EDITORIAL: LUNG CANCER WORLDWIDE
Lung Cancer in Indonesia
Oke Dimas Asmara, MD,a,b,* Eric Daniel Tenda, MD, DIC, PhD,a
Gurmeet Singh, MD, PhD,a Ceva Wicaksono Pitoyo, MD,a
Cleopas Martin Rumende, MD, PhD,a Wulyo Rajabto, MD,c
Nur Rahmi Ananda, MD,d Ika Trisnawati, MD, MSc,d Eko Budiyono, MD,d
Harik Firman Thahadian, MD, PhD,d E. Christiaan Boerma, MD, PhD,b
Achmad Faisal, MD,e David Hutagaol, MD,f Wuryantoro Soeharto, MD,f
Fahmi Radityamurti, MD,g Erika Marfiani, MD,h Pradana Zaky Romadhon, MD,h
Fathur Nur Kholis, MD,i Hendarsyah Suryadinata, MD,j
Arto Yuwono Soeroto, MD, PhD,j Soehartati A. Gondhowiardjo, MD, PhD,g
Wouter H. van Geffen, MD, PhDk
Introduction
Indonesia, situated in South-East Asia, has the world’s
fourth largest population and ranks as the fifth largest
country in Asia. It has over 270 million people spanning
an area of 1,904,569 km2 divided into 38 provinces.
Notably, Indonesia has more than 17,000 islands, with
Java being the most densely populated island in the
world with a density of 1100 people per square km2.1
Indonesia increased its life expectancy from 68.68
years in 2010 to 72.32 years in 2023. This progress can
be attributed to many recent economic advances as
Indonesia became an upper-middle-income country in
2021, with an average household income of about
10,089 U.S. dollars/year.1
According to data from the Ministry of Health,
noninfectious diseases such as cardiovascular diseases,
cancer, and noninfectious lung diseases are among the
top three causes of morbidity and mortality in Indonesia.
In addition, the nation struggles with infectious diseases
such as tuberculosis, coronavirus disease 2019 (COVID-
19), dengue fever, and malaria, which cause substantial
health threats to the population.2 Another important
challenge Indonesia faces is posed by unequal access to
health care, predominantly driven by unequal socioeco-
nomic disparities and geographic location (Fig. 1A–C).3–5
Furthermore, Indonesia has the highest smoking
prevalence among men worldwide, with over 70% of
men smoking.6 This alarmingly high smoking rate high-
lights the major threat lung cancer poses to Indonesia.
Epidemiology
In 2020, as reported by the Global Cancer Observa-
tory, an estimated 396,914 individuals in Indonesia
Journal of Thoracic Oncology Vol. 18 No. 9: 1134–1145
were diagnosed with cancer, resulting in a death toll
of 234,511.7 According to Indonesia Basic Health
Research or Riset Kesehatan Dasar (RISKESDAS) 2018,
*Corresponding author.
a
Division of Respirology and Critical Illness, Department of Internal
Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Man-
gunkusumo General Hospital, Jakarta, Indonesia, bDepartment of
Sustainable Health, Campus Fryslân, University of Groningen, Leeu-
warden, The Netherlands, cDivision of Hematology-Medical Oncology,
Department of Internal Medicine, Faculty of Medicine Universitas
Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta,
Indonesia, dDivision of Pulmonology, Department of Internal Medicine,
Faculty of Medicine, Public Health and Nursing, Universitas Gadjah
Mada, Dr. Sardjito Hospital, Yogyakarta, Indonesia, eDivision of
Cardiothoracic and Vascular surgery, Department of Surgery, Fatmawati
General Hospital, Jakarta, Indonesia, fDivision of Cardiothoracic and
Vascular surgery, Department of Surgery, Faculty of Medicine Uni-
versitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta,
Indonesia, gDepartment of Radiation Oncology, Faculty of Medicine
Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital,
Jakarta, Indonesia, hDepartment of Internal Medicine, Faculty of
Medicine Airlangga University, Surabaya, Indonesia, iDivision of Pul-
monary Disease and Critical Care Medicine, Department of Internal
Medicine, Faculty of Medicine Universitas Diponegoro, Dr. Kariadi
Hospital, Semarang, Indonesia, jDivision of Respirology and Critical
Care Medicine, Department of Internal Medicine, Faculty of Medicine
Universitas Padjadjaran, Hasan Sadikin General Hospital Bandung,
Indonesia, and kDepartment of Pulmonary Diseases, Medical Center
Leeuwarden, Leeuwarden, The Netherlands.
