SINGAPORE – Ms Mas Azura Abdul Rahman, 32, works as a clinic manager for a gynaecologist. The trained nurse knows the importance of screening for cervical cancer, which is done through regular pap smears or testing for the human papillomavirus (HPV). 

Still, the married mum of three children aged five to 13 has been hesitant to go for regular pap smears, citing discomfort and embarrassment over the test. 

In early 2022, she was diagnosed with a pre-cancerous condition and had to have the affected cells of the cervix removed. 

Subsequent testing has shown that she is out of danger, and she is now looking forward to her pap smear later in 2024 to reinforce her clean bill of health. 

Her advice to other women now is to prioritise routine testing for cervical cancer. “Don’t be scared, don’t be stubborn,” says Ms Azura. 

Cervical cancer is preventable and easily screened for, doctors say, yet it remains one of the most common cancers in women in Singapore. 

According to the Singapore Cancer Registry Annual Report 2021, which was released in 2023, cervical cancer is the 10th most common cancer in women in the country, and the 10th leading cause of cancer death for women. 

The report found that from 2017 to 2021, cervical cancer accounted for 2.6 per cent of cancers in women and 2.8 per cent of cancer deaths in women. The top killer was breast cancer, accounting for 29.7 per cent of cancers in women and 17.2 per cent of cancer deaths in women. 

About four Singapore women are diagnosed with cervical cancer every week, says Dr Ida Ismail-Pratt, who practises at Astra Women’s Specialists clinic and The Obstetrics & Gynaecology Centre, Mount Elizabeth Novena Specialist Centre. 

She adds: “Cervical cancer has a devastating impact on a woman’s life.” 

Her patients are often starting families, have young children or are reaching the peak of their careers, when the disease hits. 

Treatment may be painful, expensive and affect the patient’s fertility. 

“It’s heartrending because we know that this can be prevented,” says the obstetrician and gynaecologist, who is president of the Society for Colposcopy & Cervical Pathology of Singapore. 

As a member of the Women’s Gynaecological Cancer Awareness Month Committee of the Singapore Cancer Society, Dr Ida wants more people to be aware that cervical cancer is preventable and can be identified years before it reaches an advanced stage. 

It can also be eliminated through vaccination. Nearly all cases of cervical cancer are related to HPV infection. 

A vaccine against HPV infection has been offered to female students in Secondary 1 since 2019, as part of the school health vaccination programme. In 2022, the Ministry of Health (MOH) said that more than 90 per cent of the female Secondary 1 cohort has received the HPV vaccine. 

Viral infection leads to cancer 

Dr Wang Junjie, head and senior consultant at the Department of Gynaecological Oncology at KK Women’s and Children’s Hospital, says that cancer of the cervix – which is at the neck of the womb – is often linked to persistent HPV infection. 

There are many different types of the virus, adds Dr Wang, with lower-risk types causing conditions such as genital warts. 

Types HPV-16 and HPV-18 are most associated with cancer. Persistent infection with such high-risk types leads to mutations in the cells and to pre-malignant conditions that can eventually cause cancer, says Dr Wang. 

Dr Zhang Zewen, a consultant at National Cancer Centre Singapore’s Division of Medical Oncology, says it may take 10 to 20 years for HPV infection to develop into cancer, with a minimum period of seven years. 

Dr Quek Swee Chong, an obstetrician and gynaecologist at Gleneagles Hospital, says: “Most people who get HPV will clear the infection by the immune system in the course of a few months, without getting any cancer changes.” 

However, those with a compromised immune system may be at higher risk, since their body cannot get rid of the infection. People at high risk include those with HIV or on medication for organ transplants. 

Dr Quek adds that cervical cancer is not hereditary and a family history of cervical cancer does not increase your risk of getting it. “The major risk factor for cervical cancer is the exposure to high-risk types of HPV,” he says. “In general, HPV is usually transmitted by sexual contact.” 

Why regular testing is key 

Infections with high-risk types of HPV are usually asymptomatic, says Dr Quek. “Do not assume that just because you have no symptoms, you cannot have HPV.” 

Dr Wang says that early-stage cervical cancer is also often asymptomatic. Only later-stage cancers may present with abnormal vaginal bleeding, such as bleeding after intercourse, between menses or after menopause. 

