Cancer Screening

Background

Cancer is the leading cause of death in Singapore, accounting for nearly 1 in 3 deaths¹. Early detection and prompt treatment of these cancers through screening results in better outcomes and survival.

Table 1: Most Common Cancers and Cancer Deaths By Type From 2015 To 2019²

Most Common Cancers by Type

Most Common Cancer Deaths by Type

Males

1. Colorectal – 16.9%

2. Prostate – 15.4%

3. Lung – 13.7%

1. Lung – 25.6%

2. Colorectal – 14.5%

3. Liver – 12.9%

Females

1. Breast – 29.4%

2. Colorectal – 13.1%

3. Lung – 7.7%

1. Breast – 17.1%

2. Colorectal – 15.6%

3. Lung – 15.5%

Clinical Approach

Regular screening of selected cancers in asymptomatic individuals assessed to be clinically and cost effective can be offered to those eligible in the general population. Beyond these, the individual's past medical history and family history may also determine whether screening should be offered on a case-by-case basis.

This care protocol focuses on Category 1 Screening Recommendations made by the Screening Test Review Committee (STRC) where there is robust evidence that screening is clinically and cost effective for use at the population level. Currently, screening for three cancers (i.e., Breast, Cervical and Colorectal) is recommended for general population screening. Government subsidies are available under the Screen-For-Life (SFL) Programme – details are in the Financing section.

Table 2: STRC recommended screening tests for cancer in the general population where SFL subsidies apply³

	Eligible Population	Screening Method	Age to Start	Frequency
Breast Cancer	Asymptomatic 50–69 year-old women (Note: Those aged 40-49 years old and those 70 years and above may be offered screening under SFL based on their risk profile. To avail SFL subsidies, please see click here for further details.)	Mammogram	50 years old	Every 2 years (For those aged 40-49 years old, they may be offered annual screening if assessed to be of higher risk )
Cervical Cancer	Any female who ever had sexual intercourse For special populations, please click here	Pap Test	25–29 years old*	Every 3 years
Cervical Cancer		HPV DNA Test	30–69 years old*	Every 5 years
Colorectal Cancer	(a) Asymptomatic 50-year-olds who do not have a family history of colorectal cancer; (b) Asymptomatic at any age but with positive family history confined to non-first-degree relatives or relatives older than 60 years old. For special populations, please click here	Faecal Immuno-chemical Test (FIT) x2 OR	50 years old	Annual
Colorectal Cancer		Colonoscopy Note: Not covered under SFL. GP should discuss with patient the benefits and disadvantages of colonoscopy.	50 years old	Every 5-10 years

*For cervical cancer screening, ages indicated refer to age ranges for recommended tests.

^{^}For women who are 40-49 years old and > 69 years old, a discussion on risks and benefits of breast cancer screening should be conducted as part of the Health Plan and a recommendation made for the individual patient to proceed (or not proceed) with mammography based on this discussion.

Please note that other screening modalities such as breast MRI for breast cancer screening, and Computed Tomography (CT) Colonography and Faecal immunochemical test (FIT)-DNA test for colorectal cancer screening, are not recommended for general population screening but only for those at higher risk. Tests such as tumour markers for breast and colorectal cancer, or imaging studies such as ultrasound of the breast or pelvis, CT pelvis or abdomen, are not recommended for screening and should only be used for diagnostic purposes in patients.

Management

GPs should proactively check if their enrolled patients have undergone the nationally recommended cancer screening tests, in line with the schedule described in Table 2. If they have not done so, GPs should encourage their patients to do so. GPs may conduct the screening by referring patients to private or public sector screening providers where breast, cervical or colorectal screening is offered. If the patient has completed their screening with providers not within Public Healthcare Institutions (PHIs) (e.g. as part of workplace screening), GPs should request the patient to share the results with them. Where tests were performed within PHIs, GPs may refer to NEHR for the results of their patients.

Due to the different nature of the tests involved (i.e., breast imaging, stool collection, cervical cancer screening test), patients must be made aware of the steps involved, including when the results will be available or when the screening provider is expected to provide the result to the requesting GP.