Disclosure: Dr. van Geffen reports having various roles in ERS and
NVALT outside of the submitted work; and having trials run by his
department funded by Roche and Merck Sharp & Dohme. The remaining
authors declare no conflict of interest.
Address for correspondence: Oke Dimas Asmara, MD, Division of
Respirology and Critical Illness, Department of Internal Medicine,
Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo
General Hospital, Jl. Diponegoro Number 71, Jakarta, Indonesia.
E-mail: okedimas.asmara@ui.ac.id
ª 2023 International Association for the Study of Lung Cancer.
Published by Elsevier Inc. All rights reserved.
ISSN: 1556-0864
https://doi.org/10.1016/j.jtho.2023.06.010
September 2023 Lung Cancer in Indonesia 1135

Figure 1. Map of Indonesia. (A) Population density. (B) Poverty rates among Indonesian Province. (C) Health infrastructure
index.3–5 Data from The Lancet, 393, Agustina R et al, Universal health coverage in Indonesia: concept, progress, and
challenges, 75–102, Copyright Elsevier (2019).5 with permission. HI, health infrastructure; KM, kilometer.
1136 Asmara et al
cancer prevalence in Indonesia has been increasing
from 1.4 per 1000 individuals in 2013 to 1.8 in 1000
in 2018.8,9
Cancer puts a significant burden on the health care
system of Indonesia. In 2016, the Social Insurance
Administration Organization reported 1,308,061 treated
cancer cases, for a total spending amount of 2.2 trillion
rupiahs, equating to $486,960,633 in U.S. dollars. This
number puts cancer as the second most substantial
health care burden after cardiovascular diseases. Among
all cancers, lung cancer has consistently been the leading
cause of death in the past decade.8
In 2020, lung cancer was the most newly diagnosed
cancer in men in Indonesia, with 34,783 new cases
registered, accounting for 14.1% of all cancers. The
estimated lung cancer incidence rate among men was
19.4 per 100,000 individuals. As for cancer-related
mortality, lung cancer remains the leading cause of
death, accounting for 13.2% (30,843 deaths).7
Data analysis from 2008 to 2012 from the cancer
registry at the national referral hospital (Cipto Man-
gunkusumo National General Hospital [RSCM]) revealed
that lung cancer had the highest incidence in the group
50 to 70 years old.10 However, it is important to note
that these data may only represent a fraction of the
actual cases, as lung cancer registry and research in
Indonesia remain limited despite the existence of 14
population-based cancer registries. As these registries
cover only around 14% of the population, the actual
number of lung cancer cases is likely much higher owing
to limited diagnosis and registry modalities. This un-
derscores the need for increased efforts to improve lung
cancer registry and research in the country.
Smoking and Tobacco Control
Smoking has become an integral part of the social and
cultural life of most Indonesians. Indonesia ranks as one
of the world’s largest contributors to the total number of
smokers with approximately 69 million active smokers
on the basis of recent surveys. The number of child
smokers in Indonesia is also a subject of concern as
around 3 million (9.1%) children aged 10 to 18 and
230,000 children below the age of 10 years old are
already active smokers. Moreover, it is estimated that 89
million children are exposed to secondhand smoke.11
In addition, cigarette consumption is a significant
part of the Indonesian economy, employing around 6.1
million people and generating more than Rp 170 trillion
or 11 billion U.S. dollars in revenue in 2015.12 The Global
Adult Tobacco Survey 2021 survey indicated that
households in Indonesia spend more money on ciga-
rettes, around 300 U.S. dollars/year than on nutritious
food. The tobacco industry’s significant influence on the
Journal of Thoracic Oncology Vol. 18 No. 9
country’s economy presents challenges in implementing
effective antismoking policies and campaigns.13,14
Because the cigarette industry positioned itself as a
key contributor to Indonesia’s economy, it is even more
important to address the negative implications of
smoking and promote smoking cessation. Nevertheless,
various efforts have been implemented by the govern-
ment to address public health problems caused by
smoking. Policies have been implemented to protect the
public, particularly children, adolescents, women, and
those facing poverty owing to cigarette consumption.
