Breast Cancer in Indonesia in 2022: 30 Years of Marching in Place
Breast cancer is the most prevalent cancer in Indonesia, 19.2% out of all cancers . In 1992, most breast cancer patients (60-70%) sought medical treatment when the cancers were in late stages (stage III and IV) . Thirty years later data collected from several teaching hospitals in Indonesia shows that 68- 73% of breast cancer patients come to medical centers in the late stages [3,4,5]. It is interesting to learn why the number of late-stage breast cancer patients in Indonesia remains the same despite the advancement in early detection and therapeutical measures. This editorial will mainly discuss one factor contributing to the diagnostic and treatment delay: patients’ accessibility to proper medical attention.
Accessibility to proper medical attention for breast cancer patients in Indonesia depends on the number and distribution of trained oncologists, a concise referral system, and supportive regulation.
Indonesia is a vast archipelago country with a population of more than 273 million people. In tertiary medical centers, breast cancer patients are attended by surgical oncologists since surgery is the main treatment. As per February 2002, there are only 233 surgical oncologists practicing. This number is far below the ratio proposed by the Indonesian Society of Surgical Oncologists (Perhimpunan Ahli Bedah Onkologi Indonesia/PERABOI) which is 0.2 per 100,000 population (546 surgical oncologists needed). This number is still below the ideal ratio which is twice as much. However, setting a goal too high would make the organization frustrated, hence the revised target. The role of oncologists is vital in breast cancer cases. A multinational analysis shows that being diagnosed with breast cancer by an oncologist correlates with shorter treatment delay .
It takes at least 6 years of general surgery training plus 2 more years of surgical oncology training to produce a surgical oncologist. This does not count the 2-5 years of working experience required before a general surgeon could apply for the surgical oncologist training.
Acceleration is critical to producing more surgical oncologists, either by establishing more training centers or by modifying the training system. Establishing a surgical oncology training center is no simple procedure; especially since UU Pendidikan Kedokteran number 20/ 2013 mandates that medical specialist training must be university-based .The government should consider the role of hospital-based training to accelerate the production of surgical oncologists. The revision of the law is underway that would recognize the role of professional society and collegium in medical specialist training.
Acceleration can also be carried out through modifying the training system: from subspecialist training to specialist training. A general practitioner can enroll for the surgical oncology training without having to be a general surgeon first. The role of “collegium” is vital to ensure that the training curricula meet the requirement despite the cutting down of training time. Nevertheless, modification of the training system will take years unless there is government intervention to simplify the regulations.
Another alternative to increase the number of competent surgeons attending breast cancer patients is by establishing a crash program in surgical oncology for general surgeons. The program would train general surgeons in early detection, proper treatment, and the vital knowledge of “when to refer” to tertiary medical centers so that the patients could have the best possible treatment.
The lack in the number of surgical oncologists is worsened by the uneven distribution throughout the country. More than 50% practice in big cities in Java Island leaving some distant provinces with only one or two surgical oncologists. Distribution is vital so that expert medical advice is accessible throughout the country. The public health system and private insurance may cover the direct cost of breast cancer care but not the indirect costs such as traveling expenses to reach distant medical centers. The indirect cost is one factor contributing to patients’ delay to seek breast cancer care [8,9]. A study in Yogyakarta shows that various out-of-pocket expenses such as transportation and logistics linked to presentation, diagnosis, and subsequent breast cancer treatment remain a financial burden and hinder the patient from seeking early medical treatment . The government needs to work closely together with the Society to regulate the distribution of surgical oncologists throughout the country.
A breast cancer referral system that concisely states “what and when” to refer to tertiary medical care is necessary to prevent referral delay. A study in a tertiary medical center in Surabaya shows that only 13,8% of the patient comes through the referral system . This shows some dysfunctions in our country’s referral system. It is necessary to prepare a breast cancer referral guideline for physicians in primary and secondary medical centers. Lack of concise referral guidelines may result in some early breast cancer patients getting inadequate surgical oncology treatment in secondary medical centers and later coming to the tertiary medical center in a more advanced stage.
Reformation of some regulations is imperative in ensuring patient access to proper medical attention. Laws that regulate medical specialist training need to be reformed in order to accelerate the production and national distribution of much demanded surgical oncologists. It is necessary to establish regulation on the breast cancer referral system to avoid referral delay in secondary medical centers. There is also an urgent need to re-evaluate the regulation of the national health financing system, which often contributes to hospital delay of breast cancer treatment.
Aiming for reducing the number of late-stage breast cancer in Indonesia is a gigantic work. From the medical standpoint, it is crucial that breast cancer patients have access to proper medical attention as early as possible. Accelerating the production of surgical oncologists, ensuring their even distribution throughout the country, improving the breast cancer referral system, and reforming some regulations are indispensable measures to take. Thirty years ago, we had 60-70% late-stage breast cancer. Nowadays sadly we have similar numbers. And if we do not take necessary actions, thirty years from now we will not see much difference in the number. It would seem that breast cancer care in Indonesia is marching in place.
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