Biomed Imaging Interv J 2006; 2(1):e18
© 2006 Biomedical Imaging and
Clinical oncology in Malaysia: 1914 to present
GCC Lim, MBBS, FRCR
Department of Radiotherapy and Oncology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
A narration of the development of staff, infrastructure and
buildings in the various parts of the country is given in this paper. The role
of universities and other institutions of learning, public health, palliative
care, nuclear medicine and cancer registries is described together with the
networking that has been developed between the government, non-governmental
organisations and private hospitals. The training of skilled manpower and the
commencement of the Master of Clinical Oncology in the University of Malaya is
highlighted. Efforts taken to improve the various aspects of cancer control
which includes prevention of cancer, early detection, treatment and palliative
care are covered. It is vital to ensure that cancer care services must be
accessible and affordable throughout the entire health system, from the primary
care level up to the centres for tertiary care, throughout the whole country. ©
2006 Biomedical Imaging and Intervention Journal. All rights reserved.
Keywords: History, cancer, radiotherapy, oncology, Malaysia
Cancer is an increasing health problem in Malaysia. Good and
comprehensive cancer treatment is the right of all. The development of the
discipline of Clinical Oncology, previously known as Radiotherapy and Oncology,
is described in this paper. Much has been achieved in clinical oncology in the
past 90 years in Malaysia.
The earliest records of x-ray therapy in Malaysia show the
acquisition of a Crookes x-ray tube in Singapore in 1914 and a Coolidge tube in
1920 . Radium sources were used in the treatment of gynaecological
malignancies, skin lesions and implants of accessible lesions. The radium
needles and radium tubes from the General Hospitals of Ipoh, Johor Bahru and Penang
were later transferred and stored in the Department of Radiotherapy and
Oncology at Hospital Kuala Lumpur . A 140 kV deep x-ray therapy unit was
installed in Singapore General Hospital in 1933.
In the 1950's, external beam radiotherapy was delivered in
Kuala Lumpur with the Philips Dermopan 50 kV superficial x-ray machine (Philips
NV, Eindhoven, Netherlands), 200 kV Muller x-ray machine and 250 kV rotating
Muller x-ray machine .
The department was housed in a wooden building between the Maternity Hospital
and the Neurosurgical unit (Figure 1a). There were no dedicated
beds in the unit at that time . From 1950
to 1960, radiotherapy services were provided by Dr Lynch, an
Irish radiotherapist who shuttled between Singapore and Kuala
Lumpur, and Dr Lal from Singapore . The
support staff comprised two radiographers, a staff nurse, a
secretary/receptionist and an attendant .
[View this figure]
|Figure 1 The Department of Radiotherapy
and Oncology in the (a) 1950’s and (b) 1968
Dato' Dr. S.K. Dharmalingam (Figure 2) succeeded Dr. Lynch after returning
from the Middlesex Hospital in the United Kingdom in 1960 and
was appointed as the first Malaysian Consultant Radiotherapist.
Two more radiographers and a physicist were then recruited.
The staff comprised 4 local consultants, 8 sisters, 28 staff
nurses, 40 assistant nurses and approximately 70 attendants.
Four student radiographers were initially trained in Kuala Lumpur
for one year followed by further training in Hong Kong, while
two staff nurses were sent for training in the United Kingdom.
Overseas specialists attached to the department included Professor
Roberts of Middlesex Hospital, Professor K. Brittan from St
Bartholomew's Hospital, as well as doctors from Korea, Pakistan
and Austria .
[View this figure]
|Figure 2 Dato’ Dr. S.K. Dharmalingam
was the driving force in the early days of Radiotherapy
and Oncology in Malaysia.
