/*
* CervicalCancerTriageDecision
*
* Triage pathway logic for HPV-positive women, implementing
* WHO guideline Algorithm 5 (HPV DNA + VIA triage) with
* extension points for Algorithms 3, 4, 6, 7.
*
* This library determines:
* - Whether triage is indicated
* - The appropriate triage method for the active algorithm
* - Interpretation of triage results
* - Routing to treatment vs follow-up vs referral
*
* Algorithm 5 cascade after HPV+:
* HPV positive → VIA triage
* ├── VIA positive → Treat (→ TreatmentDecision)
* ├── VIA negative → Retest at 12/24 months (→ FollowUpDecision)
* └── Suspicious for cancer → Refer to oncology
*
* WHO Recommendations covered:
* General population: 3b (screen-triage-treat), 11 (post-triage-negative retest)
* WLHIV: 22 (triage recommended), 23 (screen-triage-treat), 31 (retest timing)
*
* @author Dan Heslinga / Hopena Health
* @version 0.1.0
* @date 2026-03-08
*/
library CervicalCancerTriageDecision version '0.1.0'
using FHIR version '4.0.1'
include FHIRHelpers version '4.0.1'
include CervicalCancerScreeningCommon version '0.1.0' called Common
context Patient
/*
* =============================================================================
* TRIAGE INDICATION
* =============================================================================
*
* @guidance Triage is indicated when the primary HPV DNA test is positive.
* In Algorithm 5, VIA is the triage method.
* In screen-and-treat approaches (Algorithm 2), VIA is still done
* but for treatment modality selection rather than triage.
*/
/*
* @output Boolean — true if triage is indicated (HPV+ without subsequent triage)
* @pseudocode HPV test positive AND no VIA result after the HPV test
*/
define "Triage Is Indicated":
Common."Most Recent HPV Test Is Positive"
and (
not exists(Common."VIA Screening Results")
or Common."Date Of Most Recent VIA" before Common."Date Of Most Recent HPV Test"
)
/*
* @output Boolean — true if triage has been performed (VIA done after HPV+ result)
*/
define "Triage Has Been Performed":
Common."Most Recent HPV Test Is Positive"
and exists(Common."VIA Screening Results")
and Common."Date Of Most Recent VIA" on or after Common."Date Of Most Recent HPV Test"
/*
* =============================================================================
* TRIAGE RESULT INTERPRETATION
* =============================================================================
*/
/*
* @output Boolean — true if VIA triage was positive
* @guidance VIA positive → proceed to treatment assessment
*/
define "VIA Triage Is Positive":
"Triage Has Been Performed"
and Common."Most Recent VIA Is Positive"
/*
* @output Boolean — true if VIA triage was negative
* @guidance VIA negative → schedule follow-up HPV retest
* General: 24 months (WHO Rec 11)
* WLHIV: 12 months (WHO Rec 31)
*/
define "VIA Triage Is Negative":
"Triage Has Been Performed"
and not Common."Most Recent VIA Is Positive"
/*
* =============================================================================
* SUSPICIOUS FOR CANCER — Referral pathway
* =============================================================================
*
* @guidance In all algorithms, if VIA or colposcopy reveals findings
* suspicious for invasive cancer, the patient must be referred
* for definitive diagnosis and staging. This bypasses triage/treatment.
*
* Note: "Suspicious for cancer" is a clinical judgment during VIA. In OpenMRS,
* this would be recorded as a separate observation or as a specific coded value
* on the VIA result. We model it as a distinct observation concept.
*
* CIEL concept needed (not yet loaded):
* - CIEL 159393: Cervical cancer screening outcome
* or a custom concept for "suspicious for cancer" finding
*
* For now, we check for an active cervical cancer condition as a proxy.
* When the concept is loaded, this definition will be updated to check
* the VIA observation value directly.
*/
/*
* @output Boolean — true if findings are suspicious for cancer
* @pseudocode Currently uses cervical cancer diagnosis as proxy;
* will be refined when suspicious-for-cancer observation concept is loaded
*/
define "Suspicious For Cancer":
Common."Has Cervical Cancer Diagnosis"
/*
* =============================================================================
* TRIAGE ROUTING — Where does the patient go next?
* =============================================================================
*/
/*
* @output Boolean — true if patient should proceed to treatment assessment
* @pseudocode VIA triage positive AND not suspicious for cancer
*/
define "Proceed To Treatment":
"VIA Triage Is Positive"
and not "Suspicious For Cancer"
/*
* @output Boolean — true if patient should be scheduled for follow-up retest
* @pseudocode VIA triage negative AND not suspicious for cancer
*/
define "Proceed To Follow Up Retest":
"VIA Triage Is Negative"
and not "Suspicious For Cancer"
/*
* @output Boolean — true if patient needs oncology referral
*/
define "Needs Referral":
"Suspicious For Cancer"
/*
* =============================================================================
* RECOMMENDED ACTION — Triage-specific guidance
* =============================================================================
*/
/*
* @output String — the recommended triage action
*/
define "Triage Recommended Action":
case
when "Suspicious For Cancer"
then 'Findings suspicious for invasive cancer — refer for diagnosis and staging'
when "Triage Is Indicated"
then 'Perform VIA triage assessment'
when "Proceed To Treatment"
then 'VIA positive — proceed to treatment eligibility assessment (see TreatmentDecision)'
when "Proceed To Follow Up Retest"
then 'VIA negative — schedule HPV DNA retest in '
+ ToString(Common."Post Triage Negative Retest Months")
+ ' months'
when not Common."Most Recent HPV Test Is Positive"
then 'No triage indicated — HPV test is not positive'
else 'Unable to determine triage recommendation'
end
/*
* @output String — triage status for downstream routing
*/
define "Triage Status":
case
when "Suspicious For Cancer" then 'refer-oncology'
when "Triage Is Indicated" then 'awaiting-triage'
when "Proceed To Treatment" then 'triage-positive'
when "Proceed To Follow Up Retest" then 'triage-negative'
when not Common."Most Recent HPV Test Is Positive" then 'not-indicated'
else 'unknown'
end
/*
* =============================================================================
* ALGORITHM EXTENSION POINTS
* =============================================================================
*
* The following definitions are stubs for future multi-algorithm support.
* Currently only Algorithm 5 (VIA triage) is implemented.
*
* Algorithm 4: HPV16/18 genotyping triage
* - Requires: HPV genotyping observation concepts
* - Logic: HPV16/18+ → treat directly; other HPV+ → VIA triage
*
* Algorithm 6: Colposcopy triage
* - Requires: Colposcopy finding observation concepts
* - Logic: CIN1+ → treat; normal colposcopy → retest at 12 months
*
* Algorithm 7: Cytology + colposcopy triage
* - Requires: Cytology result concepts (ASCUS, LSIL, HSIL+)
* - Logic: HSIL+ → colposcopy → CIN1+ → treat
*/
/*
* @output String — which triage algorithm is active
* @guidance Currently hardcoded to Algorithm 5; will be parameterized
* when multi-algorithm support is added
*/
define "Active Triage Algorithm":
'Algorithm 5 — HPV DNA + VIA Triage'
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