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Jpn J Clin Oncol 2002;32(Supplement 1)S17S21

2002 Foundation for Promotion of Cancer Research

Cancer in Indonesia, Present and Future

Didid Tjindarbumi1and Rukmini Mangunkusumo2

Departments of 1Surgery and 2Pathology, Medical Faculty, University of Indonesia/Dr. Cipto Mangunkusumo Hospital,

Jakarta, Indonesia

For reprints and all correspondence: Didid Tjindarbumi, Department ofSurgery, Division of Oncology, Medical Faculty, University of Indonesia/Dr. Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71, Jakarta, Indonesia.E-mail: [email protected]

Abbreviations: NGO, non-government organization; CT, computerizedtomography; MRI, magnetic resonance imaging; CME, continuous medicaleducation

Received February 13, 2001; accepted August 8, 2001

Cancer control has been in effect in Indonesia since the early 1920s. It was the Dutch Colonial

Government who started with the Institution for Cancer Control, which was closed by the

Japanese Occupation Administration between 1942 and 1945. After the independence of the

Republic of Indonesia, a Cancer Control Foundation was established in 1962. At present,

clinical and non-clinical departments in government teaching hospitals (there are 13 teaching

hospitals)

usually

handle

all

cancer

problems.

In

1993,

Dharmais

Cancer

Center

in

Jakarta

was established and has become the top referral cancer hospital for Indonesia. Until now, there

have been no nationwide accurate data on cancer registration, owing to a lack of funds and

manpower. Cancer data collection is usually provided as a relative frequency study from

several departments of the teaching hospitals. It is currently estimated that there will be at least170190

new

cancer

cases

annually

for

each

100 000

people.

The

most

frequent

and

primary cancers are cervix, breast, lymph node, skin and nasopharynx. Since Indonesia is now

in a transition phase and has many problems concerning the economy and health care, we

suggested a well-planned cancer control program. It includes the primary, secondary and

tertiary prevention of cancer in cities, where inhabitants can afford to subsidize a certain

proportion of the budgets for the implementation of this program.

Key words: Indonesia cancer control

INTRODUCTION

Historically, the first major effort aimed at cancer control in

Indonesia was initiated by the Dutch Colonial Government in

the early 1920s (1). The first organization for cancer control

which coordinated the activities for research and prevention

was established in Bandung in 1933, called the Nederlands

Indische Kanker Institute, which was closed during the

Japanese occupation between 1942 and 1945 (1). After in-

dependence of the Republic of Indonesia, the first Indonesian

Foundation for Cancer Control was established in 1962 in

Jakarta. This was followed by several Cancer Foundations in

several cities such as Surabaya, Solo, Yogyakarta and Band-

ung. The Coordinating Foundation of all these cancer societies

was then established in Jakarta on April 17, 1977, named theIndonesian Cancer Society. Research Institutions have also

been established such as the National Cancer Research Insti-

tute in Jakarta in 1965, under the supervision of the Depart-

ment of National Research, which was closed in 1966. In 1974,

a Research Center for Cancer and Radiology was established

under the National Health Research Institute of the Ministry of

Health.

In 1993, a new comprehensive Cancer Center Hospital was

established in Jakarta which is also affiliated to the Medical

Faculty University of Indonesia for the purpose of teaching

and training for medical postgraduates and also for research on

basic oncology.

Since the incidence of cancer goes up with increasing of life

expectancy and better control of communicable diseases, the

cancer load in developing countries such as Indonesia can soonbe expected to be formidable (24). It is currently estimated

that there will be at least 170190 new cancer cases annually

for each 100 000 people (5,6) and therefore cancer has risen to

become sixth in rank among deaths after infectious diseases,

cardiovascular diseases, traffic accidents, nutritional defi-

ciency and congenital diseases (1,57). However, most cancer

patients (6070%) seek medical treatment when it is already

too late (1,6).


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S18 Cancer control in Indonesia

Table 1.The 10 most frequent primary cancers in Indonesia: pathology based 198891

Source: CME. Prevention and Early Detection of Cancer. Jakarta: Medical Faculty, University of Indonesia 1998.

