Country context

Singapore is a high-income island nation that has experienced rapid socio-economic development since its independence in 1963. Often cited as a model for industrialization and economic growth in small countries, Singapore ranked first in the World Bank Human Capital Index in 2020. Singapore offers universal health coverage to all citizens and permanent residents, with the government subsidizing around one-quarter of public health care costs, and around 10 percent of the population making use of private health care facilities. Low-income citizens are eligible for further government subsidies, particularly to cover the costs of medicines and therapeutic treatments.

Non-communicable diseases (NCDs) accounted for around 80 percent of the total disease burden in Singapore in 2019, with cancers the leading cause of mortality and ill health. Despite aggressive anti-tobacco policies, lung cancer remains the second-most-common cancer among men, and third among women. Lung cancer is also the leading and second-highest cause of cancer death among men and women, respectively. In 2022, Singapore’s overall lung cancer incidence rate was 24.3 cases per 100,000 people, but this figure masks a large gender difference: incidence for men is 33.2 cases per 100,000, but for women it is just 15.9 cases per 100,000. The country’s mortality rate—22.2 deaths per 100,000 people—similarly obscures a significant difference for men and women. The mortality rate for Singaporean men with lung cancer in 2022 was 31.9 per 100,000 people, and for women 13.2 per 100,000.

Most lung cancer cases are diagnosed only at an advanced stage: two-thirds of Singaporean lung cancer patients have stage IV disease at the time of diagnosis, reducing their likelihood of survival and well-being, and increasing the cost of treatment. Singapore Ministry of Health (MOH) data indicates that in public hospitals, biopsies can cost on average SGD 725, surgeries SGD 3,194, and chemotherapy SGD 1,142, while the same services can cost up to SGD 5,479, SGD 28,108, and SGD 8,318, respectively, in a private facility. At the end of a patient’s life, the costs further accumulate. While the MOH launched a subsidized palliative care service—the Inpatient Hospice Palliative Care Service (IHPCS)—in 2020, out-of-pocket hospice care costs an average of SGD 7,000 per month, and currently no Singaporean insurance companies offer coverage for hospice care.

Assessing policies and programs

As the national disease burden shifted from majority infectious diseases to majority NCDs—due to economic development and an aging population—the Singaporean government adopted primary prevention strategies focused on healthy lifestyles such as promoting smoking cessation, physical activity, and healthy diets. In 2002, the government introduced a general cancer control program, including national screening programs for early detection of breast and cervical cancers, and the dissemination of educational materials through schools, radio, and television. The program also established a National Cancer Centre and a National Working Group to develop strategies to address all common cancers, including lung cancer. Of note in Singapore’s program are an emphasis on rehabilitation for survivors—calling for whole-of-society support, including from spiritual and religious communities—and palliative care for terminal cases. The program also highlights the important implementing role played by the Singapore Cancer Society, a non-governmental organization that provides free and low-cost patient care services to those unable to pay for their own treatment, and has acted as a partner with government in tackling cancer.

Despite its long-running cancer control program, Singapore does not currently have a targeted lung cancer strategy or screening program. However, some standards of care are widespread. All public hospitals have weekly multidisciplinary “tumor meetings” in which difficult cancer cases are discussed and treatment decisions made, and which bring together experts from across hospital departments as a way to identify the best path forward. For patients in treatment, Singapore’s national health insurance scheme subsidizes the cost of cancer drugs under its Medication Assistance Fund and, as of May 2023, covered around 90 percent of established cancer drugs, including around 30 lung cancer drugs. Cancer medicines represent one-quarter of the country’s total spending on drugs—and the cost of cancer drugs has reportedly risen by an average of 20 percent per year, compared to just 6 percent for other drugs. A group of Singaporean oncologists recently issued a consensus statement calling for the integration of biomarker and genomic sequencing tests into treatment for both early and advanced stage non-small cell lung cancer, indicating that new tests and treatments may soon become more widely utilized. However, novel and experimental treatments, such as immunotherapy, are not currently covered under the national insurance scheme, and clinical adoption of diagnostics such as next-generation sequencing remains low, even in private health care settings.

