KUALA LUMPUR, Feb 28 – The Covid-19 pandemic, stretching into its third year, has affected Malaysian women’s health and disrupted their access to services, particularly for cancer.
In some cases, cancers in women developed as screenings were halted due to movement restrictions and fear of visiting hospitals when many were dying from Covid-19. Late-stage diagnosis is linked to poor prognosis.
“Women’s health care has taken significant steps backwards after these two years of the Covid pandemic,” gynaecologist Dr John Teo told Ova.
“Many of the gains we had made over the last decade had simply become barely accessible or non-existent and we must redouble our efforts in rebuilding what we had lost within this short span of time. Critically, women and children had suffered the most and bear the heaviest burden during the pandemic.
“All national recovery policies and strategies must put women and children at the centre if we are to succeed in regaining all the progress made and catapult ourselves into the next few years better, brighter and more economically vibrant.”
Disruptions In Breast Cancer Screening, Treatment
Even before the pandemic, there was a notable surge in the number of breast cancer cases in the country from a total of 18,206 cases for the period of 2007 to 2011 to 21,634 cases from 2012 to 2016, according to the Malaysia National Cancer Registry Report (MNCRR) 2012-2016.
Staging, which refers to the progression of the cancer including the size of the tumour and how far it has spread from the point of origin, was reported for 13,845 cases (62.3 per cent) in 2012 to 2016.
From that number, 47.9 per cent were detected at Stages Three and Four, higher than the rate recorded in 2007 to 2011 at 43.2 per cent.
For a more recent figure, the number of new breast cancer cases recorded in Malaysia in 2020 was 8,418, according to Globocan 2020.
The number accounted for 32.9 per cent of all new cancer cases that year, making it the second highest type of cancer among new cases.
Dr Mastura Md Yusof, a consultant clinical oncologist at Pantai Hospital Kuala Lumpur, said she expects an increase in late cancer diagnosis and late relapse diagnosis this year because there were many delays in appointments and clinic visits for mammograms, ultrasounds and biopsies due not just to travel restrictions, but also fear during the height of the pandemic in the last two years.
Referrals to surgeons and procedures such as CT stagings were also postponed.
“There were also disruptions in treatment due to unnecessary paranoia regarding vaccines,” Dr Mastura told Ova.
“Some patients stopped taking tamoxifen a few months before they were vaccinated because they feared the combination might be dangerous.” Tamoxifen is a medicine used to treat and prevent breast cancer.
“I had a patient who wanted to ‘clear the vaccine’ first before surgery and as a result the tumour grew while they were waiting.”
Dr Mastura said she also observed that during the pandemic, insurance companies were changing or lowering their coverage, which caused disruptions in her patients’ care plan.
How The Pandemic Affected Three Women With Breast Cancer
Rita (pseudonym) is in her 40s and needed surgery for her Stage One cancer. Although Rita had insurance, she was concerned that it would not be sufficient to cover her procedure at a private hospital. However, most public hospitals were not accepting cases from outside due to their heavy Covid caseloads.
After three months, she returned to the private hospital for her treatment. By that time, her cancer was already stage 2B, so she also had to undergo chemotherapy, besides surgery and radiotherapy.
In another example of the danger of delaying treatment, 50-year-old Lina (pseudonym) delayed getting a mass in her breast checked because her colleague was admitted to the intensive care unit (ICU) for Covid and died after two weeks.
The lump grew and ulcerated causing frequent bleeding and anaemia. She almost fainted at work and was rushed to the hospital where it was discovered that the mass had become larger and metastasised to the bone as well.
Finally, Lucy (pseudonym) is from a remote village. She was on follow-up after three or four years from her initial breast cancer diagnosis. She noticed a swelling on her remaining breast and also felt unwell.
However, she was unable to travel due to the pandemic. She got in touch with her oncologist who asked her to see a doctor in her district. The doctor told her the swelling was a skin infection called cellulitis and prescribed her antibiotics.
When travel was allowed two to three months later, Lucy discovered that her cancer had not only recurred but had also spread to other parts of her body.
Travel Difficulties For Cancer Patients Outside Klang Valley
Dr Ibrahim Abdul Wahid, a consultant clinical oncologist at Beacon Hospital, said he has observed a slight increase in late-stage cancers in Stages Three and Four, not limited to the breast, which was inevitable given the restrictions and rules on movement in the last couple of years.
“There are not many centres for treating cancer in the outskirts and patients from certain districts in places like Terengganu and Pahang have to come all the way to the Klang Valley to receive treatment,” he said.
“Given the hassle with permission letters and all that, there is a reluctance to travel and this has resulted in the more advanced forms of cancer that we have come across.”
While Dr Ibrahim acknowledges that there is perhaps a slight increase in breast cancer cases, his outlook is not all doom and gloom. “When I started treating cancers in the early 1990s, there was not a lot of awareness about it,” he told Ova.
“Now, a lot of NGOs have emerged to play an important role in raising awareness about this disease. And there are a lot of initiatives that have improved early detection rates such as MAKNA’s mobile mammogram programme that provides free mammogram services to women in rural areas.”
He also cited subsidised mammogram services offered by the National Population and Family Development Board Malaysia (LPPKN) under the Women, Family and Community Development Ministry.
“All of these efforts have made a positive impact on improving cancer detection.”
Fewer Cervical Screenings, Cancer Cases May Rise Over The Years
The number of cervical cancer cases in Malaysia declined from 4,352 cases reported during the period of 2007 to 2011 to 3,981 cases from 2012 to 2016, according to the MNCRR. It is the third most common cancer among females and is ranked ninth overall in Malaysia.
Staging was reported for 70 per cent of the cases, which was 2,771 cases. Out of this figure, 41 per cent were detected at the late stages of Three and Four, marking a slight rise from previous reports at 40.3 per cent.
When asked if he thought HPV and cervical cancer screenings were affected by the pandemic, gynaecologist Dr Teo said most health care and medical services, including HPV tests and pap smears, were “significantly affected” as patients were also reluctant to seek out these services during the pandemic.
Whether that will have any effect on the number of cancer cases, he said, “cervical cancer takes a long time to develop and whether the two years of the Covid pandemic affecting screening uptake will lead to an increase in cervical cancer cases in the years to come remains to be ascertained.”
Dr Zaharuddin Rahmat, a gynaecologist at Sunway Medical Centre, also observed a reduced number of cervical screening tests (pap smear and HPV DNA test), especially in the private sector.
“This could be due to the fear of going out to clinics or hospitals during the pandemic and because of closure of borders,” he told Ova.
“Doctors didn’t encourage their patients to come for health screenings during the peak of the pandemic due to risk of infection transmission,” he added.
Dr Zaharuddin also said he doesn’t expect a significant increase in cervical cancer cases this year.
“This cancer is usually a slow progressing disease that will take many years to develop. But with an expected increase in screening tests, it is possible that there will be an increase in the pick-up rate of precancerous changes of the cervix.”