Cervical Cancer Prevention and Control Policy

Objectives

The policy establishes a comprehensive, rights-based cervical cancer prevention and control programme in South Africa, aiming to reduce morbidity, mortality and the wider socio-economic impact of cervical cancer through an integrated continuum of prevention, screening, diagnosis, treatment, follow-up and palliative care.[1][2][3]It aligns with universal health coverage, equity, quality, safety, efficiency, sustainability and accountability, and with national sexual and reproductive health, HIV, non-communicable disease, school health and National Health Insurance priorities.[4][2][3]

• Reduce oncogenic human papillomavirus infection by scaling up vaccination, particularly for pre-pubertal girls aged nine to 12 years before likely exposure to the virus.[5][3][6]
• Reduce invasive cervical cancer incidence from 31.7 per 100,000 women in 2017 to 20 per 100,000 by 2022 through adolescent vaccination and effective screening.[5]
• Reduce the age-standardised cervical cancer mortality rate from 18 to 15 per 100,000 women by 2022 through early detection and treatment of high-grade squamous intraepithelial lesions and overt cancer.[5][3]
• Provide structured secondary prevention for women not protected by vaccination, including free public-sector screening for eligible women and prompt treatment of high-risk pre-cancerous lesions.[7][8]
• Offer low-risk asymptomatic women screening three times in their lifetime, at ages 30, 40 and 50 where no abnormalities are detected, while applying more frequent lifelong screening to women living with HIV and other high-risk groups.[8][9]
• Address unequal access and higher burden among women living with HIV, women with immunosuppressive conditions, sex workers, adolescents, migrants, rural women and economically disadvantaged populations.[4][10][11]
• Improve quality of life for women with invasive or terminal cervical cancer through timely curative treatment, symptom management, palliative care and support for families and communities.[2][5]
• Strengthen workforce, laboratory, facility, supply, referral, communication and information-system capacities as strategic enablers of prevention and treatment.[3][12]

Implementation

Implementation uses a primary healthcare-led, tiered service model spanning communities, primary healthcare facilities, district, regional, tertiary and quaternary hospitals, with private institutions contributing within minimum service packages.[4][5][3]Delivery integrates cervical cancer interventions with immunisation, sexual and reproductive health, HIV, tuberculosis, maternal and women’s health, school health, youth health and palliative care programmes.[2][5]

• Deliver bivalent human papillomavirus vaccination through the Integrated School Health Programme, jointly involving the Departments of Health, Basic Education and Social Development, with two doses administered six months apart primarily to girls in Grades four to seven.[13][6]
• Use organised rather than opportunistic screening, supported by population targeting, high coverage, reliable laboratory services, treatment of abnormal results, follow-up, referral, communication and quality control.[14]
• Progressively transition from conventional cytology towards liquid-based cytology and human papillomavirus DNA testing, while using visual inspection with acetic acid in resource-constrained areas without laboratory capacity.[7][8]
• Increase public-sector use of liquid-based cytology to 50% and human papillomavirus-based tests to 20% of screening tests by 2020, then to 30% and 60% respectively by 2030.[7]
• Provide visual inspection with acetic acid through trained non-physician health workers at primary healthcare level, enabling immediate results and, where appropriate, same-day test-and-treat services.[15][16]
• Strengthen colposcopy, biopsy and histopathology services, use screen-and-treat approaches where appropriate, and provide cryotherapy or Large-Loop Excision of the Transformation Zone for eligible pre-cancerous lesions.[17][18][19]
• Refer women with histologically confirmed invasive cervical cancer for staging and treatment within six weeks of biopsy, using surgery for early-stage disease and chemotherapy or radiotherapy according to clinical stage and guidelines.[20][21]
• Provide follow-up for at least three to five years after invasive cancer treatment, and integrate palliative radiotherapy, home-based care, analgesia, incontinence care, hospices and family support where needed.[2][21]
• Engage civil society organisations, community health workers, community leaders, academic institutions and research bodies to raise awareness, recruit clients, support informed demand, reduce duplication and advance cost-effective technologies.[22][23][12]
• Coordinate monitoring through collaboration between the national Department of Health, provinces and districts, aligned with the national Health Information System Strategy and supported by the National Cancer Registry, District Health Information System, surveys, facility mapping and registers.[24][21][22][23]
• Monitor vaccination coverage, oncogenic human papillomavirus infection, screening access and coverage, treatment of high-grade lesions, cervical cancer incidence, five-year survival, palliative-care access, referral, follow-up and quality assurance.[14][22][23]

