Country context

Hong Kong is a special administrative region of China, but maintains autonomy over much of its policy, including health policy. While Hong Kong does not have universal health coverage (UHC), publicly funded health care is available via the Hospital Authority (HA), which provides around 90 percent of inpatient services. Outpatient care, by contrast, is largely the responsibility of private health care facilities, which undertake 68 percent of all outpatient procedures and appointments, paid for by the patients themselves or by private insurance. Hong Kong has been facing a growing lung cancer burden—since 2014, the disease has been the second-most common form of cancer for the overall population, and the most common form of cancer among men. In 2021, the most recent year with available data, the overall incidence of lung cancer was 81 cases per 100,000 people, and the disease was responsible for over one-quarter of cancer-related deaths. Concerningly, one- and five-year survival rates for lung cancer are low, largely due to the frequency of late-stage diagnosis. In 2020, for example, 58.5 percent of lung cancer patients were diagnosed at stage IV, compared to just 16.0 percent diagnosed at stage I, when a range of treatment options are available and appropriate.

Air pollution, occupational and residential carcinogen exposure, and an aging population are significant drivers of non-communicable diseases (NCDs) and particularly of lung cancer. Outdoor air pollution alone is estimated to be the cause of 17 premature deaths per day in Hong Kong, or 6,300 per year, despite the passage of an air-quality-control law (Cap. 311) in 1982. Regional transboundary haze events, the impacts of locally driven emissions from the shipping industry, and pollution from nearby mainland China—for example, the industrial Pearl River Delta Economic Zone (PRDEZ)—all drive poor air quality. However, Hong Kong has made significant progress in addressing another major risk factor for lung cancer: smoking. The passage of Cap. 371, Smoking (Public Health) Ordinance in 1982 has led to the progressive prohibition of smoking in workplaces, public outdoor areas, and public transit, and to restrictions on tobacco advertising and sales of tobacco products containing tar over a certain limit. As a result, smoking prevalence has dropped from 23.2 percent of the population in 1982 to 11.1 percent in 2010 and 9.5 percent in 2021, making Hong Kong one of few jurisdictions in the world to bring its smoking prevalence into the single digits. The island has also been a signatory of the WHO Framework Convention on Tobacco Control (FCTC) since 2006 as an extension of China’s ratification of the framework.

Assessing policies and programs

Hong Kong’s approach to lung cancer is guided by two government-led strategies: The Hong Kong Cancer Strategy 2019 (HKCS) and Towards 2025: Strategy and Action Plan to Prevent and Control NCD in Hong Kong (SAP), which launched in 2021. Both strategies take a prevention-first approach, seeking to improve healthy lifestyles and health-seeking behaviors, and reduce risk factors such as smoking and air pollution. The HKCS lays out clear, data-driven targets, focused on improving early detection, providing holistic care throughout the life-course and patient-journey, and investing in surveillance, monitoring, and innovative treatments. Of note, the HKCS provides some information on budget allocation, such as earmarking HKD 3 million (USD 384,000) to improve and expand the Hong Kong Cancer Registry (HKCaR) in the FY2019 government budget. However, subsequent budgetary decisions are not easily accessible. Similarly, the SAP lays out clear targets to meet by 2025, including targets to reduce cancer incidence and mortality. However, neither strategy focuses on lung cancer explicitly, a clear gap that must be addressed to effectively control the increasing disease burden within Hong Kong’s population.

Prevention and early detection are central to Hong Kong’s cancer control, with an emphasis on behavioral and environmental change. The SAP aims for a 30 percent relative reduction in tobacco consumption by 2025, compared to 2010, in line with WHO standards, and outlines clear actions for the government and related stakeholders to take. These include progressively increasing tobacco duty, and offering free smoking cessation services through the HA, local NGOs, and private sector doctors through a pilot Public-Private Partnership Programme on Smoking Cessation. The government also undertakes public awareness campaigns, such as the “Quit to Win” Smoke-free Community Campaign, which challenges smokers to quit and enters successful participants into a prize drawing, including a television appearance to talk about their experiences. Since 2009, the Quit to Win campaign has recruited around 1,000 smokers per year, and it is considered a highly successful awareness program.

