25 years of cancer treatment services in Sarawak General Hospital
The ESMO accredited Department of Radiotherapy, Oncology & Palliative Care celebrated 25 years of cancer service in Sarawak this year. To mark the occasion, we invited YB Dato Dr. James Dawos Mamit, the Deputy Minister of Tourism, Malaysia to present certificate of appreciation to “Friends of Cancer Patients”, the NGOs and individuals who contributed to the care of our patients in the department. From its humble beginnings, the department has made tremendous changes and transformation both in expansion and upgrading of our facilities and major improvement in the cancer services offered.
The inception of cancer services in Kuching has its beginning in late 1970s, before the difficult years of “austerity drive” in 1980s. After some delay, the project went on line and the four- storey Cancer Unit building was completed in early 1984. The photos below show the female ward at official opening.
The ground floor of the four- storey block consisted of a medical record room, patient waiting area, 3 clinics, simulator room, computerised treatment planning room, mould room, a small dispensary, a medical lab and a staff room. The Gamma camera room on the first floor also had a patient reception counter, administrative office, radioisotope preparation room, medical officer’s room, 2 specialist offices, a seminar room, a nursing sister’s office, engineering workshop and office, a physics workshop and a physicist’s office. The second floor consisted of a medical officer’s on call room, the male ward and a two bedded radioiodine room. The third floor consisted of the female ward, 2 MOs room and the Buchler HDR brachytherapy treatment room.
I arrived at the scene in SGH at the end of 1983 and spoke to the Medical Officer-in-charge (MOIC) Dr. Francis Ngu about my intention to serve in Cancer Unit. As the Unit was still under construction, I was asked to drop by to supervise from time to time. In the month of May, 1984, the two linear accelerators were moved into the treatment block, a single storey building next to the main unit, through a hole in the wall of the control room. With the help of a 2 ton fork lift and sheer muscle power of nine Kuching port authority movers including Siemen's engineer, Peter Wong (Electronic technician, SGH) and me, manoeuvring and pushing each machine inch by inch into each of the linear accelerator bunkers, we finally placed and securely locked down the two machines over two days. After that it was the task of Siemens engineer from Singapore, Gerard Ng, to put all the pieces together to get it going. By 1 October, 1984, I finally got my appointment as Medical Physicist, Grade C4 and I reported to Dr. Francis Ngu, and became the first Cancer Unit staff to work in this department. In the meantime, other civil work was carried out in the Unit, including a small car park adjacent to a nice garden with a small pavilion for patients to enjoy in the evening.
At the beginning of 1985, Mr. Bong Min Fatt and Miss Anie Kawan were the first two radiotherapy radiographers who reported for duty. Later, other radiographers were posted to the Unit. They were Abbas Shaheni, Jutiam Kinil and Sonny Yong TK. From the month of March till June1985, various pieces of equipment were installed. The Siemens single head Gamma Camera with hard copy output was installed in early 1985. Our Unit also had a Buchler HDR after loading device with a Caesium-137 source for brachytherapy located at one end of the 3rd floor female ward. The engineer from Germany made short work of it by finishing the installation, testing and commissioning in 1 week. In the meantime, the Oncology Support System (OSS), a computerised treatment planning system (TPS) with 30M hard drive was installed. This was followed by the installation of a Philips Conventional Simulator with engineer from Holland. Meanwhile, all the smaller equipment like office furniture, assets for the two wards and all that was ordered for the Cancer Unit project came in and I had to double up as the site supervisor for SGH.
By July, 1985, the nursing staff and attendants headed by Sister Julia Sim came to prepare for the start of the Cancer Unit service. Dr. Tai King Hung was the first medical officer of our department. By early August, there was frantic preparation for the impending official opening of the Cancer unit. The building was cleaned and spruced up. Souvenir programme and explanatory posters were prepared and hung with the help of Mr.Lee (Photographer from Health Education Unit, JKNS).
