Friday, May 27, 2016

ASCO issues evidence based, global guidelines for managing invasive cervical cancer.

The American Society of Clinical Oncology (ASCO) has issued recommendation on managing invasive cervical cancer.  There exist wide disparities in screening, diagnosing and treatment of patient diagnosed with invasive cervical cancer across the globe. Economic disparity and lack of resources make it impossible to adopt the same guidelines universally. 

ASCO has first time published ‘resource stratified’ guidelines that are tailored according to the resources available in a specific region.

The guidelines were published online before print on May 25, 2016, in Journal of Global Oncology.

According to WHO statistics, an estimated one million-plus women worldwide are currently living with cervical cancer of which about 84 per cent occur in less developed countries.

Dr. 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 said "In those regions, access to pathology services, skilled surgeons, radiation machines, brachytherapy, chemotherapy, and palliative care may all be constrained." 

Dr. 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 opined that At least two-thirds of the women who die from cervical cancer have not had regular screening, "If we improved screening and HPV vaccination around the world, we might be able to substantially decrease the mortality from cervical cancer." 

ASCO called upon a multidisciplinary, multinational panel of cancer specialist, medical and radiation oncology, health economic, obstetric and gynecologic, and palliative care experts to develop   guidelines that encompasses resource tiered settings.  A systemic review of literature from the year 1966 to 2015 could not yield sufficiently strong evidence to develop tailored guidelines across the different region globally, so a formal strategy of developing consensus based guidelines was adopted.

Five sets of guidelines from different bodies and societies were reviewed in current context and recommendations were formed into 4 tier that is basic, limited, enhanced, and maximal. For surgery, chemotherapy and radiotherapy treatment combinations and modalities available were formed according to the 4 tier.

  1. Surgery: In basic tier Simple (extrafascial) hysterectomy or more extensive hysterectomy can be performed while in maximal  tier facilities Radical hysterectomy, radical trachelectomy, pelvic and paraaortic LN sampling, sentinel node biopsy, and pelvic exenteration; radiation therapy, chemotherapy, interventional radiology, palliative care service, and bevacizumab are all available.
  2. Chemotherapy:  In basic tier availability of chemotherapy drugs were unpredictable, while in maximal capacity Chemotherapy available; bevacizumab is also available.
  3. Radiotherapy: In basic tier no radiation therapy available while RT including external beam and brachytherapy and interventional radiology available in maximal capacity.


The societies were the National Comprehensive Cancer Network (NCCN) in the United States, and the World Health Organization (WHO), Cancer Care Ontario (CCO) in Canada, the European Society of Medical Oncology (ESMO), the Japan Society of Gynecologic Oncology (JSGO).

Workup, Optimal therapy, follow up and post treatment surveillance and palliative care were earmarked for each of these tiers and stage of cancer.

ASCO emphasized that health care providers and health care administrators should be guided by the recommendations from the highest stratum of resource available to provide women with the best evidence based treatment modality and palliative care.

Some of the key recommendations in treatment for invasive cervical cancer are:

  • In Basic setting where radio therapy is not available, extrafascial hysterectomy, either alone or after chemotherapy, can be an option for women with stage IA1 to IVA cervical cancer.
  •  In Enhanced and Maximal settings, concurrent radiotherapy and chemotherapy is the standard of care for women with stage IB to IVA disease.
  • Adding  Low dose chemotherapy to Radiotherapy is  ideal, but if chemotherapy is not available the radiotherapy should not be delayed for it.
  • In limited resource settings where brachytherapy is not available, extrafascial hysterectomy or its modification in patients who still have residual tumor of 2-3 months after concurrent radio and chemotherapy.
  • Those patients with stage IV or recurrent cervical cancer in basic settings can be treated with single agent chemotherapy using carboplatin or cisplatin.
  • In patients who have disseminated disease and cannot be cured should be given palliative radiotherapy to relieve pain and bleeding.
  • In areas with very poor resources, multiple short courses of radiotherapy can be used for retreatment of recurrent or residual diseases.
  • In settings where good follow up care can be provided, cone biopsy in basic resources settings and cone biopsy and lymphadenectomy in limited resource setting is the treatment of choice for 1A2 disease. 
  • For patients in enhanced and maximal settings, to preserve the fertility in reproductive age group of women radical trachelectomy is recommended for those with stage IB1 disease with tumor size up to 2 cm.
  • ASCO also noted that the current guidelines are intended to complement the existing guidelines and not necessary replace it.
  • ASCO also provided future directions and stressed the need for prospective comparative research. Radical versus simple hysterectomy (the feasibility and safety of performing cone biopsy or simple hysterectomy) is an active area of investigation in limited resource settings, with stage IA2 versus 1B1 disease.


References:
http://jgo.ascopubs.org/content/early/2016/05/21/JGO.2016.003954.full




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