No. 1988 1989 1990 1991

Site % Site % Site % Site %

1 Cervix 18.41 Cervix 18.61 Cervix 19.18 Cervix 19.18

2 Breast 11.59 Breast 12.60 Breast 11.52 Breast 12.10

3 Lymph node 4.91 Lymph node 4.48 Lymph node 4.74 Lymph node 5.62

4 Skin 8.24 Skin 8.37 Skin 8.64 Skin 7.69

5 Nasopharynx 8.15 Nasopharynx 5.95 Nasopharynx 6.23 Ovary 5.31

6 Ovary 4.94 Ovary 4.68 Ovary 4.95 Nasopharynx 5.64

7 Rectum 4.42 Rectum 4.68 Rectum 4.95 Rectum 4.42

8 Soft tissue 3.50 Thyroid 3.42 Soft tissue 2.75 Thyroid 3.88

9 Thyroid 3.34 Unknown P 6.24 Unknown P 4.41 Soft tissue 2.58

10 Colon 2.81 Colon 2.88 Thyroid 3.26 Colon 2.82

Table 2.The 10 most frequent primary cancer in females: pathology based 198891


No. 1988 1989 1990 1991


1 Cervix 28.66 Cervix 29.21 Cervix 29.63 Cervix 28.66

2 Breast 18.03 Breast 19.52 Breast 18.02 Breast 17.77

3 Ovary 7.68 Ovary 7.25 Ovary 7.65 Ovary 7.77


5 Thyroid 4.07 Thyroid 3.87 Thyroid 3.72 Thyroid 4.61

6 Unknown P 3.22 Unknown P 4.32 Unknown P 3.10 Unknown P 3.73


8 Rectum 3.37 Rectum 3.13 Rectum 3.46 Rectum 3.209 Nasopharynx 3.01 Nasopharynx 2.92 Nasopharynx 3.17 Nasopharynx 3.03

10 Uterus 3.09 Uterus 3.15 Uterus 3.48 Uterus 3.00

Table 3.The 10 most frequent primary cancer in males: pathology based 198891


No. 1988 1989 1990 1991



2 Nasopharynx 11.76 Nasopharynx 11.52 Nasopharynx 11.87 Nasopharynx 11.27

3 Unknown P 8.63 Unknown P 9.75 Unknown P 6.80 Unknown P 7.50


5 Rectum 6.34 Rectum 6.54 Rectum 6.79 Rectum 7.07

6 Soft tissue 5.21 Soft tissue 4.22 Soft tissue 4.30 Soft tissue 4.19

7 Prostate 4.09 Prostate 3.81 Prostate 4.45 Prostate 4.85

8 Bladder 3.98 Bladder 4.73 Bladder 3.58 Bladder 3.97

9 Colon 3.98 Colon 4.09 Colon 4.19 Colon 4.17

10 Lung 3.95 Lung 3.64 Lung 4.68 Lung 3.99


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Jpn J Clin Oncol 2002;32(Supplement 1) S19

PRESENT SITUATION

The Indonesian archipelago consists of over 17 000 islands,

occupying almost 2 106km2of land. Administratively, Indo-

nesia is divided into 27 provinces, 241 districts, 55 municipal-

ities, 3501 subdistricts and 66 979 villages. Indonesia has a

population of more than 200 million people (1974) (7) and is

the fifth most populated country in the world after China,

India, the Russian Federation and the USA. As there are no

population based registries in Indonesia, the exact incidence

and prevalence of cancer are not known. However, data col-

lected from hospitals in several regions shows that cancer inci-

dence increased by 28% per year during the last decade (1,6).

