Manuel National de Normes et Procédures pour la Prévention du Cancer du Col Utérin

Objectives

Madagascar’s cervical cancer prevention framework aims to reduce cervical cancer morbidity and mortality by standardising prevention, screening, diagnosis, treatment and follow-up across public and private health services, as part of the National Cancer Control Policy.[1][2]It prioritises early detection and treatment of precancerous lesions, alongside communication on risk factors, responsible sexual behaviour and the continuing need for screening even where vaccination is available.[3][4]

• Increase screening coverage by seeking to recruit up to 80% of target women, principally sexually active women aged 25 to 49 years, to achieve a significant effect on cervical cancer morbidity.[2][5][6]
• Strengthen primary prevention by treating genital and sexually transmitted infections, promoting awareness of human papillomavirus and other risk factors, and using family-planning and sexually transmitted infection consultations as opportunities to offer screening.[5][7][4]
• Provide visual inspection with acetic acid screening at basic health facilities and health centres, while using cervical cytology, colposcopy, biopsy and pathological assessment at district, regional and university hospital levels with the required capacity.[2][8][9][10]
• Offer human papillomavirus DNA testing as an additional screening option for sexually active women aged 30 years and over, using either laboratory-based testing or rapid careHPV testing suited to low-resource settings.[11]
• Ensure that screening results lead to appropriate management, including routine rescreening after negative findings, cryotherapy for eligible precancerous lesions, further assessment of abnormal cytology, and referral for suspected invasive cancer or lesions unsuitable for local treatment.[6][12][7]
• Expand access to treatment for precancerous lesions through cryotherapy, loop electrosurgical excision and cold-knife conisation, while referring confirmed invasive cancers for specialist surgical, radiotherapy and oncology care.[13][14][3]
• Improve health-worker competence in screening, counselling, cryotherapy, infection prevention, clinical documentation and referral, including training at least two workers at each screening site where materials, equipment and consumables are available.[5][15]
• Increase demand for services through behaviour-change communication tailored to political and administrative leaders, health providers, men, communities and women eligible for screening, while addressing rumours, misconceptions and reluctance to attend.[3][16][4]

Implementation

The delivery model links community mobilisation, integrated primary-care screening, diagnosis, treatment and structured referral and counter-referral so that women can move through a continuum of care rather than receive screening alone.[2][5][17]Services are to be integrated into the minimum package of facility activities and connected with reproductive-health education, family planning, sexually transmitted infection care, and HIV and AIDS services.[3]

• Integrate screening into first family-planning consultations, intrauterine-device insertion visits and sexually transmitted infection consultations; recruit women through spontaneous attendance or awareness campaigns regardless of residence; and provide counselling, examination and explanation of next steps at the first visit.[5][8]
• Deliver visual inspection with acetic acid through trained paramedical staff or doctors at health centres, with privacy, examination equipment, consumables, sterilisation arrangements and reliable supplies.[8][6]
• Use result-based pathways by repeating inadequate tests, rescreening women with negative findings at specified intervals, monitoring selected low-grade abnormalities, and referring high-grade abnormalities or malignant cells for colposcopy, biopsy and hospital management.[6][12]
• Provide colposcopy, directed biopsy and endocervical curettage through qualified providers at district, regional and university hospitals where instruments and expertise are available; label and preserve specimens for histopathological diagnosis to guide treatment.[18][10][19]
• Apply differentiated treatment pathways by using cryotherapy for eligible visible lesions, loop excision where histological examination of excised tissue is needed, and conisation for lesions extending into the endocervical canal or for serious or discordant diagnostic findings.[7][20][14]
• Refer women whose needs exceed facility capacity, including those with suspected cancer, lesions unsuitable for cryotherapy, or a need for colposcopy, biopsy, loop excision or conisation; return management information to the originating facility through counter-referral arrangements.[6][17]
• Train providers and community facilitators, with trained health workers identifying facilitators to support mass mobilisation, and provide start-up assistance one month after training followed by formative supervision every three months during the first year and every six months thereafter.[15][9]
• Maintain patient-level follow-up after treatment, including review after cryotherapy, loop excision or conisation, assessment of healing and complications, repeat screening or diagnostic investigation where lesions persist, and communication of laboratory results and subsequent care plans.[13][21][14]
• Operate data collection, confidentiality and reporting arrangements through dedicated clinical forms, locked storage of site records, controlled access by authorised personnel, monthly transmission from sites through district services to central services, and feedback to facilities, regional services, partners and the Steering Committee.[4][22]
• Support quality control through supply ordering, procurement, delivery, maintenance, reporting and quality assurance, while encouraging operational research with the Faculty of Medicine, the national public-health institute and relevant services.[3][22]
• Recognise that the supplied material does not specify a consolidated programme budget, funding sources, financing gaps, quantified performance indicators, surveillance definitions or a full accountability framework.[1][4][22]