On the 15thAugust 1985, invited guests arrived at the reception area from 8.30am onwards. At 9.00am, the late Tun Ahmad Zaidi Adruce who was the Governor of Sarawak arrived, accompanied by Tun Datuk Patinggi Abang Muhammad Salahuddin, Datuk Alfred Jabu, the Deputy Chief Minister of Sarawak, the late Datuk Sim Kheng Hong, the Finance Minister of Sarawak, Datuk Dr. Wong Soon Kai, Datuk Fonseka, the Deputy Director General of health, Datuk Stalin Hardin, the State Health Director. These pictures (black & white) aptly capture the official opening of our Unit. My task was to show the VIP around and talk about the functionsof the different equipments in the Unit .
This photo (below right) was taken in the Simulator room with me explaining to the late TYT on the use of Simulator for cancer patient. The black human like object on the simulation couch is the Alderson Rando Phantom, with Dr. Perdaman Singh, Consultant Oncologist, Head of Department of Institute of Radiotherapy and Oncology and Nuclear Medicine, KL, on the left of the photo. During the visit, our guests visited the rooms with the two linear accelerators (Siemens Mevatron 74 and Mevatron 77), the Gamma Camera room with Siemens single head gamma camera, the Buchler High Dose Rate Brachytherapy machine and female ward on the third floor. The visit went on smoothly with the guests being very impressed with the facilities in our Unit.
In the afternoon of the official opening, we simulated and treated our first patient; a Ca cervix Stage IV patient, Puan Katherine. Two parallel opposed photon beams were used. With time, we treated more patients with scheduled fort nightly visits by oncologists from KL. In February, 1986, Dr. Jaswant Singh, a newly trained Oncologist from UK reported for duty and was the head of Unit from then onwards. With our full time oncologist and supervision from KL, we proceeded with the enormous task of providing cancer treatment services to patients referred from various hospitals in Sarawak. In 1986, the Unit had about 150 new patients. The years after that saw a steady increase in our new patient case load and the unit saw a small, gradual increase in our manpower providing radiotherapy, chemotherapy and hormone therapy and nuclear medicine scanning and radioisotope treatments to our patients.
In 1988, Dr. Cyril Powel-Smith, an American Oncologist and his wife Carol visited our unit. They were impressed with the facilities in our unit, which is comparable to the modern facilities in a small city in the United States. After the visit, Cyril decided to return to Kuching and offer his service free of charge to our hospital. A Greek philanthropist had kindly donated the stipend for 2 years of his voluntary work here. We helped to secure a free government quarter in Rodway Road for him during his tenure here. The addition of Cyril who had more than twenty years practice in cancer treatment gave the Unit the much needed boost in experience and expertise. Cyril worked hard to share and provided the best treatment for our patients. Sadly his time with us was over by the end of December, 1989. He left for Zimbabwe with a four years offer from WHO to help teach a Oncology Masters programme in the University of Bulawayo, Zimbabwe. Cyril left Sarawak with our appreciation and heart-felt thanks for his many contribution and best wishes for his future endeavour.
In March, 1992 Dr. Jaswant resigned for private practice in Kota Kinabalu. In the absence of our only oncologist, the scheduled visits by Oncologist from HKL resumed. The situation finally improved in November, 1992, with the arrival of our new contract oncologist Dr. Beena Devi from Singapore. By this time, the unit had about 600 new patients annually; a huge work load for one oncologist. Despite severe manpower shortage, (our team of one oncologist, one physicist and six radiotherapy radiographer), we strived hard to provide the best cancer treatment to our patients. Chemotherapy was given in day care and our wards. During that time, we used metoclopramide as the anti-emetic. This protocol was changed by Dr.Beena who felt that to have better compliance with chemotherapy, we switched to more effective anti-emetics like ondansetron and granisetron which greatly alleviate patients’ emesis.
A year later, Dr. D Basu joined the unit for 5 years, followed shortly by Dr. Barat who left us after a short stint. Subsequently in 1996, Dr. Manivanan, another contract oncologist joined our department, which by then is known as the Department of Radiotherapy & Oncology. He was transferred to HKL when Dr. Kevin Hew joined us in 2001. Two years later, Dr. Kevin resigned to join private practice in Pinang and we were down to one oncologist again. In 2004, Dr. Prem Shanmugam joined us for five years, followed by Dr.Shamir Chandran in 2008 and Dr. Rajiv Choudhary in 2009. In 2002, a contract Medical Physicist, Mr. Marimuthu joined us for three years and in 2004, another medical physicist Mr. Voon SC joined followed by Ms Woon YL in 2006, Mr. Sim KT in 2008, Mr. Harun Chan in 2009 and Ms Rosni in 2010. Our radiotherapy radiographers staffing similarly increased over the years to a total of 43 this year. Together with the nursing staff, we have now a total of 164 staff in the department.
