4 July 2015
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.
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 4th 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 6th – 10th of June, 2001 to assist Dr Beena on Data Analysis on the incidence of nasopharyngeal cancer in Sarawak.
Radiotherapy and Oncology in Universities
The academic unit was started in University Hospital Kuala Lumpur (now called University of Malaya Medical Centre) in 1997, with state of the art equipment including linear accelerator with multileaf collimators, stereotactic radiotherapy, High Dose Rate and Low Dose Rate remote afterloading brachytherapy, and virtual simulation. The oncologists were Dr Ibrahim Wahid, Dr Matin Mellor Abdullah; physicists were Ms Nicky Whylde, Mr Khoo Boo Huat, Ms Prema Rassiah and the therapy radiographer was Mr T. Yogaratnam.
Other universities that had departments of radiotherapy and oncology were Hospital Universiti Kebangsaan Malaysia and Hospital University Sains Malaysia in Kubang Kerian, Kelantan.
The Department of Nuclear Medicine, Radiotherapy and Oncology of Universiti Sains Malaysia, Kubang Kerian Campus started the first Radiotherapy service in the east coast of Peninsular Malaysia. The Radiotherapy and Oncology division was added to the existing Nuclear Medicine department in December 1995. The Radiotherapy and Oncology service was started with the guidance of Professor Mustafa Embong (then Dean of Medical School) and collaboration of Associate Professor Ahmad Zakaria (Medical Physics). Ministry of Health seconded a clinical oncologist, Dr Jayendran Dharmaratnam, and two therapy radiographers, Miss Aishah Shaari and Mr Khorlid Hassan, to the Ministry of Education for this purpose. In 1999, the High Dose Rate brachytherapy service was operational with the collaboration of IAEA and now this department is the one of the departments offering HDR interstitial brachytherapy services in Malaysia. Subsequently state of art radiotherapy techniques like 3-dimensional conformal radiotherapy and X-knife radiosurgery service were added in 20016.
Radiotherapy and Oncology in Penang
The service in Penang was upgraded in 1996 with the posting of Dr D Jayendran, a senior clinical oncologist from Ministry of Health who volunteered for this service. Chemotherapy and palliative care was provided at Penang Hospital while radiotherapy was planned and given to government patients at Mount Miriam Hospital initially, with the addition of Pantai Mutiara Medical Centre later. Oncology clinics were also run in Alor Star, Seberang Perai and Taiping.
Overview of Radiotherapy Services in Malaysia
A model of a modern Linear Accelerator
As at 2004, there are 20 centres for Radiotherapy and Oncology in Malaysia comprising 5 government centres and 15 private centres. There are 25 linear accelerators, 7 cobalt-60 teletherapy machines, 15 brachytherapy units, 11 simulators and 4 CT simulation units.
Upgrading of the radiotherapy equipment in 2000 was at a cost of RM 10 million, with the installation of linear accelerator, simulator and competerised treatment planner. The linear accelerator was equipped with multileaf collimator and capability for Intensity Modulated Radiotherapy.
Forty-one hospitals in the Ministry of Health are delivering chemotherapy besides universities and the private sector. Conventional chemotherapy is given in many general hospitals, district hospitals and private centres. High dose chemotherapy with bone marrow rescue has been carried out in University Hospital Kuala Lumpur since 1989 and in Hospital Kuala Lumpur since 1994.
In order to decrease the burden on the government centres, the Government has purchased private radiotherapy services from Mount Miriam Hospital, Pantai Mutiara Medical Centre, Mahkota Medical Centre, Pantai Ayer Keroh Medical Centre, Nilai Cancer Institute and Gleneagles Oncology Centre.
Work on the next Ministry of Health oncology centre at the Department of Radiotherapy and Oncology in Hospital Pandan, Johor. Construction would be at a cost of nearly RM558 million, with a Total Hospital Information System, 2 linear accelerators, a CT scan, operation theatres and other support services.
