : TREATMENT

RM 1029.528 M

135

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities 1. To train various professionals in rehabilitation team Rehabilitation specialists 52 52 years RM 0.5 2 M Speech therapists 21 52 years RM 0.21 M Occupational therapists 126 -52 years RM 0.65 M

GOAL 5 : REHABILITATION
Cost RM 13.6 M Time-Frame 20086-2010 Agency/Person ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support Remarks 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

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

ACTION PLANS: ACTIVITIES

No. Elements Activities Speech Therapists (6), Clinical Psychologists (6)

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person Remarks

2.

Facilities

Develop specialist-based Rehabilitation care service in 6 cancer centers (20068 -2010) NCI Putrajaya Kuantan Hospital Penang Hospital Sultan Ismail Hospital Sarawak General Hospital Likas Hospital Sabah

RM 31.2 M

20068-2010

) ) ) ) ) ) ) )

Medical Development Division / Planning & Development Division / Engineering Division

Existing facilities renovation RM 0.15 M for each hospital per year in 5 years for 2 years

3.

Equipment

Latest available technology Decide on number and type needed Purchase all needed equipments Equipment: RM 1M per center Equipment : RM 1M per center

RM 66 M

20068-2010

) ) ) )

Pharmacy Division / Engineering Division

2011-2015 easten regionsKuantan NCI + 5 Regional Hospitals 2011-2015 Easten regions-

137

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person Remarks Kuantan

4.

Drugs

1. Identify key drugs commonly used for rehabilitation purposes e.g those related to bladder & bowel training, pain, spasticity, depression, anxiety 2. Arrange bulk long term supply in rehabilitation activities 3. Keep track of drug development used to enhance rehabilitation activities

RM 7.53.0 M

20086 2010 ) Pharmacy ) Division

RM 1.5 M Per year for 6 hospital 2011-2015 RM 2 M Per year for 6 hospital Total :RM12M for 5 years

5.

Health Education

1. Develop health education materials

on cancer rehabilitation e.g. Health, wellness & fitness promotion Increase awareness on CR among health professionals

RM 2.51 M

20068-2010

HECC / IHP

RM 0.5 M for local training Per year.

138

ACTION PLANS: ACTIVITIES

No. Elements Activities 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

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person Remarks

6.

Outsourcing & Consumables Research & Development

7.

1. Prioritize Cancer Rehabilitation

Research First 5-yr evaluation of needs Subsequently quality of life assessment of cancer survivors and patients Top five cancer in Malaysia

RM 0.112 M

20086-2010

NIH

NIH NIH NIH NIH

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 =

139

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person Remarks RM50,000 To develop RMK10 onwards 2011-2015 =RM 1.0 M In collaboration with MSC Need to establish a Cancer Registry Unit

8.

Information Communication Technology and Networks

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 on CR 4. Develop e-learning on Cancer Rehabilitation 5. Establish Teleconsultation with leading CR Centers 1. Network all existing NGOs dealing with CR 2. Designate roles for specific CR by NGOs 3. Establish Consultative Forum including a division on CR 1. Establish Cancer Rehabilitation Management Units in all General and District Hospitals 2. Establish Cancer Rehabilitation 2011-2015

Telehealth MOH Telehealth Telehealth Telehealth

9.

NGOs / Corporations

) ) ) MOH / NGO ) ) ) ) ) ) ) Medical Development Division / Planning &

10.

Institutions / Organizations

140

ACTION PLANS: ACTIVITIES

No. Elements Activities support and community Centers 1. Establish SOP Cancer Rehabilitation. 2. Organize Training Program 3. Widely Circulate Standards/Guidelines

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person ) Development ) Division ) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc ) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health / ) Research & ) Technical ) Support Attorney General Office Remarks

11.

Standards / Guidelines / Codes of Practice

RM 0.2 M

2011-2015 (RM 0.2 M)

12.

Quality Assurance

1. Establish key performance indicators for Cancer Rehabilitation Management 2. Establish reporting and monitoring mechanism 3. Review and Revise Indicators 4. Establish Benchmarks with other countries Review present insurance policies which discriminate against cancer survivors who need rehabilitation to ensure good quality of life

RM 0.2510 M

2008-20105 years

13.