As part of good clinical practice, GPs should proactively check for results of screening tests ordered. The relevant cancer screening results can be found in NEHR under the Screening Tab . GPs should follow-up with patients on their screening results accordingly, particularly those with abnormal results, and encourage timely intervention.

Colorectal Cancer Screening under SFL

CHAS GPs can order FIT kits from HPB's appointed vendor for distribution to patients in their clinic.

Patients may also obtain Singapore Cancer Society (SCS) FIT kits directly at pharmacies at retailers such as Guardian, Watsons and SCS Clinic. Accompanying these kits are instructions on how to collect stool samples properly and post them to appointed laboratories.

For FIT kits issued by GPs, patient's FIT results will be sent to the clinic within 2 weeks. Patients who used the SCS FIT kits will receive their FIT results by mail and GPs will be able to view their SCS FIT results in NEHR.

For Normal Results

GPs are encouraged to follow up via face-to-face or tele-consult to close the screening episode, including advising patient on their next screening cycle. If SCS FIT kits are used, GPs are encouraged to follow up with the patient if the patient had informed GP of the screening.

For Abnormal Results

For FIT kits issued by GPs, patient's FIT results will be sent to the clinic within 2 weeks. Patients who used the SCS FIT kits will receive their FIT results by mail and GPs can view their SCS FIT results in NEHR.

Regardless of source of kits, HPB's programme coordinators will contact patients with abnormal results directly to schedule a follow-up appointment at the respective participating Assessment Centres for colorectal cancer assessment . CHAS GPs should not make appointments to the Assessment Centres for patients who did their screening under SFL (i.e. used FIT kits ordered from HPB's appointed vendor), regardless of CHAS/PG/MG status. However, CHAS GPs should provide patients with appropriate counselling and encourage patients to attend their follow-up appointment.

Refer to HPB's Referral Pathway for Patients with Abnormal FIT Results.

Breast Cancer Screening

Breast cancer screening can be done at any one of the SFL Breast Cancer screening centres and patient should make an appointment with the screening centre before visiting.

For women who are 40-49years old and > 69years old, a risk-benefit discussion is recommended by the STRC to precede breast cancer screening and should be carried out between GP and patient as part of the Health Plan, and a tailored recommendation for mammography made on the basis of this discussion. This discussion can be documented by the GP in the Health Plan (as a free text field). GP are strongly encouraged to issue a referral form for mammograms. A complete referral form ensures that patients receive both SFL and Healthier SG subsidies and facilitates the flow of screening results back to the referring GP for appropriate follow-up with the patient. GPs should remind patients to bring along the hardcopy referral form to their mammography appointment.

GPs should remind patients to bring the hardcopy referral form to their mammography appointment. After the patient has been screened, the breast cancer screening centre will mail the screening results back to the patient within 4-6 weeks. If a referral form was provided by the referring GP and presented by the patient upon registration for screening, the screening results will also be mailed to the referring GP. Otherwise, GPs can also view patients' results in NEHR.

For Normal Results

GPs are encouraged to follow up via face-to-face or tele-consult to close the screening episode, including advising the patient on their next screening cycle.

For Abnormal Results

The screening result letter will inform the patient about the participating Assessment Centre that they should make an appointment with within two weeks for further investigations. GPs are encouraged to provide patient with appropriate counselling and encourage patient to book and attend the follow-up appointment with the Assessment Centre as early as possible. This may be done opportunistically or via a phone/video call.

If no appointment has been made in 2 weeks, the Assessment Centre will send a reminder to the patient. If no follow-up action is recorded after 2 months, HPB will telephone the patient as a final reminder.

Cervical Cancer Screening

Subsidised Pap tests and HPV DNA tests are available at CHAS GPs.

However, should the patient request to undertake the cervical cancer screening at a clinic other than their enrolled Healthier SG GP (e.g. if the patient prefers the screening to be done by a female healthcare professional and this is unavailable at the enrolled Healthier SG GP), GPs may arrange for the patient to be referred to another CHAS GP that is able to offer the cervical cancer screening.

In such instances, enrolling GPs should issue a referral form to the swabbing GP to ensure that the patient receives a waiver of co-payment under Healthier SG. An updated CHAS (Medical) Referral Form will be made available to Healthier SG GP clinics by 5 July 2023 for this purpose. GPs should not refer to polyclinics as the patient will not be eligible for fully subsidised cervical cancer screening there.

