Training kit by Médecins du Monde

TRAINING FOR CERVICAL CANCER PREVENTION >> TRAINER’S HANDBOOK

A – OBJECTIVES AND CONTENT

Training for cervical cancer prevention

A – OBJECTIVES AND CONTENT 3

Target audience 3 Preliminaries 3 Training objectives 3 Programme 3 Educational objectives 4

B – TRAINING SCHEDULE 6 C – ORGANISATION 7 Number of participants 7 Equipment and materials 7 Training venue 7 Trainers / facilitators 7 D – TRAINING PLAN 8 Day 1 8 Day 2 10 Day 3 14 Day 4 16 Day 5 18

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TABLE OF CONTENTS

E – ANNEXES FOR THE EXERCISES 22

2 | 40

Maps and documents illustrating the epidemiological situation for Part 1, Session 1 22 Problem tree template for Part 1, Session 1, Slide 4, D2 26 Documents for Practical exercise 2, Session 2, Slide 12, D3 27 Background documents for A3 printing and laminating 29 Instructions and scenario for Part 2, Session 1, Slide 57 J2 32 Instructions and scenario for Part 2, Session 5, Slide 25 J4 33 Case study for Part 2, Session 7, Slide 91 J5 34 Action plan 34 Surveys for Part 2, Session 7, D5 36

2021 VERSION: CONTRIBUTORS: Coordination and writing: Najat Lahmidi, Aurélie Philipps Review: Marielle Moizan Translated from French to English by Heather Stacey Graphic design and layout: Laurène Chesnel

1. TARGET AUDIENCE

4. PROGRAMME

The target audience for this training is teams working on SRHR projects and particularly on projects with a focus on cervical cancer prevention: ➡ Teams responsible for implementing community strategy (Group 1) ➡ Teams responsible for operational implementation (e.g., medical staff, midwives, nurses, and supervisors) (Group 2).

The training begins with a general module for all participants to introduce the topic (epidemiological situation, pathophysiology, and prevention strategies). This is followed by developing a thorough understanding of MdM’s cervical cancer strategy and how it fits into MdM’s overall position on SRHR. A second module is aimed at medical teams responsible for operational implementation and covers screening, treatment, referral, and end-of-life care.

2. PRELIMINARIES ➡ Familiarise yourself with the training kit and prepare for co-facilitating the training with another trainer (division of tasks, preparation by topic) ➡ Identify the different profiles of the participants and adapt the training to the target audience ➡ Make practical preparations by sourcing documents used at the local level (leaflets, sample medical certificates, etc).

3. TRAINING OBJECTIVES 3.1 General training objective To learn to design and implement a cervical cancer prevention project based on a public health approach and on the promotion of sexual and reproductive rights.

3.2 Specific training objectives ➡ To gain a thorough understanding of MdM’s cervical cancer prevention strategy and how it fits into MdM’s overall SRHR position and strategy ➡ To be aware of the main trends in the global epidemiological situation in relation to cervical cancer, the main public health challenges and the primary and secondary prevention strategies ➡ To be able to design and implement awarenessraising activities at community level to develop the capacity of individual rights holders in relation to cervical cancer ➡ To be able to design and implement screening based on the algorithm of HR-HPV sampling or self-sampling, then triage through visual inspection ➡ To be able to design and implement treatment for precancerous lesions ➡ To be able to design and implement referral / counter-referral arrangements for treatment of precancerous lesions ➡ To be able to design and implement interventions for pain management and community support for end-of-life care.

GENERAL MODULE Groups 1 + 2 1.5 days Welcome and Introduction: Opening remarks, MdM’s position on SRHR, continuum of care Joint session 1: Introduction to cervical cancer and MdM’s cervical cancer prevention strategy Joint session 2: Human papillomavirus and cervical cancer, general overview (pathophysiology, primary and secondary prevention) Joint session 3: Intervention strategy, screening, and treatment algorithm Joint session 4: Community approach and awareness-raising messages HEALTH MODULE Group 2 3.5 days Health session 1: Individual counselling Health session 2: HPV test (including raising awareness about the use of Genexpert) Health session 3: Visual inspection with acetic acid Health session 4: Treatment of precancerous lesions and follow-up Health session 5: Treatment of cancerous lesions and referral Health session 6: Infection prevention and universal precautions Health session 7: Pain management and end-of-life care

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK OBJECTIVES AND CONTENT

TABLE OF CONTENTS

3 | 40

TOPIC

EDUCATIONAL OBJECTIVES

AUDIENCE

KNOWLEDGE TYPE

FORMAT

INTRODUCTION TO CERVICAL CANCER AND MDM’S CERVICAL CANCER PREVENTION STRATEGY

Outline the main epidemiological challenges in relation to cervical cancer

Gp 1+2

Key knowledge

Training

HUMAN PAPILLOMAVIRUS AND CERVICAL CANCER: GENERAL OVERVIEW (PATHOPHYSIOLOGY, PRIMARY AND SECONDARY PREVENTION)

Present the main elements of MdM’s cervical cancer prevention strategy

Gp 1+2

Explain the basic pathophysiology of cervical cancer

Gp 1+2

Key knowledge

Training

List the elements of primary prevention

Gp 1+2

Key knowledge

Training

List the elements of primary prevention

Gp 1+2

Key knowledge

Training

List the risk and vulnerability factors for HPV

Gp 1+2

Key knowledge

Training

Discuss the perceptions of HPV and cervical cancer

Gp 1+2

Soft skills

Training

Explain the screening and treatment algorithm that has been developed INTERVENTION STRATEGY; SCREENING AND TREATMENT ALGORITHM

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK OBJECTIVES AND CONTENT 4 | 40

INDIVIDUAL COUNSELLING

HPV TEST

Training

Key knowledge

Training

List the specific features of the ‘MdM’ model that has Gp 1+2 been developed

Practical skills

Training

Identify the different actors involved at each stage of the algorithm

Gp 1+2

Key knowledge

Training

Position the activities around cervical cancer in relation to existing services

Gp 1+2

Practical skills

Training

Develop the elements of a community strategy

Gp 1+2

Practical skills

Training

Gp 1+2

Key knowledge

Training

Gp 1+2

Practical skills

Training

List the components of individual counselling before and after screening

Gp 2

Key knowledge

Training

Outline the principles of counselling

Gp 2

Key knowledge

Training

COMMUNITY Outline the key primary and secondary prevention APPROACH AND messages to be highlighted through health education AWARENESS-RAISING activities MESSAGES Explain the added value of community-based HPV self-sampling

Gp 1+2

Key knowledge

Adopt a non-judgmental, empathetic attitude

Gp 2

Soft skills

Training

Explain the approaches to screening, treatment, and post-screening follow-up

Gp 2

Practical skills

Practical exercise

Obtain the patient’s informed consent

Gp 2

Practical skills / Soft skills

Training / Practical exercise

Outline how the HR-HPV test works

Gp 2

Key knowledge

Training

Explain to the patient how a sample is taken and offer self-sampling

Gp 2

Practical skills

Training / Practical exercise

Present the equipment needed to obtain a sample and /or a self-sample

Gp 2

Key knowledge

Training

Practical skills

Training / Practical exercise

Obtain an HR-HPV sample

Gp 2

Plan how samples obtained in the community and at healthcare facilities will be transported to the facilities that have the equipment to conduct the sample analysis

Gp 2

Learn the basic skills for using and maintaining the equipment for sample analysis

Gp 2

Practical skills Key knowledge/ Practical skills

Training

VISUAL INSPECTION WITH ACETIC ACID

TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

TREATMENT OF CANCEROUS LESIONS AND REFERRAL

INFECTION PREVENTION AND UNIVERSAL PRECAUTIONS

PAIN MANAGEMENT AND END-OF-LIFE CARE

Outline the main principles of VIA

Gp 2

Key knowledge

Training

Present the equipment needed for the inspection

Gp 2

Key knowledge

Training

Distinguish between a normal and abnormal VIA, identify the presence or absence of lesions, assess the extent of any lesions

Gp 2

Key knowledge / Practical skills

Training / Practical exercise

Describe the appropriate treatment based on the results or advise further tests

Gp 2

Key knowledge

Training

Conduct a VIA

Gp 2

Practical skills

Practical exercise

Describe the follow-up measures after a normal test

Gp 2

Key knowledge

Training

Present the different treatments for precancerous Gp 2 lesions (cryotherapy, LEEP) and the indications for them

Key knowledge

Training

Outline the principles for performing cryotherapy and LEEP (loop electrosurgical excision procedure)

Gp 2

Key knowledge

Training

Present the possible complications of these treatments

Gp 2

Key knowledge

Training

Present the equipment needed for cryotherapy and LEEP

Gp 2

Key knowledge

Training

Perform a cryotherapy treatment

Gp 2

Practical skills

Practical exercise

Perform a LEEP

Gp 2

Practical skills

Practical exercise

Describe the follow-up measures after treatment for precancerous lesions

Gp 2

Key knowledge

Training

Present the different treatments for cancerous lesions and the indications for them

Gp 2

Key knowledge

Training

Explain the main procedures for each treatment

Gp 2

Key knowledge

Training

Organise a referral and counter-referral system with facilities that treat cancerous lesions

Gp 2

Practical skills

Training

Describe the follow-up measures after treatment for cancerous lesions

Gp 2

Key knowledge

Training

Present the different universal precautions to be taken to prevent infection during screening, treatment and follow-up

Gp 2

Key knowledge

Training

Explain the methods for sterilising the different instruments and equipment used for screening and treatment of precancerous and cancerous lesions

Gp 2

Key knowledge

Training

Discuss the perceptions around disease, end of life and death

Gp 2

Soft skills

Training

Understand the ethical framework for end-of-life and palliative care

Gp 2

Key knowledge

Training

Understand the symptoms and clinical problems experienced by patients during the end-of-life stage

Gp 2

Key knowledge

Training

Assess pain using the recommended methods and explain the different methods of pain management, the indications and procedures for administering the different analgesics (painkillers)

Gp 2

Key knowledge / Practical skills

Training

Explain what needs to be put in place in partnership with local civil society for community-based end-oflife care

Gp 2

Practical skills

Training

Outline the basic principles of care at home and in the community

Gp 2

Practical skills / Soft skills

Training

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK OBJECTIVES AND CONTENT

5.EDUCATIONAL OBJECTIVES

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B – TRAINING SCHEDULE

C – ORGANISATION 1. NUMBER OF PARTICIPANTS

9.00: Welcome / Opening remarks: Introduction to participants, trainers, the programme, expectations, and objectives

DAY 2

DAY 3

DAY 4

DAY 5

Ideally, the training should be delivered to 12 people, with a maximum of 15. 9.00: Icebreaker and review of learning

9.00: Icebreaker and review of learning

9.00: Review of learning on VIA

2. EQUIPMENT AND MATERIALS Video projector, screen, and speakers IT

9.30: Recap of MdM’s position on SRHR; continuum of care

9.30: Community approach

9.30: Visual inspection with acetic acid

9.30: Complications and follow-up of treated precancerous lesions

10.30: Break

10.45: Break

9.15: Pain management and end-of-life care 11.15: Break

10.45: Introduction to cervical cancer: epidemiological situation, human papillomavirus and cervical cancer, general overview (pathophysiology)

Flipchart 1 pen and 1 marker pen per participant. Provide an additional packet of marker pens for participants and trainers + a packet of pens

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING SCHEDULE

13.00: Lunch

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14.00: Primary, prevention, secondary prevention

15.15: Break

15.30 - 17.00: Intervention strategy; screening and treatment algorithm

11.00: Cancerous lesions: diagnosis, treatment, and referral (part 1)

11.45: How to limit the number of patients lost to follow-up?

11.00: Visual inspection with acetic acid (continued)

13.00: Lunch

Pieces of coloured card: 2 per participant: 1 blue, 1 yellow 1 reel of sticky tape / blu-tack (sticky putty) Sheets of paper numbered from 1 to the number of participants Training slides and videos

11.30: Summary and key messages

Trainer’s manual (one per trainer) Participant’s manual (one per participant) TRAINING RESOURCES

Training schedule Self-assessment form (one per participant) Satisfaction survey (one per participant) Action plan (one per participant)

13.00: Lunch

14.00: Treatment and follow-up of precancerous lesions: thermocoagulation

14.00: Infection prevention and universal precautions

15.15: Break

15.45: Break

15.30: Break

15.30 - 17.00: HPV test (including awarenessraising around use of Genexpert)

16.00 - 17.30: Screening and treatment of precancerous lesions using thermocoagulation: practical exercises and case studies

14.00: Individual counselling

Post-it notes (1 colour) Index cards with numbers (1 to 3) and letters (A to D)

12.00: Cancerous lesions: diagnosis, treatment, and referral (part 2)

12.30: Summary and evaluation of Part 1 of the training

Extension cables and multiple socket extensions Video speakers

STATIONERY 10.45: Awarenessraising messages

Laptops: one per trainer; one per participant for the final day (with Adobe Acrobat Reader)

13.00: Lunch

Attendance sheets (one per participant)

14.00 - 15.00: Applying learning in context

USB stick with key documents (one per participant) 4 Eve or Natalie mannequins 4 thermocoagulators

15.00 - 15.35: Summing up and training evaluation

Speculums Cured sausage (saucisson) MEDICAL AND EDUCATIONAL EQUIPMENT

15.45-17.00: General review of learning – Cervical Cancer Quiz Show

Equipment and materials for HPV tests, VIA tests and precancerous lesion treatment (cotton wool, swabs, acetic acid, forceps, tray etc.) Printed materials on A4 laminated sheets: all the protocols and algorithms (handwashing, pre-analysis protocol, treatment algorithm etc) Handwashing training kit (black light and glo germ) Handwashing equipment Printed cervical cancer counselling booklet

OTHER MATERIALS

Dice Ball 2 or 3 packets of sweets

3. TRAINING VENUE ➡ A room with tables set up in a U shape ➡ The tables should be positioned so that the participants can see the screen and have access to a power supply.

4. TRAINERS / FACILITATORS At least two people: ➡ One person who is familiar with the training content ➡ One person to provide support with organisation and logistics.

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ORGANISATION

DAY 1

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D – TRAINING PLAN DAY 1

0.1

0.2

PARTICIPANT INTRODUCTIONS

RECAP OF MDM’S POSITION ON SRHR; CONTINUUM OF CARE

TIME

PROGRAMME

KEY MESSAGES ➡ Introduction to the trainers ➡ Run through the timetable and organisation for the week: daily evaluation ➡ Training objectives ➡ Training approach: alternating theoretical learning and practical exercises ➡ Introduction to participants ➡ Group rules (non-judgement, free speech, listening, phones on silent, participation, sharing ‘airtime’).

• • • • • • •

➡ MdM’s position on SRHR - Exercise: Q&A: (5 mins) In your opinion: What are the key elements of MdM’s position on SRHR? (Approaches? Types of intervention? Advocacy?) What are the three priority areas of the SRHR strategy? - Slide presentation: SRHR position and strategy 60 mins ➡ The continuum of care - Exercise: in groups of 3 (A with A, B with B, C with C) list the different continuum of care services and sketch out the continuum of care over time. At what point on the continuum of care would you position cervical cancer prevention? (15 mins) - Slide presentation: The continuum of care in time and space (10 mins) - Aurélie video: MdM’s conceptual framework for SRHR (15 mins)

➡ MdM’s commitment to SRHR is based on a public health approach and on promoting sexual and reproductive rights. ➡ The three strategic priorities of the continuum of care for MdM are prevention and management of unwanted pregnancies; the response to SRHR needs in crisis settings, especially the response to physical and/or sexual violence; and cervical cancer prevention.

• PPT: Day 1 • Laptop and video projector

BREAK: 15 MINS

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

1.1

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1.2.1

INTRODUCTION TO CERVICAL CANCER: EPIDEMIOLOGICAL SITUATION

INTRODUCTION TO CERVICAL CANCER: HUMAN PAPILLOMAVIRUS AND CERVICAL CANCER, GENERAL OVERVIEW (PATHOPHYSIOLOGY)

EQUIPMENT

➡ Introduction to the trainers, the topic, and the structure of discussions ➡ Participants introduce themselves and each other: “Introduce yourself, your role/ background, the country where you work, your experience and your expectations of this training”. The participants work in pairs and spend a few minutes introducing themselves to each other and talking about their expectations. Each participant then introduces 30 mins their partner to the group. The trainer writes the participants’ expectations on the flipchart. ➡ Establishing group rules The trainer hands each person a card. The card has a number (1, 2, 3) on one side and a letter (A, B, C, D) on the other side. The trainer also gives each person two coloured cards (blue and yellow).

60 mins

75 mins

- Group exercise: the participants are put into groups of 5. Each group is given a set of documents about cervical cancer (Groups 1 and 2: global epidemiological situation; Groups 2 and 3: data about the country where the training is held.). They discuss the content of the documents and prepare a 5-minute summary for all the participants. (20 mins discussion + 20 mins summaries) - Slide presentation: The global epidemiological situation for cervical cancer; the public health challenges (20 mins) ➡ Human papillomavirus - Quiz: Human papillomavirus. 5 questions: the participants have a blue card and a yellow card. For each question they have 10 seconds to respond: blue card = true; yellow card = false (10 mins) Quiz answers: 1 Condoms protect against all sexually transmitted infections FALSE 2 The number of sexual partners increases the risk of contracting HPV TRUE 3 Any intimate contact can result in an HPV infection TRUE 4 There is no point in vaccinating adolescents before they are sexually active FALSE 5 Cervical cancer is a consequence of HPV infection TRUE - Slide presentation: Human papillomavirus (the virus, how the virus causes cervical cancer, the risk factors). (15 mins) ➡ Pathophysiology of cervical cancer - Group exercise: What do you know about the cervix? In groups of 3, the participants produce a poster summarising what they know about the anatomy and physiology of a normal cervix (with illustration). The posters are then displayed around the room and the participants go round and look at each poster. 1 participant per group stays with their poster to provide any necessary explanations. (10 mins preparation + 5 mins presentation) - Slide presentation: Anatomy of the cervix (10 mins) - Slide presentation: Pathophysiology of cervical cancer (25 mins)

PPT: Day 1 Training schedule Instructions for introduction exercise Attendance sheets Cards with numbers / letters Coloured cards Laptop and video projector

BREAK: 15 MINS ➡ ➡ ➡ ➡

Over 270,000 women die from cervical cancer every year. In most cases this disease could be avoided with appropriate screening. Over 85% of these deaths occur in low or middle-income countries. Cervical cancer ranks fourth in the world for cancers affecting women.

➡ Human papillomavirus (HPV) is a group of viruses that are extremely common worldwide. ➡ There are over 100 types of HPV, at least 13 of which are carcinogenic (also classed as high-risk viruses). ➡ HPV is mostly transmitted through sexual contact and the majority of people are infected when they first become sexually active. ➡ Two types of HPV (16 and 18) cause 70% of cervical cancers and precancerous lesions. ➡ High-risk HPV infections are very common among young women, but most of these infections are transient. ➡ Only a very small percentage of all HPV infections that persist for a number of years will lead to the development of invasive cancer.

• PPT: Day 1 • Laptop and video projector

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

9 | 40

TITLE

TIME

PROGRAMME LUNCH BREAK: 13.00-14.00

1.2.2

PRIMARY AND SECONDARY PREVENTION

1.3.1

INTERVENTION STRATEGY, SCREENING AND TREATMENT ALGORITHM

1.3.2

SUMMARY OF DISCUSSIONS, REVIEW OF KEY MESSAGES

KEY MESSAGES

EQUIPMENT

LUNCH BREAK: 13.00-14.00

- Brainstorming: in your opinion, what is meant by primary, secondary and tertiary prevention? (15 mins) - Slide presentation: Primary prevention (15 mins) - Slide presentation: (45 mins) • Secondary prevention and screening tests • Target group for screening • Screening strategies recommended by the WHO.

➡ Tackling cervical cancer benefits from a multidisciplinary approach. ➡ Vaccination against HPV is not a substitute for cervical screening. ➡ The WHO recommendations support increasing the level of vaccination coverage rather than increasing screening frequency. ➡ The WHO recommends screening women between the ages of 30 and 49, but the age range can be extended depending on age-related prevalence and life expectancy.

• PPT: Day 1 • Laptop and video projector

➡ MdM’s strategy is based on 3 action principles: strengthening service provision; building the capacity of individuals; and initiating advocacy. ➡ Cervical cancer screening provision is based on an integrated approach, ‘screen and treat’ and ‘sequential testing’. ➡ Our target population is all women between the ages of 25 and 55, except those who have received treatment (cryotherapy, thermocoagulation, LEEP, cold-knife cone biopsy or more invasive treatment). ➡ Women living with HIV need close monitoring, irrespective of their age, from when they become sexually active. ➡ Identifying the barriers encountered in accessing care enables a strategy to be developed to strengthen the healthcare system.

• PPT: Day 1 • Laptop and video projector

75 mins

Slide presentation: MdM’s intervention strategy and logic model (15 mins) Slide presentation: Screening algorithm and reasoning (25 mins) Group exercise: in groups of 5 discuss the constraints / difficulties you would anticipate in the intervention context regarding the screening algorithm. What levers for change are available? (10 mins + 10 mins feedback) Slide presentation: Patient treatment by level of care (15 mins)

15 mins

- Each participant is given a number. In ascending order, the participants take it in turns to contribute a key message from the day / a new idea they have learned. (15 mins)

75 mins

DAY 2

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

1.4.1

10 | 40

1.4.2

REVIEW OF LEARNING

COMMUNITY STRATEGY

TIME

30 mins

60 mins

PROGRAMME - Ball game: The participants take it in turns to throw the ball to another participant and ask a question about the learning from the previous day (it must be a question to which they have the answer). The participant who catches the ball answers the question and then throws the ball to another participant. (20 mins) - The trainer answers any questions about the previous day’s learning. (10 mins) -Problem tree: working in groups of 5, the participants identify the causes and effects from the problem tree in relation to access to cervical cancer screening. (10 mins and 5 mins feedback per group) - Slide presentation: The main elements of community strategy (15 mins) - Which stakeholders should be involved? The participants are each given several post-it notes, and they write down their suggestions of stakeholders who should be involved. The trainer collects the post-its, sticks them on to a flipchart and then goes through them and presents them. (15 mins) BREAK: 15 MINS

1.4.3

AWARENESS-RAISING MESSAGES

60 mins

KEY MESSAGES

- Group exercise: in groups of 5, the participants prepare health education messages. Each group is given a topic: • What are human papillomavirus and cervical cancer? • Primary prevention • Secondary prevention Each group should: 1) set out awareness-raising objectives; 2) produce health education messages on their topic; 3) suggest what media might be used to convey the message. (20 mins) - Sharing: each group presents their work to the other groups for discussion and improvement. (15 mins) - The trainer provides a recap of the main conclusions, clarifies the key messages, and finishes with a summary. (5 mins) - Slide presentation: Different tools (5 mins)

EQUIPMENT • Ball • Attendance sheets

➡ Barriers to cervical cancer screening may be sociocultural, geographical, economic, political, legal, or administrative.

• PPT: Day 2 • Laptop and video projector

BREAK: 15 MINS ➡ The aim of health education is to enable everyone to adopt behaviours that suit their life choices and are beneficial to their health. ➡ Importance of working on perceptions and developing individual skills. ➡ It is important to remember that effective communication can often lead to an increase in screening rates and to the lives of many women being saved. ➡ Activities that take place outside of institutions, community mobilisation, health education and advice are essential elements for an effective programme tackling cervical cancer because they help to ensure a higher rate of vaccination coverage and screening and good compliance with treatment.

• PPT: Day 2 • Laptop and video projector • Flipchart, coloured markers

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

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1.4.4

1.4.5

TIME

HOW TO LIMIT THE NUMBER OF PATIENTS 45 mins LOST TO FOLLOW-UP

SUMMARY AND EVALUATION OF PART 1 OF THE TRAINING

PROGRAMME

INDIVIDUAL COUNSELLING

➡ With the suggested algorithm model, it will not always be possible to adopt a Test & Treat strategy, with the result that projects may experience significant levels of patients lost to follow-up. The activities should be designed in order to minimise the numbers of patients lost to follow-up, through: • A specific focus on follow-up during counselling • The establishment of a network of community actors enabling close monitoring • The establishment of an effective monitoring system

• PPT: Day 2 • Laptop and video projector

- The numbered cards are given to the participants. In ascending order, the participants take it in turns to contribute a key message they have learned in Part 1.

➡ Over 270,000 women die of cervical cancer every year. ➡ In the majority of cases this disease is avoidable with appropriate screening. ➡ Cervical cancer is usually caused by a sexually transmitted human papillomavirus (HPV) infection. ➡ Importance of working on perceptions and developing individual skills.

• PPT: Day 2 • Laptop and video projector

30 mins

75 mins

-Exercise in groups of two: define the term ‘counselling’ in 5 words (5 mins). The participants gather in pair, spend 5 mins discussing the suggested definitions and choose 5 of them. The decisions should be made by consensus. Each pair presents their five words and discusses them with the others to reach a consensus. (15 mins) - Slide presentation: Information and counselling prior to cervical cancer screening. (15 mins) - Role play: in groups of 3 the participants share out the roles of patient, healthcare professional and observer. (5 mins) - They act out a counselling session on cervical cancer prevention and screening; the consultation should include the information the woman needs and the counselling aspect which is essential in this type of consultation. (20 mins) - Sharing: discussion about the difficulties encountered and the key elements of the consultation. The trainer draws the main conclusions, clarifies the key messages, and concludes with a summary. (15 mins) BREAK: 15 MINS

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

2.2

12 | 40

PERFORMING THE HPV TEST

90 mins

EQUIPMENT

- Slide presentation: The algorithm model and the patient care pathway (10 mins) - Discussion: what are the main challenges identified? At what level is there a risk of patients being lost to follow-up? (15 mins) - Group exercise: in groups of 5 the participants should identify potential levers and suggest possible points to consider limiting the numbers of patients lost to follow-up. (20 mins)

LUNCH BREAK: 13.00-14.00

2.1.1

KEY MESSAGES

- Slide presentation: Introduction to the test and the method and technique for obtaining a sample (by a healthcare professional; self-sampling) (20 mins) - Demonstration by the trainer and practice on a mannequin (20 mins) - Slide presentation: Packaging and transportation of samples, information collection and patient record / cervical cancer prevention form (20 mins) - Slide presentation: Awareness-raising about use of GenExpert (15 mins) - Slide presentation: Giving results (15 mins)

LUNCH BREAK: 13.00-14.00 ➡ Counselling takes the form of a collaborative conversation between an individual who is recognised as the agent and subject of their own life and an interlocutor who serves as a guide to motivate, support and encourage. ➡ This technique is essential to ensure free and informed choice, to identify individual perceptions and to facilitate participation in screening. ➡ Women need accurate information about the prevention and treatment of cervical cancer. ➡ Counselling enables women to make an informed choice about screening and treatment if they are indicated. ➡ The essential qualities and attitudes for counselling are openness, empathy and listening. ➡ The basic techniques for counselling are open questions, clarification, and reformulation.

• PPT: Day 2 • Laptop and video projector • Scenario and Observation grid

BREAK: 15 MINS ➡ The molecular testing method for HPV infection is based on detecting the DNA of high-risk types of HPV in vaginal and / or cervical samples. ➡ The test does not necessarily require a gynaecological examination or inspection of the cervix. ➡ The sample can be taken by a healthcare worker with or without a speculum examination or by the woman herself.

• • • •

PPT: Day 2 Laptop and video projector Specimen HPV tests Anatomical model TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

13 | 40

DAY 3

2.3.1

2.3.2

ICEBREAKER AND REVIEW OF LEARNING

VISUAL INSPECTION WITH ACETIC ACID (PART 1)

TIME

30 mins

75 mins

PROGRAMME - Game: one participant draws numbers at random and gives them in any order to the other participants. In numerical order, the participants take it in turns to contribute one message they learned the previous day. (20 mins) - The trainer answers any questions about the previous day’s learning (10 mins)

- Q&A – discussion: what is VIA? What do you know about it? (15 mins) - Slide presentation: General overview; who to test and when; strengths and limitations (25 mins) - Slide presentation: Performing a VIA (equipment and materials, procedure) (35 mins) BREAK: 15 MINS

2.3.3

VISUAL INSPECTION WITH ACETIC ACID (PART 2)

VISUAL INSPECTION 2.3.4 WITH ACETIC ACID (PART 3)

40 mins

60 mins

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TREATMENT OF PRECANCEROUS LESIONS

2.4.2 THERMOCOAGULATION

90 mins

➡ VIA is one of the methods for detecting early cellular changes in the cervix. These changes become visible during examination with the naked eye after the insertion of a speculum and application of acetic acid to stain the cervix. Following the screening algorithm, VIA is used in triage after a positive HPV-HR test. Training with supervised practice is necessary to ensure the VIA can be performed competently.

• PPT: Day 3 • Laptop and video projector

BREAK: 15 MINS

- Practice using the mannequin: insertion of the speculum and staining the cervix (30 mins) - Quiz: a photo is displayed, and the participants have to say whether it depicts a normal result (blue card) or abnormal (yellow card); then 1 participant explains why (35 photos). (30 mins)

• PPT: Day 3 • Laptop and video projector

LUNCH BREAK: 13.00-14.00

- Q&A: which treatments for precancerous lesions are you familiar with? What are the advantages and disadvantages? In which situations are they used? (15 mins) - Slide presentation: Treatments for precancerous lesions (15 mins)

➡ There are several recommended treatments, depending on the context, the available resources, and the extent of the lesions: • Cryotherapy / Thermocoagulation as first line treatment • Loop electrosurgical excision procedure (LEEP) for lesions covering over 75% of the cervix or when the squamocolumnar junction is not visible ➡ These treatments are carried out at different healthcare levels depending on national recommendations.

• PPT: Day 3 • Laptop and video projector

- Slide presentation: Thermocoagulation, principles and general overview (15 mins) - Video – thermocoagulation procedure (15 mins) -Slide presentation: Equipment and materials (10 mins) - Slide presentation: Thermocoagulation techniques (20 mins) - Slide presentation: Precautions (5 mins) - Slide presentation: Complications (10 mins)

➡ Thermocoagulation consists of applying a probe at a very high temperature (100120°C) to the surface of the lesion which induces necrosis of the underlying area. ➡ Indications: identical to those for cryotherapy. Similarly, this procedure is not recommended if there is suspected invasive cancer. ➡ Thermocoagulation is contraindicated during pregnancy. ➡ Procedure: the procedure itself takes approximately 1 minute and doesn’t require an anaesthetic.

• PPT: Day 3 • Laptop and video projector

BREAK: 15 MINS

PRACTICAL EXERCISES: SCREENING AND 2.4.3 TREATMENT OF PRECANCEROUS LESIONS THROUGH THERMOCOAGULATION

• Attendance sheets

• PPT: Day 3 • Laptop and video projector • Pelvic model and VIA equipment

30 mins

75 mins

EQUIPMENT

- Video – VIA technique (20 mins) - Slide presentation: Interpreting the VIA? (20 mins)

LUNCH BREAK: 13.00-14.00

2.4.1

KEY MESSAGES

- Group exercise: the participants are divided into 3 groups. Each group is given a topic: HPV test, VIA or thermocoagulation. Each group should discuss the indications for the test or treatment and the different steps involved as described on the instruction sheet. The different elements for each topic are written on a flipchart and then put up on the wall. Each group goes round the different posters and can add to them if they wish. One participant per group provides a brief, 5-minute feedback. (15 mins preparation + 5 mins for additions by the other groups + 15 mins feedback) - Practice on the mannequin and clinical case studies 40 mins (can be shortened/missed out depending on the resources available)

BREAK: 15 MINS • PPT: Day 3 • Laptop and video projector • Anatomical model and medical supplies

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

15 | 40

DAY 4

ICEBREAKER 2.4.4 AND REVIEW OF LEARNING

FOLLOW-UP FOR TREATED 2.4.5 PRECANCEROUS LESIONS

TIME

30 mins

75 mins

PROGRAMME

- Quiz : true / false – complications: the participants have a blue card and a yellow card. For each question they have 10 seconds to respond: blue card = true; yellow card = false (10 mins) Quiz answers: 1. The complications of cryotherapy are the same as for thermocoagulation TRUE 2. Heavy bleeding after thermocoagulation is normal FALSE 3. Pain and cramps may last for 2 to 3 days following treatment TRUE 4. Sexual relations are not advised for a month (unless using a condom) TRUE 5. Patches all over the body are often found after thermocoagulation FALSE 6. The patient may experience dizziness, fainting or hot flushes TRUE - Group exercise: the participants are divided into groups of 5. They write the main components of post-treatment follow-up on post-it notes. The trainer collects the post-its, sticks them on a flipchart and then summarises them. (20 mins) - Slide presentation: Elements of post-treatment follow-up (20 mins) - Sharing / brainstorming: what problems do you anticipate with patient followup? What levers are available to address this? (15 mins) BREAK: 15 MINS

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

2.5.1

16 | 40

CANCEROUS LESIONS: DIAGNOSIS, TREATMENT, AND REFERRAL (PART 1)

CANCEROUS LESIONS: 2.5.2 DIAGNOSIS, TREATMENT, AND REFERRAL (PART 2)

75 mins

2.6.1

45 mins

• PPT: Day 4 • Laptop and video projector

BREAK: 15 MINS • PPT: Day 4 • Laptop and video projector • Scenario and Observation grid

- Slide presentation: Classification of the stages of development of cervical cancer (20 mins) Sharing / Discussion: what lesions are treated at what level in the context of the project? (15 mins) - Slide presentation: Treatment, overview (20 mins) - Group exercise: in groups of 5 the participants map out the referral and counter-referral systems on a flipchart. On a second flipchart they list the actions that need to be implemented by the project to ensure that these systems are effective. (20 mins)

➡ Treatment options comprise surgery, radiotherapy, and chemotherapy; a combination of these options can be used. ➡ In the absence of treatment, invasive cervical cancer is almost always fatal.

• PPT: Day 4 • Laptop and video projector

- Slide presentation: General overview and transmission cycle (10 mins) - Group exercise: in groups of 5 the participants list the different universal precautions on a flipchart. They nominate one person to feed back to the rest of the group. (20 mins) - Slide presentation: Universal precautions / Monitoring and maintenance of equipment (15 mins) - Practical exercise: handwashing / using UV light in darkened room (15 mins) - Slide presentation: Medical waste management (15 mins) BREAK: 15 MINS

GENERAL REVIEW OF LEARNING – CERVICAL CANCER QUIZ SHOW

➡ A check-up should be scheduled for 4 to 6 weeks after treatment. ➡ A check-up should be scheduled for 1 year after treatment.

➡ A woman who is diagnosed with invasive cervical cancer at an early stage can usually be cured if she receives effective treatment. ➡ It is essential that healthcare staff at the primary care level are able to recognise and swiftly refer women who present with common signs and symptoms of cervical cancer. ➡ A definitive diagnosis of invasive cervical cancer is made by doing a histopathological examination by biopsy. ➡ Always remember that your ability to listen to your patient and their view of things is one of the most powerful therapeutic tools.

LUNCH BREAK: 13.00-14.00

INFECTION PREVENTION AND 2.5.3 MEDICAL WASTE MANAGEMENT

EQUIPMENT • Coloured markers - flipchart • Attendance sheets

- Slide presentation: Clinical presentation and diagnosis of cancer (20 mins) - Slide presentation: Making a referral due to suspected cervical cancer (20 mins) - Role play: giving a cervical cancer diagnosis (20 mins) 60 mins

75 mins

KEY MESSAGES

- Game: the participants are divided into 4 groups (A, B, …) Each group identifies a key message from the previous day and provides a recap by drawing it (20 mins) - The trainer answers any questions about the previous day’s learning (10 mins)

- Game Cervical Cancer Quiz Show: the participants are divided into 4 groups. Each group chooses a topic (MdM strategy, the challenges of cervical cancer / screening / treatment) and a number of points between 100 and 500, knowing that the higher the number of points, the harder the question. The game ends once all the questions have been asked. The group with the most points wins. (45 mins)

LUNCH BREAK: 13.00-14.00 ➡ Infectious diseases remain one of the main causes of death worldwide. ➡ Healthcare professionals and their patients are at risk of contracting these diseases. ➡ The spread of infections within healthcare facilities is to a great extent due to professionals failing to wash their hands or not taking universal precautions. ➡ Poor management of the waste generated by healthcare activities can be a source of serious disease for healthcare workers, staff responsible for waste disposal, patients and the general population. ➡ EVERYONE is responsible for infection prevention.