Legislation

141

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 5 : REHABILITATION
Cost Time-Frame Agency/Person Remarks

TOTAL: REHABILITATION

RM 35.14624.906 M

142

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital Activities 1. Recruit foreign palliative care experts Overseas expert: RM 250,000/yr 1 expert for 1 year : RM 250,000 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 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

GOAL 6 : PALLIATIVE CARE

Cost RM 2.2 M Time-Frame 2008-2010 Agency/Person ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support ) ) ) Remarks 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. Elements Activities 3. 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

GOAL 6 : PALLIATIVE CARE

Cost RM 11.376 M (Emolument) Time-Frame Agency/Person Remarks

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

RM 0.6 M

2008-2010

) ) ) ) ) ) ) )

Medical Development Division / Planning & Development Division / Engineering Division

Existing facilities renovation: RM 100,000/ unit.for 6 PC Units

144

ACTION PLANS: ACTIVITIES

No. Elements iv. Activities community level Implementati on of effective Quality System in all areas of cancer management (palliative care) v. Upgrade and renovate existing facilities.

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

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

2008-2010

) ) ) ) ) ) ) ) )

Pharmacy Division / Engineering Division

Equipment: RM 100,000 /unit(State) Patient transport van: RM 80,000/unit 2008-2010: 6 Regional hospitals: Equipment: RM 600,000 Vehicle: RM 480,000

145

ACTION PLANS: ACTIVITIES

No. 4. Drugs Elements 1. 2. 3. 4. Activities Identify key drugs & demands Arrange bulk long term supply Keep track of drug development Promote local drug manufacture

GOAL 6 : PALLIATIVE CARE

Cost RM 3.6 M Time-Frame 2008-2010 Agency/Person ) ) ) ) Pharmacy ) Division ) ) ) Remarks Special drugs & consumables: RM 200,000/unit/year 2008-2010: 6 Regional hospitals: 6 x 3 years x RM 200,000 General Public awareness: RM100,000 Post-basic nursing: RM100,000 Community GP training: RM100,000 CME : RM100,000 Volunteer training: RM 50,000

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

2008-2010

HECC / IHP HECC HECC IHSR / HECC / IHP

146

ACTION PLANS: ACTIVITIES

No. 6. Elements Outsourcing & Consumables Research & Development Activities -

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

7.

1. Prioritize Cancer Research 2. Divide research priorities among institutions 3. Monitor research progress 4. Publicize research findings 5. Document & track all research

RM 0.2 M

2008-2010

NIH NIH NIH NIH NIH

Preliminary data research: 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

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.

To develop RMK-10 onwards

Telehealth MOH Telehealth Telehealth Telehealth

In collaboration with MSC Need to establish a Cancer Registry Unit To connect with Peter McCallum and Royal Adelaide Hospital in Australia.

147

ACTION PLANS: ACTIVITIES

No. 9. Elements NGOs / Corporations 1. 2. 3. 4. Activities Network all existing NGOs Designate roles for existing NGOs Establish Consultative Forum Enhance collaboration with NGOs

GOAL 6 : PALLIATIVE CARE

Cost RM 0.3 M Time-Frame 2008-2010 Agency/Person NGO ) ) ) MOH / NGO ) ) ) Remarks

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

2008-2010

) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc

Cancer Pain Management Clinical Practice Guidelines (CPG) 2011-2015: RM 100,000

148

ACTION PLANS: ACTIVITIES

No. Elements Activities 6. Review every 5 years and audit adoption of guidelines

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

12.

Quality Assurance

1. Establish accreditation criteria for 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

Audit of Cancer pain incidence & relief to begin in RMK-10: 2011-2015: RM 500,000

13.

Legislation

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

ACTION PLANS: ACTIVITIES

No. Elements Activities curriculum. 4. All hospitals with Cancer treatment facilities must also make provision for palliative care services. 5. Quality of life act

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

TOTAL: PALLIATIVE CARE

RM 19.856 M

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital 4. Activities Recruit foreign palliative care experts Overseas expert: RM 250,000/yr 1 expert for 1 year : RM 250,000

GOAL 6 : PALLIATIVE CARE

Cost RM 1.45 M Time-Frame 2006-2010 Agency/Person ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support ) Remarks Utilise existing supportive staff eg dieticians, physiotherapists 2011-2015: For 6 State hospitals:

5. Arrange counterparts for training: Recruit clinical specialists U48/54 Recruit nurses : specialist

150

ACTION PLANS: ACTIVITIES

No. Elements Activities palliative care nurses (1 in each regional center) 72 staff nurses to undergo post basic training in Palliative Care (6 per center) Clinical Psychologists 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

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame ) ) Agency/Person Remarks 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

6.

Establish new posts and recruit the following personnel: Clinical specialists (12), Medical Officers (12), Matrons (6), Nurses (72), Palliative Care staff (6), Attendants (24)

RM 11.376 M (Emolument)

2.

Facilities

Development of palliative care

RM 0.6 M

2006-2010

) Medical ) Development

Existing facilities

151

ACTION PLANS: ACTIVITIES

No. Elements Activities 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. Upgrade and renovate existing facilities.