After the patient has been screened, labs will send the screening results to the GP within 7 calendar days. If the patient was referred by his enrolling GP to another CHAS GP for screening, the results will be mailed to the swabbing GP.

For Normal Results

GP are encouraged to follow up via face-to-face or tele-consult to close the screening episode, including advising the patient on their next screening cycle, based on the recommended frequency in Table 2.

If the patient was referred to another GP clinic, the onus is on the swabbing GP to follow up with the patient. Referring GPs can access results on NEHR to facilitate health planning for their enrolled patients.

For Abnormal Results

The timeline for conducting the repeat screening/follow-up is indicated in Table 3. If the patient was referred to another GP clinic for screening, the onus is on the swabbing GP to follow-up with patients for abnormal results, including making a referral to participating SFL cervical cancer screening Assessment Centres. GPs should remind patients to make their own appointment with the Assessment Centre.

Table 3: Timeline for Conducting the Repeat Cervical Cancer Screening/Follow-up

Screening Tests	Eligibility	1st Repeat (if indicated)	2^nd Repeat (if indicated)	Follow up
Pap Test (up to 2 repeat tests)/ HPV Test (up to 1 repeat test)	As per screening eligibility	To be conducted no later than 12 months after initial screening visit date.	To be conducted no later than 12 months after 1^st repeat screening visit date.	To be conducted no later than 6 months after last screening visit date.

Click the blue information icons in Table 4 to see management workflows and referral recommendations under SFL for abnormal Pap test and HPV Test results.

Table 4: Management of Abnormal Results

For Abnormal Pap Test Results	Management of cervical cytology screening Management of unsatisfactory cytology results Management of abnormal cytology results with no past history of CIN or genital tract cancer
For Abnormal HPV Test Results	Possible outcomes of HPV test and the corresponding follow-up actions and potential benefits.

GPs may make subsidised referrals for patients to follow up at the participating SFL Assessment Centres, if they fulfill the following criteria:

Singapore Citizens including non-CHAS/non-PG/non-MG cardholders, who are eligible for screening and follow-up under SFL; and
Found to have any abnormal cervical cancer screening Pap test and HPV test results under SFL and require a referral to an Assessment Centre for treatment and care management

GPs may also refer patients with clinically suspicious looking cervix to Assessment Centres for subsidised follow-up, regardless of the cervical cancer screening result.
GPs may use the CHAS (Medical) Referral Form to make subsidised referrals to Assessment Centres. The referral form can also be found in Healthier SG-compatible CMS and on the PCDS web-portal. GPs should tick "SFL" under the item named "Is this referral related to a CHAS/SFL/VCDSS visit?". The actual subsidy status will be determined by prevailing SFL eligibility.
CHAS GPs should provide eligible patients with i) a completed CHAS (Medical) Referral Form, ii) the relevant lab results, and advise them to bring these documents with them for their appointment, along with their NRIC.

Data Submission

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments. These are aligned to data being submitted for SFL claims.

Screening Type*

Colorectal Cancer: FIT/ Colonoscopy
Cervical Cancer: Pap/HPV DNA test
Breast cancer: Mammogram

Date*
Screening Outcome Code*
Review Date*

Financing

Free Screening Tests under Healthier SG

For Singapore Citizens enrolled in Healthier SG, the Faecal Immunochemical Test (FIT) for colorectal cancer screening and the Pap/HPV test for cervical cancer screening will be provided free-of-charge when conducted or referred by their enrolled GP, if conducted in line with the schedule and eligibility criteria laid out in Table 2. This includes repeat tests if needed for cervical cancer screening. Healthier SG GPs therefore do not need to collect payments from SCs enrolled to their clinics. Instead, Healthier SG GPs should claim for the full remuneration using the same process and to the same bank account for payments made under the SFL scheme. GPs are advised to check the enrolee's eligibility for the screening subsidies using the subsidy eligibility tool for SFL in MHCP.

Details on GP remuneration for providing SFL screenings to eligible SCs can be found in the prevailing CHAS agreement. Details on the GP annual service fee can be found in the Healthier SG Enrolment Programme Agreement.

References