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Following is a question by the Dr Hon Elizabeth Quat and a written reply by the Secretary for Food and Health, Dr Ko Wing-man, in the Legislative Council today (May 8):
Question:
Statistics of the World Health Organization show that, in 2010, 54.8 women in every 100 000 women in Hong Kong had breast cancer. Compared with the world average ratio (39 women had breast cancer in every 100 000), Hong Kong is a place with an above average incidence rate. According to the statistics of the Hospital Authority (HA), breast cancer tops the list of the "Top Ten Cancers" for women in Hong Kong. In 2010, the life-time risk of Hong Kong women having breast cancer was one in 19. Also, eight women were diagnosed with breast cancer and at least one died of breast cancer every day on average. The Hong Kong Breast Cancer Foundation has pointed out that information of the International Cancer Screening Network shows that population-based breast cancer screening can reduce the mortality rates of various countries/regions by 20% to 38% and, at present, more than 34 countries and regions around the world (including Mainland China and Taiwan) have implemented population-based breast cancer screening. As Hong Kong has not implemented such screening, less than 5% of the 1.5 million women aged 40 to 69 have undergone the screening. On the other hand, statistics of HA indicate that, in 2010, the life-time risk of women having cervical cancer was one in 145, and one in every 445 women died of cervical cancer. In this connection, will the Government inform this Council:
(a) of the respective numbers of newly confirmed cases and deaths of breast cancer and cervical cancer in Hong Kong in each of the past five years;
(b) of the respective total expenditure on prevention and treatment for breast cancer and cervical cancer by public healthcare institutions in each of the past five years, and set out in a table the details of the amounts of expenditure on health education, medical examination and assessment, specialist treatment, operations and in-patient services, and follow-up rehabilitation, etc.; the total and a breakdown of the projected expenditure in each of the next five years;
(c) whether public healthcare institutions have provided subsidised breast cancer screening for women with family history of the cancer; if so, of the number of women screened, the expenditure incurred, and the breast cancer detection rate in each of the past five years; of the number of women to be screened and the projected expenditure in each of the next five years;
(d) whether it knows the number of women screened for breast cancer on their own expenses in private healthcare institutions, the fees involved and the breast cancer detection rate in each of the past five years;
(e) whether it has assessed the expenditure to be incurred each year for implementing a free breast cancer screening programme for women aged 40 to 69; if it has, of the details; if not, the reasons for that;
(f) of the number of women of the relevant age cohort who received screening for cervical cancer provided by public healthcare institutions, the expenditure incurred, and the cervical cancer detection rate in each of the past five years; the number of women to be screened and the projected expenditure in each of the next five years;
(g) whether it knows the number of women who received cervical cancer screening and cervical cancer vaccinations on their own expenses in private healthcare institutions and the fees involved in each of the past five years;
(h) whether it has assessed the respective expenditure to be incurred each year for implementing a free cervical cancer screening programme and a free cervical cancer vaccination programme for all women; if it has, of the details; if not, the reasons for that; and
(i) of the respective numbers of women who received screenings for breast cancer and cervical cancer provided by each of the Woman Health Centres (WHCs) and Maternal and Child Health Centres (MCHCs) under the Department of Health in each of the past five years; whether there were differences in the numbers of women screened among various WHCs and MCHCs; if so, of the reasons for that; of the respective estimated numbers of women using such services in each of the next five years; whether there are measures to enable more women to know about such services; if so, of the details; if not, the reasons for that?
Reply:
President,
Cancer is a major public health issue in Hong Kong. Its prevention, control and screening policies must be grounded on fact, scientific evidence and public interest. In examining whether to introduce a population-based screening programme or vaccination programme for a specific disease, the Government needs to carefully consider a number of factors, such as the prevalence of the disease in Hong Kong, the accuracy and the safety of the tests for the local population, as well as the effectiveness in reducing incidence and mortality rates of the disease. The Government also needs to give due consideration to the actual circumstances, such as the feasibility and cost-effectiveness of the screening programme and public acceptance.
The Government has established the Cancer Coordinating Committee, which I chair, to formulate comprehensive strategies and make recommendations for effective prevention and control of cancer. The Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) was set up under the Committee to provide recommendations on preventive measures and screening of cancers.
At present, cervical cancer screening is the only population-based cancer screening in Hong Kong which bears sufficient evidence on its effectiveness. Taking into account the recommendations of CEWG, the Department of Health (DH) has been running a territory-wide Cervical Screening Programme in collaboration with public and private healthcare providers since March 2004, to encourage women aged 25 to 64 who have ever had sexual experience to have regular cervical smears to prevent cervical cancer. The Cervical Screening Programme also includes public education and the establishment of the Cervical Screening Information System which stores smear records and reminds women to have regular cervical smears.
The human papillomavirus (HPV) vaccine offers protection against cervical cancer, but cannot effectively protect against infections of some types of high risk HPV which are not included in the vaccine. It also cannot clear the virus in those who are already infected. For this reason, women who have received the vaccination must continue to have regular cervical smears. According to the latest recommendations issued by the Scientific Committee on Vaccine Preventable Diseases and the Scientific Committee on AIDS and Sexually Transmitted Infections under the Centre for Health Protection of DH, Hong Kong should consider the local context and the development of scientific evidence, as well as conduct health economic evaluation of any vaccination programme. The Scientific Committees also recommended that we should strengthen the implementation of the Cervical Screening Programme in Hong Kong, raise public awareness and enhance the public's understanding of the HPV vaccine through health education and publicity. The Scientific Committees will continue to keep in view the latest developments on this subject.
