Based on current estimates, there 429 women who are diagnosed with cervical cancer every year in Singapore and 70 die from it. It’s alarming how a preventable disease remains to be among the top 10 cancers affecting women in the country today.
This makes screening an important topic for discussion because it draws the fine line from potentially fatal consequences and survival.
Cervical cancer is a disease that stems from the cervix or the neck of the womb. The Human Papilloma Virus (HPV) has over 100 different strains and 15 of these are classified as highly likely to develop cancer. In most cases, cervical cancer is attributed to two types – HPV-16 and HPV-18 (high-risk HPV).
Most women infected with HPV do not develop cervical cancer since 90% of infections resolve on their own within 2 years. Those with persistent infection are the ones who have a higher risk of developing cervical cell abnormalities and eventually cancer. Even if a woman is infected with HPV within a few years after she first had sex, the incidence of cervical cancer peaks at around 45 years of age. This means that the progression from persistent infection and invasive cervical cancer peaks well into your 40s.
However, what’s so sneaky about it is that if the problem persists, there are no red flags on any abnormal changes. It is only when the problem has advanced that it starts to show symptoms.
Precancerous cellular changes and early cancers of the cervix are very discreet. These changes occur years before cancer develops, giving you a good window of opportunity for screening and early detection.
As the disease advances, it usually comes with the following symptoms:
- Pelvic pain that is unrelated to your menstrual cycle
- Heavy or unusual discharges that may be thick or watery with a foul odor.
- Abnormal bleeding:
- Between the regular menstrual period
- After sexual intercourse
- Pelvic exam
- After douching
- After menopause
- Pain during urination
- Pain during intercourse
- Increased urinary frequency
These symptoms may also be related to other health problems aside from cervical cancer. Nevertheless, it is important that you seek medical advice if anything is out of the ordinary.
Short for Papanicolaou Test, Pap-smears help detect cervical cancer in its early stages. Doing so makes it easier to be treated with surgery, chemotherapy, or radiotherapy. This gives you a stronger chance at survival.
How it is done:
During the procedure, you lie on your back with your knees up and bent while your feet are placed on stirrups. The doctor will then insert a small metal or plastic instrument called a speculum. This is used to open the vagina to properly visualise its walls as well as that of the cervix. This may be slightly uncomfortable, but it is tolerable.
Using a small cervical brush or broom, the doctor obtains a sample of the cervical cells. A pap test should not be painful. So, if you feel any pain during the procedure, inform your doctor.
The samples are then sent to the lab and examined for abnormalities. An abnormal result doesn’t always mean that you have cervical cancer. This means that there is something that requires further evaluation by the doctor. A colposcopy may be done, which is an examination that uses a microscope to confirm if it is indeed cervical cancer.
While a Pap Smear test is a reliable tool for screening, it is not 100% accurate. It detects only about 55-65% of the time when there is an abnormality. This means that if there are 100 women who had cervical cell abnormalities, a Pap test will currently detect 55-65 and miss out on 35-45.
Cost of Pap Smear in Singapore
If you are not aware of this yet, you can get a Pap smear done free through the Singapore Cancer Society. Alternatively, you can also get it at an affordable cost because of the program rolled out by the Health Promotion Board. You can get it for $5 if you are a Singapore citizen (check your eligibility, here) and $12.25 for Permanent Residents.
If you are a CHAS (Community Health Assist) card holder, your Pap test will have a subsidized rate of $2. However, this is only applicable to participating clinics and healthcare centres.
Since a Pap Smear is subject to false negative and interpretation errors, HPV testing is regarded as a more accurate screening tool. However, it will not tell you whether you have cancer, rather it will detect the presence of HPV and what strain is in your system.
Having the knowledge of what type of HPV you are infected with allows you and your doctor to better decide on the next steps in your health care. If a woman’s HPV test is negative, it means that high-risk HPV types were not detected, she has a low risk of developing cervical cancer. A negative result will also mean that you don’t have to return for 5 years. If you tested positive, you will have to go back to your doctor every 6 months for monitoring.
How it is done:
The process is similar to a Pap Smear where a speculum is inserted into the vagina so the doctor can collect samples of your cervical cells. Sometimes, an HPV test is done at the same time as a pap test so that the doctor can obtain 2 samples for both.
A Help for Helpers
The country has widened its scope in a strong effort to help more women prevent or overcome this disease by making cervical cancer screenings free for foreign domestic helpers. It aims to lower the incidence of cervical cancer to these population of women who may not have access to it.
