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.
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.
- 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.
- Chemotherapy: In basic tier availability of chemotherapy
drugs were unpredictable, while in maximal capacity Chemotherapy available;
bevacizumab is also available.
- 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
