Guide de Détection Précoce des Cancers du Sein et du Col de l’Utérus

Objectives

Provide a national reference framework for integrating early detection of breast and cervical cancers into reproductive health services, standardising screening, early diagnosis, clinical management, health education and counselling across levels of care. The overarching aim is to reduce cancer-related morbidity and mortality through earlier recognition and timely, less aggressive treatment.[1][2]The programme responds to the substantial burden of breast and cervical cancers in Morocco and their frequent late-stage diagnosis.[3][4]

• Integrate screening, diagnosis and treatment into an organised national pathway spanning primary, intermediate, secondary and tertiary care.[1][5]
• Screen women aged 45 to 69 years for breast cancer, including those with a family history, using clinical breast examination every two years after a negative result; exclude women previously diagnosed with breast cancer.[5]
• Screen women aged 30 to 49 years for cervical cancer using visual inspection with acetic acid every three years after a negative result; exclude women previously diagnosed with cervical cancer and women from the eighth week of pregnancy.[6]
• Ensure screening tests are affordable, reliable, safe and acceptable, and are supported by accessible, effective diagnostic and treatment services.[7][4]
• Improve service availability, quality of care and use of reproductive health services, while strengthening programme monitoring, evaluation, information systems and research.[5]
• Promote participation through health education, tailored counselling, advocacy and civil-society mobilisation, with attention to informed consent, confidentiality and privacy.[8][9][10]
• Achieve and maintain annual screening participation of approximately 50% to 60% after three years, with another programme section specifying a 60% target for both cancers.[11][12]

Implementation

Deliver services through a tiered model in which urban and communal health centres provide screening, Reproductive Health Reference Centres undertake diagnostic confirmation, and oncology centres, maternity units, provincial hospitals or proximity chemotherapy services provide treatment and follow-up.[13]Primary facilities conduct clinical breast examination and cervical visual inspection with acetic acid, while reference centres provide radiology, colposcopy, biopsy, cytopuncture and management of cervical precancerous lesions.[1]Continuity depends on defined referral and counter-referral pathways, shared participant information and coordinated care across levels.[5][13]

• Equip and staff health centres to provide private screening consultations, participant reception and information, clinical examination, infection prevention, waste management and routine documentation.[11][8]
• Train general practitioners, midwives and maternal and family-planning nurses to perform clinical breast examination and cervical visual inspection with acetic acid, and use specialist gynaecology, radiology, pathology and technical staff at reference-centre level.[14][15][16]
• Refer abnormal breast findings for mammography, ultrasound, cytology or biopsy, and send confirmed cancers to oncology centres for multidisciplinary treatment decisions.[17]
• Refer positive or inconclusive cervical screening results for colposcopy, biopsy where required and pathological interpretation; offer loop excision for eligible precancerous lesions or selected micro-invasive disease, and refer invasive disease to oncology centres.[18][19][17]
• Plan implementation at health-centre, provincial, regional and national levels, with facility managers responsible for local delivery, provincial reproductive health units coordinating training and reports, regional authorities integrating implementation and national services setting standards, coordinating partners and overseeing performance.[11][20][21]
• Use annual action plans to determine target populations, participation objectives and human, technical, information-technology and audiovisual resource requirements.[17][11]
• Maintain a computerised information system and paper records that follow women longitudinally through screening, diagnosis, treatment, referral and counter-referral.[21][13]
• Monitor participation, referral, diagnostic activity, detected cancers and cervical intra-epithelial lesions, treatment coverage and loss to follow-up.[12][22]Submit reports monthly at provincial level and quarterly at regional and central levels, supported by dashboards, supervision checklists and periodic implementation review.[13][12][9]
• Calculate annual participation as screened women divided by the relevant annual target population, and plan for referral of approximately 12% to 15% of screened women to reference centres.[11][16]
• Provide post-treatment surveillance, including cervical colposcopic review nine months after loop excision and annually for five years, before return to routine three-yearly screening if examinations remain normal.[23]

Monitoring & Evaluation

The guide establishes a multi-level monitoring, evaluation and information framework for Morocco’s integrated early detection programme for breast and cervical cancers. It combines routine case documentation, service registers, referral and counter-referral records, periodic reporting, supervision, dashboard review and programme-level performance monitoring across primary care, reproductive health reference centres, provincial, regional and national levels.[8][21][13]