The Burden of Cancer
While the idea of a National Cancer Registry was first reported in the Star on 7th April, 1978, the First Report of the National Cancer Registry was realized on 4th July, 2003. For the first time, the real cancer burden in Malaysia was confidently estimated. A total of 26,098 cancers were diagnosed among all residents in Peninsular Malaysia in the year 2002. The corresponding figures for Sabah and Sarawak were 1748 and 2002 respectively. The cumulative risk of Malaysians getting cancer in their lifetime was 1 in 5. Taking into account the unregistered cases, the cumulative lifetime risk was 1 in 47. Since then, the Second Report of the National Cancer Registry has been released in December 2004.
The Penang Cancer Registry in its Five Year Report from 1994-1998 demonstrated that 53.1% of cancers were in the advanced stages, i.e. Stage III or Stage IV. This was published on 15th December 20038
Tackling the Burden of Cancer
The role of public health cannot be underestimated. This includes public awareness, education, screening and early detection of disease, as well as rehabilitation and palliative care. The Ministry of Health launched its campaign against cancer as part of its ongoing Healthy Life Style approach to the prevention and control of some of our major public health problems in 19959.
Decreasing the proportion of cancers presenting at a late stage would lead to increasing chances of cure or long term control of the cancer. In Sarawak, where the three commonest cancers present at an advanced stage in at least 70% of the cases10, efforts have been made at early detection. Allied health professionals, such as medical assistants and nurses have been trained on how to detect early signs and symptoms of cancers of the nasopharynx, breast and cervix.
Despite the awareness campaigns and public talks that have been given, the practice of screening for cancer is not widespread enough. The Second National Health and Morbidity Survey11 revealed that the overall prevalence of Pap smear was only 26%. The overall prevalence for breast self examination is 46.8%10. Screening rate by Breast Self Examination was 34.1%, followed by Health Worker Examination (31.1%). Mammography was carried out only in 3.8% of women. Health education programmes have to target the population subgroups that would benefit from screening, including women in the older age groups.
Efforts at improving palliative care services throughout the country are being actively undertaken by governmental and non-governmental agencies.
Palliative Care was introduced by non-governmental organizations (NGO) in Kuala Lumpur and Penang in 1991, by Ministry of Health in Sabah in 1995. In 2000 a National policy was launched. Palliative care continues to be NGO driven. Most training programmes in Palliative Care are still run by NGOs. The NGOs continue to work closely with Palliative Care Units where they can. The setting up of Rumah Hospis in Penang would enhance palliative care in Penang. Home care nursing by some government general hospitals serve to enhance continuity of care of terminally ill patients after discharge from hospital, for example, in Hospital Kuala Lumpur, which was started in 1995 for patients within a 10 kilometer radius of the hospital.
In the East Malaysia, Palliative Care Programmes have been started with Palliative Care Units as well as Hospice Home Care as part of a community-based service. The programmes include the training of doctors, nurses, medical assistants and lay volunteers in the palliative care of terminally ill cancer patients. Palliative Care Units have been set up in several government hospitals, for example in Queen Elizabeth Hospital in Kota Kinabalu in 1995 and have undertaken training of Ministry of Health personnel.
There are now 11 Palliative Care Units and 48 Palliative Care Teams in various hospitals in the Ministry of Health, and 17 hospice organizations (NGOs) under an umbrella organization called the National Hospice Council that was formed in June 1998.
The palliative care unit of Hospital Selayang was started in December 2002 as part of the Ministry of Health’s policy to support palliative care services in all government hospitals throughout Malaysia. As Hospital Kuala Lumpur was largely overcrowded and there was no space for the development of a new ward, it was decided that this new palliative care unit and service be started in Hospital Selayang which is also a regional centre for pain control.
Non-governmental organizations (NGOs) have been actively involved in various aspects of cancer welfare, such as in cancer education, cancer counselling services, moral support to cancer patients, welfare services, organizing national and international symposia, providing therapeutic facilities.
Training is an integral part of any cancer programme. The number of specialists in cancer treatment and the facilities available need to be increased in order to cope with the workload. There are 32 clinical oncologists in Malaysia of whom 21 are in the private sector. Physicists number 26, while there are 104 therapy radiographers, 2 medical technologists dan 45 nurses who have undergone post-basic oncology training.