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame ) ) ) ) ) ) Agency/Person Division / Planning & Development Division / Engineering Division Remarks renovation: RM 100,000/ unit.for 6 PC Units

152

ACTION PLANS: ACTIVITIES

No. 3. Elements Equipment 6. Activities Study latest available technology 7. Decide on number and type needed 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

GOAL 6 : PALLIATIVE CARE

Cost RM 1.08 M Time-Frame 2006-2010 ) ) ) ) ) ) ) ) ) Agency/Person Remarks 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

Pharmacy Division / Engineering Division

4.

Drugs

5.

Identify key drugs & demands 6. Arrange bulk long term supply 7. Keep track of drug development 8. Promote local drug manufacture

RM 6 M

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

153

ACTION PLANS: ACTIVITIES

No. 5. Elements Health Education Activities 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

GOAL 6 : PALLIATIVE CARE

Cost RM 0.45 M Time-Frame 2006-2010 Agency/Person HECC / IHP HECC HECC IHSR / HECC / IHP Remarks General Public awareness: RM100,000 Post-basic nursing: RM100,000 Community GP training: RM100,000 CME : RM100,000 Volunteer training: RM 50,000 -

6.

Outsourcing & Consumables

154

ACTION PLANS: ACTIVITIES

No. 7. Elements Research & Development Activities

GOAL 6 : PALLIATIVE CARE

Cost RM 0.2 M Time-Frame 2006-2010 Agency/Person NIH NIH NIH NIH NIH Remarks Preliminary data research: 1 research asst.: RM2,500/month RM30,000/yr x 5 =RM150,000 Other equipment and facilities: RM 50,000

6.
7.

Prioritize Cancer Research Divide research priorities among institutions 8. Monitor research progress 9. Publicize research findings 10. Document & track all research

8.

Information Communication Technology and Networks

6. Establish Malaysian Cancer Portal 7. Link with International Networks 8. Develop e-learning on Cancer 9. Establish Tele-consultation with leading Centers for teaching, training and consultation. 10. High-speed Internet connection in all hospitals /palliative care centers for information search and research.

To develop RMK-10 onwards

Telehealth MOH Telehealth Telehealth Telehealth

In collaboration with MSC Need to establish a Cancer Registry Unit To connect with Peter McCallum and Royal Adelaide Hospital in Australia.

155

ACTION PLANS: ACTIVITIES

No. 9. Elements NGOs / Corporations 5. 6. Activities Network all existing NGOs Designate roles for existing NGOs 7. Establish Consultative Forum 8. Enhance collaboration with NGOs 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

GOAL 6 : PALLIATIVE CARE

Cost RM 0.5 M Time-Frame 2006-2010 Agency/Person NGO ) ) ) MOH / NGO ) ) ) Remarks

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

2006-2010

) Academy of ) Medicine / ) Medical ) Development ) Division / ) Engineering ) Division etc

Cancer Pain Management Clinical Practice Guidelines (CPG) 2011-2015: RM 100,000

156

ACTION PLANS: ACTIVITIES

No. Elements Activities 10. Publish guidelines 11. Create awareness and promotion of guidelines 12. Review every 5 years and audit adoption of guidelines

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

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

) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health

Audit of Cancer pain incidence & relief to begin in RMK-10: 2011-2015: RM 500,000

13.

Legislation

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

NA

157

ACTION PLANS: ACTIVITIES

No. Elements Activities must have palliative care nursing curriculum.

GOAL 6 : PALLIATIVE CARE

Cost Time-Frame Agency/Person Remarks

4.

All hospitals with Cancer treatment facilities must also make provision for palliative care services. Quality of life act

TOTAL: PALLIATIVE CARE

RM 21.706 M

158

ACTION PLANS: ACTIVITIES

No. 1. Elements Human Capital 1. 2. 3. 4. Activities

GOAL 7 : TRADITIONAL AND COMPLEMENTARY MEDICINE

Cost RM 0.8 M Time-Frame 20067-2010 Agency/Person ) Human ) Resource Div / ) Training Div / ) Medical / ) Public Health / ) Research & ) Technical ) Support ) ) ) Remarks

T/CM practitioners outsourcing. Recruiting T/CM practitioners Formulating Training Plan Identify candidates for training

RM 2.2 M

Outsource team / hospital consists of a. TCM practitioner -3 b. Acupuncturists -3 c. Traditional Masseur -3 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

New budget allocation

159

ACTION PLANS: ACTIVITIES

No. Elements Activities

GOAL 7 : TRADITIONAL AND COMPLEMENTARY MEDICINE

Cost Time-Frame Agency/Person Remarks

2.

