Challenges Revolving Around Cervical Cancer and HPV Vaccination in Singapore

In this article, we explore the difficulties encountered in delivering adequate cervical cancer screening and HPV preventive care to patients. The article also aims to debunk some of the common misconceptions about HPV, cervical cancer, and HPV vaccination. It is written to increase awareness of the importance of proactive measures in screening and preventing HPV infection and HPV-related cancers.

Cervical cancer 

Cervical cancer is a preventable medical condition, yet hitherto remains the 10th most common cancer affecting females in Singapore. We now understand cervical cancer is due to a chronic infection of the cervical cells from human papillomavirus (HPV). While there are over 150 strains of HPV, high-risk HPV that can be associated with cancer includes HPV type 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.

Through proper regular screening, early detection, and treatment of pre-cancerous stages of cervical cancer, this is a type of cancer that we can avoid.  HPV vaccinations have proven effective by more than 90% in protecting against HPV infection and HPV-related cancers such as cervical cancer.

HPV vaccination is encouraged and offered to BOTH women and men from the age of 9 to 45 years old. 

Cervical cancer incidence trend in Singapore 

Following the introduction of the Cervical Screen Singapore programme in 2004, there had been a steady initial decline in the incidence of cervical cancer up until 2015, when the incidence of cervical cancer plateaued. Unfortunately, in recent years, there has been evidence of a possible rise in cervical cancer incidence.

WHO’s global move to curb cervical cancer

In an attempt to eliminate cervical cancer by 2030, the World Health Organization (WHO) advocates a target goal of 90-70-90 where: 

• 90% of females are fully vaccinated against HPV by the age of 15
• 70% of women are screened for cervical cancer by age 35 and age 45
• 90% of women with cervical abnormalities received medical treatment

Currently, our local cervical cancer screening rate is only 48%, way below our national target rate of 70%.

Local awareness of cervical cancer screening and prevention in the younger adult group (age 25-29) is only 76.5%, while awareness is better at 91% in the older adult group (age 30-69). 

Issues related to the poor uptake of pap smear/HPV testing and HPV vaccination

Uptake of cervical cancer screening

The poor uptake of pap smear and HPV testing is multifactorial, involving the obstacles faced by patients, health care providers, and the health system as a whole. In this article, we focus mainly on issues faced by patients. 

Three key points that will determine whether a patient will opt for the screening test:

• Awareness or understanding of the screening tests/implications of a delayed diagnosis of cervical abnormalities
• Belief and perception of screening tests and HPV as a medical condition
• Motivation to undergo pap smear or HPV testing

Misinformation about HPV infection and cervical cancer is common. Although the majority of women have heard of a pap smear, the purpose of the test and the screening frequency of the tests remain uncertain to most patients. Patients also may deem screening against cervical cancer unnecessary as they ‘feel fine’, asymptomatic, or feel the test is not required due to ‘lack of sexual activity’.

Furthermore, the uptake of cervical cancer screening tests is correlated to a person’s educational background, personal beliefs, and cultural barriers. Patients tend to confuse HPV with other STDs (such as chlamydia, gonorrhoea, HIV, etc) and may view HPV testing as taboo. Additionally, one may have the wrong impression that HPV infection only occurs in a person who is promiscuous in their sexual habits. The stigma associated with HPV infection can dissuade a person from getting screened for cervical cancer. 

Reluctance to get cervical cancer screening is often due to fear, embarrassment, and potential discomfort from the procedure. As cervical cancer screening is usually performed by health care providers involving examination of a female’s genital region, this can be a turn-off for females to undergo pap smear or HPV testing.

Other reasons for poor uptake of cervical cancer screening include the financial burden of regular medical screening, missed appointments, unable to find time for screening, and generally uninterested in screening.

Uptake of HPV vaccination

The lack of HPV vaccination uptakes can be multifactorial. A few common reasons include:

• Lack of awareness of the availability of the HPV vaccine as a preventive measure against cervical cancer or high-risk HPV infections.
  • Frequently, females may not be updated on the latest vaccination guidelines and think they are not eligible for the vaccine if they are over 26. 
  • Some people may not be aware that the vaccine can be administered to males and may not understand its benefits.

• Patients tend to be reluctant as they may not see the vaccine's immediate ‘tangible’ benefits (such as, if you are given drug A, you should see an immediate positive after-effect). 
• Concerned about the side effects of HPV vaccination may deter patients from getting the HPV vaccination.
• Financial limitations can demotivate patients from receiving the HPV vaccination.
• As the full course of HPV vaccination requires three doses, some patients may lose follow-up between doses and be unable to complete the vaccination schedule.

Key facts on HPV infection and cervical cancer

• The majority of HPV infections do not have symptoms. Patients commonly have no symptoms, even if they have cervical abnormalities or early cervical cancer. 
• The only way to detect cervical cancer is through screening. Early treatment is curative.
• As long as one has engaged in penetrative sexual activities, one may be exposed to HPV infection and should consider regular cervical cancer screening.
• HPV infection can affect couples even if couples are practising monogamy.
• HPV vaccination can be offered to males and females from the age of 9 until 45.
• HPV vaccination is safe.
• HPV vaccination has robust evidence to significantly prevent and reduce the risk of HPV infection and HPV-related cancers.

What can we do to improve uptakes of cervical cancer screening and prevention?

The move towards better uptake of HPV vaccination and cervical cancer screening will require concerted effort from all parties, including the health care system, the government and legislation, the allocation and availability of resources, and the participation of patients and the community. 

As a community and as a patient, we can each play our part as below: 

1. Empower everyone by getting the correct information regarding HPV and screening tests. If we have uncertainties regarding HPV infection, obtaining the proper facts from reliable sources—such as your trusted healthcare providers—is imperative rather than unverified online sources or word of mouth from others.
2. Liaising with female healthcare providers that you are comfortable with for cervical cancer screening procedures can mitigate personal fear and barriers against screening.
3. Ensure we get our HPV vaccination up to date if this has not yet been done and we are within the eligibility age. 

References

1. Chua BWB, Neo P, Ma VY, Lim LM, Ng JSY, Wee HL. Health care provider's experience and perspective of cervical cancer screening in Singapore: A qualitative study. Front Public Health. 2022 Jul 26;10:853453
2. World Health Organization . Cervical Cancer Elimination Initiative (2020). Available online at: https://www.who.int/initiatives/cervical-cancer-elimination-initiative 
3. Jin AZ, Louange EC, Chow KY, Fock C. Evaluation of the national cervical cancer screening programme in Singapore. Singapore Med J. (2013) 54:96–101.
4. Chua B, Ma V, Asjes C, Lim A, Mohseni M, Wee HL. Barriers to and facilitators of cervical cancer screening among women in Southeast Asia: a systematic review. Int J Environ Res Public Health. (2021) 18:4586