Malaysia’s Liver Cancer Management: Multi-Stakeholders Need To Come Together

Liver cancer, a result of chronic liver disease that spans decades, can be prevented with early detection and intervention, amid the progress of new treatment options.

KUALA LUMPUR, July 5 — Malaysia’s health care system has failed to curb liver cancer, a highly preventable disease with the highest fatality rate among the top 10 cancers in the country, say physicians.

Liver cancer is the eighth most common cancer in Malaysia, according to the Malaysia National Cancer Registry Report 2012-2016.

The proportion of Stage Four disease in liver cancer in Malaysia rose from 65 per cent in the period of 2007 to 2011, to 74 per cent in the period of 2012 to 2016.

Five-year survival rate for liver cancer in Malaysia is only 12.8 per cent, second to lung cancer’s 11 per cent. However, median survival following diagnosis is 5.4 months for liver cancer, compared to slightly more than six months for lung cancer.

Former Health director-general Dr Ismail Merican, who is also a senior consultant hepatologist, told the Liver Cancer Roundtable that the cost of managing liver cancer was about RM4 million per year in 2013, with an estimated high costs currently at 70 to 80 per cent of cases in Malaysia due to late diagnosis.

“Liver cancer is preventable either by immunisation or by liver cancer surveillance in patients with known hepatitis or cirrhosis, where if small lesions are picked up early, they can be ablated or resected and the patient can be cured. However, that is often not the case these days, as many come in too late for curative treatment,” Dr Ismail said at the roundtable meeting.

He added that new treatments for patients with advanced liver cancer are now available with better outcomes for patients. “We’re very excited with these advancements that is being offered right now from targeted therapy to immunotherapy. However, these new treatments has to be accessible and affordable.”

Overall mortality-to-incidence ratio (MIR) for liver cancer is 0.95, indicating the highest fatality among the 10 most common cancers in Malaysia. (MIR is calculated by dividing the number of deaths in a given year by the number of newly diagnosed cases for cancer in the same year).

“Physicians consider the current situation a public health failure because liver cancer is highly preventable,” said the Galen Centre for Health and Social Policy in its report on the liver roundtable discussion it organised with hepatologists, among others, on liver cancer.

“From a clinician’s point of view, there is disappointment in that diagnosis is often made too late. Timely intervention of liver disease by physicians at the right time can prevent progression into liver cancer. This, however, is not picked up and often leads to patients presenting with liver cancer.”

In a panel discussion featuring 12 medical experts, including hepatologists and oncologists, and representatives from patient groups, the speakers stressed the importance of primary health care in early detection and awareness of liver cancer.

“There are cases of patients who get diagnosed on routine ultrasound with fatty liver disease, but no action is taken after years because of confusion on which primary team should manage the patient due to lack of awareness. Primary care physicians and general practitioners should be addressing fatty liver disease which is becoming more prevalent in communities,” Galen Centre’s report quoted them as saying.

Practitioners in settings with low-range ultrasounds, they said, could miss lesions if they are not well trained on the screening criteria and scanning protocol for liver disease.

Professor Dr Rosmawati Mohamed, a consultant hepatologist at University Malaya Medical Centre, cited studies by University Malaya that showed fatty liver is rapidly catching up to Hepatitis B as the etiologic agent (agent causing disease) for liver cancer. Globally, 17 per cent of liver cancer cases are related to fatty liver disease, previously referred to as cryptogenic cirrhosis.

Prevalence of cryptogenic cirrhosis in Malaysia doubled from 18 per cent in the 2006-2009 period to 36 per cent in 2015.

“What is more alarming is that it is set to overtake Hepatitis B as the commonest cause of liver cancer. The most recent study (in press) highlights fatty liver to be the etiologic agent in 42 per cent of cases, close to 44 per cent caused by Hepatitis B,” said Dr Rosmawati.

According to the National Health and Morbidity Survey (NHMS) in 2019, half of adults and one-third of children in Malaysia are overweight and obese.

“The implication on liver health is that one in four adults have fatty liver disease, which is rapidly becoming the commonest cause of liver cancer,” said the Galen Centre.

Medical experts at the roundtable pointed out that the Malaysian population is heterogeneous, where people have varying access to different health services, as well as different levels of health literacy, socio-economic status, and health belief systems, necessitating tailored advice, strategies, or education to combat liver cancer. One third of adults in Malaysia have low health literacy, according to NHMS 2019.

“The system is inevitably broken, and there are fundamental systemic issues that need to be addressed before effective health promotion and literacy can be achieved. Interventions today have not engaged the target population enough,” they told the panel discussion.

The panel also highlighted gaps in cancer support for rural communities and the lack of support groups in public hospitals, noting that support groups and advocacy efforts are mainly located in cities with better education and accessibility.

National Cancer Society Malaysia president Dr Saunthari Somasundaram noted that most other cancers occur without underlying chronic disease, but for most liver cancer cases, patients did not realise they had underlying conditions that could lead to liver cancer.

She stressed that emotional support for cancer survivors must be accompanied with psychosocial support and dealing with the economic and social impact of cancer.

Zuraini Kamal, a cancer survivor, highlighted the lack of health education in rural areas that drives cancer patients to alternative medicine, as they are unable to ask their doctors questions and have these addressed.

“The management of cancer requires a holistic approach, but there are limitations for those from rural areas. These patients lack understanding and usually cannot participate in discussions with their health care providers,” she said at the roundtable.

“There is a severe gap in education and screening among these communities and organisations, such as Cancer Survivor Malaysia, are helping to address this gap without much support from the government or other civil societies,” she said.

Medical experts called for more behavioural research that also looks at different ethnic groups’ language, socioeconomic circumstances, and belief systems, in order to draft better health promotion strategies, “knowing full well existing strategies do not work”.

Health education, they said, should be taken out of the health arena and put into the community, such as public education in schools, as health behaviours are learned throughout childhood and early adulthood.

The roundtable recommended adopting non-communicable disease (NCD) strategies into liver disease strategies to improve liver disease detection, amid the rise of fatty liver disease in Malaysia.

Panelists also suggested decentralising liver disease identification and testing strategies at the primary care level, such as by using digital health solutions to expand the capacity of health care providers, primary care providers, communities, and support staff.

A coalition on liver cancer, hosted by the NCSM, could also be set up.

Liver cancer, said the roundtable, must be portrayed as a preventable cancer, as liver cancer is a result of chronic liver disease spanning decades.

“Early detection and intervention prevent liver cancer. Patient groups have mentioned that early diagnosis is a challenge in public hospitals due to long waiting times and suggested more accessible screening mechanisms. The messaging must be spread across the whole of society,” said the Galen Centre’s report.

Finally, health care professionals must be adequately trained on liver disease guidelines, screening criteria, and scanning protocol, in order to avoid missing small lesions that cause patients to present later with more serious liver disease in advanced stages.

“There is a need to change the narrative surrounding liver cancer and implement a new agenda for hope,” said the Galen Centre.

This event was supported by Roche with the objective of providing a platform for multi-stakeholders to discuss challenges and opportunities to help improve the management and outcome of liver disease and liver cancer patients in Malaysia.

Roche believes that the complex challenge of liver disease cannot be tackled by just one entity, and that an integrated approach is needed to bring improved end-to-end solutions for patients along the disease continuum.

Roche supports the formation of a multi-stakeholder coalition and partnership across the health care ecosystem to tackle the growing disease burden of liver cancer. The pharmaceutical company believes more initiatives around the control and management of liver disease can be realised if all stakeholders take a joint effort and create a unified voice.

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