National Guideline for Cervical Cancer Control and Management

Objectives

Reduce cervical cancer incidence, mortality and socio-economic harm through an integrated continuum of primary prevention, screening, diagnosis, treatment, survivorship support and palliative care, implemented alongside the National Cervix Cancer Control and Prevention Policy.[1][2]The programme seeks to reduce oncogenic human papillomavirus infections, detect and treat cervical pre-cancer promptly, and ensure timely treatment and palliation for invasive disease.[1]

• Prevent human papillomavirus infection through vaccination of pre-pubertal girls, particularly those aged 9 to 12 years, before likely exposure to high-risk viral types.[2]
• Reduce oncogenic human papillomavirus infection between 2017 and 2022 from 25% to 20% among women living without HIV and from 60% to 55% among women living with HIV.[2]
• Reduce invasive cervical cancer incidence from 31.7 per 100,000 women in 2017 to 20 per 100,000 by 2022 through vaccination and effective screening.[2]
• Reduce the age-standardised mortality rate from 18 to 15 per 100,000 women by 2022 and improve quality of life for women with terminal cancer through palliative care.[2]
• Provide free cervical cancer screening to eligible women through the public healthcare system and progressively transition provinces towards human papillomavirus molecular testing as the preferred screening approach.[3][4]
• Prioritise lifelong screening, follow-up and treatment for women living with HIV and other high-risk groups, while offering low-risk women screening from age 30 to 50 at defined intervals.[4][5]
• Ensure all women diagnosed with high-grade squamous intraepithelial lesions or cervical intraepithelial neoplasia grades 2 or 3 receive clinically appropriate ablative or excisional pre-cancer treatment.[6]
• Require histological staging before treatment for cervical cancer and provide evidence-based, stage-appropriate care that considers comorbidities, patient preferences and service availability.[7][8]
• Provide patient-centred palliative care from diagnosis to death, addressing physical, psychosocial and spiritual suffering while maintaining dignity and supporting families.[9][10]
• Integrate nurse and patient navigation into cervical cancer care to overcome informational, psychological, socio-economic and health-system barriers, promote adherence and improve outcomes.[11]

Implementation

Deliver care through an integrated, tiered service model linking prevention, primary care, district and regional referral services, specialised oncology centres, community services and palliative care.[12][13][10]The approach combines clinically guided screening and treatment pathways with coordinated referral, multidisciplinary care, quality assurance, patient navigation and collaboration among government, providers, civil society, communities, patients and families.[12][13][9][14]

• Deliver two human papillomavirus vaccine doses to eligible Grade 4 girls aged 9 years or older through public schools, including special schools, with the second dose administered six months after the first and informed consent procedures provided for parents, guardians and eligible learners.[15]
• Integrate screening within primary care, wellness, sexual and reproductive health services, using conventional cytology, liquid-based cytology, human papillomavirus testing or visual inspection with acetic acid according to available laboratory, specialist and health-system capacity.[12][3][4]
• Use self-collected high-vaginal specimens for human papillomavirus testing where appropriate, reducing dependence on speculum examinations and constrained human resources.[16][3]
• Examine symptomatic women immediately with a vaginal speculum and screening test, and urgently refer suspected growths, ulcers, fungating masses or invasive carcinoma for biopsy and specialist assessment.[5][17][16]
• Manage pre-cancer through cryotherapy, large loop excision of the transformation zone and cold knife cone treatment according to lesion characteristics and clinical indications; permit treatment without prior colposcopy where limited capacity and high disease prevalence require this.[18][19]
• Organise referral through District Colposcopy/Cervix Units, Regional Colposcopy/Cervix Units and Specialised Cervix Units in a hub-and-spoke model, with direct linkages intended to prevent delays and fragmented care.[13][20]
• Equip District Colposcopy/Cervix Units to provide counselling, navigation, biopsy and large loop excision of the transformation zone; enable Regional Colposcopy/Cervix Units to provide specialist gynaecological, radiological and anaesthetic services; and maintain multidisciplinary oncology, radiotherapy planning and complex surgical capacity in Specialised Cervix Units.[21]
• Meet service timeliness standards by communicating screening results to providers within two weeks, completing biopsy or excision histology within four weeks, limiting colposcopy referral waits to eight weeks, and referring new cancer cases to cancer centres within two weeks of results.[13]
• Use staging, risk categorisation, clinical algorithms, standardised laboratory templates, facility databases and electronic reporting platforms to guide diagnosis, follow-up, referral and service oversight.[12][13][22][23]
• Provide multidisciplinary palliative care through tertiary specialist teams, district teams, clinics, community health workers, home-based care, non-governmental organisations and hospices, with flexible referral between hospital, clinic and home settings.[10][24]
• Maintain access to morphine and essential palliative medicines across service levels, and use functional assessment, including Eastern Cooperative Oncology Group Performance Status, to tailor packages of care and visit frequency.[10][24]
• Deploy trained nurse and patient navigators to educate patients, track results and missed appointments, coordinate referrals, transport and allied health support, provide psychosocial assistance, and track interventions and outcomes.[11]
• Assess navigation pilots for effectiveness and feasibility before national rollout, and use findings on defaulting, missed investigations and missed treatment appointments to improve delivery.[11]