Population-based breast cancer screening by mammography is a subject of controversy. In some Western countries where the incidence rate of breast cancer is relatively high, population-based mammography screening programmes have been implemented since the 1980s. However, studies have found that screening programmes were only followed by a slight drop or even no reduction in the mortality rate of breast cancer. Some studies also revealed that screening programmes have caused harm such as over-diagnosis. As a result, some Western countries are beginning to adjust their breast cancer screening policies. Separately, while some Chinese or Asian communities have implemented population-based breast cancer screening programmes, there is no published data that reflects the effectiveness or cost-effectiveness of the programmes. There are also no studies indicating that the programmes can effectively reduce the mortality rate of breast cancer. Internationally, an independent study report in 2011 concluded that it was unclear whether mammography screening does more good than harm. Hong Kong should take reference from these experiences. CEWG considers that individual women at increased risk of breast cancer (e.g. those with a family or personal history of the disease) should seek medical advice about whether they should receive breast cancer screening, but considers it unclear as to whether population-based mammography screening does more good than harm to asymptomatic women. The Government will continue to promote healthy lifestyles as the main prevention strategy, encourage breastfeeding and promote breast awareness among women, so that medical attention could be sought early if any abnormalities of the breast are identified. CEWG will continue to keep in view the latest developments on this subject.
As a matter of fact, the risk factors associated with many cancers are closely related to lifestyles. CEWG has pointed out that cancers, including breast cancer, can be effectively prevented through the adoption of healthy lifestyles, such as avoiding smoking and alcohol consumption, having regular exercise, and eating less meat and more vegetables. In this connection, DH actively promotes healthy diets, encourages regular exercise, implements effective tobacco control measures and educates the public on alcohol-related harm, in order to prevent cancer.
Against the above background, my reply to the nine parts of the questions is as follows:
(a) The Hong Kong Cancer Registry of the Hospital Authority (HA) collects cancer data of the overall population in Hong Kong. The incidence and mortality of breast and cervical cancer in the female population are at Annex A.
(b) The expenditure for prevention and treatment of respective cancers cannot be broken down as required by the question. DH's spending on public health education is not classified by types of cancer. In providing treatment and care services for cancer patients, HA adopts a multidisciplinary approach across a number of clinical specialties. Doctors will arrange different forms of examination, pharmaceutical treatment and other adjuvant treatments in light of the patients' needs, their clinical conditions and the complexity of their diseases. Moreover, cancer patients often require integrated medical services, including general out-patient clinic and specialist out-patient clinic services, acute care, extended care and hospice care, etc. Some cancer patients also need treatments for other diseases such as diabetes and hypertension.
(c) There are three Woman Health Centres (WHCs) and ten Maternal and Child Health Centres (MCHCs) under DH providing Woman Health Service to women aged 64 or below. The service includes clinical breast examination for all participants. Women at increased risk of breast cancer will receive mammography screening after medical assessment. If abnormalities are found, they will be referred to specialists for follow-up management.
Enrolment figures for the Woman Health Service under DH, the number of women receiving mammography screening and the number of cases referred to specialists due to breast problems are at Annex B. DH does not keep data on the breakdown in expenditure on mammography screening or breast cancer detection rate.
(d) DH does not collect data on mammography screening performed in private institutions.
(e) Given the lack of public health evidence at present, the Government has no plan to introduce a free population-based mammography screening programme, hence it has not assessed the annual expenditure for the implementation of such programme. We will continue to keep in view of the research findings by the medical sector.
(f) The attendance of cervical screening service at MCHCs under DH and cases referred to specialists are at Annex C. The expenditure of the Cervical Screening Programme is at Annex D. These figures are expected to remain stable over the next five years.
(g) DH monitors the coverage of cervical screening among Hong Kong women through the Behavioural Risk Factor Surveillance System. According to the Behavioural Risk Factor Survey conducted in April 2012, 69.2% of women from the age group of 25-64 have ever received cervical smears. DH does not collect data on the fees for this service provided in private institutions.
DH also does not collect data on the number of people receiving cervical cancer vaccines in private institutions or the fees involved.
(h) Under the territory-wide Cervical Screening Programme implemented by the Government, women who wish to receive cervical smears can select their preferred service providers. As far as DH is concerned, all 31 MCHCs provide cervical screening services. Fees will be waived for Comprehensive Social Security Allowance recipients. Moreover, a variety of woman health services are also made available by local non-government organisations (NGOs), including non-profit-making cervical screening services at a lower price. These established arrangements have been effective and hence the Government has not assessed the expenditure required for a free cervical screening programme.
Separately, as there is no health economic evaluation supporting a population-based HPV vaccination programme in Hong Kong, the Government has no plan to implement a population-based HPV vaccination programme, and hence it has not assessed the annual expenditure required for such a programme. We will continue to closely keep in view of the development of scientific evidence.
(i) As stated in part (c), the Woman Health Service of DH provides clinical breast examination to all participating women. The numbers of women who have enrolled for the Service, received mammography screening and cases referred to specialists due to breast problems are at Annex B. Compared with MCHCs, there are more women using the Woman Health Service at WHCs. This is because WHCs provide the Woman Health Service on a full time basis, while MCHCs also provide other services including antenatal and postnatal care, family planning, cervical screening and child health services.
Cervical screening services are provided by DH at MCHCs. The attendance for the service is at Annex C.
At present, a number of NGOs, private hospitals and doctors already provide a wide array of health programmes for women, including breast examinations and cervical screening services. DH has also been providing women with accurate information on women's health as well as relevant community resources through different channels in an effort to empower women to make choices that are conducive to their health and seek appropriate health care services where necessary. DH will also make reference to the primary care development strategy in planning the long term development of various healthcare services. The Government will continue to collaborate with other service providers, including private doctors and NGOs, so as to enhance the primary care services.
Ends/Wednesday, May 8, 2013
Issued at HKT 17:10
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