Cervical Cancer Diagnosis & Treatment in Singapore
How common is Cervical Cancer in Singapore?
Cervical cancer, the 10th most common cancer among women in Singapore, includes types such as squamous cell carcinoma and adenocarcinoma, which are generally treated in similar fashion. Neuroendocrine small-cell cancer of the cervix is a rare type of cancer, and the treatment will not be discussed here.
Treatment options for cervical cancer are typically recommended based on the extent of the disease and the overall health of the patient. Approaches may include surgery, radiation therapy, chemotherapy, targeted drug therapy, immunotherapy, or a combination of these methods.
When formulating treatment plans, the doctor may categorise cervical cancer into:
- Early cancer
- Locally advanced cancer
- Advanced cancer
Early Cervical Cancer
Early cervix cancers are cancers confined to the cervix. Most early-stage cervical cancers are addressed with surgery – hysterectomy, which involves removing the cervix and the womb (uterus). Part of the vagina, the ovaries and nearby lymph nodes in the pelvis may also be removed. For many women, surgery may be the only procedure required, but some women may require additional treatments such as radiation and chemotherapy to reduce the risk of potential recurrence. The majority of women with early cervical cancer can expect to be cured.
Fertility-sparing Surgery for Early-stage Cervical Cancer
Removing the uterus can make it impossible to become pregnant. Women who wish to retain their fertility may discuss with their oncologist the feasibility of surgical procedures that will help keep fertility. In some cases, the doctor may suggest:
- Cone Biopsy: For very small cancers, it may be possible just to remove the cancer with a cone biopsy. This procedure involves cutting away a cone-shaped piece of cervical tissue, but leaving the rest of the cervix intact.
- Trachelectomy: This method involves the removal of the cervix and some surrounding tissue. The uterus remains intact, and pregnancy is still possible.
Ovarian Transposition
In cases where radiation might follow surgery, ovarian transposition could be recommended to minimise the potential of radiation-induced ovarian failure.
For cervical cancer patients who may not be suitable for surgery, the doctor may recommend radiation as an alternative treatment method.
Locally Advanced Cervical Cancer
Locally advanced cervical cancer is characterised by significant tumour growth or spread to surrounding organs and pelvic lymph nodes. For such cases, a combined approach of radiation treatment and chemotherapy, known as concurrent chemo-radiation, is typically employed. This strategy enhances the effectiveness of the therapy, aiming to reduce the tumour size and minimise the spread.
Radiation therapy utilises high-energy X-rays to target and destroy cancer cells. It includes:
- External Beam Radiation: This method involves directing radiation beams at the affected area from outside the body, targeting the cancerous tissues.
- Internal Radiation (Brachytherapy): This involves the temporary insertion of a hollow tube (applicator) containing radioactive material directly into the vagina, close to the cervix. This method allows a high radiation dose to be delivered to the tumour site with minimal impact on surrounding healthy tissues.
Possible side effects of radiation may include:
- Fatigue
- Diarrhoea
- Skin changes
- Radiation cystitis
- Vaginal pain
- Infertility
- Early menopause
There is also a risk for potential long-term side effects such as:
- Vagina stenosis: Narrowing of the vagina due to the formation of scar tissue, which may make sexual intercourse painful. This can be prevented with the use of a vaginal dilator.
- Second cancer: Rarely, women may develop a second cancer many years after their radiation treatment.
The most commonly used drug for cervical cancer chemotherapy is cisplatin, which is administered professionally in low doses. It is administered once a week as an infusion, coinciding with daily radiation treatments over six weeks. Both radiation and chemotherapy are generally conducted on an outpatient basis, reducing the need for hospital stays.
Possible side effects of cisplatin chemotherapy may include:
- Fatigue
- Nausea and vomiting
- Loss of appetite
- Decrease of white blood cells, which may increase the risk of infection
- Anaemia
- Bleeding due to lowering of platelets
- Kidney damage
- Tingling or numbness in hands and feet
Despite these side effects, cisplatin is generally well-tolerated and does not cause hair loss.