Data which have been collected from 13 pathological labora-

tories throughout Indonesia during the period of 198891 show

that in the combined picture, cervical, breast, lymph node, skin

and nasopharynx are the five major anatomical sites for cancer

disease (8) (Table 1). Among females, the most common

cancers are cervical, breast and ovarian cancer (Table 2), and

among males skin, nasopharynx and lymph node cancer (Table

3). The relative proportions between male and female patients

can be seen in Table 4, where most cancer patients are female,

with a proportion of 65.4% in comparison with 34.5% for

males for an observation period of 4 years (198891). The inci-

dence rate of various cancer sites in males and females showed

an increasing rate each year in every cancer site. Regarding age

incidence, the major cancer group were aged between 45 and

54 years (26.19%), followed by the age group 5564 years

(21.84%). The trend showed that our cancer patients are

mostly from the aging population (Table 5). The general

pattern of cancer occurrence in Indonesia is mostly similar incertain areas, as can be seen in Table 6, where the most

common cancers are cervical uterus cancer followed by breast,

nasopharynx and skin.

Since smoking tobacco is a very common habit among Indo-

nesian men, increasing attention has recently been paid to lung

and bronchial cancer (9). Realizing that the primary prevention

strategy for tobacco-related cancer would necessarily be a

comprehensive anti-tobacco program, the government of the

Republic of Indonesia is considering various anti-tobacco leg-

islative measures, and also measures aimed at tobacco product

modification to render them less hazardous.

Recently we found that among men, 12% of cancer occur-

rence is in the liver, which is linked to aflatoxin and also tohepatitis B virus.

The facilities for cancer care have improved recently in

Indonesia. Efforts at controlling cancer have been undertaken

by the government and the private sector, including the

professional organizations and non-government organizations

(NGOs). These efforts can be generally classified into preven-

tion, early detection and treatment (1,6,10). Rehabilitation,

cancer registration and research are still in their very early

stages. Activities being conducted for primary prevention and

early detection are as follows:

proposing legislation to reduce tobacco consumption and other

carcinogenic substances (11);

the Ministry of Health and the Indonesian Cancer Society

facilitate the National Pathology Based Cancer Registry

through the Indonesian Pathologists Association, for baseline

data for the Indonesian National Cancer Control Program

(8,10,11);

providing the health facilities for cytological examination of

the cervix (11);

promotion of breast self-examination through public educa-

tion.

In 1989, the Ministry of Health established a National

Committee for Cancer Control which was meant to plan a

Table 4.Gender distribution: pathology based 198891

Source: CME. Prevention and Early Detection of Cancer. Jakarta: MedicalFaculty, University of Indonesia 1998.

Gender 1988 1989 1990 1991 Total %

Male 6.258 6.449 7.054 5.944 25.705 34.5

Female 11.312 11.807 12.833 12.826 48.778 65.4

No information 36 34 11 81 0.1

Total 17.606 18.290 19.898 18.770 74.564 100.0

Table 5.Age distribution: pathology based 198891


Age (years) 1988 1989 1990 1991

75 3.02 3.05 3.35 3.10

Lost 2.45 2.46 2.65

Total 100% 100% 100% 100%

Table 6.Relative frequency of the three most frequent primary cancers: site

by geographic distribution


Island First Second Third

Sumatra ( 3 medical centers) Cervical uterus Skin Breast

Java (6 medical centers) Cervical uterus Breast Skin

Sulawesi (2 medical centers) Cervical uterus Breast Skin

Bali (1 medical center) Cervical uterus Nasopharynx Breast

Jakarta (1 medical center) Cervical uterus Breast Rectum
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S20 Cancer control in Indonesia

comprehensive Cancer Control Program in terms of:

prevention

early detection

early diagnostic

prompt treatment

follow-up

rehabilitation

cancer registration

cancer research

This program has to be set up and distributed throughout the

whole of Indonesia and must be applied in most of the hospi-

tals that are provided with complete facilities for diagnostics

and treatment.

In 1993, the Indonesian government has also built a compre-

hensive Cancer Center Hospital in Jakarta with a clear focus on

research and health services. This hospital must also function

as a teaching hospital for postgraduate training, which is affil-

iated to the Medical Faculty University of Indonesia in Jakarta.

