Guide Technique de Prévention du Cancer du Col par la Méthode IVA-Cryothérapie

Objectives

Madagascar’s cervical-cancer guidance forms part of a wider women’s-health and cancer-control agenda, seeking to reduce cervical-cancer morbidity and mortality through prevention, early detection and treatment of precancerous disease.[1]It also identifies cervical and breast cancers as major gynaecological public-health concerns and promotes accessible prevention, screening, early diagnosis and curative care.[2]

• Prevent human papillomavirus infection and persistence through sexual-health education, prevention and treatment of sexually transmitted infections, condom use, family planning, smoking reduction and consideration of human papillomavirus vaccination.[3][4]
• Detect precancerous cervical lesions early through visual inspection with acetic acid and Lugol’s iodine, with screening principally directed towards women aged 25 to 50 years, particularly those with risk factors.[5][6]
• Treat eligible precancerous lesions with cryotherapy and refer women with extensive lesions, suspected cancer or lesions unsuitable for cryotherapy for further assessment and treatment.[7][6]
• Promote breast examination and palpation as part of routine services to support earlier detection of breast cancer.[2][5]
• Extend screening access through mass-screening activities, including in hard-to-reach areas, while linking community services to primary, secondary and tertiary care pathways.[6]

The strategy is founded on the long natural history of cervical cancer: persistent human papillomavirus infection is the principal precursor of precancerous lesions, and progression to invasive cancer generally takes more than 10 to 20 years.[5][4]This interval is presented as an opportunity to prevent cancer through screening and treatment, as many precursor lesions may be reversible or curable.[3][4]Visual inspection is prioritised as an accessible alternative to conventional cytology, which is difficult to scale because of cost, whereas visual inspection is described as non-invasive, relatively inexpensive and feasible across health-system levels using readily available materials.[2][5]

The guidance also seeks to equip health workers with practical knowledge of cervical carcinogenesis, counselling, screening, diagnostic orientation, cryotherapy, infection management and referral.[1][7]Its principal operational focus is cervical cancer, although the guide includes breast examination and situates cervical and breast cancers within the broader burden of gynaecological malignancies.[2][8]

Implementation

The delivery model combines community sensitisation, informed counselling, routine clinical assessment, visual cervical screening, same-visit treatment where appropriate, structured follow-up and referral for specialised diagnosis or cancer care.[4][6]It is intended primarily for doctors, midwives and other health-facility personnel who provide services to women at risk.[1][5]

• Engage communities through health education and sensitisation delivered with local authorities, opinion leaders, husbands and men generally.[4]
• Provide clear counselling to women and partners on cervical cancer, risk factors, prevention, screening procedures, possible results, treatment options, adverse effects and participation requirements.[9]
• Obtain informed consent before visual inspection or cryotherapy, respect the right to refuse without coercion, record consent or refusal, and maintain confidentiality of participant information and results.[9][10]
• Conduct clinical history-taking and examination, including breast, abdominal, external genital, speculum and vaginal assessment, before or alongside cervical visual inspection.[11][8][12]
• Perform visual inspection by viewing the cervix under good light, applying 3–5% acetic acid, waiting about one minute and recording the findings; Lugol’s iodine may also be used to support assessment.[13][14][15]
• Record cervical appearance, transformation-zone visibility, lesions, acetic-acid reaction, iodine staining and suspicious vascular patterns on an observation form, then discuss results and management with the client.[13][16][17]

Visual inspection produces an immediate result, enabling providers to make a treatment decision during the visit or arrange referral.[5]Women with normal findings may be advised to repeat screening after five years, while selected findings require repeat visual inspection after six months or one year.[6][12][15]The guidance also provides a one-year follow-up examination after cryotherapy and instructs women to return earlier for symptoms such as persistent fever, severe lower-abdominal pain, heavy bleeding or purulent discharge.[11][15]

Cryotherapy is offered to consenting women with positive visual inspection findings only when lesions are fully visible, non-suspicious for cancer, sufficiently limited in size and location, and otherwise eligible for treatment.[18]Pregnancy, the early postpartum period, suspected cancer, previous treatment of precancerous lesions and pelvic inflammatory disease are among the stated exclusions.[18]Providers are instructed to use carbon dioxide or nitrous oxide equipment, apply a three-minute freeze, five-minute thaw and second three-minute freeze cycle, verify ice-ball formation and check for bleeding before ending the procedure.[19]Post-treatment counselling covers expected discharge or cramps, temporary abstinence or condom use, avoidance of vaginal tampons and adherence to follow-up.[11][9]

Women with suspected cancer, extensive lesions or lesions ineligible for cryotherapy are referred for further examination, biopsy or specialised treatment.[6][12]The guide identifies colposcopy, cervical cytology, human papillomavirus DNA testing and biopsy as additional diagnostic approaches; biopsy is identified as the method that confirms a cancer diagnosis.[20][21]Referral resources include oncology, surgical, anatomical pathology and designated cryotherapy services, while cytology capacity is identified in six provincial capitals as well as Antsirabe and Moramanga.[22]

