The American Society of Clinical Oncology (ASCO) issued its first clinical practice guideline on invasive cervical cancer. This resource-stratified guideline is the first of its kind from ASCO, offering treatment recommendations tailored to resource availability.
Access to cervical cancer care varies between regions of the world, both among and within countries. Lower resource settings tend to have limited or no cervical cancer screening programs. As a result, women often have advanced cervical cancer at diagnosis, which requires treatments that may not be readily available in these areas.
"Even though cervical cancer is largely preventable, a quarter of a million women die of this disease every year globally. The vast majority of those deaths occur in less-developed regions of the world, such as Southeast Asia, the Western-Pacific, India, and Africa," said Linus Chuang, MD, MS, Co-chair of the ASCO Expert Panel that developed the guideline, and a Gynecologic Oncologist and Professor of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai in New York, N.Y. "In those regions, access to pathology services, skilled surgeons, radiation machines, brachytherapy, chemotherapy, and palliative care may all be constrained."
Evidence-Based Treatment
This guideline provides evidence-based recommendations for four resource tiers: basic, limited, enhanced, and maximal. For each setting, and for each stage of cervical cancer, the guideline recommends optimal therapy and palliative care.
"Regardless of resources, health care providers should always strive to deliver the highest level of care to all women with cervical cancer," said Jonathan S. Berek, MD, MMS, co-chair of the ASCO Expert Panel that developed the guideline, and Professor and Chair of Obstetrics, Gynecology-Gynecologic Oncology at Stanford University School of Medicine in Stanford, Calif. "This guideline is a starting point. We hope that it will generate discussion and much needed research in the field."
The guideline recommendations were developed by a multidisciplinary panel of experts in cancer control; gynecologic, medical, and radiation oncology; health economics; obstetrics and gynecology; and palliative care. The panel included experts from the U.S., Spain, Mexico, Turkey, Canada, Argentina, Zambia, Uganda, South Korea, China, and India, as well as a cancer survivor.
The panel conducted a systematic review of medical literature published from 1966 to 2015, and reviewed existing guidelines and cost-effective analyses. Recommendations were made based on evidence from literature and/or panel expertise. All recommendations reflect formal expert consensus. Key guideline recommendations include the following:
* In basic settings where patients cannot be treated with radiation therapy, extrafascial hysterectomy either alone or after neoadjuvant chemotherapy may be an option for women with stage IA1 to IVA cervical cancer.
* Concurrent radiotherapy and chemotherapy is standard in enhanced and maximal settings for women with stage IB to IVA disease. The panel stresses the addition of low-dose chemotherapy during radiotherapy, but not at the cost of delaying radiation therapy if chemotherapy is not available in limited settings.
* In limited resource settings where there is no brachytherapy, the ASCO Expert Panel recommends extrafascial hysterectomy or its modification for women who have residual tumor 2-3 months after concurrent chemoradiotherapy and additional boost.
* If the resources are available and the patient cannot receive treatment with curative intent, palliative radiotherapy should be used to relieve symptoms of pain and bleeding.
* Where resources are constrained, single- or short-course radiotherapy schemes can be used with re-treatments if feasible for persistent or recurrent symptoms.
* For patients with stage IV or recurrent cervical cancer, single-agent chemotherapy (carboplatin or cisplatin) is recommended in basic settings.
* Concurrent radiotherapy and chemotherapy followed by brachytherapy is standard in enhanced and maximal settings for women with stage IB to IVA disease.
"At least two-thirds of cervical cancer deaths [occurred] in women who hadn't been screened regularly. If we improved screening and HPV vaccination around the world, we might be able to substantially decrease the mortality from cervical cancer," said Berek. ASCO will address cervical cancer prevention and screening in two separate resource-stratified guidelines to be published later this year.
The guideline, "Management and Care of Women with Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline" was published in the Journal of Global Oncology, and is available at http://www.asco.org/rs-cervical-cancer-treatment-guideline along with supplementary materials. It has been endorsed by the Society of Gynecologic Oncology.
ASCO encourages feedback on its guidelines from oncologists, practitioners, and patients through the ASCO Guidelines Wiki at http://www.asco.org/guidelineswiki.
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