• PPT: Day 4 • Laptop and video projector • Hand-washing kit

BREAK: 15 MINS • PPT: Day 4 • Laptop and video projector • Quiz Show PPT

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

17 | 40

DAY 5

2.6.2

2.6.3

VIA: REVIEW OF LEARNING

PAIN MANAGEMENT

TIME 15 mins

55 mins

PROGRAMME - Exercise: A photo is displayed, and the participants have to say whether it shows a normal result (blue card) or an abnormal result (yellow card); then 1 participant explains why. The participants answer questions from the trainer about each photo. (30 mins) - Q&A: In your opinion, what are the barriers to effective pain management? What could be possible levers for removing these barriers? (20 mins) - Slide presentation: WHO analgesic ladder, non-pharmacological treatments and approaches which help to relieve pain (25 mins) - Quiz: true / false – complications: the participants have a blue card and a yellow card. For each question they have 10 seconds to respond: blue card = true; yellow card = false (10 mins) I should wait as long as possible before taking pain medication. FALSE, the aim of treatments for pain is to relieve the pain continuously and thus to prevent it from recurring. If the pain is suppressed with medication, I won’t be able to tell if the disease is getting worse. FALSE, there are more effective methods for monitoring disease development (symptoms etc.). Analgesics don’t treat the cause of the pain. TRUE AND FALSE: relieving pain means the cancer can be better treated. The patient eats better, sleeps better, is less anxious and can better tolerate the cancer treatments. Pain management is thus indirectly a means of facilitating cancer treatment. If I’m offered morphine, it means it’s serious. FALSE, the use of morphine is linked to the intensity of the pain and not to the seriousness of the illness (childbirth). With morphine people sleep all day, it’s not a solution. TRUE AND FALSE. Drowsiness is common at the beginning of treatment and is linked to the cumulative lack of sleep and the sedative effect of opioids. The drowsiness is temporary and will gradually diminish. Morphine is a drug. TRUE AND FALSE It is a derivative of opium which is why some people are wrongly worried about becoming drug addicts

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

BREAK: 15 MINS

18 | 40

2.7.1

2.7.2

END-OF-LIFE CARE / PALLIATIVE CARE

SUMMARY AND APPLYING LEARNING IN CONTEXT

KEY MESSAGES

EQUIPMENT • PPT: Day 5 • Laptop and video projector

➡ Pain management is an integral part of treatment ➡ The majority of pain can be relieved effectively by using a wide-ranging combination of medical and non-medical approaches. ➡ The treatment of symptoms is heavily dependent on access to all the necessary medications, equipment, and supplies, both in healthcare facilities and within patients’ homes.

• PPT: Day 5 • Laptop and video projector

BREAK: 15 MINS ➡ End-of-life care is in an important part of tackling cervical cancer. ➡ It helps to improve quality of life for patients and families faced with the challenge of cervical cancer and can enable women who present with the condition at an advanced stage to preserve their dignity and peace of mind at a difficult time in their lives. ➡ The mechanisms for implementing palliative care, such as education and availability of drugs, must be strengthened.

• PPT: Day 5 • Laptop and video projector • Case study

75 mins

- Discussion: (30 mins) The participants are divided into groups of 5. The following question is discussed: in the context of the country and considering the services available, what can be done through the project in terms of end-oflife care? The participants are in groups. (10 mins) After 10 mins, the groups come together and agree the answer they will give to the trainer. (15 more mins). The trainer selects one person to feed back for all the participants. - Case study: The participants receive a case study and familiarise themselves with it. The trainer asks 2 of the participants to read it out loud. The trainer then asks the participants to list the strong points of the treatment described and to identify any possible weak points. In terms of the activities to be implemented through the project, what aspects for reflection are there? The trainer asks a volunteer to write the key points of the discussion on a flipchart. (25 mins) - Slide presentation: Summary: end-of-life care and palliative care – definitions and key elements (20 mins)

➡ A woman dies of cervical cancer every two minutes. ➡ Women aged 30 to 49 are most at risk of developing cervical cancer. ➡ Cervical cancer is a preventable disease. ➡ There are tests that can detect early changes in the cervix which can develop into cancer if left untreated. ➡ There are safe and effective treatments for these early changes. ➡ There is a vaccine which can be given to girls and which can help to prevent the occurrence of cervical cancer.

• PPT: Day 5 • Laptop and video projector

90 mins

- Numbered pieces of paper are handed out at random to the participants. In ascending order each participant gives 2 key messages they have learnt from the training. (10 mins) - Slide presentation: The key points – Summary (80 mins) - Exercise: The participants divide into 4 groups or teams. Each group prepares 5 questions on one of the following topics: HPV; treatment of precancerous lesions; palliative care; and cervical cancer. The questions are asked to each team, with the team asking the question also judging the answers. If the team answers the question correctly, 1 point is awarded. If the answer is wrong but the team that asked the question gives the wrong answer, that team loses 1 point. (30 mins) LUNCH BREAK: 13.00-14.00

LUNCH BREAK: 13.00-14.00

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TITLE

19 | 40

TITLE

2.7.3

35 mins

KEY MESSAGES

EQUIPMENT

- Exercise by healthcare facility The participants are grouped by healthcare facility and, based on the template provided, they develop their action plan: what actions are you going to implement directly through your projects after this training? (30 mins)

• PPT: Day 5 • Laptop and video projector • Action plan

The trainer hands out the self-assessment form and satisfaction survey. - Self-assessment by participants (knowledge before and after training) (10 mins) - Satisfaction survey for the training (training content, usefulness, methods, interactivity, organisation, trainers, recommendations) (10 mins) - Oral evaluation The trainer returns to the first flipchart sheet on which the participants’ expectations were written and takes stock. Use blue and yellow cards. Go round the group and thank yous. (15 mins)

• Self-assessment form

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

TRAINING EVALUATION

30 mins

PROGRAMME

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK TRAINING PLAN

2.7.4

ACTION PLAN

TIME

20 | 40

21 | 40

E – ANNEXES FOR THE EXERCISES

FIGURE 4 : GLOBAL ESTIMATE OF CERVICAL CANCER DEATHS BY 2030, WHO

1. MAPS AND DOCUMENTS ILLUSTRATING THE EPIDEMIOLOGICAL SITUATION FOR PART 1, SESSION 1 DEATHS ATTRIBUTED

600

MAP 1 : INCIDENCE OF CERVICAL CANCER AT GLOBAL LEVEL, WHO 2020 Estimated age-standardized incidence rates (World) in 2020, cervix uteri, all ages

543 000

500

Mat erna

l mo

400 300 200 100

cancer om cervical Mortality fr

190 000

0 1990

443 000

-47%

rtali

287 000 275 000 +45%

1995 2000 2005

2010

2015

2020

2025

2030

ASR (World) per 100 000 ≥ 25.2 16.7–25.2 11.7–16.7 7.0–11.7 < 7.0

Not applicable No data

All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization / International Agency for Research on Cancer concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate borderlines for which there may not yet be full agreement.

Data source: GLOBOCAN 2020 Graph production: IARC (http://gco.iarc.fr/today) World Health Organization

MAP 2 : MORTALITY FROM CERVICAL CANCER AT GLOBAL LEVEL, WHO 2020

22 | 40

ASR (World) per 100 000 ≥ 16.4 9.0–16.4 5.7–9.0 2.8–5.7 < 2.8

Not applicable No data

Data source: GLOBOCAN 2020 Graph production: IARC (http://gco.iarc.fr/today) World Health Organization

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Estimated age-standardized mortality rates (World) in 2020, cervix uteri, all ages

23 | 40

Burkina Faso

Source: Globocan

Source: Globocan 2020

Incidence, Mortality and Prevalence by cancer site

Geography

New cases

Breast 1 927 (16%)

Liver 1 242 (10.3%) Other cancers 6 086 (50.5%)

Cervix uteri 1 132 (9.4%)

Numbers at a glance Total population

Prostate 997 (23.2%)

20 903 278

Other cancers 1 781 (41.4%)

12 045

Liver 792 (18.4%)

Non-Hodgkin lymphoma 219 (5.1%)

Number of deaths

Bladder 313 (7.3%)

8 695

Total: 4 305

Number of new cases in 2020, females, all ages

18 884

Cervix uteri 1 132 (14.6%)

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Number

Rank

(%)

Cum.risk

Number

Prop. (per 100 000)

Breast

1 927

16.0

3.20

1 142

13.1

2.03

3 214

30.73

Liver Cervix uteri

1 242 1 132

2 3

10.3 9.4

1.14 2.02

1 197 839

1 3

13.8 9.6

1.13 1.67

1 597 1 757

7.64 16.80

Prostate Bladder Ovary

997 661 438

4 5 6

8.3 5.5 3.6

3.67 0.82 0.84

608 399 339

4 5 6

7.0 4.6 3.9

2.03 0.54 0.71

1 335 1 001 678

12.78 4.79 6.48

7 8

3.5 3.2

1.06 0.32

143 289

15 7

1.6 3.3

0.41 0.29

749 672

7.16 3.21

9 10 11

2.9 2.4 2.3

0.17 0.28 0.41

239 231 266

9 11 8

2.7 2.7 3.1

0.14 0.23 0.40

613 406 265

2.93 1.94 1.27

Stomach Oesophagus Kidney

246 236 215

12 13 14

2.0 2.0 1.8

0.40 0.28 0.12

232 224 158

10 12 13

2.7 2.6 1.8

0.38 0.27 0.10

348 301 457

1.66 1.44 2.19

Lip, oral cavity Brain, central nervous system Lung

179 161 159

15 16 17

1.5 1.3 1.3

0.24 0.14 0.22

124 139 146

17 16 14

1.4 1.6 1.7

0.18 0.14 0.21

269 271 185

1.29 1.30 0.89

Multiple myeloma

109

0.90

0.17

1.1

0.16

162

0.77

Rectum Thyroid Kaposi sarcoma Melanoma of skin

88 80 73 66

19 20 21 22

0.73 0.66 0.61 0.55

0.07 0.08 0.05 0.10

69 37 44 31

19 25 22 27

0.79 0.43 0.51 0.36

0.06 0.04 0.02 0.05

117 154 124 111

0.56 0.74 0.59 0.53

Salivary glands Vulva Hypopharynx Larynx Vagina

65 60 56 50 42

23 24 25 26 27

0.54 0.50 0.46 0.42 0.35

0.10 0.10 0.02 0.07 0.07

44 38 44 37 27

21 23 20 26 28

0.51 0.44 0.51 0.43 0.31

0.07 0.08 0.02 0.06 0.05

123 116 45 79 64

0.59 1.11 0.22 0.38 0.61

Gallbladder Hodgkin lymphoma Oropharynx

41 41 30

28 29 30

0.34 0.34 0.25

0.03 0.02 0.02

37 22 21

24 30 31

0.43 0.25 0.24

0.03 0.01 0.01

55 83

0.26 0.40

Anus Testis Nasopharynx Penis Mesothelioma

30 28 11 3 2

31 32 33 34 35

0.25 0.23 0.09 0.02 0.02

0.03 0.02 0.01 0.00 0.00

24 13 8 2 2

29 32 33 35 34

0.28 0.15 0.09 0.02 0.02

0.02 0.01 0.00 0 0.00

44 44 45 16 4 3

0.21 0.21 0.43 0.08 0.04 0.01

All cancer sites

12 045

11.60

8 695

8.89

18 884

90.3

Age-standardized (World) incidence rates per sex, top 10 cancers

Data source and methods

Other cancers 3 376 (43.6%)

24 | 40

Cum.risk

355 294 278

Number of prevalent cases (5-year)

Breast 1 927 (24.9%)

(%)

417 380

Number of new cases

Colorectum 203 (4.7%)

Rank

Corpus uteri Leukaemia

Total: 12 045

Number of new cases in 2020, males, all ages

Prostate

Country-specific data source: Registre des cancers de Ouagadougou Method: "All sites" estimates from neighbouring countries partitioned using frequency data

Liver 450 (5.8%)

Corpus uteri 417 (5.4%)

Males

Incidence

Ovary 438 (5.7%)

Mortality

Total: 7 740

Country-specific data source: No data Method: Estimated from national incidence estimates by

Summary statistic 2020 Males

Females

Both sexes

Population

10 444 713

10 458 565

20 903 278

Number of new cancer cases

4 305

7 740

12 045

Age-standardized incidence rate (World)

96.1

128.1

112.0

Risk of developing cancer before the age of 75 years (%)

10.0

13.1

11.6

Number of cancer deaths

3 248

5 447

8 695

Age-standardized mortality rate (World)

74.7

94.1

84.4

Risk of dying from cancer before the age of 75 years (%)

7.6

10.0

8.9

5-year prevalent cases

6 466

12 418

18 884

Top 5 most frequent cancers excluding non-melanoma skin cancer (ranked by cases)

Prostate Liver Bladder

Breast Cervix uteri Liver

Breast Liver Cervix uteri

Non-Hodgkin lymphoma Colorectum

Ovary Corpus uteri

Prostate Bladder

modelling, using incidence:mortality ratios derived from cancer registry data in neighbouring countries

Females

35.9 32.7

Breast 14.1

Liver

7.9 18.2

Cervix uteri 7.4

Bladder

5.9

Corpus uteri

8.0

Ovary

7.8

Colorectum

3.6

Pancreas Leukaemia

4.0

3.2

Prevalence

3.8 2.1

2.9

1-;3- and 5-year prevalence ratios from Nordic countries for the period (2006-2015), and scaled using Human Development Index (HDI) ratios.

Age-standardized (World) incidence and mortality rates, top 10 cancers

Incidence Prostate

Mortality

35.9

23.8 32.7

Breast

20.3 18.2

Cervix uteri

14.3 10.9

Liver

10.6

Corpus uteri

8.0

Ovary

7.8

Bladder

2.9 6.4

6.5

Colorectum

4.2 3.8

3.1

Leukaemia

Page 1

ASR (World) per 100 000

Computed using sex-; site- and age-specific incidence to

Pancreas

5-year prevalence (all ages)

Number

Non-Hodgkin lymphoma Colon Pancreas

Prostate 997 (8.3%)

Bladder 661 (5.5%)

Deaths

Cancer

3.0

2.5

ASR (World) per 100 000

Page 2

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Number of new cases in 2020, both sexes, all ages

25 | 40

2. PROBLEM TREE TEMPLATE FOR PART 1, SESSION 1, SLIDE 4, D2

3. DOCUMENTS FOR PRACTICAL EXERCISE 2, SESSION 2, SLIDE 12, D3

INFORMED CONSENT The doctor / health worker has explained to me in detail about the tests with vinegar (VIA) and iodine (VILI) which enable the early detection and prevention of cervical cancer. I know that the surface of my cervix will be examined following the application of vinegar (5% acetic acid/diluted iodine solution), to detect or rule out precancer / cancer. I know that these examinations are not painful but that they can sometimes cause irritation or slight bleeding that will soon subside. I understand that if the test is positive, I will be advised to have other examinations, such as visual inspection of the cervix magnified using an instrument called a colposcope and analysis of a tissue sample from my cervix (biopsy), before I am given treatment. I have also been informed that, if abnormalities are detected (infection, precancer, cancer or complications), it may be necessary to prescribe treatment for me with medication or thermocoagulation (destruction of the diseased part of the cervix using a heated probe) or to remove the diseased part through a minor or more serious surgical intervention which may or may not be followed by radiotherapy.

26 | 40

Access to cervical cancer screening

Signature : Date : Name : Adress :

* Delete as appropriate

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

I hereby consent to the above tests and the treatment, if it is advised. * / I do not wish to undergo the above tests. *

27 | 40

4. BACKGROUND DOCUMENTS FOR A3 PRINTING AND LAMINATING

VIA RESULTS SUMMARY FORM 1. Unique number /clinic / record: __________________________

2. Date of test: ____________________________

3. Name: ___________________________________________________________________________ 4. Adress: ______________________________________________________________________ _________________________________________________________________________________________ 5. Age (in years): _______________________________

6.Education : ________________________________

7. When was your last period? ________

((1: None; 2: Primary; 3: Lower secondary; 4: Upper secondary; 5:

(1: Less than 12 months ago; 2: More than 12 months ago)

University; 9: Not specified))

8. Marital status: _______________________________ (1: Married; 2: Widowed; 3: Separated; 8: Other; 9: Not specified)

10. Total number of pregnancies /miscarriages: _________

9. Age at first sexual intercourse: _____

11. Are you experiencing any of the following symptoms?

(99, if not specified)

(Tick if answer is yes; leave blank if answer is no):

❏

Heavy vaginal discharge

❏

Pain during sexual intercourse

❏

Itching in the external anogenital region

❏

Bleeding after sexual intercourse

❏

Ulcers in the external anogenital region

❏

Bleeding between periods

❏

Pelvic pain

❏

Back pain

12. Results of visual inspection

28 | 40

❏

Squamocolumnar junction fully visible

❏

Leukoplakia

❏

Cervical polyp

❏

Genital warts (condyloma)

❏

Nabothian cysts

❏

Tumour

❏

Cervicitis

13. Results one minute after application of 5% acetic acid (VIA): _________ (1: Negative; 2: Positive; 3: Positive, invasive cancer) [ ]

14. If the VIA is positive, does the acetowhite lesion extend into the endocervical canal? _________ (1: Yes; 2: No)

15. S If the VIA is positive, how many quadrants are affected by the acetowhite lesion(s)? _________ (1: Two or fewer; 2: Three; 3: Four quadrants)

16. Diagram (indicate the squamocolumnar junction with a dotted line and the acetowhite / iodo-negative region(s) with a solid line)

IVA

17. Measures taken: __________________________________________________________ (1: Follow-up advised every five years; 2: Therapeutic treatment recommended for cervicitis and check-up in six months; 3: Referral for a colposcopy; 4: Referral for immediate treatment; 5: Referral for classification and treatment for invasive cancer; 6: Other, please specify_____________________________________________________________________________________________________________)

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

(Tick if answer is yes; leave blank if answer is no):

29 | 40

SCREENING AND TREATMENT ALGORITHM DEVELOPED WITHIN THE MDM PROJECTS IN BURKINA FASO AND IVORY COAST (2018)

TARGET POPULATION: WOMEN AGED 25 TO 55*

COMMUNITY

INSTRUCTIONS FOR - SELF-SAMPLING

HPV TEST

HR HPVHIV-

HR HPVHIV+

Screening at 5 years

HEALTH PROFESSIONAL OR SELF-SAMPLING

HR HPV+

Screening at 3 years

PRIMARY HEALTHCARE FACILITY

VIA TEST

VIA+

LESIONS AND VISIBLE SQUAMOCOLUMNAR JUNCTION, PRECANCEROUS LESION < 75% <75%

Screening at 1 year

VIA+

PRECANCEROUS LESIONS > 75 % OR ENDOCERVICAL

VIA+

SUSPICION OF CANCER

Conization hysterectomy

Do not carry out the test during menstrual periods No sexual intercourse the day before

REFERENCE HOSPITAL

BIOPSY

IN SITU CANCER

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Gently rotate the swab three times in the vagina and remove the swab

Immediately place it in the transport medium and seal the sample.

Precautions before sampling:

Thermocoagulation

COLPOSCOPY / LEEP

30 | 40

Gently insert the swab in the vagina on around 2/3 of the distance

Do not carry out vaginal wash or apply any product in the prior 24 to 48 hours Do not put any product in the vagina

INVASIVE CANCER

Surgery, radiotherapy, chemotherapy

*ALL HIV+ WOMEN AND SEXUALLY ACTIVE, AGE RANGE TO BE ADAPTED, ACCORDING TO THE MINISTRY OF HEALTH

PREVENTING INFECTIONS BY WASHING YOUR HANDS

SAMPLING PATHWAY PROTOCOL

SAMPLING

Transfer to the laboratory

TRANSPORTATION IN A COOLER WITH TEMPERATURE DISPLAY (VERIFICATION / TRACEABILITY / DATE OF SAMPLING)

Wet your hands Reception and registration

Quality control – Temperature display (15 to 30 °) - storage time less than 48 hours – traceability

pre-analysis

Technical information

Curve validation / interpretation

Transmission of the report within the deadline or contact with the health care professional if the sample is HR HPV+

Put the soap

Lather and scrub for 20 seconds

Rinse for about 10 seconds

Don't forget to wash:

NON-COMPLIANCE OF SAMPLING

RECEPTION OF REPORT BY THE MIDWIFE

between the fingers under your nails the top of your hands

Dry your hands

Turn off the water tap

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

VIA-

You dispose of a tube containing a swab. Open the tube

31 | 40

6. INSTRUCTIONS AND SCENARIO FOR PART 2, SESSION 5, SLIDE 25, D4

CERVICAL CANCER COUNSELLING SESSION: INSTRUCTIONS FOR PARTICIPANTS

COUNSELLING SESSION – SUSPECTED CERVICAL CANCER: INSTRUCTIONS FOR PARTICIPANTS

One set of instructions per person: the participants are divided into groups of three and allocate the roles of patient, healthcare professional and observer between them.

One set of instructions per person: the participants are divided into groups of three and then allocate the roles of patient, healthcare professional and observer between them.

You are going to perform a role play of a counselling session on cervical cancer prevention and screening. The consultation should enable the necessary information to be conveyed to the woman and include a counselling element which is essential for this type of consultation. (20 mins)

You are going to perform a role play of a counselling session following a consultation and the discovery of suspected cervical cancer. The consultation should enable the necessary information to be conveyed to the woman and include a counselling element which is essential for this type of consultation. (20 mins)

Instructions for scenario 1

Instructions for scenario 2

How are the following aspects covered by the actors in the role play?

Role 1: You are playing the role of a patient seeking information about cervical cancer because you have never heard of it. Role 2: You are playing the role of a healthcare professional. Role 3: You are the observer and will use the observation grid. 1 copy per observer.

Role 1: You are playing the role of a patient coming for a simple screening test and presenting with symptoms of irregular bleeding, but you don’t mention this during the screening. Role 2: You are playing the role of a healthcare professional who has discovered budding when taking a sample for the HPV test. Role 3: You are the observer and will use the observation grid. 1 copy per observer.

SCENARIO

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Aspects to look out for:

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Your comments:

SCENARIO Aspects to look out for:

Appropriate attitude (e.g., gestures, not interrupting the patient, empathy)

Tailored communication (e.g., language, tone)

Confidentiality

Respect (e.g., respect for choices, respect for other patients)

Positive points

Points to improve

Sharing:

Timing: 15 mins

Discuss the difficulties encountered and the key elements of the consultation. The trainer provides a recap of the main conclusions, clarifies the key messages, and finishes with a summary.

Your comments:

Discuss the difficulties encountered and the key elements of the consultation. The trainer provides a recap of the main conclusions, clarifies the key messages, and finishes with a summary.

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

5. INSTRUCTIONS AND SCENARIO FOR PART 2, SESSION 1, SLIDE 57, D2

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7. CASE STUDY FOR PART 2, SESSION 7, SLIDE 91, D5

8. ACTION PLAN FOR PART 2, SESSION 7, D5

ACTION PLAN

WHO PRACTICAL CASE STUDY (Comprehensive cervical cancer control – A guide to essential practice, 2nd Edition – 2017)

1 copy per healthcare facility Write down the actions you intend to take over the next 12 months.

‘Amelia’s story Amelia is a 57-year-old Angolan woman, with six children and many grandchildren. She was taken to the nearest district hospital, 95 km away from her home, by her eldest daughter, after she developed a vaginal discharge with a very bad odour, which persisted for many months. The doctor who examined her did some tests, and explained that she had advanced cervical cancer that had spread from her cervix to her vagina and bladder and the walls of her pelvis. The bad odour was caused by urine leaking from her bladder into her vagina and mixing with discharge from the tumour.

ACTION TO BE TAKEN

WHEN

PERSON RESPONSIBLE

34 | 40

The local health worker came to visit Amelia as promised. She told and showed Amelia and her daughter how to deal with some of the problems they were facing: how to prepare pads from old, clean clothes to absorb the vaginal discharge; how often to change them and how to wash them; how to apply petroleum jelly to the vaginal area as the skin was beginning to get irritated from the constant moisture; how to gently wash the area daily with soap and water and have sitting baths. With Amelia’s permission, she spoke to the family about supporting Amelia and each other during her illness and emphasized the importance of sharing the work as Amelia’s condition got worse. There would be more laundry, as bedding and underwear would need to be washed often; the bed should be protected from discharge and urine with a plastic sheet; medicines for pain could be bought at low cost from the local mission hospital, and someone would need to fetch them regularly; other help at home was available through Amelia’s church. Amelia’s family was poor, but the health worker helped to organize support from the community, the church and the local mission so that the needed supplies were usually there. The local health worker helped Amelia’s family to understand the importance of keeping Amelia involved in their daily lives, and the life of the community. The family arranged for friends to visit when Amelia felt well enough, they took turns preparing food and, when she became too weak to leave her bed, they made sure that someone was always there for her. Amelia felt that she was not cast aside because of her illness. Even as she approached death, conversation and good spirit kept the house full of life and Amelia felt loved and needed until the end of her life.’

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

The doctor said that unfortunately, at this stage, there was no treatment or cure for her cancer, but that she could be cared for and made comfortable at home. She also gave Amelia and her daughter instructions for managing and reducing the vaginal discharge and odour. She added that she worked with community health workers near Amelia’s village, who provide home-based care for people who are very sick with AIDS, cancer or other illnesses. Then the doctor wrote a referral note to the woman in charge of the home-based care organization, explaining Amelia’s condition and asking her to visit her at home. The doctor said she would work from a distance with the local health workers closer to Amelia’s village to make sure that Amelia would have the medicines she needed, including medicine for pain, which might get worse as the cancer progressed. Although Amelia and her daughter were shocked and saddened by the news, the doctor’s kindness and concern reassured them. Her promise to watch over her care with the local health workers made them both feel more confident and hopeful.

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9. SURVEYS FOR PART 2, SESSION 7, D5

CERVICAL CANCER EVALUATION: PRE-TEST AND POST-TEST 15 to 20 mins maximum Select the right answers (circle the correct answers)

The aim of this survey is to collect your opinions and suggestions relating to the training. Put a tick in the column you feel most reflects your experience for each question.

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

DID THE CONTENT OF THE TRAINING MEET YOUR EXPECTATIONS?

36 | 40

VERY SATISFIED

PARTLY SATISFIED

NOT REALLY SATISFIED

VERY DISSATISFIED

1. Do you think this training is useful for the design and implementation of your projects? 2. What do you think of the approach of alternating theory and practice? 3. What do you think about how well the group participation worked? 4. What do you think about the way the trainers delivered the training? 5. Do you think the training was good quality? 6. Do you feel you were made welcome? 7. What do you think about the way the training was programmed (amount of information, duration etc.) 8. What do you think about the venue and the way the training was organised?

Please note any suggestions or recommendations of how we could improve this training in the future

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Please tell us what you particularly enjoyed about the training

1. What are the risk factors for cervical cancer? a. Sexually transmitted infections b. Genital warts (condylomas) c. Tobacco d. Human papillomavirus (HPV) infection. 2. Human papillomavirus infection: a. Can be transmitted through any intimate contact b. Is completely avoidable by using a condom c. Can disappear spontaneously d. Can be transmitted by people of both sexes. 3. Precancerous lesions a. Can disappear spontaneously b. Can develop into cancer in 5 to 15 years c. Are a rare consequence of HPV d. In terms of histological classification, there are 4 types of precancerous lesions (CIN 1, CIN 2, CIN 3 and CIN 4) 4. HPV vaccination a. Provides protection from cervical cancer throughout the individual’s lifetime b. Provides protection from other types of cancer apart from cervical cancer c. Provides protection from all the oncogenic HPV types d. Provides protection mainly from HPV types 14 and 18. 5. What are the recommendations for cervical cancer screening? a. Every year if the patient is HIV positive and has a negative HPV test b. Every 3 years if the patient is HIV negative and has a negative HPV test c. Every 5 years if the patient is HIV negative and has a negative HPV test d. Every 3 years if the HPV test is positive but the VIA is negative. 6. Thermocoagulation… a. Has the same contraindications as cryotherapy b. Has genital infections as an absolute contraindication c. Has a side effect of heavy bleeding for 1 week d. Facilitates the necrosis of precancerous lesions at a depth of over 15mm.

Initial:

7. What are the appropriate precautions the health worker must communicate to a patient who comes for thermocoagulation? a. To come back if they have a fever lasting for 48 hours b. To come back if they have heavy bleeding for more than 5 days c. To use protection during sexual intercourse for 3 months d. To use only water for daily vaginal douching. 8. What do you do if you have doubts about a VIA following a positive HPV test? a. I assess it as negative b. I refer the patient to a higher-level healthcare facility or ask them to come back another day c. I ask a colleague to help me d. In the event of persistent doubt about a VIA, I perform a thermocoagulation procedure. 9. Cervical cancer a. Is the most deadly female cancer in Burkina Faso b. The standard treatment in the advanced stages is a combination of radiotherapy and chemotherapy c. Is a rare consequence of human papillomavirus (HPV) infection d. Is avoidable through screening. 10. Palliative care a. Only refers to end-of-life care b. Is part of primary care c. Is recognised as a fundamental human right for everyone d. Allows the provision of pain management.

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

TRAINING SATISFACTION SURVEY

37 | 40

SATISFACTION SURVEY BY TOPIC

SELF-ASSESSMENT FORM

The aim of this survey is to collect your opinions and suggestions about the training by topic (epidemiology of cervical cancer; HPV test; VIA test; and treatment of precancerous lesions). Put a tick in the column you feel most reflects your opinion for each question.

VERY SATISFIED

PARTLY SATISFIED

NOT REALLY SATISFIED

VERY DISSATISFIED

Relevance of the topic

The aim of this survey is to evaluate your knowledge. It is a self-assessment. Please complete the two columns (knowledge before training, knowledge after training). 1 = not at all capable 4= completely capable

SCORE YOUR KNOWLEDGE OF THE FOLLOWING TOPICS BETWEEN 1 AND 4

BEFORE TRAINING SCORE 1 TO 4

AFTER TRAINING SCORE 1 TO 4

Explain the general principles and challenges of cervical cancer screening (HPV test and VIA)

Educational approach Explain the natural history of cervical cancer Time management

38 | 40

Observation / Suggestion

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Ability to provide cervical cancer counselling

Ability to provide thermocoagulation treatment for precancerous lesions

Explain the principles and challenges of palliative care

TRAINING FOR CERVICAL CANCER PREVENTION - TRAINER’S HANDBOOK ANNEXES FOR THE EXERCISES

Working atmosphere

39 | 40

This document is supported by the Agence Française de Développement. The ideas and opinions expressed in this document do not necessarily represent those of AFD.

TRAINING PROGRAMME ON CERVICAL CANCER PREVENTION (P-CC) >> PARTICIPANT HANDBOOK

BASED ON REFERENCE DOCUMENTS AND RECOMMENDATIONS BY THE WHO

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GLOSSARY

CONTENTS

ACCP

Alliance for Cervical Cancer Prevention.

AGUS

Atypical Gandular Cells of Undetermined Significance

ASCUS

Atypical Squamous Cells of Undetermined Significance

Glossary Contents Foreword Aim of the programme

Cervical Cancer

INTRODUCTION

CIN

Cervical Intraepithelial Neoplasia

CIS

Carcinoma In Situ

CST

Cervical Smear Test

HSPC

Health and Social Promotion Centre

FIGO

International Federation of Gynaecology and Obstetrics

GICR

Global Initiative for Cancer Registry development

HIV

Human Immunodeficiency Virus

HPV

Human Papilloma Virus

HR-HPV

High Risk Human Papilloma Virus

HSIL

High-grade squamous intraepithelial lesion

IARC

International Agency for Research on Cancer

LSIL

Low-grade squamous intraepithelial lesion

MSCC

Medical Centre with Surgical Services

PAHO

Pan American Health Organisation

PATH

Programme for Appropriate Technology in Health

PCL

Precancerous lesions

SCJ

Squamocolumnar junction

SIL

Squamous Intraepithelial Lesion

SRHR

Sexual and Reproductive Health and Rights

STI

Sexually Transmitted Infection

VIA

Visual Inspection with Acetic Acid

VILI

Visual Inspection with Lugol’s Iodine

MDM POSITION: SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

PART 1: PREVENTION OF CERVICAL CANCER – COMMON SESSIONS COMMON SESSION 1: INTRODUCTION TO THE ISSUE OF CERVICAL CANCER AND MDM STRATEGY FOR PREVENTION AND CONTROL I. Background information on the eradication of cervical cancer II. Epidemiological situation COMMON SESSION 2: HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER I. Human papilloma virus II. Physiopathology of cervical cancer III. Prevention COMMON SESSION 3: INTERVENTION STRATEGY, PROTOCOL TESTING ALGORITHM AND DECISION-MAKING I. Screening strategies recommended by the WHO II. MdM’s screening strategy COMMON SESSION 4: COMMUNITY HEALTH APPROACH I. The multiple determinants of access to screening II. A community heath approach

2 3 4 5

6 14

16 17 18 22 23 24 27

34 35 35 44 45 45

COMMON SESSION 5: AWARENESS-RAISING AND HEALTH EDUCATION I. Health education II. Awareness-raising III. HIV and cervical cancer IV. Avoiding loss to follow-up

52 53 54 57 57

PART 2: CERVICAL CANCER PREVENTION – HEALTH SESSIONS

HEALTH SESSION 1: INDIVIDUAL COUNSELLING I. Counselling

60 61

HEALTH SESSION 2: HPV TESTING I. Introduction II. Available methods III. Xpert HPV test IV. Performing the sampling procedure V. Conditioning and shipment of samples VI. Delivery of test results

68 69 69 69 70 71 71

HEALTH SESSION 3: VISUAL INSPECTION WITH ACETIC ACID I. Background information II. Procedure III. Interpretation of the results

76 77 77 78

HEALTH SESSION 4: TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP I. Overview of available methods II. Thermocoagulation III. LEEP procedure IV. Background information

82 83 85 86 86

HEALTH SESSION 5: TREATMENT OF CANCEROUS LESIONS AND REFERRAL 92 I. Clinical form and cancer diagnosis 93 II. Staging system for cervical cancer development 96 HEALTH SESSION 6: INFECTION CONTROL AND UNIVERSAL PRECAUTIONS I. Background information and transmission cycle II. Basic principles of universal precautions III. Equipment monitoring and maintenance IV. Medical waste disposal

102 104 104 104 105

HEALTH SESSION 7: PALLIATIVE CARE, PAIN MANAGEMENT AND END-OF-LIFE CARE I. Palliative care: definition, key components II. Pain management III. End-of-life care

108 109 109 114

APPENDICES

118

FOR FURTHER INFORMATION

124

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK CONTENTS

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK GLOSSARY

•

3 | 128

FOREWORD

AIM OF THE PROGRAMME

Since 2010, Médecins du Monde (MdM) has considered sexual and reproductive health (SRH) to be a key issue and a priority. In 2012, the practical implementation of the SRH conceptual framework is based on a holistic approach and is integrated in the healthcare and rights continuum. It takes an approach based on human rights, reduction of gender inequalities and empowerment of individuals and communities. In 2013, the SRH Guidelines are developed to support the implementation of our projects.

OVERALL OBJECTIVE:

These three priorities are also part of a political statement in favour of the respect of sexual and reproductive health and rights, statement that is taken forward at project level as well as in more cross-sectional spaces of influence at regional and global level. Since sexual and reproductive rights are an essential requirement for sexual and reproductive health, MdM has progressively adopted the concept of Sexual and Reproductive Health and Rights (SRHR).

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK FOREWORD

As a part of MdM’s priorities, SRHR benefit from the continuous elaboration of tools based on international protocols that support our projects in a quality approach that enables our responses to be adapted to the populations’ needs and expectations.

