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SCMP Reporter

THE brightly-coloured lobby of the Lam Tin Well-Woman Clinic buzzes with smartly-dressed, chattering, smiling women with little but praise for the facilities and treatment they have received since the centre opened last year.

  Yet doctors around Hong Kong fear inadequate monitoring and treatment by inexperienced surgeons may do some of these women more harm than good.

  The warning comes as the number of women dying from breast cancer in Hong Kong is on the rise.

  In 1985 262 died from the disease. In 1993 - the latest figures available - that figure had risen to 313.

  The Lam Tin centre, the first of three to be set up by 1997 around the territory, saw 2,695 women between May last year and this June.

  It offers a screening service for women of 45 to 65 for breast and cervical cancer, as well as other illnesses which increase with age. Diabetes, brittle bones and high cholesterol top the list.

  After being screened at Lam Tin, 18 women have been diagnosed and treated for breast cancer; two for cervical cancer and another four are being treated for pre-cancerous cervical lesions.

  Many of those screened have also been found to have high sugar levels in their blood and high blood pressure.

   Some of those whose health or even lives were at risk were among women who greeted Chief Secretary Anson Chan Fang On-sang at the official opening of the clinic in February.

  Now well, they had every reason to celebrate.

  But statistics prove that for nearly every woman successfully treated for breast cancer in Hong Kong, another has had a breast or part of it removed because a benign tumour was present.

  Some of these women may have gone through the trauma of having a whole breast taken off for nothing as doctors disagree on whether removing benign tumours is a good or bad thing.

  Even if the woman has kept her breast, tissue that has been operated on to remove lumps or even test for malignancy is harder to analyse by mammography afterwards.

  Because the flesh has been tampered with, tiny alterations that could be the start of cancer become harder to pick up, says breast surgeon Yvonne Lau at Kwong Wah Hospital.

  The dilemma of balancing screening and treatment with leaving well alone is the problem screening services worldwide have to cope with.

  But doctors around Hong Kong are concerned that inexperience in the territory's hospitals and inadequate monitoring and management of screened women could lead to more unnecessary treatments than is considered acceptable elsewhere.

  Of 318 women sent between May 1994 and June 1995 by Lam Tin to hospitals or doctors for further examination by cancer surgeons, 193 were referred with suspected breast abnormalities and 17 for cervical irregularities.

   Of these, 41 were suspected to have breast cancers, with 18 confirmed.

  Principal medical and health officer for family services, Dr Cindy Lai Kit-lim, says she is aware of the problems.

  A review of the first year's work at Lam Tin - to be published early next year - will consider how to improve liaison with surgeons.

  But head of the Kwong Wah mammogram screening service, Dr Lam Hon-shing, says this is not good enough.

  He says a screening service should be constantly monitored so it knows exactly what its success rate is in detecting cancer. At the Family Planning Association (FPA), more than 10,000 women have a gynaecological checkup every year.

  A breast examination that shows possible problems leads to mammograms being taken by a private radiologist.

   If there is cause for concern, the woman is referred to one of 10 hospitals or clinics around the territory.

  Yet the FPA does not consider monitoring of the results to be its business.

  Representative Angela Pau says it does not have resources to check what has happened to the women.

  The treatment given by the surgeons is 'a matter of ethics', she says.

   Doctors are not suggesting that surgeons intend to perform operations that are not needed.

  But the separate parts of the screening process need to work as a team to improve the whole service, says breast surgeon Dr Lau.

  There is also concern that women are sent to hospitals around Hong Kong where surgeons may not have a great knowledge of breast cancer. Nine hospitals have seen women from Lam Tin, with some hospital staff seeing only one or two of them.

   Dr Lam at the Kwong Wah mammogram screening service says some doctors are given mammograms which they are not used to analysing, which probably do not show anything wrong and on which tiny changes are difficult to diagnose.

  Allied with a radiologist's inconclusive report and a surgeon's attitude that comes from constantly dealing with sick people who need treatment, they will be more likely to operate to be on the safe side.

  'Surgeons usually take things out,' Dr Lam says.

   'But if they remove something unnecessarily that will do harm.

  'It's not like treating sick people.'   Kwong Wah hospital breast surgeon Dr Lau says: 'What you must remember is that these women are not patients, they are well.

  'Of 10 abnormalities shown on the X-ray, nine are likely to be benign.

  'You may have nine women having unnecessary treatment to catch one cancer.'   But if you do not treat the nine, the one may slip through the net, other doctors argue.

  THAT is just the sort of surgeon's response that Dr Lau fears. The patient is anxious because the hospital and clinic have made her so, she points out.

  'If the woman is anxious, treat her anxiety, talk to her, don't just operate,' she says.

  Dr Theva Alagaratnam at Queen Mary Hospital agrees there are shortcomings in monitoring and assessment.

    'I think they haven't got into the real well-woman screening programme you see in Western countries,' she says.

  'But given a little time they should try to do things a little more effectively.'    What are needed are radiologists and doctors experienced in handling breast cancer, says Dr Lam.

  If women choose their nearest hospital for convenience, they might be seen by a surgeon who has only seen a few other breast cancer patients in the last month.

  At Kwong Wah a full-time breast radiologist works with the radiographers who take the X-ray pictures and they get feedback from the doctors on how accurate the diagnosis is.

  Dr Lam says: 'We have done more than 15,000 screening operations.

  'We can tell the patient the probability of things being malignant from our experience, so they have the option of taking it out or not.

  'I think the woman has the right to know.'   He admits that the Department of Health has to start somewhere, and having just one specialised clinic in one hospital would not be ideal because the idea is to attract women from all over Hong Kong.

  But with the Chai Wan Well-Woman clinic starting up and another planned to open next year, he suggests training staff at Kwong Wah and setting up two or three hospital centres of excellence where surgeons specialise in breast cancer.

  The last thing any of these doctors want is for women to be put off going for screening.

  At Lam Tin particularly, other health gains are huge, such as in diagnosing diabetes and high blood pressure.

   But Dr Lau fears that if Hong Kong's breast screening is not carried out properly, many women may end up worse off than if they had not gone at all.



Harm that results from over-caution