Breast cancer reality check: We're dying more than we should

  • Wellness
  • Tuesday, 02 Apr 2019

Some of the deaths due to breast cancer are caused by the disparity in access to cancer care between the rich and poor in Malaysia. — AFP

Globocan– an acronym for Global Cancer Incidence, Mortality and Prevalence – is a project of the International Agency for Research on Cancer (IARC) that provides estimates by cancer site and sex using the best available data in each country and several methods of estimation.

Globocan estimated that there were 23,218 new cancer cases in Malaysian females in 2018, with 12,458 deaths.

The risk of developing cancer before the age of 75 was 25.8%, i.e. about one in every four people would develop cancer before they hit 75 years of age.

The risk of dying from cancer before the age of 75 was 19.8%, i.e. about one in every five people would die from cancer before that age.

The commonest cancer in females was breast cancer, followed by colorectal and cervical cancers.

The Malaysian National Cancer Registry Report 2007-2011 stated that breast cancer accounted for 32.1% of all female cancers, with an overall lifetime risk of one in 30, i.e. one woman in 30 will get breast cancer in her lifetime.

Breast cancer occurred more frequently in Malaysia compared to Thailand and China, but less frequently than in Singapore, according to the report.

In terms of ethnicity, the highest occurrence was in the Chinese, followed by Indians and Malays, with lifetime risks of one in 22, one in 24 and one in 35 respectively.

Excellent Survival Rates

A private hospital in the Klang Valley reported excellent survival rates for breast cancer, with an overall relative survival rate at five years of 88%.

The relative survival rate was 100% for stage I, 95% for stage II, 69% for stage III and 36% for stage IV. These survival rates were comparable with that in developed countries.

All women treated at the hospital between 2008 and 2012 were enrolled in the study, published in the Asian Pacific Journal of Cancer Prevention in 2015.

A total of 675 patients were treated: 65% with early breast cancer, 20% with locally advanced breast cancer and 4% with metastatic breast cancer.

Death was ascertained through record linkage with the national death register, hospital registration system and through direct contact by telephone or home


Wide Disparities

However, a study in the Global Journal of Health Science reported wide disparities in breast cancer care for the general Malaysian population.

The number of avoidable deaths is the difference between the number of deaths estimated by Globocan 12 for Malaysia and the expected number of deaths if all patients with breast cancer had experienced the age-ethnic-stage specific survival outcomes observed in the private hospital above.

The study, published in 2017, reported: “Of the 2,312 excess deaths due to breast cancer, 2,048 (88%) were avoidable.

“Of these avoidable deaths, 1,167 (57%) were attributable to late presentation, while 881 (43%) were due to lack of access to optimal treatment.

“Sensitivity analyses, however, show that the 88% avoidable deaths may be as low as 50%, taking into account differences in socio-economic status, overdiagnosis and lack of very long-term survival data.”

The authors concluded: “The huge number of avoidable deaths highlights the high cancer mortality rate among the deprived and vast disparity in access to cancer care between the rich and poor in Malaysia, which mirrors the global cancer divide between rich and poor countries.”

Another study, i.e. the 2012–2014 Asean Costs in Oncology (Action) Study, prospectively followed-up 9,513 newly diagnosed cancer patients from eight countries from March 2012 to September 2013.

Malaysian residents accounted for 1,662 of those studied and breast cancer comprised 26% of the overall numbers.

The overall and country-specific incidence of financial catastrophe, i.e. out-of-pocket health costs (equal or more than 30% of annual household income), economic hardship (inability to make necessary household payments), poverty (living below the national poverty line) and all-cause mortality, were determined.

The study found that the proportion of previously-solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45%) and Indonesia (42%), and lowest in Thailand (16%).

The specific finding of the Action study for Malaysia was that out-of-pocket expenditure pushed 51% of surviving patients into financial hardship a year after diagnosis and treatment, with 46% having used up their personal savings, 39% unable to pay for medicines; 35% unable to pay for consultation fees or tests; 22% unable to pay rent or mortgage, and 19% discontinuing treatment.

Accelerated Action Needed

Malaysia aspires to meet the Sustainable Development Goals (SDG) by 2030. SDG 3 is to “ensure healthy lives and promote well-being for all at all ages”.

One of the targets of SDG 3 is to reduce premature mortality from non-communicable diseases – of which cancer is one – by one-third by 2030 through prevention, treatment and promotion of mental health and well-being.

Another target is to “achieve universal health coverage (UHC), including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality and affordable essential medicines and vaccines for all”.

The authors of the 2017 Global Journal of Health Science study concluded: “The cancer care system that delivers such disastrous and inequitable outcomes is clearly under-performing. It is in urgent need of reform.”

A local think-tank has already made policy recommendations to parliamentarians and policymakers in September 2018.

The wide disparity in breast cancer outcomes cannot be acceptable to anyone. The results of the studies and policy recommendations above should have been acted upon by policymakers.

The announcement of studies of ways to reduce cancer treatment costs are of no comfort to affected patients and their families. Definitive action is required, not prevarication.

In order to achieve the SDG 3 targets for cancer mortality and UHC, accelerated action is needed to improve cancer care, achieve global targets to reduce deaths from cancer and provide healthcare for all consistent with UHC.

Otherwise, Malaysia will be unable to achieve UHC.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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