Japanese Journal of Clinical Oncology 32:S17-S21 (2002)
© 2002 Foundation for Promotion of Cancer Research
Cancer in Indonesia, Present and Future
Departments of 1Surgery and 2Pathology, Medical Faculty, University of Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPRESENT SITUATIONSUGGESTIONS FOR CANCER CONTROL...REFERENCES |
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Cancer control has been in effect in Indonesia since the early 1920s. It was the Dutch Colonial Government who started with the Institution for Cancer Control, which was closed by the Japanese Occupation Administration between 1942 and 1945. After the independence of the Republic of Indonesia, a Cancer Control Foundation was established in 1962. At present, clinical and non-clinical departments in government teaching hospitals (there are 13 teaching hospitals) usually handle all cancer problems. In 1993, Dharmais Cancer Center in Jakarta was established and has become the top referral cancer hospital for Indonesia. Until now, there have been no nationwide accurate data on cancer registration, owing to a lack of funds and manpower. Cancer data collection is usually provided as a relative frequency study from several departments of the teaching hospitals. It is currently estimated that there will be at least 170–190 new cancer cases annually for each 100 000 people. The most frequent and primary cancers are cervix, breast, lymph node, skin and nasopharynx. Since Indonesia is now in a transition phase and has many problems concerning the economy and health care, we suggested a well-planned cancer control program. It includes the primary, secondary and tertiary prevention of cancer in cities, where inhabitants can afford to subsidize a certain proportion of the budgets for the implementation of this program.
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INTRODUCTION |
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Historically, the first major effort aimed at cancer control in Indonesia was initiated by the Dutch Colonial Government in the early 1920s (1). The first organization for cancer control which coordinated the activities for research and prevention was established in Bandung in 1933, called the ‘Nederlands Indische Kanker Institute’, which was closed during the Japanese occupation between 1942 and 1945 (1). After independence of the Republic of Indonesia, the first Indonesian Foundation for Cancer Control was established in 1962 in Jakarta. This was followed by several Cancer Foundations in several cities such as Surabaya, Solo, Yogyakarta and Bandung. The Coordinating Foundation of all these cancer societies was then established in Jakarta on April 17, 1977, named the Indonesian Cancer Society. Research Institutions have also been established such as the National Cancer Research Institute in Jakarta in 1965, under the supervision of the Department of National Research, which was closed in 1966. In 1974, a Research Center for Cancer and Radiology was established under the National Health Research Institute of the Ministry of Health.
In 1993, a new comprehensive Cancer Center Hospital was established in Jakarta which is also affiliated to the Medical Faculty University of Indonesia for the purpose of teaching and training for medical postgraduates and also for research on basic oncology.
Since the incidence of cancer goes up with increasing of life expectancy and better control of communicable diseases, the cancer load in developing countries such as Indonesia can soon be expected to be formidable (2–4). It is currently estimated that there will be at least 170–190 new cancer cases annually for each 100 000 people (5,6) and therefore cancer has risen to become sixth in rank among deaths after infectious diseases, cardiovascular diseases, traffic accidents, nutritional deficiency and congenital diseases (1,5–7). However, most cancer patients (60–70%) seek medical treatment when it is already too late (1,6).
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PRESENT SITUATION |
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TOPABSTRACTINTRODUCTIONPRESENT SITUATIONSUGGESTIONS FOR CANCER CONTROL...REFERENCES |
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The Indonesian archipelago consists of over 17 000 islands, occupying almost 2 x 106 km2 of land. Administratively, Indonesia is divided into 27 provinces, 241 districts, 55 municipalities, 3501 subdistricts and 66 979 villages. Indonesia has a population of more than 200 million people (1974) (7) and is the fifth most populated country in the world after China, India, the Russian Federation and the USA. As there are no population based registries in Indonesia, the exact incidence and prevalence of cancer are not known. However, data collected from hospitals in several regions shows that cancer incidence increased by 2–8% per year during the last decade (1,6).