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Given the importance of skills and competencies in order to implement the developed strategies and approaches, strengthening skills for MdM staff is a core element of the strategic orientations on this topic. This specific training programme was thus developed to enable teams and partners of MdM to gain an understanding of the topic of CC and enhance the integration of a promotion of sexual and reproductive health and rights approach in their projects. This programme aims at developing technical skills regarding: ➡ Prevention of cervical cancer ➡ Provision of quality care of precancerous lesions ➡ Taking advocacy measures in favour of the promotion and exercise of sexual and reproductive health and rights. Training of MdM teams and other actors in the field of CC is supported and laid down by a Multiannual Partnership Agreement 2018-2021 signed between MdM and AFD (French Development Agency), which targets two countries of intervention for this topic: Burkina Faso and Ivory Coast.

➡ To be able to develop and implement a project regarding the prevention of CC (P-CC) and care of precancerous lesions based on a public health approach and underpinned by the promotion of sexual and reproductive rights.

SPECIFIC OBJECTIVES: ➡ To take ownership of MdM’s strategy on P-CC and its integration in the overall SRHR strategy. ➡ To have a general understanding of the global epidemiological situation regarding CC, the main public health issues at stake and the strategies for primary and secondary prevention. ➡ To be able to devise and implement awareness-raising activities at community level so as to strengthen users’ individual capacities on the issue of CC and promote the empowerment of individuals and communities. ➡ To be able to devise and implement CC screening and testing activities as per the defined algorithm: testing or self-sampling (HR-HPV) and triage using visual inspection. ➡ To be able to devise and implement activities regarding care of precancerous lesions. ➡ To be able to devise and implement activities for the referral and counter-referral in case of diagnosed cancerous lesions. ➡ To be able to devise and implement activities in relation to pain management and community end-of-life care (palliative care).

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK AIM OF THE PROGRAMME

In 2014, the SRH strategy was validated with a focus on three elements, three breaking points in the healthcare and rights continuum. These points are key public health issues that are subject to both stigma and neglect, despite their major impact on mortality and morbidity for women and girls: 1. Prevention and management of unwanted pregnancies through access to comprehensive sexuality education, contraception, and safe abortion. 2. Response to SRH needs in crisis settings, including prevention and care for survivors of Gender-Based Violence (GBV). 3. Prevention of cervical cancer (CC) through screening and early treatment of precancerous lesions.

INTRODU

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1. INTRODUCTION TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS: KEY CONCEPTS AND DEFINITIONS

SRHR (see below figure on continuum of care in SRHR). Because sexual and reproductive rights are an essential premise to sexual and reproductive health, MdM decided to use the term of SRHR as defined by the Guttmacher-Lancet Commission.

Sexual and reproductive health and rights

2. MDM’S POSITION AND STRATEGY IN SEXUAL AND REPRODUCTIVE HEALTH

‘Sexual and reproductive health is a state of physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity. Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust, and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right1 .

a) MDM’s position regarding SRHR Health is a universal human right to which every person is entitled, and it must be guaranteed by the States. For MdM, this implies to support and strengthen public health systems so that they ensure access to care and respect of the right to health. It is also necessary to strengthen the individual capacities of users, as rights holders, so that they become aware of their rights and may claim them. In 2010, MdM asserted its commitment towards the respect of SRHR and universal access to sexual and reproductive health services. This implies strengthening the healthcare continuum from community level to reference centres, at all steps of the users’ life.

REFERRAL COUNTER-R EFERRAL FIRST LEVEL HEALTH CARE FACILITY

COMMUNITY

CHILDHOOD

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE: ➡ ➡ ➡

ADULTHOOD

OLD AGE

INFORMATION, COUNSELING AND SERVICES FOR SEXUAL HEALTH AND WELL-BEING

INFORMATION, COUNSELING AND SERVICES FOR SUBFERTILITY AND INFERTILITY

PREVENTION, DETECTION, IMMEDIATE SERVICES AND REFERRALS FOR CASES OF SEXUAL AND GENDER-BASED VIOLENCE

COMPREHENSIVE SEXUALITY EDUCATION

SAFE ABORTION SERVICES AND TREATMENT OF COMPLICATIONS OF UNSAFE ABORTION

ANTENATAL, CHILDBIRTH AND POSTNATAL CARE, INCLUDING EMERGENCY OBSTETRIC AND NEWBORN CARE

COUNSELING AND SERVICES FOR A RANGE OF MODERN CONTRACEPTIVES

PREVENTION AND TREATMENT OF HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS

PREVENTION, DETECTION AND MANAGEMENT OF REPRODUCTIVE CANCERS, ESPECIALLY CERVICAL CANCER

Definition of sexual and reproductive health and rights MdM’s position and SRHR strategy Key advocacy messages.

L RRA EFE R R TE COUN

PRACTICAL SKILLS: ➡ ➡

ADOLESCENCE

Identify the main barriers to exercising sexual and reproductive health and rights Identify the core elements of the national regulatory framework in relation to sexual and reproductive rights.

L ERRA REF

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The implementation of this commitment is based on two complementary approaches: ➡ A public health approach through the provision of holistic, quality care services that respect the healthcare continuum and are accessible to all.

CONTINUUMCONTINUUM OF CARE IN SRH FIGURE 1: HEALTHCARE IN SRHR

R E F E R RA L

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

In order to guarantee sexual and reproductive health and rights, an essential package of intervention must be made available: comprehensive sexuality education, counselling and services offering effective contraceptives, antenatal care, emergency obstetric care (both antenatal and postnatal), comprehensive abortion care, prevention and treatment of HIV and other STI, prevention, screening and care of genderbased violence (GBV), information, counselling and services in sexual health and well-being, and services regarding hypofertility and infertility. These interventions are essential and a part of MdM’s approach to ensure the healthcare continuum in

IMPORTANT: SRH ACTIONS ARE NOT ONLY FOR WOMEN BUT MUST INCLUDE MEN, LGBT AND INTERSEX PEOPLE.

REFERRAL HOSPITAL

1. Guttmacher-Lancet Commission, Accelerate Progress—Sexual and Reproductive Health and Rights for All, 2018

CONTINUUM OF CARE OVER TIME CONTINUUM OF CARE IN SPACE

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

INTRODUCTION MDM POSITION: SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS

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Financial barriers And sociocultural determinants that may prevent access to services.

For further information, see: Sexual and Reproductive Health and Rights Guideline

b) MDM’s strategy MdM acknowledges the importance of a holistic approach that enables care of people throughout the continuum of care, at community level, primary care level through to reference centres. This holistic approach enables care to be delivered to people throughout their life course in the area of sexuality and reproduction. (See figure 1.) The identification of the components of this continuum and the associated healthcare provision is based on the definition of integrated health and sexual and reproductive rights given by the Guttmacher Lancet Commission in 2018. Enhancing access to healthcare services and respect of the right to health are essential ways to strengthen the healthcare continuum. To achieve this, four elements must be taken into account (see figure 2): Geographical barriers Legal and administrative barriers

This is why the implementation of projects providing sexual and reproductive health care, requires strengthening or enhancing the development of initiatives that may lift these barriers. Regarding financial barriers, any initiative allowing care to be delivered free of charge should be encouraged. Regarding geographical barriers, the development of referral pathways between the community, primary healthcare centres and reference centres is paramount. Regarding legal barriers, advocacy actions in favour of the respect of sexual and reproductive rights will be undertaken. In addition, the consideration of sociocultural barriers can also strengthen the adequacy between the offer of care and the needs of the individuals. Reflection on access to healthcare services should be undertaken in partnership with health authorities and local stakeholders so as to work hand-in-hand and avoid creating parallel or contradictory strategies. Three delays are pointed out that are the cause of most maternal deaths and disabilities2: ➡ Delayed arrival at the healthcare centre: This delay is structural, due to impassable roads and limited

communication which delay the point of first contact with healthcare services. ➡ Delayed identification of complications: Lack of knowledge of clinical signs, difficulty in assessing risk and insufficient access to family planning services are reasons for delayed first contact. ➡ Delay in dispensing appropriate care: Health centres do not have the operative resources to care for the patients. There is a lack of skilled professionals along with a lack of human and material resources that limit the scope of care for complications linked to delivery. Therefore, MdM’s strategy aims at strengthening capacities in order to exercise sexual and reproductive health and rights and at implementing integrated comprehensive and quality SRHR services in the countries of intervention. The aim of this strategy is to (see figure 3): 1. Strengthen the continuum of care in SRHR at all stages of the project and in partnership with the actors involved. 2. Enhance users’ ability to exercise their sexual and reproductive health and rights. 3. Strengthen the exercise of sexual and reproductive rights and reduce gender inequalities through the involvement of community actors and users at each step of the project.

FIGURE 2: BARRIERS AND DELAYS IN ACCESSING CARE IN SRHR

BARRIERS

DELAYS

CHILDHOOD

ADOLESCENCE

ADULTHOOD

EM PO W

DELAYS

OLD AGE

CONTINUUM OF CARE OVER TIME >>

SRH IN A CRISIS CONTEXT

PREVENTION OF CERVICAL CANCER

BARRIERS

For further information: SRH Strategy 2014-2017.

EMPOWERMEN T / GEN DER-B ASE D

GEOGRAPHICAL BARRIERS

ECONOMIC BARRIERS

DELAY IN DECIDING TO SEEK CARE AND IN IDENTIFYING HEALTHCARE SERVICES DELAY IN DISPENSING APPROPRIATE CARE AT HEALTH FACILITY LEVEL

2. WHO (2003), Maternal deaths disproportionately high in developing countries, press release, Media Centre

APP RO AC H

EMPOWERMENT

CHILDHOOD

ADOLESCENCE

ADULTHOOD

OLD AGE

CONTINUUM OF CARE OVER TIME >>

MENTAL HEALTH

SRH IN A CRISIS CONTEXT

PREVENTION OF CERVICAL CANCER

REFERRAL HOSPITAL

ADVOCACY

DELAYS

LEGAL BARRIERS

T EN M ER

HEALTHCARE PROVISION

ACH PPRO ED A S A R-B DE EN /G

PREVENTION AND CARE OF UNWANTED PREGNANCIES

RRAL R-REFE COUNTE

In reaction to breaking points in the continuum of care in SRHR, three areas of intervention have been identified as priorities:

BARRIERS

PREVENTION AND CARE OF UNWANTED PREGNANCIES

Similarly, MdM focuses its action in areas where health services are most scarce, as well as in crisis or conflict settings, where access to SRHR services is often impeded and girls and women are more vulnerable.

SOCIAL AND CULTURAL BARRIERS DELAY IN GOING TO A HEALTH FACILITY

EMPO WERME NT / GENDE R-BASED APPROACH

R I G H T S BAS E D

AC H O R APP

WERMENT / EMPO GE NR E

ERRAL REF

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

FIRST LEVEL HEALTH CARE FACILITY

COMMUNITY

REFERRAL

8 | 128

COUNTER-REFERRAL

MdM is specifically involved in improving women’s right to choose their motherhood, the number of children and the spacing of pregnancies, and thus in improving access to services that enable to exercise these rights in safe conditions. Adolescents are a vulnerable group that require particular attention with regards to sexual and reproductive health. Young girls are specifically exposed to the risks of sexual violence, early marriages and pregnancies that are risk factors for their health.

3: MDM’S SRHR STRATEGY: CONCEPTUAL FRAMEWORK MEDECINSFIGURE DU MONDE SRHR STRATEGY – CONCEPTUAL FRAMEWORK

BARRIERS AND DELAYS TO SRHR CARE

REFERRAL

4. Accompany social change and contribute to changes in public policy to improve the acknowledgement of sexual and reproductive rights and guaranteeing universal and effective access to SRHR services.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

➡ An approach based on promotion of sexual and reproductive health and rights through advocacy actions in favour of the right to access adequate health services.

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UNWANTED PREGNANCIES

Unmet contraceptive needs : 214 MILLION WOMEN

25 MILLIONS

unsafe abortions per year

3RD CAUSE of maternal mortality

SHRH AND GBV IN CRISIS SETTINGS

61% OF MATERNAL DEATHS are recorded in countries facing a humanitarian crisis OVER 71% OF WOMEN EXPERIENCE GBV in countries affected by crises

CERVICAL CANCER PREVENTION

311,000 DEATHS per year

85% IN LOW OR MEDIUM INCOME COUNTRIES

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

MEETING THE NEEDS FOR MODERN CONTRACEPTION AND QUALITY CARE CAN HELP REDUCE :

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75%

unwanted pregnancies

74%

induced abortions

73%

maternal deaths

3. DETERMINANTS OF SRHR AND TYPES OF BARRIERS TO EXERCISING SRHR A person’s state of health is defined by complex interactions between individual, social, cultural, environmental, financial, and political factors. These determinants of health explain the inequalities in health within a country or between two countries. It is important to take them into account and address these determinants to improve a population’s health. Moreover, these determinants have an impact on the availability of adequate and quality provision of care but also on the access to healthcare services. The presence of an available service does not necessarily guarantee that it is used in practice. By taking account of all determinants of access to sexual and reproductive healthcare, MdM strengthens its commitment to enhancing the links between levels of care for women and newborns.

a) Sociocultural barriers

Sociocultural determinants of access to healthcare may be defined as all popular norms, values, knowledge and practices associated with health, and governing actions and thinking about health, illness and also care. Taking account of sociocultural determinants enables to strengthen communication between the various actors of a given health project and the targeted population, and thus improves the quality of our projects by taking account of needs, values and norms held by service users. Performing a sociocultural diagnosis at the onset of a project is a recommended step in order to identify the key community actors, to understand the barriers to accessing care, the therapeutic pathways and understand the views on sexual and reproductive health, in particular regarding unwanted pregnancies. For further information: MdM Guideline: Access to healthcare and sociocultural determinants.

b) Geographical barriers

Geographical barriers represent the physical distance that exists between care provided and demand for it. Geographical access is determined by the distance and time of transportation, which depends on the mode of transportation available for the woman and the difficulty of the journey. First and foremost, it depends on the availability of SHRH services in health facilities close to communities. To reduce geographical barriers, it is important to ensure the availability and quality of services, to improve referral pathways and to reduce the financial impact of transportation on families’ budget.

c) Financial barriers

Direct payment by users in health facilities is an obstacle to healthcare. Healthcare is often costly and unpredictable for families with a low income. Financial barriers include direct and indirect cost of care. Indeed,

seeking care may also imply shortfalls as a result of the interruption of income-generating activities. MdM took a stand in 2012 on financial access to care and is committed to introducing or extending free access to primary health care. Thus, we particularly act in support of free healthcare policies covering all aspects of the continuum in SHRH. For further information: MdM Position paper 2012 Améliorer l’accessibilité financière aux soins de santé primaire [Improving financial access to primary healthcare].

d) Legal and political barriers

Barriers to accessing SHR services, in particular access to contraception (notably for minors), to post-abortion care or to medical abortion, may be induced by a restrictive political and legal environment regarding these issues. Inappropriate administrative procedures can also impede the free exercise of rights (e.g., compulsory advice from several persons, “cooling-off” period…) An analysis of the regulatory framework is an essential premise of any SHRH project and must be continued throughout the implementation of the project, as it influences the quality and nature of the service provision, as well as the manner in which the rights of women are considered. Beyond service provision, integrating advocacy actions to the project can help lift barriers and enhance the exercise of sexual and reproductive rights. CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

FIGURE 4: 3 PRIORITIES AREAS OF INTERVENTION IDENTIFIED BY MDM

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NOTES

KEY MESSAGES ➡ Sexual and reproductive health is a state of complete well-being, physical, emotional, mental, and social in relation to sexuality and the reproductive system, and is not merely the absence of disease, dysfunction, or infirmity. This includes the ability to: • Have a satisfying sex life • Access information on family planning (FP) and use a chosen contraceptive method • Access health services that accompany women in pregnancy and birth.

➡ What do I take away from this session? ➡ What elements require further clarification?

➡ To achieve and maintain good sexual health, all individuals must see their sexual rights respected, protected, and exercised. ➡ MdM supports the right of women to choose their motherhood, the number of children and the spacing of pregnancies. ➡ MdM’s commitment to SRHR is based on both a public health approach and the promotion of sexual and reproductive rights approach.

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➡ Sexual and reproductive rights are regulated by international legal instruments in relation to human rights in general and women’s rights in particular, which are binding for the States. ➡ Barriers to the exercise of SRHR can be sociocultural, geographical, financial, legal, administrative. ➡ MdM participates in advocacy actions in favour of universal access to contraception and in favour to lifting legal restrictions and obstacles to safe abortion.

➡ Understandings to develop?

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION

➡ SRHR are a key theme for MdM and must be understood as a part of the healthcare continuum. However, three breaking points in this SRHR continuum have been identified as priorities: • Prevention and management of unwanted pregnancies • Responses to SRHR needs in crisis settings, and notably response to physical and/or sexual violence, • Prevention of cervical cancer.

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PART 1 CERVICAL CANCER PREVENTION COMMON SESSIONS

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I. BACKGROUND INFORMATION ON THE ERADICATION OF CERVICAL CANCER « One woman dies of cervical cancer every two minute. Each one is a tragedy, and we can prevent it. » Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) Cervical cancer is a disease caused by a viral infection by human papilloma virus (HPV). This virus is sexually transmitted, and most cases could be avoided through adequate screening. Due to inequalities, this cancer’s mortality rate is higher in low- or middle-income countries with failing health systems. In addition to its impact on mortality, it also has a human, social and financial impact that constitutes a real burden for these countries. Prevention and screening of precancerous lesions, followed by appropriate treatment when required, are essential to prevent new cases of cancer. The last WHO recommendations include the involvement of countries and leaders globally. In fact, it is the first time that 194 countries commit to eradicating that type of cancer, following the adoption of a resolution during the World Health Assembly in 2020.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION TO THE ISSUE OF CERVICAL CANCER

a) The strategy for elimination of CC adopted on November 16th, 2020 is based on the following standpoints:3

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MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ Knowledge of epidemiological data on cervical cancer ➡ Articulate the key elements of MdM’s strategy for prevention of cervical cancer.

PRACTICAL SKILLS:

➡ Understanding MdM’s strategy ➡ Understanding the challenges of setting up CC prevention.

➡ View participation to the response given to noncommunicable diseases as a step toward universal access to health. ➡ Recognize the commitment of populations, in particular women and girls, families, and communities. ➡ Include all stakeholders as essential to the management of the health system, to fully empower people to improve and protect their own health. ➡ Promote access to diagnosis, screening, treatments, and affordable care, as well as to vaccination reducing the risk of cancers such as CC and view this promotion as a step towards a more comprehensive approach to prevention and control. ➡ Implement and upscale any measures proved as financially effective to achieve eradication of CC as a public health issue, including the following: HPV vaccination, screening and testing for precancerous lesions, early diagnosis and treatment of invasive cancers, and use of palliative care. ➡ Embrace a holistic approach to prevention and control of CC: This includes vaccination programmes, screening and treatment programmes, specific services for adolescents, specific services for HIV and sexual and

reproductive health, and both communicable and non-communicable diseases. ➡ Encourage the creation of strategic and inclusive partnership at national, regional, and global level, with a scope that goes beyond the health sector. ➡ Consider prioritisation of young girls’ vaccination against HPV as the most effective long-term intervention to reduce the risk of CC. To that end, access to vaccination must be enhanced and their distribution must be facilitated by reducing costs to foster the integration of the HPV vaccination in national immunisation programmes. ➡ Foster research and collaborations, which will enable innovation in the fields of vaccination, screening, diagnosis, treatment, and provision of care in relation to CC.

b) The WHO strategy is based on 3 key steps: vaccination, screening, and treatment. The global strategy for the eradication of cervical cancer suggests the following goals to be pursued: ➡ A world where CC is eliminated as a public health problem. ➡ A threshold of 4 per 100 000 women per year affected by CC, for elimination as a public health problem. ➡ The 90-70-90 targets must be reached by 2030 for countries that are on the path towards cervical cancer elimination. ➡ A mathematical model that illustrates the benefits of achieving the 90-70-90 targets for the eradication of CC by 2030 in low- or middle -income countries. ➡ The median CC incidence rate must decrease by 42% by 2045, and 97% by 2120, thus preventing over 74 million new cases of CC. ➡ The aggregated median number of avoided deaths from CC will be of 300 000 by 2030, over 14 million by 2070, and over 62 million by 2120. The main risk factor for developing cervical cancer is a persisting infection with Human Papilloma Virus (HPV). HPV is mainly transmitted through sexual contact. 99.7%4 of cervical cancers are indeed associated with an HPV infection. HPV is therefore a necessary condition for the development of cervical cancer and precancerous lesions. At first, the persistence of the virus does not cause cytological or histological modifications (latent infection); eventually, it may cause lesions such as condyloma or intraepithelial neoplasia. Therefore, Médecins du Monde acts by tackling different angles: ➡ Developing the experience and technical expertise of the organization on this topic.

3. The Seventy-third World Health Assembly (03/08/2020), Global strategy to accelerate the elimination of cervical cancer as a public health problem and its associated goals and targets for the period 2020–2030, Agenda item 11.4 4. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, et al. (1999), Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol.;189(1):129

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION TO THE ISSUE OF CERVICAL CANCER

COMMON SESSION 1 INTRODUCTION TO THE ISSUE OF CERVICAL CANCER AND MDM STRATEGY FOR PREVENTION

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FIGURE 5: 90-70-90, WHO*

MAP 2: INCIDENCE OF CC MORTALITY AT GLOBAL LEVEL, WHO 2020

Estimated age-standardized mortality rates (World) in 2020, cervix uteri, all ages

ASR (World) per 100 000

Not applicable No data Data source: GLOBOCAN 2020 Graph production: IARC (http://gco.iarc.fr/today) World Health Organization

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION TO THE ISSUE OF CERVICAL CANCER 18 | 128

➡ Integrating screening and treatment of precancerous lesions within SHRH services. ➡ Setting-up partnerships and referral pathways to guarantee the continuum between the community and primary healthcare facilities, or secondary facilities in the case of uterine cancer. ➡ Developing operational research activities to facilitate the implementation of the screening algorithm, as well as the implementation of effective care adapted to the context of each intervention, in order to influence international recommendations in terms of P-CC.

II. EPIDEMIOLOGICAL SITUATION a) Definition Epidemiology is the study of the distribution and determinants of the state of health and events linked to health, as well as the use of this knowledge to fight illnesses and other health issues.

b) Global epidemiology

MAP 1: GLOBAL INCIDENCE OF CC, WHO 2020

Every two minutes, a woman dies of cervical cancer worldwide, 266 000 in 2012, 90% of which occurred in a low- or middle-income country. Among the 528 000 new cases of cancer diagnosed in the world, 85% occurred in the least developed regions.

According to the World Health Organisation (WHO), cervical cancer will kill 443 000 women per year in the world in 2030. Over 98% of these deaths will occur in developing countries, among which 90% in SubSaharan Africa. The increase in cervical cancer rates in the world, and particularly in Africa, is currently undermining the progress made in the last 20 years in terms of reducing maternal mortality and morbidity.

ASR (World) per 100 000

Not applicable No data

The data presented above underlines important disparities between women living in high-income countries and those living in low-income countries.

The main reason for this disparity is the relative absence of efficient screening programmes. Cervical cancer is thus diagnosed too late, preventing the recourse to efficient treatment. In high-income countries, the incidence and mortality rates for cervical cancer have decreased in the last 30 years, through prevention programmes (screening, diagnosis, and early treatment of cancers).

Estimated age-standardized incidence rates (World) in 2020, cervix uteri, all ages

≥ 25.2 16.7–25.2 11.7–16.7 7.0–11.7 < 7.0

Cervical cancer is the most frequent female cancer in 45 countries. These countries are in Sub-Saharan Africa, many countries in Asia and some countries of Central America (see maps 1 and 2)5.

Data source: GLOBOCAN 2020 Graph production: IARC (http://gco.iarc.fr/today) World Health Organization

FIGURE 6: WHO ESTIMATED MORTALITY RATES BY CC 2012 600 DEATHS ATTRIBUTED

* WHO (17 November 2020), 2030 targets toward the elimination of cervical cancer, Official twitter account

543 000

500

Mat erna

l mo

400 300 200 100

ncer

m cervical ca

Mortality fro

190 000

0 1990

443 000

-47%

rtali

287 000 275 000 +45%

1995 2000 2005

2010

2015

2020

2025

2030

c) HIV and CC 6 « As the world commits to working together to eliminate CC, let us pay attention and we will end this avoidable burden on women and girls with HIV. It is our work » Dr Princess Nono Simelea, Assistant Director-General for Family, Women, Children and Adolescents at WHO. Women who are HIV positive are six times more likely to develop CC. This increased risk is present throughout the life cycle and begins with a higher risk of being infected with HPV and a quicker progression into cancer, less chance of regression of precancerous lesions and higher rates of disease recurrence after treatment. 40-50% of women living with HIV have cervical cancer. It is therefore essential to screen them.

5. WHO (2019), Estimated age-standardized mortality rates (World) in 2018, Cervix uteri, Females, All age 6. WHO (November, 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV, https://www.who.int/news/ item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION TO THE ISSUE OF CERVICAL CANCER

≥ 16.4 9.0–16.4 5.7–9.0 2.8–5.7 < 2.8

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NOTES

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➡

Over 340 000 women die each year of cervical cancer. This represents one woman every two minutes.

➡

Illness caused by the persistence of HPV, a sexually transmitted virus.

➡

This illness could be avoided in a majority of cases through adequate screening.

➡

Over 85 % of deaths occur in low- or middle-income countries, where access to screening and treatment is insufficient.

➡

4th female cancer in the world.

➡ What do I take away from this session? ➡ What elements require further clarification?

➡ Understandings to develop?

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTRODUCTION TO THE ISSUE OF CERVICAL CANCER

KEY MESSAGES

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II. HUMAN PAPILLOMA VIRUS a) Introduction

LESIONS

Infection by Human Papilloma Virus (HPV) is the most frequent viral infection in the reproductive system. Most men and women with a sexual activity will be infected at one point in their life, and some may be infected several times. There are many types of HPV, a lot of which cause no disorder. HPV infections generally disappear without treatment within a few months and 90% will spontaneously disappear within 2 years after the date of the infection. A small proportion of infections caused by certain types of HPV can persist and develop into cancers. Cervical cancer is by far the most frequent illness linked with HPV. Almost all cases of cervical cancer can be linked to HPV infection. While data is limited regarding anogenital cancers other than cervical cancers, there is a growing body of evidence that enables a correlation to be made between HPV and anal, vulvar, vaginal, and penile cancer. Even if these cancers are less frequent than cervical cancer, their association with HPV makes them potentially avoidable using the same primary prevention strategies as those applicable to cervical cancer. Some oral cancers and laryngeal cancers can also be caused by oncogenic HPV, contracted through oral sexual contact.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

b) Human Papilloma Virus

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➡ High oncogenetic risk HPV or HR HPV, present in cases of invasive cervical cancers

Characteristics HPV is a DNA virus which belongs to the family of the Papilloma Viridae which encompasses 200 types of virus. ➡ Low oncogenetic risk HPV causing acuminated condyloma

Cutaneous warts Acuminated condyloma Intra-epithelial cervical neoplasia, cervical cancer, anal and genital cancers Oral papillomatosis, recurring laryngeal papillomatosis Laryngeal Carcinoma

THEORETICAL KNOWLEDGE:

➡ Explain the basic physiopathology of CC ➡ Cite elements of primary and secondary prevention ➡ Cite elements of risk and vulnerability to HPV.

PRACTICAL SKILLS:

➡ Discuss representations around HPV and CC.

6, 11

16, 18

The typology of HR HPV varies depending on the geographical area, however HR HPV 16 and 18 are the most frequent in the case of diagnosed cancer.

c) Mode of transmission Direct transmission HPV transmission is mostly through sexual contact, even without penetration. Skin-to-skin contact of sexual organs can be enough to infect the partner. HPV virus is highly contagious. The risk of infection is at its highest at the beginning of sexual activity for both men and women. Low-oncogenetic types of HPV can coexist with HR HPV. Indirect transmission Due to its resistance to environmental conditions, the papillomavirus may be transmitted indirectly, however this is rare; it can resist in water, towels, public baths, saunas… (e.g., plantar warts).

MAP 3: TYPE OF HPV BY GEOGRAPHICAL LOCATION, WHO

MODULE LEARNING OUTCOMES

ASSOCIATED TYPES OF HPV 1, 2, 3, 7, 63, 26, 27... 6, 11, 16, 51… 16, 18, 31, 45, 33, 68…

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

COMMON SESSION 2 HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER BACKGROUND INFORMATION

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e) Risk factors for the occurrence of HPV

HPV causes infections that are most often benign and asymptomatic.

Infection with HPV is necessary to cause cancer, but it is not sufficient as such. Several cofactors have been identified to date7 that may facilitate the contamination with HPV and therefore may participate in increasing risk of developing cervical cancer:

Depending on the type, there may be a variety of associated lesions: condyloma, cutaneous warts, oral papillomatosis, or -in the case of HR HPV- cervical, anal, vaginal, or vulvar cancers. The virus can cause lesions that may appear a few months after contracting the virus but in some cases, the silent period can last months or years. This period where the virus is present but dormant is called the latency period.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

The types of HPV which are non-carcinogenic (6 and 11 in particular), can cause acuminated condyloma and respiratory papillomatosis (whereby tumours develop in the respiratory tract between the nose and mouth and the lungs). While these affections rarely cause death, they may result in a strong occurrence of the illness. Acuminated condyloma are frequent and highly contagious.

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Condyloma Condyloma are small lesions of the mucosa and can take many forms: ➡ Acuminated condyloma: look like skin-coloured, small warts or cauliflower-like growths. They may be isolated or grouped in one or several localisations. ➡ Papular condyloma: take the shape of small warts (papula) skin-coloured or pink, isolated or confluent. ➡ Condyloma lata: look like plane spots (macula), they are red or skin-coloured. Therefore, they are not always visible. They are localised in the genital or anal area and are most often not painful. They can be external or internal. Depending on sexual practices, it is possible that condyloma be found in the mouth. Lesions can disappear spontaneously, but their size and number usually tend to grow. Cervical cancer In the case of high oncogenetic risk HPV-16 and HPV-18, which are responsible for cervical cancer, the symptoms are directly related to advanced precancerous lesions and can take the form of: ➡ Abnormal vaginal bleeding: outside regular monthly bleeding or during sexual intercourse ➡ Pain in the back, leg, or pelvis ➡ Loss of appetite or weight loss ➡ Tiredness ➡ The evolution of a cancer takes places over 15 to 20 years (except for women with HIV where evolution is quicker, in 4-5 years).

Exogenous factors ➡ High number of sexual partners ➡ Young age at first intercourse seems to play a role, however there is a link between young age and high number of partners. ➡ Tobacco through cocarcinogenic action and immunodepression. ➡ Multiparity: having given birth several times vaginally exposes a zone of the cervix called ectocervix. This exposure facilitates HPV infection. ➡ A link has been demonstrated between the occurrence of cervical cancer and co-infection by another STI, in particular HSV-2, chlamydia trachomatis and of course, HIV. Viral cofactors Infection with a HR HPV is a requirement but the oncogenetic profile depends on the genotypes. HPV 16 and 18 are major factors of an evolution into cancer. Host factors Endogenous hormone rates (number of pregnancies, menopausal status); genetic factors and individual immune response capacity (individual immune deficiency) play a role in carcinogenesis8.

II. PHYSIOPATHOLOGY OF CERVICAL CANCER a) Anatomy of the cervix Anatomy The uterine cervix is about 3 cm long. It is positioned on the lower end of the uterus and forms a canal between the uterus and the vagina. It is primarily composed of connective tissue and muscles. It can be divided into two main regions: ➡ The endocervix, which is the internal part of the cervix attached to the uterus; ➡ The ectocervix, which is the external, circular lip-shaped part of the cervix protruding into the vagina. The endocervical canal is the area in the centre of the cervix which links the uterine cavity with the vagina. The cervix opens into the vagina through the external os. The supravaginal area of the cervix meets the muscular area of the uterus at the internal os. Multiparous women have voluminous cervix and the

7. Munoz N, Castellsague X, de Gonzalez AB, Gissmann L (august 2006). Chapter 1: HPV in the etiology of human cancer. Vaccine 8. Faridi R, Zahra A, Khan K, Idrees M. (2011), Oncogenic potential of Human Papillomavirus (HPV) and its relation with cervical cancer. Virol J.;8(6):18.

external os is uneven and wide and has a fish-mouth appearance. Nulliparous women have an external os which appears smooth and round. FIGURE 7: FRONT AND SIDE VIEW OF FEMALE INTERNAL ORGANS, WHO9

fallopian tube

uterus ectocervix

ovary

endometrium endocervix vagina vulva

endocervical area), on the ectocervix, which is called ectropion. After menopause, there is a retraction of the SCJ into the endocervical canal. At microscopic level, two main types of cells are found in the cervix: ➡ Columnar Cells cover the endocervical canal. These are glandular cells that produce mucus. They are named columnar cells because of their column-like shape and their length. ➡ Squamous Cells cover the ectocervix and the vagina. They are flat and thin, similar to fish scales.

FIGURE 9. THE TRANSFORMATION ZONE OF THE CERVIX OF A PAROUS WOMAN OF REPRODUCTIVE AGE, WHO11

original (native) squamocolumnar junction transformation zone new squamocolumnar junction

The ectocervix is the part of the cervix that is exterior to the external os. It is the only visible part of the cervix during a speculum examination. The part of the cervix that lies internally, above the external os is called the endocervix. FIGURE 8: UTERINE CERVIX, WHO 10

squamocolumnar junction (SCJ) endocervix (columnar epithelium) ectocervix (squamous epithelium)

original (native) squamous epithelium metaplastic squamous epithelium columnar epithelium external os

The area where the squamous cells meet the columnar cells is called the squamocolumnar junction. It is also referred to as the transformation zone, as large columnar cells constantly change into squamous cells, in particular during puberty and the reproductive period. Precancerous lesions and most cervical cancers originate in this transformation zone.

b) Physiopathology The cervix is in a precancerous condition when the changes undergone by certain cervical cells make them more at risk of developing into a cancer. This condition is not yet a cancer but there is a high risk of evolving into cervical cancer if untreated. When a precancerous condition is not treated, it may take up to 10 years before a cancer develops, but it may be shorter than that.

The ectocervix and the endocervix join at the squamocolumnar junction. The endocervical canal is the canal within the cervix that links the uterine cavity with the vagina. It lies from the internal os to the external os. The squamocolumnar junction (SCJ) is a hormonally determined zone and therefore its localisation changes overtime. During puberty, pregnancy and under progestogen treatment, there may be appearance of physiological columnar mucosa (as found in the 9. WHO (2014), Comprehensive Cervical Cancer Control, A guide to essential practice, 2nd Edition 10. Ibid. 11. Ibid.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

d) Symptoms of an infection with HPV

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mild pre-cancer

moderate to severe pre-cancer

invasive cancer

superficial layer

d) The phenomenon of clearance13

Precancerous lesions are also called cervical intraepithelial neoplasia or CIN. They can take various forms that are more or less severe. A classification helps differentiate three main types of lesions according to their severity:

The amount of time between the infection with HPV and the development of cancer is varying. In fact, at least 60% of mild dysplasia will spontaneously clear whereas 10% will evolve into moderate dysplasia within 2 to 4 years following the time of infection, and only 50% of dysplasia will develop into invasive cancer. HPV infection is mostly TRANSIENT and in time the cytological and histological abnormalities will disappear.

intermediate layer

CIN 1: abnormal cells represent 1/3 of the thickness of the epithelium; CIN 2: abnormal cells represent 2/3 of the thickness of the epithelium; CIN 3: abnormal cells touch the entire epithelium.

basal layer  basement membrane 

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

Precancerous conditions of the cervix initiate in a region that is called the transformation zone. This is where a type of coating (columnar cells), continuously transform into another type (squamous cells). The transformation of columnar cells into squamous cells is a physiological process. However, it makes these cells more sensitive to the effects of human papilloma virus (HPV). Precancerous modifications of the cervix are somewhat frequent. They can occur at any age, but it is mostly women in their 20’s or 30’s. Infection with human papilloma virus (HPV) is the main risk factor for precancerous changes in the cervix and of cervical cancer.

