“I feel sorry for these cervical cancer survivors,” said Dr Siu-King Mak, President of the Hong Kong Public Doctors’ Association, during a consultation meeting for the 2018–19 Budget. “Their sufferings seldom end with victory against cancer. For many patients, the journey to recovery is long and painful, and extremely costly to the government. A majority of these cases could have been prevented with human papillomavirus [HPV] vaccination before the patients became sexually active.”

In this exclusive interview, Mak shared with MIMS the reasons why the government should provide universal access to HPV vaccines — from a public health perspective — beyond benefits to all girls in the city.

Weighing the cost of universal vaccination against treatment

The government has been heavily promoting its cervical screening programme in recent years. Just last month, the Community Care Fund (CCF) rolled out a 3-year pilot scheme to provide free or subsidized cervical cancer screening for eligible low-income women.

“It’s a positive initiative. Through regular screening, even if the cervical cellular changes have become malignant, patients could still be treated at an earlier stage — and hence, given a higher chance to survive,” said Mak, who was urging Professor Sophia Chan, Secretary for Food and Health, to consider adding HPV vaccines to the government’s regular vaccination programme.

“Many of these survivors once thought things would be turning positive after their recovery from cancer, but that’s not the case. Morbidity from the severe side effects of radiation therapy continues to progress decades after completion of treatment. Even after undergoing successful surgeries to alleviate the side effects, these patients are still coming back eventually, with their health conditions getting worse every time,” he continued.

In cervical cancer, survivors may experience severe side effects following radiation therapy, including urinary complications that require surgery and urinary diversion. These side effects may present much later after the completion of radiation treatment. One study even reported an average onset of severe urinary symptoms 15 years after radiation treatment. As a result, these late side effects are often underestimated and underreported.

Occasionally, cervical cancer survivors came to Mak as they noticed blood in their urine. Mak explained that this is often caused by an increased growth of small blood vessels in the bladder after radiotherapy. Since these blood vessels are very fragile, they easily break and bleed. “As time goes on, the blood clots may block urine flow, making urination difficult or even impossible. In this case, we usually need to insert a flexible tube into the patient’s bladder to try to flush out the blood clot,” said Mak.

Cervical cancer survivors might expect that their sufferings could end with victory against cancer. However, oftentimes, their journey to recovery is long and painful.
Cervical cancer survivors might expect that their sufferings could end with victory against cancer. However, oftentimes, their journey to recovery is long and painful.

Looking into data in the public sector, Mak found that almost 60 cervical cancer survivors had undergone similar — or more complicated — surgeries to treat severe side effects of radiotherapy last year. “These patients would have to stay for at least a week in the hospital for the surgeries. That means, on average, we were treating one of these patients per week throughout the year,” Mak pointed out. “This not only brings tremendous pain to the patients, but also incurs a significant burden to the government, including the costs of performing these surgeries, hospital stays, manpower and so on. What’s more, we are just talking about the costs of treating severe side effects for cervical cancer survivors. The costs associated with cervical cancer would be even higher if we take into account the treatment costs for patients who are still battling with the disease.”

“So, the question to the government is: is providing universal access to HPV vaccines for all girls in Hong Kong really more expensive than the provision of all these treatments?” he asked.

Prevention is key in primary healthcare

According to the Hospital Authority (HA)’s latest annual report submitted to the Legislative Council, a deficit of HKD 1.52 billion was recorded in the year ending 31 March 2017. In response, Professor Sophia Chan admitted that rising public hospital spending would be inevitable, and boosting primary healthcare services in the community would be the key to cope with future population growth.

“It is a known fact that public hospitals in Hong Kong are overloaded. If so, why don’t we focus more on prevention in primary healthcare rather than eventually dealing with more problems in secondary and tertiary levels of care?” Mak echoed. “Some consider primary healthcare as a means to enhance access to healthcare services for people in the lower social class only, but this is not true. Primary healthcare includes prevention and the first level of treatment for the entire population. It is better health for all, and prevention is the key focus.”

While some point out HPV vaccines do not cover all HPV genotypes, and hence, may not be an effective means to prevent cervical cancer, Mak argued that this is a dangerous presumption. “The latest vaccine developed covers the HPV genotypes that account for 90 percent of cervical cancer cases. Similar to flu vaccines, the government would not advise the public against taking flu shots even if they are not effective against certain viral strains, as they still offer some level of protection,” he explained.

Mak is urging the government to consider adding HPV vaccine to the government’s regular vaccination programme.
Mak is urging the government to consider adding HPV vaccine to the government’s regular vaccination programme.

Mak also emphasized that women should still undergo cervical cancer screening even if they have already received HPV vaccines. “One downside of the programme is that it is somehow dependent on patients’ compliance to undergo screening every 3 years despite the government’s efforts to promote the initiative. This is where universal HPV vaccination comes in to fill the gap for prevention,” said Mak. “But as I said, this does not mean women no longer need to undergo screening. Both vaccination and screening are crucial steps to prevent cervical cancer.”

Speaking about primary healthcare, Mak said he is supportive of the initiative, particularly due to the mounting pressure in the public sector. “In Urology, we have around 130 specialists in the city. However, only around 40 of them work in HA, which serves 90 percent of the Hong Kong population. As one of the frontline doctors working in HA, I understand the pressure. It’s not surprising that many may be disappointed with HA’s system and have decided to leave the public sector,” shared Mak.

“But I don’t want to give up just yet. What I’m trying to do now is to reflect the problems I see in the frontline to the management. Hopefully, one day, this will not only alleviate the pressure in public hospitals, but also bring benefit to patients in the long run,” he said. MIMS

(Editor’s note: This article is updated as of 24 January, 2018.)

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The struggle in combating cervical cancer in Hong Kong