At present the various modalities of therapy for cancer which

are used in Indonesia are in the following proportions:radiotherapy 70%

surgery 2025%

chemotherapy 510%

Radiotherapy is only available in 11 teaching hospitals:

Sumatra 3

Java 5

Sulawesi 2

Bali 1

A multi-disciplinary approach, which is the key to successful

cancer treatment, can only be found at the state university

hospitals (13) and has not been adopted in most municipal

hospitals. Cancer surgery is practiced in all state university

hospitals.

Medical oncology divisions have so far started in only nine

state university hospitals. Pathology and cytology facilities are

well organized in most of the state university hospitals.

There is a gross deficiency of diagnostic and radiotherapy

equipment throughout the state university hospitals. CT scan,

MRI and nuclear medicine facilities are not available in all

medical faculties in Indonesia.

There are only four pediatric oncology departments among

the 13 state medical faculties in Indonesia. A running hospital-

based tumor registration can only be found in Jakarta and

Surabaya.

Rehabilitation services and research and developmentactivities in cancer control are conducted only in Jakarta and

Surabaya.

SUGGESTIONS FOR CANCER CONTROL

MEASURES IN THE FUTURE FOR INDONESIA

A well planned cancer control program aimed at improving

cure rates to reduce the morbidity and mortality rates and also

to improve the quality of life of cancer patients is desirable. In

order to achieve these goals, efforts have to be made in the

following areas.

PRIMARYPREVENTIONOFCANCER(11)

More epidemiological studies on risk factors of cancer with

high mortality rates, especially factors relating to life style,

diet, reproduction and the environment, as well as cross-

cultural studies should be encouraged.

Cancer registration should cover all clinics and medical

institutions and ensure the validity of the diagnosis.

Education programs should be introduced through institu-

tions and mass media concerning factors related to the

commoncancersinthepopulation;encouragingbehaviorand

life style that lead to the inhibition or suppression of the risk

conditions.

Research is required on understanding the biology of cancer

and the clinical, physical or infective agents to which people

are likely to be exposed, in order to determine the cancer

possibilities today and in the future.

More clinical trials on effective treatment methods should be

launched.

SECONDARYPREVENTIONOFCANCER(12)

This is aimed at making an early diagnosis of cancer, so that

the development of cancer can be interrupted. One of the activ-

ities in this program is the referral system, which is categorized

as follows:

the patient is referred to a health unit;

a specimen is referred to the laboratory or histopathology

unit;

knowledge and ability are referred to health personnel and

health units.

TERTIARYPREVENTIONOFCANCER(13)

This is conducted in the last/outside of the control program

where symptoms and signs of the tumor already appear on the

surface. The purpose of this last prevention is to give proper

treatment that will stop the development of the cancer and

avoid death. If the patient is still alive as a result of such inter-

vention, follow-up care and rehabilitation should be adminis-

tered. Supportive care and pain relief facilities should also be

set up for advanced and terminal cancer patients (14).

PLANOFACTION

To carry out these objectives, the following action has to betaken. Efforts should be aimed at preventing the occurrence of

cancer. This can be achieved by reducing the exposure to

carcinogenic substances and increasing the resistance of the

population to carcinogenic agents e.g. via tobacco smoking

(11).

EARLYDETECTION

Efforts should be made to detect cancer at an early stage, e.g.:

increasing facilities for cytological examination (cervical

cancer);


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Jpn J Clin Oncol 2002;32(Supplement 1) S21

promoting breast self-examination through public health

education, etc. (12).

DIAGNOSTICANDTREATMENTSERVICEFORCANCER

PATIENTS

All A-class hospitals (top referral hospitals; there are only

two hospitals, one in Jakarta and the other in Surabaya) must

function as cancer centers. They have to carry out tertiary

referral services, education and research in the field of cancer.

All 23 B-classhospitals and 26 first-class private hospitals

must have cancer teams and their facilities should be increased.

All 124 C-classhospitals and 41 intermediate-class private

hospitals should be equipped with facilities and personnel to

carry out early diagnosis and supportive treatment.

Analgesic drugs, including oral morphine, should be readily

available at all hospitals and community health centers (14).

REHABILITATIONSERVICES

These activities have been performed in all A-and B-class

hospitals.

