::.. College of Radiology - History of Radiotheraphy & Clinical Onclogy in Malaysia

Radiotherapy and Clinical Oncology in Malaysia – How it all began?
By Dr Gerard Lim Chin Chye, MBBS, FRCR, Department of Radiotherapy and Oncology, Kuala Lumpur Hospital, Malaysia - Dec 2004

With acknowledgements to the following for their contributions:
Professor Dato’ Dr Tahir Azhar, Dato’ Dr S K Dharmalingam, Mr T Yogaratnam, Mr Khoo Boo Hock, Dr Beena Devi, Dr D Jayendran, Dr B M Biswal, Dr Perdamen Singh, Prof Dr Ismail Saad, Dr Fuad Ismail, Dr Anita Zarina Bustam, Dr Albert Lim Kok Hooi, Dr Mohd Roslan Haron, Mr Lee Kok San, Mr Mahfuz Mohd Yusop, Dr Richard Lim Boon Leong, Dr Ednin Hamzah

Note: This article is reproduced with some modifications and with permission from the Biomedical Imaging and Intervention Journal, Biomed Imaging Interv J 2006; 2(1):e18
doi: 10.2349/biij.2.1.e18, http://www.biij.org/2006/1/e18/default.asp

Cancer is an increasing health problem in Malaysia. The following relates the development of the discipline of Clinical Oncology, which was previously known as Radiotherapy and Oncology.

Development of Radiotherapy in Kuala Lumpur

The earliest records of x-ray therapy in Malaya were the acquisition of a Crookes x-ray tube in Singapore in 1914 and a Coolidge tube in 1920¹. Radium sources were purchased for treatment of gynaecological malignancies, skin lesions and implants of accessible lesions. The radium needles and radium tubes from the General Hospitals of Ipoh, Johor Bharu and Penang were later transferred and stored in the Department of Radiotherapy and Oncology at Hospital Kuala Lumpur¹.

A 140 kV Deep X-ray Therapy unit was installed in Singapore General Hospital in 1933. In the 1950’s, external beam radiotherapy was delivered in Kuala Lumpur with the Phillips Dermopan 50 kV superficial x-ray machine, 200 kV Mueller x-ray machine and 250 kV rotating Muller X-ray machine¹. Treatment plans were all carried out manually. Shielding of critical structures was based on check films done with lead cut-outs and lead blocks.

The department was housed in a wooden building between the Maternity Hospital and Neurosurgical unit. There were no beds dedicated to the unit at that time. In the period between 1950 and 1960, the radiotherapy services were provided by Dr Lynch who was an Irish radiotherapist, shuttling between Singapore and Kuala Lumpur, and Dr Lal who was from Singapore.

Dato’ Dr S K Dharmalingam

The First Malaysian Consultant Radiotherapist & Staff of the “early” Radiotherapy Department

Dato’ Dr S K Dharmalingam succeeded Dr Lynch after returning from the Middlesex Hospital in the United Kingdom in 1960 and was appointed as the first Malaysian Consultant Radiotherapist.

Mr George Phang was the first physicist in the Department of Radiotherapy, Kuala Lumpur General Hospital in 19602. Staff comprised 4 local consultants with several expatriates from Korea and Pakistan, 8 sisters, 28 staff nurses, 40 assistant nurses and approximately 70 attendants. A number of specialists from overseas attached to the department included Professor Roberts of Middlesex Hospital, Professsor Keith Brittan from St Bartholomew’s Hospital, as well as doctors from Korea, Pakistan and Austria².

Additional equipment that was acquired included a radium safe costing $35,000 in 1965 and another 300 kV orthovoltage treatment machine. At the time when Tun Omar Ong Yoke Lin and Tun Tan Siew Sin were the Minister of Health and Minister of Finance respectively, an allocation of $3 million was set aside for the establishment of the new Institute of Radiotherapy and Oncology and Nuclear Medicine at Kuala Lumpur General Hospital. The physical construction of the building started in August 1967 and was finished in November 1968. It was a facility with 180 beds, its own operation theatre for brachytherapy, separate laboratory and pharmacy, and outpatient department. The Cancer Ambulant Ward was also established to cater to the cancer patients who needed accommodation and did not require hospital admission. This was necessary in particular for those from other states. Before the establishment of the Cancer Ambulant Ward, such patients had been put up in the New Hotel through the assistance of the National Cancer Society of Malaysia, and at the old Tai Wah Hospital which was refurbished². The equipment included a Siemens Betatron which provided electron treatments ranging from 5 MeV to 43 MeV, and two single energy 6 MV linear accelerators (MEL-75)¹.

Nuclear Medicine in Kuala Lumpur

Nuclear medicine was started under the Department of Radiotherapy and Oncology in 1962. The doctors who were involved in the early days of Nuclear Medicine included Dato’ Dr Dharmalingam and V. Mahadev⁴. The first technician, Mr Anthony Ng was sent to the Royal Melbourne Institute of Technologists for training. The Radioisotope Laboratory was established at the University Hospital Kuala Lumpur in 1967¹.