Treatment of Advanced or Recurrent Cancer of the Cervical Cancer
Advanced and recurrent cervical cancers, which have spread to distant organs or returned after initial treatment, require systemic drug treatments aimed at controlling the disease and managing the symptoms. Historically, chemotherapy was the primary treatment mode for these cancers in Singapore. Now, there are newer options for cervix cancer treatment, including targeted drug treatments and immunotherapy, which can be administered on an outpatient basis.
Drug Treatments:
This approach is often the first line of treatment for advanced cervical cancer. The drugs used are typically administered as infusions. This allows the medicine to circulate and target cancer cells throughout the body. Commonly used drugs include cisplatin, carboplatin, paclitaxel, gemcitabine, and vinorelbine. These drugs might be used on their own or combined as a two-drug cocktail, depending on the patient’s specific condition. A typical course of chemotherapy may span approximately five months.
Possible side effects of the treatment may vary depending on the drugs used and the patient. They are generally reversible upon the completion of treatment. Not all chemotherapy drugs will result in hair loss.
Bevacizumab is a drug used in the treatment of cervical cancer to inhibit the growth of blood vessels that supply nutrients to the tumours, thereby starving the cancer cells. This infusional treatment is administered every three weeks, often in combination with chemotherapy.
Common side effects may include high blood pressure and protein loss in urine. The less common but more severe side effects may include bleeding, blood clots, and poor wound healing. In patients who have previously received radiation to the pelvis, there may be an increased risk of developing a fistula – an abnormal connection between the vagina and part of the intestine.
This approach typically involves the use of immune checkpoint inhibitors, such as Pembrolizumab, to help boost the body’s immune response against cancer cells. It is administered as a short infusion every three weeks.
Possible side effects may include fatigue, nausea, skin rash, loss of appetite, joint, or muscle pain. In some cases, the immune system may become overactive and attack other organs such as the intestines, thyroid, lungs, liver, or other areas.
Immunotherapy is generally well-tolerated, but it is advisable for patients to be monitored for any serious effects due to immune system activation.
What Do I Need to Do if I Have Cervical Cancer?
If you are worried about getting cervical cancer, you can talk to a specialist in Singapore about getting vaccinated against HPV (Human Papillomavirus). Regular HPV testing or Pap smears may also help detect any early signs of the disease.
If you or a loved one is already diagnosed with cervical cancer, schedule an appointment with a professional oncologist to help manage the recommended treatment plan.
What is Cervical Cancer?
Cervical cancer arises from the cervix, the lower part of the uterus that connects to the vagina. It is a significant health concern in Southeast Asia and, historically, was one of the leading causes of cancer-related deaths among women. However, due to advancements in screening and vaccination, the incidence of cervical cancer in Singapore has been falling, and it is now the 10th most common cancer affecting women in the region.
What Are the Signs and Symptoms of Cervical Cancer?
Recognising the signs and symptoms of cervical cancer is crucial for early detection and potentially effective treatment. In its early stages, cervical cancer may not produce noticeable symptoms. As the cancer progresses, more noticeable symptoms may appear, including:
- Vaginal bleeding after intercourse, between menstrual periods, or after menopause.
- Watery or bloody vaginal discharge that may be heavy and have a foul odour.
- Pain in the lower belly or pelvis, especially during sexual intercourse.
- Frequent urge to urinate or discomfort when urinating.
- Persistent pain in the lower back.
- Unexplained weight loss, fatigue, and loss of appetite.
It is advisable to consult a healthcare provider if you experience any of these symptoms, especially if they persist. Early medical evaluation and diagnosis can help improve the efficacy of the treatment.
How is Cervical Cancer Diagnosed?
If cervical cancer is suspected, several investigations will be undertaken. This often involves colposcopy examination by a cervical cancer specialist. A magnifying instrument (colposcope) will be used to inspect the cervix and any abnormal areas will be biopsied and sent to the laboratory to test for cancer.
