Screening and Management of Cervical Cancer at Secondary Level Health Care Facilities

Objectives

Strengthen prevention, screening, diagnosis, treatment and follow-up for cervical precancer and cervical cancer within India’s National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, with emphasis on reducing invasive disease and mortality through early detection and timely treatment.[1][2]The clinical strategy uses the prolonged progression from persistent high-risk human papillomavirus infection to precancer and invasive cancer as an opportunity for secondary prevention.[3][4]

• Detect precancerous lesions among apparently healthy women through cervical screening and treat eligible lesions before progression to invasive cancer.[2][4]
• Provide management algorithms for precancerous and cancerous cervical lesions at secondary-level facilities with colposcopy, biopsy and treatment capacity.[1]
• Use screening methods including Papanicolaou smear cytology, visual inspection with acetic acid, visual inspection with Lugol’s iodine, visual inspection with low-level magnification, and human papillomavirus DNA-based testing.[2][4]
• Prioritise visual inspection with acetic acid for population-based screening, while allowing States with cytology or human papillomavirus testing capacity to select an appropriate test.[5]
• Reduce loss to follow-up and treatment delays through screen-and-treat and see-and-treat models, while balancing higher treatment coverage against the risk of overtreatment.[6]
• Ensure that treatment addresses the entire transformation zone rather than only the visible lesion, using ablative or excisional methods according to lesion characteristics and clinical circumstances.[7][8]
• Preserve fertility where clinically appropriate while achieving high cure rates for high-grade cervical intraepithelial neoplasia and managing invasive cancer according to stage.[9][10]
• Maintain surveillance after treatment, including co-testing at 12 and 24 months where available and long-term routine screening for at least 20 years after negative follow-up tests.[9]
• Develop and refresh training for Accredited Social Health Activists, Multi-Purpose Workers, Auxiliary Nurse Midwives, Medical Officers and specialists involved in non-communicable disease services.[1][11]

Implementation

Deliver services through a tiered clinical model centred on secondary-level facilities, where gynaecologists and Lady Medical Officers assess screen-positive women and provide or arrange diagnostic confirmation and treatment.[1][5]National implementation is supported by the Ministry of Health and Family Welfare Non-Communicable Diseases Technical Advisory Group and a national training team intended to train state-level trainers.[1][12][11]

• Screen women using visual inspection with acetic acid in population-based services, particularly where the cost and infrastructure requirements of cytology and human papillomavirus testing constrain access.[13][5]
• Refer women assessed as true visual-inspection-positive for colposcopy, biopsy and further assessment, including endocervical curettage where an endocervical lesion is suspected but not visible.[14][5]
• Apply screen-and-treat for eligible screen-positive women, using immediate cryotherapy or thermocoagulation where lesions are fully visible on the ectocervix, occupy less than 75% of it, do not extend into the canal or vagina, and are not suspicious for cancer or glandular abnormality.[6][7]
• Use see-and-treat services to combine colposcopic triage, diagnosis and treatment, commonly with loop electrosurgical excision procedure, particularly when fewer visits may prevent non-attendance.[6][15]
• Perform colposcopy using systematic examination with saline, 5% dilute acetic acid and Lugol’s iodine, assess the transformation zone and lesion features, and obtain biopsy from the most suspicious area.[16][17][18]
• Use the Swede score to support management decisions: scores below 5 do not require biopsy, scores of 5 to 7 require biopsy, and scores above 7 indicate a see-and-treat approach.[19]
• Provide ablative treatment through cryotherapy or thermocoagulation, and use excisional treatment such as loop electrosurgical excision procedure or cold-knife conization when lesions extend into the canal, colposcopy is inadequate, findings are discordant, recurrence occurs, or invasion or glandular abnormality is suspected.[20][21][8][22]
• Manage invasive cervical cancer through stage-specific surgery, radiation therapy, chemotherapy or palliative treatment, with concurrent platinum-based chemoradiation for stages IIB, III and IVA and symptom-directed treatment for stage IVB.[23][24]
• Strengthen provider competency through regular assessment of visual inspection with acetic acid providers and competency-based training to improve specificity and reduce overcalling and overtreatment.[13]
• Record colposcopy, biopsy, referral, histopathology and treatment information using standardised forms, including lesion features, Swede score where applicable, pathology findings, signatories and dates.[25][26][12]
• Maintain clinical quality and safety by auditing overtreatment below 10%, keeping haemorrhage after treatment for cervical intraepithelial neoplasia below 5%, and keeping admissions for treatment complications below 2%.[6][15]
• Apply infection-prevention procedures for instruments, gloves, waste and clinic surfaces, including decontamination, cleaning, sterilisation or high-level disinfection according to the item’s risk category.[24][27][25]

