More can be done to prevent and eliminate cervical cancer in Singapore. Here’s why

WHO aims to eliminate the risk of cervical cancer as a public health issue within a century and has three lead initiatives to be implemented by countries around the world by 2030 – but is Singapore on track towards this goal? President of the Asia-Oceania (Research) Organisation for Genital Infection and Neoplasia, gynaecological oncologist and medical director of Thomson Women Cancer Centre, Dr Tay Eng Hseon, weighs in

Regular screening, treatment and early access to vaccinations are key to preventing HPV-related cancers. PHOTO: GETTY IMAGES

Cervical cancer is one of the preventable diseases, with regular screening for pre-cancers, treatment and vaccination. Yet, it remains the second most common cause of death for females aged between 15 and 44 in Singapore.

This is a pressing public health issue that requires immediate attention not only in Singapore, but globally, as well.

A recent projection by the World Health Organization (WHO) has estimated ​that ​the annual global statistics of new cervical cancer cases ​could​ grow from 570,000 to 700,000 between 2018 and 2030, and ​fatalities, ​from 311,000 to 400,000 in the same duration.

To tackle this problem, it launched a cervical cancer elimination strategy which it hopes will help countries get on the path to eliminate the disease worldwide within the century.

The WHO's strategy maps out three key pillars: to prevent, screen and treat by conducting effective vaccination, screening programmes and providing an early cancer diagnosis, as well as treatments for invasive cancer management.

This initiative could drastically reduce the number of females developing cervical cancer caused by human papillomavirus (HPV), an essential co-factor in the development of almost all cases of cervical cancers.

HPV-related cancers can be prevented

Certain skins in our body are especially vulnerable to the damaging effects of persistent HPV infection leading to cancer. The mucosal skin of the cervix is one such area.

While cervical cancers and pre-cancers can be caught early by screening for treatment, they can actually be prevented by having HPV vaccinations. That is why prevention from HPV early in life, when one's immunity is at its peak, is recommended. PHOTO: GETTY IMAGES

Many think of HPV as a sexually transmitted disease, but its main mode of transmission is via skin-to-skin contact between individuals, and is mostly introduced to the cervix through normal sexual activity.

Among the over 100 types of HPV strains, about 14 are known to cause cancers in both women and men. The HPV strains 16, 18, 33, 52 and 58 are said to be among those that commonly trigger high-grade cervical lesions in women.

Aside from cervical diseases, genital warts and other types of cancers, such as those of the anus, vagina and vulvar, can be attributed to HPV. According to the United States' National Cancer Institute, high-risk HPVs account for about five per cent of all cancers worldwide, with an estimated 570,000 women and 60,000 men getting an HPV-related cancer each year.

Hence, it is highly recommended that males be protected against the virus, so they can reduce the risks of contracting these diseases, too.

While cervical cancer can be caught early with screening, other forms of diseases caused by HPV cannot be detected until symptoms arise. This is why protection from HPV early in life, when one's immunity is at its peak, is recommended.

The race against cervical cancer

Public accessibility to vaccination and screening initiatives is crucial in the race to eliminate cervical cancer.

Together with countries across the Americas, to Europe, Africa, South Asia, and the Pacific, among others, Singapore has joined WHO's movement to launch the global strategy to accelerate the elimination of cervical cancer.

Illustration of human papilloma virus (HPV). Aside from cervical diseases, genital warts and other types of cancers, such as those of the anus, vagina and vulvar, can be attributed to HPV. PHOTO: GETTY IMAGES

In Singapore, HPV vaccinations are included in the National Childhood Immunisation Schedule and the National Adult Immunisation Schedule for Singaporean females aged nine to 26. To further encourage the uptake of cervical cancer prevention initiatives among local females, the Ministry of Health launched a national HPV immunisation programme protecting all Secondary 1 girls in 2019.

This move is accompanied by the introduction of an HPV DNA test for women aged 30 and above that raises the chances of pre-cancer detection.

With these programmes, along with allowing all eligible individuals to offset the cost of all HPV vaccinations through MediSave, Singapore could make remarkable progress towards WHO's goal.

With an age-standardised incidence rate (ASIR) of 7.1 per 100,000 women contracting cervical cancer (2013-2017), Singapore ranks closely behind Australia, which has a rate of 6 in every 100,000 women - one of the lowest in the world.

However, for women in the prime working age group of 35 to 64 years, the incidence is significantly higher with an ASIR of 15.2 per 100,000 women, more than double the national average.

Globally, we are also observing an increase in more men at risk for genital warts and HPV-related cancers such as anal cancers.

Much can be learned from Australia's remarkable progress in its battle against cervical cancer and HPV. Experts believe the country could become the world's first to successfully achieve WHO's goal.

A study published in 2018 by The Lancet Public Health, a research journal, showed that less than four women in every 100,000 could be diagnosed with cervical cancer annually in Australia by 2028. It was also found that by 2066, that projection would fall to less than one woman per year.

Australia's national immunisation programme, which focuses on HPV prevention in both females and males between the ages of 12 and 13, is one of the main catalysts for its success.

By being one of the first to introduce a national HPV immunisation strategy for females in 2007, and then extending HPV protection towards the male cohort in 2013, Australia has actively accelerated herd immunity within its population, reaping the long-term benefits of the programme.

A concerted effort across the healthcare ecosystem in Singapore is crucial to protect our loved ones from HPV preventable diseases and cancers. PHOTO: GETTY IMAGES

Looking beyond 2030

How can Singapore take the lead from Australia and adopt a broader and longer-term perspective of preventing HPV-related cancers and diseases?

The Covid-19 pandemic has taught the world that in dealing with a virus-related disease, we should boost herd protection across the population, as a critical priority.

Looking ahead, we need to focus more on primary prevention for long-term cost-containment through a fully accessible national vaccination initiative. Eventually this strategy would reduce the reliance on secondary prevention through screening and the incidence of HPV-related diseases resulting in the containment of the ever-escalating cost of the treatment.

While Singapore has commendable programmes for females in place, we see significant potential in enhancing access to include all eligible individuals in our national and school programmes. Offering equal access to eligible individuals to offset the cost of all HPV vaccinations through their MediSave could accelerate Singapore's progress on this front.

It is essential that we work closer than before in a concerted effort across the healthcare ecosystem including medical professionals, community, academia, government and industry, to ensure our population undergoes regular screening, treatment and gains access to vaccinations early, as well as a public education campaign to dispel misinformation and increase confidence in vaccines.

These times call for an even greater effort to protect our loved ones from HPV preventable diseases and cancers.

Dr Tay Eng Hseon was one of the founding members and is currently the President of the Asia-Oceania (Research) Organisation for Genital Infection and Neoplasia (AOGIN). Dr Tay has been sub-specialising in gynaecological oncology since 1996 and is currently the medical director of Thomson Women Cancer Centre, Singapore. He was the Principal Investigator (Singapore site) for the pivotal Global HPV Vaccines Trial conducted in 2002-2005.

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