Indonesia actively follows the MPOWER strategy devel-
oped by the WHO. According to MPOWER measures,
Indonesia has made significant progress, especially in
protecting people at risk from secondhand smoke. A
total of 459 cities and districts have promoted smoke-
free regulation as of 2022.14 The Ministry of Finance
claims that, in the past 10 years, the Directorate General
of Customs and Excise has helped reduce the number of
cigarette factories from 4669 factories to 754 factories
between 2016 and 2022. Consequently, cigarette pro-
duction had also decreased to 323.9 billion cigarettes in
2022 compared with 359 billion in 2019.13,15
Health Care System and Infrastructure
In 2014, President Joko Widodo introduced a novel
universal health care system named National Health In-
surance (Jaminan Kesehatan National [JKN]) providing
coverage for universal health care. The JKN grew rapidly,
and within 5 years, it covered 203 million people, mak-
ing it the largest single-payer National Health Insurance
in the world. The implementation of JKN has led to
improved health equity and service access.5 In 2021,
Indonesia had a total of 10,292 community health cen-
ters (Pusat Kesehatan Masyarakat) and 3112 hospitals to
cover an area of 1.9 million km2. In 2016, the govern-
ment spent approximately 3.4% of the gross domestic
product on health care.16
Most of the diagnostic procedures and treatments for
lung cancer are covered in the JKN with a referral system
in public hospitals (Fig. 2). After the referral process
from Pusat Kesehatan Masyarakat, there are four types
of hospitals on the basis of the type of specialists, sup-
porting facilities, and therapies available. These hospitals
are categorized as types A and B as tertiary level and
types C and D as secondary level, with type A being the
most comprehensive and type D being the least
comprehensive in terms of services and resources.17 The
availability of type A hospitals, which offer comprehen-
sive facilities for the diagnosis and treatment of lung
cancer, is extremely limited.
Some patients with lung cancer in Indonesia are
eventually referred to national referral hospitals for lung
September 2023 Lung Cancer in Indonesia 1137

Figure 2. The scheme illustrating the sequential steps of the referral process by JKN that patients with lung cancer undergo.
CT, computed tomography; IHC, immunohistochemistry; JKN, Jaminan Kesehatan National; PET-CT, positron emission
tomography–computed tomography; PUSKESMAS, Pusat Kesehatan Masyarakat (community health centers); RSCM, Cipto
Mangunkusumo National General Hospital; RSK Dharmais, Rumah Sakit Kanker Dharmais (Dharmais National Cancer Hospital);
RSUP Persahabatan, Rumah Sakit Umum Pusat Persahabatan (Persahabatan General Hospital); x-ray, radiograph.

cancer: RSCM, Dharmais National Cancer Hospital, and
Persahabatan Hospital. These three public hospitals are
all located in Jakarta. In addition, there are several types
of A-type university hospitals in several provinces that
have adequate facilities for lung cancer management.
Examples of these hospitals include the Hasan Sadikin
General Hospital (West Java), Dr. Karyadi General Hos-
pital (Central Java), Dr. Sardjito General Hospital
(Yogyakarta), and Dr. Soetomo General Hospital (East
Java). However, owing to the need for patients to travel
to Jakarta or other major cities in Java for further ex-
aminations and treatment, only those who are financially
capable of covering the expenses and staying for an
extended period can pursue these referrals. Unfortu-
nately, patients who cannot afford it may only receive
symptomatic treatment at the nearest hospital to their
place of residence.
Because of the shortage of hospitals with health care
professionals and facilities for lung cancer management,
there is a high caseload in referral center hospitals. With
a population of more than 270 million people, there are
approximately a total of 5244 internists that include 80
internist pulmonologists and 162 medical oncologists,
and 1500 pulmonologists available to treat patients with
lung cancer. Moreover, the number of these specialists
focused on lung cancer is even fewer. As a result, the
caseload for these health care workers is very high. In
addition, these specialists are not evenly distributed
throughout the country, with more than 50% of them
practicing in Java. This situation places a large burden on
the hospital and creates long waiting times for patients
to receive necessary examinations and treatments. A
study of 294 patients conducted by the RSCM revealed
that 86% experienced treatment delays of more than 90
days beyond the appropriate time frame.18
Lung Cancer Screening
Currently, there is no government-mandated lung
cancer screening program in Indonesia. Although it is
recommended by the national guidelines, lung cancer
screening programs are carried out voluntarily and at
the patient’s own expense at private hospitals. Unfortu-
nately, because it is not covered by JKN, the screening
program remains inaccessible to most of the population.
