Cervical Cancer in Malaysia

Mohamad Khairi bin Ghazali Zakiyah Binti Karim

1. Introduction
The burden of cervical cancer in Southeast Asia is moderately high, where the costs of nationwide organized cytology screening have been a significant limitation. The use of Pap testing for cytology-based screening has been highly effective in preventing cervical cancer in industrialized countries and will most likely be effective in countries where screening is limited or nonexistent. Hence, the use of alternative screening modalities, such as visual inspection of the cervix aided by acetic acid (VIA) with or without magnification, is currently under evaluation. In addition, prophylactic human papilloma virus (HPV) vaccination for the prevention of infection and related disease is being considered as an additional cervical cancer control strategy.

2. Burden of cervical cancer in Malaysia

Cervical cancer incidence and mortality Cervical cancer second most common cancer in Malaysia, Furthermore, it is the fourth most common cause of death in women in Malaysia. In Southeast Asia, cervical cancer incidence (age-standardized rate (ASR) 15.7 per 100,000) is similar for Indonesia and Malaysia.

Fig. 1 shows the ASR of cervical cancer in countries with existing cancer registries and the high variability within Malaysia

 In Malaysia, the overall incidence rate is 19.7 per 100,000 women, however differs by ethnic group. Chinese women have the highest ASR of 28.8 per 100,000 women. Indians with 22.4 per 100,000 women. Malays (includes Peninsular Malaysia but not East Malaysia) with 10.5 per 100,000 women.

3. HPV prevalence in Malaysia

HPV-16 and 18 are the two most common HPV types in Southeast Asia, although HPV-18 alone is relatively more frequent compared to the type distribution estimates in the rest of the world. The estimate for Malaysia is based on a small number of cases (N = 23) and there was a high number of co-infections for HPV16 and 18, therefore, the interpretation of these data is limited.

Figure 2. Five most frequent HPV types in women with cervical cancer in Indonesia, Malaysia, the Philippines, and Thailand [10] and [11].

4. Risk factors for HPV infection and cervical cancer in Malaysia

The prevalence of cofactors - smoking, oral contraceptive use, and fertility - for cervical carcinogenesis in Malaysia are shown below:

Cofactors
Current smoking (% of women) Ever use of oral contraceptives (%) Total fertility Rate (per woman)

Malaysia 11.6

13.4

2.8

 In a cross-sectional school survey of 1219 year old adolescents, 5.4% (of which 8.3% were males and 2.9% were females) reported having had sexual intercourse. Median age at first sexual intercourse was 15 years; however, this estimate may be underreported given that talking about sex is a culturally taboo subject in Malaysia. However, an increasing proportion of adolescents are engaging in premarital sex, which may reflect the rapid social changes in the country and the increased likelihood of being exposed to HPV and other sexually transmitted infections (STI).

5. Current cervical cancer screening programs

In 1969 screening program started using the Pap smear. In 1981 screening extended to include all family planning users. In 1995 various agencies, e.g.: the National Population and Family Development Board (NPFDB), private clinics and hospitals, university and army hospitals, and non-governmental organizations like the Federation of Family Planning Association of Malaysia (FFPAM) provided Pap smear services as part of a cancer campaign where the Pap testing was available once every 3 years for all females aged 2065 years. According to the World Health Organization (WHO) Health Surveys 2001/2002, Pap smear coverage was only 23%. The highest Pap smear uptake was among women aged 3039 years (36.6%) compared to women in other age groups: 1829 years (14.6%), 4049 years (28.8%), 5059 years (20.9%) and 60 69 years (5%).

 The 2003 National Guidelines on Pap Smear Screening recommended that all sexually active women aged 2065 years should attend screening annually for two consecutive years. If both smears are normal, screening can continue every 3 years. In 2003, the Malaysian Ministry of Health (MoH)allocated 3.55 million MYR (~18 million CZK) for free Pap smear tests to women attending public health facilities. The predominant screening method is conventional cytology with only a few public health services and the private sector offering liquid-based cytology. In 2005, public health facilities and government hospitals contributed 69% of all Pap smear tests compared to private health facilities, which contributed only 20.6%. From 1996 to 2005, the annual number of Pap tests ranged from 350,000 to 400,000 smears, with no significant variation in the total number of tests over the years. Abnormal Pap smears and unsatisfactory ones for evaluation accounted for 0.86% and 3.1%, respectively.

 The 1991 Bethesda reporting system is still in use and an effort to review the 2004 Pap Smear Guide Book is underway. MoH has initiated a project to develop a centralized database system for both public and private sectors to determine the feasibility and cost-effectiveness of an organized screening program to reduce the incidence of cervical cancer through a call-recall system, and to develop a national Pap smear registry. This project also aims to increase Pap smear coverage to 75% among women aged 2065 years. The project is currently undertaken in Klang, Selangor and in Mersing, Johor Baharu with completion targeted for 2011. MoH has taken the initiative to also develop a National Colposcopic Training program and to evaluate the role of VIA and cryotherapy as modalities for secondary prevention. With support from WHO, a demonstration project on VIA and cryotherapy is in its early implementation phase in the low socioeconomic district of Sik in the northern state of Peninsular Malaysia.

6. Cervical cancer prevention and HPV vaccination

The Malaysia Drug Authority approved the use of the quadrivalent HPV vaccine (Gardasil, Merck & Co., Inc., Whitehouse Station, NJ, USA) in October 2006 Other studies on the prevalence of HPV and invasive cervical cancer are also underway.

A National Immunization Technical Committee under the Disease Control Division of MoH has been given the responsibility to study and make recommendations on the role of the HPV vaccine in Malaysia. Currently, the MoH, non-governmental organizations (NGOs) and pharmaceutical companies are actively involved in increasing knowledge on HPV and cervical cancer using mass media, media electronics, posters and pamphlets.

References
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