Rise in late-stage cervical cancer in SG linked to suboptimal screening uptake

Local researchers note a rising trend of late-stage cervical cancer in Singapore, a pattern that they say is likely to be an effect of a less than optimal uptake of screening for the disease.

“While systematic age-appropriate human papillomavirus (HPV) vaccination has been adopted, a similar adoption has not been observed for cervical cancer screening (CCS),” according to Brandon Chua and colleagues from National University of Singapore. [https://www.moh.gov.sg/news-highlights/details/hpv-school-based-programme]

The reason why CCS uptake remains suboptimal relates to not having an organized screening program with a call and recall capacity, challenges for expanding CCS under current clinical settings, and patient preferences, they added.

In their study, Chua and colleagues interviewed 18 healthcare professionals (HCPs; including physicians, nurses, program administrators, and laboratory technicians) involved with CCS from 12 institutions in Singapore health system to understand the impact of patient, provider, health system, and health promotion factors on CCS. Most of the respondents were women (61.1 percent) and worked in public health institutions (72.2 percent), and half had at least 10 years of experience related to CCS. [Front Public Health 2022;doi:10.3389/fpubh.2022.853453]

Patient factors

The respondents pointed to the lack of patient awareness of cervical cancer and screening as a key factor. While many women were aware about pap smears, CCS was mostly deemed to be unnecessary owing to good health, older age, and the lack of sexual activity. Furthermore, acceptance to screening was lower in primary care than in tertiary care settings.

“Patient refusal of screening appeared to be low in the tertiary care setting, especially when patients were also consulting for other gynaecological conditions… When conversations on CCS were initiated in primary care settings, patient acceptance to CCS could be low owing to mental fatigue from other medical conditions,” Chua noted.

HCP factors

At the primary care level, the respondents noted that HCPs prioritized discussion of acute conditions and multiple chronic diseases with patients before considering preventative health such as CCS, given the limited time available per patient due to high caseload.

Some general practitioners, especially males, also did not offer CCS, since it required a female chaperone, who may not be readily available. In addition, counselling on CCS provided by existing HCPs was described to be inadequate.

Other challenges faced by HCPs were the extra work required to submit CCS subsidy claims, as well as the tedious process of tracing and disseminating screening results to patients, with results often taking up to 2 weeks to be released from the laboratories.

Health system, health promotion level gaps

“Key challenges faced by HCPs in Singapore suggest that investments in infrastructures for CCS, such as a comprehensive national call-recall type registry, may be necessary. With a central registry to track age-eligible patients, send automatic screening reminders, and track responses, CCS uptake could be improved while reinforcing the importance of age-appropriate CCS as a national priority,” Chua pointed out.

Such an approach can take the burden of monitoring and initiating CCS conversations off physicians and HCPs, as well as allay concerns of tertiary care physicians of losing patients to follow-up for subsequent screening in the primary care settings.

“However, substantial financial resources and legislative support are required for the implementation of an organized screening program backed with a national screening registry… It is therefore crucial to evaluate the long-term cost-effectiveness of such infrastructures in Singapore,” he added.

Chua also called for reconsidering health promotion approaches toward CCS, as the lack of awareness of cervical cancer and screening continues to be a key challenge for improving CCS uptake in Singapore. He identified significant opportunities for health promotion delivery via online platforms, since majority of Singaporeans have begun using online sources of information for health promotion and disease prevention. [https://tinyurl.com/2dukgpsa]

“Further, social media can shape health behaviour, and harnessing this power to increase consciousness around evidence-based cost-effective approaches to personal health is important. In addition, national digital health platforms, such as HealthHub, has been established since 2016 to enable greater accessibility to health information. These should be leveraged together with the digital and mobile health technology momentum generated by COVID-19 to complement existing efforts on cervical cancer prevention,” he said. [Am Med Inform Assoc 2015;22:243-256; Int J Environ Res Public Health 2021;18:334]