Additional equipment that was acquired in 1965 included a
radium safe costing $35,000 and a 300 kV orthovoltage treatment machine. When
Tun Omar Ong Yoke Lin and Tun Tan Siew Sin were the Minister of Health and
Minister of Finance respectively, an allocation of MYR 3 million was made for
the establishment of the new Institute of Radiotherapy, Oncology and Nuclear
Medicine at the Kuala Lumpur General Hospital. The physical construction of the
building was started in August 1967 and was completed in November 1968 (Figure
1b). The facility had 180 beds, its own operation theatre for brachytherapy, a
separate laboratory, a pharmacy, and an outpatient department. The Cancer
Ambulant Ward was established to cater to cancer patients from other states in
the country who needed accommodation but were well enough not to be in a
regular ward. Before, such patients had been put up in the New Hotel, through
the National Cancer Society of Malaysia, and at the old Tai Wah Hospital, which
was refurbished . The equipment included a Siemens Betatron (Siemens AG, Erlangen,
Germany) that provided electron treatments ranging from 5 MeV to 43 MeV, and
two single energy 6 MV linear accelerators (MEL-75) .
Nuclear medicine was started under the Institute of Radiotherapy,
Oncology and Nuclear Medicine in 1962 . The first technician, Mr. Anthony Ng
was sent to the Royal Melbourne Institute of Technologists for training .
The Radioisotope Laboratory was established at the University Hospital, Kuala
Lumpur in 1967 .
In 1974, a physicist post was created in the engineering division
in the Ministry of Health. A physics workshop with two lathe machines, a
shaping machine, drilling, cutting machines and a physics mould room were also
installed in the institute for preparation of lead shielding devices and other
special treatment devices. Two Farmer Dosemeters type 2502 (PTW-Freiburg, Freiburg,
Germany) were used for dose calibration and measurement of the megavoltage
machines. The analog Farmer Dosemeters have been replaced by digital dosemeters
for more accurate dosimetry. A single energy linear accelerator and a
telecaesium unit were installed in 1977 and 1978 respectively to replace the
orthovoltage machines. The physicists were doing the isodose planning by manual
summation until a computerised treatment planner, Mevaplan (Siemens AG,
Erlangen, Germany), was introduced under the project of upgrading and
replacement of old machines in 1987 and 1988 . Shielding of critical
structures was based on check films done with lead cut-outs and lead blocks
. Radium-226 was the earliest radioisotope used in brachytherapy.
Caesium-137 replaced radium-226 from 1993 until 2004, after which iridium-192
Phase II development of the Institute which was completed in
1995 established facilities such as Day Care and saw the renovation of the
operation theatre. Equipment that were installed since then included two new
linear accelerators in 1997 and 2001, a high dose rate remote afterloading
brachytherapy system in 1997, three-dimensional treatment planning system and a
digital imaging simulator in 2001. Services such as total body irradiation
benefited patients requiring bone marrow transplant, not only at the Hospital
Kuala Lumpur, but also at the University of Malaya Medical Centre as well. Some
of the early treatment machines and personnel are shown in Figures 3 to 6.
Stereotactic radiosurgery began in Hospital Kuala Lumpur on 4 March 199 9.
High dose rate remote afterloading system for brachytherapy
has completely replaced the manual afterloading system since
October 2003 in Hospital Kuala Lumpur.
[View this figure]
|Figure 3 Mr. F.C. Fam with a patient
on one of the earliest linear accelerators in the
The service in Penang was upgraded in 1996 with the posting
of Dr. D. Jayendran, a senior clinical oncologist from the Ministry of Health.
Chemotherapy and palliative care was provided at Penang Hospital while
radiotherapy was provided for government patients at Mount Miriam Hospital and
Pantai Mutiara Medical Centre.
The Department of Radiotherapy and Oncology in Sarawak General
Hospital was officially opened on 15 August 1985. The first clinical
oncologist to serve here was Dr. J. Singh. The Nuclear Medicine section was
started soon after. In 1993, day chemotherapy was started in the department.
Currently, the department has 68 beds. It originally had two linear
accelerators, a conventional simulator and a Buchler medium dose rate remote after-loading
brachytherapy machine (Amersham plc, Buckinghamshire, United Kingdom) that used
caesium-137 as the radioactive source. A new cobalt unit was installed in the
department in 1996. One of the linear accelerators was replaced with a new one
in 1997. In June 2001, the Buchler brachytherapy unit was replaced with a high dose
rate brachytherapy unit. Patients with nasopharyngeal cancer could now be
treated with brachytherapy in Sarawak General Hospital. Previously, the
brachytherapy machine only treated patients with gynaecological malignancies
Palliative care service was started in the Department of Radiotherapy and Oncology
and Hospice home care service was started in 1995 in Kuching.
