To Mrs Carrie Lam, Chief Executive
Hong Kong Special Administrative Region Government
Address: Policy Innovation and Co-ordination Office,
26/F, West Wing, Central Government Offices, 2 Tim Mei Avenue, Tamar, Hong Kong
Email: policyaddress@pico.gov.hk
Cancer Strategy Concern Group’s Submission on 2019 Policy Address
A comprehensive cancer strategy has been much needed for cancer patients in Hong Kong. Ranging from prevention, diagnosis, palliative care to rehabilitation, each element is vital in the formulation of a cancer strategy. Meanwhile, maintaining the quality of life for patients is essential alongside the treatment journey.
In light of 2018 Policy Address, the Cancer Coordinating Committee chaired by the Secretary for Food and Health was drawing reference from World Health Organization’s recommendations, international practices and actual local situations. The Government would map out a strategy related to cancer prevention and care services for the period between 2020 and 2025, thereby reducing the cancer burden on society. The Food and Health Bureau promulgated the Hong Kong Cancer Strategy on 26th July 2019. The Cancer Strategy is a holistic plan for cancer prevention and control for Hong Kong. The goal is to reduce the hit rate of cancer, to provide cancer screening and treatment to all in need, and to offer support services to survivors and their carers. The Government oversees and updates data of Cancer Registry continuously with the data provided by private hospitals. In addition, in collaboration with NGOs, a systematic cancer rehabilitators care-giving plan will be introduced. To perfect the Hong Kong Cancer Strategy, we at the Cancer Strategy Concern Group (“CSCG”) recommends the following measures for the 2019 Policy Address.
1. Prevention and diagnosis
Some cancers, including colorectal cancer, cervical cancer and breast cancer could be prevented via screening measures. Regarding colorectal cancer and cervical cancer, Hong Kong SAR Government has already launched screening programme while the discussion of screening for breast cancer is still ongoing.
Breast cancer is the commonest cancer among women in Hong Kong. In 2016, 26.6% of all new cancers among female were diagnosed of breast cancer, accounting for a total of 4,108 new breast cancer cases. In Hong Kong, many organizations are devoted to advocate for the universal breast cancer screening for years, hoping to facilitate early detection and treatment of breast cancer. According to data, early treatment of breast cancer can lead to an over 90% survival rate. However, the Government is still not considering any concrete plan on this subject, for instance, timetable of launching universal screening, participants and screening style. Seeing other overseas examples from a macroscopic perspective, and 34 countries and regions, including Europe and Canada, have already implemented a systemic and effective universal breast cancer screening system.
According to the data provided by Hong Kong Breast Cancer Foundation, most breast cancers cases are not hereditary. Only 15% of the patients have breast cancer in family history. Another study shows that among 2,549 breast or ovary cancer patients who are clinically considered to be of high risk, only 9.6% of them have gene mutations in the BRCA. This indicates that most breast cancer patients cannot detect the disease through genomic testing; therefore it is necessary for them to undergo breast cancer screening for arranging early treatments once diagnosed with suspected breast cancer. In addition, in the Prevention and Screening for Breast Cancer published in April 2014 by the Cancer Expert Working Group from the Department of Health, it has pointed out that breast cancer screening was proven to be beneficial for women with a higher risk of developing breast cancer.
We thereby recommend the Government to implement universal 3D mammography breast screening for high-risk women in Hong Kong. We believe that “early discovery and early treatment” can alleviate problems posed by advanced breast cancer, including patients’ painfulness, increasing treatment costs, and prolonged recovery period.
2. Limited treatment options and problem of safety net to enlist oncology items
Innovative and appropriate targeted therapy and immunotherapy are extremely expensive to cancer patients. Patients, particularly those from grassroot to middle classes, are unlikely able to afford the drug costs. A portion of second line treatment options are proven with better efficacy and smaller side effects relative to first line treatment options. They should be regarded as first line treatment options for health care professionals’ prescription.
Taking lung cancer treatment as an example, health care professionals will arrange biopsy examination to assess whether genetic mutation has occurred. Either ALK targeted therapy or immunotherapy will be prescribed as treatment options based on the biopsy examination result.
Regarding ALK targeted therapy, Alectinib focuses on controlling ALK+ lung cancer with a median of 34.8 months progression-free survival. In addition, brain metastasis always occurs for ALK+ lung cancer patients. Alectinib as second generation drug can prevent brain metastasis with better efficacy relative to first generation drug. The CSCG” recommends Alectinib should be enlisted as first line treatment option.
Immunotherapy has been widely applied to treat various cancer diseases. PD-L1 inhibitor, Atezolizumab is one of immunotherapies. It could be regarded as second line treatment for metastatic lung cancer without gene mutation. When first line treatment options are invalid to patients, second line treatment could be applied to sustain life and to maintain the quality of life.
Regarding metastatic liver cancer, the Hospital Authority Standard Drug Formulary has been offering only one item to treat liver cancer for years. Last year, Lenvatinib has been approved by Food and Drug Administration of USA as a first line targeted therapy to treat liver cancer. It greatly broadens treatment options for health care professionals.