Implementation requires basic examination supplies, appropriate lighting, specula, acetic acid, Lugol’s solution, gloves, saline and recording forms, as well as cryotherapy equipment and gas where treatment is provided.[13][18][8]Reusable equipment is processed through cleaning and disinfection or sterilisation procedures, including boiling, steam sterilisation or chlorine disinfection as specified.[17][23]The Ministry of Health and Family Planning, health-facility staff and the World Health Organization are identified as participating or supporting institutions, although detailed governance roles are not specified.[1]

The guidance supports accountability mainly through clinical documentation, client records, consent forms and scheduled follow-up.[22][12][10]It does not specify a comprehensive programme-level monitoring framework, performance indicators, reporting schedule, surveillance dataset or evaluation design.[6][22][10]

Monitoring & Evaluation

Monitoring and follow-up are primarily embedded in clinical screening, treatment, referral and record-keeping processes rather than in a documented programme-wide performance framework. Visual inspection with acetic acid and Lugol’s iodine, assessment of suspected cancer, cryotherapy, cytology, human papillomavirus DNA testing, colposcopy and biopsy are described as screening, diagnostic or case-management procedures.[7][20][21]No consolidated indicator set, targets, reporting schedule, surveillance database, evaluation design or formal accountability structure is specified in the supplied extracts.[1][2][3][11][17][24][12]

• Record clinical observations and visual screening findings, including cervical appearance, discharge, transformation-zone visibility, lesion features, acetic-acid reactions, Lugol staining, punctation, mosaic patterns and vascular abnormalities.[13][16]Complete the observation form after examination, communicate results to the client, and prescribe appropriate follow-up or management.[17]
• Document screening date, case and centre identification numbers, facility and administrative affiliations, demographic information, sexual, social, gynaecological and obstetric histories, findings, conclusion, examination location, and examiner name and signature.[22][12][14]Use a personal record booklet to document health events and support continuity at subsequent examinations.[15]
• Use visual-inspection results, lesion characteristics, pregnancy and infection status, and eligibility for cryotherapy to determine treatment, postponement, surveillance or referral.[6]Visual inspection is reported to have an average sensitivity of 75% in settings where it has been applied.[5]
• Provide immediate screening results to enable a same-visit treatment decision or referral for further care.[5]Refer women with extensive lesions, lesions ineligible for cryotherapy, suspected cancer or confirmed cancer for further assessment or treatment through primary, secondary and tertiary pathways.[6]
• Schedule repeat screening and clinical review according to findings: a normal visual-inspection result may lead to repeat testing after five years; selected findings require repeat visual inspection after six months or one year; and post-cryotherapy review is required after one year.[6][12][15]Cytology follow-up may occur six months after a screening smear, at one year and then every three years until age 65, with discontinuation after age 65 possible when the two most recent smears are normal.[21]
• Advise earlier return for fever lasting more than two days, severe lower-abdominal pain, heavy or clot-containing bleeding, or purulent discharge after cryotherapy.[11]Monitor immediate cryotherapy delivery through eligibility checks, a three-minute freeze, five-minute thaw and second three-minute freeze cycle, verification of an ice ball, and a check for cervical bleeding before speculum removal.[19]
• Record consent or refusal for participation and testing, including signatures, dates and reasons for refusal where applicable.[10]Administer a questionnaire to women who refuse visual inspection with acetic acid and Lugol’s iodine to understand refusal reasons and encourage later attendance if they reconsider.[9]
• Protect confidentiality by identifying participants with numbers and excluding names and identification numbers from data shared with other researchers.[10]A Responsible Officer for Monitoring and Evaluation is listed within the Directorate of Health Promotion, but the extracts do not define that role’s responsibilities, indicators or reporting arrangements.[25]

Costing & Financing

Cost and financing information is limited. Prevention is characterised as the most effective and economical response to cervical cancer, while visual inspection and cryotherapy are presented as accessible approaches with demonstrated effectiveness in several countries.[1]Visual inspection is also described as relatively inexpensive, non-invasive and adaptable across health-system levels using readily available equipment.[5]The supplied extracts do not provide an overall programme budget, quantified expenditure plan, financing mechanism, resource-mobilisation strategy, allocation framework or funding-gap analysis.[1][3][20][24][12]

• Recognise conventional cervical cytology and breast mammography as difficult to scale because of their costs.[2]
• Use visual inspection as a lower-cost screening alternative requiring readily available materials and equipment.[5]
• Mobilise technical and financial support acknowledged from the World Health Organization, although the amount, timing and terms of this support are not specified.[1]
• Plan for required service resources, including trained personnel, equipped screening and colposcopy centres, laboratory and anatomical pathology capacity, cryotherapy equipment, refrigerant gas, reusable instruments, infection-prevention supplies, and referral services.[20][21][18][8][22]No unit prices, procurement costs, operational budgets or financing sources are provided for these inputs.[20][21][18]
• Note that treatment for infections is described as available at an affordable price, but no monetary amount, subsidy, payer or funding source is identified.[15]
• Interpret the stated estimate that developing countries have access to less than 5 per cent of existing therapeutic resources for cervical-cancer cases as a contextual resource constraint, rather than as a defined programme budget or funding gap.[2]