In addition to smoking, prevention policy in Hong Kong takes the form of the Clean Air Plan for Hong Kong 2035, which launched in 2021 and aims to improve air quality and reduce pollution-driven illness and premature mortality. The Plan, augmented by Air Quality Objectives, which are re-assessed every five years, targets emissions from personal and commercial vehicles—including promotion of electric vehicles—public transit, and industry. Notably, the Plan includes a regional collaboration with Guangdong Province, China—the two territories have set shared emissions-reduction targets for 2025 and 2030. Currently, there do not appear to be government-led initiatives to reduce occupational exposure to carcinogens, but some private-sector companies have begun to address the issue in partnership with NGOs. The Institution of Occupational Safety and Health (IOSH), for example, launched its No Time to Lose campaign in 2016 and has delivered educational briefings to Hong Kong-based companies on how to reduce occupational cancer-risk factors, including diesel exhaust, solar radiation, asbestos, and silica dust.

Given the trend of late diagnosis of lung cancer in Hong Kong, which contributes to poor patient health care outcomes, early detection and diagnosis are also key areas for improvement. Hong Kong does not have a national population-screening program for lung cancer, and low-dose computed tomography screening is only available selectively through the private sector, even though Hong Kong has successfully implemented national screening programs for both colorectal and cervical cancers, signaling that the same is possible for lung cancer with adequate prioritization. PET and PET-CT scans are used commonly for early detection, and the HKCS identifies the reduction of wait times between referrals and diagnostic stages for all cancers as a critical goal to improve detection. Radiotherapies such as intensity-modulated radiation treatment (IMRT) and stereotactic ablative radiotherapy (SABR) are available for treatment, and immunotherapy has been available to patients since 2015, although it is not covered under the public health care system. As of 2019, over 100 cancer treatment drugs were either completely or partially funded by the HA.

Notably, Hong Kong offers patients the option to integrate Chinese medicine into their treatment plans (for example, by using acupuncture or herbal medicines to assist in pain relief). Chinese medicine is also available as an addition to palliative and terminal cancer care, following a successful pilot period. Palliative care is provided by the HA, in partnership with local NGOs and community groups, and the HKCS highlights a push by the government to treat cancer as a chronic condition that lasts and has effects throughout the lifetime. As part of this initiative, the HKCS references services caring for the social and psychological needs of patients, families, and caregivers, although specifics are lacking, which makes independent monitoring and evaluation of these services challenging.

FIGURE 2

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

Hong Kong has made promising progress toward specific goals around tobacco usage and has laid the groundwork for effectively addressing lung cancer via a series of interconnected strategies. Still, more can be done to improve patient outcomes and prevent lung cancer. In particular, Hong Kong lacks a lung cancer-specific strategy or action plan, despite the heavy toll the disease places on the population, and the inequities in treatment access which exist, particularly for the 8 percent of residents who are non-Cantonese speaking ethnic minorities. Specific targets and strategies to address lung cancer could be highly effective if the government can secure buy-in from cross-sectoral partners, including the private health care sector and those working on the environment and pollution.

Nevertheless, Hong Kong’s current cancer and NCD strategies highlight promising avenues for future development. The HA is working to introduce a framework for the provision of genetic and genomic testing, to enhance early detection of certain cancers—including lung cancers—in high-risk patients and those with a family history of cancer. Tests of these kinds could be highly effective in supporting early detection and identifying the best treatment methods. In addition, the HKCS highlights the potential for partnership with the pharmaceutical industry to create co-financing plans for expensive or innovative cancer drugs, which could lead to greater leverage of public-private partnerships and reduce the burden of health costs on individuals and families. Finally, the HKCS outlines plans to update cancer treatment centers with modernized technology and equipment, including resources to enable next-generation sequencing.