With no signs or symptoms to watch out for, regular testing for the presence of abnormal cells or persistent HPV infection are key in the fight against cervical cancer. 

Dr Wang says: “In its earliest stages, cervical cancers are highly curable. Early detection is therefore the key to improving survival. 

“At KKH, our five-year survival rate for cervical cancer in Stage 1 is about 80 to 90 per cent, Stage 2 is 60 to 70 per cent, Stage 3 is 60 per cent and Stage 4 is 20 per cent.” 

Even those who have received the HPV vaccine should go for regular screenings, doctors say. 

Dr Zhang explains that the vaccine provides long-lasting protection for women who have not been exposed to HPV-16 and HPV-18. 

“However, the HPV vaccine does not protect against all types of HPV, so regular pap smears or HPV test screenings are still recommended for women who have had the vaccine.” 

During the pap smear test or HPV test, a scraping of cells from the surface of the cervix is obtained during a vaginal examination, says Dr Zhang. 

It is a quick procedure but many women, like Ms Azura, may find it hard to endure. 

She says: “I was scared and apprehensive about doing a pap smear. It’s uncomfortable and you need to open yourself up to people.” 

At the urging of friends and her gynaecologist employer, she opted in 2022 to use a self-sampling kit and send the sample for HPV testing. Thanks to this, her pre-cancerous condition was identified and treated early. 

Dr Ida says that in Singapore, it is recommended that women who have ever sexually active should get a pap smear every three years from ages 25 to 29. 

Women aged 30 to 69 can opt for the HPV test every five years. “This can be done through self-sampling and is potentially less painful and intrusive, and maintains a woman’s privacy,” she adds. 

Following abnormal results in cervical cancer screening, doctors do another screening called a colposcopy and a cervical biopsy to detect pre-cancerous cells. Treatment at this stage involves either burning or cutting away the usually small area of the cervix where abnormal cells have been found. 

“Once cervical cancer develops, the management in all stages may involve a combination of hysterectomy, radiotherapy and chemotherapy,” she says. 

Low screening rates 

Women in Singapore are aware of cervical cancer screening tests, yet most of them do not opt for such screenings, according to MOH’s National Population Health Survey 2022. 

The survey found that most Singapore women aged 25 to 74 were aware of the pap smear test (89.9 per cent) and more than half were aware of the HPV test (54.6 per cent). 

Yet only 43.1 per cent of these women reported having gone for cervical cancer screening. 

Screening participation rates had also dropped significantly from the 57.9 per cent reported in 2007. 

Doctors tell The Straits Times that women might opt out of screening for a number of reasons. 

Dr Wang says: “Patients may be hesitant due to fear, embarrassment, lack of awareness or concerns about discomfort. Access barriers, such as time constraints or financial considerations, can also impact screening rates. It is crucial to address these factors to encourage regular cervical screenings.” 

Misconceptions also abound regarding HPV. Dr Ida says that many think of HPV as a sexually transmitted disease (STD), leading to stigma around those who are found to be infected by it. 

Ms Azura, too, was worried at first that her technician husband might misunderstand her positive HPV test results. “A lot of people think that HPV is an STD.” 

He did not misunderstand and was supportive throughout the treatment process, but this is not always the case. 

Dr Quek says: “What people don’t understand is that HPV infection should be considered a marker of sexual activity, rather than being labelled as a sexually transmitted disease. 

“It is well recognised that the vast majority of both men and women, 80 per cent or more, will be exposed to HPV at some stage in their lives, and that cervical cancer is a very rare outcome of this very common infection.” 

He adds that more should be done to increase HPV vaccination for both females and males. In men, HPV can lead to anal cancers, cancer of the penis, and certain throat and oral cancers. 

The incidence of HPV infection and HPV-linked cancers in men is less well studied. The World Health Organisation estimates that globally in 2019, there were 70,000 new cancers in men linked to HPV, compared with 620,000 new cancers in women. 

Dr Ida says that outreach efforts to reduce cervical cancer incidence should go beyond educating women and target family members who can encourage their female relatives to go for cervical cancer screening. 

“Cervical cancer is not a woman’s problem. Cervical cancer is everybody’s problem,” she says.