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Precancerous lesions include both cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ. Both lesions are asymptomatic. There usually is a long-time span between their appearance and their evolution into invasive lesions, which leaves time for screening and diagnosis. Persistent infection of cervical mucosa by HPV is necessary to the development of precancerous lesions and cervical cancer. Precancerous conditions of the cervix are characterised by the extent of the abnormalities of the cells (visible using a microscope) and the severity of cellular changes. They are grouped according to the type of cell that present with abnormalities.

Cervical intraepithelial neoplasia CIN represent a variety of lesions characterised by cellular disorganisation, mainly linked to impaired differentiation and proliferation of abnormal cells. The number and localisation of these abnormalities enable to classify CIN with regards to their severity and talk about simple infections lesions (CIN 1) or pre-invasive lesions (CIN 2 and 3). Epidemiological data suggests a recent rise in the incidence and prevalence rates of CIN and a decreased mean age of patients presenting these lesions. For patients with a CIN 3, the risk of developing a cancer after 30 years is estimated between 31 and 50% in the absence of treatment. For CIN 3 the estimated time to develop a cancer varies between 5 and 19 years, but faster evolutions are sometimes reported, specifically when there is infection with HPV16. Adenocarcinoma in situ The Adenocarcinoma in situ (AIS) represents 1% of precancerous cervical lesions and is usually found in women between 25 and 30 years, thus 10 to 20 years before the development of invasive adenocarcinoma. The frequency of these lesions is rising for young women. Around 50% of AIS are associated with intra-epithelial squamous lesions. Up to 90% of AIS are said to be HPV-induced (especially HPV18).

LESIONS

REGRESSION

PERSISTENCE

PROGRESSION INTO A HIGHER SEVERITY OF CIN

DEVELOPMENT INTO INVASIVE CANCER

CIN 1

57%

32%

11%

CIN 2

43%

35%

22%

CIN 3

32%

56%

It will take between 10 and 20 years for mild dysplasia to develop into carcinoma. This slow evolution makes cervical cancer easily avoidable if it is screened. Figure 10 illustrates this clearance phenomenon.

III. PREVENTION a) Introduction Prevention and diagnosis of precancerous lesions, followed by adequate treatment when required, are the key actions to prevent the 530 000 new cases of uterine cancer that are diagnosed every year.

Today, some screening tests exist that are affordable and easy to use, which could reduce the burden of death by cervical cancer in the least developed countries. The WHO recently acknowledge the importance of committing to prevention and screening of cervical cancer at a global scale. Some countries are beginning to integrate this issue in national health policy. However, there is a lack of resources that prevents effective implementation and access of women to simple and effective solutions to prevent this disease that may have disastrous consequences in the case of delayed diagnosis. Primary prevention: the public health aim is to reduce infection with HPV. The key interventions are the following: vaccination, comprehensive sexuality education and promotion of the use of condoms. Secondary prevention: the public health aim is to reduce the prevalence and the incidence of CC and its associated mortality, by preventing precancerous lesions of developing into invasive cancer. The key interventions are information, screening, and treatment of precancerous lesions.

FIGURE 11: WHO’S COMPREHENSIVE APPROACH TO CERVICAL CANCER CONTROL: OVERVIEW OF PROGRAMMATIC INTERVENTIONS DELIVERED ACROSS THE LIFETIME TO PREVENT HIV INFECTION AND CERVICAL CANCER

HPV infection

Pre-cancer

9 Years old

15 Years old

30 Years old

Cancer

45 Years old

60 Years old

PRIMARY PREVENTION

SECONDARY PREVENTION

TERTIARY PREVENTION

GIRLS 10-14 YO

WOMEN AGED 30 OR MORE

WOMEN SUFFERING FROM INVASIVE CANCER

• HPV Vaccination: 10-14 years old • sexual health and health education : > − 10 YO - Sex education adapted to age - Counselling in contraception - Preventing tobacco use and smoking cessation for smokers

Screening and treatment: • ‘Screen and treat’ low-cost strategy [VIA followed by cryotherapy] • Molecular screening test and typing of HR HPV

• Surgery • Radiotherapy • Chemotherapy

>12 * Adapted from WHO Guidance Note (2013) Comprehensive cervical cancer prevention and control: a healthier future for girls and women, Geneva 13. WHO (2007), Comprehensive Cervical Cancer Control, A guide to essential practice

12. WHO (2014), Comprehensive Cervical Cancer Control, A guide to essential practice, 2nd Edition

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Normal

c) Histological Classification

ESTIMATED RELATIVE PREVALENCE

FIGURE 10: PROGRESS FROM NORMAL EPITHELIUM INTO INVASIVE CANCER, WHO 12

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➡ Comprehensive sexuality education. ➡ Promotion of the use of condoms.

b) Primary prevention

The age range must be adjusted at national level, in accordance with available data on sexual activity for young people. There are three types of vaccines to date, the characteristics of which are summarised and compared in the following table:

Vaccination The WHO recommends systematic vaccination against HPV for young girls aged 9 to 14, given that in most countries they do not have any sexual activity at that age.

Primary prevention aims at reducing infection with HPV through 3 actions: ➡ Vaccination of young girls aged 9 to 14 years-old (3 injections 6 months apart).

TABLE: SUMMARY OF THE CHARACTERISTICS OF ANTI-HPV VACCINES*

CHARACTERISTICS

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TYPE OF VACCINE

BIVALENT (CERVARIX)

QUADRIVALENT (GARDASIL®/SILGARD®)

Virus-Like Particle (VLP) Virus-Like Particle (VLP) with with L1 recombinant plasmid L1 recombinant plasmid

NINEVALENT 9VHPV Virus-Like Particle (VLP) with L1 recombinant plasmid

TYPES OF HPV IN THE VACCINE

16, 18

6, 11, 16, 18

6, 11, 16, 18, 31, 33, 45, 52, 58

PROTECTION

Cervical cancer (and precancerous genital lesions of the cervix, vulva and vagina)

Cervical cancer (and precancerous genital lesions of the cervix, vulva and vagina) Condyloma acuminata

CROSS-PROTECTION

31, 33

31, 45

Unnecessary

NUMBER OF REQUIRED DOS-ES

DOSING INTERVAL

0 and 6 months (no maximum interval, but it is recommended not to exceed 12-15 months)

0 and 6 months (no maximum interval, but it is recommended to not exceed 12-15 months)

MODE OF ADMINISTRATION

Intramuscular injection

PHARMACEUTICAL FORM AND TYPE OF VACCINE VIAL MON-ITOR (VVM)

Single dose vial, VVM 30 Two-dose vial, VVM 30

Single dose vial, VVM 30

Single dose vial, VVM to be determined

STORAGE TIME

48 months at 2-8 °C for the single dose vial

36 months at 2-8 °C for the two-dose vial The vaccine is freezesensitive.

36 months at 2-8 °C, the vaccine is freeze-sensitive

EFFECTIVE COADMINISTRATION WITH OTHER VACCINES FOR ADOLESCENTS**

Hepatitis B Diphtheria/Tetanus/ Pertussis Poliomyelitis

Diphtérie/ Tétanos/ Coqueluche Poliomyélite

CONTRA-INDICATIONS

Severe allergic reaction to one of the constituents of the vaccine following the first dose Severe febrile illness Pregnancy

While there is no maximum interval between doses, it is suggested not to exceed 12 to 15 months. If the interval between doses is inferior to five months, a third dose will be administered at least 6 months after the first dose, regardless of the reasons for this early injection. A three doses schedule (0, 1-2, 6 months) is recommended for girls aged 15 or more and for immunosuppressed patients, including those positive for HIV (whether or not they are treated with antiretroviral). It is not necessary to screen for infection with HPV or HIV before vaccinating against HPV. The present recommendations regarding the immunisation schedule apply to both bivalent and quadrivalent vaccines. Natural infection is not a protection label. The low concentration of antibodies is not enough to provide protection against reinfection and reactivation of the virus. HPV vaccination for boys and men is under discussion, and it is important to increase the co-responsibility of people regardless of gender, to the public health problem of CC. However, it is less cost-effective in reducing the incidence of CC in comparison with large scale vaccination of a high proportion of young girls in the targeted age group. This is all the more the case that there is a current shortage of vaccines worldwide. To ensure vaccination uptake, the programme must be associated with strong communication to stand up against the rise of anti-vaccination movements. This is why particular focus should be given to advocacy actions and community involvement, to reassure populations on the efficiency, safety, and benefits of the vaccine. The WHO website provides regular updates of summary tables on recommendations for systematic vaccination. For further information regarding vaccination, refer to chapter 4 of Comprehensive Cervical Cancer Control, A guide to essential practice.

Severe allergic reaction to one of the constituents of the vaccine following the first dose Severe febrile illness Pregnancy

* WHO (2016), Guide to introducing HPV vaccine into national immunization programmes ** WHO (2017), WHO Guidance Note - Comprehensive cervical cancer prevention and control: a healthier future for girls and women, Geneva 28 | 128

According to the WHO Guidance Note 14 (November 2020), the targeted population should be girls between 9 and 14 years old, before the beginning of sexual activity. The recommended immunisation schedules should provide two doses spaced by 6 months, for girls under the age of 15 (this also includes girls 15 or older when injected with the 2nd dose).

Promoting comprehensive sexuality education15 « Comprehensive sexuality education is a curriculumbased process of teaching and learning about the cognitive, emotional, physical and social aspects of sexuality. It aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to realize their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives. » UNESCO 2018. The contents must be adjusted to age and cultural context and must include messages to decrease unsafe sexual behaviours. Promoting the use of condoms Encourage appropriate and systematic use of condoms (masculine or feminine), promoting condoms (masculine and feminine) are key factors to reduce STI.

c) Secondary prevention Secondary prevention of cervical cancer focuses on three components: Access to information This requires an in-depth understanding of social, cultural and structural barriers in a given environment so as to develop strategies that guarantee easy access to services. Women from local communities must be decision-makers in these programmes, as they are allies 16. Screening Enhancing the integration of screening services in spaces usually dedicated to sexual and reproductive health services17. Treatment of precancerous lesions Screening for cervical cancer is achieved by systematic testing of cervical abnormalities in an asymptomatic population. The women targeted in this screening may feel perfectly healthy and feel no need to consult in a health facility. Screening services may be organised or opportunistic (this is when women are screened on the occasion of their access to services for another reason), or both. It is common knowledge that organised screening is more cost-effective than opportunistic screening, as it enables better use of available resources and larger coverage of the service.

14. WHO (November 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV, https://www.who.int/news/ item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination 15. UNESCO (2015), Emerging evidence, lessons and practice in comprehensive sexuality education: UNESCO (2018), Education 2030: International technical guidance on sexuality education, An evidence-informed approach. UNESCO (2010), International Technical Guidance on Sexuality Education: An Evidence informed approach for schools, teachers and health educators, Vol.1, The Rationale for Sexuality Education 16. WHO (November 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV, https://www.who.int/news/ item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination 17. Ibid.

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Tertiary prevention: the public health aim is to reduce the number of deaths caused by CC. The key interventions are the setting up of referral pathways for patients to adequate facilities, accurate and timely diagnosis of CC and appropriate treatment at each stage in accordance with the diagnosis. It is important to work on health professionals’ representations as they may influence professional practice.

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The current available options to screen and treat precancerous lesions include the following: « Screen, triage and treat » – Use of a screening test providing immediate results (HPV test) followed by a triage examination and immediate treatment (through thermocoagulation of the lesions) without waiting for additional test results, except if cancer is suspected. Early detection and treatment of precancerous lesions enable to prevent most of cervical cancers. Three different types of tests are currently available: ➡ Traditional test (Papanicolaou smear test) and liquid-based cytology (LBC) ➡ Visual inspection with acetic acid (IVA) ➡ HPV test enabling the identification of high-risk HPV. (for example, types 16 and 18).

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HUMAN PAPILLOMA VIRUS AND CERVICAL CANCER

Sequential testing – realisation of a second screening test (triage test) for patients screened positive for the first test, and treatment if precancerous lesions are confirmed.

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Screening and realisation (for women with positive test results) of colposcopy and biopsy, and treatment according to the results of the biopsy. In 2012, there were almost a billion women between 30 and 49, and most of these women had never been screened in their life.

d) Tertiary prevention In many countries, the capacities to provide these services are insufficient, or the existing services are not accessible or affordable for a majority of women. The main difficulties faced in the implementation of efficient treatment systems are the following: ➡ Elaborating reference documents and guidelines developing and promoting the implementation of measures to manage cervical cancer18. ➡ Enhancing access to high quality equipment19. ➡ Enabling broader access to surgical treatment20. ➡ Developing and sustaining a referral network

towards a specialised referral facility: The main challenge in delivering treatment is to develop and sustain an efficient and quality network that will enable referral and timely access to care, while ensuring the continuum by linking the health facility with the referral unit, the laboratory and diagnosis and treatment centres. A referral protocol and effective communication system must be in place to ensure the efficiency of the referral system. The referral network may vary between countries and also depends on the health system of each country. ➡ Treatment compliance: it is also very difficult to get a treatment completed when it requires prolonged stay in a treatment centre location at regional or national level. Geographical, financial, and social barriers frequently lead to noncompliance, in particular regarding radiotherapy. Ensuring support for accommodation and travel expenses and/or providing an allocation to compensate lost working hours may play an essential role in enabling women and their families to overcome difficulties for the duration of the treatment. In countries that lack the resources to treat this type of cancer, it is useful to be aware of intergovernmental agreements for referral to neighbouring countries and put them to use. ➡ Palliative care: Ensure that patients with cervical cancer in a life-threatening stage benefit from care regarding pain and suffering (physical and psychological). This requires resources, specialised skills, and supervision. Effective palliative care implies a team of physicians, nurses and other specialists and members of the community working in collaboration at facility level, community level and family level. According to Hunt, Nouvet, Chénier et al. (2020) 21, many barriers exist to the integration of palliative care, specifically in the humanitarian field. These barriers include: ➡ The prevailing notion of Ethos (saving lives) encourages focus on reducing mortality, thus leading to health professionals setting aside other approaches such as alleviation of suffering. ➡ The lack of time in crisis setting leading actors to overlook palliative care instead of including them as an integrated element of the humanitarian response. ➡ The lack of available resources and need to prioritise will lead professionals to set aside patients that might require palliative care. ➡ The difficulty to communicate with funders on this type of approach. ➡ The lack of guidelines, specific protocols, and

18. WHO (November 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV, https://www.who.int/news/ item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination 19. Ibid. 20. Ibid. 21. Hunt, Nouvet, Chénier, et al. (2020), Addressing obstacles to the inclusion of palliative care in humanitarian health projects: a qualitative study of humanitarian health professionals’ and policy makers’ perceptions. Conflict and Health

clinical standards. ➡ The scarcity of skilled members with experience of palliative care. ➡ Barriers to accessing opioids in some countries. ➡ Cultural barriers. Nonetheless, there is growing discussion on palliative care and end-of-life. Humanitarian action ought to integrate issues around suffering and respect of patients’ dignity, alongside the fight to prevent mortality.

e) Possible intervention Requires a cross-sectional and ambitious approach with the following foundations: ➡ Empowering women: strengthening selfdetermination and women’s capacity to make their own decisions ➡ Reducing gender inequalities ➡ Respecting fundamental rights for all ➡ Reducing poverty. Key components ➡ Adopt a health promotion approach enhancing empowerment and a healthy life course ➡ Protecting the exercise of rights to health, education, safety, etc. ➡ Strengthening comprehensive sexual education ➡ Planning preventative interventions for the age group 25-50 years old ➡ Eliminating marriage before the age of 18, preventing violence and sexual coercion ➡ Involving men to help them contribute to their health ➡ Taking action with local stakeholders and public services ➡ Enabling women to participate in the development of projects that affect them should be the cornerstone of any action. The true challenges are the fight against poverty, gender inequalities, discrimination and lack of access to services.

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To treat precancerous lesions, the favoured technique is loop electrosurgical excision procedure (LEEP). In contexts where this method cannot be used, or where resources are limited, the most recent WHO guidelines recommend cryotherapy as another method to satisfactorily treat lesions diagnosed by Visual Inspection with Acetic Acid (VIA). In countries that have the adequate resources, other techniques such as cold knife cone may be used.

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NOTES

KEY MESSAGES ➡

Papillomavirus is a very frequent group of viruses worldwide, but most infections are transient.

➡

HPV is a necessary condition: CC is mainly caused by infection by HPV transmitted through sexual contact. HPV represents a group of over 200 types of viruses, of which over 40 can be transmitted through genital contact.

➡

Only a small percentage of the overall infections with HPV will be responsible

➡ What do I take away from this session? ➡ What elements require further clarification?

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➡

Two vaccines are approved in most countries, that enable the prevention of infection by high-risk HPV types 16 and 18. The vaccine cannot be used as therapeutic treatment.

➡

Vaccination of young girls before the beginning of sexual activity is an important aspect of primary prevention.

➡

Even the girls who were vaccinated will need to be screened and test for cervical cancer. Vaccination do not provide protection for all HPV, and in addition, we do not know the duration of the effectiveness of the vaccine.

➡ Understandings to develop?

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for invasive cancer.

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I. SCREENING STRATEGIES RECOMMENDED BY THE WHO The WHO recommends strategies that allow women to benefit from timely care and that avoid loss to followup as much as possible. Thus, they encourage the use of rapid screening methods that enable the delivery of results and treatment of women in a single visit. This is the case for the « test and treat » and « sequential testing » methods that are carried out with rapid tests (VIA/VILI and/or point-of-care HPV testing). ‘Screen & treat’: a single visit with a method that allows for immediate delivery of results (e.g.: VIA) and immediate treatment if necessary. Sequential testing: carry out an initial screening test, followed by a confirmation test (if initial tests results are positive), and treat if necessary. Both tests may be carried out on the occasion of a single visit, or two sequential visits. The step requiring confirmation of the diagnosis by colposcopy and biopsy is not efficient in low-income countries.

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The WHO recommends expanding the coverage of the screening rather than its frequency.

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The WHO recommends screening all women aged 30 to 49. This age group may be extended depending on age-related prevalence and life expectancy. Screening by HPV testing results in an important increase in false positives.

FIGURE 12:. SCREENING STRATEGY, WHO*

HPV TEST

POSITIVE

NEGATIVE

Rescreen after a minimal interval of 5 years

VIA NEGATIVE

VIA

IVA POSITIVE

Effectuer un nouveau dépistage après 1 ans

SUSPICIOUS FOR CANCER

Refer to appropriate diagnosis and treatment

Eligible for cryotherapy, treat with cryotherapy

Not eligible for cryotherapy, treat with LEEP

Post-treatment follow-up at 1 year

II. MDM’S SCREENING STRATEGY a) MdM’s strategy to prevent CC The MdM Strategy Médecins du Monde’s objective to reduce morbidity and mortality caused by cervical cancer takes

MODULE LEARNING OUTCOMES

account of recommendations by the WHO. It includes three innovations based on scientific and technical knowledge of the area. The three suggested innovations are:

POWER TO TAKE ACTION

Choice between self-sampling and test by a health professional

QUALITY

Screening of HPV by PCR technique to improve the quality of the screening

THEORETICAL KNOWLEGE:

➡ Explain the developed screening and testing algorithm ➡ Identify the key actors involved at each stage of the algorithm.

INNOVATION

Use of thermocoagulation as an alternative to cryotherapy to treat precancerous lesions

PRACTICAL SKILLS:

➡ State the specificities of the MDM model and their rationale ➡ Position the activities linked to CC in relation to existing services.

* WHO (2014), Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention, WHO guidelines, http://www. who.int/reproductivehealth/publications/cancers/screening_and_treatment_of_precancerous_lesions/en/

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COMMON SESSION 3 INTERVENTION STRATEGY, PROTOCOL TESTING ALGORITHM AND DECISION-MAKING

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Our algorithm is based on the following 4 elements to enhance programme optimisation: ➡ Definition of the target population ➡ Choice of screening test ➡ Elaboration of the screening modalities ➡ Definition of the interval between screenings. Target population The WHO recommends to screen women between

30 and 49 years old, favouring coverage over the repetition of the screening for a given patient. This is because infections with HR-HPV are very frequent in young girls, but most of these are transient: they will disappear spontaneously from the woman’s body. Only a small percentage of HPV infection persist for several years and will cause cervical cancer. However, younger, or older women may be offered screening, depending on their risk of developing precancerous lesions. Screening women under 30, in particular for HR-HPV, will increase false positives

FIGURE 13: FIGURE SUMMARISING SAMPLING PROCEDURES IN P-CC (MÉDECINS DU MONDE 2019),

TARGET POPULATION: WOMEN AGED 25 TO 55*

COMMUNITY

HPV TEST

HR HPVHIV-

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Screening at 5 years

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HR HPVHIV+

HEALTH PROFESSIONAL OR SELF-SAMPLING

HR HPV+

Screening at 3 years

PRIMARY HEALTHCARE FACILITY

VIA TEST

VIA-

Screening at 1 year

VIA+

LESIONS AND VISIBLE SCJ, PRECANCEROUS LESION < 75% <75%

VIA+

PRECANCEROUS LESIONS > 75 % OR ENDOCERVICAL

VIA+

SUSPICION OF CANCER

Thermocoagulation

COLPOSCOPY / LEEP

REFERENCE HOSPITAL

BIOPSY

IN SITU CANCER

Conization hysterectomy

INVASIVE CANCER

Surgery, radiotherapy, chemotherapy

*ALL HIV+ WOMEN AND SEXUALLY ACTIVE, AGE RANGE TO BE ADAPTED, ACCORDING TO THE MINISTRY OF HEALTH

and overtreatment. Indeed, a majority of women will contract an HPV infection during the first sexual intercourses, and this may cause cervical lesions, most of which will heal spontaneously. Screening for women older than 55 is not deemed pertinent, given the life expectancy in many countries, and since CC is an illness that requires years to develop (approximately 10 years). The WHO is also in favour of expanding coverage rather than increasing frequency of screenings. In HIV+ patients, screening will be offered for all sexually active women as soon as they are aware of the seropositive status, and regardless of their age. People excluded from the target population: ➡ Women who have had a hysterectomy (for a benign disease) ➡ Age groups defined by WHO recommendations and national strategies <30 years and > 50 years ➡ Women having been treated twice by cryotherapy and thermocoagulation ➡ Women with suspected cervical cancer ➡ Women up to date with their tests (avoid over testing which has no added benefit). Screening modalities Screening makes it possible to select people in general population who are carriers of an affection through systematic use and not on the basis of symptoms. It is a public health action. It therefore classifies a large number of apparently healthy people into two categories: those who probably have the disease and those who probably do not, with the aim of reducing the morbidity and/or mortality of the disease in the screened population. There are two different types of screening: ➡ Organized (or mass) screening applies to an age group, by invitation. It is set up according to specifications and is subject to quality control. It applies to the population with no particular risk factor. ➡ Opportunistic (or individual) screening is an individual, not a collective, approach. During a contact with a health professional, a person requests or is offered screening. Choice of screening test 22 The 2020 WHO recommendations include: ➡ Visual inspection with acetic acid (only if the junction zone is visible). ➡ Search for HR-HPV with a threshold ≥1.0 pg/ml: the search for HR-HPV is the method of choice recommended by the WHO in middle-income countries when this is financially possible, as an addition or in substitution of direct visualisation methods.

The WHO suggests triaging patients whose acetic acid screening is positive: only patients that are positive to both the HPV test (HPV+) and the acetic acid test (VIA+) will be offered treatment. Women with positive HPV (HPV+) that have a negative acetic acid test (VIA-) will be tested again after a year. In addition, the WHO points out that even if carrying out a test with acetic acid is easy to implement in contexts where the resources are limited, its quality depends on the expertise of the practitioner, which makes for variations in effectiveness. Defining the screening modalities Two aspects must be envisaged regarding screening modalities for CC, that depend on the choice of screening test: ➡ The use of self-sampling in the screening for HRHPV ➡ The development of a ‘screen, triage and treat strategy’. Self-sampling: Screening was more efficient with self-sampling when these tests enable to increase coverage by >20%, despite the loss of sensitivity when compared to tests by a practitioner. In the recommendations published in 2020, the WHO recommends setting up a ‘screen, triage and treat’ programme where treatment is decided upon a positive test result, without need for the histological confirmation by a diagnostic test. The testing strategy may be in the form of single test, which, if positive, will suffice to begin treatment. It may also be in the form of sequential testing, in which case women with all tests positive will be treated, while the others will be more closely monitored. Women at risk of developing precancerous lesions must benefit from adequate treatment, and women with suspected invasive cancer must be referred to an appropriate facility. Given that one of our tests is based on the search for HPV, the ‘screen, triage and treat’ strategy will only be possible in facilities with a laboratory. Definition of the interval between tests The timespan between two screenings depends on the patient’s medical history: ➡ 1 year: seronegative patients with HR-HPV positive and VIA negative test results, patients must then benefit from an HPV test. ➡ 3 years: HIV positive patients with HPV negative results. ➡ 5 to 10 years: HIV negative patients with HR-HPV negative results. This interval may be adapted according to the evolution of knowledge and research in the field.

22. WHO (November 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV, https://www.who.int/news/ item/19-08-2020-world-health-assembly-adopts-global-strategy-to-accelerate-cervical-cancer-elimination

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b) Intervention Algorithm

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FIGURE 14: FIGURE SUMMARISING SAMPLING PROCEDURES IN P-CC (MÉDECINS DU MONDE, 2019)

c) Issues at stake MdM strategic issues

Encouraging all eligible women to cervical cancer screening

COMMUNITY

Counselling all women about cervical cancer HEALTH PROFESSIONAL OR SELF-SAMPLING

Training

Interdependent nature of VIA

Referral pathway

Setting up a pathway depending on the diagnosis or course of action

Communication system

Efficient communication system between health facilities is required to en-sure the efficacy of the referral pathway (indicator)

Lost to follow-up/ Patient follow-up

Common definition of lost to follow-up Setting up a contact system (contact persons) Establishing a register

HPV TEST

Link ensured between screening services and treatment and follow-up af-ter treatment CANCER SUSPICION

HR HPVHIV-

Screening at 5 years

HR HPVHIV+

HR HPV+

Screening at 3 years

Recommending VIA / counseling

REFUSES

ACCEPTS

The patient must be referred elsewhere if she wishes

AFFECTED BY CERVICITIS

YES: provide ATB

PRIMARY HEALTHCARE FACILITY

Traceability

Developing a data protection system with anonymisation

Medical waste

Partnership with reference hospital

Quality of sample transportation

Quality indicator Appropriate equipment

Referral and counter-referral Partnerships between health facilities Evaluation

To set up

The elaboration of the patient pathway is a crucial step in defining MDM’s strategy of intervention.

The following figures highlight the various barriers in the care pathway.

It takes account of any obstacles that patients may face in their pathway of care. Medical waste management is also an important issue to address.

The barriers to accessing services must lead to the elaboration of a strategy to strengthen the health system. G

VIA TEST

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VIA+, PRECANCEROUS LESION > 75 % OR ENDOCERVICA

VIA+ ,VISIBLE SQUAMOCOLUMNAR JUNCTION, PRECANCEROUS LESION < 75%

FIGURE 15: PATIENT PATHWAY / HSPC (WITHOUT LABORATORY) VIA-

“SCREEN, TRIAGE AND TREAT” IN 2 MEDICAL CHECK-UP

Recommending thermocoagulation Counselling

REFUSES

Advise to repeat VIA or HPV test within 1 year

ACCEPTS

Screening at 1 year

Awareness-rising at community level in HSPS

The patient must be referred elsewhere if she wishes

HPV sampling (self-sampling or by a practitioner)

transport in a cooler sample analysis

PATIENT PATHWAY / HSPC

THERMOCOAGULATION

RISKS OF LOSS TO-FOLLOW-UP

result reporting and appointment in HSPS RISKS OF LOSS TO-FOLLOW-UP

VIA+

Coming back within a year

VIA-

medical follow-up consultation / couseling patient discharge

VIA / thermo-coagulator advice for use

Refer for further evaluation or cancer treatment

REFERENCE HOSPITAL

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VIA+

SUSPICION OF CANCER

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FIGURE 16: PATIENT PATHWAY / MEDICAL CENTER (WITH LABORATORY)

KEY MESSAGES

“SCREEN, TRIAGE AND TREAT” IN 1 MEDICAL CHECK-UP

HPV sampling (self-sampling) Awareness-rising at community level in HSPS

sample analysis

PATIENT PATHWAY / MEDICAL CENTER

➡

The MDM strategy is based on three principles of action: strengthening service provision, reinforcing individual capacities, and taking advocacy actions.

➡

The service provision for the screening of CC is based on an integrated approach of ‘screen, triage and treat’.

➡

The target population are all women from 30 to 55, except women who have benefitted from treatment (cryotherapy, thermocoagulation, LEEP, cold knife cone or more invasive).

➡

Women who are HIV + require close monitoring regardless of their age and from the onset of their sexual life.

➡

Identifying all the barriers to service provision should enable to develop a strategy for strengthening the health system.

result reporting / counseling

medical follow-up VIA / thermo-coagulator

patient discharge

advice for use

FIGURE 17: MEDICAL WASTE MANAGEMENT

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TRACEABILITY ISSUES

Medical waste

HPV sampling (self -sampling) / endocervical

Transport by cooler with temperature indicator to MC

QUALITY ISSUES

Sample analysis

TRAINING ISSUES

Destruction of medical waste / Refrence hospital

PARTNERSHIP ISSUES Medical waste transportation

Medical waste disposal

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MEDICAL WASTE MANAGEMENT

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➡ Understandings to develop? CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INTERVENTION STRATEGY, PROTOCOL TESTING ALGORITHM AND DECISION-MAKING

NOTES

➡ What do I take away from this session? ➡ What elements require further clarification?

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I. THE MULTIPLE DETERMINANTS OF ACCESS TO SCREENING

and treatment of cervical cancer.

‘Sensitisation and awareness-raising alone are not enough to improve screening uptake. During the design phase, screening programmes should take into account structural and cultural barriers that may negatively impact on the uptake of screening services and, where possible, address these.’23 Barriers to accessing screening for CC are not limited to the availability of the test or the dissemination of information. Many other factors can be involved such as the lack of transportation, women’s uneasiness with male healthcare practitioners, lack of confidentiality or hygiene in health facilities, language barriers, family commitments limiting or preventing women from travelling, lack of support from men who have the power over women’s health choices, etc. Unless there is an in-depth understanding of the context of the intervention, a project to promote screening for CC may be inefficient at best, if not counterproductive24.

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Thus, during the design stage and throughout the interventions, it is crucial to explore, identify and take account of all structural determinants (financial, political, legal etc.) and sociocultural determinants (gender relationships, health practices, perception of body and illness, etc.) that have an impact on acceptability and accessibility to screen, prevention,

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The involvement of the people who are directly affected through a community approach, from the onset of the intervention is paramount to correctly identify the determinants of access to screening and to set up activities that are adapted to the people and context and respond to their needs.

II. A COMMUNITY HEALTH APPROACH ‘Cervical cancer prevention programs that listen to and learn from the community and that involve community members in program implementation and materials development are more likely to increase demand, ensure follow-through for treatment, and, ultimately, reduce disease burden’25 What is a community health approach? Strengthening community action is one of the five pillars of health promotion as defined by the WHO in the Ottawa Charter 26. It is defined as ‘the process of enabling people to increase control over and to improve their health and that of the community”. It is defined as the process through which individuals and families take responsibility for their own health and well-being, participate in enhancing community health, and develop their ability to get involved in individual and community health27. Indeed, health promotion requires effective participation of the community in defining priorities,

PROBLEM TREE The problem tree is a visual support and reflection tool that facilitates exploration and discussion around the consequences and determinants of a given health issue (e.g., limited access to CC).

Access to cervical cancer screening

MdM can facilitate or support the use of the problem tree with or by the people directly concerned so that they identify and become aware of the factors that have an impact on their health. They will be in the best position to identify and develop appropriate strategies and actions to influence the situation. For more information on the use of the problem tree in a community approach, refer to: Empowerment en Pratique #1 - L’arbre de santé : un outil de réflexion collective (only in French)

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ State the essential components of a community approach.

PRACTICAL SKILLS:

➡ Articulate the components of a community strategy ➡ Explain the added value of community-based HPV self-sampling.

23. O’Donovan J, O’Donovan C, Nagraj S. (2019) The role of community health workers in cervical cancer screening in low-income and middle-income countries: a systematic scoping review of the literature. BMJ Global Health ;4:e001452 24. Isaac R, Finkel M, Olver I, et al. (2012) Translating evidence into practice in low resource settings: Cervical cancer screening tests are only part of the solution in rural India. Asian Pac J Cancer Prev ;13:4169–72. 25. Agurto I, Arrossi S, White S, et al. (2015), Involving the community in cervical cancer prevention programs. Int Journal of Gynaecology Obstetrics 2005 ;89 Suppl 2:S38–S45 26. The others are: Building Healthy Public Policy, Creating supportive environments, Reorienting Health Services, Developing personal skills 27. WHO (1986) Ottawa Charter for Health Promotion

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COMMON SESSION 4 COMMUNITY HEALTH APPROACH

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Listening

PROMOTING ACCOUNTABLE HEALTH SERVICES SENSITIVE TO THE NEEDS OF THE COMMUNITY

MOVING TOWARDS & PROMOTING INCLUSION OF MARGINALISED INDIVIDUALS AND GROUPS

DEVELOPING APPROPRIATE STRATEGIES AND COMMUNICATION TOOLS WITH THE COMMUNITY EMPOWERING WOMEN AND FOSTERING MALE RESPONSIBILITY

Learning

Designing with the community MOBILISING AND CREATING ALLIANCES STRENGTHENING AND PARTNERSHIPS RESOURCES OF THE WITH COMMUNITY COMMUNITY IN THE LEADERS AND IMPLEMENTION OF OUR ORGANISATIONS ACTIONS

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Being accountable to the community

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making decision, developing, and implementing planning strategies aimed at achieving better health. At the heart of this process lies the empowerment of individuals and communities, who are considered capable of taking their destinies in their own hands and to take responsibility for their actions. Community development builds on the human and material resources of the community to foster self-help and social support, to establish flexible systems that are likely to reinforce participation and public control around health.

a) Creating alliances and partnerships with community leaders and organisations

What is a community? The term ‘community’ encompasses complex and dynamic concepts. We have multiple identities, and each individual belongs to multiple communities (geographical, professional, family, etc.) It must never be assumed that a group of people sharing a living area, or a workplace automatically becomes a ‘community. Indeed, individuals in each group may hold different or opposing interests.

These actors can both participate in identifying multiple barriers and levers of prevention, and also participate in the elaboration of strategies and actions that are culturally appropriate and adapted to the local context. Co-creating actions from the onset with community actors contributes to community taking ownership of the topic. In turn, these people will become ambassadors who will convey information to their peers. When there are no such organisations or when they are not formally constituted, the opportunity to support the creation or reinforcement of community organisation capacities should be considered and weighed.

In a community approach we are seeking to gather individuals and groups around what they have in common, common interests, to ‘congregate’ around a given health issue. The core principles of the community approach: A community-based approach to health is based on some core principles that should be continuously implemented.

Dès les phases de conception et d’élaboration d’uneIt is necessary to identify and establish alliances with community organisations and influent community members from the design stage of an intervention. These organisations and people can be varied in nature: formal or informal women’s groups, village or neighbourhood committees, health services, political groups, religious leaders, or institutions, etc.

In an aim of good governing, transparency and accountability, it is also advised to associate community partners in the formal governance of the projects (e.g., through steering committees) throughout the project.

