DATA DOCUMENTATION TOOLS

KENYA NATIONAL CANCER SCREENING GUIDELINES I 113

ANNEX

DATA DOCUMENTATION TOOLS

Cervical Cancer Screening Tools

• Cervical Cancer Screening Card

• Cervical Cancer Screening and Treatment Form

• Cervical Cancer Referral Form

• Daily Activity Register

• Cervical Cancer Program Monthly Summary Form

• ANC Register

• PNC Register

• MOH 711 Integrated summary

Current Indicators for Cervical Cancer Available in DHIS

• Cervical cancer clients receiving VIA /VILI /HPV VILI / HPV

• Cervical cancer clients with Positive VIA/VILI result

• Cervical cancer clients screened using Pap smear

• Cervical cancer clients with suspicious cancer lesions

• Cervical cancer clients with Positive Cytology result

• Cervical cancer clients treated using Cryotherapy

• Cervical cancer treated using LEEP

• Cervical cancer clients with Positive HPV result

• Cervical cancer clients screened using HPV test

CANCER SCREENING FORM

SERIAL NUMBER

CANCER SCREENING AND EARLYDIAGNOSIS FORM

FACILITY NAME DATE

SECTION A: SOCIO-DEMOGRAPHIC DATA

Inpa ent/Outpa ent number————— Na onal ID no —————– Name—————————————– Sex————- Age (years) —— Marital status————- No. of children ———-

Pa ent phone no——————-Address——————–

Next of kin (nok) name——————– rela onship to n.o.k————– N.O.K. phone

No——————

Current residence county Sub-county Ward/Estate———– Length of me lived in current residence (years) ———–

Highest educa onal level——————- Occupa on—————————-

Ethnicity/Race———————————————— Where did you learn about this screening program?

Word of mouth From media

Healthcare worker other (specify) ———— Screening service point MCH FP CCC GOPC OUTREACH

other (specify) ————————-

Referred to this facility? Yes No if yes, from———————————

REASON FOR

REFERRAL———————————————————————— VITAL SIGNS BP PULSE RATE – WEIGHT HEIGHT BMI

BLOOD SUGAR LEVEL—————————–

CSF 1

SECTION B: FAMILY HISTORY Any history of cancer in the family? If yes, which cancer?

Sibling 1st or 2nd

0ther (Specify) ——————

What was the age at diagnosis? (Years)—————————- What was

SECTION C: CLINICAL/RISK FACTOR HISTORY

Tick as appropriate

RISK FACTORS

Risk factors history T
Smoking
Alcohol intake
treatment
Any other (specify)

COMMON SYMPTOMS

Symptom history
Blood in stool
Yellow eyes
Blood in urine
Epistaxis (nose bleeding)
General weight loss
Abnormal vaginal bleeding
Enlarging/changing skin moles
Chronic skin ulcers
Any lumps or swellings
Chronic cough
Persistent headaches
Changing bowel habits
0thers (specify)

CSF 2

SECTION D: TYPE OF CANCER SCREENING

Cancer V isit type Screening modality Last Date of
screening last
modality screening
done
Cervical Repeat screening Pap smear
Post-treatment screening VIA VILI
Breast Repeat screening Clinical breast
Ultrasound
Post-treatment screening Mammogram
Prostate Repeat screening PSA t
Post-treatment screening
Colorectal Fecal occult blood test
Repeat screening Colonoscopy
Post-treatment screening
(known At birth Eye exam under anaesthesia
history)

1.

6 years

2.

D – y history for parent

D At birth, then every month for 3 months, then every 3 months for 3 years

D –

D At birth, then every month for 3 months, then every 3 months for 1 year

CSF 3

SECTION E: SCREENING RESULTS

Cancer S creening modality
Cervical • HPV
• Pap smear
• VIA VILI
Breast • Clinical breast
• Ultrasound (<40
years)
• Mammogram
40 years
Prostate • DRE in
Colorectal • Fecal occult

blood test

• Colonoscopy

• Eye exam

SECTION F: FOLLOW UP

Return date

Referred to

Referred for further screening (give reasons)

Health service provider:

Name Cadre Signature

CSF 4

THE TYRER-CUZIK MODEL FOR RISK ASSESSMENT MODEL

Personal History
Age
Weight
Height
Menarche
Has the woman given Unknown No Yes
birth to more than one
child
If yes, at what age was
the first live birth?
Has the woman gone Don’t know No Yes In menopause now
through menopause
If yes, at what age ?
Hormonal replacement Never Stopped >5 Stopped use Current user
use years A5 years ago
Does the woman have Unknown Tested BRCA 1 BRCA 2
BRCA 1 /2 normal
Has the woman had No Yes
ovarian cancer
Has the woman had No prior Prior Hyperplasia, Atypical LCIS
breast biopsy biopsy biopsy no atypia hyperplasia
results
unknown
Family history of breast No Yes
or ovarian cancer

NOTE:

1. Better calculation in the web http://ibis.ikonopedia.com/

2. Not intended to assess the risk of women who have already been diagnosed with breast cancer

LIST OF CONTRIBUTORS

NAME ORGANIZATION
1. Christine Were PS-Kenya
2. David Makumi KENCO
3. Dorcas J. Kiptui MOH -DNCD
4. Dr Ahmed Kalebi Pathologists Lance Kenya
5. Dr Alfred Karagu National Cancer Institute (NCI – Kenya
6. Dr Andrew Odhiambo UoN
7. Dr Anne Ng’ang’a MOH – Head, NCCP
8. Dr Catherine Murithi Roche Diagnostics
9. Dr Charles Muturi Mama Lucy Kibaki Hospital, Nairobi County
10. Dr Daniel Ojuka KNH
11. Dr David Kimani KNH
12. Dr Doreen Mutua Gertrude’s Children’s Hospital
13. Dr Edna Kamau KNH
14. Dr Elizabeth Dimba UoN
15. Dr Eric Hungu KNH
16. Dr Eunice W. Gathitu MOH – NCCP
17. Dr Gladwell Kiarie Nairobi Hospital
18. Dr Grace Kariuki MOH – DNCD FELTP
19. Dr Gregory Ganda JOOTRH
20. Dr Jamilla Rajab UoN
21. Dr Joan-Paula Bor MOH – NCCP
22. Dr Joseph Kibachio MOH – Head, DNCD
23. Dr Khadija Warfa AKUH
24. Dr Lilian Mbau Amref Health Africa
25. Dr Linus Ndegwa KEMRI
26. Dr Mary Nyangasi MOH – NCCP
27. Dr Michael Mwachiro Tenwek Hospital
28. Dr Miriam Mutebi AKUH
29. Dr Njoki Njiraini MOH/KNH
30. Dr Richard Njoroge MOH – NCCP/NPHLS
31. Dr Sarah Muma Kijabe Hospital
32. Dr Teresa Kinyari Mwendwa UoN/PHSK
33. Dr Valerian Mwenda MOH – NCCP FELTP
34. Dr Vera Manduku KEMRI
35. Dr Wycliffe Kaisha KNH
36. Evans Obaga MOH – NCCP
37. Hannah N. Gitungo MOH – NCCP
38. Linda Ogol MOH-NCCP
39. Lydia W. Kirika MOH – NCCP
40. Pamela Were MTRH AMPATH Oncology Institute
41. Patricia Njiri CHAI
42. Prof Jessie Githang’a UoN
43. Prof Lucy Muchiri UON
44. Roselyn Okumu KNH

LIST OF REVIEWERS

• Dental Services Unit – MOH

• Ophthalmic Services Unit – MOH

• Reproductive and Maternal Health Services Unit (RMHSU)

• Gastroenterology Society of Kenya (GSK)

• Kenya Association of Radiologists (KAR)

• Kenya Association of Urological Surgeons (KAUS)

• Kenya Dental Association (KDA)

• Kenya Obstetrical and Gynaecological Society (KOGS) –

Gynaecologic Oncology Committee

• Kenya Society of Hematology & Oncology (KESHO)

• Surgical Society of Kenya (SSK)

• Prof Constance Tenge – MTRH/Moi University

• Prof Elly Ogutu – UoN

• Dr Festus Njuguna – MTRH/Moi University

• Dr Gladwell Gathecha – MOH DNCD

• Dr Johnson Wambugu – Kenya Dental Association

• Dr Kahaki Kimani – UoN

• Prof Mark Chindia – UoN

• Dr Russell E. White – Tenwek Hospital

• Dr Wilson Miriti – KNH

122 I KENYA NATIONAL CANCER SCREENING GUIDELINES

 

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