Data which have been collected from 13 pathological laboratories throughout Indonesia during the period of 1988–91 show that in the combined picture, cervical, breast, lymph node, skin and nasopharynx are the five major anatomical sites for cancer disease (8) (Table 1). Among females, the most common cancers are cervical, breast and ovarian cancer (Table 2), and among males skin, nasopharynx and lymph node cancer (Table 3). The relative proportions between male and female patients can be seen in Table 4, where most cancer patients are female, with a proportion of 65.4% in comparison with 34.5% for males for an observation period of 4 years (1988–91). The incidence rate of various cancer sites in males and females showed an increasing rate each year in every cancer site. Regarding age incidence, the major cancer group were aged between 45 and 54 years (26.19%), followed by the age group 55–64 years (21.84%). The trend showed that our cancer patients are mostly from the aging population (Table 5). The general pattern of cancer occurrence in Indonesia is mostly similar in certain areas, as can be seen in Table 6, where the most common cancers are cervical uterus cancer followed by breast, nasopharynx and skin.
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Since smoking tobacco is a very common habit among Indonesian men, increasing attention has recently been paid to lung and bronchial cancer (9). Realizing that the primary prevention strategy for tobacco-related cancer would necessarily be a comprehensive anti-tobacco program, the government of the Republic of Indonesia is considering various anti-tobacco legislative measures, and also measures aimed at tobacco product modification to render them less hazardous.
Recently we found that among men, 12% of cancer occurrence is in the liver, which is linked to aflatoxin and also to hepatitis B virus.
The facilities for cancer care have improved recently in Indonesia. Efforts at controlling cancer have been undertaken by the government and the private sector, including the professional organizations and non-government organizations (NGOs). These efforts can be generally classified into prevention, early detection and treatment (1,6,10). Rehabilitation, cancer registration and research are still in their very early stages. Activities being conducted for primary prevention and early detection are as follows:
proposing legislation to reduce tobacco consumption and other carcinogenic substances (11);
the Ministry of Health and the Indonesian Cancer Society facilitate the National Pathology Based Cancer Registry through the Indonesian Pathologists Association, for baseline data for the Indonesian National Cancer Control Program (8,10,11);
providing the health facilities for cytological examination of the cervix (11);
promotion of breast self-examination through public education.
In 1989, the Ministry of Health established a National Committee for Cancer Control which was meant to plan a comprehensive Cancer Control Program in terms of:
• prevention
• early detection
• early diagnostic
• prompt treatment
• follow-up
• rehabilitation
• cancer registration
• cancer research
This program has to be set up and distributed throughout the whole of Indonesia and must be applied in most of the hospitals that are provided with complete facilities for diagnostics and treatment.
In 1993, the Indonesian government has also built a comprehensive Cancer Center Hospital in Jakarta with a clear focus on research and health services. This hospital must also function as a teaching hospital for postgraduate training, which is affiliated to the Medical Faculty University of Indonesia in Jakarta.
At present the various modalities of therapy for cancer which are used in Indonesia are in the following proportions:
radiotherapy 70%
surgery 20–25%
chemotherapy 5–10%
Radiotherapy is only available in 11 teaching hospitals:
Sumatra 3
Java 5
Sulawesi 2
Bali 1
A multi-disciplinary approach, which is the key to successful cancer treatment, can only be found at the state university hospitals (13) and has not been adopted in most municipal hospitals. Cancer surgery is practiced in all state university hospitals.
Medical oncology divisions have so far started in only nine state university hospitals. Pathology and cytology facilities are well organized in most of the state university hospitals.
There is a gross deficiency of diagnostic and radiotherapy equipment throughout the state university hospitals. CT scan, MRI and nuclear medicine facilities are not available in all medical faculties in Indonesia.
There are only four pediatric oncology departments among the 13 state medical faculties in Indonesia. A running hospital-based tumor registration can only be found in Jakarta and Surabaya.
Rehabilitation services and research and development activities in cancer control are conducted only in Jakarta and Surabaya.
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SUGGESTIONS FOR CANCER CONTROL MEASURES IN THE FUTURE FOR INDONESIA |
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TOPABSTRACTINTRODUCTIONPRESENT SITUATIONSUGGESTIONS FOR CANCER CONTROL...REFERENCES |
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A well planned cancer control program aimed at improving cure rates to reduce the morbidity and mortality rates and also to improve the quality of life of cancer patients is desirable. In order to achieve these goals, efforts have to be made in the following areas.