Community involvement should go beyond diagnosis and elaboration, and we should create opportunities for community members to engage directly in the implementation stage of the projects. This is in line with the ethical principle ‘Nothing About Us Without Us’. It is also important in order to ensure effectiveness by recognising and appropriately mobilising existing skills and expertise in communities that are necessary to the success of a project. This involvement may take various forms: mobilisation, training and support to community health agents, development of a network of educators (volunteers or paid workers), identification and training of intermediaries, support to self-help groups (for example groups of people living or having lived with cervical cancer), etc. Their close ties with other members of the community and their expertise based on their own experience will make these actors able to contribute to strengthening trusting relationships between community and health services, and thus enhancing the acceptability and uptake of screening. They are more able to adapt health information to the local culture and context. Community members can also be involved in carrying out studies or research (e.g., on barriers to access for prevention, or about the perception of the illness or perception of health services) as investigators to analyse the data and put it to use. Participatory research can significantly contribute to the success of actions of prevention and screening of cervical cancer28. Community agents must benefit from appropriate and sufficient support in terms of training, supervision and acknowledgement, etc. to be able to play an essential role without compromising their health, safety or wellbeing. Finally, the role of community agents must be viewed as flexible and adapted to the local context. In some settings, a woman will prefer to address people outside her community to stay anonymous, in others she will prefer to address people she trusts in her closer circles.

A PRACTICAL EXAMPLE IN KENYA In Kenya, the ACCP (Alliance for Cervical Cancer Prevention - a group of 5 international NGOs) developed a partnership with Maendeleo Ya Wanawake, which is a national women’s organisation that brings together 25 000 local women’s groups throughout the country. Thirty-five members of the organisation in the area of intervention volunteered to inform and motivate other women in their communities to participate in the screening. Group-based activities were carried out with women’s organisations, religious congregations, parent groups and during local meetings. Home visits were carried out to provide a more intimate setting so that woman can talk more freely and inquire about screening services and possible support from trained community health workers1. 1. Alliance for Cervical Cancer Prevention (ACCP) (2005). Improving Screening Coverage Rates of Cervical Cancer Prevention Programs: A Focus on Communities. Cervical Cancer Prevention Issues in Depth No. 4. Seattle: ACCP

THE CRUCIAL ROLE OF COMMUNITY HEALTH AGENTS IN INDIA In March 2010, the CNCI (Chittaranjan National Cancer Institute) initiated a project to promote screening and treatment of cervical cancer for women living in rural areas around Kolkata. This project is based on a strong involvement of community health agents recruited on a part-time basis in each village concerned by the intervention. These women were trained for 2 days on the concepts, needs and steps of cervical cancer. A FAQ booklet (Frequently Asked Questions) was provided in their native language. They played a central role in the dissemination of information, health education and support to women to make an informed choice. They carried out home visits to provide counselling to women who required it and motivate them to participate in screening actions. They also transmitted the information to husbands and other family members. In addition, they also participated in delivering test results, carried out post-test counselling interviews and provided support to women requiring further testing or treatment. This model of community intervention has proved extremely efficient in ensuring acceptance of screening and adherence to treatment.1 1. Mittal S, Mandal R, Banerjee D, et al. HPV detection-based cervical cancer screening program in low-resource setting: lessons learnt from a community-based demonstration project in India. Cancer Causes Control 2016;27:351–8.

For further information, please refer to the MdM guide “Working with communities”

28. Colón-López V, González D, Vélez C, et al. (2012), Community-Academic partnership to implement a breast and cervical cancer screening education program in Puerto Rico. P R Health Sci J 2017;36:191–7 ; Nguyen-Truong CKY, Lee-Lin F, Leo MC, et al. A community-based participatory research approach to understanding Pap testing adherence among Vietnamese American immigrants. J Obstet Gynecol Neonatal Nurs ;41:E26–E40; Agurto et. Al Op.Cit.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK COMMUNITY HEALTH APPROACH

b) Mobilising and strengthening community resources around implementation of actions

FIGURE 18: THE KEY COMPONENTS OF A COMMUNITY APPROACH TO PREVENTION OF CC

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We must ensure participation of community members in the elaboration of strategies and materials for health information, education, and communication. This participation may take various forms: participatory research to study knowledge, attitudes and practices of each community in relation to cervical cancer, workshops and focus groups to elaborate key messages and identify appropriate communication tools, formation of “test groups” to assess and refine communication tools, participation of community members in the creation and elaboration of tools (such as films, theatre plays, radio broadcast, visual tools, etc), dissemination of information between peers. Particular attention should be given to the representativeness of these groups in the settingup stage (issues such as language, literacy, level of education should be considered).

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK COMMUNITY HEALTH APPROACH

Involving the community helps make sure that message make sense in the local culture. Moreover, their participation fosters acknowledgement of the value of their expertise and competence and strengthen the sense of ownership over the implementation and outcomes of an intervention. People who contributed to the elaboration of tools will play a role in the dissemination of the messages in their social circles. These mechanisms must foster dialogue and mutual learning between communities and professionals outside communities and can lead to negotiations around what can be said and done in a local context. Professionals ensure that the contents are accurate and do not contribute to strengthen stereotypes. For populations, this helps fight the negative image of health education, often experienced as control and imposition of knowledge. In addition, communities can participate in elaborating communication tools for their communities as well as communication and training tools for professionals. This will contribute to a better understanding of patients’ views and realities by healthcare professionals.

d) Promoting accountable health services sensitive to the needs of the community

Poor uptake of screening services can be attributed to poor quality of welcome and of service, gap between the service provision and needs of populations29. Moreover, health services are not always inclusive to marginalised groups.

PARTICIPATORY ELABORATION OF INFORMATION TOOLS IN SALVADOR As part of a project for promotion of screening for cervical cancer in Salvador, the ACCP team (Alliance for Cervical Cancer Prevention) begun to make a list of the communication tools used by the ministry for health. These tools were analysed on the basis of the language used, design, size, and understanding by women of key messages. This analysis showed that existing material used fear as the main argument and that contents were inaccurate and not up to date. Focus groups were set up in rural and urban zones to refine the messages. A logo and graphic materials that put forward the benefits that women could expect from screening were developed and tested. New and updated information were integrated into new tools including: a prevention leaflet destined to women, a counselling guide for health professionals, and a guide for post-treatment. To facilitate the dissemination of these tools, training for professionals were set up across the country.

In the aim of improving the quality of services with regards to patients’ needs, it is essential to promote accountability of health services to communities. Various activities can participate in this accountability: qualitative studies that explore the perceived quality of services by its users, participation of community members in awareness-raising and training of health professionals, the development of feedback mechanisms for users after their contact with any service, satisfaction surveys, involvement of communities in health facilities’ governance, etc.

e) Developing outreach activities and promoting inclusion of marginalised individuals and groups Cervical cancer is revealing of social inequalities in health. Those who have the highest risk of developing cervical cancer are among the most vulnerable people30 who are also those who face most of the barriers in accessing healthcare and prevention services. In order to break the vicious circle of exclusion, targeted and affirmative actions must be taken throughout our projects to enhance participation and inclusion of marginalised individuals or groups. Specific efforts must be made so that marginalised individuals and groups are represented and heard by project decision-making and governing bodies, as well as by the health services that ought to respond to their needs. These actions must contribute to the fight against stigma and discrimination. In order for health services to improve their

29. Agurto I, Bishop A, Sanchez G, Betancourt Z, Robles S .(2004) “Perceived barriers and benefits to cervical cancer screening in Latin America”. Prev Med ;39(1):91 –8. & Bingham A, Bishop A, Coffey P, Winkler J, Bradley J, DzubaI, et al. “Factors affecting utilization of cervical cancer prevention services in low-resource settings”. Salud Publica Mex 2003;45(3):S408—16. 30. In the described Kolkata project, the women most affected were the least educated, those who had married early and who had the highest number of children. (see Mittal, op.cit)

accessibility for marginalised populations, specific measures must be considered such as: setting-up premises to enable wheelchair access, interpretation services for allophone populations, outreach strategies for geographically isolated populations, recruitment of healthcare intermediaries from marginalised groups, etc. Promotion and availability of HPV self-sampling is also a powerful tool to promote the inclusion of marginalised women31.

f) Empowering women and increasing men’s responsibility THE MOBILE CLINIC EXPERIENCE IN OSMANABAD, INDIA The ACCP project in the Osmanabad district in India took place in 722 villages with a total population of 1,239,009 inhabitants. The female literacy rate in this area is 39%, and the cervical cancer incidence rate ranges from 55 to 77 cases per 100,000 women among women aged 30—69 years. A fully equipped van was sent out to 32 primary health care clinics, as well as other settings such as municipal offices, classrooms in local schools, and buildings housing women’s organizations that could be used for screening women using visual inspection. Project staff met with district administrative and health authorities, the president and members of the local civic bodies (panchayaths), village community leaders, teachers, and others to explain the details of the project and to seek their cooperation. On the evening before the services were to be available, eligible women, their partners, and elders in the village were invited to a meeting where a film about cervical cancer prevention was shown. On the screening day, medical social workers were on hand to explain the screening and treatment procedures to women waiting to be screened. Afterward, female health workers explained screening results and organized appointments for women with positive results of screening tests. Of the women invited, 63.4% attended and were screened through mobile clinics.

➡ Shame and fear in the presence of health professionals ➡ Low access to social and financial resources… These reasons justify the need to develop women’s power to take action and men’s sense of responsibility as a core element of our projects in cervical cancer prevention. To achieve this aim, professionals need to act as facilitators and defenders of the exercise of sexual and reproductive rights of women. Women must be viewed as rights holders rather than “beneficiaries” of services. Women must access clear, objective, and adequate information on the rights, anatomy of sexual reproductive health, intimate hygiene, prevention, or any other information necessary in order for them to make informed health choices. Professionals must be proactive in associating women in therapeutic and preventative choices and accompany their decision with support and counselling. Support to care facilities, possibly by peers, should be provided, (e.g., for those in need of additional examinations or treatment) for women facing barriers to accessing care, with the objective of enhancing their autonomy.

WOMEN AND MEN ASSOCIATED IN THEIR COMMITMENT TO FIGHTING CERVICAL CANCER IN SOUTH AFRICA Khayelitsha is a large town in the vicinity of Cape Town. Up to this day, there was no coordinated programme to prevent cervical cancer. The number of screening tests has significantly decreased between 1988 (5000 tests) and 1995 (only 1332). A new project for health promotion initiated in the city identified the important role of men in improving women’s participation and adherence to screening and treatment of precancerous lesions. Thus, interventions were carried out to mobilise men in this community. A training programme was developed to train peer educators so that they may inform men on cervical cancer prevention and encourage them to support women in using screening services and adhering to treatment. An evaluation after the training showed significant impact on attitudes and knowledges of the men who attended.

Making choices on one’s own sexual and reproductive health is a human right. However, this right is not fully exercised and there are many contexts where women face reduced power to exercise free and informed choices on their sexuality. The following barriers to exercising this right are the following: ➡ Imbalance in power between men and women within the couple and the family ➡ Women’s lack of autonomy and of power of decision ➡ Reduced access to information on rights, health, and sexuality ➡ Low self-esteem

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c) Developing health education strategies and education material adapted to communities

31. Franco, E. L. (2018). Self-sampling for cervical cancer screening: Empowering women to lead a paradigm change in cancer control. Current Oncology, 25(1), 1. 48 | 128

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Alongside these actions, men must be involved and targeted by actions to inform them of their role and responsibility in terms of prevention and fight against cervical cancer, in order to enhance autonomy of women and encourage gender equality. Actions to strengthen women’s capacity to negotiate with men may also contribute to reducing inequalities and increase women’s empowerment.

NOTES ➡ What do I take away from this session? ➡ What elements require further clarification?

In addition, all actions that aim at reinforcing selfesteem, financial autonomy, education, and women’s social role may contribute to reducing inequalities in cervical cancer. Conclusion Each cervical cancer programme should build on these six components and adapt the practical examples to local contexts in order to develop a comprehensive and effective community mobilisation strategy.

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KEY MESSAGES ➡

The barriers to cervical cancer screening can be sociocultural, geographical, financial, legal, or administrative.

➡

Extra-institutional activities, community involvement, health education and counselling are essential elements of an effective programme to fight cervical cancer, as they enable high immunisation coverage, high screening coverage, and good adherence to treatment.

➡

Importance of working on representations and development of individual capacities.

➡ Understandings to develop?

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For further information, please refer to the guide “Working with communities” on the Médecins du Monde Intranet page.

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I. HEALTH EDUCATION a) Principles of health education Health education is a key approach to health promotion as defined by the Ottawa Charter. Health promotion is the process of enabling people to increase control over, and to improve their health. Health education aims to enable people to adopt healthier behaviours by providing them with necessary knowledge, skills and attitudes. It also aims at promoting community ownership of health issues and at encouraging community participation.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK AWARENESS-RAISING AND HEALTH EDUCATION

➡ Health education is not limited to information on health. It is more than that and seeks to provide individuals with the knowledge, skills and attitudes that they need, in order to change behaviours or strengthen health promoting behaviours for them or their community, should they wish to do so. ➡ Health is thus considered a resource in daily life and it’s up to each individual to make his or her choices, to find his or her balance and to determine what is good for him or her. Health education therefore aims at enabling each and every one to make responsible and informed choices regarding behaviours impacting individual or community health. ➡ Individual involvement also aims at promoting a participatory approach to health.

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Health education is built on 4 elements: ➡ A target: the recipient of the information ➡ Materials: media, poster, leaflet, mediation… ➡ A setting: meetings, public talks, theatre sessions, television broadcasts, waiting rooms… ➡ A messenger: the person who articulates the message (health agent, peer, community actor…) All four elements must be present and appropriate so that the target effectively has access to the message. When a health education project is set up aiming at behaviour change, considering individual level is not sufficient. All potential barriers must be considered and lifted to make behaviour change possible. This includes barriers such as environmental barriers, financial barriers, social barriers, cultural barriers.

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ Key information to be delivered to various audiences about CC.

PRACTICAL SKILLS:

➡ Formulate simple and understandable messages.

SOFT SKILLS:

➡ Behave in a non-judgmental and sympathetic manner.

While health education aims to enable individuals to adopt health-promoting behaviours, the decision to do so is theirs. The aim is to empower people, not to enforce new behaviours! Thus, it is important to consider a few ethical principles: ➡ Individual autonomy: respect individual choices and avoid laying blame. ➡ Beneficence: Use scientifically validated tools and ensure non-maleficence.

➡ Do no harm: always question the methods used (the end does not justify the means) and ensure that the intervention will not have harmful consequences in other areas than health. ➡ Equity and social justice: Health education must not increase social inequalities in health or create new inequalities. Messages must be adapted so that they are accessible for all. ➡ Monitor actions regularly to adjust if required. For further information, please refer to MdM guide: Health Education - A Practical Guide for Health Care Projects – 2010

b) Elaboration of messages and awarenessraising tools Communication Transmission of information implies: Filters Sender

Receiver

Transmission of the message

Feedback

Filters include elements such as: noise, psychological state of the receiver, lack of clarity in the message, accent or language, physical barrier… Communication channels are auditory, visual or kinaesthetic (through practice). The effectiveness of the transmission usually is the following: ➡ Auditory channel ➝ 20% retention ➡ Auditory + visual channels ➝ 40% retention ➡ Auditory + visual + kinaesthetic channels ➝ 80% retention. Steps for the elaboration of messages and educational material ➡ Identification of needs in terms of health education • To be carried with the users or the population • Identification of a health issue requiring educational material and identification of the determinants of that issue. ➡ Defining the target group • Health education must be specific to the target group: to its needs, its reality, its information channels… • The definition of the target group must be precise: primary target population can be identified separately from a secondary target population that will indirectly benefit from education. ➡ Collecting and organising adequate information that will define messages and educational

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COMMON SESSION 5 AWARENESS-RAISING AND HEALTH EDUCATION

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➡

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➡

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➡

➡ ➡

➡

To guarantee acceptability and adequacy of educational messages and materials, representatives of the target group must be involved at all stages (see session 4 ‘A community Health Approach‘). This also gives an opportunity to the target group to become actors of their education, according to their desire and abilities.

c) Health education and prevention of cervical cancer Concerning prevention of CC, messages should be adapted to all groups and individual realities. Messages may mention the following: ➡ Information about responsible and enjoyable sexuality ➡ Anatomy of male and female genital organs ➡ Importance of medical care ➡ Contraceptive methods ➡ Available services and means to access them ➡ Discussion around reasons for not using contraception when one wishes to avoid or delay pregnancy ➡ Individual rights regarding contraception, sexuality, abortion, access to healthcare services…

II. AWARENESS-RAISING Awareness-raising involves sharing information with the aim of increasing knowledge on preventative health in order to stay healthy and prevent illnesses such as cervical cancer. Awareness-raising actions must also communicate information on available services.

a) Which population should be targeted? The aim of awareness-raising is to maximise coverage and use of cervical cancer services. To achieve this aim, the following priority populations should be targeted: ➡ Young women and men (vaccination, use of condoms, sexuality education) ➡ Women targeted by the screening programme ➡ Vulnerable groups: women with HIV, sex workers, refugees, and other marginalised groups ➡ Political, religious and community leaders ➡ Men ➡ Organisations, private sector.

b) How to raise awareness on screening for cervical cancer? The person conducting awareness raising should: ➡ Have a good grasp on the topic. ➡ Be at ease with the topic, not experience any embarrassment when talking about female anatomy and sexuality. ➡ Be clear and coherent. Issue key messages that are easy to understand and appropriate for the audience, be coherent with these messages. Prepare and test messages and tools on some people and adjust them accordingly. ➡ Work on messages to counter fears and misconceptions. (see table). ➡ Be receptive and non-judgmental. ➡ Provide support and a listening ear. Be patient and understanding and help women and families to find solutions.

➡ Be welcoming and encouraging. People who feel welcome are more likely to come back for care when they need it. ➡ Tailor messages to the intended audience (women under 30, over 30, seropositive women, sex workers, men, etc.). ➡ Given their closeness with the target population, peer educators have knowledge of the population and personal experience that makes them key actors in awareness-raising campaigns.

c) Key messages for primary and secondary prevention of cervical cancer You must keep in mind that effective communication often leads to increasing screening tests rates and to saving the life of many women. Health workers must be able to speak about sexuality in a non-judgemental manner and to deal with the issues of screening while protecting all patients’ intimacy and privacy. It is important to think about what key messages to communicate to men (encourage their partners,

MESSAGES TO AVOID

UNEXPECTED OUTCOMES

Women with cervical cancer or precancerous lesions have an STI.

Discourages women to undergo screening and cause them problems in their relationship.

The screening test searches for the presence of cervical cancer.

Leads people to think that a positive result to the test is a diagnosis of cancer.

The use of an IUD or of a contraceptive pill may cause cervical cancer.

Women will be afraid of using contraceptives even if this information is incorrect.

Women will be afraid of the The screening test is painful: screening tests. Fear can during the procedure, a also reach family members part of the woman’s body is who will prevent them from removed. getting tested.

There is no need to screen for cervical abnormalities because when the result is positive it means that the woman has a life-threatening disease and will die.

Only a small number of women will get tested if they believe there is no solution.

sisters and mothers to vaccinate, get tested and follow treatment if necessary, use condoms to avoid STI and pregnancy), all the while avoiding to strengthen power imbalance between men and woman, specifically trying to avoid reinforcing the power of decision of men over women. Encourage HIV+ women to get a yearly test from an early age and encourage women to get tested for HIV. This adaptation to care for people living with HIV should not result in increased stigma and discrimination of these women. Key messages: ➡ Cervical cancer is an avoidable illness. ➡ Test exists that enable an early detection of any change of the cervix that may develop into cancer if untreated. ➡ There are safe and effective treatments for these lesions. ➡ Every woman aged 30 to 55 years should be tested at least once for cervical cancer. ➡ There is a vaccine for girls that prevents cervical

ALTERNATIVES

• Cervical cancer is caused by a virus called HPV that is transmitted by sexual contact; most people will be infected with this virus at one point in their life. • Most HPV infections spontaneously disappear without the person being aware that he/she was infected.

• The screening test is a simple procedure (cervical smear test, VIA or HPV test) that enables early detection of cervical abnormalities (called precancerous lesions), before they develop into cancer. • The use of IUD does not increase the risk of cervical cancer. • Contraceptive pills may cause a very small increase of the risk of cervical cancer, but the benefits of pregnancy prevention outweigh that risk. • The use of contraceptive pills decreases the risk of ovary and colorectal cancer. • Some women find speculum examination uncom-fortable, but the test is not painful. • During the test, the practitioner uses a swab or a soft brush to sample a few cervical cells. • The test is simple and only lasts a few minutes. • A screening test is different from a biopsy or a sur-gery. Screening tests require no incision. • If a woman is diagnosed with precancerous lesions, she will be offered safe and simple treatment. • If the test is carried out at the appropriate age, it is possible de prevent cervical cancer. • When it is diagnosed early, cervical cancer can be cured.

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➡

material. For example: • Target group’s behaviours with regards to the health issue. • Target group’s knowledge with regards to the health issue. • Characteristics of the target group (demographic, economic, social, political, religious, cultural…) that may influence the reception of the message. • Readiness of the target group to receive the message. • Level of education. • Interests: meeting locations, sports, etc. • The channels usually used to transmit and receive information and those that are most suitable and accessible for this group. Identifying existing resources • Human resources: people, skills, experience in the team… • Material and structural resources (adequate location to meet users involved in the development of the project). • Financial resources. Listing existing educational material • Opportunity to use existing material that has already proved effective by adapting it if necessary. • Ensure that the existing material does not deliver contradictory messages to what we are trying to put forward. Defining the objectives of health education • These objectives will be associated with indicators that will allow to monitor the behaviour change that is sought. Defining messages • They must be clear and directly related to the identified issue. • Adequate messages include the benefits of following the message conveyed, provide accurate and validated information… Defining channels and materials for the dissemination of the message Determining the time and location for transmission • Limit the number of ideas per material • Find a balance between educational aspects and artistic aspects: messages must be attractive and satisfy the group’s artistic tastes. Pre-testing and adjusting the material • Helps verify comprehension, acceptability, ease of use…

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III. HIV AND CERVICAL CANCER

TOPIC CERVICAL CANCER

HPV

RELATIONSHIP BETWEEN HPV AND CERVICAL CANCER

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HPV TEST

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KEY MESSAGES ➡ ➡

Cervical cancer occurs when there is an unusual rise of cervical cells. Cervical cancer is caused by persistent infection with high-risk HPV.

➡ ➡ ➡ ➡

HPV is a very frequent virus and is transmitted through sexual contact. A majority of people will be infected at one point in their life. In most cases the HPV infection will spontaneously disappear. Some infections will persist and will lead to the development of cervical cancer.

➡ ➡

Persistent high-risk HPV infection causes cervical cancer within 10 to 15 years. Being infected with HPV doesn’t mean having cancer.

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An HPV test detects the presence of HPV infection. This test can be a self-sampling or be carried out during a gynaecological examination by sampling cervix cells using a vaginal swab. The swab is then placed in a tube and sent to the laboratory for analysis. Self-sampling has the advantage of permitting the patient to do it herself. Self-sampling: evidence suggests that the results of HPV self-sampling can be similar to tests carried out by a practitioner.

➡ ➡

HPV TEST RESULTS

➡ ➡ ➡

The result is positive or negative. A negative result means that no high-risk HPV infection was found. A positive result means that there is an infection with a high-risk type of HPV and that another test using visual inspection with acetic acid must be carried out.

VIA TEST

➡

The VIA test does not require any anaesthesia and is not painful

VIA TEST RESULTS

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A positive result means that there are precancerous lesions likely to develop into cervical cancer.

THERMOCOAGULATION

➡ ➡ ➡

This is a technique that uses high temperature to destroy precancerous lesions. The cervix does not include any nerves, so this is painless. Safe and effective treatment of precancerous lesions.

Key messages to deliver to women living with HIV are the following: ➡ Women living with HIV are at higher risk of being infected with HPV and cervical cancer. Screening must be more frequent and initiated as soon as the diagnosis of HIV is made, regardless of the age. ➡ Cervical cancer progresses faster for women with HIV, hence the higher frequency of screening tests. ➡ If you have precancerous lesions, you will need to be treated. When the HIV infection rates of a country are high, women must be encouraged to test for HIV. It is important to identify where testing is possible.

IV. AVOIDING LOSS TO FOLLOW-UP The proposed algorithm will not permit all cases to benefit from a ‘screen and treat’ strategy, thus making projects at risk of high lost to follow-up rates. All activities must be developed with specific thought of how to reduce these lost to follow-up: ➡ Specific focus on counselling ➡ Developing a network of community actors for close monitoring ➡ Setting up an effective monitoring system.

FOR - SELF-SAMPLING FIGUREINSTRUCTIONS 19: INSTRUCTIONS FOR SELF-SAMPLING

d) Awareness-raising tools Awareness-raising tools are most effective when they are developed with people from the target population. Develop key messages and tools, test them on an audience and modify them according to the feedback.

Conditions of use: ➡ Do not carry out the test during menstrual periods ➡ No sexual intercourse the day before ➡ Do not carry out vaginal wash or apply any product in the prior 24 to 48 hours

Material: ➡ Flap boards ➡ Leaflets ➡ Plays and role plays ➡ Radio broadcasts and video clips

Figure 19: Instructions for self-sampling: ➡ Partially open the packaging. ➡ Do not touch the cotton or drop the swab. If this occurs, request another sampling kit. ➡ Remove the swab from the bag. ➡ Hold the swab as shown in figure 1, by placing the thumb and the index at the top of the swab. ➡ Spread your labia with one hand so that the swab does not touch the external parts (see figure 2). ➡ Gently insert the swab in the vagina on around 2/3 of the distance (see figure 2). ➡ Gently rotate the swab three times during 10 to 30 seconds. Make sure the swab touches the vaginal mucosa so that the moist is absorbed by the swab. ➡ Remove the swab without touching the skin. ➡ Immediately place it in the transport medium and seal the sample.

Specific tool regarding self-sampling: Self-sampling helps increase the coverage rates. Indeed, women may experience fear of pain or embarrassment at the idea of a gynaecological examination, thus discouraging them from getting test. Self-sampling increases the acceptability of screening and widen access to some populations by lifting the practitioner barrier (no need for speculum examination) or geographical barrier in cases when the screening is organised locally.

You dispose of a tube containing a swab. Open the tube

Gently insert the swab in the vagina on around 2/3 of the distance

Gently rotate the swab three times in the vagina and remove the swab

Immediately place it in the transport medium and seal the sample.

Precautions before sampling: Do not carry out the test during menstrual periods No sexual intercourse the day before

Do not carry out vaginal wash or apply any product in the prior 24 to 48 hours Do not put any product in the vagina

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK AWARENESS-RAISING AND HEALTH EDUCATION

cancer.

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PART 2 CERVICAL CANCER PREVENTION HEALTH SESSIONS

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I. COUNSELLING a) What is counselling?32 Counselling is a conversation that takes place between a person acknowledged as actor and subject of his/her history and an external player who provides guidance. Both of these two individuals engage in a collaborating relationship. The external player motivates, supports and strengthens. He/she does not direct, nor does he/she adopt a wait-and-see approach, as the aim is to modify behaviours and practices. The aim is that the person identifies what he/she wants and wishes to change within the scope of his/her abilities and resources. ‘Counselling is a type of psychological and social guidance and designates a situation in which two people construct a relationship, one explicitly requesting support from the other in addressing, solving and taking ownership of issues he/she is facing.’33

➡ An interview is authoritarian, when there is no listening. The person is being informed but there was no prior assessment of the need for information, and all questions are closed question (answered by YES or NO) that serve no other purpose but to confirm the professional’s course of thinking. ➡ An interview is passive, when the user expresses many thoughts but is not being steered, channelled or if he/she does not receive any new information. ➡ An interview provides guidance, when open questions are asked to the person so as to identify his/her thoughts, so that the various available possibilities that would be suitable for his/her wishes and capacities can be given to them. Alternatively, it is also possible de provide the opportunity for the person to come up with these solutions herself. DIRECT

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INDIVIDUAL COUNSELLING

b) Counselling principles and attitudes

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Attitudes ➡ The basis of counselling is active listening so as to encourage better expression of wishes and resources that the person has, with the aim of changing or adopting a new method or practice. ➡ The professional must have a positive and unconditional attitude: regardless of the person’s practices and will to change, the professional must not judge or express agreement with the person’s opinions and practices. ➡ His role is that of a non-expert. His attitude is what enables the person who knows what he/she wishes to attain, to identify strategies appropriate to his/her situation and that will be achievable. ➡ The counselling interview increases motivation for change and ability to put it into practice (empowerment).

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ Key information to be delivered to various audiences about CC ➡ Principles of counselling ➡ Components of counselling about CC in order to foster free and informed choice.

PRACTICAL SKILLS:

➡ Carry out a counselling session ➡ Adopt appropriate attitudes and relationship approaches.

SOFT SKILLS:

➡ Behave in a non-judgmental and sympathetic manner ➡ Request informed consent from the patient.

Natural communication styles ➡ There are several communication attitudes. Some are authoritarian: the professional enforces his/ her opinion. Some are passive: the professional is not set to provoke change. The appropriate attitude in counselling is one that provides guidance to a person thereby moving towards a change that the person wants. DIRECT •Inform without permission or without assessing need •Suggest solutions •Question

GUIDE •Motivate •Support •Steer •Strengthen

FOLLOW •Accompany •Leave one be •Express empathy without guidance

GUIDE

•Inform with choices

• Inform

• Active empathetic listening

• Listening

• Inform • Listening • Question: Closed questions

• Question: Open questions

•Question

Appropriate approach ➡ During a counselling interview, the relationship is a collaboration and provides autonomy for the user, as opposed to a more ‘traditional’ approach whereby the professional is an expert, and the user is expected to obey the prescriptions. ➡ Ideally, counselling should instate trust between the user and the professional. « VERTICAL »

MOTIVATIONAL

User

Passive

Actor

Practitioner

Expert

Guide « Coach »

Relationship

Authority Confrontation Prescription

Autonomy Collaboration Education

c) Counselling techniques Various techniques can be used during a counselling interview. They require effort and practice to be used, as they often are contrary to spontaneous communication reflexes. Thereafter we present the

32. See fiche pratique counselling – Module de formation [counselling practice sheet - Training module] – Médecins du Monde 2013 33. C Tourette-Turgis (1996). Le counselling. Ed. PUF, Coll. Que Sais-je? p. 25 (translation by MdM)

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HEALTH SESSION 1 INDIVIDUAL COUNSELLING

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Listening This is a core competence for counselling. It is both an attitude and a skill. Listening is a way to engage that implies sensibility and attention to others. It enables to grasp more than the mere content of the conversation. Sometimes this is all a person needs. By reformulating, it enables a person to listen to his/herself and reflect more deeply. Openness Openness is a fundamental attitude in counselling. It is directed to others. The practitioner must show that he/she is trying to understand the person and accept him/her. It is shown by verbal expressions and nonverbal attitudes.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INDIVIDUAL COUNSELLING

Non-judgmental position Being non-judgemental ensures a trusting relationship that leads to greater authenticity, integrity, and an honest relationship. Judgment is a major obstacle. It impedes one’s empowerment. It may cause dependency and sometimes cause people to run from the relationship.

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Empathy Empathy is a form of understanding defined as the ability to perceive and understand feeling through the eyes of another. The practitioner must bracket his/her own world of references without losing it and focus on the other’s view of reality. Empathy must be expressed to the user. It is about putting words on what we perceive as being a dominant emotion for the person, by listening to his/ her immediate needs, seeking to understand his/her perspective, and rephrasing his/her view. When the user does not feel judged but understood, empathy increases self-esteem. It improves the quality of the dialogue, and fosters the expression of deeper emotions, experiences, and practices. Therefore, it facilitates the identification of weaknesses and resources. Congruence I do what I say and what I say is what I think. It is what lies between the professional and his being and emotions, and the thoughts triggered by the user. One should not try to be different. The congruence of the practitioners facilitates the congruence of the user. Open questions The practitioner must favour open questions so as to: ➡ Introduce the topic in a non-authoritative manner ➡ Establish trust and acceptance ➡ Be open to the other being ➡ Better understand the person’s perspective ➡ Steer to an aim. Open questions foster sharing and exploration of attitudes, feelings, values, and behaviours. The form and the tone must not provoke feelings of intrusion.

A list of closed questions tends to put the person in a defender’s position, who will then be only partly truthful. Closed questions give a feeling of control and structure for the practitioner, but they keep the user in a passive attitude. The question ‘Why’ should be avoided as it can be viewed as a request for justification and can provoke resistance and lead the person to argue for the status quo. Rephrase with open questions. Mirroring / rephrasing It is more than a mere repetition of the phrase. It is about trying to say what was just state with one’s own words. Rephrasing helps to: ➡ Check that the understanding is correct ➡ Ensure the person feels listened to ➡ Summarise what is being said ➡ Deepen the understanding without judgment or confrontation ➡ Demonstrate that you understand and accept the state of mind, experience, and view of that person without judgement or criticism, ➡ Show that he/she will not be pushed until he/she is ready. It is of great help in developing and exploring the relationship. Clarification Clarification enables the practitioner to ensure that he/she has correctly understood the person’s statement. It shows that the practitioner is interested in what is being said and gives an opportunity to further clarify his/her thoughts. ‘What do you mean by…?’. ‘Please tell me about…’ ‘And then…what else?’

d) Counselling for cervical cancer screening It is important that women understand that this is not a screening test for cervical cancer, but that the test identifies women at risk of developing a cancer in the future. Objectives ➡ Provide clear information and counselling so that each person can acquire new knowledge and adapt this knowledge in practice to make their own decision to get screened or not for cervical cancer. ➡ Identify medical conditions that imply specific care or that can influence adherence to screening (HIV, pregnancy, menopause, menstrual cycle). ➡ Discuss the possibility of undergoing the screening test. The counselling step helps screening to be well accepted and followed up, in accordance with each patient’s personal context. Enabling the user to be an actor of her medical pathway has the following advantages:

➡ Increased satisfaction ➡ Decreased lost to follow-up ➡ Higher adherence. The steps to take to help in the choice to screen or not are based on the GATHER model (developed by the WHO): ➡ Greet • Greet the patient and introduce yourself • Ensure confidentiality • Explain the role, objectives and detail what will happen during the counselling session. ➡ Ask • Ask questions and listen to the patient • Explore what she has (state of health), what she does (family, profession), what she knows (in terms of cervical cancer screening), what she believes (about cervical cancer), how she feels (regarding her relationships and sexual life, her gynaecological follow-up), what she needs (projects, wishes, pregnancies). ➡ Tell • Deliver clear, tailored, and relevant information • Ensure that the information is well understood • Information includes self-sampling, analysis of the presence of HPV, VIA, thermocoagulation, and further possible investigations at a referral centre. ➡ Help • Help her to make her own choices • Insist on the fact that the final decision belongs to the users • To help with the choice, it is possible to encourage the user to think about her family situation, her preferences, the benefits/ risks of carrying out this screening and the consequences of her choice • The caregiver encourages the user to respect her choice to be screened and choose if and when to treat precancerous lesions, depending on the context. ➡ Explain • Discuss adherence to CC screening • Inform about the nature of cervical cancer and the consequences of an HPV infection • Inform of the possibility of self-sampling or sampling by a practitioner • Explain the importance and aim of the HPV test and the visual inspection with acetic acid test (VIA) • Provide detailed information on the subsequent stages of the screening process (if negative HR HPV, carrying out visual inspection with acetic acid, and possibility of treating precancerous lesions) • Offer written material that can help.

➡ Return • Follow-up appointments are to evaluate healing after thermocoagulation • Offer the option to continue her gynaecological routine check-ups • Repeat screenings regularly all her life. Favouring a “Motivational Interviewing” approach “Motivational interviewing” is a directive, clientcentred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence”. (Miller et Rollnick, 1991). The underpinning principles of the method are the following: ➡ An approach based on collaboration rather than prescription ➡ Respect for individuals’ autonomy and decision ➡ Trigger rather than give orders ➡ Importance of encouraging the person to suggest change and the way to achieve it ➡ Decision to renounce an authoritative role ➡ Choice of exploring capacities rather than limitations of the person ➡ Express a genuine interest for a person’s experience and views. In other words, this is a communication method where the professional is facilitator that helps the person to set her own course according to her own life aims. The person is the expert of his or her life. Therefore, it is two experts (patient and professional) who collaborate, by sharing their expertise to analyse the situation and make a joint decision regarding the future. The professional directs the course of the interview but not the choice of theperson. The principles of Motivational Interviewing are: ➡ Expression of empathy ➡ Exploration of ambivalence or dilemma experienced when facing possible change or decision with impact on the life of patients ➡ Lead the patient to express her own personal aims ➡ Assist her in understanding the contradictions between the current situation and her personal aims ➡ Discuss available options (e.g.: different contraceptive methods including emergency contraception) and guide her in finding an adapted and acceptable choice in her view.

e) Pre and post HPV test counselling Contents of the interview ➡ Information: • Explain the screening algorithm • Explain HPV tests • Go into detail explaining the sampling procedure and inform of the possibility of selfsampling • Depending on the woman’s choice, explain

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INDIVIDUAL COUNSELLING

main counselling techniques and attitudes:

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CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INDIVIDUAL COUNSELLING

➡ Counselling • For the choice to go through with screening • Assessment of the woman’s support (make sure she is not coerced) • Discussion on the rationale for her discussion, should she wish to • Counselling leads to a decision to go through with the screening or not.

