ASCO GUIDELINES FOR CERVICAL CANCER

The American Society of Clinical Oncology (ASCO) has issued its first clinical practice guideline on invasive cervical cancer.

Because of the wide global disparities in both screening and care, the guideline is "resource-stratified," and gives treatment recommendations that are tailored to the availability of healthcare resources in specific regions. This is the first time that guidelines have been produced in this way, according to ASCO.

The guideline, published online May 25 in the Journal of Global Oncology, has been endorsed by the Society of Gynecologic Oncology.

Largely Preventable Cancer

Cervical cancer is largely preventable, the guideline states, but access to screening and subsequent treatment varies considerably among and within individual countries.

About a quarter of a million women die of cervical cancer every year, and the vast majority of those deaths occur in less-developed regions of the world, such as Africa, India, Southeast Asia, and the Western Pacific.

"In those regions, access to pathology services, skilled surgeons, radiation machines, brachytherapy, chemotherapy, and palliative care may all be constrained," said Linus Chuang, MD, MS, professor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York City, who is cochair of the ASCO expert panel that developed the guideline.

At least two-thirds of the women who die from cervical cancer have not had regular screening, said Jonathan S. Berek, MD, MMS, professor and chair of obstetrics, gynecology, and gynecologic oncology at the Stanford University School of Medicine in California, and who is also cochair of the ASCO expert panel.

"If we improved screening and HPV vaccination around the world, we might be able to substantially decrease the mortality from cervical cancer," Dr Berek pointed out.

Key Recommendations

The multidisciplinary, international panel of experts that developed the guideline conducted a systematic review of the medical literature published from 1966 to 2015. The experts also reviewed five sets of current guidelines — from Cancer Care Ontario (CCO) in Canada, the European Society of Medical Oncology (ESMO), the Japan Society of Gynecologic Oncology (JSGO), the National Comprehensive Cancer Network (NCCN) in the United States, and the World Health Organization (WHO).

The ASCO panel structured their evidence-based recommendations into four resource tiers: basic, limited, enhanced, and maximal.

For each of these tiers, as well as for each stage of cervical cancer, the guideline recommends optimal therapy and palliative care.

Overall, the goal should be to provide women with the most effective evidence-based therapy and palliative care interventions, the panel notes. If these cannot be readily accessed, the patient might need to be treated with lower-tier modalities, depending on the regional capacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care.

Some of the Key Recommendations

In basic settings, where radiation therapy is not an option, extrafascial hysterectomy, either alone or after chemotherapy, can be an option for women with stage IA1 to IVA cervical cancer.

Concurrent radiotherapy and chemotherapy is the standard of care in enhanced and maximal settings for women with stage IB to IVA disease. The addition of concurrent low-dose chemotherapy with radiotherapy is emphasized, but not at the cost of delaying radiation therapy if chemotherapy is not available.

In limited-resource settings where brachytherapy is not available, extrafascial hysterectomy or a modification in patients who have residual tumor 2 to 3 months after concurrent chemoradiotherapy and additional boost is recommended.

Patients with stage IV or recurrent cervical cancer in basic settings can receive single-agent chemotherapy (carboplatin or cisplatin).

For patients who cannot be treated with curative intent, palliative radiotherapy should be used to relieve symptoms of pain and bleeding, if resources are available.

In settings of scarce resources, single- or short-course radiotherapy regimens can used for retreatments, if feasible, for persistent or recurrent symptoms.

If follow-up care is available, cone biopsy is recommended for women with stage 1A2 disease in basic-resource settings, and cone biopsy plus pelvic lymphadenectomy is recommended in limited settings. For patients in enhanced and maximal settings, radical trachelectomy is recommended for those with stage IB1 cervical cancer with tumor size up to 2 cm who desire fertility-sparing surgery.

"Regardless of resources, healthcare providers should always strive to deliver the highest level of care to all women with cervical cancer," Dr Berek said in a statement.

"This guideline is a starting point. We hope that it will generate discussion and much needed research in the field," he added.