If cervical cancer diagnosis is confirmed, further tests, such as MRI scan of the pelvis, CT scan or PET-CT scan, will be undertaken to determine if the cancer has spread and help to stage the cancer.
What Are the Causes and Risk Factors of Cervical Cancer?
Almost all cases of cervical cancer (99.7%) are linked to infection with the human papillomavirus (HPV).
HPV infection, acquired through sexual contact, is the most predominant cause of cervical cancer. It is a prevalent infection in sexually active women. However, most women’s immune systems are able to get rid of this infection spontaneously. In the minority of women, there will be persistent infection of the cancer-causing HPV strains (“high-risk” HPV), which may lead to cervical cancer.
Other risk factors may include:
Having multiple sexual partners.
Engaging in sexual activities at a young age (before 18 years old).
Weakened immune system and therefore more susceptible to persistent HPV infections. For example, organ transplant recipients on immunosuppressive medications and those with Human Immunodeficiency Virus (HIV).
Smoking
Long-term use of oral contraceptive pills.
Can Cervix Cancer be Prevented?
The HPV vaccine can help minimise the risk of HPV infections, which may lead to cervical pre-cancers or cancers. It aims to provide up to 90% protection against cervix cancer. The Singapore Cancer Society recommends HPV vaccination for females between the ages of 9 and 26. This vaccine has also been shown to be helpful in women below the age of 45. It may be potentially helpful if administered prior to the first sexual encounter, as it cannot cure an existing HPV infection. Women who are vaccinated are advised to continue with routine Pap smears or HPV testing as the vaccine may not guarantee 100% protection.
How Does Cervical Cancer Screening Work?
Cervical cancer screening is a preventive measure that helps detect pre-cancer and early-stage cervical cancers, potentially enhancing treatment outcomes. In Singapore, two main types of screening are recommended:
- HPV Testing: This test helps detect the presence of high-risk HPV strains that may cause cervical cancer. More helpful than a Pap smear, HPV testing is recommended for women starting from age 30 as it directly targets the virus responsible for most cervical cancers.
- Pap Smear: This traditional test involves collecting cells from the cervix to look for pre-cancers or cell changes. Starting from age 25, it is advisable for sexually active women to undergo Pap smear screening as it can help detect abnormal cells that may develop into cancer.
Regular screening is advised as it allows for early intervention, which can help prevent the development of invasive cervical cancer. Both tests are typically simple, quick, and may help save lives through early detection.
What Are the Stages of Cervical Cancer?
The International Federation of Obstetrics and Gynaecology (FIGO) is the most commonly used staging system for cervical cancer. In Singapore, the stages are as follows:
- Stage I: Cancer confined to the cervix.
- Stage II: Cancer has spread to surrounding organs – uterus, upper vagina or tissues surrounding the cervix (parametrium).
- Stage III: Cancer has spread to lower vagina or pelvic wall or causing kidney blockage or spread to lymph nodes in pelvis or abdomen.
- Stage IV: Cancer has spread to organs such as the bladder or rectum or to distant organs such as lungs, liver or bones.
Frequently Asked Questions About Cervical Cancer in Singapore
Detecting a recurrence of cervical cancer involves monitoring and regular follow-ups with your healthcare provider. Symptoms such as unusual vaginal bleeding, pelvic pain, unexplained weight loss, or changes in urinary habits could signal a return. Advanced imaging tests like PET scans or MRIs might be employed to confirm and evaluate the extent of recurrence. It is advisable for cancer survivors to undergo regular check-ups and report any new symptoms to their oncologist immediately.
If you are undergoing treatment for cervical cancer, it is advisable to avoid activities that may exacerbate symptoms or interfere with recovery. These include:
- Smoking, as it may affect the effectiveness of treatment and worsen outcomes.
- High-impact activities that may strain the pelvic area.