Singapore’s anti-smoking and anti-tobacco policies have been identified as a model for tobacco control. The government has steadily increased excise tax on tobacco products, including a significant 10 percent tax increase in 2018, and has banned e-cigarettes and shisha (alternatively known as hookah) entirely. Packaging on tobacco products is standardized, with graphic warning labels, and the legal age at which one may buy cigarettes was increased to 21 years in 2021. In combination, these policies have led to one of the lowest rates of smoking in the region, averaging between 12 and 14 percent each year. While the success of these initiatives is reflected in the low smoking and tobacco consumption rates in Singapore, smoking is only one lung cancer risk factor among many, and non-smokers comprise an increasing share of lung cancer patients in Singapore.

Air pollution may be another driver of lung cancer in Singapore, particularly as it—along with Indonesia and Malaysia—experiences an annual haze event. Singapore passed its Clean Air Act in 1971, but recent policies, such as a government program facilitating energy efficiency and the use of non-fossil fuels by Singapore-based businesses, also aim to reduce air pollution and mitigate climate change. The National Environment Agency (NEA) sets air-quality targets in partnership with the Ministry of Sustainability and Environment (MSE), based on the WHO Air Quality Guidelines, which are regularly reviewed and adjusted. However, as the NEA and Singaporean policymakers note, reducing the seasonal haze will require a regional response. As part of this effort, Singapore hosts the ASEAN Specialized Meteorological Centre, which monitors the progress of forest fires and the haze itself. The NEA has also created the Pollutant Standards Index (PSI), which acts as a health advisory for the public, in an effort to reduce adverse health impacts.

GRIP: Gains, Risks, Innovations, Prospects in Policies and Programs

Opportunities ahead

Key to the success of a Singaporean lung cancer policy will be tailoring initiatives and investments to the local context. Lung cancer patterns and prevalence in Singapore, like elsewhere in the Asia Pacific region, differ significantly from their presentation across Global North countries. As such, a screening program may require a unique set of criteria for targets. Targeted policies for early lung cancer detection—particularly screening programs, including those that cover non-smokers and the rapidly aging population—could be highly beneficial to Singapore due to the high cost and low survival rate for cancer treatment. In 2019, the five-year survival rate for lung cancer patients was just 18 percent, and 75 percent of patients were presenting at such an advanced stage that the disease was not curable.

Seeking to prevent or intervene early in lung cancer cases, and to improve chances of survival, the Lung Cancer Policy Model-Asia estimated that the implementation of a targeted low-dose computerized tomography (LDCT) screening program in Singapore, using age and smoking history as eligibility criteria, could lead to an estimated 3.8 percent reduction in mortality, and a gain of 8,118 life years across the population. Such screening is widely available in private hospitals and is even recommended for high-risk individuals by the Ministry of Health, but it has not been adopted into a national-level screening program despite its potential benefits, likely due to concerns over false positives leading to unnecessary treatment. Singapore’s College of Radiologists has advocated that a national LDCT screening program could enable increased diagnosis of lung cancer in stages I and II, improving prognosis and decreasing mortality over time. It recommends the implementation of a program that customizes inclusion criteria based on Singapore’s population and lung cancer incidence, targets recruitment to high-risk populations, and is integrated with both smoking-cessation programs and the full spectrum of lung cancer care at all stages. Once cancer is diagnosed, adequate care and support at all stages of the patient’s journey can be most effective when provided by integrated, multidisciplinary teams. In particular, bringing primary care physicians and general practitioners into the continuum of cancer care will enable effective monitoring of survivors for secondary cancers or recurrences. Relatedly, prioritizing the provision of rehabilitative services and psychological support can help survivors to thrive.