The American Society of Clinical Oncology (ASCO) has published its first clinical practice guideline on invasive cervical cancer, and the guidelines are the first to offer treatment recommendations tailored to resource availability.1
Access to screening for cervical cancer varies widely between different regions of the world, often with limited or no cervical cancer screening programs in areas with lower resource settings. The trend is that women present with advanced cervical cancer at diagnosis, requiring treatments that may not be available in those 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 South-East 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 City. “In those regions, access to pathology services, skilled surgeons, radiation machines, brachytherapy, chemotherapy, and palliative care may all be constrained.”
Recommendations for 4 tiers of resources are provided by these new guidelines: basic, limited, enhanced, and maximal. The guideline provides recommendations for the optimal therapy and palliative care for each setting and for each stage of cervical cancer.
“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, California. “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 worldwide, multidisciplinary panel of experts and 1 cancer survivor.
The key guideline recommendations included that, 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.
Another key recommendation is that 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 to 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-course or short-course radiotherapy schemes can be used with retreatments 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 occur 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 2 separate resource-stratified guidelines to be published later this year.
1. Chuang LT, Temin S, Camacho R, et al. Management and care of women with invasive cervical cancer: American Society of Clinical Oncology resource-stratified clinical practice guideline [published online May 25, 2016]. J Global Oncology. doi:10.1200/JGO.2016.003954.