ASCO issues new evidence based recommendations for global cervical cancer screening.

AmericanSociety of Clinical Oncology (ASCO)[i]  releases new resource stratified, evidence based global screening guidelines for secondary prevention of cervical cancer. ASCO called upon multidisciplinary, multinational team of cancer control, public health, oncology, epidemiology, primary care and patient advocacy experts to review the earlier guidelines and formulate recommendations according to the resources available.  

The panel of expert identified 7 existing guidelines, reviewed them and formed the evidence base, along with cost effective analysis and four systematic reviews leading to more than 75% agreement.

The basic aim of the guidelines was utilizing the resources available in countries across the globe to screen the maximum number of women to detect precancerous lesions and treatment and follow-up thereafter.

According to Medscape Surendra S. Shastri, MD, MBBS, co-chair of the ASCO expert panel that developed the guideline and professor of preventive oncology at Tata Memorial Center in Mumbai, India said "Every woman ― no matter where she lives ― should have at least one good cervical cancer screen in her lifetime, but unfortunately, we are not even close to that."

The guidelines were published online October 12 in the Journal of Global Oncology.[ii]

The countries around the world are divided into 4 tier based on available healthcare resources- maximal resources, enhanced resources, limited resources and basic resources. Countries with most resources are in the maximal resource group while countries with very limited resources were labelled as into basic resources group.

The panel then evaluated that what type of screening will be suitable for each tier.

Key Recommendations as published in the Journal of Global Oncology:

Primary Screening

• Human papillomavirus (HPV) DNA testing is recommended in all resource settings.
• Visual inspection with acetic acid may be used in basic settings.
• The recommended age ranges and frequencies in each setting are as follows:
• Maximal: 25-65 years, every 5 years
• Enhanced: 30-65 years, if two consecutive negative tests at 5-years intervals, then every 10 years
• Limited: 30-49 years, every 10 years
• Basic: 30-49 years, one to three times per lifetime

Exiting Screening

• Maximal and enhanced: ≥ 65 years with consistently negative results during past ≥ 15 years
• Limited and basic: ≤ 49 years, resource-dependent; see specific recommendations

Triage

• In basic settings, visual assessment for treatment may be used after positive HPV DNA testing results.
• If visual inspection with acetic acid was used as primary screening with abnormal results, women should receive treatment.
• For other settings, HPV genotyping and/or cytology may be used.

After Triage

• Women with negative triage results should receive follow-up in 12 months.
• In basic settings, women should be treated if there are abnormal or positive triage results.
• In limited settings, women with abnormal results from triage should receive colposcopy, if available, or visual assessment for treatment, if colposcopy is not available.
• In maximal and enhanced settings, women with abnormal or positive results from triage should receive colposcopy.

Treatment of Women With Precursor Lesions

• In basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure (LEEP).
• In other settings, LEEP (if high level of quality assurance) or ablation (if medical contraindication to LEEP) is recommended.
• Twelve-month post-treatment follow-up is recommended for all settings.

Special Populations

• Women who are HIV positive or immunosuppressed for other reasons should be screened with HPV as soon as diagnosed and screened twice as many times in a lifetime as the general population.
• The management of abnormal screening results for women with HIV and positive results of triage is the same as in the general population
• Women should be offered primary screening 6 weeks postpartum in basic settings and 6 months postpartum in other settings.
• Screening may be discontinued in women who have received a total hysterectomy for benign causes with no history of cervical dysplasia or HPV. Women who have received a subtotal hysterectomy (with an intact cervix) should continue receiving routine screening.

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[i] https://pilotguidelines.atlassian.net/wiki/display/SPCCRG/Secondary+Prevention+of+Cervical+Cancer+Resource-Stratified+Guideline+Home

[ii] http://jgo.ascopubs.org/content/early/2016/10/08/JGO.2016.006577.full#abstract-1

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://www.wcrf.org/int/cancer-facts-figures/data-specific-cancers/cervical-cancer-statistics

http://www.who.int/reproductivehealth/topics/cancers/en/

http://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/2016-RS-Cervical-Cancer-Treatment-Summary-Table.pdf

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