The Department of Radiotherapy & Oncology and Palliative Care Unit, Sarawak General Hospital, Kuching, is happy to announce the research work that had been conducted and received international recognition. We see about 1500 new cases per year and are supported in our work by 4 medical physicists, 35 radiographers and 95 nurses.

The team at Sarawak General Hospital

Dr Beena Devi

Putting in a patient for CT simulation

CT Simulation in progress

Dr Tang Tieng Swee, Senior Medical Physicist /Physical Science Principal Officer

International Research Grant Award 9th February 2009:
Our award: “Dr. Ben Anderson, Chair of The Expert Steering Committee (ESC) and a team of independent Reviewers have reviewed your Application titled "Epidemiologic, Clinical and Socio-economic Aspects of Breast Cancer in the Ethnic Population of Sarawak, Malaysia" and found that your proposed research project was evaluated and rated as being among the most suitable of those applications submitted, in accordance with the criteria identified in the GSK ERI Guidelines, and as further defined by the ESC Review Panel. In fact, your application was one of only 2 that were unconditionally approved by the ESC, out of 23 final applications”. That was the reply received when we participated in the GSK ERI global initiative and submitted a research proposal on breast cancer. We were elated as this was encouragement for our ongoing quest to strengthen our research work in the department.

The ESC review panel is comprised of 12 experts in breast cancer genetics, immunology, epidemiology and other basic research disciplines, all of whom have been reviewers for the National Institutes of Health (NIH), the Susan Komen Foundation and other world renowned research grant programs. Our research will explore the epidemiologic, clinical, survival and socio-economic profile of the three ethnic groups of Sarawak.

How it all began…
Our interest in research began in 1993 when the analysed data of cases seen in the department revealed that more than 80% of our top five cancers presented in the advanced stage. We decided to act on this matter with urgency. We began two programs in 1994, an Early Cancer Surveillance Program aimed at training our own health staff from hospitals as well as rural clinics on the early signs and symptoms of cancer with special focus on three main cancers, i.e. nasopharyngeal, breast and cervix cancers. The other program was training the same group on palliative care as it was evident that the terminally ill cancer patients will require continuous and holistic care. An indirect result of our program revealed that we had the highest incidence of nasopharyngeal cancer in the world amongst the Bidayuhs (one of the ethnic groups in Sarawak). The risk in the Bidayuh people was 2.3 fold (males) and 1.9 fold (females) higher than the Sarawak average and about 50% higher than that in Hong Kong – the highest recorded by any population-based registry for the same period. This paper was published as “High Incidence of Nasopharyngeal Cancer in the native people of Sarawak, Malaysia” Journal of Cancer Epidemiology, Biomarkers and Prevention, 2004.Vol.13 (3) 482-486.

Improvements in Cancer Pain Management
Part of our endeavor was to explore the knowledge of our doctors in cancer pain as pain management forms a large part of cancer management especially in the advanced stage. This led to a statewide questionnaire survey and resulted in the publication of the paper as “What do doctors know about cancer pain management (CPM)? An exploratory study in Sarawak, Malaysia”
Journal of Pain & Palliative Care Pharmacotherapy, 2006.Volume (20) Number 2, pages 15-22. This paper highlights that knowledge about cancer pain management was low and barriers to morphine prescription were high with only 16.2% of our doctors choosing an oral mode of administration of pain medication. The majority of doctors were deterred from using morphine because of fear of addiction (36.5%) and respiratory depression (53.1%).

As pain forms a crucial part of our in-patient care, we customised a pain assessment chart by using the short form of the Brief Pain Inventory and Wong-Baker Faces scale. In 2000, we began to use it for all patients admitted for pain. This study was later published as “Documenting pain as the fifth vital sign: a feasibility study in an oncology ward in Sarawak, Malaysia.”  Oncology 2008; 74 (Suppl.1): 35-39 (DOI: 10.1159/00014216). The results revealed the method was easy to use for both nurses and patients. The mean number of days to reduce pain was found to be 3.1 days for that sample in the study.

Reducing the number of patients presenting in late stage cancer
From our department’s registry when we analysed our stage of presentation for the three common cancers, we observed that there was a reduction in late stage presentation. Breast cancer in stage III and IV were reduced from 60% (1994) to 35% (1998) and cervical cancer in stage III and IV from 60% (1994) to 26% (1998).These results were published as “Reducing by half the percentage of late stage presentation for breast and cervix cancer over 4 years: A pilot study of clinical down staging in Sarawak, Malaysia”

Annals of Oncology, 2007.18: 1172-1176. As the pick up rate of PAP smear was only 5% of the cases, it revealed that community awareness played a crucial role in the down staging. No down staging was observed for nasopharyngeal cancer. In addition, in the WHO Guide for effective programmes; module 3:33, 2007 “A pilot study of early diagnosis in Sarawak, Malaysia. Early Detection Cancer control: knowledge into action:” was included. This paper was also selected by a US based Breast Cancer.Net, a reputable online news alert on breast cancer research, on 8th August 2007.

Palliative Care Progress
For the program on palliative care, we used total morphine usage in the programme as an indicator, similar to the way the World Health Organization (WHO) gauges progress in cancer pain management. Our results revealed a 7-fold increase in morphine usage since 1993 when the program was started. In addition, the number of patients increased by 661% from 1994 to 2006 owing to the increase in the number of trained health staff. The study results were published as, “Setting up home-based palliative care in countries with limited resources: a model from Sarawak, Malaysia.” Annals of Oncology 19: 2061-2066. 2008.

This paper was then selected by UICC for their Global News Alert Feb Issue, Vol 3, Number 2, Feb 2009. The editors highlighted that caring for the terminally ill cancer patients in low and middle income countries can be a challenge when working in remote areas or with limited resources. They commended that the model in Sarawak was both sustainable and cost efficient with the key component being training of nurses, other health care workers and family members, especially on pain management and more importantly, facilitating access to pain medication and simplifying referral to the oncology department.