The recent headlines on the First Lady's demise from metastatic breast cancer strikes a poignant note yet again on the complex challenges which interact with the rising costs of modern medical therapy.

Pak Lah subsequent response was that it would be his mission to slash cancer treatment costs . This is noble and well-intentioned but is it feasible?

The WHO has pointed out for a while that the cancer epidemic has already started in developing countries and that in a decade or so, most of the world's burden of cancer will be focused in the developing world where only a fraction of spending power resides.

So, they have already predicted that for the majority of the world's population who get cancer, the only practical and sensible management would be good quality palliative care. However, that does not mean that oncologists should not practise in developing countries but those who do, will face the challenge of allocating their finite resources for the best possible distribution.

This is the painful part of oncological practice in developing countries - should a family sell their home to purchase a course of expensive chemotherapy agents in order to prolong the life of an elderly (or younger) relative?

This philosophical question runs into the issue of opportunity costs. For example, if society has to fund this, how many babies may be saved from malnutrition, (if there is malnutrition) or, how many more young children can be vaccinated against mumps, measles and rubella or, how many more years of schooling a younger member of the family will benefit from if this cost had not been expended?

The peculiarities of practising oncology in a developing country is that conventional scientific treatments compete with bogus treatments because the latter are much lower in economic cost.

This is the same within the medical profession - competition to treat advanced cancer is futile if it is between a surgeon (who specialises in surgery) and an oncologist (who may either specialise in the use of medications, i.e. the medical oncologist) or, local irradiation i.e. the radiotherapist or clinical oncologist).

What is most disconcerting is that the competition progressively decimates the patient's financial resources along the cancer journey and may not necessarily lead to optimal outcomes.

So, what reforms are needed? What solutions can be offered? Let us step back and look at prevention, then treatment. Sadly, nothing much has happened with prevention strategies. If they are indeed there, they have not worked.

Cancer rates in Malaysia continue to soar and the only possible prevention strategy which is working is the cervical screening programme. This may be related to better diagnosis combined with a true increase in rate.

There is, however, scientific doubt about the indiscriminate non-evidence based mammographic screening of young women, of various endoscopic screening procedures and of health screening programmes - all driven by the vibrant and commercialised private sector. What is amazing is that the government wishes to transform Malaysia into a centre for health tourism!

Treatment strategies and policy planning will continue to be a very major challenge with many practitioners claiming to be oncologists when they really are not. With this comes a very wide range of treatment options both from the scientific evidence base and equally more from the commercial non-evidence base.

One of the most important changes in cancer care which is increasingly being realised is teamwork care. But the finer points of this have never been worked out and multi-disciplinary care is virtually non-existent in Malaysia.

In essence, some areas of cancer care in Malaysia have been superficially gleaned over and much as I wish to be hopeful and helpful and not cynical, there is much for Pak Lah to do in realising his intended noble mission.