The American Society of Clinical Oncology (ASCO) today issued a new global guideline on screening for cervical cancer, one of the leading causes of cancer related death among women worldwide. The guideline provides evidence-based recommendations for screening, follow-up of positive screening results, and treatment of women with cervical pre-cancers in countries worldwide.
ASCO's guideline recommends that all women in appropriate age groups - in low-resource, middle-resource, and high-resource settings - be screened for cervical pre-cancers. It specifically aims to establish consistent minimum standards for screening across countries, while accounting for wide variations in resource levels and health systems.
It is the first global screening guideline to incorporate the landmark 2013 finding that visual inspection with acetic acid (vinegar) - an inexpensive and simple method also known as VIA - can reduce cervical cancer mortality in some of the world's poorest regions. However, it stresses that this method should only be used as a stepping stone to testing for human papillomavirus (HPV), which is the cause of virtually all cervical cancers.
"Every woman - no matter where she lives - should have at least one good cervical cancer screen in her lifetime. Unfortunately, we are not even close to that," said 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. "We hope that this guideline will bring us closer to the goal of providing high-quality preventive care to all women, regardless of their circumstances."
While cervical cancer is a largely preventable disease, lower-income countries often lack mass screening and HPV vaccination programs. As a result, more than 85% of the world's cervical cancer diagnoses and deaths occur in less developed regions. Access to cervical cancer prevention and treatment varies not only among countries but also within them.
In alignment with ASCO's mission to improve cancer treatment and prevention globally, the Society's guideline was developed by a panel of experts from an array of international health and advocacy organizations and academic institutions. The panel outlined the minimum standards for cervical cancer screening in four distinct types of healthcare settings: basic, limited, enhanced and maximal. The tiers pertain not only to a country or region's financial resources, but also to the strength of its health system — including personnel, infrastructure and access to services.
"Over the past decade, ASCO has made a major commitment to improving cancer care worldwide. Our latest guideline represents a key step in achieving that goal ─ making sure that we detect changes that may lead to cervical cancer early, so that we can save more lives around the world," said ASCO President Daniel F. Hayes, MD, FASCO, FACP.
The World Health Organization (WHO) last issued a global cervical cancer screening guideline in 2013. ASCO's guideline builds upon WHO's recommendations by providing a minimum set of standards across all countries based on their existing resources, and by accounting for the 2013 VIA study and other recent data.
Key guideline recommendations:
- Human papillomavirus (HPV) DNA testing is recommended in all resource settings; VIA may be used in basic setting as a "stepping stone" that helps build health service capacity until HPV testing becomes available. Although co-testing with HPV and Pap smear is an option in the maximal setting, the panel determined that the added value on the basis of increased costs of such dual screening is limited.
- Self-collection of samples may be used for HPV testing.
- The recommended age ranges and frequencies for screening are:
- maximal setting, ages 25-65 years, every 5 years (≥9 screens in a lifetime);
- enhanced setting, ages 30-65 years, if two consecutive negative tests at 5-year intervals, then every 10 years (≥5 screens in a lifetime);
- limited setting, ages 30-49 years, every 10 years (≥3 screens in a lifetime);
- basic setting, ages 30-49 years, one to three times during that age range (≥1 screens in a lifetime).
- The guideline also provides separate screening recommendations for women who are HIV positive, those who had recently given birth, and those who have undergone a hysterectomy.
- After a positive HPV DNA testing result, VIA may be used for triage (follow-up) in basic and limited settings. If VIA was used as a primary screening with abnormal results, women should receive treatment. For other settings, HPV genotyping and/or cytology may be used for triage.
- Women with abnormal triage results should receive immediate treatment in basic and limited setting, or colposcopy in all other settings.
- The recommended treatment options for women with pre-cancers (precursor lesions) are LEEP, or ablative treatments such as cryotherapy or cold coagulation. Twelve-month post-treatment follow-up is recommended for all settings.
"We are recommending the minimum screening and follow-up care every woman should receive. This a place to start, but it doesn't mean that more shouldn't be done, if resources permit," said Philip Castle, PhD, member of the Steering Committee of the ASCO Expert Panel that developed the guideline and professor of epidemiology and public health at Albert Einstein College of Medicine in Bronx, NY. "Our guideline is consistent with and builds on existing North American and European guidelines, as well as the important work of the World Health Organization."
This is the second in a series of three resource-stratified guidelines from ASCO, which provide recommendations tailored to health resource availability. The guideline was developed by a panel of world renowned experts in cancer control, gynecologic oncology, medical oncology, epidemiology, biostatistics, health economics, public health and radiotherapy. The panel included experts in North America, Latin America, South Asia, South and East Africa, China, Australia, and Western Europe, as well as a patient representative from India. The recommendations were made using evidence from existing guidelines, literature and clinical experience. All recommendations reflect formal expert consensus.
"These recommendations could have a significant impact on women's health because they provide guidance for implementing proper strategies for women who are not accessing screening now and are at the highest risk of developing cervical pre-cancer and cancer," said Jose Jeronimo, MD, co-chair of the ASCO Expert Panel that developed the guideline and senior advisor for women's cancers at PATH in Seattle, WA. "Education of health care providers and policy makers will be critical to get the most benefit from this ASCO guideline."
The panel also stresses the need to develop infrastructure for HPV testing, diagnosis and treatment in basic settings and/or those without current mass screening.
The guideline, Secondary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline was published today in the Journal of Global Oncology, and is available at www.asco.org/rs-cervical-cancer-secondary-prev-guideline along with supplementary materials.
This guideline has been endorsed by the International Gynecologic Cancer Society (IGCS) and the American Society for Colposcopy and Cervical Pathology (ASCCP).
Separate ASCO resource-stratified guidelines provide recommendations on the treatment of women with invasive cervical cancer and on HPV vaccination or primary prevention of cervical cancer (forthcoming).
American Society of Clinical Oncology (ASCO)