## Abstract

Background: The registry of the Oncology Departmental in Sarawak General Hospital showed that 79% of nasopharyngeal, 77% of breast and 70% of cervix cancer patients were diagnosed at an advanced stage (stages III and IV) for year 1993. Hence, a low cost Early Cancer Surveillance Program was started in 1994, with the intent of downstaging these three most common cancers in Sarawak.

Materials and methods: The program consisted of (i) training health staff in hospital and rural clinics to improve their skills in early cancer detection, (ii) raising public awareness through pamphlets, posters and sensitization by health staff.

Results: Data analysis revealed that the program achieved downstaging in two of the cancers. Breast cancer in stage III and IV was reduced from 60% (1994) to 35% (1998) (P < 0.0001) and cervical cancer in stage III and IV from 60% (1994) to 26% (1998) (P < 0.0001). No reduction was observed for nasopharyngeal cancer at 88% (1994) to 91% (1998).

### population

The statistics presented are based on hospital case series as no accurate population-based registry was available in Sarawak at that time. However, we feel that these series can give a good representation of the Sarawak cancer pattern. That is due firstly to the fact that DRO is the only cancer facility on the island and that <2% of patients can afford to go out of the state for treatment. Secondly, in Malaysian public hospitals free treatment and free travel for treatment are provided easily to those who need, ensuring that almost all cases go for treatment. During the studied period, 1993–1999, all NPC, breast, cervix, lung, colon and rectum cancer cases of Sarawak were referred to the DRO. The four private and the five public surgeons performing surgery on breast, colon and rectal cancer surgery, consistently referred their patients for adjuvant treatment, either radiotherapy or chemotherapy. Until 2000, as no gynecologic surgery was available in Sarawak, cervical cancers were also consistently referred to DRO for radiotherapy. All lung cancers were referred unless they were so advanced that no form of treatment would have any benefit. Non-Sarawak patients (mainly Indonesians) were excluded from the series. We thus estimate that the case series studied here represent at least 80% of the cancer cases of Sarawak for the studied period, the cases missed being the ones at both ends of the socioeconomic spectrum.

### statistics

Data on PAP smear programs were obtained from the Central Laboratory Services of SGH and compared with the DRO's data. Paper files data from the registry of the DRO were entered and analyzed with Excel. P values provided correspond to Fisher's exact chi-square test calculated online at: www.matforsk.no/ola/fisher.htm.

## results

### clinical downstaging

As shown in Figure 3, the percentage of breast cancer patients presenting for treatment at late stage (stage III and IV) dropped from 77% (69/90) in 1993 to 37% (42/115) in 1998 (χ2 = 17.0; P < 0.0001). Similarly, for cervical cancer, the late-stage presentation dropped from 70% (47/67) in 1993 to 27% (28/105) in 1998 (χ2 = 31.4; P < 0.0001). For NPC, the figure shows no change from 79% (84/106) in 1993 to 92% (147/160) in 1998 (nasopharyngeal = 8.9; P > 0.40). During the same period, cancers not targeted for downstaging did not display any stage variation at presentation. Between 1994 and 1998, the percentage of late stage remained stable with 93% (n = 72) to 91% (n = 96) for lung, 63% (n = 26) to 65% (n = 26) for colon and 66% (n = 18) to 68% (n = 22) for rectum.

Figure 3.

Percentage of patients presented at late stage for nasopharyngeal cancer (NPC), breast and cervix in Department of Radiotherapy and Oncology (DRO), Sarawak General Hospital (SGH) (1991–1999).

Figure 3.

Percentage of patients presented at late stage for nasopharyngeal cancer (NPC), breast and cervix in Department of Radiotherapy and Oncology (DRO), Sarawak General Hospital (SGH) (1991–1999).

We feel that raised public awareness was more efficient than health staff training to achieve the breast and cervix results, all the more so since health staff were rotated or transferred rather rapidly and we were not able to provide multiple training in some of the sites for the period 1994–1998.

### inefficiency of the PAP smear program

The DRO's medical record review for 1993–1999 showed that most of the cervix cancer cases consulted because of symptoms (postcoital bleeding, foul smelling discharge per vagina) questioning the efficiency of the screening program implemented since 1963. This extensive review of all cervix cancer medical records showed that only 5% of the cases got a PAP smear at asymptomatic stage showing that the screening program did not reach its target.

## discussion

### validity of results

Although the statistics carried out for this analysis were based on a case series, we feel that the bias present in this series may not be sufficient to invalidate the conclusions. The Sarawak patients not seen at the DRO during the studied period would be either wealthy people (who may go for treatment abroad) or people from very remote areas who were too sick to travel at the time they were referred. Only the behavior of this last group may have been altered by the program. By decreasing late-stage presentation, the program may have decreased the number of people too sick to travel, and thus increase the absolute number of cases seen at DRO. This effect may explain the increasing number of NPC cases observed between 1995 and 1998. Such an increase in absolute case number cannot create a false positive result (i.e. spurious increased proportion of early-stage presentation).

To assess the efficiency of the program it would have been adequate to compare stage at presentation in patients from districts where the training had been done and patients from districts where the training had not been done yet. Unfortunately, such comparison was not possible because geographical origins of patients were uncertain (a large proportion of patients do not give their own address but the one of the nearest family member). In order to check if the trends observed for NPC, breast and cervix were not due to increasing global health awareness, comparisons were made with other frequent cancers for which no program had been instituted, and no changes were observed.

Our result shows that clinical approach to downstaging was achievable for cervix and breast cancer but was not successful for NPC. Increased public awareness about the signs and symptoms incorporated with easier referral to doctors helped to achieve these results. As symptoms of NPC mimic certain benign conditions, there is a need for innovative methods for early detection of this cancer and presently a novel approach is being tested in an area in Sarawak which has a high risk population and the preliminary results are encouraging.

## conclusion

Early cancer surveillance programs including education of public and heath staff can achieve clinical downstaging. The successful downstaging observed here for breast and cervix cancers is a crucial finding that is relevant to developing countries where simple and inexpensive methods could be integrated into existing health care programs. The resultant downstaging should lead to a reduction in mortality for these cancers. Educating women empowers them to self-care and gives them the opportunity to seek treatment earlier. In countries with limited financial and manpower resources, downstaging of cancers is a cost-effective way of tackling the problem of cancer burden.

The authors would like to thank the State Health Department for their assistance in funding the program.

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