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

Cancer in Indonesia, Present and Future

Didid Tjindarbumi1 and Rukmini Mangunkusumo2
Departments of 1Surgery and 2Pathology, Medical Faculty, University of Indonesia/Dr. Cipto Mangunkusumo Hospital,
Jakarta, Indonesia
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 least
170190 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 independence 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 Bandung. The Coordinating Foundation of all these cancer societies
was then established in Jakarta on April 17, 1977, named the
Indonesian Cancer Society. Research Institutions have also

For reprints and all correspondence: Didid Tjindarbumi, Department of

Surgery, Division of Oncology, Medical Faculty, University of Indonesia/
Dr. Cipto Mangunkusumo Hospital, Jl. Diponegoro No. 71, Jakarta, Indonesia.
E-mail: dtjindarbumi@yahoo.com

been established such as the National Cancer Research Institute in Jakarta in 1965, under the supervision of the Department 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 soon
be 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 deficiency and congenital diseases (1,57). However, most cancer
patients (6070%) seek medical treatment when it is already
too late (1,6).

Abbreviations: NGO, non-government organization; CT, computerized

tomography; MRI, magnetic resonance imaging; CME, continuous medical
education

2002 Foundation for Promotion of Cancer Research

S18

Cancer control in Indonesia

Table 1. The 10 most frequent primary cancers in Indonesia: pathology based 198891
No.

1988

1989

1990

1991

Site

Site

Site

Site

Cervix

18.41

Cervix

18.61

Cervix

19.18

Cervix

19.18

Breast

11.59

Breast

12.60

Breast

11.52

Breast

12.10

Lymph node

4.91

Lymph node

4.48

Lymph node

4.74

Lymph node

5.62

Skin

8.24

Skin

8.37

Skin

8.64

Skin

7.69

Nasopharynx

8.15

Nasopharynx

5.95

Nasopharynx

6.23

Ovary

5.31

Ovary

4.94

Ovary

4.68

Ovary

4.95

Nasopharynx

5.64

Rectum

4.42

Rectum

4.68

Rectum

4.95

Rectum

4.42

Soft tissue

3.50

Thyroid

3.42

Soft tissue

2.75

Thyroid

3.88

Thyroid

3.34

Unknown P

6.24

Unknown P

4.41

Soft tissue

2.58

Colon

2.81

Colon

2.88

Thyroid

3.26

Colon

2.82

10

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

Table 2. The 10 most frequent primary cancer in females: pathology based 198891
No.

1988

1989

1990

1991

Site

Site

Site

Site

Cervix

28.66

Cervix

29.21

Cervix

29.63

Cervix

28.66

Breast

18.03

Breast

19.52

Breast

18.02

Breast

17.77

Ovary

7.68

Ovary

7.25

Ovary

7.65

Ovary

7.77

Skin

6.23

Skin

6.32

Skin

6.73

Skin

5.89

Thyroid

4.07

Thyroid

3.87

Thyroid

3.72

Thyroid

4.61

Unknown P

3.22

Unknown P

4.32

Unknown P

3.10

Unknown P

3.73

Lymph node

3.24

Lymph node

2.84

Lymph node

2.79

Lymph node

3.40

Rectum

3.37

Rectum

3.13

Rectum

3.46

Rectum

3.20

Nasopharynx

3.01

Nasopharynx

2.92

Nasopharynx

3.17

Nasopharynx

3.03

Uterus

3.09

Uterus

3.15

Uterus

3.48

Uterus

3.00

10

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

Table 3. The 10 most frequent primary cancer in males: pathology based 198891
No.

1988

1989

1990

1991

Site

Site

Site

Site

Skin

11.79

Skin

10.02

Skin

11.99

Skin

11.59

Nasopharynx

11.76

Nasopharynx

11.52

Nasopharynx

11.87

Nasopharynx

11.27

Unknown P

8.63

Unknown P

9.75

Unknown P

6.80

Unknown P

7.50

Lymph node

7.94

Lymph node

7.49

Lymph node

8.34

Lymph node

10.40

Rectum

6.34

Rectum

6.54

Rectum

6.79

Rectum

7.07

Soft tissue

5.21

Soft tissue

4.22

Soft tissue

4.30

Soft tissue

4.19

Prostate

4.09

Prostate

3.81

Prostate

4.45

Prostate

4.85

Bladder

3.98

Bladder

4.73

Bladder

3.58

Bladder

3.97

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

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

Jpn J Clin Oncol 2002;32(Supplement 1)

Table 4. Gender distribution: pathology based 198891

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

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

Source: CME. Prevention and Early Detection of Cancer. Jakarta: Medical

Faculty, University of Indonesia 1998.

<15

1988

1989

1990

1991

2.76

2.83

2.53

2.43

1524

5.13

4.75

4.65

4.59

2534

11.38

11.46

10.63

10.99

3544

19.44

19.81

19.21

19.60

4554

25.80

26.79

26.14

25.96

5564

19.93

21.25

20.75

20.03

6574

10.09

10.05

10.27

10.76

>75

3.02

3.05

3.35

3.10

Lost

2.45

2.46

2.65

Total

100%

100%

100%

100%

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

Source: CME. Prevention and Early Detection of Cancer. Jakarta: Medical

Faculty, University of Indonesia 1998.

Table 5. Age distribution: pathology based 198891

Age (years)

S19

Source: CME. Prevention and Early Detection of Cancer. Jakarta: Medical

Faculty, University of Indonesia 1998.

