EARLIER this year, when Indonesia’s first private cancer hospital opened for business, its backers believed they were tapping an important market. Along with non-communicable diseases such as diabetes and cardiovascular disease, cancer has emerged as one of the primary causes of death in the relatively prosperous urban areas of East and Central Java.

Judging by the size of the investment in the new medical facility, the smart money also believes this situation is likely to continue. The US$138 million (S$178 million) Mochtar Riady Comprehensive Cancer Centre, located in Jakarta’s Semanggi district, doesn’t just claim to be the biggest cancer hospital in Indonesia. It also aims to be one of the best-equipped cancer centres in Asia.

But while businessmen see an opportunity to take advantage of the changing pattern of disease as the size and prosperity of the nation’s middle class increases, policymakers have focused on prevention.

In August this year, for example, Bali began a school-based cervical cancer vaccination programme for teenage girls in Denpasar. The programme, part of a wider reproductive health education programme, is aimed at eliminating the disease from the island by 2020.

The Health Ministry has also been engaged in a long-running campaign to discourage cigarette smoking because of its association with lung and colon cancer. In Indonesia, around 90 per cent of the adult male population smokes. Under a Health Law passed in 2009, cigarette producers and importers must place pictorial warnings on cigarette packs or face a fine of up to 500 million rupiah (S$70,000). However, under pressure from local cigarette manufacturers, the government has yet to issue the supporting regulations required to enforce the law.

If it was just a matter of raising awareness and overcoming vested interests, the way ahead for anti-cancer campaigners would at least be clear cut. The reality, however, is that fighting cancer in Indonesia is turning out to be far more complex.

The link between smoking and lung cancer has been underlined by local experience. But research at the government-funded Dharmais Cancer Hospital in West Jakarta suggests that many other cancers in Indonesia may involve risk factors unknown in industrialised countries.

Breast cancer, for example, is the most common form of cancer among women in Jakarta, a situation not very different from in many other large cities in the world. But, unlike the West, preliminary research by oncologist Noorwati Sutandyo at the University of Indonesia suggests that the number of receptors for the female hormone oestrogen on the affected cells of Indonesian patients is not particularly high. Such a discovery, if confirmed through further research, suggests that some risk factors identified in the West (such as hormone therapy after menopause) may need to be re-examined. Other, yet to be discovered, influences may well be at work.

Studies by researchers at the University of Indonesia in cooperation with the Dharmais Cancer Hospital also challenge widely held ideas about risk factors in other cancers. Colorectal cancer, the second most common cancer in Jakarta males after lung cancer, is associated in the West with a low fibre intake. Indonesians, however, continue to have a lot more vegetables in their diet than Westerners.

And while the incidence of colorectal cancer peaks in the West at around age 50 to 60, research undertaken by Dr Aru Wisaksono Sudoyo, an oncologist at Cipto Mangunkusumo hospital in Central Jakarta, has shown that in Indonesia the disease appears to be more common around the age of 40 to 45.

Anecdotal observations by the nation’s practising oncologists could also have important policy implications. Liver cirrhosis, a particularly aggressive form of cancer, is often associated with hepatitis B (in the West) and excessive alcohol consumption (in Japan). But according to the Dharmais Cancer Hospital’s Dr Evlina Suzanna, many of the patients who seek treatment at this medical facility in West Jakarta do not have hepatitis B. Nor do their livers show any signs of excessive alcohol consumption. Dr Suzanna is the surgical pathologist ultimately responsible for the diagnosis of all cancer cases in the hospital.

Indonesians are not heavy drinkers, and while campaigns designed to eliminate hepatitis B are laudable, they may not do as much to reduce the incidence of liver cirrhosis in Indonesia as many believe.

Dr Suzanna points to another possibility – carelessness in the preparation of tempe bongkrek (a soyabean cake made with coconut pulp) that is a favourite of many Javanese. Certain types of fungus used to ferment the tempe, she says, can be contaminated with a bacterium that produces a toxin known to cause liver damage in animals.

That said, there are few large-scale studies of the role of risk factors in the local context to guide policymakers. And only now are officials beginning to collect nationwide data. Clearly, Indonesia’s battle against cancer has only just begun.

Copyright © 2011 Singapore Press Holdings Ltd