In the near future, JKN will also expand its coverage from
not only curative but also preventive and promotive
approaches. Whether lung cancer screening will be
covered by the JKN remains unclear, and if so, access to
it will remain a problem owing to, for example, a
shortage in computed tomography (CT) capacity.
1138 Asmara et al Journal of Thoracic Oncology Vol. 18 No. 9

Despite these challenges, lung cancer screening has
already been incorporated into the national guidelines.
The Indonesian Guidelines for Lung Cancer Management
(Panduan Penatalaksanaan Kanker Paru) recommends
low-dose chest CT examinations for high-risk patients.
High-risk patients are defined as those older than 40 years
with a history of smoking of at least 30 years, or patients
aged 50 years and older with a history of smoking of at
least 20 years and the presence of at least one other risk
factor. Ex-smokers can also be screened if they quit
smoking within 15 years before the examination. Low-
dose CT examination for screening should meet the
following criteria: (1) at least 16 multislice CT; (2) gantry
rotation time less than or equal to 0.75 seconds; (3)
received radiation of 3 to 5 mSv (body mass index
30);
(4) slice width less than or equal to 2.5 mm (better if
1
mm); and (5) detector collimation less than 1.5 mm. In
limited-resource settings, screening can be conducted by
anamnesis, physical examination, and chest radiograph.
The guidelines also emphasize the importance of pro-
moting smoking cessation during every screening visit.8,19
Diagnosis
The infrastructure for diagnosing lung cancer in
health care facilities across Indonesia is limited.
Although chest radiographs are the primary radiologic
examination used to diagnose suspected lung cancer, CT
scans are a more effective radiologic examination for
lung cancer diagnosis. However, their availability is
extremely limited in many parts of Indonesia, particu-
larly in the eastern regions. For example, in the Papua
region, which has a population of nearly four million
people, there is only one CT scan facility available. Some
patients must travel to other islands, such as Maluku or
Sulawesi, for CT scan examination. Positron emission
tomography scans are even less accessible, with only five
facilities available in the entire country located in three
provinces and not covered by JKN (Fig. 3).

Figure 3. Sequential diagnostic examinations for the diagnosis of lung cancer. BAL, bronchoalveolar lavage; cfDNA, cell-free
DNA deoxyribonucleic acid; CT, computed tomography; EBUS, endobronchial ultrasound; EUS, endoscopic ultrasound; JKN,
Jaminan Kesehatan National; IHC, immunohistochemistry; PD-L1, programmed cell death-ligand 1; PET/CT, positron emission
tomography/computed tomography; TBLB, transbronchial lung biopsy; TBNA, transbronchial needle aspiration; TTB, trans-
thoracic biopsy; TTNA, transthoracic needle aspiration; x-ray, radiograph.
September 2023
As radiologic findings in tuberculosis can mimic lung
cancer appearances, patients are sometimes treated for
tuberculosis, which turns out to be undetected lung
cancer. With a lack of other diagnostic options aside
from chest radiographs, there is an unmet need for a
cheap point-of-care tool in the diagnosis pathway for
lung cancer. New techniques, such as the electronic nose,
perhaps could be of future use in Indonesia to address
this need.20
As tissue sampling is essential for diagnosing lung
cancer, for selected cases a multidisciplinary approach
can be used to plan the sampling procedures. In RSCM,
the top national referral hospital, a Chest meeting is held
every week, with regular members consisting of inter-
ventional pulmonologists, internist pulmonologists,
thoracic surgeons, oncologists, radiologists, pathologists,
and oncology radiologists. This meeting is only available
in referral hospitals, and with the recent advancement of
telemedicine, complex lung cancer cases outside Jakarta
can be discussed online with the RSCM team. Sometimes
an internist/pulmonologist/oncologist outside of Jakarta
or Java island faces a difficult case that needs an evalu-
ation from a multidisciplinary team. Before sending the
patient to Jakarta, a meeting will be held to plan what is
the best strategy to manage the patient. This method can
be implemented not only for diagnosis but also for
treatment or more complex interventional pulmonology
procedures.
Interventional pulmonologists in RSCM are capable of
performing a wide range of pulmonary procedures for
tissue sampling, from basic bronchoscopy or CT-guided
transthoracic biopsy to endobronchial ultrasound
transbronchial needle aspiration, and transbronchial
lung biopsy, combined with real-time C-arm and rapid
Figure 4. Simplified treatment algorithm for lung cancer management in Indonesia. TKI, tyrosine kinase inhibitor.