Primary Prevention of Cancer (11)
More epidemiological studies on risk factors of cancer with high mortality rates, especially factors relating to life style, diet, reproduction and the environment, as well as cross-cultural studies should be encouraged.
Cancer registration should cover all clinics and medical institutions and ensure the validity of the diagnosis.
Education programs should be introduced through institutions and mass media concerning factors related to the common cancers in the population; encouraging behavior and life style that lead to the inhibition or suppression of the risk conditions.
Research is required on understanding the biology of cancer and the clinical, physical or infective agents to which people are likely to be exposed, in order to determine the cancer possibilities today and in the future.
More clinical trials on effective treatment methods should be launched.
Secondary Prevention of Cancer (12)
This is aimed at making an early diagnosis of cancer, so that the development of cancer can be interrupted. One of the activities in this program is the referral system, which is categorized as follows:
• the patient is referred to a health unit;
• a specimen is referred to the laboratory or histopathology unit;
• knowledge and ability are referred to health personnel and health units.
Tertiary Prevention of Cancer (13)
This is conducted in the last/outside of the control program where symptoms and signs of the tumor already appear on the surface. The purpose of this last prevention is to give proper treatment that will stop the development of the cancer and avoid death. If the patient is still alive as a result of such intervention, follow-up care and rehabilitation should be administered. Supportive care and pain relief facilities should also be set up for advanced and terminal cancer patients (14).
Plan of Action
To carry out these objectives, the following action has to be taken. Efforts should be aimed at preventing the occurrence of cancer. This can be achieved by reducing the exposure to carcinogenic substances and increasing the resistance of the population to carcinogenic agents e.g. via tobacco smoking (11).
Early Detection
Efforts should be made to detect cancer at an early stage, e.g.:
• increasing facilities for cytological examination (cervical cancer);
• promoting breast self-examination through public health education, etc. (12).
Diagnostic and Treatment Service for Cancer Patients
All ‘A-class’ hospitals (top referral hospitals; there are only two hospitals, one in Jakarta and the other in Surabaya) must function as cancer centers. They have to carry out tertiary referral services, education and research in the field of cancer.
All 23 ‘B-class’ hospitals and 26 first-class private hospitals must have cancer teams and their facilities should be increased.
All 124 ‘C-class’ hospitals and 41 intermediate-class private hospitals should be equipped with facilities and personnel to carry out early diagnosis and supportive treatment.
Analgesic drugs, including oral morphine, should be readily available at all hospitals and community health centers (14).
Rehabilitation Services
These activities have been performed in all ‘A-’ and ‘B-class’ hospitals.
Cancer Registration
To meet the special needs of cancer incidence, at least a hospital-based cancer registry should be developed, especially in ‘A-class’ and several ‘B-’ and ‘C-class’ hospitals (15). Population-based cancer registries should also be developed in certain areas with a population not more than 2–3 million, such as Yogyakarta, Semarang or Palembang.
Research and Development
R&D should be planned from now on in order to establish the size of cancer problem and to identify high-risk groups, so that we can meet these problems with appropriate technology and treatment (16,17). On November 28th, 1990, the Indonesian Government via the Ministry of Health established a National Cancer Control Action Plan to consolidate and escalate the efforts for a National Cancer Control Program. The success of this effort depends greatly on the effectiveness of the coordination and management by the government institutions concerned and also the active participation of the professional organizations and the public and private sectors.
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FOOTNOTES |
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+ For reprints and all correspondence: Didid Tjindarbumi, Department of Surgery, Division of Oncology, Medical Faculty, University of Indonesia/ Dr. Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71, Jakarta, Indonesia. E-mail: dtjindarbumi@yahoo.com
Abbreviations: NGO, non-government organization; CT, computerized tomography; MRI, magnetic resonance imaging; CME, continuous medical education
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REFERENCES |
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TOPABSTRACTINTRODUCTIONPRESENT SITUATIONSUGGESTIONS FOR CANCER CONTROL...REFERENCES |
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Received February 13, 2001; accepted August 8, 2001.
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