Guía de tamizaje de cáncer de cuello uterino y mama

Objectives

The guideline establishes a national framework for reducing morbidity and mortality from cervical and breast cancer in Bolivia through equitable, quality-assured early detection, timely referral, treatment and follow-up. It is situated within the Family, Community and Intercultural Health model, which pursues universal access, social participation, intersectoral action, interculturality and comprehensive health promotion.[1]

• Increase coverage of women screened for precancerous cervical lesions and establish coverage for early breast-cancer detection.[1]
• Offer visual inspection with acetic acid as an alternative cervical-screening method alongside cytology, particularly where laboratory capacity or quality assurance for cytology is limited.[1][2]
• Improve early diagnosis, timely treatment and appropriate follow-up for cervical intraepithelial lesions and early breast lesions.[1]
• Ensure care respects women’s privacy, dignity, informed consent and sociocultural context.[1][3]
• Promote breast health through information, counselling, breast self-examination, annual clinical breast examination and mammography according to age and risk. Annual clinical examination is indicated for women over 30, while mammography is indicated annually for women over 35 with risk factors and for women from age 40.[4]
• Prioritise active detection among women over 30 through combined cervical screening and clinical breast examination, while targeting breast screening to all women over 40 and younger women with risk factors.[5]

The strategic rationale is the substantial national burden of cervical cancer, historically the most frequently reported cancer site, alongside the increasing importance of breast cancer. Cytology coverage had not exceeded approximately 15 to 16% in the periods reviewed, indicating limited reach of the existing screening approach.[6][7]The guideline therefore presents screening as a route to identify apparently healthy women with possible disease, while recognising that screening tests require diagnostic confirmation.[8]

• Strengthen cervical screening through visual inspection with acetic acid, Papanicolaou cytology and, where feasible, human papillomavirus DNA testing.[9]
• Use human papillomavirus testing as a complementary or alternative method within organised screening, including for triage, post-treatment follow-up and possible primary screening with cytology triage.[10]
• Support breast screening through self-examination, trained clinical examination, mammography, complementary ultrasound and biopsy where indicated.[11]
• Improve programme quality across the pathway from identifying the target population to follow-up and treatment of women with abnormal results, with the intended outcome of lower morbidity and mortality.[12]

Implementation

Implementation applies the guideline throughout Bolivia’s Unified Health System as part of national standards for cervical-cancer detection and control and breast-cancer prevention, control and follow-up.[8]It combines community-oriented health promotion, active case-finding, screening in routine contacts with health services, referral and counter-referral, information systems, supervision and continuing education.[1][13]

• Deliver promotion, prevention, counselling and screening through first-level facilities, mobile teams and community-oriented family-health services, rather than relying only on self-presentation for specialised examinations.[5][13]
• Perform visual inspection with acetic acid through trained general practitioners or other trained personnel, using a speculum examination, adequate illumination and 3% to 5% acetic acid, with immediate interpretation of acetowhite changes.[14][15]
• Maintain cervical cytology through a pathway linking sample collection, laboratory assessment, result delivery, infrastructure, personnel and continuous quality control.[16]
• Refer positive or suspicious cervical screening findings for colposcopy and possible biopsy, and breast abnormalities for higher-level assessment, imaging, aspiration or biopsy as appropriate.[8][11]
• Provide clear results, written return dates and accessible explanations without presenting suspected disease as a confirmed diagnosis before assessment.[17][18]
• Keep the interval between screening detection and treatment initiation within 30 calendar days, and return assessed users to the referring facility within 30 days with findings and follow-up instructions.[13]

Responsibilities are distributed across national, departmental, network and facility levels. The Ministry of Health and Sports leads administrative, technical and normative management of the National Programme in coordination with departmental health services, municipalities and civil-society organisations.[19]Departmental Sexual and Reproductive Health or non-communicable disease officials verify implementation, while network coordinators, municipal health directorates, social-security providers, non-governmental and faith-based organisations, armed forces, police and private facilities participate in delivery.[8][13]

• Organise referral networks so first-level facilities send suspected cases to hospitals with colposcopy, gynaecology and obstetrics expertise, mammography and ultrasound capacity where relevant.[13]
• Schedule referred users at least one fixed day weekly and within 15 days, follow up non-attendance through home visits where necessary, and report referral activity monthly.[13]
• Use a single-visit see-and-treat approach with cryotherapy for eligible acetowhite lesions where approved by the Ministry and departmental health service.[13]
• Provide practical, supervised training and continuing education, using virtual refresher courses and online examinations where possible.[12]

Quality assurance relies on routine registration, supervision, peer review, user feedback and coordinated analysis of National Cancer Registry and National Health Information System data.[20]Facilities record daily screening activity, promotion and prevention work, referrals and counter-referrals, while monthly reporting uses form SNIS 301.[13]

• Monitor cervical indicators including service availability, Pap or visual-inspection coverage, positive-result confirmation by histology, biopsy, treatment, follow-up, incidence and mortality. Targets include 80% screening coverage, 100% biopsy after positive visual inspection, 100% treatment for eligible confirmed high-grade lesions and a 50% reduction in cervical-cancer incidence over 10 years.[12]
• Monitor breast indicators including clinical-examination and mammography coverage, histopathological investigation, treatment, positive-test rates, early-stage disease and incidence. Targets include 80% clinical-examination coverage, 30% mammography coverage, 100% treatment after positive histopathology, 0.9% positive tests and 50% early-stage disease among detected cases.[12]
• Undertake supervision through facility visits, remote methods where access is difficult, equipment and supply checks, record review, provider self-assessment, community participation and satisfaction feedback.[20]

No programme budget, financing allocation, quantified funding gap or costed implementation plan is specified.[12]

