"99.6% of cervical cancer can be prevented, and should be eradicated like smallpox." Dr. Chia Yin Nin, a gynaecological oncologist at Gleneagles Hospital Singapore, emphasised passionately during our interview. With relatives who have suffered from cancer diseases, Dr. Chia had always dreamed of becoming a doctor to help people and to find a cure for cancer from a young age. She is also currently the President of Society for Colposcopy and Cervical Pathology Singapore (SCCPS). SCCPS aims to educate and spread knowledge of the prevention and management of cancer of the female lower genital tract. In conjunction with Cervical Cancer Awareness Month Singapore in May, SCCPS worked with Roche Diagnostics to survey the awareness of cervical cancer and the human papillomavirus (HPV), as well as the percentage of women who underwent screening tests for cervical cancer. They surveyed 308 women aged 25-55 years old between August-October 2015.
Dr. Chia commented, "The survey results are quite alarming. Less than half of Singaporean women are aware of HPV infections and just under half of women have never undergone a Pap Smear. This clearly shows the need for continuous education for women about HPV and cervical cancer. Cervical cancer is one of the most preventable cancers. It can be treated by surgery, radiotherapy and chemotherapy with timely diagnosis." The survey showed that only 41% of women surveyed had awareness of HPV, and only 45% of women knew that HPV is linked to cervical cancer. Furthermore, 2 in 5 women had never undergone a Pap Smear.
HPV infect cells at the neck of the womb in women called the cervix.  In 80% of cases, the virus clears itself and cells of the cervix return back to normal. However, in 20% of cases, the infection remains, and the cells progress towards cancerous cells. According to the Singapore Cancer Society, almost 200 new cases are diagnosed and 70 deaths result from cervical cancer each year. 
Dr. Chia strongly feels that this should not be the case. "In this day and age, no women should die of cervical cancer. We know its cause and the various prevention strategies against cervical cancer." The most common screening method used in Singapore currently is the Pap Smear. This involves a nurse or doctor collecting a sample of cells from the cervix, to send to the laboratories to test for abnormal cells. "After you get the virus infection, the cells in the cervix go through pre-cancer changes (Cervical Intraepithelial Neoplasia (CIN) symptoms) years before the cancer develops." The Pap Smear is the screening for secondary prevention, as it picks up cell changes that have occurred already. It is supposed to be done every 3 years, but Dr. Chia recommends taking the test yearly to reduce chances of forgetting and to increase Pap Smear’s accuracy. “This is due to the reason that – Pap Smear depends on the people who take the samples of the cervix or interpret the testing, so sometimes the negative Pap Smear may not be a true negative Pap Smear. Hence we can say that the accuracy of Pap Smear depends on the frequency of doing it,” explained Dr. Chia. On top of that, research has actually shown that Pap Smears are prone to false negative results, with almost one-third of women diagnosed with cervical cancer having negative Pap Smears within 3 years before their diagnosis. 
Therefore, a more accurate and sensitive new test has been developed - the HPV test. HPV test is the screening for primary prevention, which means we are detecting whether the HPV virus present in cervix, before any cell changes. The presence of small amounts of DNA of the virus is able to give a positive result. The sampling method is the same as Pap Smears, but the HPV test result is read by machines, so human error of misinterpretation of results can be avoided. There are pooled HPV tests, and also HPV tests specifically to identify HPV Types 16 and 18 (Types 16 and 18 cause 70% of cervical cancers).
Many may shy away from screenings as they may be worried about any pain involved in the procedure. However, Dr. Chia clarifies that both Pap Smears and HPV tests incur only slight discomfort, and are not painful procedures generally. "In Singapore, we highly recommend that women go for cervical cancer screening, using both the Pap Smear and HPV test for more accurate results. Prior to the development of the HPV test, Pap Smear was the default option. With the advent of technological advancements, it has now enabled us to precisely detect the presence of HPV directly with the HPV test. This means that the HPV test can be used as a primary screening method or co-tested with the Pap Smear. Screening is an essential first step in cervical cancer prevention. It is time for women to take health matters into their own hands.”
"Some countries like Thailand have already made the HPV test as their default screening for cervical cancer. Australia is in the works of replacing their Pap screening system with the HPV test by 2017." When queried on whether Singapore is planning to do so as well, Dr. Chia said, "The Singapore government is in discussion with the Ministry of Health (MOH) to move towards HPV testing." However, there are several obstacles faced. "There has to be changes in the whole healthcare infrastructure. Also, the HPV test is not cheap, costing SG$100 more than the Pap Smear. MOH wants to be very careful as well, since the HPV test is so new to the market." Dr. Chia qualified though, that the HPV test need not be done for women less than 30 years old. "A lot of transient infections occur during this age group, so positive HPV tests may have a higher likelihood of not being cervical cancer. A conventional Pap Smear is sufficient. Those beyond 30 years of age are recommended to do the HPV test, as theirs are likely to be persistent infections leading to cervical cancer."
With these screenings available for the public, why then are people still not going to screen themselves for cervical cancer? Dr. Chia believes there are 3 overall groups of people, with their reason. "The first group is the less privileged. They could be less informed and thus not aware of this latent disease; or they have insufficient money to foot the cost of follow-ups needed every few years. The second group of women is those who naively think that cervical cancer will not happen to them as they feel that living a healthy lifestyle will protect them from cancer. “Cancer is very fair, it strikes the rich, the poor, the young and the old. The third group is well-informed, educated women, but they are simply too busy to make time for screening."
"There is a big misperception that cervical cancer only happens to people with multiple sex partners. They think that if they have a steady sex partner, they won't get cervical cancer. Cervical cancer can happen to us all. HPV is easily transmittable, even via intimate skin-on-skin contact. Also, there can be no symptoms shown - no bleeding, no discharge." That is why Dr. Chia repeatedly stressed how important it was to get screened regularly.