From 1996 onwards, the Hospice home care service was extended
statewide after more nurses were trained from various parts
of Sarawak. In 2003, a dedicated Palliative Care Ward was completed.
The department now has 16 beds for palliative care, with 8 beds
for acute care and 8 beds for continuing care. The Palliative
Care Ward has the task of ensuring that palliative care service
is developed properly and that the service is available to patients
in Sarawak. A system of drug delivery was also set up to ensure
that patients even in the most remote parts of Sarawak get the
drugs for symptom relief. Palliative care training for doctors,
nurses and paramedics has been conducted by the Department of
Radiotherapy and Oncology in Sarawak General Hospital since
1995 (Figure 7). The training sessions were initially conducted
in Sarawak General Hospital, and extended to Sibu in 1996 and
Miri in 1997.
[View this figure]
|Figure 7 The Radiotherapy Unit
is connected to the main building of the Sarawak General
Hospital by a covered walkway.
Early Cancer Surveillance Training was started in 1995 as
more than 70% of patients with common cancers, that is, nasopharyngeal, breast
and cervix, were in an advanced stage. Training, which involved theory as well
as practical sessions, was given to nurses and medical assistants from various
hospitals and peripheral clinics.
The Breast Support Group was started in 1993. In addition to
its regular monthly Breast Support Group meeting, the group has hosted annual
dinners and regular parties for patients in the department. Separate Cancer
Patient Support groups for male and female patients, as per their request, was
started in 1997. The patients meet regularly to discuss and share matters of
Dr. P. Pisani from the Epidemiology Unit of the World Health
Organisation (WHO), Lyon, France visited Sarawak from 6-10 of June 2001 to
assist Dr. B. Devi on data analysis on the incidence of nasopharyngeal cancer
in Sarawak .
While there was a government facility in Sarawak, the
services were provided by Sabah Medical Centre, a private facility from which
the government purchases radiotherapy services.
The academic unit was started in the University Hospital Kuala
Lumpur (currently known as the University of Malaya Medical Centre) in 1997,
with state-of-the-art equipment, including linear accelerator with multileaf
collimators, stereotactic radiotherapy, high dose rate and low dose rate remote
afterloading brachytherapy, and virtual simulation. The oncologists were Dr. I.
Wahid, Dr. M.M. Abdullah; physicists were Ms. N. Whylde, Mr. B.H. Khoo, Ms. P.
Rassiah; and the therapy radiographer was Mr. T. Yogaratnam.
Other universities with radiotherapy and oncology
departments were Hospital Universiti Kebangsaan Malaysia and Hospital Universiti
Sains Malaysia in Kubang Kerian, Kelantan.
The Department of Nuclear Medicine, Radiotherapy and
Oncology of the Universiti Sains Malaysia, Kubang Kerian Campus started the
first Radiotherapy service in the east coast of Peninsular Malaysia. The
Radiotherapy and Oncology division was added to the existing Nuclear Medicine
department in December 1995. The Radiotherapy and Oncology service was started
with the guidance of Professor M. Embong (then Dean of Medical School) and
Assoc. Professor A. Zakaria (Medical Physics). Ministry of Health seconded a
clinical oncologist, Dr. D. Jayendran, and two therapy radiographers, Ms. A.
Shaari and Mr. K. Hassan, to the Ministry of Education for this purpose. In
1999, the high dose rate brachytherapy service was operational with the collaboration
of IAEA (International Atomic Energy Agency) and now this department is one of
the departments offering high dose rate interstitial brachytherapy services in Malaysia.
Subsequently, state-of-the-art radiotherapy techniques like three-dimensional conformal
radiotherapy and x-knife radiosurgery service were added in 2001 .
OVERVIEW OF RADIOTHERAPY SERVICES IN MALAYSIA
Today there are 19 centres for Radiotherapy and Oncology in Malaysia,
comprising 5 government centres and 14 private centres. There are 25 linear
accelerators, 7 cobalt-60 teletherapy machines, 15 brachytherapy units, 11
simulators and 4 computerised tomography-simulation units.