Lung Cancer in Indonesia 1139
onset evaluation. However, the availability of endo-
bronchial ultrasound procedures in Indonesia is also
limited, with fewer than 10 hospitals in six provinces
offering this procedure. Endoscopic ultrasound exami-
nation—typically performed by gastroenterologists for a
gastrointestinal indication—for lung cancer staging is
even rarely practiced.
Cytology, histopathology, immunohistochemistry
(IHC), and molecular testing are also challenging aspects
of diagnosing lung cancer. Not all major hospitals have
IHC and molecular testing capabilities. Currently, JKN
only covers EGFR mutation testing for molecular testing
with a quantitative reverse transcriptase-polymerase
chain reaction panel. Patients who require tests for
other molecular driver alterations and programmed
death-ligand 1 (PD-L1) IHC testing must seek private
molecular laboratories. The availability of these crucial
tests is a major issue because they are available in less
than 10 provinces, mostly in Java, and only in tertiary
public hospitals.8,21
Therapy
Compared with the limited infrastructure for diag-
nostic facilities, the infrastructure for managing lung
cancer and its complications in most Indonesian health
care facilities is even more limited. This limitation ex-
tends beyond rural areas and also affects large cities in
Java. Typically, patients diagnosed with lung cancer must
be referred to larger hospitals for treatment because
more than 80% of newly diagnosed cases are in the late
stage, requiring various treatment modalities. These can
include surgery, radiation therapy, chemotherapy, tar-
geted therapy, immunotherapy, and palliative care, as
illustrated in Figure 4.
1140 Asmara et al
Surgery
Surgery is a viable option for treating lung cancer
stages I, II, and IIIA, encompassing various procedures
such as pneumonectomy, lobectomy, segmentectomy,
sublobar resection, and also metastasectomy. Whereas
an anatomical resection has the highest survival rate,
patients with cardiovascular comorbidities or lower lung
capacity may undergo segmentectomy or sublobar
resection.8
The number of surgeries performed specifically for
lung cancer treatment in Indonesia is currently un-
known. Along with technological advances, thoracic
surgery in Indonesia has developed into a distinct
surgical subspecialty, boosted by the introduction of
video-assisted thoracoscopic surgery in several public
hospitals since 2010. Open thoracotomy is reserved for
complex and high-risk cases. Another modality is meta-
stasectomy by means of video-assisted thoracoscopic
surgery or thoracotomy, used for very selective cases of
stage IV. The number of surgeries performed specifically
for lung cancer treatment in Indonesia is currently
unknown.
The availability of thoracic surgeons has not kept
pace with demand, and 19 out of 38 provinces in
Indonesia do not have thoracic surgeons. Currently,
there are only 200 thoracic surgeons in Indonesia,
mostly based in Jakarta predominantly focused on car-
diac surgery rather than lung surgery. Only two uni-
versities, Universitas Indonesia in Jakarta and Airlangga
University in Surabaya have thoracic surgeon education
centers, training only 18 to 20 new specialists annually.
Systemic Therapy
Chemotherapy remains the frontline systemic ther-
apy for both NSCLC and SCLC in Indonesia, as it is
covered by JKN. It is used in all lung cancer stages.
Platinum-based chemotherapy is readily available.
For early-stage lung cancer, chemotherapy can be
administered as neoadjuvant or postsurgical adjuvant
therapy. In clinical practice, clinicians administer adju-
vant platinum-based chemotherapy (platinum þ vinor-
elbine/pemetrexed [adenocarcinoma only]/taxanes/
gemcitabine) for resected patients with stage IB, IIA, IIB,
and IIIA NSCLC every 3 weeks for three to four cycles.
Even though positive result from the ADAURA trial was
exhibited with adjuvant osimertinib in EGFR-mutant
NSCLC after adjuvant chemotherapy, adjuvant osimerti-
nib is not administered at public hospitals owing to lack
of coverage by JKN. Clinicians can administer adjuvant
osimertinib at private hospitals, which are either
covered by patients’ private health insurance or paid for
by themselves.22
In October 2022, the U.S. Food and Drug Adminis-
tration approved atezolizumab for adjuvant treatment
Journal of Thoracic Oncology Vol. 18 No. 9
after resection and platinum-based chemotherapy in
patients with stage II to IIIA NSCLC with PD-L1 expres-
sion greater than 1% on tumor cells on the basis of the
result of the IMpower-010 randomized phase 3 open-
label trial.23 The JKN does not, however, cover adju-
vant atezolizumab at public hospitals, although it may be
an option for patients with private insurance or if pa-
tients pay for it themselves. Sometimes, clinicians
administer neoadjuvant platinum-based chemotherapy
in patients with resectable stage IB to IIIA with NSCLC
after multidisciplinary tumor board meetings at public
hospitals. Unfortunately, nivolumab is not yet available
in Indonesia, preventing its use as neoadjuvant therapy
despite positive results from the CheckMate 816 trial.24
In cases of stage III NSCLC that are unresectable,
concurrent chemoradiotherapy, or chemotherapy fol-
lowed by sequential radiotherapy is the standard of care.