• Monitor screening participation, referrals for abnormalities, diagnostic procedures, confirmed cancers, cervical intra-epithelial lesions, treatment coverage and counter-referrals through health-centre and reference-centre registers, participant files and regular reports.[13][12]
• Calculate annual breast-screening participation as participating women aged 45 to 69 divided by the annual target population in that age group, multiplied by 100; calculate cervical-screening participation equivalently for women aged 30 to 49.[11]
• Target screening participation of 50% to 60% after three years, with another programme indicator set specifying 60% participation for both cancers after three years.[11][12]
• Target referral rates of 10% to 13% for breast and cervical abnormalities and 100% treatment coverage for diagnosed breast and cervical cancers.[12]
• Plan for referrals to reproductive health reference centres equivalent to approximately 12% to 15% of women screened, and estimate annual expected cases using 30 breast-cancer cases per 100,000 women aged 45 to 69 and 10 cervical-cancer cases per 100,000 women aged 30 to 49.[16]
• Submit reports monthly at provincial level and quarterly at regional and central-service levels; annex reporting tools also provide for periodic and quarterly reporting by province or prefecture and by urban or rural setting.[13][12][24]
• Maintain longitudinal records for each woman from screening through diagnosis, treatment and follow-up, and transfer relevant information at each referral and counter-referral between care levels.[21][13]
• Record participant details, clinical and examination findings, results, conclusions, referrals, appointments and follow-up actions in designated forms, medical records and women’s health records.[25][26][18]
• Use a computerised information system to standardise, protect, complete and disseminate data, automate summary reports, track care pathways, support planning and monitor programme performance.[21]
• Display dashboards containing target populations, annual objectives, key indicators and achievement graphs, and retain centre-specific action plans, activity reports and updated equipment and consumables management records.[9][22][27]
• Hold coordination and monitoring meetings weekly at health-centre level, monthly at provincial level and quarterly at central level.[9]
• Conduct regular supervision using common checklists that assess infrastructure, privacy, hygiene, equipment, supplies, trained staffing, scheduling, participant information, data management, referral processes and service quality.[9][28][29]
• Track quality and accountability through supervision observations, activity reports, dashboard review, supervisor comments, improvement priorities, and dated and signed supervision records.[22][27][30]
• Require provincial authorities to transmit periodic reports and evaluate implementation; require regional authorities to follow implementation and adapt the programme; and assign national services responsibility for performance oversight, research coordination and national information management.[20][21]
• Assess screening-test performance using sensitivity, specificity, positive predictive value and negative predictive value, and consider interval cancers, reading errors, programme cost, benefits and potential psychological, economic and physical harms.[7][4][31]
• Undertake clinical surveillance after treatment, including breast-cancer follow-up every three months for the first two years, every six months for the following five years and annually thereafter.[32]
• Follow women treated by cervical loop excision with colposcopy at nine months and then annually for five years; return women with consistently normal findings to routine three-year screening.[23]

Costing & Financing

No monetary programme budget, expenditure, unit cost, funding allocation, funding gap or quantified economic assumption is specified in the supplied material.[11][33][13]

• Mobilise human and financial resources nationally, while provincial and regional authorities determine requirements and arrange staff, equipment, supplies, continuing education and communication activities.[33]
• Provide human resources, medical equipment, consumables, information-technology systems, audiovisual materials and diagnostic platforms at health-centre, reference-centre and hospital levels, without associated prices or allocations.[11][16][34][35]
• Recognise that mammography requires human and material resources that may not be consistently available, supporting the use of clinical breast examination as a feasible screening option in resource-constrained settings.[32]
• Use screening tests intended to be inexpensive, reliable, safe and acceptable, while ensuring diagnostic and treatment capacity is available.[7][4]
• Consider that early detection may reduce overall treatment costs by enabling less intensive treatment, whereas false-positive results can create unnecessary and costly investigations and screening intervals should take programme cost into account.[7][4][31]
• Provide screening free of charge at health centres; the supplied material does not identify the financing source supporting this provision.[10]
• Note the broader economic rationale that avoidable deaths from cervical cancer among women with family and work responsibilities represent a significant economic loss when disease is not detected and treated early.[3]
• Record that the World Health Organization financed stages of guide development, the Lalla Salma Association for the Fight Against Cancer provided technical and financial support, and the United Nations Population Fund supported Ministry of Health programme implementation.[36]