Forty-one hospitals in the Ministry of Health are providing
chemotherapy services in addition to universities and the private sector.
Conventional chemotherapy is given in many general hospitals, district
hospitals and private centres. High dose chemotherapy with bone marrow rescue
is provided by paediatric oncologists and haematologists in University Hospital
Kuala Lumpur and Hospital Kuala Lumpur.
In order to decrease the burden on government centres, the government
has purchased private radiotherapy services from Mount Miriam Hospital, Pantai
Mutiara Medical Centre, Mahkota Medical Centre, Pantai Ayer Keroh Medical
Centre, Nilai Cancer Institute, Gleneagles Oncology Centre and Sabah Medical
Quality assurance is an essential part of radiotherapy
services and much work has been put into it since the early days. Quality
assurance ensures both effectiveness and safety of radiotherapy services .
THE BURDEN OF CANCER
While the idea of a National Cancer Registry was first reported in the Star
on 7 April 1978, the First Report of the National Cancer Registry
was only realised on 4 July 2003 (Figures 8 and 9). For the
first time, the real cancer burden in Malaysia was confidently
estimated. A total of 26,098 patients were diagnosed with cancer
among all residents in Peninsular Malaysia in 2002. The corresponding
figures for Sabah and Sarawak were 1,748 and 2,002, respectively.
The cumulative risk of Malaysians getting cancer in their lifetime
was 1 in 5. Taking into account the unregistered cases, the
cumulative lifetime risk was 1 in 4 .
The Penang Cancer Registry in its Five Year Report from 1994-1998,
published on 15 December 2003 , demonstrated
that 53.1% of cancers were in advanced stages, that is, Stage
III or Stage IV.
[View this figure]
|Figure 8 (a) The alarm over the
incidence of cancer was felt in this country in 1970’s;
(b) The need for a national cancer registry was expressed
a quarter of a century ago.
The role of public health cannot be overestimated. Public
education, awareness campaigns and the promotion of healthy lifestyles must be
emphasised while not neglecting the development of facilities for treatment.
Efforts have been made to enhance prevention of cancer, screening, early
detection of disease, equitable and accessible treatment, rehabilitation and
palliative care (Figures 11 and 12). The Ministry of Health launched its
campaign against cancer as a part of its ongoing Healthy Life Style approach to
the prevention and control of some of our major public health problems in 1995
Networking between the public and private sectors and
non-governmental organisations, establishment and upgrading of treatment
facilities, and training of skilled staff in the treatment of cancer have been
Decreasing the proportion of cancers presenting at a late
stage would lead to increasing the chances of cure. In Sarawak, where the three
commonest cancers are present at an advanced stage in at least 70% of the cases
, efforts have been made at early detection. Allied health professionals,
such as medical assistants and nurses have been trained to detect early signs
and symptoms of cancers of the nasopharynx, breast and cervix.
Despite the awareness campaigns and public talks, the
practice of screening for cancer is not widespread enough. The Second National
Health and Morbidity Survey  revealed that the overall prevalence of Pap
smear was only 26%, while the overall prevalence for breast self examination
was 46.8%. Screening rate by Breast Self Examination was 34.1%, followed by
Health Worker Examination (31.1%). Mammography was carried out only in 3.8% of
women. These figures underscore the need for health education programmes to
target population subgroups that would benefit from screening.
Efforts at improving palliative care services throughout the
country are being actively undertaken by governmental and non-governmental
Palliative Care was introduced by non-governmental organisations
(NGOs) in Kuala Lumpur and Penang in 1991, by the Ministry of Health in Sabah
in 1995. Among the first non-governmental organisations involved in palliative
care was Hospis Malaysia. In 2000 a National policy was launched. Palliative
Care continues to be NGO-driven. Most training programmes in Palliative Care
are still run by NGOs. The NGOs continue to work closely with Palliative Care
Units. The setting up of Rumah Hospis in Penang would enhance palliative care
in Penang. Home care nursing by some government general hospitals serves to
enhance the continuity of care of terminally ill patients after discharge from
hospital. For example, Hospital Kuala Lumpur started such service in 1995 for
patients within a 10-kilometre radius of the hospital.
