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 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 requirements in).	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.

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, Pap 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 vendors 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 Normal 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 will be able to view their SCS FIT results in NEHR.

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 patient if 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 the follow-up appointment at the respective participating Assessment Centres for colorectal cancer assessment . CHAS GPs should not make appointments to the Assessment Centres for SFL patients, regardless of CHAS/PG/MG status. However, CHAS GPs should provide patients with appropriate counselling and encourage patients to follow up with the 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 BreastScreen Singapore' (BSS) screening centres and patient should make an appointment with the screening centre before visiting.

GPs should issue a referral form for their enrolled patients to receive free mammogram. 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 may use the electronic simple referral form on their own HSG-compatible CMSes or the PCDS web-portal [insert hyperlink]. GPs should continue to keep a local copy of the referral as part of their routine clinical documentation.

Alternatively, GPs may fill in the hardcopy “Referral Form for Screening Mammography". The referral form can be printed from MHCP or GPs can contact gp@CHAS.sg to request for a set of the forms.

Please remind your patients to bring along the hardcopy referral form in order to waive off payment.

After the patient has been screened, the BSS screening centre will mail the screening results back to the patient and enrolling GP within 4-6 weeks. 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 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 prefer the screening to be done by a female healthcare professional, GPs may arrange for the patient to be referred to another female CHAS GP.

In such instances, enrolling GPs should issue a referral form to the female swabbing GP to ensure that the patient receives SFL and Healthier SG subsidies. [Placeholder: Template for the referral form is currently being developed; insert hyperlink to referral form, which should be hosted on AIC Primary Care Pages.] We do not encourage GPs to refer to polyclinics for cervical cancer screening.

For Normal Results

GP 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, based on the recommended frequency in Table 2.

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

For Abnormal Results

The timeline for conducting the repeat screening/follow-up is indicated in Table 3. If patient was referred to another GP clinic for screening, the results will be mailed to the swabbing GP. The onus is on swabbing GP to follow up with patients for abnormal results, including making a referral to participating SFL Cervical Screen Singapore (CSS) 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 links 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 SOC Referral Form to make subsidised referrals to Assessment Centres. The referral form can also be found in HSG-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 SOC 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 your case notes as part of good clinical practice for all patients enrolled to your 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

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 as for payments made under the SFL scheme. [Placeholder: Hyperlink to MOH Circular showing summary of the SFL GP remuneration for providing SFL screenings to eligible SCs.]

References