When we asked about what a woman should do to recover if she is diagnosed with cervical cancer, Dr. Chia noted that, “First of all, she has to get herself treated properly. A lot of women delay treatment because they refuse to lose the womb or want to try alternative therapy. However, if women get themselves treated in the early stages, they can potentially recover fully from the disease. One example that I tell my patients is Anita Mui. Anita Mui was not willing to lose her womb, that’s why she refused the initial treatment proposed by her doctors. I believe the cancer was in the early stages as the proposed treatment was surgery. She must have tried all sorts of alternative therapy and if they worked, she would be alive today.”
For women who have yet to engage in sexual activity, they are recommended to take the vaccine for cervical cancer. The existing vaccines are available for females aged 9 upwards and its effectiveness is lifelong. The 2 types of vaccines - Cervarix and Gardasil, have been around in the market for 9 years. Both vaccines protect against the virulent HPV Types 16 and 18. These 2 HPV strains cause higher chances and speed of contracting HPV, and 70% of cervical cancer is due to them. Gardasil protects against 2 more strains of HPV (Type 6, 11). "These vaccines do not cover all strains of HPV, but will protect you from cervical cancer by 70-80%," said Dr. Chia during the interview. In countries such as Malaysia, UK and Australia, they have already incorporated the cervical vaccine into their national school vaccination program. Singapore has not done this so far, but patients can use up to SG$400 under the Medisave400 scheme to pay for HPV vaccination, which is available from polyclinics, as well as GPs and specialist Obstetrics & Gynecology clinics. 
When asked about how to increase awareness of cervical cancer and its screenings, Dr. Chia harped on the point of simply talking about it amongst friends and people around us. The incidence of cervical cancer has dropped to 10th spot over the years, due to more women going for Pap Smears. This may have resulted in a decreased visibility, and thus lower awareness of cervical cancer among women. “However, women are still succumbing to cervical cancer when they should not be." Dr. Chia illustrated how she herself strives to get the message out. "As a doctor, I ask patients to spread the word on cervical cancer to their young daughters, their friends and colleagues, etc. As President of SCCPS, we organise public talks and events in collaboration with Health Promotion Board (HPB)." An event she highlighted was 'Globe-athon'. It is a global national movement on the prevention and detection of all gynaecological cancers. 
SCCPS organised its second Globe-athon Singapore in 2015, with the theme "Power Over Women's Cancer". They incorporated exercises such as Zumba, Pilates and Kickboxing, together with health talks on cervical cancer. Dr. Chia encouraged younger ladies to start relevant conversations among their friends, bringing up the message of the importance of cervical cancer screenings for prevention. "It is our duty to do our part in educating the public. Someone needs to get the conversation on cervical cancer going within their peer group, to spread the word on cervical cancer and HPV."
The 3rd Globe-athon Singapore, with Roche Diagnostics sponsoring the event, will be held on 20 November this year from 8.45am to 12.30pm at the OCBC Arena. To register, please visit the website: www.sccps.org.
About the Interviewee
Dr. Chia Yin Nin is currently a gynaecological oncologist at Gleneagles Hospital in Singapore. Her specialty interest is in the management and treatment of gynaecological cancers, namely cancers of the cervix, uterus, ovary, fallopian tubes, vulva and peritoneum, pre-cancer gynaecological diseases, and complex pelvic surgeries including open, laparoscopic and robotic surgeries. She performed the first laparoscopic radical hysterectomy in Singapore in 2011. Her other areas of practice include the management of general and benign gynaecological conditions, as well as the screening and prevention of gynaecological cancers.
Dr Chia was awarded the Hoops Medal for Distinction in Obstetrics and Gynaecology and the Singapore Medical Association Bronze medal for excellent academic achievement for her MBBS. In 2008, she obtained her certification in Gynaecology Oncology from the Royal Australian New Zealand College of Obstetricians & Gynaecologists.
Dr Chia was previously the deputy head of the department of Gynaecological Oncology as well as the head of the Gynaecological Cancer Unit of the Department of Gynaecological Oncology at KK Hospital. Her other past appointments include: KK Hospital Medical Board member and adjunct assistant professor at the Duke-NUS Medical School, Singapore where she received numerous teaching awards for her exemplary teaching.
One of the founding members and council members of the Asian Society of Gynaecologic Oncology, Dr Chia also sits on the Editorial Board for the Journal of Gynaecologic Oncology. Her other academic appointments include President for the Society for Colposcopy and Cervical Pathology Singapore (SCCPS) and council member of the Gynaecology Oncology subsection of the College of Obstetrics and Gynaecology in Singapore.
Dr Chia has keen research interest in the areas of gynaecological cancer and Human Papillomavirus (HPV) vaccines and has participated in key landmark clinical trials in these disease areas. Conditions she treats include abnormal pap smears, cervix cancer, fibroids, endometriosis, heavy menses, irregular menses, menstrual cramps, ovarian cancer, ovarian cysts, primary peritoneal cancer, pre-cancerous changes of the cervix, vagina and vulva, prolapse, uterus cancer, vagina cancer and infections, and vulva cancer. She also provides human papillomavirus (HPV) tests and Pap Smears at her clinic.
- Singapore Cancer Society. Cervical Cancer Screening - Pap Smear, 2015.
- Journal of the National Cancer Institute. Cervical Cancer in Women With Comprehensive Health Care Access: Attributable Factors in the Screening Process. 2005.
This interview was conducted by APBN,
Cheryl Lee Zhi Qin & Carmen Loh Jia Wen