In East Malaysia, Palliative Care Programmes have been
started in Palliative Care Units as well as Hospice Home Care as a part of a
community-based service. The programmes include the training of doctors,
nurses, medical assistants and lay volunteers in the palliative care of
terminally ill cancer patients. Palliative Care Units have been set up in
several government hospitals, such as Queen Elizabeth Hospital in Kota Kinabalu
in 1995, and they have untaken training of Ministry of Health personnel. There
are 11 Palliative Care Units and 48 Palliative Care Teams in various hospitals
in the Ministry of Health, and 17 hospice organisations (NGOs) under an
umbrella organisation called the National Hospice Council that was formed in
The Palliative Care Unit of Hospital Selayang was started in
December 2002 as part of the Ministry of Health's policy to support palliative
care services in all government hospitals in Malaysia. As Hospital Kuala Lumpur
was largely overcrowded and there was no space for the development of a new
ward, it was decided that the new Palliative Care Unit be started in Hospital
Selayang, which is also a regional centre for pain control.
Training is an integral part of any cancer programme. The
number of specialists in cancer treatment and the facilities available need to
be increased to cope with the workload. There are 39 clinical oncologists in
Malaysia of whom 23 are in the private sector. Compared to the United Kingdom
which has a ratio of 8 oncologists per million population , Malaysia now
has 1.6 per million population. Clearly, one of the main immediate concerns is
to address the acute shortage of oncologists. Physicists number 26, while there
are 104 therapy radiographers, 2 medical technologists and 45 nurses who have
undergone post-basic oncology training.
In 1971, it was reported that there were about 30 radiotherapists and radiologists
in West Malaysia, and the Ministry of Health at that time was
doing all it could to increase the number of these specialists
(Figure 10). The measure adopted then was recruitment from Pakistan
and Egypt, while the long term plan was to send more Malaysians
overseas for training .
The School of Radiography was started at the General
Hospital Kuala Lumpur in 1963. Mr. A.R. Hutchinson was the Radiotherapy Advisor
. The first five student radiotherapy radiographers commenced training in
October 1967 and sat for the examination in 1969.
In 1981 the Ministry of Health Malaysia curriculum was
introduced and the training period was increased to 3 years. On 6 July 1995 the
name for School of Radiography and Radiotherapy was changed to College of
Radiography and Radiotherapy, Kuala Lumpur Hospital. From January 2002, the
administration of the College of Radiography and Radiotherapy was transferred
from Kuala Lumpur Hospital to the Department of Health, Federal Territory Kuala
Lumpur . The post basic course for therapy radiographers in Radiation
Therapy Planning was started in August 1998 at the College of Radiography and
Radiotherapy, Kuala Lumpur. The College of Radiography and Radiotherapy was
officially shifted from the Malaysian Medical Association Building in Jalan
Pahang to Sg. Buloh on 31 December 2004 .
The post basic course for Oncology Nursing was started at
the School of Nursing in Kuala Lumpur on 1 October 1996.
The First ASEAN Association of Radiologists' Scientific Meeting
was held from 30 October to 1 November 1980 at the Faculty of Medicine,
University of Malaya. Invited speakers included Professor J.G. Bloom from the
Royal Marsden Hospital, London.
The International Atomic Energy Agency organised the IAEA
Regional Training Course on Brachytherapy of uterine cancer using Manual and
Remote After-loading Techniques at the Faculty of Medicine, National University
Hospital and General Hospital of Kuala Lumpur from 6-26 October 1986. It was
organised in cooperation with the Government of Malaysia and Universiti
Kebangsaan Malaysia, in collaboration with General Hospital Kuala Lumpur and
the Nuclear Energy Unit of the Prime Minister's Department. The Organising
Committee comprised Professor I. Saad, Dr. P. Singh, Dr. M.T. Azhar, Dr. A.