PRESENT SITUATION
The Indonesian archipelago consists of over 17 000 islands,
occupying almost 2 106 km2 of land. Administratively, Indonesia is divided into 27 provinces, 241 districts, 55 municipalities, 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 collected from hospitals in several regions shows that cancer incidence increased by 28% per year during the last decade (1,6).
Data which have been collected from 13 pathological laboratories 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 incidence 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 in
certain 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 Indonesian 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 legislative measures, and also measures aimed at tobacco product
modification to render them less hazardous.
Recently we found that among men, 12% of cancer occurrence is in the liver, which is linked to aflatoxin and also to
hepatitis 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 prevention, 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 education.
In 1989, the Ministry of Health established a National
Committee for Cancer Control which was meant to plan a

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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 hospitals that are provided with complete facilities for diagnostics
and treatment.
In 1993, the Indonesian government has also built a comprehensive 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 affiliated 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 hospitalbased tumor registration can only be found in Jakarta and
Surabaya.
Rehabilitation services and research and development
activities 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.

PRIMARY PREVENTION OF CANCER (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 crosscultural 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 institutions and mass media concerning factors related to the
common cancers in the population; encouraging behavior and
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.
SECONDARY PREVENTION OF CANCER (12)
This is aimed at making an early diagnosis of cancer, so that
the development of cancer can be interrupted. One of the activities 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.
TERTIARY PREVENTION OF CANCER (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 intervention, follow-up care and rehabilitation should be administered. Supportive care and pain relief facilities should also be
set up for advanced and terminal cancer patients (14).
PLAN OF ACTION
To carry out these objectives, the following action has to be
taken. 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).
EARLY DETECTION
Efforts should be made to detect cancer at an early stage, e.g.:
increasing facilities for cytological examination (cervical
cancer);

Jpn J Clin Oncol 2002;32(Supplement 1)

promoting breast self-examination through public health

education, etc. (12).
DIAGNOSTIC AND TREATMENT SERVICE FOR CANCER
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-class hospitals and 26 first-class private hospitals
must have cancer teams and their facilities should be increased.
All 124 C-class hospitals 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).
REHABILITATION SERVICES
These activities have been performed in all A- and B-class
hospitals.
CANCER REGISTRATION
To meet the special needs of cancer incidence, at least a hospital-based cancer registry should be developed, especially in
A-class and several B- and C-class hospitals (15). Population-based cancer registries should also be developed in certain
areas with a population not more than 23 million, such as
Yogyakarta, Semarang or Palembang.
RESEARCH AND DEVELOPMENT
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
efforts for a National Cancer Control Program. The success
of this effort depends greatly on the effectiveness of the coordination and management by the government institutions
concerned and also the active participation of the professional
organizations and the public and private sectors.

S21

References
1. Poorwo Soedarmo S. dan Suhardi: Kecenderungan dan permasalahan
penyakit kanker. Litbang Kes. Depkes RI. Diajukan pada Lokakarya
Implementasi Penanggulangan Kanker di Indonesia. Ciawi 2 s/d 6 Agustus 1992.
2. Guiding Principles for Formulation of National Cancer Programmes in
Developing 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 in
Indonesia. University of Indonesia, School of Public Health, Field Epidemiology Training Programme. Presented at the National Seminar on the
Implementation of Cancer Management in Indonesia, Ciawi, August 26,
1992.
4. Stjernward J, Stanley D, Eddy M, Tsechkovski L, Sobin I, Koza, Notaney
KH. Cancer control: Strategies and priorities. Bulletin of the WHO World
Health Forum 1985;6.
5. Khanna S. Implementation of cancer management in Indonesia, WHO
representative to Indonesia. Presented at the National Seminar on the
Implementation 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 Meeting
on 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 Detection
and Prevention of Cancer. Medical Faculty, University of Indonesia,
Jakarta, September 2325, 1998.
8. Mangunkusumo R. Frequency of malignant tumors in Indonesia, a pathological base observation. Presented at the 4th Continuing Medical Education on Early Detection and Prevention of Cancer. Medical Faculty,
University of Indonesia, Jakarta, September 2325, 1998.
9. Stanley K, Stjernward J. Lung Cancer in Developed and Developing
Countries, Cancer Unit, WHO 1211 Geneva 27 Switzerland, Lung Cancer
IV Ed. H. Hansen, Martinus Nijhoff Publ., Boston 1988.
10. Pringgoutomo S. Efforts on cancer control in Indonesia. Presented at the
National Seminar on the Implementation of Cancer Management in
Indonesia, Caringin, Sukabumi, August 26, 1992.
11. Soedoko R. Prevention of primary cancer. Presented at the National
Seminar 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 Cancer
Management in Indonesia, Caringin, Sukabumi, August 26, 1992.
13. Haryanto AR. Guidance for cancer patient therapy. Presented at the
National Seminar on the Implementation of Cancer Management in
Indonesia, Caringin, Sukabumi, August 26, 1992.
14. Ramli M. Palliative and pain treatment. Presented at the National Seminar
on the Implementation of Cancer Management in Indonesia, Caringin,
Sukabumi, August 26, 1992.
15. Pringgoutomo S. Guidance for hospital base registration. Directory for
Health Services, Ministry of Health Republic of Indonesia. Presented at
the National Seminar on the Implementation of Cancer Management in
Indonesia, Caringin, Sukabumi, August 26, 1992.
16. Krishnan Nair M. Ten Year Action Plan for Cancer Control in Kerala Submitted for Consideration of the State Control Advisory Board of Kerala.
Trivandrum: Regional Cancer Center 1988.
17. General Strategies and Provisians for Cancer Control in Chile, Republic of
Chile Ministry of Health, Planning Department. Bulletin WHO, Can/88.1.