Aug 24, 2016
By Cheryl Alkon and Sarah Temin
Cervical cancer affects women worldwide, but resource disparities mean that treatments differ based on health system strength and/ or geographic location—which explains the high rate of cases and deaths from cervical cancer in systems/areas where screening, prevention, and treatment services are not easily accessible.
An ASCO guideline published in May in the Journal of Global Oncology and online at asco.org/guidelines—“Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline”1—gives recommendations based on four tiers of resources in locations and health systems around the world, classified as basic, limited, enhanced, and maximal resource settings. Using “settings,” rather than “countries,” emphasizes that resources are not limited to a country’s income, but include other factors (e.g., the presence of trained professionals), and that resources can differ within countries and health systems.
This guideline helps answer the question, “What can we recommend to countries and health systems that do not have the resources that we are so richly blessed with in most areas of the United States?” said Jonathan S. Berek, MD, MMS, FASCO, of Stanford University School of Medicine and Co-Chair of the Cervical Cancer Treatment (Resource Stratified) Expert Panel that developed the guideline.
Dr. Berek co-chaired the panel with Linus T. Chuang, MD, of the Icahn School of Medicine at Mount Sinai. The recommendations “are the first of their kind for ASCO—resource-stratified for the best evidence of how to treat patients with cervical cancer, both in high-resource parts of North America and other areas, and for regions with lower resources, such as in parts of sub-Saharan Africa and Central America,” Dr. Chuang said.
Cervical cancer kills approximately 4,000 women in the United States each year and a quarter of a million women around the world, with more than 500,000 new cases each year worldwide.2,3 Approximately 85% of cervical cancers occur in low- and middle-income countries/regions. “The death rate is appalling,” Dr. Berek said. “It is particularly a problem in sub-Saharan Africa and parts of Asia because of a lack of early detection and screening. In many regions, when a woman is diagnosed with cervical cancer, it is a death sentence.”
The guideline was written with a panel of international experts, including those in medical oncology, gynecologic oncology, radiation oncology, palliative care, health economics, obstetrics and gynecology, and the patient advocacy community. Experts hailed from the United States, Spain, Mexico, Turkey, Canada, Argentina, Zambia, Uganda, South Korea, China, and India. The panel evaluated existing literature and similar guidelines, and reviewed cost-effectiveness analyses to determine how best to develop the guidelines for each tier. The recommendations note that they are intended to “complement, but not replace, local guidelines.”
In each tier, and for each stage of cervical cancer, the recommendations discuss the optimal therapy, which can include a mix of radiation, chemotherapy, and/or surgery, when appropriate, given the clinical setting and the patient’s particular situation, as well as palliative care, which includes pain management. For example, many women live in areas without access to radiotherapy (including equipment and personnel), a key element of treatment; the guideline suggests actions for clinicians practicing in such situations. The authors hope that the guideline provides a tool for clinicians to implement in their practices, and to take to policymakers in their regions and health systems to show what the right resources can offer women who are diagnosed with cervical cancer—often young women in their most productive years. They may be caregiving and/ or working in other sectors inside or outside the home, formally or informally, and providing economic and health benefits to family and society.4 Promoting and sustaining their health supports global development.5
“The hope is that because of ASCO’s effort, the guideline will provide support and perhaps even political clout to colleagues around the world who are trying to do their best to save the lives of women who might not otherwise be saved,” Dr. Berek said. Many regions in the basic tier are facing priority problems, such as infectious disease or deaths from malnutrition and unclean water. “They are dealing with issues so fundamental to society that when you talk about cancer, it’s almost not important to them,” he said. Nonetheless, raising awareness about the potential positive impacts of preventing and treating this disease may encourage investment in these modalities and lower cervical cancer’s societal impact. ASCO joins other groups advocating for radiotherapy resources (e.g., Global Task Force on Radiotherapy for Cancer Control) and supports other ongoing global efforts to increase the availability of surgery (e.g., The Lancet Oncology Commission on Global Cancer Surgery).
“For policymakers, the guideline is a way to let governments take notice of what needs to be done and what they should be aiming for, for patients with cervical cancer,” Dr. Chuang said.
Additional guidelines in development
ASCO experts are developing two additional resource-stratified guidelines to further address cervical cancer, both on prevention. One will address the importance of cervical cancer screening and treating precursor lesions, and the other will focus on the prevention of HPV infection, which can lead to the development of cervical cancer, with the use of an HPV vaccine. Both guidelines are expected to publish later in 2016.
Ms. Alkon is a freelance writer. Ms. Temin is a senior practice guidelines specialist at ASCO.
- Chuang LT, Temin S, Camacho R, et al. JGO. Epub May 25, 2016.
- Centers for Disease Control and Prevention. United States Cancer Statistics: 1999– 2012 Incidence and Mortality Web-based Report. Accessed March 15, 2016.
- World Cancer Research Fund International. Worldwide data. Accessed March 15, 2016.
- Langer A, Meleis A, Knaul FM, et al. Lancet. 2015;386:1165-210.
- Gates M. Lancet. 2015;386:e11-2.