Lim, Mr. J.T. Wong, and Mr. T. Yogaratnam. Lecturers included Mr. H. Tsujii,
Dr. S. Ganesan and Dr. M.K. Tan. Participants comprised 23 representatives from
10 countries and one representative from the Middle East. The Ralstron B 20
(Shimadzu Corp., Kyoto, Japan) that was generously donated by the Government of
Japan and channelled through the IAEA to Malaysia, was an essential component
of the training course , and was the first remote afterloading
brachytherapy machine installed in Malaysia.
Regional cancer meetings in which Malaysia has taken part
included Asian Oceanian Congress of Radiology (June 1995) and Asia Pacific
Cancer Congress (October 1996) . The First Malaysia/IAEA Brachytherapy
Course was jointly organised by the Ministry of Health Malaysia and Hospital
Universiti Kebangsaan Malaysia from 24-27 February 2004, with cooperation from
the Malaysian Institute of Nuclear Technology and Research (MINT) and was
attended by 93 participants from around the world. The foreign expert was
Professor S. Nag. The participation and cooperation between the government,
university and private sector was remarkable.
While post-graduate training in radiotherapy and oncology
had traditionally been in the United Kingdom and Ireland, the Malaysian
Government sent two trainees to Hong Kong for the first time in 2002. This was
due to the increasing difficulties encountered by our trainees in pursuing
post-graduate training in the United Kingdom. The Master of Clinical Oncology
was started in University of Malaya in November 2002, with strong support from
the Ministry of Health. The first professional examination was held in November
2003, with Professor M. Barton and Professor Dato' Dr. M.T. Azhar as external
examiners from Sydney and International Islamic University, respectively. The
external examiners gave favourable and encouraging reports regarding the
standards and conduct of the examination.
As evidenced by the First Report of the National Cancer
Registry of Malaysia  and Second Report of the National Cancer Registry of
Malaysia , it cannot be overemphasised that the optimal number of
oncologists needed must be much higher than the number available at the moment.
Both overseas training and a local post-graduate course for clinical oncology
are being supported simultaneously by the government to train more clinical
oncologists as quickly as possible.
Good and comprehensive cancer treatment is the right of all.
Efforts are being intensified to improve cancer services in the country, with
emphasis on training of skilled manpower, equipment and facilities. The
blueprint includes the setting up of the National Cancer Institute, the
strengthening of existing centres as well as establishing new facilities. Networking
between the various sectors will be given more emphasis. Multidisciplinary care
will be further strengthened.
The Ninth Malaysia Plan (2006-2010) will see a concerted
effort to improve the various aspects of cancer control which includes
prevention of cancer, developing and enhancing programmes for diagnosis and
early detection, treatment, rehabilitation and palliative care. The role of
herbal, traditional and complementary therapies will be explored.
While there is a great need to build facilities and train
more staff skilled in cancer management, it is equally vital to ensure that
cancer care services are accessible and affordable throughout the entire health
system, from primary care level up to the centres for tertiary care, throughout
the whole country.
Acknowledgements to the following individuals for their
contributions: Professor Dato' Dr. M.T. Azhar, Dato' Dr. S.K. Dharmalingam, Mr.
T. Yogaratnam, Mr. B.H. Khoo, Dr. D. Beena, Dr. D. Jayendran, Dr. B.M. Biswal,
Dr. P. Singh, Professor Dr. I. Saad, Assoc. Professor Dr. I. Fuad, Dr. A.Z.
Bustam, Dr. A.K.H. Lim, Dr. M.R. Haron, Mr. K.S. Lee, Dr. E. Hamzah, Mr. M.
Mohd. Yusop, Dr. R. B.L. Lim, Mr. M.F. Jaafar, Mrs. R. Yahya, Mrs. N. Ahmad,
Mr. A.H. Jabir; and also to the Director-General of Health of Malaysia
for permission to publish the information contained within this paper.
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|Received 29 August 2005; received in revised form 17 March 2006; accepted 27 March 2006
Correspondence: Department of Radiotherapy and Oncology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia. Tel: 6-03-26155810; Fax: 6-03-26925713; E-mail: firstname.lastname@example.org (Gerard Chin-Chye Lim).
Please cite as: GCC Lim, Clinical oncology in Malaysia: 1914 to present,
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