CANCERREGISTRATION

To meet the special needs of cancer incidence, at least a hospi-

tal-based cancer registry should be developed, especially in

A-classand several B-and C-classhospitals (15). Popula-

tion-based cancer registries should also be developed in certain

areas with a population not more than 23 million, such as

Yogyakarta, Semarang or Palembang.

RESEARCHANDDEVELOPMENT

R&D should be planned from now on in order to establish the

size of cancer problem and to identify high-risk groups, so that

we can meet these problems with appropriate technology and

treatment (16,17). On November 28th, 1990, the Indonesian

Government via the Ministry of Health established a National

Cancer Control Action Plan to consolidate and escalate the

effortsforaNationalCancerControlProgram.Thesuccess

of this effort depends greatly on the effectiveness of the co-

ordination and management by the government institutions

concerned and also the active participation of the professional

organizations and the public and private sectors.

References

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2. Guiding Principles for Formulation of National Cancer Programmes inDeveloping Countries. Report of a Joint WHO/Euro Meeting, Geneva,October 47, 1983, Can/84.1.

3. Bernstein RS, Sidharta Y. Epidemiology and preventability of cancer inIndonesia. University of Indonesia, School of Public Health, Field Epide-miology Training Programme. Presented at the National Seminar on theImplementation of Cancer Management in Indonesia, Ciawi, August 26,1992.

4. Stjernward J, Stanley D, Eddy M, Tsechkovski L, Sobin I, Koza, NotaneyKH. Cancer control: Strategies and priorities.Bulletin of the WHO World

Health Forum1985;6.5. Khanna S. Implementation of cancer management in Indonesia, WHO

representative to Indonesia. Presented at the National Seminar on theImplementation of Cancer Management in Indonesia, Ciawi, August 26,1992.

6. Wasisto B. The National Cancer Control Programme in Indonesia.Ministry of Health, Republic of Indonesia. Presented at the WHO Meetingon National Cancer Programme, Geneva, Switzerland, November 2529,1991.

7. Mulyadi B. Cancer Control Programme in Indonesia. Ministry of Health.Presented at the 4th Continuing Medical Education on Early Detectionand Prevention of Cancer. Medical Faculty, University of Indonesia,Jakarta, September 2325, 1998.

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9. Stanley K, Stjernward J. Lung Cancer in Developed and DevelopingCountries, Cancer Unit, WHO 1211 Geneva 27 Switzerland, Lung CancerIV Ed. H. Hansen, Martinus Nijhoff Publ., Boston 1988.

10. Pringgoutomo S. Efforts on cancer control in Indonesia. Presented at theNational Seminar on the Implementation of Cancer Management inIndonesia, Caringin, Sukabumi, August 26, 1992.

11. Soedoko R. Prevention of primary cancer. Presented at the NationalSeminar on the Implementation of Cancer Management in Indonesia,Caringin, Sukabumi, August 26, 1992.

12. Djakaria M. Policy on early detection and referral of cancer patients.Presented at the National Seminar on the Implementation of CancerManagement in Indonesia, Caringin, Sukabumi, August 26, 1992.

13. Haryanto AR. Guidance for cancer patient therapy. Presented at theNational Seminar on the Implementation of Cancer Management inIndonesia, Caringin, Sukabumi, August 26, 1992.

14. Ramli M. Palliative and pain treatment. Presented at the National Seminaron the Implementation of Cancer Management in Indonesia, Caringin,Sukabumi, August 26, 1992.

15. Pringgoutomo S. Guidance for hospital base registration. Directory forHealth Services, Ministry of Health Republic of Indonesia. Presented atthe National Seminar on the Implementation of Cancer Management inIndonesia, Caringin, Sukabumi, August 26, 1992.

16. Krishnan Nair M. Ten Year Action Plan for Cancer Control in Kerala Sub-mitted for Consideration of the State Control Advisory Board of Kerala.Trivandrum: Regional Cancer Center 1988.

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Chile Ministry of Health, Planning Department.Bulletin WHO, Can/88.1.

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