On the basis of the PACIFIC clinical trial, durvalumab
significantly prolonged progression-free survival as
compared with placebo among patients with stage III,
unresectable NSCLC who did not experience disease
progression after concurrent chemoradiotherapy. How-
ever, the JKN does not cover durvalumab in public
hospitals.25
The management approach for advanced NSCLC is a
multimodality one, combining systemic therapy options
(chemotherapy, immunotherapy, targeted therapy) with
other modalities (such as radiotherapy), with the pur-
pose of providing palliative treatment or prolonging
survival.26 For patients with advanced NSCLC without
targetable drivers, chemotherapy may be prescribed as a
treatment option. The recommended first-line chemo-
therapy regimen is platinum-based chemotherapy such
as cisplatin or carboplatin combined with paclitaxel,
docetaxel, gemcitabine, pemetrexed (adenocarcinoma
only), and vinorelbine. A study in Indonesia comparing
1-year survival of patients with wild-type adenocarci-
noma receiving different chemotherapy regimens
without immunotherapy revealed no significant differ-
ence among different drug regiments.27
Because the national health insurance JKN does not
cover pembrolizumab, only very few patients can be
prescribed chemotherapy and pembrolizumab for
advanced NSCLC with unknown PD-L1, PD-L1 1% to
49%, or pembrolizumab monotherapy with PD-L1
greater than or equal to 50%.
In patients with advanced NSCLC with targetable
drivers for NSCLC with EGFR mutation, first- (gefitinib
and erlotinib) and second-generation (afatinib) EGFR
tyrosine kinase inhibitor (TKI) are covered by the JKN.
At Dharmais National Cancer Hospital, patients with
advanced NSCLC who were treated with gefitinib, erlo-
tinib, or afatinib had a median progression-free survival
of 11 months.28 Patients that progress after first- or
September 2023
second-line EGFR TKI and have T790M mutation can be
administered osimertinib; however, the JKN does not yet
provide coverage for osimertinib (Table 1). Although
first-line EGFR TKI is found to be effective even in recent
studies, TKI treatment patterns such as those seen in
Japan and Western Europe are not yet realized.29,30
Furthermore, laboratories that offer tests for this muta-
tion are limited, meaning, for most patients with lung
cancer, the mutational status remains unknown.
Other driver mutations and aberrations are only
seldom tested, let alone treated. Patients who require the
drugs and tests must pay for them themselves, and they
are quite costly. For example, crizotinib, alectinib, brig-
atinib, and lorlatinib can be given to patients with a
positive ALK gene fusion. ROS-1 gene fusions can be
targeted by several drugs, including crizotinib and
Table 1. List of Drugs Available in Indonesia for Advanced
NSCLC
List of Drug Available in Indonesia for Advanced NSCLC
Drugs Available for JKN Not Available for JKN
Gefinitib
Erlotinib
Afatinib
Osimertinib
Crizotinib
Pembrolizumab
Atezolizumab
Durvalumab
Brigatinib
Lorlatinib
Bevacizumab
Lung Cancer in Indonesia 1141
lorlatinib. Sotorasib can be given to patients with KRAS
G12C mutation. The availability of these specific targeted
therapies is extremely limited and data regarding their
use and results in Indonesia is unknown until now.