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➡ Medical history: (to be recorded by the professional/practitioner/midwife) • Reasons for contact: pregnancy symptoms, circumstances… • Obstetric history: number of pregnancies • Gynaecological history: Date of last period, regularity of the menstrual cycle, any gynaecological affections, contraceptive history… • Search for clinical signs of cervical cancer: post-coital bleeding, irregular bleeding… • Sexual history: partner(s), STI symptoms, HIV status (if this is unknown, encourage testing). • Surgical/medical history: chronic illness, surgical interventions • Treatment and allergies • Social history: domestic environment, violence, etc. ➡ Clinical examination: • Holistic health assessment • Abdominal examination • Pelvic examination: signs of infection, signs of cancer (granular aspect of the cervix) • Offer a self-sampling test or a test carried out by a professional (using a speculum). ➡ Laboratory tests: the sample is sent to the laboratory. ➡ Communicate test results • If visual inspection reveals a granular aspect leading to suspicion of cervical cancer: explain referral and insist on the importance of an appointment to confirm the cancer diagnosis. Explain that the only way to confirm this diagnosis is biopsy and detail the procedure. Reassure the patient by stating that treatments exist to treat cervical cancer. • The test results are negative. This means that

the virus that can lead to cervical cancer was not found in the analysis of the sample, and that there will be no precancerous or cancerous lesions in the 5 coming years. • The test results are positive. This means that you have been in contact with a virus that may cause precancerous or cancerous cervical lesions. Offer VIA. Patients whose HPV test is positive who have not come to retrieve their test results must be contacted over the phone. Attention must be given to: ➡ Ensuring confidentiality, respect for intimacy and culture of all users ➡ Protecting users’ medical records ➡ Remembering that women are more likely to comply with treatment if it was their choice.

f) Pre and post VIA counselling Contents of the interview ➡ Information on: • The detailed procedure of visual inspection with acetic acid. • Duration of the procedure • Expected sensations that they may experience during the test with acetic acid. ➡ Counselling: • For choices regarding VIA testing • Assessment of woman’s support network (ensure that she is not being coerced) • Discussion about the reasons for her choice if she wishes to discuss them • Counselling leads to a decision to get tested or not. ➡ Clinical examination: • Holistic health assessment • Abdominal examination • Pelvic examination: signs of infection, signs of cancer (cervix with a granular aspect). ➡ Gynaecological examination: • Breast examination • Pelvic examination • Speculum examination • Apply acetic acid, identify lesions and draw them for the patient if necessary, for more precise understanding. ➡ Delivering test results • The test is negative. This means that the patient will not have any precancerous or cancerous cervical lesions in the 3 coming years. • The test is positive. This means that the patient has precancerous lesions that may develop into

cancerous lesions of the uterine cervix. > Option of immediate treatment with thermocoagulation > Referral for further investigations or other possible treatments (LEEP). If the visual inspection shows a granular aspect of the cervix that leads to suspect cervical cancer: offer referral and insist on the importance of an appointment to confirm the diagnosis of cervical cancer. Explain to the patient that the only way to diagnose cancer is biopsy and explain the procedure. Reassure the patient by telling her that treatments exist for cervical cancer.

g) Care before treatment of precancerous lesions Objectives ➡ Provide comprehensive information and counselling so that each woman may make her own decision about getting test for cervical cancer. ➡ Identify any medical conditions that would imply specific care or may influence adherence to treatment (HIV, pregnancy, menopause, menstrual cycle).

intercourse, vaginal ring or menstrual cup: one month is necessary for proper healing. If this waiting time is impossible, recommend the use of a condom for that duration. ➡ Counselling • For choices regarding treatment • Assessment of the woman’s support network: ensure she is not being coerced • Discussion about the reasons for her choice if the woman wishes to discuss them • Counselling leads to a decision to go through with treatment or not. Clear and accurate information must be disclosed regarding the benefits and drawbacks of the procedure. ➡ Clinical examination: • Holistic health assessment • Abdominal examination • Pelvic examination: signs of infection, … • Speculum examination: apply acetic acid and identify and characterise the precancerous lesions. Treat immediately with thermocoagulation. ➡ Discussion about 1 year-follow-up

Content of the counselling interview

h) Post-thermocoagulation care

➡ Information about: • The details of the thermocoagulation procedure, its risks, and benefits; request the patient’s consent • Expected duration of the procedure • Risks and possible complications of thermocoagulation in the 2 to 4 weeks following the procedure (e.g., cramps, pain, bleeding similar to menstruation) and available pain relief • The time required before resuming sexual

➡ ➡ ➡ ➡

Objectives Identify and care for any complications Provide information about thermocoagulation Determine whether there is any other need in terms of sexual and reproductive health that might require additional care.

Contents of post-thermocoagulation care ➡ Before discharge from the health facility (following thermocoagulation):

BREAST CANCER 1. Generalities: first female cancer in high-, medium- and low-income countries. The incidence of breast cancer is rising. Early detection is the main tool to fight breast cancer, and this is achieved through clinical examination. Mammography after the age of 50 remains costly and not easily accessible. 2. Clinical examination: It includes inspection and palpation in standing and supine position. It may appear strictly normal when the tumour is small and/or when the breast volume is large (lumps discovered through imaging during screening). The characteristics of the tumour can be identified. a. Inspection b. Palpation: hands placed flat on, gentle pressure, soft rotating movements that assess the tissue between the skin and the chest wall. This should be done for each quadrant, with specific attention to the upper outer quadrant (where 60% of cancers are located). 3. Self-examination: Self-examination is recommended as a tool for awareness-raising, rather than as a proper screening method. It enables women to take responsibility and ownership of their health.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INDIVIDUAL COUNSELLING

the procedure for self-sampling/sampling by a health practitioner • Explain the analysis process and waiting times for the delivery of results (48 hours or 3 to 4 hours). • Reassure the patient on the fact that a positive test result does not mean that she has cancer (especially if the patient is under 30. Explain the clearance phenomenon and how they are more at risk of having a positive HPV test).

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• Provide quality counsel, active listening to the woman and her needs • Deliver clear oral and written information including:  Sexual relations or the introduction of any vaginal item (vaginal ring for example) should be avoided for 1 month  Side effects: possible bleeding and cramps  The woman must consult the health facility if she experiences abdominal pain of increasing intensity, major bleeding, or fever. • Prescribe iron if necessary (in case of anaemia), pain relief, emotional support if requested. • Refer to other services after needs assessment (contraception, STI/HIV testing, violence, social

needs, etc.). ➡ A follow-up visit should be planned between 9 and 12 months following the treatment. Attention should be given to: Referring women to other services that might address other needs. Staff will raise the subject of prevention of STI/HIV and insist on the importance of condoms and infection control (specially for people at risk).

NOTES ➡ What do I take away from this session? ➡ What elements require further clarification?

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➡

A counselling interview is a collaborative conversation between a person acknowledged as both subject and actor of his/her history and a professional who provides guidance. The professional motivates, supports, and strengthens.

➡

Counselling is an essential tool to strengthen individual capacities. It also ensures informed consent and helps identify individual views and encourage adherence to screening and treatment of precancerous lesions.

➡

The following attitudes and abilities are essential for adequate counselling: openness, empathy, active listening.

➡

The core set of methods for effective counselling interview are open questions, clarification, rephrasing.

➡

Confidentiality is crucial and should not be overlooked. Make sure that nobody else is hearing the conversation.

➡

The key topics of counselling on cervical cancer screening are: • Understanding users’ views of cervical cancer • Providing accurate and adequate information • Making sure the woman understands the benefits and risks of screening and treatment • Support the woman’s choice.

➡ Understandings to develop?

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KEY MESSAGES

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I. INTRODUCTION

II. AVAILABLE METHODS

An HPV test identifies the presence of oncogenic papillomavirus in cervical cells. This is of high interest as it has been demonstrated that cervical cancer is caused by a virus.

Virological methods are limited: HPV are hard to grow and serologies are not very useful. This is why HPV is identified through molecular methods, that are more sensitive than cytology34. There are different techniques for the detection of HPV DNA: ➡ Solution-phase hybridation ➡ PCR amplification coupled with immuno-enzymatic detection ➡ Real-Time PCR

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HPV TESTING

There are various screening methods. A cervical smear test is costly (requires training for cytologists), dependent on the cytologist, and has low sensibility. It has no quality check, which is problematic to ensure quality results. In addition, results are not immediately available. As for VIA (visual inspection with acetic acid) or VILI (visual inspection with Lugol’s iodine), techniques for which many staff can be trained, the results are immediately available and easily integrated into primary health care services. However, the specificity is moderate which leads to overtreatment, and it is also a practitioner-dependent method. The HPV test has a high negative predictive value (NPV). However, it lacks specificity (a positive test result does not mean that lesions are present).

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Large scale randomised trials have demonstrated that HPV screening is more efficient (+30%) to detect CIN 3 on the first screening cycle compared to cytology. In a metanalysis of four randomised trials conducted in Europe, the HPV test provided higher protection against invasive cancer than cytology. The risk of cancers within 3 years after a negative HPV test was about 70% lower than after a negative cytology test. For that reason, the WHO recommends that when these methods are available, screening should be carried out using HPV testing followed by VIA to avoid overtreatment. Sensitivity of the test: the smallest amount of targeted marker (HPV) that can be precisely detected. Excellent predictive value that enables to reassure patients with a negative test and space the screening intervals for these patients.

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ Articulate the modalities of an HR-HPV test ➡ List the equipment required to carry out an HPV test or a self-sampling test ➡ Have basic knowledge of the use of sample analysis equipment.

PRACTICAL SKILLS:

➡ Explain the procedure to the patient and offer self-sampling ➡ Carry out sampling for an HPV test ➡ Plan the sample’s pathway from the community or health facilities to centres that are equipped to perform the analysis.

SOFT SKILLS:

➡ Behave in a non-judgemental and non-discriminatory manner ➡ Establish a respectful and trusting relationship.

Specificity: the ability of the method to identify only the targeted marker, probability that a positive test be indeed positive. The HPV test lacks specificity (a positive HPV test does not mean that there are lesions).

Amplification by polymerase chain reaction (PCR) is an in vitro gene amplification technique used in molecular biology. It selectively amplifies (with a billion-multiplying factor) trace amounts of a known DNA or RNA sequence. This can help detect HPV for example. The technique is a 3-step technique: Thermic denaturation of DNA: when the temperature reaches 95°C, hydrogen bonds are broken, and the 2 DNA strands are forced apart. DNA becomes a single strand in the reaction medium. Hybridisation of the primers: the reaction medium contains 2 primers, that each assemble with one of the 2 strands. The primers will bind to the DNA single strands when the temperature is between 50 and 65°C. The primers are in excess amount and will bind as soon as they meet with complementary sequences. Extension of the primer: primers are extended by integrating deoxyribonucleic acids that correspond to the sequence of the strand to which the primers are bound. This step takes place at a temperature of 72°C.

III. XPERT HPV TEST The Xpert® HPV technique takes place inside a cartridge that must be labelled by the technician. The sample is vortexed before 1ml of the solution is poured into the reaction tube using the provided pipette. The reaction tube is then inserted in the cartridge for automated analysis.

The HPV test uses molecular biology to detect the presence of HPV (detection of viralDNA ), either in cervical cells or in a vaginal swab. The HPVs that are targeted are the ones usually considered directly associated to cervical cancer (high risk HPV or oncogenic HPV).

The HPV Xpert® test can identify the region E6/ E7 of viral DNA for all 14 high risk HPV. There is a channel that enables the detection of HPV 16, one for HPV18/45 and three others that detect the other 55 high risk HPV: 31, 33, 35, 39, 51, 52, 56, 58, 59, 66 et 68.

While an HPV test will detect more transient infections for woman under 30, the later the test is being used, the more the detection of an HR-HPV infection might be the sign of high-risk persistent infection that might lead to cervical cancer.

The automated system requires a single use cartridge that holds the PCR reagents, houses the sample, and carries out the PCR processing. The first stage is the ultrasound cell lysis which frees nucleic acids from both HPV virus and human cells. The DNA is then

34. Clavel C. Tests diagnostiques HPV : réalisation et interprétation [HPV Diagnostic tests: technique and interpretation]. SPECTRA Biol N°171. March 2009.

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HEALTH SESSION 2 HPV TESTING

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CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HPV TESTING

The Xpert® HPV test is a single-sample test, it takes 1 minute to prepare the cartridge and launch the test. The analysis lasts less than an hour. Several cartridges can be launched one after the other. There is very little manipulation time by the technicians (less than 2 minutes). It includes the following steps: ➡ Transfer of the sample into the cartridge ➡ Scanning barcodes for the cartridge and the sample ➡ Insertion of the cartridge in the analysis robot ➡ Unloading of the cartridge at the end of the test ➡ Retrieve the results in the Xpert® software and transcribe in the LIS (Laboratory Information System).

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HR-HPV genotypes will be detected using 5 different fluorescent probes. Five graphs will appear on the results: one graph for HPV 16, another for HPV 18/45 and three for the pooled results for the 11 other HRHPV, since 3 channels correspond to these genotypes: Canal P3: HPV 31, 33, 35, 52, 58 / Canal P4: HPV 51 et 59 / Canal P5: HPV 39, 56, 66, 68. In a table over the graph, the Ct will be visible as well as the result stated as POSITIVE or NEGATIVE. The probe check control (PCC) ensure that the probe is active (will appear as PASS) or not (will appear as ERROR and render the analysis invalid).

HPV Testing advantages and drawbacks Method of choice recommended by the WHO, especially as part of the ‘screen and treat’ strategy in middle-income countries in addition to or in replacement of direct visualisation methods such as VIA.

IV. SAMPLING PROCEDURE The sample can be done with or without speculum examination and can be carried out by a health professional or by the woman herself. Indeed, several studies have shown comparable effectiveness of selfsampling versus practitioner sampling. For the test to be analysed correctly, it must not be carried out in the following situations: ➡ Menstrual period (can be done in case of light vaginal bleeding) ➡ Sexual intercourse within 24 hours of sampling ➡ Vaginal wash within 24 hours of sampling ➡ Use of any vaginal solution within 24 hours of sampling. Remember to mark the sample with patient’s name, reference number, date, and time of the test.

FIGURE 20: INSTRUCTIONS FOR CERVICAL SELFINSTRUCTIONS FOR - SELF-SAMPLING SAMPLING

You dispose of a tube containing a swab. Open the tube

Gently insert the swab in the vagina on around 2/3 of the distance

Gently rotate the swab three times in the vagina and remove the swab

Immediately place it in the transport medium and seal the sample.

a) Sampling technique This is the same technique as the one used for pap smear test. It only lasts a few minutes and can cause mild discomfort, some pressure, or cramps, however it is usually not painful. To carry out the HPV screening test, the practitioner gently inserts a speculum in the vagina. This is to separate the vaginal walls so that the practitioner can see the upper part of the vagina and the cervix. He/ she inserts the swab up to the cervix and/or upper vagina and rotates the brush 5 times clockwise. After sampling the cells, the physician, midwife or nurse puts them in a container. The sample is sent to a laboratory where it is analysed to identify if its DNA is that of an HR-HPV. There is a possibility of light vaginal bleeding for one or 2 days after an HPV test.

b) Self-sampling ➡ Self-sampling can be done in a confidential and private location. ➡ Partially open the packaging. ➡ Do not touch the cotton or drop the swab. If this occurs, request another sampling kit

ADVANTAGES

DRAWBACKS

Better sensibility

Lower specificity in populations where HPV prevalence is high/young people.

Spacing of screening interval (good NPV)

Cost (human resources and equipment as this is not self-sampling). Cost of the analysis robot and sampling kits, laboratory equipment and electric and water cost.

Objectivity of the test

Need for a laboratory

Possibility of self-sampling

Sampling method

Any health agent can interpret the test after a short training

Delayed diagnosis Validation of various rapid tests Constraints of transportation: T°, time

Precautions before sampling: Do not carry out the test during menstrual periods No sexual intercourse the day before

➡ Remove the swab from the bag. ➡ Hold the swab as shown in figure 1, by placing the thumb and the index at the top of the swab. ➡ Spread your labia with one hand so that the swab does not touch the external parts (see figure 2). ➡ Gently insert the swab in the vagina to around 2/3 of the distance (see figure 2). ➡ Gently rotate the swab three time during 10 to 30 seconds. Make sure the swab touches the vaginal mucosa so that the moist is absorbed by the swab. ➡ Withdraw the swab voiding contact with the skin. ➡ Immediately place the swab in the container and seal it.

V. CONDITIONING AND SHIPMENT OF SAMPLES The transportation process must enable to: ➡ Ensure patient confidentiality and anonymity ➡ Protect the sample from any damage (fall, leak, etc.) ➡ Ensure that the conditions are respected for transportation in a timely manner with regards to HPV DNA stability and in appropriate temperature conditions. The samples must be placed in plastic bags: one bag per patient. ➡ Fold the laboratory order and put it in the bag ➡ Store the sample in a cooler to keep it between 15 and 30°C ➡ Transfer to a laboratory as soon as possible ➡ For samples that are transferred by a courier, a

Do not carry out vaginal wash or apply any product in the prior 24 to 48 hours Do not put any product in the vagina

transport tracing sheet must also be filled out; the time of delivery at the laboratory must be mentioned by a member of staff in the laboratory or by the courier. ➡ Upon reception of the samples, the technician and the courier check the traceability, date and time of the sample and the temperature. ➡ In case of non-compliance, the information must be recorded, and the reasons should be mentioned.

Pre analysis The HPV Xpert® test is a single-sample test for which only one minute is necessary to prepare the cartridge and launch the test. The analysis is carried out in less than an hour. Several cartridges can be launched one after the other.

VI. DELIVERY OF TEST RESULTS Results consist in a simple POSITIVE or NEGATIVE with a colour code (green/red).

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK HPV TESTING

purified on a filtration column and eluted. The DNA is thus made ready for real-time amplification and detection, similarly to PCR. Cellular control called control of the adequacy of the sample is performed that enables the detection of a single copy human gene and ensures that the sample holds enough cells to enable the detection of the presence or not of HPV.

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How to interpret the results?

FIGURE 21: SAMPLING PATHWAY PROTOCOL

The test will come back either positive or negative. ➡ Negative result (low risk of developing cervical cancer in the next 5 years) ➡ Positive result (contact with a virus that is likely to cause precancerous lesions): offer VIA; reassure, if there is not suspicion of cancer, by explaining that the test does not mean that she has cervical cancer and that a majority of women who have HPV infection will not develop cervical cancer.

SAMPLING

Transfer to the laboratory

Reception and registration

TRANSPORTATION IN A COOLER WITH TEMPERATURE DISPLAY (VERIFICATION / TRACEABILITY / DATE OF SAMPLING)

Quality control – Temperature display (15 to 30 °) - storage time less than 48 hours – traceability

pre-analysis

Technical information

Curve validation / interpretation

NON-COMPLIANCE OF SAMPLING

Transmission of the report within the deadline or contact with the health care professional if the sample is HR HPV+

RECEPTION OF REPORT BY THE MIDWIFE

FIGURE 22: HR HPV SAMPLE PRE-ANALYSIS PROCEDURE

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Put 3 ml of 9% NaCl solution in the flocked nylon tube

Place the swab with the sample in the test tube and rotate it back and forth for 10 seconds

Caution before use: Do not use this device in case of power outage

Pour 1 ml of the solution into the geneXpert cartridge

Insert the cartridge and start the test

RESULTS IN 1 HOUR

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HR HPV SAMPLE PRE-ANALYSIS PROCEDURE

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NOTES

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➡

Research show that the HPV screening test is very useful for screening cervical cancer. Its association with VIA will avoid overtreatment.

➡

Molecular screening methods to screen for HPV infection is based on the detection of HR-HPV DNA in vaginal and/or cervical samples.

➡

The sampling can be performed by a health practitioner (with or without a speculum) or by the woman herself.

➡

All studies show similar sensitivity between self-sampling and sampling by a practitioner.

➡ What do I take away from this session? ➡ What elements require further clarification?

➡ Understandings to develop?

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KEY MESSAGES

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I. BACKGROUND INFORMATION

II. PROCEDURE

a) What is visual inspection?

The person in charge of performing visual inspection must have solid knowledge in anatomy, physiology, and pathology of the cervix. He/she must be aware of the clinical aspects of benign affections, inflammation, precancerous lesions and invasive cervical cancer.

Naked-eye visual inspection of the cervix is a simple test for early detection of precancerous lesions and developing invasive cancer. Several techniques exist: ➡ Visual inspection with acetic acid (VIA) ➡ Visual inspection with acetic acid and magnification (VIAM) ➡ Visual inspection with Lugol’s iodine (VILI) Barriers to the implementation of cytological screening in environments where resources are scarce have led to explore the possibility of alternative tests such as VIA or VILI. The results of VIA or VILI are immediately available and do not require any laboratory service. The results are classified according to change of colour in the cervix. Perfect knowledge of the anatomy, physiology and pathology of the cervix are a prerequisite to the understanding and interpretation of this test.

b) Anatomical and pathological basis of VIA Application of 5% acetic acid is believed to cause reversible coagulation or precipitation of the cellular proteins. It also causes swelling in the epithelial tissue, columnar and any abnormal squamous epithelium.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK VISUAL INSPECTION WITH ACETIC ACID

c) Conditions of the test

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VIA can be performed at any moment of the cycle and during the menstrual period for a woman suspected of STI or HIV, or in the case of diagnosed infections.

d) Limitations/Strengths LIMITATIONS

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ ➡ ➡ ➡

State the steps of VIA inspection List the necessary equipment for this examination procedure Determine the appropriate treatment depending on the results or refer for further investigations Articulate the follow-up procedure after a normal examination.

PRACTICAL SKILLS:

➡ Recognise a normal VIA aspect and identify the presence and extent of the lesions ➡ Perform VIA.

SOFT SKILLS:

➡ Establish a trusting and respectful relationship.

a) Material Biomedical equipment ➡ Examination table ➡ Light source ➡ Sterile bivalved speculum (Cusco’s or Grave’s) ➡ Instrument tray. Medical instruments ➡ Compress/cotton ➡ Pickup forceps ➡ Medical gloves ➡ Recently prepared acetic acid solution (3 to 5%) ➡ A plastic container with 0.5% chlorine solution to decontaminate instruments ➡ A plastic bucket with a polythene bag to dispose of contaminated swabs and other waste items ➡ Sheet or form to record the events ➡ Timer. Maintenance ➡ Material ➡ Bleach ➡ Steriliser ➡ Preparation of 5% acetic acid solution: add 5ml of glacial acetic acid to 95ml of distilled water. ➡ If vinegar is used make sure that the concentration of acetic acid is 5%.

b) Procedure STRENGTHS

Overtreatment (it is not a diagnosis test but a screening test)

Simple and requires minimal equipment

Requires developing standardised training and quality assurance standards

Low cost for setting-up and maintenance

Less accurate for menopausal women

Immediate availability of test results

False positives: immature squamous meta-plasia, leukoplasia and condyloma

VIA can be integrated in primary health cen-tres

Interpretation depends on the practitioner and requires quality assurance control measures.

Can be performed at any time of the cycle.

Advice before VIA test Provide women with the following information: ➡ Nature of cervical cancer and consequences of an HPV infection ➡ Risk factors for the illness ➡ Role and importance of VIA screening ➡ Consequences of not continuing tests after a negative HPV result ➡ Options for treatment if the VIA test is abnormal. Medical interview Patient’s history: bleeding pattern, parity, contraception, risk factors for cervical cancer. Examination: ➡ Vulva, vagina, cervix ➡ Perform a bimanual and rectovaginal examination if necessary. Search for: • Cervical motion tenderness • Pregnancy • Uterine anomaly

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HEALTH SESSION 3 VISUAL INSPECTION WITH ACETIC ACID

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Procedure ➡ Wash hands ➡ Inspect external genital parts and examine the urethral orifice for any discharge ➡ Gently insert the speculum until feeling a resistance and gently open it to reveal the cervix ➡ When the cervix is entirely visible, block the speculum open so that it stays in place and reveals the cervix ➡ Adjust light source to see the cervix ➡ Inspect the cervix and look for signs of infection (cervicitis) such as a white purulent discharge (mucopus); ectopy (ectropion); visible tumours or cysts, ulcerations or lesions. ➡ Use a clean swab to remove any discharge, blood, or mucus from the cervix. ➡ Identify the cervical os and the squamous columnar junction (SCJ) around it ➡ Dip a clean swab in acetic acid solution and apply it to the cervix ➡ After applying acetic acid, wait for at least one minute and inspect the cervix to detect in changes in colour ➡ Pay careful attention to the SCJ: easy bleeding, any white or thickened areas ➡ If necessary, apply more acetic acid and swab the cervix to remove mucus, blood or any discharge that might appear during inspection and impede proper visualisation ➡ After completing visual inspection of the cervix, use a clean cotton swab to remove any remaining acetic acid from the cervix and vagina ➡ Gently remove the speculum • If the VIA test is negative, dip the speculum in a 0.5% chlorine solution for 10 minutes for decontamination • If the VIA test is positive and if the patient opts for treatment, place the speculum on a highlevel disinfected plate, or in a recipient so as to be able to reuse it for thermocoagulation. Counselling after negative results: ➡ Deliver the test results to the woman ➡ Give the information that the next appointment should be 3 years later (or 1 year if HIV +). Counselling after positive results: ➡ Deliver the results to the woman ➡ Explain recommended further investigations to perform and procedures to follow ➡ Reassure the woman. Infection control ➡ Remove gloves ➡ Dispose of gloves in a bucket with a plastic bag ➡ Wash hands after the examination ➡ Decontaminate instruments in 5% chlorine solution for 10 minutes then sterilise in an autoclave or by immersion in boiling water for 20

minutes.

Tools to help identify precancerous lesions.

Information system ➡ Fill out the register ➡ Fill out individual records (VIA report and/or personal records).

III. INTERPRETATION OF THE RESULTS a) Classification At the interpretation stage, one must carefully observe: ➡ The intensity of the white colour of the acetowhite lesions: are they shiny white, cloudy white, pale white or dull white? ➡ The border and demarcations of the white lesions: distinctly clear and sharp or indistinct diffused margins? raised or flat? regular or irregular margins? ➡ Are the lesions uniformly white in colour or does the colour intensity vary across the lesions or are there any areas of erosion within the lesion? ➡ Location of the lesion: is it near, or far away from the transformation zone? Is it abutting (touching) the squamocolumnar junction? Does it extend into the endocervical canal? Does it occupy the entirety, or only a part of the transformation zone? Does it involve the entire cervix (which usually indicates early preclinical invasive cancer)? ➡ Size (extent or dimensions) and number of the lesions. If in doubt, it is safe to repeat the test a few times, taking care not to induce bleeding. Women with suspected invasive cancers should be referred for further investigations and treatment. VIA categories ➡ An acetowhite area is not significant if it is far from the squamocolumnar junction and does not touch it ➡ An acetowhite area close to the squamocolumnar junction is significant. VIA OUTCOME

CLINICAL SIGNS

NEGATIVE TEST

No acetowhite lesions or mildly acetowhite, polyps, cervicitis, inflammation, Nabothian cysts

POSITIVE TEST

SUSPICION OF CANCER

Distinct, well defined dense acetowhite areas (opaque/dull or oyster-white) with regular or irregular margins close to the squamocolum-nar junction Condyloma and leukoplasia close to the squamocolumnar junction Visible ulcerated lesions, growths on the cervix that bleed on touch.

b) Negative VIA Test results VIA screening is reported as negative in the case of any of the following observations: ➡ No acetowhite reaction ➡ No acetowhite lesions are observed on the cervix ➡ Polyps protrude from the cervix with bluish white acetowhite areas ➡ Nabothian cysts appear as button-like areas, as whitish acne, or pimples ➡ Dot-like areas are present in the endocervix, which are due to grape-like columnar epithelium staining with acetic acid ➡ Presence of shiny, pinkish white, cloudy white, bluish white, faint patchy or doubtful lesions with ill-defined, indefinite margins, blending with the rest of the cervix ➡ Angular, irregular, digitating acetowhite lesions, resembling geographical regions, distant (detached) from the squamocolumnar junction (satellite lesions) ➡ Faint line-like or ill-defined acetowhitening is seen at the squamocolumnar junction ➡ Streak-like acetowhitening is visible in the columnar epithelium.

c) Positive VIA results The VIA test result is reported as positive in any of the following situations: ➡ There are distinct, well-defined, dense (opaque, dull- or oyster-white) acetowhite areas with regular or irregular margins, close to or abutting the squamocolumnar junction in the transformation zone or close to the external if the squamocolumnar junction is not visible ➡ Strikingly dense acetowhite areas are seen in the columnar epithelium • The entire cervix becomes densely white after the application of acetic acid • Condyloma and leukoplasia are located close to the squamocolumnar junction, turning intensely white after application of acetic acid.

d) VIA positive for invasive cancer The result of the test is reported as invasive cancer when: ➡ There is a clinically visible ulceroproliferative growth on the cervix that turns densely white after application of acetic acid and that bleeds on touch.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK VISUAL INSPECTION WITH ACETIC ACID

➡ Enlargement or tenderness of the uterine appendages.

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NOTES

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➡

VIA is one of the methods for early detection of cellular alterations of the cervix, lesions which become visible to the naked eye after application of acetic acid on the cervix during a speculum examination.

➡

As part of the defined screening algorithm, it is used as triage and takes place after a positive HR-HPV test.

➡

Training and guided practice is necessary to ensure competent performance of VIA.

➡

Possibility to train for VIA. http://screening.iarc.fr/digital/cdVIAen/cdVIAen.html

➡ What do I take away from this session? ➡ What elements require further clarification?

➡ Understandings to develop?

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KEY MESSAGES

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I. OVERVIEW OF AVAILABLE METHODS

b) Thermocoagulation

Early detection through targeted screening followed by treatment of the diagnosed precancerous lesions can prevent most cases of cervical cancer.

Thermocoagulation treats precancerous lesions by causing tissue necrosis. A high temperature probe is applied to the abnormal area. Cervical tissue heals in around a month. Indications are the same as for cryotherapy.

As per the ‘screening and treatment’ approach, the decision of treatment is based on a screening test and not a diagnostic test, and the treatment must take place as soon as possible if the test is positive. Decision for treatment is based on a VIA positive outcome and does not require a histological confirmation (diagnosis). WHO recommendations for the treatment of precancerous lesions are: ➡ Cryotherapy/ thermocoagulation ➡ LEEP ➡ Cold-knife cone

a) Cryotherapy Cryotherapy treats precancerous lesions by freezing precancerous cells and causing cellular dehydration. This is achieved by applying a low temperature cryogenic probe on the abnormal zone. Cervical tissue heals in around a month.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

Principle: Application of a low temperature probe on the surface of the lesions to freeze abnormal areas by cellular dehydration.

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Technique: Use of carbonic snow (CO2) or liquid nitrogen (N2O). Indications: ➡ Visible lesions ➡ Lesions covering less than 75% of the cervix ➡ Lesions covering less surface than the probe ➡ Visible SCJ.

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ List the different treatment techniques for precancerous lesions (cryotherapy, thermocoagulation, LEEP and cold-knife cone) and their indications. ➡ Articulate basic principles of the implementation of thermocoagulation and LEEP. ➡ List the possible complications of these various treatments. ➡ List the required equipment to carry out thermocoagulation and LEEP. ➡ Enunciate the modalities for follow-up monitoring and treatment of precancerous lesions.

PRACTICAL SKILLS:

➡ Carry out treatment using thermocoagulation.

SOFT SKILLS:

➡ Establish a trusting and respectful relationship.

Contra-indications: ➡ Endocervical lesions ➡ Invasive cancer ➡ Pregnancy. Procedure: ➡ 15 minutes ➡ No anaesthesia ➡ Probe is positioned on the cervix ➡ Apply gas twice for a duration of 3 minutes with a 5-minute interval between both applications. Side-effects: Cramps (2 to 4 weeks) / Uncomfortable discharge (2 to 4 weeks). Customary advice: ➡ No vaginal douche ➡ No tampons ➡ No sexual intercourse for a month ➡ Use condoms for 6 weeks.

Principle: Application of a high temperature probe to the surface of a lesion to cause necrosis of abnormal areas. Technique: Application of the probe at 100°C on the uterine cervix while exerting pressure on the cervix for 1 minute. Indications: ➡ Visible lesions ➡ Lesions covering less than 75% of the cervix ➡ Lesions covering less surface than the probe ➡ Visible squamocolumnar junction (SCJ) Contra-indications: ➡ Endocervical lesions ➡ Invasive cancer ➡ Pregnancy. Procedure: ➡ 2 minutes of procedure ➡ No anaesthesia ➡ Probe is positioned on the cervix ➡ Apply the probe at 100°C on the zone for 1 minute. Side-effects: Cramps (2 to 4 weeks) / Uncomfortable discharge (2 to 4 weeks). Customary advice: ➡ No vaginal douche ➡ No tampons ➡ No sexual intercourse for a month ➡ Use condoms for 6 weeks.

c) Loop electrosurgical Excision Procedure (LEEP) The Loop Electrosurgical Excision Procedure uses a wire loop that cuts the tissues so as to remove abnormal zones while ensuring haemostasis. This haemostasis is ensured with a ball electrode. The tissue can be sent for anatomopathological analysis to assess of the extent of the lesion. Principle: Electrosurgical removal of a part of the cervix (with the aim of sparing as much tissue as possible). Technique: Use of a thin electrosurgical loop to remove abnormal areas to entirely eliminate the lesion and the transformation zone.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

HEALTH SESSION 4 TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

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Technique: Uses a scalpel to remove abnormal zones of the cervix. The cone must extend the abnormal zone by at least 3 mm and be sufficiently deep. Indications: ➡ Lesions covering over 75% of the cervix ➡ Endocervical lesions ➡ SCJ not visible.

Contra-indications: ➡ Invasive cancer ➡ Pregnancy. Procedure: ➡ 15 minutes without anaesthesia ➡ Anaesthesia (local, locoregional or general) ➡ Partial removal of the cervix using an electrosurgical loop ➡ Haemostasis with a ball electrode. Side-effects: ➡ Bleeding ➡ Foul-smelling discharge ➡ Abdominal pain ➡ Risk of preterm labour

CRYOTHERAPY THERMOCOAGULATION LEEP COLD-KNIFE CONE

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

a) Background information

Recovery rates: ➡ 96% for CIN 1 ➡ 95% for CIN 2 and 3.

The following table summarises the key characteristics of the different treatments.

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All patients can freely decide to accept or refuse treatment. If it is refused, offer the patient screening one year later (see chapter on Counselling). ➡ Provide detailed information on the procedure, the risks, the benefits ➡ Encourage the patient to ask questions ➡ Ask the patient to confirm her consent to treatment ➡ Expected side-effects: o Cramps o Vaginal discharge (abundant, aqueous) o Light bleeding

Procedure: ➡ 15 minutes without anaesthesia ➡ Anaesthesia (local, locoregional or general) ➡ Performed using a scalpel.

Principle: Surgical removal of a cone-shaped part of the cervix (hence the name) and biopsy.

INDICATIONS

Thermocoagulation should not be performed during pregnancy. Pregnant women will be asked to come back 3 months after their delivery for a new assessment and treatment, if still necessary.

Effectiveness: ➡ Comparable to cryotherapy, CKC or LEEP ➡ Little perspective regarding evaluation.