Lenvatinib Traditional targeted therapy
Median Overall Survival (mOS) 13.6 months 12.3months
Median Progression-free Survival (mPFS) 7.3 months 3.6 months
Median Time to Progression 7.4months 3.7months
Objective Response Rate (ORR) 40.6% 12.4%
The above data proves Lenvatinib effectively extends patients’ overall survival, shrinks the cancer as observed by Objective Response Rate, controls the disease and maintains patient’s quality of life. Besides, Lenvatinib will not lead to limbs to ache of patients, despite of leading to high blood pressure. Health care professionals could prescribe different drugs based on patients’ conditions.
Another unneglectable disease is metastatic ovarian cancer. Among metastatic ovarian cancer patients, 80% patients will relapse. For the sake of extending overall survival, minimizing cancer relapse frequency and extending the interval between disease relapses, Niraparib, a targeted therapy serves as maintenance therapy. Its median of progression-free survival rate reaches 19.1 months. Yet, this item has not been enlisted to Community Care Fund First Phase Medical Assistance Programme. Patients from grassroot class and middle class can only hinge on the free drug assistance programme offered by pharmaceutical companies. Without the subsidy from the Government’s safety net, a stable supply of drugs to patients at a relatively affordable price cannot by guaranteed. Patients are worrying about whether they have appropriate drugs to sustain their life as well as their quality of life.
Apart from ovarian cancer treatment, women’s health surely involves breast cancer treatment. Traditional treatment options include surgical ablation, radiotherapy, chemotherapy, targeted therapy and endocrine therapy. Breast cancer medical treatment options have been evolving drastically in recent years, benefitting young females who suffer from metastatic breast cancer. One of obvious examples is a new targeted therapy, Ribociclib. It is appropriate to treat HR-positive, HER2-negative metastatic breast cancer in combination with an aromatase inhibitor, particularly for pre-menopause females. It significantly improves median overall survival with nearly 30% reduction of death. It also significantly improves median progression-free survival to 23.8 months from 13 months. It effectively procrastinates the first time to conduct chemotherapy. This drug can reduce the pain brought by treatment course, sustaining normal daily activities and maintaining their quality of life. Besides, targeted therapy, Eribulin, can significantly treat metastatic breast cancer by inhibiting cancer cell division and lead to death of cancer cells.
The aforementioned drugs have not been enlisted to the Community Care Fund First Phase Medical Assistance Programme. Hence, the respective patients are required to pay tens of thousands of drug costs, which is unaffordable for most of patients. The fundamental cause of such problem attributes to the drug list of the Programme only being reviewed twice each year.
We suggest increasing the review frequency of the drug list of Community Care Fund First Phase Medical Assistance Programme from twice to four times each year. This arrangement expedites the enlistment of appropriate drugs to the drug list which ultimately benefits cancer patients.
3. Palliative care, financial and carer’s support
Palliative care should not be the final treatment; rather, it should be introduced in the early diagnose and treat of cancer. There are cases in other areas that palliative care is promptly introduced to patients once diagnosed with cancer. This aims to maintain patients’ quality of life during treatment. Besides, nurses could be ‘case managers’ of respective cancer patients to follow up the whole patient journey of each patient ranging from preliminary diagnosis, treatment, support to recovery to minimize patients’ physical and psychological burden.
On one hand, due to sickness, patients’ working abilities are constrained. Some of their income had dropped sharply, while some cannot even assure whether their lives will continue. The cost for treatment could be very high, leading to huge financial pressure. Besides, under the current Inland Revenue Ordinance, patients still need to pay provisional salary tax. This put further heavy financial burden on patients.
On the other hand, regarding the means test mechanism on drug items and community support, many patients expressed that they do not know how to fill in the assessment application form. They also have difficulties in submitting copies of documentary proof since their application is in family unit. They express concern that if any family member is worried of potential legal problem due to any misrepresentation and omission in the application, this will affect the application process. And the patients will not be able to receive the protection they deserve.
We suggest the Government to strengthen the support to cancer patients, family members and carers from governmental and non-governmental layers. This is to allow patients and carers to receive immediate financial, social and mental support soon after diagnosis. Besides, the application for test-based drug item assistance should be changed from family unit to individual single unit. This will reduce unnecessary difficulties and stress for the patient applicants. At the same time, the design of the application form should be streamlined. Apart from that, we also recommend the Government should amend regulations or consider exercising discretion to exempt patients from paying the provisional salary tax until they are fully recovered from cancer in order to alleviate their financial burden.
4. Support on Cancer Survivors
Due to the scientific improvement, some cancer cases are under control and some of the cancer patients are nearly fully recovered. Cancer becomes a kind of chronic disease. “Living with cancer” is the latest cancer strategy in recent years. Yet, Hong Kong people are used to living in a fast pace, some cancer patients would return to their workplace immediately after being discharged from the hospital. Some of them could not adapt to the long working hours and increase the odds of cancer recurrence.
We suggest the government putting resources on studying the support on cancer survivors and implementing long-term supporting policies.
5. Conclusion
Our advocate is an integrated, efficient, patient-centred cancer strategy. We would be grateful for the Government’s consideration to implement the above suggested measures to alleviate the sufferings of cancer patients and their family members, and to benefit the health of greater Hong Kong citizens.
Cancer Strategy Concern Group
2nd August 2019
Convener: Mr. Samuel MAK (Tel: 9882-1717)
Email: cscghongkong@gmail.com