Facilities

1. Construct the facilities The regional hospitals will plan to use 0.6M for the construction of its facilities.

RM 0.6 M

20068-2010

2. Maintain the facilities.

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 Herbal medicine Introduce end product of herbal preparation which is commonly used to minimize the side effect of chemo / radiotherapy as an adjunct therapy

RM 0.2 M

) ) ) ) ) ) ) )

T/CM/Medical Development Division / Planning & Development Division / Engineering Division

2006-2010

4.

Drugs

RM 1 M

20086-2010

) ) ) ) Pharmacy ) Division )

160

ACTION PLANS: ACTIVITIES

No. Elements

GOAL 7 : TRADITIONAL AND COMPLEMENTARY MEDICINE

Cost Time-Frame ) ) Agency/Person Remarks

Activities 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. 1. Develop health education materials 2. Divide workload among media 3. Organize continuous media coverage 4. Study effects of public education 5. Awareness program

5.

Health Education

RM 0.4 M

20068-2010

HECC / IHP HECC HECC IHSR / HECC / IHP

RM400,000/year for each hospital for preparation of public speech, T/CM information leaflets, campaign and in house training.

6.

Outsourcing & Consumables

161

ACTION PLANS: ACTIVITIES

No. 7. Elements Research & Development Information Communication Technology and Networks Activities

GOAL 7 : TRADITIONAL AND COMPLEMENTARY MEDICINE

Cost RM 3.8 M Time-Frame Agency/Person NIH Remarks

Research on the T/CM practice

8.

1. Establishing T/CM registration and licensing 2. Maintenance 3. Enhance T/CM registration and licensing 4. Maintenance

20066-2010 -

9.

NGOs / Corporations

1. Network all existing NGOs 2. Designate roles for existing NGOs 3. Establish Consultative Forum

NGO ) ) MOH / NGO

Practitioner bodies need to obtain funding from the operating budget.

10.

Institutions / Organizations

1. Establish National Cancer Advisory Council to include representative from the T/CM Division 1. Establish Cancer Management Standards 2. Organize Training Program 3. Established

NIH Secretariat ) Medical ) Development ) Division / In collaboration with practitioner bodies.

11.

Standards / Guidelines / Codes of Practice

RM 0.5 M

20086-2010

162

ACTION PLANS: ACTIVITIES

No. Elements Activities Standards/Guidelines

GOAL 7 : TRADITIONAL AND COMPLEMENTARY MEDICINE

Cost Time-Frame Agency/Person Remarks

12.

Quality Assurance

1. Establish key performance indicators for Cancer Management 2. Establish reporting and monitoring mechanism 3. Review and Revise Indicators 4. Establish Benchmarks with other countries

) IHSR / NIH / ) Medical ) Development ) Division / ) Public Health / ) Research & ) Technical ) Support 2006-2010

13.

Legislation

1. T/CM Act and Regulation

TOTAL: TRADITIONAL AND COMPLEMENTARY MEDICINE

RM 9.5 M

163

ACTION PLANS : SUMMARY OF BUDGET REQUIRED (2008 2010)

PREVENTION SCREENING AND EARLY DETECTION DIAGNOSIS TREATMENT REHABILITATION PALLIATIVE CARE TCM R&D

APPENDIX 5
TOTAL %

ELEMENTS

COSTS (RM 000,000) 1. Human Capital - Training - Emolument 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Facilities Equipment Drugs Health Education Outsourcing & Consumables Research & Development ICT and Networks NGOs / Corporations Institutions / Organizations Standards / Guidelines Codes of Practice Quality Assurance Legislation 1 0.12 0.6 0.52 0.88 1.517 0.25 0.25 0.25 0.1 0.05 0.5 2.38 2.387 1.250.25 0.12 0.12 0.01 1 0.31 0.14 2319 (Vaccines) 210 11.2150.76 1.05 1.08 19.21 6.5 47.3 23.005 76.855 79.8 130.9 65 2.0 12.59 1 74.294 5.7 2.12 0.8 0.3 13.5344 39.894 8.12 222.65 619.53 0.5 123.75 0.11 0.2 3.8 1.6 11.896 1.2 6 3 1 2.2 11.376 0.6 1.08 3.6 0.45 1 0.4 2 45 3 0.8 4.815 5.19 23.73 209.2254 (44.4194) (164.806) 103.21 431.66 1011.13 14.35 210.634 56.81 3.22 0.4 10.23 (2.617 ) (8.05) 5.05 21.1 49.43 0.7 10.3 2.78 0.16 0.052

TOTAL BUDGET

20.8332.26 (16.24%)

90.8 (4.44%)

460.071 (22.49%)

1203.788 (50.33%)

24.906 (1.22%)

19.856 (0.97%)

9.5 (0.46%)

80.735
(3.95%)

2,045.6564

164

165