1. CANCER OF THE CERVIX SCREENING AND EARLY TREATMENT Dr Nelly R. Mugo MBchB, MMED, MPH Dr Rose J. Kosgei MBchB, MMED, Msc Kenyatta National Hospital: Department of Reproductive Health

2.  KNH is currently 106 yrs old  KNH & MTRH are both National Referral & Teaching Hospitals  KNH: Serves as a teaching hospital for the University of Nairobi, School of Health sciences and the Medical Training Center for Paramedical personnel  Centenary Celebrations in 2001 Kenyatta National Hospital: Background

3. Presentation Outline  Introduction: Kenyatta National Hospital & Division of Reproductive Health  Screening and treatment options  Clinic set-up  Patient flow algorithm  KNH protocols and encounter forms  Work load  Training  Monitoring and evaluation  Successes and challenges  Proposed way forward

4. KNH mandate legal notice No. 109 (6 th April 1987) – Receive patients on Referral – Provide facilities for medical education & research – Participate in national planning & policy formulation KNH: Mandate

5. Department of Reproductive Health  The department of reproductive health provides family planning & cervical cancer screening services in ‘clinic 66’  KNH Cancer treatment center, is the only public service radiotherapy unit  Referrals for radiotherapy bookings run for up to 6 months

6. Screening and Treatment Options Screening methods: – Pap smear – VIA/VILLI Same visit approach – VIA/VILLI and cryotherapy Almost starting Staff trained Cryotherapy machine available – Diagnosis: Colposcopy – Treatment: LEEP & Cryotherapy (to start soon)

7. Clinic Set-up Three clinics – Clinic 66 : Pap smears, Colposcopy, LEEP and Cryotherapy (to start) – HIV clinic: VIA/VILI – Gynecology out patient clinics: Pap smears Equipment – Two colposcope machines – One Cryotherapy machine – Smoke evacuator – LEEP electrodes and cyrotips – Electrosurgical system – Coated speculums – Biopsy punches – curretes Clinic days Thursdays and Friday mornings

8. Patient Flow Algorithm CLINIC 66 Pap smears VIA/VILLI Colposcopy LEEP HIV CLINIC VIA/VILI GYN OUTPATIENT CLINIC Pap smears GYNAE WARDS Pap smears OTHER FACILITIES VIA/VILI and Pap smears In Clinic 66 appropriate management and linkage is offered Cancer Treatment Center

9. KNH Protocols and Encounter Forms 6 protocols : 1.Pap smear 2.VIA/VILLI 3.Colposcopy 4.LEEP 5.Cryotherapy 6.invasive cancer 3 encounter forms: 1.Cervical cancer screening 2.Colposcopy 3.Cryotherapy and LEEP

10. Work Load Monthly averages – 300 Pap smears – 32 Colposcopies – 16 LEEPs

11. Training  2009 PAP Team supported training: Cytology, Colposcopy & LEEP training  2010: ACSSP training of 30 clinicians on colpo/LEEP 2010: Pap team – 20 nurses on pelvic and breast exam  2012: JHPIEGO training of nurses and physicians on VIA/VILLI & cryotherapy – 30 KNH & MOH clinicians  Trained and proficient in colposcopy and LEEP  10 Ob/Gyn  3 nurses

12. Monitoring and evaluation Currently – Paper based: Registers Structured encounter forms – M&E department are able to do simple analysis Electronic data system is underway – Still at design phase

13. Successes Supportive management and team at KNH Able to identify and treat early disease Electronic system under way Training of residents

14. Challenges Data management – Lack of electronic data, for ease of analysis – Data in files Multiple clinic visits and follow up – Pap smear –results-book colpo- colposcopy-colpo results-book LEEP –LEEP Require forum for discussions with pathologist Cost of cytology, LEEP services Unscreened population Management of lesions may vary by specialist

15. Proposed Way Forward Same day visits – VIA/VILLI + Cryotherapy – Colposcopy + LEEP Promote visual screening methods All inclusive fee from diagnosis to treatment Strengthen integration of screening with other services Disposable speculums