The 1990s was a period of hard work and service innovations. With Dr. Beena's interest in cancer down staging and palliative care work, she started the state wide Early Cancer Surveillance Programme and the Palliative Care Programme. Our objective was to achieve down staging on cancers of the nasopharynx, breast and cervix. The trainees for the two programmes were mainly nurses, JM, MA, some doctors and other related medical staff. With funds approved by Dr Zulkipli Jantan (now Dato' and State Pengarah), who was the deputy director of JKNS then, and with the assistance of ENT specialist & Gynaecologists, we conducted the first session in Kuching in 1994. In all, more than 21 training session were carried out over the years, covering places like Kuching, Serian Sri Aman, Sarikei, Sibu, Kapit, Bintulu, Miri, Marudi and Limbang. To date we have trained more than 1100 personnel. Our hard work bore fruits when we analysed our cancer statistics later which revealed the down staging of cervical and breast cancer in Sarawak shortly after our programme began.
Between 1993 and 2010, the department has undergone many physical changes. We acquired our Cobalt teletherapy machine in 1995 which allowed us to treat more patients with less treatment interruption due to machine failure. After giving 12 years of faithful service, we replaced the old linear accelerator in 1997. The old TPS was replaced with a new Nucletron Plato TPS with brachytherapy software and the old Buclher afterloader replaced by Nucletron HDR brachytherapy machine. The new brachytherapy machine allowed us to make improvement in dose optimisation in brachytherapy.
In 2001, a new Palliative Care Ward with 9 beds was set up in the first floor. The individual cubicles offered better privacy and had facilities for accompanying relatives. With this, the Department of Radiotherapy, Oncology and Palliative Care (DRO) came into existence. The adjacent photo shows Dr. Yao SC (far right) with Matron Ella, Dr. Beena and Sister Lim, visiting out newly renovated Palliative Care ward.
Major renovation work began in 2005 of our treatment block with the expansion of treatment waiting area, a seminar room, mould room, counselling room, a new waiting area for new patient clinics, clinic rooms. A new Nucletron conventional simulator and a Siemens Primus linear accelerator with MLC were installed in the newly refurbished rooms. The end result was worth the dusty days with the transformation of our old dull area into a pleasant, sunny, cheerful patient friendly place which by now has got the name “the art gallery of Sarawak General Hospital”. We were delighted to hear positive feedback and praises for the work well done.
In 2007, a new Siemens Primus replaced the old Cobalt machine and a New Siemens CT simulator was also installed in the newly renovated rooms. The introduction of a CT simulator signalled the start of our more sophisticated 3D conformal radiotherapy (3DCRT) and Intensity Modulated Radiotherapy treatment (IMRT). We are now able to offer more high tech treatment with better target dose conformation and better avoidance of organ at risk. This translated into better treatment outcome and lower radiotherapy morbidity.
In 2009, based on the quality of cancer care provided by the department, the type of research that was carried out and the publications in high impact peer-reviewed journals, the department became the first in SE Asia to be accredited as an ESMO Designated Centre of Integrated Oncology and Palliaitve care.
The department was indeed very honoured when in 2012 was again selected as ESMO Designated Centre for the second term. This once again proves the standard of care that the department offers the patients in Sarawak.
In 2011, Dr. Beena Devi was awarded the prestigious Paul Calabresi award by SIOG (International Society of Geriatric Oncology) for her contribution to improving cancer care in Sarawak and bringing it on par to international standards. She has pioneered the cancer care for the older patients in Sarawak.
In addition to providing cancer treatment, training and palliative care services, our department was also actively involved in clinical trial on new cancer treatment agents from 2004. By our participation in trials, our eligible patients had the opportunity to use new drugs which otherwise would have not been accessible. To date we have seven trials and some of which are still going on.
(History as of 24 Feb, 2014)