Collaborative study between Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands, Dr. Sardjito Hospital/ Gadjah Mada University, Yogyakarta, Indonesia, and UCL Cancer Institute, London, UK
Decentralising biopsies – Early detection of NPC in rural areas of Yogyakarta Province
Nasopharyngeal cancer (NPC) has a high incidence in Indonesia as compared with the Western world. NPC is very sensitive to radiotherapy in the early stages however there is often a delay in the diagnosis. This delay is multifactorial, but one aspect identified has been the availability of diagnostic services. Patients often have to travel large distances, to academic centres, to avail of these services. This study will investigate if the decentralisation of biopsies will result in an earlier NPC diagnosis and if it will result in NPC positives in the patient cohort who previously refused to travel for their biopsy and would have otherwise been undiagnosed.
In Southern and Eastern Asia nasopharyngeal cancer (NPC) is a major health problem. In Indonesia NPC it is the most frequent cancer of the head and neck area and ranks as the 4th most common tumour found in males (1,2). The incidence is estimated at 6 per 100,000, leading to 15,000 new cases per year. This, however, might be an underestimation due to insufficient cancer registries and patients never diagnosed.
In rural areas of Indonesia in particular, patients with NPC are often diagnosed at an advanced stage due to limited health care facilities. Most remote areas have less than one primary health care centre per 100,000 and some areas do not even have one hospital per million, or less than two hospital beds per 10,000 (3).
Gold standard for diagnosis of NPC is a biopsy. However, this diagnostic test is often not available in district hospitals. When certain facilities are not available patients are referred to an academic hospital. Patients have to travel long distances and often lack financial means to do so. In many cases they choose to return home without being diagnosed. By the time the patient arrives at the hospital with more sever complaints, the tumour has progressed to a more advanced stage and may have spread to other organs. Treatment is then not curative anymore. Studies conducted in Yogyakarta revealed that 11% of the patients already had distant metastasis at diagnosis. In 90% of patients, advanced stage of disease was seen at diagnosis (according to AJCC staging 2002) (4).
In this project we will offer patients a biopsy at their own district hospital, Wonsari District Hospital, Yogyakarta. The sample will be sent and processed at the Dr. Sardjito University Hospital. The outcome of the biopsy will be directly communicated back to the Ear, Nose and Throat specialist at the district hospital. In this way the patient does not have to travel and all costs are covered by international funding from the Dutch cancer society and ASEA UNINET.
The aim of this study is to determine whether decentralisation of biopsies will lead to more histologically proven NPC in patients who initially refused referral to the academic hospital.
Preliminary results show that 33% of suspected NPC patients (7 out of 21) were actually diagnosed with NPC. All these patients were referred to the Dr. Sardjito Hospital for further diagnosis and treatment. All patients had advanced stage of disease or were too weak to travel.
These preliminary results tell us that many patients, who refused to be referred when their symptoms were mild and did not hinder their daily activities, already had developed advanced NPC. This emphasises the importance of the ability to diagnose patients in their own district hospital preferably and an earlier stage. In addition the preliminary results of this study stress the need of an adequate collaboration between academic hospital, the district hospital, the doctors in the primary health care centres and the community.
- Adham M, Kurniawan AN, Muhtadi AI, Roezin A, Hermani B, Gondhowiardjo S, et al. Nasopharyngeal carcinoma in Indonesia: epidemiology, incidence, signs, and symptoms at presentation. Chin J Cancer. 2012 Feb 7;:–.
- World CanCer report 2008. 2008 Dec 19;:1–267.
- Rokx C, Giles J, Satriawan E, Marzoeki P, Harimurti P, Yavuz AE. New Insights into the Provision of Health Services in Indonesia: A Health Workforce Study – ISBN: 9780821382981. 2010 Apr 1;:1–160.
- Wildeman MA, Fles R, Herdini C, Indrasari RS, Vincent AD, Tjokronagoro M, et al. Primary treatment results of Nasopharyngeal Carcinoma (NPC) in Yogyakarta, Indonesia. PLoS ONE. 2013;8(5):e63706.