Monitoring & Evaluation

Monitoring is primarily embedded in clinical algorithms, outcome targets, laboratory reporting, referral time standards, quality assurance and patient follow-up. A consolidated monitoring and evaluation framework, routine reporting schedule, surveillance architecture and named accountability body are not specified.[12][2][13]

• Monitor oncogenic human papillomavirus infection among women living without HIV and women living with HIV, targeting reductions by 2022 from 25% to 20% and from 60% to 55%, respectively.[2]
• Monitor invasive cervical cancer incidence, with a target reduction from 31.7 per 100,000 women in 2017 to 20 per 100,000 by 2022, and monitor age-standardised mortality, with a target reduction from 18 to 15 per 100,000 women.[2]
• Use screening-result categorisation, diagnostic algorithms, staging, risk classification and defined repeat-screening intervals to guide clinical follow-up.[12][5][6]
• Repeat screening for women living with HIV every three years following a negative result and annually following a positive result until normalisation; continue lifelong screening for this group.[5][17]
• Refer high-grade, carcinoma and specified glandular cytology findings to a Cervical Evaluation Centre, and urgently refer suspected invasive carcinoma for specialist colposcopic biopsy.[16][5][6]
• Communicate screening results and recommendations to healthcare providers within two weeks, complete biopsy or large loop excision of the transformation zone histology within four weeks, and refer new cancer cases to a cancer centre within two weeks after results are available.[13]
• Enable patients to receive laboratory results within six weeks of a smear and treatment within six to eight weeks after diagnosis.[20]
• Use facility databases, electronic reporting platforms, gynaecologist outreach and quality control to support service oversight.[13][21]
• Maintain training and quality assurance for visual inspection with acetic acid providers, as provider experience supports identification of a normal cervix and inconsistent supervision may contribute to overtreatment.[25]
• Record patient, specimen, test, diagnosis, recommendation, laboratory and authorisation details through standardised cytology and histology templates.[22][23]
• Assess palliative-care needs repeatedly from cancer diagnosis and at clinically indicated intervals, using an appropriate screening tool and functional assessment, including Eastern Cooperative Oncology Group Performance Status where applicable.[26][10][27]
• Monitor patient navigation through post-pilot impact assessment, periodic review against anticipated outcomes, and tracking of missed appointments, incomplete staging or treatment, defaults and loss to follow-up.[11]

Costing & Financing

Financial provisions are largely unquantified. Cervical screening is to be offered free of charge to eligible women through the public healthcare system, while most excerpts identify resource needs, access barriers or comparative cost considerations without budgets, allocations, financing sources, funding-gap estimates or resource-mobilisation targets.[3][13]

• Provide free cervical cancer screening to all eligible women through the public healthcare system.[3]
• Phase in liquid-based cytology according to resource availability and progressively transition to human papillomavirus molecular testing because of its stated accuracy and cost-effectiveness.[3][4]
• Recognise that human papillomavirus molecular testing has a high unit cost and requires complex laboratory capacity, specimen transport and reagent storage; combining it with a Pap smear increases sensitivity but also increases cost.[4]
• Recognise that conventional cytology may be strengthened through modest investment in existing programmes, whereas liquid-based cytology requires more expensive supplies and laboratory facilities.[4]
• Consider that liquid-based cytology may reduce repeat smears and associated costs, while visual inspection with acetic acid is described as probably poorly cost-effective when treatment is unavailable on-site and referral is required.[28][25]
• Address patient and family costs, transport and accommodation barriers, shortages of specialised and support staff, and inadequate equipment and infrastructure that can delay treatment.[13]
• Resource District, Regional and Specialised Cervix Units with essential equipment, medicines and personnel, including diagnostic, treatment, oncology, radiotherapy and surgical capacity appropriate to their service level.[1][21][7]
• Resource palliative care with multidisciplinary staffing, training, morphine and other essential medicines across service levels, although no associated financial values are provided.[10][24]
• Use the nurse and patient navigator pilot to inform programme scope, cost and strategy before potential national roll-out; no budget or financing mechanism is specified.[11]