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