Monitoring & Evaluation

The guideline establishes a monitoring and quality-assurance framework for cervical and breast cancer screening, combining service records, National Cancer Registry data, the National Health Information System, supervision, provider self-assessment and user feedback. It aims to track screening coverage, diagnosis, treatment, follow-up, incidence and mortality, while improving service quality across the full pathway from identifying the target population to managing abnormal results.[12][20]

• Monitor cervical screening through indicators covering facilities providing visual inspection with acetic acid, Pap test or visual-inspection coverage, first-time screening, screening outside the target population, concordance between positive visual inspection and histology, biopsy completion, treatment, post-treatment follow-up, incidence and mortality.[12]
• Apply cervical-screening targets of 80% coverage, biopsy for 100% of positive visual-inspection findings, treatment for 100% of women with a positive visual-inspection result and a high-grade lesion confirmed by biopsy, and a 50% reduction in cervical-cancer incidence over 10 years.[12]
• Monitor breast screening through indicators on facilities reporting clinical breast examinations, coverage with clinical examination and mammography, first-time detection, histopathological investigation after a positive result, treatment, post-treatment control, positive-test rates, early-stage disease and incidence.[12]
• Apply breast-screening targets of 80% clinical breast-examination coverage, 30% mammography coverage, treatment for 100% of women with a positive histopathological diagnosis, 0.9% positive tests among screened women, and 50% early-stage disease among detected cases.[12]
• Review breast-cancer incidence as new cases per 100,000 women every five years, with a stated 10-year impact objective of reducing incidence.[20]
• Use data from the latest census, health-establishment records, Form SNIS 301 of the National Health Information System, and coordinated National Cancer Registry and health-information-system data.[12][20]
• Report indicators at frequencies ranging from monthly and quarterly to six-monthly, annually, every three years and every five years, according to the indicator.[12]

Routine information management is integrated into delivery. Facilities are to maintain daily screening registers and promotion and prevention activity registers, submit monthly Form SNIS 301 reports, and record referrals and counter-referrals. First-level facilities report referrals monthly, while network coordinators verify hospital attendance and report referred patients monthly to the departmental cancer-detection programme.[13]Operational annexes include clinical-record, patient, referral and counter-referral forms, daily screening records, promotion registers and a supportive-supervision form.[21]

• Track the proportion of examined women with positive visual inspection with acetic acid, clinical breast examination or cervical cytology results, and the proportion subsequently diagnosed with neoplasia.[13]
• Document visual-inspection findings, referrals and written return dates, and arrange follow-up or colposcopic assessment for suspicious or unclear findings.[17]
• Ensure referred women receive hospital appointments within 15 days, return assessment information to the referring facility within 30 days, and seek to initiate treatment within 30 calendar days of screening detection.[13]
• Maintain continuous quality control throughout the cytology pathway, including sample collection, laboratory assessment and result delivery.[16]

Supervision is intended to be continuous, supportive and multi-level. National authorities supervise registry and health-information data, allocate supervision resources, define information requirements, form a national supervision team and coordinate feedback and training. Departmental teams plan external supervision, review facility information, adapt indicators to local conditions and identify training needs. Local teams review facility data, monitor screening quality, control supplies, request service-strengthening support and enable community participation in facility evaluation.[20]

• Review registration, counselling, screening, treatment, infection-prevention documentation, patient records, equipment functionality, supplies, recruitment of eligible women, coverage, abnormal-result rates and treatment rates during supervision.[20]
• Use facility visits, peer review, provider self-assessment, interviews, suggestion boxes, waiting-room note books, home visits and remote supervision through internet, mobile phones, digital cameras or videoconferencing where access is difficult.[20]
• Provide practical training and refresher support, including virtual courses and online examinations, while considering provider competence, experience, workload, lighting, materials and patient characteristics that affect screening performance.[12]

Evidence in the guideline highlights major performance gaps and the rationale for strengthened monitoring. Earlier cervical screening coverage did not exceed 16%, and programme results had not controlled cervical-cancer incidence or mortality.[7]A preceding 2006–2010 sectoral period lacked an organised monitoring and evaluation process and an overall assessment of programme and project progress.[1]The guideline also records the importance of surveillance data: cervical cancer was the most frequent cancer site in Bolivia in the comparisons cited, while breast cancer rose in ranking over time.[22]

Before the consolidated framework, several sections specify only local clinical documentation, referral verification or quality controls rather than programme-level accountability arrangements. Departmental Sexual and Reproductive Health or non-communicable disease officials are assigned to verify implementation, and implementing organisations are responsible for assessing service quality.[8][19]The source does not define audit sanctions or a single named body responsible for enforcing all targets.[13]

Costing & Financing

The guideline identifies resource requirements for screening, supervision, training, information systems, supplies and referral capacity, but does not provide a programme budget, costed implementation plan, quantified funding gap, financing allocation or economic assumptions.[13][12]

• Programme resources for supervision are required, alongside functioning screening equipment and reliable supplies, although no expenditure amount or funding source is specified.[20]
• Coordinate procurement, transport and storage of 5% acetic acid through departmental Sexual and Reproductive Health leads, and coordinate supply acquisition through network coordinators and departmental programme leads.[16]
• Provide visual inspection with acetic acid using general consultation infrastructure and acetic acid as the principal additional input; the method is characterised as affordable or low cost, without quantified unit costs.[14][2]
• Cover the Ayre spatula and endocervical brush through public insurance, although the source gives no price, reimbursement level or period of coverage.[18]
• Recognise that higher cost limited HPV DNA testing in Bolivia to pilot activities rather than mass implementation; no cost estimate, budget or financing mechanism is provided.[23]

International cooperation supported equipment provision, human-resources training and related cervical-screening development, while the Pan American Health Organization and World Health Organization provided technical assistance for the publication. No monetary value is reported for this support.[7][24]