In 1971, it was reported that there were about 30 radiotherapists and radiologists in West Malaysia, and the Ministry of Health at that time was doing all it could to increase the number of these specialists. An immediate measure was recruitment from Pakistan and Egypt, while the long term plan was to send more Malaysians overseas for training12.
School of Radiography was started at the General Hospital Kuala Lumpur in 1963. Dato’ Dr Dharmalingam initiated the establishment of the School of Radiotherapy at the Kuala Lumpur General Hospital. With Mr A R Hutchinson as the Radiotherapy Advisor, the first five student radiotherapy radiographers commenced training in 19691.
Post basic course for Oncology Nursing was started at the School of Nursing in Kuala Lumpur on 1st October, 1996.
The First ASEAN Association of Radiologists Scientific Meeting was held from 30 October 1980 to 1 November 1980 at the Faculty of Medicine, University of Malaya. Invited speakers included Professor J G Bloom from the Royal Marsden Hospital, London.
The International Atomic Energy Agency (IAEA) organised the IAEA Regional Training Course on Brachytherapy of uterine cancer using Manual and Remote After-loading Techniques at the Faculty of Medicine, National University Hospital and General Hospital of Kuala Lumpur from 6 to 26th October 1986. It was organised in cooperation with the Government of Malaysia and National University of Malaysia, in collaboration with General Hospital Kuala Lumpur and the Nuclear Energy Unit of the Prime Minister’s Department. The Organising Committee was chaired by Professor Ismail Saad, co-chaired by Dr Perdamen Singh, while the Secretary was Dr Md Tahir Azhar, Assistant Secretary Dr Albert Lim, and the Technical and Scientific Committee included Mr Wong Jin Tin and Mr T Yogaratnam. Lecturers included Mr Hirohiko Tsujii, Dr S Ganesan and Dr M K Tan. Participants comprised 23 representatives from 10 countries and one representative from the Middle East. The Ralstron B 20 (Shimadzu) which was generously donated by the Government of Japan and channeled through the IAEA to Malaysia, was an essential component of the training course13 and was the first remote afterloading brachytherapy machine installed in Malaysia.
Regional cancer meetings in which Malaysia has taken part included Asian Oceanian Congress of Radiology (June 1995), Asia Pacific Cancer Congress (October 1996)14.
The First Malaysia /IAEA Brachytherapy Course was jointly organized by the Ministry of Health Malaysia and Hospital Universiti Kebangsaan Malaysia from 24-27th February 2004, with cooperation from Malaysian Institute of Nuclear Technology (MINT). The foreign expert was Professor Subir Nag. The participation and cooperation between the government, university and private sector was remarkable throughout the organization and conduct of the course, which was attended by 93 participants.
Our Own Malaysian Clinical Oncology Training Began in 2002
While post-graduate training in radiotherapy and oncology had traditionally been in the United Kingdom / Ireland, the Malaysian Government sent two trainees to Hong Kong for the first time in 2002. This was due to the increasing difficulties encountered by our trainees in pursuing post-graduate training in the United Kingdom. The local Master in Clinical Oncology was started in University of Malaya Medical Centre in November 2002, with strong support from the Ministry of Health. The first professional examination was held in November 2003, with Professor Michael Barton and Professor Dato Dr Tahir Azhar as external examiners from Sydney and International Islamic University respectively. The external examiners gave favourable and encouraging reports regarding the standards and conduct of the examination.
As evidenced by the publications of the First and Second Reports of the National Cancer Registry of Malaysia, it cannot be overemphasized that the optimal number of oncologists needed must be much higher than the number available at the moment. Both overseas training and a local post-graduate courses for clinical oncology are being supported simultaneously by the Government in order to train more clinical oncologists as quickly as possible.
Much has been achieved in oncology in the past 40 years. Good and comprehensive cancer treatment is the right of all. Cancer care services must be accessible and affordable throughout the entire health system, from the primary care level up to the centres for tertiary care.
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