Customary advice: ➡ No vaginal insertion for 1 month ➡ No sexual intercourse for 1 month

d) Cold Knife Cone (CKC)

b) Counselling

Contra-indications: ➡ Invasive cancer ➡ Pregnancy.

Side-effects: ➡ Bleeding ➡ Foul-smelling discharge ➡ Abdominal pain ➡ Infection ➡ Risk of preterm labour.

Customary advice: ➡ No vaginal insertion for 1 month ➡ No sexual intercourse for 1 month.

II. THERMOCOAGULATION

PROCEDURE

ADVANTAGES

LIMITATIONS

• .Visible lesions • Covering less than 75% • Lesions no wider than the probe • Visible squamocolumnar junction

• • • •

15 minutes No anaesthesia Probe on the cervix Apply gas twice for 3 minutes with a 5-minute interval

• Affordable, no need for consumables (gas) • Short duration 15’ • No need for electricity

• Lower success rates with large lesions • No histological confirmation • Unreliable supply (requires liquid nitrogen or dry ice)

• Visible lesions • Covering less than 75% • Lesions no wider than the probe • Visible SCJ

• • • •

2 minutes No anaesthesia Probe on the cervix Apply 100°C probe on the zone for 1 Minute

• Affordable since no need of consumables • Short duration (2’) • Minimal equipment needs • Easy procedure • Few complications

• Lower success rates with large lesions • No histological confirmation

• Lesions covering more than 75% • Endocervical lesions • Non-visible SCJ

• 15 minutes excluding anaesthesia • Anaesthesia (local, locoregional or general) • Partial removal of the cervix using an electrosurgical loop • Haemostasis with ball electrode

• Possibility of a biopsy • Few side effects and complications

• Local anaesthesia (paracervical block) • Costly equipment • Advanced technical facilities

• Lesions covering more than 75% • Endocervical lesions • Non-visible SCJ

• 15 minutes excluding anaesthesia • Anaesthesia (local, locoregional or general) • Use of a scalpel

• Possibility of a biopsy

• Costly equipment • Advanced technical facilities

Advantages: ➡ Affordable as it does not require consumables (gas) ➡ Effects comparable to cryotherapy for 100°C thermocoagulation ➡ Easy-to-use equipment ➡ No anaesthesia required ➡ Easy procedure ➡ Few complications. Limitations: ➡ Lower success rates with large lesions ➡ No histological confirmation. Indications: ➡ Positive screening test ➡ Lesions not more than 2 mm larger than the probe ➡ Entirely visible lesions not extending to the endocervical area or towards the vaginal wall. Exclusion criteria: ➡ Suspicion of glandular dysplasia or invasive carcinoma ➡ Lesions more than 2 mm larger than the probe ➡ Pregnancy ➡ Menstruation.

Médecins du Monde (2019), Photo taken by the teams, Internal document

c) Equipment and material Examination table Light source Bivalve speculum (Cusco or Graves) Instrument plate or recipient Thermocoagulation machine Cotton swabs Unused examination gloves or high-level disinfection surgical gloves ➡ Unused wooden spatula and/or a condom ➡ 0.5% chlorine solution to decontaminate the instruments ➡ A sheet to record the events. ➡ ➡ ➡ ➡ ➡ ➡ ➡

d) Procedure ➡ Warn the patient that speculum is going to be inserted and that she may feel some pressure ➡ Gently insert the speculum entirely until feeling a resistance and open it to see the cervix ➡ When the cervix is entirely visible, fix the speculum in open position so that it stays in place with the cervix visible ➡ Adjust the light source to see the entirety of the cervix ➡ Use a cotton swab to remove any discharge, blood, or mucus from the cervix

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

Indications: ➡ Lesions covering over 75% of the cervix ➡ Endocervical lesions ➡ SCJ not visible.

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➡ ➡ ➡ ➡

Identify the cervical os, the SCJ and the location and size of the lesion o If required, apply acetic acid to reveal the lesion Hold the thermic probe perpendicular to the cervix Hold the trigger for one minute Remember to exert pressure on the cervix At the end of the procedure, carefully observe the cervix to make sure a white ball-shaped area appears.

e) Complications and customary advice

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

Complications: ➡ Abdominal pain (2 to 4 weeks) ➡ Foul-smelling discharge (2 to 4 weeks) ➡ Bleeding ➡ Infections.

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Limitations: ➡ Requires local anaesthesia (paracervical block) ➡ Costly equipment ➡ Requires advanced technical facilities.

b) Equipment and material ➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡

LEEP electrosurgical unit and energy source Smoke evacuator and filter Trolley Examination table Halogen lamp Speculum covered with nonconducting material covered with a condom Pickup forceps Needle holder/Long surgical scissors (in case of bleeding) Loop electrode and ball electrode Electric scalpel Neutral electrode Suction tube Local anaesthetic (syringe, needles) Sterile gloves Cotton swabs 3 to 5% acetic acid Monsel’s paste (for haemostasis) Tamponade gauze 0-polysorb suturing thread Formol (if anatomopathological investigation).

Customary advice: ➡ How to take care at home (paracetamol) ➡ No vaginal douche ➡ No tampons ➡ No sexual intercourse for 1 month ➡ Use a condom for 6 weeks ➡ Contact a health practitioner in case of fever exceeding 48 hours, heavy bleeding and severe abdominal pain.

➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡ ➡

III. LEEP PROCEDURE

c) Procedure

Loop Electro Excision Procedure (LEEP) is the partial removal of the area of the cervix comprising the junction zone between the columnar epithelium and the squamous epithelium, using a thin loop connected to an electrosurgical generator. This removal must prevent the development of precancerous lesions into cervical cancer. It is adapted to patients with a theoretical indication for destructive treatment but whose lesions extends beyond 75% of the cervix or extend to the endocervical area, or in cases where the SCJ is not entirely visible. LEEP is not recommended in the case of suspected invasive cancer. It is also contra-indicated during pregnancy. Pregnant women will have to come back 3 months after delivery for a new assessment followed by treatment if this is still necessary.

a) Background information Recovery rates: Depending on the size of the lesion, between 80 and 96%. Advantages: ➡ Possibility of a biopsy ➡ Few side effects and complications.

LEEP is achieved by using an electrode to cauterise the cervix: ➡ An alternating electric current with low tension and high frequency is applied to a thin electronic looped wire ➡ The electrode is slowly inserted into the cervix ➡ The cauterisation of the lesion is achieved with the ball-shaped end electrode.

d) Complications ➡ ➡ ➡ ➡

Bleeding Foul-smelling discharge Abdominal pain Risk of preterm labour.

IV. FOLLOW UP When treatment for cervical cancer has been successful, follow-up monitoring must be set up to ensure the continuum of care. This must be adjusted to the situation and will notable help address side effects of the treatment and ensure that a good quality of life is recovered. It also aims at early detection of a possible relapse. Regarding patients treated with thermocoagulation A follow-up visit must be planned at 4 to 6 weeks after

treatment. This visit will include: ➡ Gynaecological examination to ensure cervical healing ➡ Delivery of information insisting on the importance of regular gynaecological check-ups. Gynaecological check-ups aim at: o Guaranteeing personalised contraception o Preventing and screening for STI o Detecting female cancers such as breast and cervical cancer. Follow-up visits will be planned 1 year after the treatment and will include a VIA Screening test. If the lesion evolves or persists, the treatment will be repeated, maximum once. After that the follow-up visit must be carried out in a higher-level facility. Regarding patients whose tests were negative Patients with negative results must be screened again at 5 to 10 years in the case of a negative HPV test. Patients with negative VIA results following a positive HPV test should repeat an HPV test at 1 year. Of course, these recommendations are to be adjusted to each project’s financial resources.

FIGURE 23: ALGORITHM FOR SCREENING FOLLOW-UP*

Repeat test 5 - 10 years

Negative

HPV TEST Positive

TRIAGE

Positive

Negative

Coloscopy Diagnosis Treatement

Repeat HPV testing after 1 year BIOMARKERS

Positive

* WHO - guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention (2021) ** Médecins du Monde (2019), Figure summarising the sampling procedure, CC

Negative

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FIGURE 24: ALGORITHM FOR SCREENING FOLLOW-UP (DETAILED VERSION)*

KEY MESSAGES

Encouraging all eligible women to cervical cancer screening

COMMUNITY

➡

In order for cervical cancer prevention to be effective, women whose screening test is positive must receive efficient treatment.

➡

There are several types of recommended treatments depending on the context and available resources and depending on the size of the lesions: Cryotherapy / Thermocoagulation are a first line treatments and loop electrosurgical excision procedure (LEEP) is adequate for any lesion covering over 75% of the cervix or in cases where the SCJ is not visible.

➡

These various treatments can be carried out at different levels of care depending on national recommendations.

➡

Using a ‘screen and treat’ approach helps reduce the number of lost to follow-up and may reduce the waiting time before the woman benefits from treatment.

➡

Importance of follow-up to ensure early detection of relapse.

➡

It is important to maintain medical care on a lifelong basis, even in the absence of severe illness.

Counselling all women about cervical cancer HEALTH PROFESSIONAL OR SELF-SAMPLING

CANCER SUSPICION

HPV TEST

HR HPVHIV-

Screening at 5 years

HR HPVHIV+

HR HPV+

Screening at 3 years

Recommending VIA / counseling

REFUSES

ACCEPTS

The patient must be referred elsewhere if she wishes

AFFECTED BY CERVICITIS

YES: provide ATB

PRIMARY HEALTHCARE FACILITY

VIA TEST VIA+

VIA+, PRECANCEROUS LESION > 75 % OR ENDOCERVICA

VIA+ ,VISIBLE SQUAMOCOLUMNAR JUNCTION, PRECANCEROUS LESION < 75%

Recommending thermocoagulation Counselling

REFUSES

ACCEPTS

Screening at 1 year

The patient must be referred elsewhere if she wishes

Advise to repeat VIA or HPV test within 1 year

THERMOCOAGULATION

VIA+

Coming back within a year

Refer for further evaluation or cancer treatment

VIA-

REFERENCE HOSPITAL

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

SUSPICION OF CANCER

* Médecins du Monde (2019), Figure summarising the sampling procedure, CC

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➡ Understandings to develop? CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF PRECANCEROUS LESIONS AND FOLLOW-UP

NOTES

➡ What do I take away from this session? ➡ What elements require further clarification?

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CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF CANCEROUS LESIONS AND REFERRAL

Cervical cancer is caused by the development of abnormal cells in the uterine cervix, characterised by their ability to proliferate. The cervix is composed of three types of tissues: ➡ Ectocervical squamous epithelium: it covers the external part of the cervix called ectocervix. ➡ Endocervical columnar epithelium: it covers the internal part of the cervix called endocervix. Connective tissue or supporting tissue: covered by both previous tissues that meet on a line named the ’junction zone’ or ‘transformation zone’. Cervical cancer develops from one of the three following elements: ➡ Squamous cell carcinoma (85%): initiates in the ectocervix. It is by far the most frequent cervical cancer ➡ Adenocarcinoma (15 %): initiates in the endocervix ➡ Sarcoma: initiates in the connective tissue. This type of cancer is extremely rare.

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‘In situ’ cancers are caused by cervical dysplasia: only superficial epithelium is affected. The basal membrane and underlying connective tissue are not affected. Squamous cell carcinoma and adenocarcinoma are considered invasive when they pass the basal membrane separating them from connective tissue and progress into the underlying connective tissue.

MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ List the different treatment options for cancerous lesions and their indications. ➡ Explain the modalities for each treatment. ➡ Articulate the follow-up strategy following treatment of cancerous lesions.

PRACTICAL SKILLS:

➡ Organise a referral and counter-referral system to facilities that are equipped to care for cancerous lesions.

SOFT SKILLS:

➡ Deliver care in a respectful, empathetic, non-judgmental manner that is supportive of women. ➡ Respect confidentiality and protect medical data at all times.

Risk factors ➡ Sexual activity: early first intercourse (<17 years old) and number of sexual partners are major risk factors. ➡ Tobacco consumption: currently seems to be the second factor ➡ Oral contraception: the effect of oestroprogestogens is debated. They seem to facilitate carcinogenesis. ➡ Immune deficiencies are new elements that have been identified as risk factors, such as kidney transplants and HIV seropositivity.

a) Symptoms of invasive cervical cancer There is a possibility for cervical cancer to go unnoticed at the first stages of the illness, causing no sign or symptoms. Indeed, cancer may be a silent illness; symptoms usually appear when the tumour has developed in the neighbouring tissues and organs.

• • • • •

• • • • • • • •

Unusual, sometimes foul-smelling, vaginal discharge Irregular bleeding (of any kind) during reproductive life Bleeding after sexual intercourse whatever the age, even in the case of young women Post-menopausal bleeding In the perimenopausal period, any unusual bleeding must lead to suspecting cervical cancer, especially if bleeding persists despite adequate treatment.

Frequent and urgent needs to urinate Back pain (may be severe) Lower pelvic pain Weight loss Decreased urine output (ureteral obstruction or kidney failure) Urinary incontinence or faecal vaginal incontinence (caused by a fistula) Oedema of the lower limbs Breathing difficulties (dyspnoea) caused by anaemia or rarely by pulmonary metastasis or pleural effusion.

b) Clinical assessment and cancer diagnosis Medical history and interview Clinical examination must be carried out after a comprehensive interview of the patient’s medical and gynaecological history and risk factors. This examination comprises a gynaecological examination (speculum examination, vaginal and rectal examination) and palpation of abdomen and lymph nodes. Gynaecological examination During speculum examination, extensions in the vaginal walls will be evidenced when the speculum is being opened. Vaginal examination aims at assessing volume, cervical motility and vaginal fornices. Rectal examination can detect parametrial invasion of cervical cancer. Bimanual inspection can help assess the lateral extent of the tumour along the uterosacral ligaments. Cervical cancer can be suspected in the presence of an abnormal screening (gynaecological examination and/or VIA) or in the presence of symptoms. Further investigations are required to confirm the diagnosis. The aim of these investigations is threefold: ➡ Confirm the diagnosis of cancer and identify the

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF CANCEROUS LESIONS AND REFERRAL

When a woman accesses health services to complain about irregular blood loss, post-coital bleeding or postmenopausal bleeding, or even persistent vaginal discharge (despite treatment of STI), they must be offered a speculum examination to identify any unusual aspect and refer the patient in case of suspected cervical cancer.

Other medical disorders may cause similar symptoms. This is why it is necessary to refer patients to a referral facility to perform a biopsy that will lead to a diagnosis. Signs and symptoms of cervical cancer include the following:

EARLY SIGNS

I. CLINICAL FORM AND CANCER DIAGNOSIS

DELAYED SYMPTOMS

HEALTH SESSION 5 TREATMENT OF CANCEROUS LESIONS AND REFERRAL

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histological type of cancer ➡ Assess the extent of the illness (its stage) ➡ Identify any contra-indications to some of the treatments. This may seem a time-consuming stage but conducting precise assessment is crucial in choosing an adequate treatment.

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Diagnosis Since women whose results are positive for the screening tests do not necessarily have precancerous lesions, it is normally expected that they undergo a diagnostic test that will confirm or not the presence of lesions, and possibly assess the stage of the illness.

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Colposcopy is an examination of the vulva, vagina and cervix using a powerfully lit and magnifying instrument. This can be paired with digital cameras. The colposcope is a costly equipment and its use requires training. It is used after screening to guide biopsies and may help in the choice of the most adapted treatment (cryotherapy/LEEP). The most commonly used diagnostic examinations are: ➡ Biopsy: this is a sample of cervical tissue that is sent for anatomopathological analysis, which helps confirm the presence of the precancerous or cancerous lesion and assess their extent (CIN 1 to 3, in situ tumour or invasive tumour). It is the gold standard. It can be performed on lesions visible during VIA or using colposcopy if no lesions are visible.

➡ Endocervical curettage in case extension of lesions in the endocervical area are suspected, or if the squamocolumnar junction is inside the endocervix. Biopsy is necessary to assert the diagnosis and define the histological type. Biopsy consists in removing small samples using a biopsy forceps. The sample is sent to histopathology for analysis. Biopsy can be carried out without anaesthesia. Bleeding is usually minimal.

c) Announcing suspected cervical cancer The sooner the diagnosis is made, the better the chances of healing with limited heavy treatment. The welcome the patient receives at first point of contact in the pathway of care and the quality of listening and information provided upon announcement of the diagnosis are major elements that will influence the rest of the pathway.

Aims ➡ Provide understandable information and counselling so that each woman may make her own decisions. ➡ Explain the upcoming stages of care and treatment. Contents of care ➡ Announce the suspicion of cancer ➡ Explain what will happen in the hospital (confirming the diagnosis and stage of the cancer) ➡ Further examinations (blood sample, biopsy). ➡ Upon confirmation, specialists will explain and discuss procedures and treatment ➡ Make an appointment with the hospital ➡ Provide contact details of the facility and organisations so that she has adequate support when needed. Counselling ➡ Discussion with the patient (and her family if she so wishes) ➡ Listening capacities = powerful therapeutic tool ➡ Request permission to discuss the situation before speaking ➡ Be clear and straightforward when announcing a suspected cervical cancer, and state that the only diagnosis tool is biopsy.

➡ Give people time to understand what you are saying. ➡ Remember to say that all women can be treated for cervical cancer with existing treatments ➡ If patients do not understand very well, use drawings or sketches, and let them know that you will be available for further questions that may arise. ➡ Evaluate the patient’s understanding, listen to what her feelings are about the diagnosis, her fears, her expectations, and her knowledge of existing treatments. ➡ Be ready to explain that unless treated, the cancer will develop and eventually cause death. ➡ Assess psychological support and offer the help of support groups. ➡ Other aspects to consider: o Discuss with her to find out whether she intends to use traditional healers o Do no judge, but rather use combined efforts for optimised care.

The announcement of a suspected cancer is a difficult moment for any patient. Adherence to care and treatment is improved by adequate and timely information delivered to the patient. Therefore, the announcement must include a medical step that will detail the stages that are to be followed. The information delivered must be clear and understandable. The patient must be provided with contact details for the facility or organisations that she might need to support her during the course of care.

PHOTOS: UTERINE CERVIX AFTER TREATMENT

KEY MESSAGES ➡

A woman who is diagnosed with invasive cervical cancer at an early stage can usually recover if provided with effective treatment.

➡

Without treatment, invasive cervical cancer is almost always lethal.

➡

Definitive diagnosis of invasive CC is provided by histological examination of a biopsy sample.

➡

It is essential that health professionals in primary healthcare facilities be able to identify and quickly refer women presenting with symptoms and frequent signs of CC.

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PHOTOS: UTERINE CERVIX BEFORE TREATMENT

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It will be chosen to treat cancers with metastasis beyond the pelvis. In that case it may be used alone or combined with radiotherapy (external, most times). It can slow down or stop the development of cancer.

that are used, as well as the dosage and the patients (who may react differently to the same treatment). Some side effects can be reduced or avoided by preventative treatments and practical tips.

radioactive sources

Duration of the treatment: The total duration can vary. It may take place continuously, every day for a given period of time, or it can be fractioned into cycles whereby cures are spaced with a resting period.

➡ ➡ ➡ ➡ ➡ ➡

EXTERNAL BEAM RADIOTHERAPY

Side effects: Side effects of chemotherapy depend on the drugs

INTRACAVITARY RADIOTHERAPY

Cervical cancer treatment includes surgery, radiotherapy, chemotherapy, which can be used combined or individually.

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Principle: It consists in using ionising radiations to destroy cancerous cells. It may be used to treat both early and advanced stages of cancer. It is a completely painless procedure, that only lasts a few minutes. There are two types of radiotherapy treatments. ➡ Intracavitary radiotherapy is the most frequently used type of radiotherapy for cervical cancer. It consists in introducing an applicator to apply radioactive substance in the vagina or uterus. ➡ External beam radiotherapy involves using an external treatment device close to the body that directs high intensity X-radiations towards the tumour.

stretcher

Duration of treatment: The number of irradiations as well as the duration of the treatment are subject to various factors: stage of the cancer, overall health condition, other treatments. Treatment is spread so as to protect normal tissues. Side-effects: The most frequent side effects are: ➡ Skin alterations ➡ Tiredness ➡ Loss of appetite Complications: ➡ Menopause ➡ Infertility ➡ Dyspareunia

c) Chemotherapy When chemotherapy is used to treat cervical cancer, it is often associated with radiotherapy. This combination is the reference treatment of tumours that are larger than 4 cm or that have extended beyond the cervix into the pelvis. Principle: Chemotherapy treatment is based on the administration of anti-cancer drugs. It is also referred to as medical treatment. It is a general treatment that affects the whole body. It can affect cancerous cells regardless of their location, even if they are isolated and were not identified during diagnosis. Chemotherapy treatments destroy cancerous cells by impeding their division process. Recommendations: Chemotherapy is not offered routinely. Its use and effectiveness vary depending on the stage of the cancer and its extent.

EXTERNAL BEAM RADIOTHERAPY

INTRACAVITARY RADIOTHERAPY Consists in delivering radiation using radioactive sources place in specific implants in the cervical canal and vaginal fornices.

CHEMOTHERAPY

Cisplatin or Carboplatin by intravenous (IV) injection are the most frequently used chemotherapy drugs.

Major surgery requiring general anaesthesia and removal of the cervix, uterus (possible ovaries), para-metrial tissue, upper vagina, and pelvic lymph nodes.

Early stages (Stage I and some cases of stage IIA).

All stages including palliative care.

Advance stages (in association with radiotherapy). Palliative care. Relapse.

Between 10 and 14 days.

Daily treatment lasts 10-15 minutes. The regimen requires around 20-25 cures spread over 4 to 5 weeks (5-6 weekly cures).

Low-dose brachytherapy requires only one hospitalisation of 2-3 days.

Chemotherapy can be administered in ambulatory care/ outpatient clinic in weekly cures for 5 weeks.

Skin alteration Tiredness Loss of appetite.

Skin alteration Tiredness Loss of appetite Pain.

Hair loss Nausea and vomiting Diarrhoea Musculoskeletal pain Tiredness.

Menopause Infertility Dyspareunia.

Infertility

Infection Haemorrhage Lesions of neighbouring organs Thromboembolic risk Hysterectomy causes infertility and dysfunction in the bladder and/or intestines.

Consists in targeting the tumour using a radiation beam from an external source, also called teletherapy.

Treatment of cancer is centralised and provided by tertiary health facilities.

Effective care of women with cervical cancer ought to be multidisciplinary (gynaecologist, oncologist, radiotherapist, etc.). Follow-up is recommended after treatment for 2 to 5 years to monitor the effectiveness of the treatment and prevent relapse.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF CANCEROUS LESIONS AND REFERRAL

b) Radiotherapy

RADICAL SURGERY

DESCRIPTION

Complications: ➡ Infection ➡ Haemorrhage ➡ Lesions of neighbouring organs ➡ Risk of thromboembolic event ➡ Hysterectomy leading to sterility and bladder and/ or intestine dysfunction.

The following table summarizes these treatments:

INDICATIONS

Treatment duration: 10 to 14 days of hospital stay

Hair-loss Nausea and vomiting Diarrhoea Musculoskeletal pain Tiredness Mouth sores

radiation source

DURATION OF TREATMENT

Indication: The choice of treatment is based on the size and clinical form of the cancer: Surgery as primary treatment: Surgery is used as primary treatment option and consists in the removal of a variable portion of tissue depending on the development of the cancer in the pelvis and other individual characteristics of each patient. Surgery as secondary treatment: This can still aim at healing the patient. It consists in radical hysterectomy including removal of a portion of the upper vaginal to reduce the risk of relapse of the cancer. Surgery as palliative care: This is sometimes carried out when the cancer is at an advanced stage to reduce intestinal obstruction or treat fistula (abnormal communication between the vagina and the urinary tract or the rectum) resulting from the irradiation or extension of the primary cancer.

mobile support

SIDE-EFFECTS

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF CANCEROUS LESIONS AND REFERRAL

Principles: Major surgery practiced under general anaesthesia that consists in removing the cervix, the uterus (with or without ovaries), parametrial tissue, the upper area of the vagina and the pelvic lymph nodes.

COMPLICATIONS

a) Surgery

LEVEL

II. STAGING SYSTEM FOR CERVICAL CANCER DEVELOPMENT

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CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK TREATMENT OF CANCEROUS LESIONS AND REFERRAL

Survival depends on the stage of the cancer. Usually, the earlier the diagnosis and treatment, the better the chances of survival for cervical cancer. There is no available statistical data on the various stages of cervical cancer. The following information was drawn from multiple sources and may include data from different countries:

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STAGE

SURVIVAL RATE AT 5 YEARS

93 %

80 %

IIA

63 %

IIB

58 %

IIIA

35 %

IIIB

32 %

IVA

16 %

IVB

15 %

The prognosis is influenced by many determinants, among which the following: ➡ Medical history ➡ Type of cancer ➡ Stage of the cancer ➡ Specific characteristics of cancer ➡ Treatment options ➡ Response to treatment.

e) Differential diagnosis A non-cancerous or benign tumour is a cervical growth that does not extend to other body parts (no metastases). A non-cancerous tumour is usually not life-threatening. This section details the non-cancerous tumours that can be found in the uterine cervix. Cervical polyp Cervical polyp is the most frequent non-cancerous tumour in the cervix. Most of them are benign but some can become cancerous or malignant. Cervical polyp is usually found in women over 20. It is rarely found in young girls before menstruation. It is a red shape resembling a finger. It initiates in the endocervical canal (that links the uterus to the vagina), sometimes protruding into the vagina. Cervical polyps do not systematically cause symptoms. Some women may have unusual vaginal bleeding or yellow to white vaginal discharge. The polyp is diagnosed during pelvic examination. It usually does not require any treatment. If it is large or if it seems abnormal, it can be removed:

➡ With a gentle twisting movement ➡ By circling it using a special thread to stop blood supply ➡ By grasping it with specific forceps ➡ By applying heat produced by electric current (electrocauterization) or a laser beam at the base of the polyp. Nabothian Cyst Nabothian cysts usually appear on the surface of the cervix. Endocervical cells produce mucus. Sometimes, squamous cells that are usually found in the ectocervix begin to develop on cells that produce endocervical mucus. They trap the mucus in the cervix, and this mucus continues to be produced and accumulates in a round smooth growth called a Nabothian cyst. This can be diagnosed during a routine pelvic examination. It does not usually require any treatment. In some cases, it can become big enough to modify the shape of the cervical canal and prevent adequate pelvic examination. In that case, it is possible to drain the cyst to evacuate the mucus. Cervical fibroma Cervical fibroma, also known as leiomyoma, initiates in the muscular tissue of the uterine cervix. Its aspect is similar to the uterine fibroma, but it is less frequent. Cervical fibroma is usually small, measuring 0.5 to 1 cm wide. It can be found in women of any age. Most women with a cervical fibroma present with no clinical signs or symptoms. Usually, there is no need for treatment except if it causes symptoms such as bleeding or pain. Some women will use medication to control these symptoms. Others may require surgery to remove the fibroma.

KEY MESSAGES ➡

Treatment options include surgery, radiotherapy, and chemotherapy; they can be used as a stand-alone treatment or combined.

➡

Without treatment, invasive cervical cancer is almost always lethal.

➡

A multidisciplinary approach is required to ensure efficient care for women with cervical cancer.

➡

With appropriate treatment, the survival rate at 5 years is over 80% for stage I cancers, 70% for stage IIA, 50% for stage IIB, and less than 10% for stage IV.

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d) Prognostic factors

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NOTES ➡ What do I take away from this session? ➡ What elements require further clarification?

➡ Understandings to develop?

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I. BACKGROUND INFORMATION AND TRANSMISSION CYCLE Definition A nosocomial infection is a local or general infection caused by an infectious agent that was not present on admission in the health facility. Any microorganism may cause infection. All human beings are sensitive to most infectious agents if they are not immune (vaccine). Infection transmission cycle

Host

Infectious agent

Portal of entry

Reservoir

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Mode of transmission

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Portal of exit

Infectious agent: pathogenic organism that may cause an infection. Reservoir: Environment where the infectious agent can survive, whether it develops there or not (human, animal, equipment). Portal of exit: the means by which a pathogen exits from the reservoir (respiratory, genital, urinary, mucosa, blood, etc.). Mode of transmission: an infectious agent can be transmitted through one or several routes. Direct con-

tact (person to person) or indirect (via an inanimate object or surface) such as airborne transmission, vector-born transmission (insect) or via a vehicle (food, drugs, droplets, sneezing). Portal of entry: respiratory tract, genital or urinary tract, digestive tract, mucosa, parenteral transmission, transplacental transmission. Host: a person that lacks sufficient resistance to a specific microorganism.

II. BASIC PRINCIPLES OF UNIVERSAL PRECAUTIONS Universal precautions are a set of simple measures to prevent infection transmissions during service provision. This includes minimising the risk of severe infections (hepatitis B, hepatitis C and HIV) from or to: ➡ Patients ➡ Service providers ➡ Other members of staff such as cleaning and maintenance staff. This is all the more important since many infections are asymptomatic. Thus, prevention is essential regardless of the status of the patient, and each person must be considered at risk of being contagious and/or being infected. The measures are based on several components: ➡ Hand washing is the main practical technique to avoid cross-contamination ➡ Use physical barriers (mask, apron, protection goggles) ➡ Use safe working procedures ➡ Isolate patients in case they cannot be protected against airborne transmission ➡ Practice equipment maintenance in accordance with recommended practice on infection control.

PREVENTING INFECTIONS BY WASHING YOUR HANDS

FIGURE 25: PREVENTING INFECTIONS BY WASHING YOUR HANDS

MODULE LEARNING OUTCOMES

Wet your hands

Put the soap

Lather and scrub for 20 seconds

Rinse for about 10 seconds

THEORETICAL KNOWLEDGE:

➡ Articulate the different universal precautions to implement in order to prevent infections during screening, treatment and follow-up. ➡ Explain the sterilisation procedures for various instruments and equipment used for screening and treatment of precancerous and cancerous lesions.

Don't forget to wash: between the fingers under your nails the top of your hands

Dry your hands

Turn off the water tap

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HEALTH SESSION 6: INFECTION CONTROL AND UNIVERSAL PRECAUTIONS

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c) Manipulating instruments and material

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Single-use material and contaminated surfaces ➡ Dispose of single-use items soiled with blood or body fluids using a sealed plastic bag. ➡ Place sharp instruments and needles in safe containers. ➡ Never reuse a needle and syringe. ➡ Do not recap, twist, or break needles before discarding them. ➡ Dispose of medical waste with the usual precautions, etc. ➡ Clean sheets, reusable linen with detergent, sundry them and iron them if possible. ➡ Clean and disinfect working surfaces such as examination tables and floors. Non-disposable instruments and gloves ➡ Any instrument that was in contact with the vaginal and cervix (speculum, forceps, gloves, etc.) must be decontaminated, cleaned, and sterilised or undergo high level disinfection after each use. ➡ Thermic probes must be decontaminated, cleaned, and subjected to high level disinfection. ➡ Examination tables must be decontaminated after each patient. Other instruments (thermocoagulation device, light) must be decontaminated at least daily and if they are soiled.

III. EQUIPMENT MONITORING AND MAINTENANCE Instrument maintenance is subject to three steps: ➡ Decontamination

b) Cleaning Soon after decontamination, the instruments must be cleaned. This is achieved by scrubbing them with a brush under running water and with detergent. The staff in charge of that step must wear a mask or protection goggles and cleaning gloves. When thoroughly cleaned, the instruments are rinsed with boiled water. Instruments with teeth-shaped or screw-shaped components, or articulated devices must receive particular attention at that stage.

Bad management of medical waste may cause serious illnesses for health professionals and staff in charge of waste disposal, as well as the general population. It is therefore necessary to prevent infection of all staff members in contact with the waste. Contents of medical waste ➡ 80% of waste in health facilities is not contaminated (paper, boxes, plastic containers). ➡ 20% only is contaminated (blood, body fluids, outdated vaccines, bottles, mercury from thermometers), part of which are considered hazardous waste. Its elimination requires specific technical and organisational procedures.

NOT HAZARDOUS

HAZARDOUS

PHARMACEUTICAL

c) Sterilisation / High-level disinfection Sterilisation Sterilisation consists in the destruction of all microorganisms. Instruments that are in contact with sterile parts of the body, i.e., that penetrate the skin, or the uterus must go through that sterilisation stage. To achieve sterilisation, there are two options: ➡ Autoclave steam sterilisation: 20 minutes for unwrapped instruments, 30 minutes for wrapped instruments. It is the method of choice. ➡ Chemical sterilisation: soak instruments for 8 to 10 hours in a 2-4% glutaraldehyde solution or 24 hours in an 8% formaldehyde solution, then rinse them with sterile water. High-level disinfection HLD destroys all micro-organisms excluding bacterial spores. It is an alternative when there is no sterilisation equipment or when the instruments are too fragile for sterilisation. The following options can be used: ➡ Boil instruments for at least 20 minutes in drinking water. The water must be renewed daily. Ensure that it covers the instruments and set the timer when boiling is effective. Do not add anything in the container after setting the timer. ➡ Soak instruments for 20 minutes in a 0.1% chlorine

Compresses, syringes, gloves, infusion line.

Infectious

Needle, tube, scalpel, glass vial, etc.

Outdated drugs or vaccines, vial containing residues of drugs.

Wounds Toxic Infectious Transmission of resistant Accidental Blood Exposure pathogens. (HIV, hepatitis B or C)

Gloves, handwashing Gloves, Containers for infectious handwashing, waste Avoid bad habits procedure for waste (like recapping needles). disposal.

TOXIC

Chemical waste: solvent, detergent, disinfectant, engine oil, Cytotoxic (chemotherapy) Mercury (thermometer, fluorescent lamp), radiological fluid.

Carcinogenic properties, teratogenic properties, Toxic for the environment.

Never mix toxic solutions Waste should be disposed of in hermetic waterproof con-tainers.

Waste should be sorted on the place of use, based on waste management protocols.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK INFECTION CONTROL AND UNIVERSAL PRECAUTIONS

Protection goggles, aprons, and masks In the event of splashes of body fluids like during delivery.

IV. MEDICAL WASTE DISPOSAL

MEDICAL WASTE

Gloves Wear gloves before touching a wounded skin, mucosa, blood or any body fluid, or soiled instruments. Use new gloves for each patient to avoid crosscontamination. Keep gloves on when touching soiled instruments or material or when disposing of contaminated waste.

Decontamination is the process that enables instruments and gloves that have already been used to be manipulated without risk. This step inactivates hepatitis B and HIV viruses. It is achieved by immersion of instruments and gloves immediately after use in a big plastic bucket containing a 0.5% chlorine solution for 10 minutes (no longer because chlorine is corrosive), then rinse them with clear water. Chlorine solution is obtained by putting together 1 volume of bleach with 9 volumes of water. The solution must be prepared every day and destroyed as soon as it is soiled. This solution can also be replaced by ethanol or 6090% isopropanol to decontaminate surfaces.

EXAMPLES

b) Protective equipment

a) Decontamination

solution or 2% glutaraldehyde solution. An alternative is to soak them for 30 minutes in 6% oxygenated water. Thoroughly rinse with boiled water, leave to dry, and wrap in a sterile cloth. Chemical products are corrosive and may reduce the duration of the use of instruments that are regularly disinfected with this method.

RISKS

Hand washing is the easiest way to prevent crosscontamination. Wash hands with water and soap, before and after each action. ➡ Patient examination ➡ After removing gloves (possible holes in gloves) ➡ After touching blood or other body fluids, even with gloves.

➡ Cleaning ➡ Sterilisation or high-level disinfection.

PROTECTION MEASURES

a) Hand washing

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NOTES

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➡

Infectious diseases continue to be a major cause of death on a global scale.

➡

Health professionals and their patients are at risk of contracting these diseases.

➡

Transmission of infections within health facilities is mainly caused by lack of respect for handwashing and universal precautions.

➡

Inadequate waste management in care facilities can be the starting point of serious illnesses for health professionals, for staff in charge of waste disposal, for patients and for the wider community.

➡

Infection control is EVERYONE’s responsibility.

➡ What do I take away from this session? ➡ What elements require further clarification?

➡ Understandings to develop?