- Using tampons or douching during treatment, especially if undergoing radiation therapy, as these may irritate the treatment area.
Feel free to discuss any dietary or activity concerns with your oncologist to design a treatment plan that aligns with your lifestyle.
Cervical cancer may affect an individual’s daily life in various ways, depending on the stage of cancer and treatment type. Patients may experience fatigue, pain, and other side effects from treatments like chemotherapy and radiation. Emotional stress is also common, as patients may have to cope with the diagnosis and ongoing management of their health. Support from healthcare providers, counsellors, and support groups is recommended in managing the physical and emotional impacts of cancer. Adjustments to daily routines and work schedules may be necessary to accommodate treatment schedules and energy levels.
Oncologists at OncoCare with Clinical Interests in Cervical Cancers
At OncoCare, our team of cancer doctors in Singapore is dedicated to helping you address your condition with suitable advice and recommended treatments. Other than cervical cancer, we also offer advice on different types of cancer, including breast, colon, lymphoma, and liver cancer. Whether you are seeking an initial diagnosis, a treatment plan, or a second opinion, our oncologists are here to offer the support and expertise necessary for your journey.
Senior Consultant, Medical Oncologist
MBBS (Australia, Honours), MRCP (United Kingdom), MD (United Kingdom)
Dr Lim specialises in the treatment of gynaecological cancers, such as cancer of the ovary, uterus, cervix and vulva. She trained under several renowned oncologists, including Professor Hani Gabra, a world renowned expert on ovarian cancer.
Dr Lim joined the Department of Gynaecological Oncology at KK Women’s and Children’s Hospital, specialising in the treatment of gynaecological cancers (cancers of the ovary, uterus, cervix and vulva). She also led the Chemotherapy Centre at KK Hospital and served as chairperson of the Singapore Cancer Network (SCAN).
- Graduated from Monash University, Australia (Honours) in 1996
- MRCP (UK), Royal College of Physicians of the United Kingdom, 2001
- Certification in Medical Oncology by the United Kingdom Postgraduate Medical Education Training Board in 2008
- Doctor of Medicine (MD) , United Kingdom in 2009
- Executive Committee Member of the GyneCologic Cancer Group Singapore (GCGS) since 2018
- Former Senior Consultant Medical Oncologist at the Department of Gynaecological Oncology at the KK Women’s and Children’s Hospital (KKH), Adjunct Associate Professor at DUKE-NUS Medical School
- Visiting Consultant at KK Women’s and Children’s Hospital
Senior Consultant, Medical Oncologist
MBBS (Singapore) – ABIM Int. Med (USA) – ABIM Med Onc(USA) – FAMS (Medical Oncology)
Dr. Tay has been recognised as one of the top cancer doctors doing research. He was awarded the prestigious center grant by the National Medical Research Council of Singapore. He actively collaborates with other leading Asian researchers based in Korea, Taiwan, Hong Kong and USA. Dr Tay has published his findings in numerous journals, including Nature Genetics, the Journal of Clinical Oncology, The Lancet Hematology, American Journal of Medicine, Leukemia & Lymphoma and Seminars in Hematology.
Dr Tay’s subspecialty interest is in women related cancers such as breast cancers & gynaecological cancers, melanoma, brain cancers, soft tissue & bone sarcomas and also hematological malignancies such as lymphoma, multiple myeloma and leukemia.
- Graduated from the National University of Singapore in 1998.
- Board Certified, Internal Medicine, American Board of Internal Medicine, 2006
- Board Certified, Medical Oncology, American Board of Internal Medicine, 2009
- Chief Resident, Department of Medicine, John A. Burns School of Medicine, University of Hawaii, 2006
- Chief Fellow, Medical Oncology Branch, National Cancer Institute, National Institute of Health, Bethesda, 2008
More about Cervical Cancer
Get experts’ insights on cancer treatment, research breakthroughs, nutrition advice, healthy living and more…