In general, the choice of treatment modalities in
limited-stage SCLC is a combination of platinum-based
chemotherapy (cisplatin/carboplatin with etoposide as
the first choice and cisplatin/carboplatin with irinote-
can), radiotherapy, and surgery (in very early stages that
are eligible for surgery). As for extensive-stage SCLC,
chemotherapy with carboplatin and etoposide or irino-
tecan is the main choice with or without palliative ra-
diation on primary and metastatic lesions.8
Radiotherapy
Radiation therapy is a crucial treatment modality for
lung cancer in Indonesia. It can be used in all stages of
NSCLC and SCLC as curative therapy whether definitive,
neoadjuvant, adjuvant, or palliative therapy. Radiation
therapy is also used for superior vena cava syndrome as
palliative treatment. The basic technique of radiotherapy
used for patients with lung cancer in Indonesia is
intensity-modulated radiotherapy. When there are more
advanced technologies available, such as volumetric-
modulated arc therapy, image-guided radiation therapy,
four-dimensional CT, positron emission tomography–CT,
immobilization devices, active breathing control, and
stereotactic body radiotherapy, it is recommended to use
them instead. These newer technologies will improve the
accuracy and safety profile of the radiotherapy process.8
Radiotherapy became a rapidly growing field in
Indonesia in the past decade. In 1998, Indonesia had less
than 20 radiation therapy centers with 31 radiation
oncologists. In 2022, there were 135 radiation oncolo-
gists with 82 megavoltage (MV) machines in the country,
comprising 60 linear accelerators, 21 cobalt systems,
and one tomotherapy unit. By the end of 2030, it is ex-
pected that an additional 78 new machines will be
installed. With 348,809 new cancer cases reported in
2018, a total of 379 MV machines would have been
required to ideally meet the radiotherapy utilization rate
(54.3%). However, with an expected 475,502 annual
new cancer patient diagnoses by 2030, the number of
MV machines would need to increase to at least 517.31
Currently, there is only one institution that provides a
radiation oncology residency program—the Faculty of
Medicine Universitas Indonesia in Jakarta. The program
was initiated in 2008 and followed the International
Atomic Energy Agency syllabus. Most of the radiation
oncology facilities are located on the island of Java and
60% of the centers were operating with a single machine
(Fig. 5). As for the other treatment facilities in Indonesia,
access is a challenge for patients; therefore, when a
1142 Asmara et al
Figure 5. Access to oncology radiation service in 2020. Modified from Gondhowiardjo et al.33 MV, megavoltage. JKN, Jaminan
Kesehatan National.
patient comes from a different island, shorter treatment
regimen is often being used. However, regardless of
these challenges, and even during the COVID-19
pandemic, efforts were in place that ensured the
continuation of safe and sustainable radiotherapy
services.31–33
Palliative Care
Since 1992, Indonesia has made efforts to improve
palliative care, with the Ministry of Health implementing
a policy in 2007 to address this need. Indonesia’s Na-
tional Cancer Control Program began incorporating
palliative care in cancer treatment between 2014 and
2019. Furthermore, in 2015, the Singapore International
Foundation, in cooperation with Cancer Foundation
Jakarta, provided basic training to 12 hospitals in
Jakarta. Despite these efforts, progress has been slow
owing to several challenges such as the lack of guidelines
and standards, a referral system, and adequate funding.
Certified palliative care is currently only available in
major cities with cancer facilities, leaving many areas
without access. According to The Economist Intelligence
Unit’s 2015 Quality of Death Index, Indonesia was
ranked fifty-third for palliative care.34
Other challenges in developing palliative care in
Indonesia are linked to government policies, lack of edu-
cation, health care professionals’ attitudes, and sociocul-
tural conditions. Palliative care is sometimes regarded as
an option only when active treatment is no longer viable.
Journal of Thoracic Oncology Vol. 18 No. 9
Resistance to palliative care referral is fueled by attitudes
such as the following: (1) patient request for curative
treatments at all costs, (2) taboos surrounding death and
the disclosure of prognosis, (3) family decision-making,
and (4) preference or reliance on traditional medicine.
Regional/hospital regulation and basic training on family
caregivers can improve the quality of life for those
receiving palliative care. To address this, in 2016, the
Ministry of Health established a national standard for
palliative cancer management, and this initiative has been
continuously growing since then.34
Challenges for Indonesia
One of the most critical challenges that Indonesia
faces in health care is the uneven distribution of health
infrastructure, experts, and supporting facilities. The
issue leads to unequal access to health care for all In-
donesians, which remains far from achieving the aspi-
rations outlined in the country’s constitution. The
constitution stated that everyone has the right to fulfill
their basic needs, live in physical and mental prosperity,
have adequate housing and a healthy living environment,
and have access to health care, regardless of their loca-
tion or socioeconomic status. To improve early detection
and, consequently, the prognosis of patients with lung
cancer, efforts should be made to enable nationwide
access to standard lung cancer diagnostic tools.
