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.