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KEY MESSAGES

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I. PALLIATIVE CARE: DEFINITION, KEY COMPONENTS a) Definition The WHO defines palliative care as a means to improve quality of life for patients and families faced with the issues associated with illnesses. It is not reduced to end-of-life care, as it encompasses interventions throughout the development of the illness. It aims at providing care for all distressing symptoms, notably pain, and takes account of the emotional and spiritual needs of patients and their close ones. Palliative care can be delivered by members of the community, health staff, and can take place in the patients’ homes or in health facilities. Each year, an estimated 40 million people require palliative care, and 78% of them live in low- or middleincome countries. On a global scale, need for palliative care will continue to rise, caused by an increasing number of noncommunicable diseases and aging populations. Palliative care is considered a fundamental human right and is stated in international human right statements.

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b) Key components

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MODULE LEARNING OUTCOMES THEORETICAL KNOWLEDGE:

➡ Awareness of the ethical framework in terms of end-of-life care and palliative care. ➡ Knowledge of the most frequent clinical signs in end-of-life patients.

PRACTICAL SKILLS:

➡ Use recommended methods for pain assessment and explain the modalities of pain management, including indications and administration regimens of pain relief treatments. ➡ Explain activities to set up, in partnership with local civil society partners, to develop community-based care. ➡ Articulate the basic principles of home and community care.

SOFT SKILLS:

➡ Behave in a respectful, empathetic, non-judgemental manner, supportive of women. ➡ Discuss representations of illness, end-of-life, and death.

Palliative care is meant to improve quality of life for patients and their close relatives who face issues associated to life-threatening diseases. These issues may be physical, psychosocial, or spiritual. Palliative care is characterised by the following items: ➡ Provides pain relief treatments and address other distressing symptoms ➡ Affirms life and regards dying as a normal process ➡ Intends neither to hasten or postpone death ➡ Integrates the clinical, psychological, and spiritual aspects of patient care ➡ Enables patients and their close ones to be as empowered as possible in their decision-making ➡ Provides a support system for families during the course of care ➡ Improves quality of life and may positively influence the course of the illness ➡ Must be offered early in the course of the illness, as soon as the advanced stage of the illness is confirmed. The resolution on palliative care was adopted during the World Health Assembly in 2014 and commits governments worldwide to further develop norms and services at national level to increase access to palliative care for all patients.

II. PAIN MANAGEMENT « Access to pain relief is a human right» Pain has a strong impact on quality of life and psychological well-being, as patients find their suffering increased by a vicious circle of painapprehension-suffering. For these reasons, treatment of pain caused by cervical cancer must be integrated in care. Since pain is a subjective sensation, its intensity can be experienced differently depending on the individual. For that reason, to provide efficient pain relief, the starting point is always to assess it as precisely as possible, and to achieve this, one must have an understanding of the complexity of pain.

a) What is pain? Definition The International Association for the Study of Pain (IASP) defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’. Characteristics of pain ➡ Acute pain is associated with sudden damage of tissues or organs. ➡ Chronic pain is pain that last over 3 months, either persisting or recurring. Pain then shifts from becoming the symptom of an illness to being the illness itself, as it will impact the person’s functional, relational capacities and therefore will have an effect on daily activities. Types of pain ➡ Nociceptive pain, caused by lesions of a body part (burns, fractures, inflammation...). This type of pain is part of the body’s warning mechanisms to alert that something is wrong. ➡ Neuropathic pain is caused by the effects on sensitive nerves of lesions that may be caused by compression or tear due to trauma, or compression by a cancerous tumour. Neuropathic pain is chronic by nature and is described as an electric pulse, stabbing pain, or burning in the body parts linked to the nervous lesions. This type of pain can persist after the lesion is healed, as is the case for persistent pain after cancer recovery. ➡ Idiopathic pain or pain of unknown origin is probably linked to an alteration of pain control systems. Cervical cancer pain A majority of women with advanced cervical cancer will experience pain at a point of the development of their illness. This is a complex type of pain that includes both nociceptive and neuropathic components with various origins, intensity, and duration.

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HEALTH SESSION 7 PALLIATIVE CARE: PAIN MANAGEMENT AND END-OF-LIFE CARE

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In fact, many cancer drugs, notably chemotherapy and radiotherapy have neurotoxic effects. These treatments can cause nociceptive pain at the time of treatment and neuropathic pain later.

WHO PAIN RELIEF LADDER

Pain assessment using facial expressions and gestures ➡ If the patient is unreactive, does not communicate or if her behaviour is hard to interpret, heteroassessments (where pain is assessed by the practitioner) can be used. This requires additional training (Doloplus Algoplus scales).

Step 1+Step 2; Step 1+ Step 3

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Medical interview ➡ Where is the pain located? (use body diagrams) ➡ What improves or worsens pain? How is it progressing with time? ➡ How long has the pain been present? ➡ What pain relief medications have been used? ➡ What is the intensity of the pain? ➡ Is there any psychological or spiritual element that adds to the physical issues of the illness? Is the patient worried, anxious, depressed, or sad? ➡ Does pain limit normal physical activity? (sitting, standing up, walking, running, interacting socially). Quantify the intensity of pain Pain intensity is ideally evaluated when the patient is not in pain so that her concentration is not affected. This may require beginning medical pain relief prior to the interview. ➡ If the patient is communicative and cooperative, it makes sense to use self-assessment tools such as a VAS (Visual analogue scale). To have a better grasp of the intensity of the pain that is experienced, health professionals commonly use a visual analogue scale (VAS), in the form of a ruler graduated from 0 (no pain) to 10 (highest possible pain). PATIENT SIDE NO PAIN

WORST PAIN IMAGINABLE

MEASUREMENT SIDE

STEP 1 NON-OPIOID PAIN RELIEF 0 NO PAIN

Pain is a subjective and personal experience that cannot be measured but can be assessed. It requires personalised treatment and therefore its management is time consuming. Pain assessment is conducted by interviewing the patient and evaluating pain. Pain evaluation must be carried in a non-judgemental manner, the reality of pain being the patient’s perception.

Examples of pain linked to cervical cancer Pelvic pain, severe back pain, dyspareunia (caused by the reduction of size of the vagina after surgery or hardening of vaginal tissue following radiotherapy etc.).

b) Pain assessment

Synergic combination

1 MILD PAIN

2 MODERATE PAIN

3 SEVERE PAIN

4 5 VERY SEVERE EXCRUCIATING PAIN PAIN

As soon as the treatment is delivered, the team carries out a new evaluation to ensure that it is effective. If pain does not decrease after the adequate time for the medication to be efficient, the drug or its dosage are inappropriate and must be questioned. Thus, pain must be regularly assessed. Disparities between pain as assessed by the practitioner and pain expressed by the patient can be reduced through discussion.

c) Pain relief Key elements: In 2010, the International Narcotics Control Board state that there were 121 countries where the opioid consumption levels were insufficient or very insufficient to satisfy basic medical needs. In 2011, this represented 83% of the world population living in these countries with insufficient access to opioids. Therapeutic principles: ➡ Provide early treatment of the cause of the symptom ➡ Prevent the pain by continuous drug intake (fixed hours) ➡ Relieve the symptom completely and remove its memory ➡ Keep the patient valid as so far as is possible ➡ Protect the patients’ intellectual capacities (avoid sedative treatments) ➡ Favour oral or rectal treatments ➡ Personalised prescription.

PARACETAMOL

SALICYLATE

STEP 2

STEP 3

WEAK OPIOID

STRONG OPIOID

NSAID

CODEINE

Analgesic, antipyretic, antiinflammatory at high dose, antiplatelet agent at low dose.

Analgesic for moderate pain

MORPHINE

INDICATIONS

Analgesic, antipyretic

Analgesic, antipyreptic, antiinflammatory at high dose antiplatelet agent at low dose

DOSING REGIMEN

500 mg 2 every 4 to 6 hours

600 mg every 4 hours

400 mg every 6 hours

2.5 mg to 5 mg every 4 hours, 30 to 60 mg/4h double the dose if the pain persists.

PHARMACEUTICAL FORMS

Oral, rectal, IV

Oral

COMMENTS

Well tolerated, can be associated with other pain relief treatments.

Maximum dose of 3000 mg (7.5

SIDE-EFFECTS

Hepatotoxicity

Digestive disorders, stomach ulcer, allergy, asthma, haemorrhage, tinnitus.

CONTRAINDICATIONS

Liver failure, known allergy.

Peptic ulcer, anticoagulant treatment

The use of the pain relief ladder for the administration of pain relief treatment is efficient in addressing pain. Symptoms are sometimes difficult to control at all stages of the illness and must be closely monitored. To relieve pain, the WHO ladder (see table above) must be used in link with national protocols. Pain relief treatment administration ➡ Begin by Step 1 analgesics (paracetamol, aspirin, or ibuprofen).

Digestive disorders, kidney disorders, cutaneous affections.

Analgesic for severe pain

Oral or rectal

No upper limit, the in-tensity of the pain guides the dosage. Nausea and vomiting (decrease with 8 to 10 days), constipation (prevent with laxative treatment and monitor bowel function), Drows-iness, Sedative effect, Nightmares, Hallucina-tions, Respiratory de-pression, redness and pruritus. OVERDOSE antidote: naloxone.

➡ If pain increases or persists, use a weak opioid such as codeine, which may be associated with a step 1 analgesic. In order to prevent the side-effects of opioids, laxative and antiemetic treatments should be administered. ➡ If pain continues to increase, administer morphine, associated or not with opioids.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK PALLIATIVE CARE

Pain can be caused by the cancer itself (compression by the tumour, by infiltration of malignant cells or metastasis…), but also by the treatments of the cancer.

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Women with advanced cervical cancer can present with foul-smelling and bloody vaginal discharge due to bacterial proliferation. The following solutions can be offered: ➡ Sitting baths with warm water. Gently dry the zones using zinc oxide cream or petroleum jelly. ➡ Absorb the discharge with clean cloth or menstrual pads. ➡ Carry out vaginal douche with one of the following solutions made with boiled water: o 1 tablespoon of sodium bicarbonate (baking soda) in 2 cups of water o Half a cup of vinegar in 2 cups of water o 5 to 10 crushed tablets of metronidazole dissolved in two cups of water. ➡ Pack the vagina with clean cloths soaked in one of these solutions, twice daily. ➡ Broad-spectrum antibiotic should be prescribed with caution (only temporarily effective and at risk of vaginal yeast infection). The patient should complete the course of treatment otherwise this may worsen the symptoms.

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Fistula (abnormal passage between the vagina and the urinary bladder or the rectum). This may be caused by extension of the cancer into these organs or by radiotherapy. Fistulas cause foul-smelling irritating discharge. In that case the vagina should not be douched or packed. Alternative solutions may be offered: ➡ Sitting baths with warm water. Gently dry the zones using zinc oxide cream or petroleum jelly. ➡ Absorb the discharge with clean cloth or menstrual pads. ➡ Broad-spectrum antibiotic should be prescribed with caution (only temporarily effective and at risk of vaginal yeast infection). The patient should complete the course of treatment otherwise it may worsen the symptoms. Vaginal bleeding may result of the insertion of any item in the vagina. Vaginal douches and vaginal packing are not recommended. Alternatives to sexual penetration should be preferred. In the case of bleeding, the woman should: ➡ Lie down and monitor the bleeding in case of light bleeding ➡ Access a health facility in case of heavy bleeding. The following table summarises how to manage the most frequent symptoms at advanced stages of cervical cancer.

e) Holistic health support Following a healthy diet, exercising, and avoiding risky behaviours such as tobacco and excess alcohol consumption will enhance health and well-being.

Achieving a healthy diet Nutrition advice and support in following a healthy diet are neglected aspects of care during illness. Nutritional balance can be modified during treatment for people with cancer. Tiredness, loss of appetite, nausea, vomiting, aversions to food, modified sense of taste and smell… are some of the most frequent complaints. A few key actions can be taken in such situations: ➡ Drink 1.5 litres of water each day ➡ Have set number of daily rations of vegetables, fruit, and wholegrain products (wholegrain bread, pasta, rice…) ➡ Ensure sufficient protein intake ➡ Avoid excess fat, salt, and sugar. This advice should be followed wholeheartedly. Feeling coerced into a healthy diet will result in a loss of energy. This may have negative impact on nutritional status and therefore on quality of life. Maintaining a good nutritional status is important in the fight against cancer and improves chances of success in the treatment. Good nutritional status is first and foremost guaranteed by sufficient protein and calorie intake. At that point, these calories or proteins may come from a less healthy diet, which is not of primary importance. Women should be encouraged to eat food that is appealing to them, even if they do not crave for healthy and balanced diets. Physical exercise More and more studies demonstrate the benefits of physical exercise as tertiary prevention, notably for patients with cancer. Physical exercise reduces stress, nausea, constipation, and may improve appetite. Patients with cancer have altered cardiorespiratory and muscular capacities. These modifications may lead to a state of intolerance to exercise, causing diminished autonomy, quality of life, self-esteem, and increased physical and psychological signs of tiredness.

SYMPTOMS

VAGINAL DISCHARGE

Avoid risky behaviours ➡ Quit smoking or reduce tobacco consumption ➡ Avoid passive smoking by no staying in a room with smokers ➡ Limit alcohol consumption.

Tumoral necrosis Fistula Bacterial proliferation

FISTULA

The tumour causes a passage

VAGINAL BLEEDING

Caused by the tumour

NAUSEA AND VOMITING

DIARRHOEA

CONSTIPATION

If the patient is well enough to allow it, exercising for 5 to 10 minutes a day is recommended for people with little previous exercise habits. For people who already regularly exercised, they should maintain their habits as long as possible. The sooner physical exercise can be introduced (or maintained) in the pathway of care, the more beneficial the effects on the patient.

CAUSE

LOSS OF APPETITE

WEAKNESS TIREDNESS

PREVENTION

Hard to prevent Palliative radiotherapy or surgical removal of the tumour.

MEDICAL CARE Vaginal packing soaked with solution twice daily. Antibiotic or antifungal treatment.

HOME CARE

Frequent sitting baths Menstrual pads Douches

Frequent sitting baths Menstrual pads Douches Zinc oxide cream or petroleum jelly.

Hard to prevent

None

Palliative radiotherapy

Transfusion in case of heavy bleeding

Avoid physical efforts and sexual intercourse Resting

Opioids Sever pain Radiotherapy Chemotherapy Fever

Antiemetic treatment from the onset of the cancer / Pain relief treatment

Metoclopramide or promethazine

Small regular sips of fluids (cola tea, ginger)

Gastroenteritis Parasites Radiotherapy

Good food hygiene Handwashing Boiled drinking water

Opioids Dehydration

Drink fluids High fiber diet Laxative treatment

Associate opioids with laxative treatment

Change diet

Frequent, light meals Fresh food

Possibility of using co-steroids

General care

Treat cause if possible

General care

Illness Treatment

Illness Post-operative period Anaemia

Treat the cause Loperamide

Rehydration solution Food on demand Keep patient clean Avoid skin disorders

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d) Care of distressing symptoms

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III. END-OF-LIFE CARE

Most types of pain can be efficiently treated using a broad association of medical and non-medical approaches. Cultural and traditional approaches may be used as an addition to modern medicine but should never replace it.

a) Preparing for death

Psychological support to patient and families Drugs have limitations in the treatment of complex types of pain linked to cancer or cancer treatment. It is necessary to listen to patients, take account of their personal, family, and professional issues. Thus, psychological support can be as useful as pain relief treatments. Each treatment must be personalised, adjusted to the needs and characteristics of a patient and her family. The aim is to relieve pain or make it bearable to minimise impact on daily life and alteration of quality of life. Therapeutic education consists in explaining the illness, its treatments, and expected side effects.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK PALLIATIVE CARE

Support the patient in developing self-care skills and adaptations skills that will be useful in improving and maintaining health, quality of life for him/her and his/ her family.

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Alternative medicine A number of patients make use of complementary methods as an addition to medical treatment. Such treatments are taken alongside the classical treatment. Some of these methods contribute to improve wellbeing and quality of life during and after treatment. Some methods who claim to be substitutes to modern medicine are not recommended. Some of these complementary methods are listed below: ➡ Cultural traditions/local customs (in addition but not substituted to pain relief) ➡ Emotional support: family’s care and support are essential ➡ Physical methods (massage) ➡ Distractions (music, art therapy, expression, relaxation, etc.) ➡ Meditation or prayer as per the patients’ habits ➡ Massage therapy. Unharmful practices can turn out to be very beneficial. Choice of a possible complementary method will be made after personal discussion with the patient in a non-judgmental manner. Thus, every practitioner should be aware of the importance of: ➡ Empathetic listening ➡ Patients’ various emotional states (different stages: shock, why me? etc.) ➡ Not imposing a point of view ➡ Encouraging family to support the patient.

End-of-life is a very difficult period for everyone. Sadness can leave close ones lost or helpless. Families as well as the patient may feel like the efforts came to nothing. Even if they are made aware of the severity of the illness, members of the family are often surprised and feel like they had not been properly warned and prepared for this time. Therefore, it is important to prepare for death with the family by: ➡ Encouraging family members to discuss things to make death less harrowing and facilitate grieving ➡ Informing family members of mood that may affect the patient (for example when she expresses anger towards her family), explaining that these crises must be accepted ➡ Discussing things with the patient in light of the cultural context. The caregiver can support the patient by: ➡ Relieving her pain ➡ Helping her to overcome her feelings of guilt and regret ➡ Offering referral to spiritual or religious support, or to a support group ➡ Remembering to ask where and with who she wishes to die ➡ Being available to discuss and respond her questions when needed ➡ Reassuring that her wishes will be respected.

b) Death At the time of death, it is important to respect local traditions and rites, as well as the patient or the family’s wishes regarding body hygiene, funeral, etc.

c) Grief The family has a great need for support in these painful moments. Caregivers may also provide a listening ear, support, and comfort to families. This will help them come to terms with the loss of the patient. Caregivers and/or community agents who participated in the patient’s care may suggest discussion or reminiscence of memories.

KEY MESSAGES ➡

Pain relief is a core part of care.

➡

Most types of pain can be efficiently relieved using a broad combination of medical and non-medical approaches.

➡

Symptom management strongly relies on access to drugs, material, and equipment both in health facilities and at home.

➡

End-of-life care is a key element of the fight against cervical cancer.

➡

Palliative care aims improving women and families’ quality of life when they are faced with CC and can help people at advanced stages to face this difficult time in peace and dignity.

➡

Prerequisites to palliative care such as education and availability of drugs must be strengthened.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK PALLIATIVE CARE

f) Non-pharmacological treatment

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➡ Understandings to develop? CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK PALLIATIVE CARE

NOTES

➡ What do I take away from this session? ➡ What elements require further clarification?

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APPENDICES

APPENDIX 2: INFORMED CONSENT

APPENDIX 1: FIGO CLASSIFICATION OF CERVICAL CARCINOMA Stage I

Stage 1 carcinoma is strictly confined to the cervix. Extension to the uterine corpus should be disregarded. Diagnosis of stages IA1 and IA2 is based on microscopy, preferably with a cone encompassing the entire lesion.

Stage IA: Invasive carcinoma that can be diagnosed only by microscopy. Stromal invasion does not exceed 5 mm depth and 7mm width. Stage IA1: Stromal invasion does not exceed 3mm depth and 7 mm width. Stage IA2: Stromal invasion is between 3 and 5 mm deep and its width does not exceed 7mm. visible lesion even superficial is classified IB. Stage IB1: Lesions do not exceed 4 cm. Stage IB2: Lesions exceed 4 cm.

Stage II

Stage II carcinoma invades beyond the uterus but has not extended onto the lower third of the vagina or to the pelvic wall. It involves the upper two-thirds of the vagina. Stage IIA: Invasion is limited to the upper two-thirds of the vagina without parametrial involvement. Stage IIB: Parametrial involvement but not up to the pelvic wall.

Stage III

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

The carcinoma has extended to the pelvic wall. Rectal examination confirms there is no zone between the tumour and the pelvic wall that has not be invaded. The tumour involves the lower third of the vagina. All carcinoma causing hydronephrosis or non-functioning kidney are stage III cancers. Stage IIIA: No extension to the pelvic wall, involves lower third of the vagina. Stage IIIB: Extension to the pelvic wall, hydronephrosis or non-functioning kidney.

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Stage IV

The carcinoma has extended beyond the pelvis or has involved the mucosa of the bladder and/or rectum. Stage IVA: Spread to adjacent pelvic organs. Stage IVB: Spread to distant organs.

The doctor/health practitioner has explained in sufficient detail the tests with vinegar (VIA) and iodine (VILI) that will enable early detection and prevention of cancer in my cervix. I am aware that the surface of my cervix will be observed after application of vinegar (5% acetic acid) or iodine solution, to detect precancerous lesions or cancer. I know that these procedures are not painful but may cause irritation or light bleeding that will disappear spontaneously. I have understood that, if the test is positive, I will be offered further investigations such as visual inspection with a magnifying device named colposcope, and the analysis of a sample of cervical tissue (biopsy) before I am offered any treatment. In the event of anomalies (infection, precancerous lesions, cancer, or complications), I have been informed that I might require medical treatment or thermocoagulation (destruction of the abnormal part of the cervix using a thermal probe) or undergo a surgical procedure that may be followed by radiotherapy. By signing this form, I agree to submit to the above-mentioned tests and treatment if necessary* / I do not wish to submit to these tests. *

Source: TNM Classification of malignant tumours. L. Sobin and Ch Wittekind (eds.), UICC International Union against Cancer, Geneva, Switzerland. pp155-157; 6th ed. 2002.

Signature: Date: Name: Address:

* Delete as appropriate

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

Stage IB: Clinical lesions are confined to the cervix, or subclinical lesions are more important than stage IA. Any

INFORMED CONSENT

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APPENDIX 3: CLEANING AND STERILISATION OF INSTRUMENTS AND EQUIPMENT USED FOR EARLY DETECTION AND TREATMENT OF CERVICAL NEOPLASIA

PREPARATION OF A 0.5% CHLORINE SOLUTION

The formula to prepare diluted chlorine solution using chlorine bought in a shop is the following: Total number of doses of water = [% of concentrated solution / % diluted solution] -1.

INSTRUMENT/MATERIAL

Speculum, vaginal spacer, biopsy forceps, tissue forceps, pickup forceps, Cheatle forceps.

PROCEDURE

Decontamination and cleaning followed by sterilisation or HLD (High level disinfection).

SUGGESTED TECHNIQUE

Immersion for 10 minutes in a 0.5% chlorine solution followed by cleaning with water and detergent, clean instruments can then be immersed for 20 Minutes in boiling water (HLD) or sterilised in an autoclave before being reused.

For example, to prepare 0/5% chlorine solution using household 5% chlorine solution is = [5,0% / 0,5%] - 1 = 10 - 1 = 9 doses of water; thus, you must add one dose of bleach to nine doses of water. If the chlorine bought in the shop is powder, use the following formula to calculate the dose of power (in grammes) that you will need to prepare 0.5% chlorine solution: Grammes / litre = [% diluted solution / % concentrated solution] x 1000. For example, to prepare a 0.5% chlorine solution using a 35% calcium hypochlorite powder = [0,5% / 35%] x 1000 = 14,2 g. You must add 14.2 g of power to 1L of water or 142 g to 10L of water. The instruments should not stay in the bleach for over ten minutes and must be cleaned with boiling water immediately after decontamination, to avoid fading colour and corrosion of the metal.

Decontaminating the floor of the screening centre:

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Gloves

Decontamination, cleaning, and sterilisation.

Immersion for 10 minutes in a 0.5% chlorine solution followed by cleaning with water and detergent, sterilisation in an autoclave before wrapping.

Examination table, halogen, electric lamps, trolley, trays.

Low- or medium-level disinfection.

Wipe with 60-90 % ethanol or isopropanol or with 0.5% chlorine solution.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

This must be carried out daily using chemical detergents such as iodophors (e.g. 10% povidone iodine).

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a) 5% Acetic Acid solution Ingredients Amounts 1. Glacial acetic acid 5 ml 2. Distilled water 95 ml Preparation: Carefully add 5 ml of glacial acetic acid in 95 ml of distilled water and mix. Storage: Any unused solution must be disposed of at the end of the day. Label: 5% acetic acid Caution: Glacial acetic acid should always be diluted, otherwise it may cause serious chemical burning if applied to the epithelium.

b) Lugol’s solution Ingredients Amounts 1. Potassium iodide10 g 2. Distilled water 100 ml 3. Iodine 5 g

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

Preparation A. Dissolve 10 g of potassium iodide in 100 ml of distilled water B. Gradually add 5 g of iodine with constant mixing C. Filter and store in an amber glass bottle in the dark.

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Storage: 1 month

c) Monsel’s paste Ingredients/Amounts 1. Ferric sulphate 15 g 2. Ferrous sulphate power 3. Sterile water for mixing 10 ml 4. Glycerol starch (see preparation below) 12 g Preparation Caution: the reaction is exothermic (emits heat) A. In a glass beaker, add a few grains of ferrous sulphate powder to 10 ml of sterile water. Shake. B. Dissolve the ferric sulphate base in the solution by stirring with a glass stick. The solution should become crystal clear. C. Weigh the glycerol starch in a glass mortar. Mix well. D. Gradually add the ferric sulphate solution to the glycerol starch, constantly mixing to get a homogeneous mixture. E. Place in a 25 ml brown glass bottle. F. Most practitioners prefer to leave the stopper of the bottle loos to allow the mixture to evaporate until it has a sticky paste-like consistency and looks like mustard. This may take 2-3 weeks depending on the environment. The top of the bottle must be secured for storage. If necessary, sterile water can be added to the paste to thin it. Note: This solution contains 15% of iron. Storage: 6 months Label: Monsel’s paste; Shake before use; External use only; Use by: (date)

d) Glycerol starch (ingredient in Monsel’s paste) Ingredients/Amounts 1. Starch 30 g 2. Sterile water for mixing 30 ml 3. Glycerine 390 g

Label: Lugol’s solution; Use by: (date) Preparation A. In a china crucible, dissolve the starch in the sterile water. B. Add glycerine. Shake well. C. Heat the crucible and its contents over a Bunsen burner. Mix constantly with a spatula until the mass takes on a thick, swelling consistency. Do not overheat or the mixture will turn yellow. Storage: 1 year Label: Glycerol starch; Store in a cool place; For external use only; Use by: (date) Caution: Do not overheat or the mixture will turn yellow.

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

APPENDIX 4: PREPARATION OF 5% ACETIC ACID SOLUTION, LUGOL’S SOLUTION AND MONSEL’S PASTE

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Background information on SHRH and health promotion

MDM (2012), Accès aux soins : Les déterminants socioculturels [Access to care: sociocultural determinants] MDM (2013, revised in 2019), Santé sexuelle et reproductive, Cadre de référence,[Sexual and reproductive health guideline] MDM (2014), Note de présentation : Stratégie SSR 2014-2017 [Position paper: SRH Strategy 2014-2017] WHO (1986), Ottawa Charter

Texts and documents on sexual and reproductive health rights

CEDAW (1976), Convention on the Elimination of All Forms of Discrimination against Women CEDAW (2000), Optional protocol CEPED (2007), Les facteurs de la contraception en Afrique de l’ouest et en Afrique centrale au tournant du siècle, Rapport de synthèse [Synthesis report: Determinants of Contraception Use in Western and Central Africa at the turn of the century] Inter-American Specialized Conference on Human Rights (1969) Inter-American convention on the Prevention, Punishment and Elimination of Violence Against Women (1994) Beijing declaration and platform for action (1995), Paragraph 95 UNFPA (1994), International Conference on Population and Development Sustainable Development Goals (SDG) (2015) Maputo Action Plan (2006) Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa (2003) Family Planning Summit (2012)

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

Documents relating to cervical cancer

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JHPIEGO (2005), Preventing Cervical Cancer in Low-Resource Settings, From Research to Practice La LIGUE CONTRE LE CANCER (January 2009), Les cancers de l’appareil génital féminin (col et corps de l’utérus, ovaires) [Cancer of the female reproductive organs (cervix, uterus, ovaries)], Grand Public MBUMBA et. al. (06/02/2017), Cervical Cancer in Sub-Saharan Africa: an emerging and preventable disease associated with oncogenic human papillomavirus, Médecine et Santé tropicales, Focus WHO (2002), Cervical cancer screening in developing countries, report of WHO consultation, Programme on Cancer control, Department of Reproductive Health and Research, Geneva WHO (2007), Comprehensive Cervical Cancer Control, A guide to essential Practice WHO (May 2012), Cervical Cancer Prevention and Control Costing Tool (C4P) User’s Guide, Geneva, Switzerland WHO (2013), Comprehensive cervical cancer prevention and control - A healthier future for girls and women, WHO Guidance Note WHO (2014), Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention, WHO Guidelines WHO (2015), Use of cryotherapy for cervical intraepithelial neoplasia, WHO guidelines WHO (2017), Advocacy for cervical cancer prevention and control in Africa, Facilitator Manual, Regional Office for Africa WHO (2017), Strategic planning for cervical cancer prevention and control in Africa, Training Manual WHO (2017), Comprehensive Cervical Cancer Control, A guide to essential Practice, 2nd edition WHO (2018), A toolkit for cervical cancer prevention and control programmes, Improving data for decisionmaking. WHO (2020), Introduction to cervical cancer, Official website WHO (November 16th, 2020), New estimates of the global burden of cervical cancer associated with HIV. WHO, PAHO (2016), Integrating HPV testing in cervical cancer screening programs, a manual for program managers. WHO, PAHO (2018), Plan of action for cervical cancer prevention and control 2018-2030, 56th directing Council 70th session of the Regional Committee of who for the Americas

Documents relating to palliative care and pain relief

CHUANG et al. (2016), Management and care of women with invasive cervical cancer: American society of clinical oncology resource-stratified clinical practice guideline, American Society of Clinical Oncology, volume 2, issue 5 KIM et al. (2015), Retrospective review of symptoms and palliative care interventions in women with advanced cervical cancer, Gynaecologic Oncology, Elsevier WHO (1987), Cancer Pain Relief, Geneva WHO (2018), Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents

RUDD et al. (2017), Cervical cancer in southern Malawi: A prospective analysis of presentation, management, and outcomes, cervical cancer in southern Malawi, Malawi Medical Journal 29 (2) The American Cancer Society (2016), Caring for cancer patients a booklet for caregivers of cancers patients

Documents relating to the HPV test

ASCIUTTO et al. (2018), Self-sampling with HPV mRNA analyses from vagina and urine compared with cervical samples, Journal of Clinical Virology A LATIFF et al. (2018), Comparative assessment of a self-sampling device and gynaecologist sampling for cytology and HPV DNA detection in a rural and low resource setting: Malaysian experience, comparison of self-sampling and gynaecologist sampling for cytology and HPV DNA detection in Malaysia ARBYN et al. (2014), Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis, The Lancet, volume 15 CASTELL et al (2017), Treatment of cervical intraepithelial lesions, Wiley CATARINO et al. (2014), Feasibility of at-home self-sampling for HPV testing as an appropriate screening strategy for non-participants in Switzerland: preliminary results of the DEPIST study, American Society for Colposcopy and Cervical Pathology. HAGUENOER et al. (2017), L’auto-prélèvement vaginal est une méthode efficace pour augmenter la participation au dépistage du cancer du col de l’utérus : un essai randomisé en Indre-et-Loire, Vers la généralisation du dépistage organisé du cancer du col de l’utérus, [Self-sampling as an effective tool to increase cervical cancer screening : a randomised trial in Indre-et-Loire, Towards widespread screening of cervical cancer], 2-3

Documents relating to VIA

WHO (2014), Monitoring national cervical cancer prevention and control programmes: quality control and quality assurance for visual inspection with acetic acid (VIA)-based programmes WHO (2020) Anatomical and pathological basis of visual inspection with acetic acid (VIA) and with Lugol’s iodine (VILI), A practical manual on visual screening for cervical neoplasia, Chapter 1; https://screening.iarc.fr/ viavilichap1.php?lang=2 WHO (2020), Testing and reporting the results of visual inspection with 5% Acetic acid (VIA), A practical manual on visual screening for cervical neoplasia, Chapter 2 https://screening.iarc.fr/viavilichap2.php?lang=2

Documents relating to thermocoagulation

WHO (2013), Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention supplemental material: grade evidence-to-recommendation tables and evidence profiles for each recommendation VIVIANO et al. (2017), Feasibility of thermocoagulation in a screen-and-treat approach for the treatment of cervical precancerous lesions in sub-Saharan Africa, BMC Women’s health NHS Foundation trust (2018), Having a cold coagulation procedure under local or general anaesthetic following a colposcopy, Guy’s and St Thomas NAUD et al. (2015), Efficacy, safety, and acceptability of thermocoagulation for treatment of cervical intraepithelial neoplasia in a hospital setting in Brazil, International Journal of Gynaecology and Obstetrics SANDJONG et al. (2015), Evaluation of the prevention and treatment of the precancerous lesions of the uterine cervix according to the ‘see and treat’ approach BASU et al. (2017), Management algorithms for cervical cancer screening and precancer treatment for resourcelimited settings, Wiley CASTLE et al. (2017), Treatment of cervical intraepithelial lesions, Wiley PAPOUTSIS (October 2017), Cold Coagulation for the treatment of uterine cervix with cervical intraepithelial neoplasia, gynaecologic survey, Chapter 2 CAMPBELL et al. (2016), Use of thermo-coagulation as an alternative treatment modality in a « screen-and-treat » programme of cervical screening in rural Malawi, International Journal of Cancer DRUMMOND et al. (2017), Cervical cancer data and data systems in limited- resource settings: Challenges and opportunities, Wiley DUMONT et al. (2017), Cervical cancer screening in rural Madagascar: Feasibility, coverage and incidence Wiley UMULISA et al. (2018), Evaluation of human-papillomavirus testing and visual inspection for cervical cancer screening in Rwanda, BMC Women’s Health WHO (June 2017), Consolidated guidelines on person-centre HIV patient monitoring and case surveillance, Guidelines

Documents relating to NICT and their use in the fight against CC

AFD (2013) L’utilisation des nouvelles technologies de l’information et des communications (TIC) dans le domaine de la santé maternelle et infantile en Afrique subsaharienne ), [Using new information and communication

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

FOR FURTHER INFORMATION

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technology to improve maternal and child health in sub-Saharan Africa] AMREF Health Africa (2018), White Paper for the 1st digital health meeting in West Africa (WA), Dakar GALLAY and al. (2017), Cervical cancer screening in low-resource settings: A smartphone image application as an alternative to colposcopy, International journal of women’s health ITU, WHO (2017), Be @lthy Be mobile: A handbook on how to implement Cervical Cancer

Documents relating to the effective use of GeneXpert platforms

CERVICAL CANCER PREVENTION TRAINING PROGRAMME - PARTICIPANT HANDBOOK APPENDICES

CATARINO et al. (2017), Accuracy of self-collected vaginal dry swabs using the Xpert human papilloma virus assay, PLOS ESBER et al. (2018), Feasibility, validity and acceptability of self-collected samples for Human Papillomavirus (HPV) testing in rural Malawi, Malawi Medical Journal EPERON et al. (2013), Randomized comparison of vaginal self-sampling by standard vs. dry swabs for Human Papillomavirus testing, BMC Cancer KUNCKLER et al. (2017), Cervical cancer screening in a low-resource setting: a pilot study on an HPV-based screen-and-treat approach, Cancer Medicine NDLOVU et al. (2017), Multidisease testing for HIV and TB using the GeneXpert platform: A feasibility study in rural Zimbabwe, PLOS wet cervical samples for Human Papillomavirus testing, Journal of Clinical Virology VASSILAKOS et al. (2016), Use of swabs for dry collection of self-samples to detect Human Papillomavirus among Malagasy women, Infectious agents and Cancer

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2021 VERSION. CONTRIBUTORS: Coordination and writing: Najat Lahmidi Review: Olga Bautista, Laeticia Clouin, Tim Leicester, Marielle Moizan, Charlotte Ngo, Joan-Anastasie Poisson, Joseph Zahiri Translated from French to English by Caroline Matteo Graphic design and layout: Laurène Chesnel

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This document is supported by the Agence Française de Développement. The ideas and opinions expressed in this document do not necessarily represent those of AFD.

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Any intimate contact can result in an HPV infection TRUE