Birth of the Medical Physics Division

Among the physicists who served in the 1970s was the former national badminton player, Mr Tan Aik Huang. In 1974, a physicist post was created in engineering division in the Ministry of Health. A physics workshop with two lathe machines, a shaping machine, drilling, cutting machines and a physics mould room were also installed in the institute for preparing lead shielding devices and other special treatment devices. Two Farmer Dosemeters type 2502 were used for dose calibration and measurement of those megavoltage machines. The analog Farmer Dosemeters have been replaced by digital dosemeters for more accurate dosimetry.

Kuala Lumpur Acquires More Therapy Equipment

Another single energy linear accelerator and a telecaesium unit were installed in 1977 and 1978 respectively thus replacing the orthovoltage machines. The physicists were doing the isodose planning by manual summation until a computerized treatment planner, Mevaplan, was introduced to the department under the project of upgrading and replacement of old machines in 1987 and 1988³.

Phase II development of the Institute was completed in 1995, and facilities such as a Day Care Center and renovation of the operation theatre were achieved. With the installation of two new high end linear accelerators in 1997 and 2001, a high dose rate remote afterloading brachytherapy system in 1997, three-dimensional treatment planning system, digital imaging simulator in 2001, the department could offer stereotactic radiosurgery, High Dose Rate brachytherapy, conformal radiotherapy with multi-leaf collimators and total body irradiation. Total body irradiation in Hospital Kuala Lumpur has been used for the bone marrow transplant programmes of both University of Malaya Medical Centre as well as Hospital Kuala Lumpur itself.

Stereotactic radiosurgery was started in Hospital Kuala Lumpur on 4^th March 1999. High dose rate remote afterloading system for brachytherapy has completely taken over from the manual afterloading system since October 2003 in Hospital Kuala Lumpur.

Development of Radiotherapy and Oncology in Sarawak

The Department of Radiotherapy and Oncology in Sarawak General Hospital was officially opened on 15 August, 1985. The first clinical oncologist to serve in Sarawak was Dr Jaswant Singh.

The Nuclear medicine section was started at the same time. In 1993, day chemotherapy was started in the department. Currently the department has 68 beds. It originally had two linear accelerators, a conventional simulator and a Buchler Medium Dose Rate remote after-loading brachytherapy machine that used caesium-137 as the radioactive source. A new Cobalt machine was installed in the department in 1996. One of the Linear accelerators was replaced with a new one in 1997. In June 2001, the Buchler Brachytherapy unit was replaced with an HDR brachytherapy unit. Patients with nasopharyngeal cancer in Sarawak General Hospital could now be treated with brachytherapy as the previous brachytherapy machine only treated patients with gynaecological malignancies⁵.

Palliative Care Service in Sarawak

The palliative care service was started in Department of Radiotherapy & Oncology and Hospice home care service was started since 1995 in Kuching. By 1996 onwards, the Hospice home care service was extended statewide when more nurses were trained from various parts of Sarawak. In 2003, a dedicated Palliative Care Ward was completed. The department now has 16 beds for Palliative care, i.e 8 beds for acute care and 8 beds for continuing care. The Palliative Care Unit in the Department has the task of ensuring that palliative care service is developed properly and that the service is made available to patients who require the service in Sarawak. A system of drug delivery was also set up to ensure that patients even the most remote parts of Sarawak get the drugs for symptom relief. Palliative care training for doctors, nurses and paramedics has been conducted by the Department of Radiotherapy and Oncology in Sarawak General Hospital since 1995. The training sessions were initially conducted in Sarawak General Hospital, with extensions to Sibu in 1996 and Miri in 1997.

Early Cancer Surveillance Training was started in 1995 as more than 70% of patients with common cancers i.e nasopharyngeal, breast and cervix presented in an advanced stage. The training which involved theory as well as practical sessions was given to nurses and medical assistants from various hospitals and peripheral clinics.

The Breast Cancer Support Group

The Breast Support Group was started in 1993. In addition to its regular monthly Breast Support Group meeting, the group has hosted regular parties for the patients in the Department and annual dinners. A Cancer Patient Support group for patients was started in 1997 with separate groups for both sexes as requested by the patients. These patients meet from time to time to discuss and share on matters of common interest.

Dr. Paola Pisani from Epidemiology Unit of World Health Organisation (WHO), Lyon, France visited Sarawak on 6^th – 10^th of June, 2001 to assist Dr Beena on Data Analysis on the incidence of nasopharyngeal cancer in Sarawak.

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Bibliography

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Research in K.L. on oral cancer. Govt. all-out to recruit specialists. The Malay Mail. Tuesday. October 5, 1971.
Proceedings of the IAEA Regional Training Course. Brachytherapy of the Uterine Cancer Using Manual and Remote After-loading Techniques. International Atomic Energy Agency. 1988.
Medicine in Malaysia: Radiotherapy and Oncology. A K H Lim. Med J Malaysia. 50 (Suppl A):S39-41. 1995.

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Tuesday, 01 January 2008