Cervical Screening Guidelines in Singapore
Who are advised to undergo screening?
- All women who have ever had sexual intercourse are advised to have their first pap smear test from the age of 25.
- Women who have never had sexual intercourse don’t have to undergo screening, but if they exhibit any symptoms, they should consult a doctor.
Frequency of Screening
According to the National Cervical Cancer Screening Programme, the frequency is as follows:
- Age 25-29 years – Pap smear must be taken once every 3 years
- Age 30-69 years – HPV test alone every 5 years for a negative HPV test. The reason for not testing girls younger than 30 is because almost a quarter will be HPV positive at that age and most will clear up within a year. It will not help doctors in triaging who is at a higher risk.
Under a non-national screening programme the options for those 30 years of age and above the following applies:
- Pap Smear alone every 3 years
- HPV test alone every 5 years
- Co-testing with Pap smear and HPV test every 5 years
Discharge from Screening
Cervical cancer screening is not indefinite. If a woman has committed to regular screenings, she can already stop doing so at age 69 if she has:
- 3 consecutive negative pap smear tests
- Or 2 consecutive negative HPV tests in the last 10 years, with most recent test occurring within the last 5 years
- Or 2 consecutive negative Co-tests (pap smear + HPV testing) in the last 10 years, with the most recent test occurring within the last 5 years.
Routine screening will continue for at least 20 years in women with a history of CIN2, CIN3 or AIS. It will still apply even if it extends beyond 69 years of age. You may visit our clinic for a thorough discussion on this.
Since HPV infection is necessary for the development of cervical cancer, it is only logical to give yourself a blanket of protection through vaccinations. Screening is only secondary prevention, but an HPV vaccination is considered the primary line of defense. Therefore, it is only right to add it into the discussion because screening and vaccinations go hand in hand so you can safeguard better.
An HPV vaccine not only protects you from cervical cancer, it also prevents other cancers like anal, vulva and mouth cancer. It can even protect you from genital and anal warts.
Who Gets the Shot?
Girls and even boys can get HPV vaccinations. Under the National Childhood Immunisation Schedule, the government encourages girls aged 9-26 to get vaccinated. In April 2019, all 13-year-old girls in Singapore (citizen and PR) can get the HPV vaccine for free. This is an opt-in scheme, which means that parents must give their consent.
The reason why this vaccine is encouraged to be given at a young age is because it serves as a preventive measure and not a treatment. It is advised that you get vaccinated before you become sexually active. When administered too late, it may not be effective in giving you protection. If you are above 26 and haven’t gotten the HPV vaccine yet, you may discuss this with your doctor to see if you are a suitable candidate.
Boys must also get into the movement because men can also catch and spread HPV. It can also cause cancers of the throat, genitals or anus in men. Unfortunately, there are no national healthcare programmes that will subsidise HPV vaccines for boys.
There are 3 types of HPV vaccines that are approved for use in Singapore at present and these are:
- Gardasil 4 (4-valent vaccine) – protects against HPV-6, 11, 16 and 18; for boys and girls aged 9-26 years of age
- Gardasil 9 (9-valent vaccine) – protects against HPV-6, 11, 16, 18, 31, 33, 45, 52, and 58; for boys and girls aged 9-26 of age
- Cervarix – protects against HPV-16 and 18; licensed only for girls 9-25 years of age
Vaccination Schedule and Recommendations
- 3-dose schedule: 0,2 and 6 months for individuals 9-26 years of age.
- 2-dose schedule: 0 and 6 months for individuals 9-13 years of age.
- 3-dose schedule: 0,1 and 6 months in females 9-25 years of age.
- 2-dose schedule: 0 and 6 months in females 9-14 years of age.
The protection you need against cervical cancer is already available today. You only need to make the first step; even the government is making efforts to help. Don’t allow yourself to be part of the statistic, seek the protection you need today.
If you have more questions, do give us a call so we can schedule your appointment. Let’s get into an in-depth discussion on this matter.
Dr Pamela Tan is a board certified obstetrician and gynecologist in Singapore. She finished her undergraduate studies at the National University of Singapore and earned her post-graduate degree at the Royal College of Obstetricians and Gynaecologists in the UK. She is an accredited specialist by the Specialist Accreditation Board (Ministry of Health), and a fellow of the Academy of Medicine, Singapore. She subspecialises in colposcopy and is certified to perform Level 3 minimally invasive keyhole surgeries such as laparoscopic hysterectomy, myomectomy and cystectomy. Dr Pam also supports the natural birthing method and she strives to provide a personalised care and treatment for each patient.