Monitoring & Evaluation

Monitoring combines service-level supervision, clinical follow-up, documentation, referral records and a multi-level data-management process. The programme aims to reach up to 80% of target women, which can serve as a coverage objective, but the extracts do not establish a comprehensive indicator framework, surveillance definitions or formal audit system.[2][5][4][22]

• Conduct start-up assistance one month after training, then provide formative supervision every three months during the first year and every six months thereafter for visual inspection with acetic acid and cytology services.[15][9]
• Maintain registration records, examination and treatment forms, observation forms, referral documentation, laboratory-result forms and arrangements for sending slides, tissue specimens and results.[12][19][23]
• Record screening, cryotherapy and follow-up information, including referrals, complications, adverse effects and one-year follow-up, while protecting confidentiality through controlled access, locked storage and sealed transmission of paper records.[4]
• Submit site data monthly to district services for collection, compilation, feedback and onward reporting to regional and central levels; central services compile and analyse data with the Technical Coordination Committee, while SLMV/DGS reports to the Steering Committee and communicates with partners.[22]
• Use referral and counter-referral records to document the originating and receiving facilities, clinical findings, actions taken, reason for referral, management provided and follow-up instructions.[17]
• Arrange clinical follow-up according to intervention and result, including repeat screening after negative results, post-cryotherapy review, cytology and colposcopy surveillance after treatment, laboratory-result review after biopsy or curettage, and reassessment of persistent lesions.[6][24][13][14]
• Assess diagnostic quality through colposcopy, histopathology, cytology, biopsy and curettage where indicated; the source estimates colposcopy sensitivity at around 85% and specificity at approximately 70%.[18]
• Support operational research through partnerships with the Faculty of Medicine, INSPC and relevant departments and services.[22]
• Subject innovative initiatives, including potential HPV care testing, to pilot implementation, formal validation, monitoring and evaluation.[2]

Costing & Financing

No quantified programme budget, financing plan, funding gap, allocation formula or resource-mobilisation strategy is specified. The material nevertheless identifies substantial delivery inputs and presents prevention and early treatment as less costly than managing confirmed cancer; it also describes advanced cervical cancer as imposing costs largely on patients and families.[1][3][4][22]

• Characterise Madagascar as a low-resource setting and identify mass screening through visual inspection with acetic acid as an effective and cost-effective approach demonstrated during a pilot phase.[2]
• Identify a socioeconomic burden associated with late diagnosis, reporting that more than 60% of cervical cancers are detected at an advanced stage and that treatment is largely borne by patients and families.[1]
• Communicate to decision-makers that prevention costs less than treatment of confirmed cancer and may affect health-system and budget pressures; inform communities about screening and precancerous-lesion treatment costs.[3][16]
• Require workforce capacity, equipment, consumables, laboratory services, transport, sterilisation, waste management, anaesthesia and referral capability across screening, diagnosis and treatment services, without assigning monetary values.[12][19][21][14]
• Describe laboratory-based molecular HPV DNA testing as costly and sophisticated-equipment intensive, while presenting rapid careHPV testing as suitable for low-resource settings and able to produce results in approximately two and a half hours.[11]
• Specify quantities of selected cryotherapy inputs per client, provider room, centre and month, but provide no unit prices, procurement budget or financing source.[20]