The available material identifies national and state training structures, clinical providers, technical experts and participating institutions, but does not specify a comprehensive governance framework, budget, financing mechanism, programme-wide reporting system, surveillance arrangement or accountability structure beyond clinical documentation, training arrangements and specified quality standards.[1][26][12][11]

Monitoring & Evaluation

Monitoring and quality assurance centre on clinical documentation, provider competency, diagnostic classification, treatment safety and follow-up rather than a comprehensive programme-level evaluation system. The document does not specify an overarching monitoring and evaluation framework, routine surveillance system, reporting schedule, population-level targets, evaluation timetable, or formal accountability mechanism.[1][28][4][23]

• Assess cervical screening performance through test sensitivity and specificity, with reported visual inspection with acetic acid sensitivity ranging from 49% to 90%, and pooled visual inspection with Lugol’s iodine sensitivity of 95.1% and specificity of 87.2%.[2][4]
• Strengthen quality assurance for visual inspection with acetic acid through competency-based training and regular assessment of providers, to improve specificity and reduce overcalling and overtreatment.[13]
• Use colposcopy after positive screening to assess suspected precancer or cancer, recognising reported sensitivity of around 85% and specificity of about 70%.[13][14]
• Document colposcopic findings using the 2011 International Federation of Cervical Pathology and Colposcopy nomenclature, including examination adequacy, squamocolumnar junction visibility, transformation-zone type, lesion characteristics and signs of invasion.[17][18]
• Apply the Swede score across acetowhitening, margins and surface, vessels, lesion size and iodine staining; scores below 5 do not require biopsy, scores of 5 to 7 require biopsy, and scores above 7 support a see-and-treat approach.[18][19]
• Classify biopsy findings as cervical intraepithelial neoplasia grades 1, 2 or 3, and report histopathological type and grade when cancer is identified.[14]
• Maintain clinical records through colposcopy, histopathology request and reporting forms that capture patient and facility details, indications, findings, biopsy status, referrals, specimen information, microscopy, diagnosis, signatures and dates.[29][25][26][12]
• Record treatment completion in the individual case record form and provide post-treatment follow-up advice after ablative or excisional treatment.[20][21][8]
• Audit see-and-treat overtreatment periodically and keep the rate below 10%; monitor haemorrhage after treatment for cervical intraepithelial neoplasia below 5% and admissions for treatment complications below 2%.[6][15]
• Monitor loop electrosurgical excision procedure complications, including pain, perioperative bleeding, post-operative bleeding, infection and late cervical stenosis; reported perioperative bleeding is below 2% and late cervical stenosis below 1%.[30]
• Arrange follow-up six months after loop electrosurgical excision procedure and at one year after treatment for cervical precancer, with earlier care-seeking for specified complications.[8][31]
• Perform cytology and high-risk human papillomavirus co-testing at 12 and 24 months after treatment for cervical intraepithelial neoplasia, repeat testing after three years when both tests are negative, and continue routine screening for at least 20 years after negative follow-up tests.[9]
• Use annual visual inspection with acetic acid where cytology and human papillomavirus testing are unavailable, referring positive results for colposcopy.[9]
• Maintain infection-prevention quality standards through instrument processing, environmental decontamination, personal protective equipment and appropriate storage of processed instruments.[27][25]

Costing & Financing

No costed implementation plan, budget allocation, financing mechanism, funding source, resource-mobilisation strategy, quantified funding gap or economic assumption is specified. Resource considerations nevertheless favour lower-cost screening and treatment approaches where infrastructure and specialist capacity are limited.[1][8][9][12][11]

• Recognise high cytology costs, shortages of trained cytopathologists, infrastructure constraints and quality-assurance limitations as barriers to widespread screening.[2]
• Prioritise visual inspection methods in resource-constrained settings because they are low cost, can be delivered by trained health workers and provide immediate results.[4][13]
• Adopt visual inspection with acetic acid for population-based screening where establishing cytology and human papillomavirus testing facilities would require costly infrastructure.[5][6]
• Recognise that available human papillomavirus detection tests have high current costs, limiting widespread use in resource-poor settings despite high sensitivity and negative predictive value.[13]
• Recognise that liquid-based cytology is less feasible in low-resource settings because equipment and consumables are prohibitively costly.[4]
• Use cryotherapy as an inexpensive ablative treatment option while ensuring access to compressed refrigerant resupply; it can be performed by non-physicians and does not require electricity or anaesthesia.[21]
• Plan for the equipment, consumables, laboratory services and infection-prevention supplies required for colposcopy, biopsy processing, ablative treatment and loop electrosurgical excision procedure, although the source provides no prices or budget lines for these requirements.[16][20][22]
• Recognise thermocoagulation equipment as expensive, without a stated purchase cost or financing arrangement.[8]