ASCO Releases Resource-Stratified Invasive Cervical Cancer Guidelines

The American Society of Clinical Oncology (ASCO) has released a clinical practice guideline on invasive cervical cancer. For the first time, ASCO created the guideline based on resource availability, tailoring recommendations to support basic- or limited-resource settings.

“Even though cervical cancer is largely preventable, a quarter of a million women die of this disease every year globally. The vast majority of those deaths occur in less developed regions of the world, such as South-East Asia, the Western Pacific, India, and Africa,v said Linus Chuang, MD, MS, of Mount Sinai University in New York, who co-chaired the ASCO expert panel that developed the guideline, in a press release. “In those regions, access to pathology services, skilled surgeons, radiation machines, brachytherapy, chemotherapy, and palliative care may all be constrained.”

The guidelines incorporate all relevant treatment modalities, including surgery, chemotherapy, radiotherapy, pathology services, and palliative care. Since some of those are not available in all settings, the guidelines specify replacements in certain scenarios. For example, in basic settings where radiotherapy is not available, extrafascial hysterectomy either alone or following chemotherapy is an option for women with stage IA1 to IVA cervical cancer. Similarly, single- or short-course radiotherapy schemes might be used where feasible if resources are constrained, to address persistent or recurrent symptoms.

Also in basic settings, women with larger tumors or advanced-stage disease should be treated with chemotherapy if possible, to shrink the tumor prior to a hysterectomy. For women in “enhanced” or “maximal” settings with more resources, concurrent radiotherapy and chemotherapy is considered standard care for women with stage IB to IVA disease. The expert panel stressed the addition of low-dose chemotherapy during radiotherapy, “but not at the cost of delaying radiation therapy if chemotherapy is not available.”

In limited-resource settings where brachytherapy may not be available, women with residual tumor 2 to 3 months following concurrent chemoradiotherapy should undergo extrafascial hysterectomy. Also in basic settings, women with stage IV or recurrent cancer should receive single-agent chemotherapy with carboplatin or cisplatin.

More generally, the guidelines recommend that when treatment with curative intent is not available, palliative radiotherapy is recommended to relieve symptoms of pain and bleeding. The guidelines also include discussion of cost implications of certain treatments, specifics regarding post-treatment follow-up, and other considerations.

“Regardless of resources, health care providers should always strive to deliver the highest level of care to all women with cervical cancer,” said Jonathan S. Berek, MD, of Stanford University Medical School in California, who co-chaired the expert panel with Dr. Chuang. “This guideline is a starting point. We hope that it will generate discussion and much needed research in the field.”