Monitoring & Evaluation

The policy establishes monitoring and evaluation as a strategic enabler for cervical cancer prevention and control, linking implementation tracking to health-system information, quality assurance, service follow-up and population outcomes.[3][21][22]It identifies the National Cancer Registry, District Health Information System, laboratory data, facility registers, surveys and facility mapping as relevant evidence sources.[24][5][22][23]

• Monitor progress towards reducing oncogenic human papillomavirus infection, invasive cervical cancer incidence, age-standardised mortality and terminal-care quality of life targets.[5][3][22][23]
• Track human papillomavirus vaccination coverage among Grade 4 girls and access to, availability of and coverage of screening among eligible women.[14][22]
• Monitor treatment of high-grade squamous intraepithelial lesions or cervical intraepithelial neoplasia grades 2–3, five-year survival after cervical cancer diagnosis, and hospice or palliative-care receipt among women with terminal cancer.[22][23]
• Measure screening programme performance through population targeting and coverage, Pap smear adequacy, laboratory reliability, treatment of abnormal findings, referral completion, follow-up, communication and quality control.[14][8]
• Apply quality assurance to liquid-based cytology, visual inspection with acetic acid, human papillomavirus testing and self-sampling, recognising that visual inspection performance depends on reader training and supervision.[15][16]
• Maintain follow-up after treatment for cervical lesions and invasive cancer, including re-screening schedules based on risk status and at least three to five years of follow-up after invasive cancer treatment.[2][9][17][19]
• Develop a detailed monitoring framework jointly involving the national Department of Health, provinces and districts, covering inputs, activities, outputs and input, process and output indicators.[21]
• Align monitoring and evaluation with the national Health Information System Strategy and strengthen personnel, resources, technology and information management.[21][22]
• Require facilities treating cervical cancer to monitor and report improvements against indicators defined in the policy’s monitoring chapter.[21]

Available baseline evidence shows persistent disease burden and inequity: the National Cancer Registry recorded 4,907 cervical cancer cases in 2011, including 4,056 among black women and 437 among white women.[10]Screening coverage among women aged 30 years and over increased from 54.5% in 2014/15 to 57.4% in the second quarter of 2015/16.[10]Registry data are recognised as important for decision-making but have gaps in representativeness and timeliness.[24]

The extracts do not specify a complete national reporting timetable, evaluation methodology, surveillance protocol, indicator definitions, review cycle or named accountability body.[2][3][8][21][22][23]Accountability is nevertheless a guiding principle, and all care providers are expected to uphold quality, dignity and patient rights.[2][3]

Costing & Financing

The policy identifies substantial resource needs across prevention, screening, diagnosis, treatment, referral, transport, palliative care, workforce development, laboratories, equipment and information systems, but the supplied extracts provide no monetary budget, expenditure estimate, financing allocation, funding source, funding gap or resource-mobilisation target.[25][2][5][3][12]

• Provide free cervical cancer screening to eligible women through the public healthcare system as a national priority.[6][7]
• Recognise that cytology-based screening requires complex and sustained human, financial and physical infrastructure, with costs rising as the screened age range, number of examinations and frequency of screening increase.[14]
• Use visual inspection with acetic acid as a lower-cost, low-commodity option in resource-constrained settings, potentially delivered by trained non-physician health workers with same-visit treatment.[15]
• Consider liquid-based cytology because it may reduce repeat Pap smears and related costs, and human papillomavirus DNA testing because it may be cost-effective and less dependent on human resources.[7][8]
• Address cost, logistics and technology barriers associated with commercially available human papillomavirus testing; adapting existing GeneXpert machines may limit initial capital expenditure.[15]
• Prioritise human papillomavirus vaccination, described as the most cost-effective strategy for preventing cervical cancer.[3]
• Recognise the high cost and morbidity of cold knife excision and conisation, which require general anaesthesia, while expanding outpatient cryotherapy or Large-Loop Excision of the Transformation Zone services to improve access.[19]
• Plan for resource-intensive tertiary and quaternary services, including surgery, radiation, chemoradiation and patient transport, alongside integrated palliative care, pain control, care facilities and home-care support.[2][5]

Pre-invasive lesion detection, treatment and follow-up place substantial pressure on primary and district facilities, while radiation and other treatment are characterised as expensive and concentrated mainly in tertiary and quaternary hospitals.[24]Patients may also face out-of-pocket travel, accommodation and living costs during treatment and follow-up, alongside wider household and economic consequences of illness and caregiving.[24]

Cost-effectiveness considerations support differentiated screening: general-population screening below age 30 may lead to overtreatment and is not considered cost-effective, whereas earlier routine screening is recommended for sexually active women living with HIV because of their elevated risk.[17]Research is proposed into cost-effective technologies for maintaining the National Cancer Registry, but no financial value is given.[23]