Despite being the fourth most populous country in
the world, Indonesia has not taken full advantage of its
September 2023
potential to develop a large and diverse cancer database.
The country has an unequal distribution of cancer reg-
istries with relatively few research initiatives compared
with other countries with a large populations. To
make the most of this demographic advantage, it is
important to foster better collaboration between in-
stitutions and organizations, such as educational/
professional institutions and the government. With 92
medical faculties and approximately 700 public hospitals
throughout the country, there is a viable, but currently
undeveloped, opportunity to pool data and conduct
multicenter studies.
Next to lung cancer, Indonesia is facing multiple
health challenges that place a significant burden on its
health care system—the triple-burden disease, which
includes the following: (1) the emergence of new infec-
tious diseases such as COVID-19; (2) the continued
prevalence of infectious diseases such as tuberculosis;
and (3) the increasing incidence of noncommunicable
diseases. These health challenges often impact the
diagnosis and treatment of lung cancer, especially
tuberculosis.
Furthermore, the popularity of alternative and
traditional medicine not supported by scientific evi-
dence among the Indonesian population presents an
additional challenge. It is crucial to address the
dissemination of accurate and trustworthy information
in the current era.
In conclusion, lung cancer remains a significant health
problem in Indonesia, characterized by high incidence and
mortality rates. The country faces several critical chal-
lenges in addressing this disease, primarily, the uneven
distribution of health infrastructure, including limited
diagnosis and therapeutic modalities, experts, supporting
facilities, and the current smoking rate among the popu-
lation. Although the JKN provides coverage for lung cancer
diagnosis and most treatments, there is a need to increase
efforts to improve the distribution of cancer management
services throughout the country. The government should
increase spending on health care and address the uneven
distribution of health care infrastructure and professionals
to ensure better access to health care services for all In-
donesians. Better collaboration between institutions and
organizations, such as educational/professional in-
stitutions and government, can help to improve cancer
registries and research and foster the potential to conduct
multicenter studies. Furthermore, more tobacco control
measures are needed to reduce the nationwide lung cancer
incidence. Despite these challenges, Indonesia has the po-
tential to enhance lung cancer management and address
other health challenges in the country. By prioritizing
resource allocation and by improving collaboration in
health care infrastructure, Indonesia can work toward
achieving better lung cancer management and improving
Lung Cancer in Indonesia 1143
overall health care outcomes. Continuous efforts and im-
provements are necessary to ensure that Indonesia can
provide optimal lung cancer management on par with
other developed countries.
CRediT Authorship Contribution
Statement
Oke Dimas Asmara: Conceptualization, Investigation,
Resources, Writing – original draft, Writing – review &
editing, Visualization, Project administration.
Eric Daniel Tenda: Conceptualization, Resources,
Writing – review & editing, Project administration,
Supervision.
Gurmeet Singh: Writing – review & editing,
Supervision.
Ceva Wicaksono Pitoyo: Writing – review & editing,
Supervision.
Cleopas Martin Rumende: Writing – review &
editing, Supervision.
Wulyo Rajabto: Resources, Writing – original draft,
Writing – review & editing.
Nur Rahmi Ananda: Resources, Writing – review &
editing.
Ika Trisnawati: Resources, Writing – review &
editing.
Eko Budiyon: Resources, Writing – review & editing.
Harik Firman Thahadian: Resources, Writing –
review & editing.
E.C. Boerma: Writing – review & editing,
Supervision.
Achmad Faisal: Resources, Writing – review &
editing.
David Hutagaol: Resources, Writing – review &
editing.
Wuryantoro Soeharto: Writing – review & editing,
Supervision.
Fahmi Radityamurti: Resources, Writing – review &
editing.
Erika Marfiani: Resources, Writing – review &
editing.
Pradana Zaky Romadhon: Resources, Writing –
review & editing.
Fathur Nur Kholis: Resources, Writing – review &
editing, Supervision.
Hendarsyah Suryadinata: Resources, Writing –
review & editing.
Arto Yuwono Soeroto: Writing – review & editing,
Supervision.
Soehartati A. Gondhowiardjo: Writing – review &
editing, Supervision.
Wouter H. van Geffen: Conceptualization, Writing –
original draft, Writing – review & editing, Resources,
Funding acquisition, Project administration, Supervision.
1144 Asmara et al
Acknowledgments
The figures presented in this article were developed by
Afdilla Rayhani using software from http://vemaps.
com.
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