SIGN guidelines on managing cervical cancer

New guidance on services for women with cervical cancer highlights the need for more screening. By Mr Tito Lopes

The Scottish Intercollegiate Guidelines Network (SIGN) was formed in 1993 with the objective of improving the quality of healthcare for patients in Scotland by reducing variation in practice and outcome.

It aims to achieve this through developing and disseminating national clinical guidelines, which are systematically developed statements to assist practitioner and patient in making decisions about appropriate healthcare for specific circumstances.

Development of the SIGN guidelines is based on three core principles: multidisciplinary, nationally representative groups, a systematic review to identify and appraise the evidence, and recommendations linked to supporting evidence.

Managing cervical cancer
The new guideline on management of cervical cancer1 provides a concise overview of what the current standard of care should be for women with the condition.

The guidance not only assesses treatment options, but also provides recommendations for the holistic approach to patient care, including management of sexual morbidity, lymphoedema and other treatment complications, as well as psychosocial care and support for the patient and her carers.

Most, if not all, patients with cervical cancer in Scotland will already be managed by specialist multidisciplinary teams in designated centres where the majority of the recommendations are in place. However, the national guidelines now provide a strong case for local implementation of any remaining points, irrespective of resource implications.

Outside the multidisciplinary teams, the guidance will be particularly useful for those involved in the care of women with gynaecological cancers or those who merely want an excellent review of the evidence and recommendations for current management of cervical cancer.

Recommendations and good practice
This guideline, like all SIGN guidance, was developed through a systematic review of the medical literature from 1999 to 2005, in which the quality of the evidence was rated from one to four. Based on the strength of the evidence, recommendations were made and graded from A to D.

Box 1 lists 10 key points from the recommendations and good practice points listed in the guidance. It is perhaps a sad reflection of the quality of medical research that of the 72 recommendations, only one was based on high quality meta-analyses or randomised controlled trials (grade A) and 39 (54 per cent) were based on non-analytical studies or expert opinion (grade four).

  • Test women who have non-specific symptoms, such as intermenstrual, post-coital and postmenopausal bleeding, for chlamydia and treat if appropriate
  • Women with visible, biopsy-proven cervical carcinoma, except those with International Federation of Gynecology and Obstetrics (FIGO) IV disease, require MRI
  • Assess sexual function and concerns before treatment and offer women support before and after treatment
  • Offer women with operable disease, who wish to preserve their fertility, options such as radical trachelectomy, cold knife conisation or large loop excision of the transformation zone
  • Offer concurrent chemoradiotherapy with platinum-based chemotherapy to women with FIGO IB2, IIA, IIB, IIIA, IIIB and IVA disease, with brachytherapy as an essential component
  • There is no evidence that pregnancy accelerates cervical cancer. Therapy may be delayed in early disease to allow foetal maturity. Make decisions as for non-pregnant patients
  • If lymphoedema develops, offer access to a lymphoedema practitioner for information, support and treatment
  • If a woman has advanced disease and her condition declines, offer comprehensive palliative care
  • Provide tailored information and psychological support at diagnosis and throughout management
  • Be aware of risk factors for psychosocial problems, such as those who are younger or live alone, or who have a poorer prognosis or more functional impairment. If there are concerns about the patient’s psychological well-being, contact psychiatry or clinical psychology services

Another salient point identified in the introduction to the guideline is that only 30 per cent of cervical cancers in Scotland are detected by screening, with the majority occurring in women who have never had a smear or have been irregular participants in the screening programme.

Although the guideline makes no clinical recommendations regarding this point, it does identify as its primary research recommendation the need to explore how to encourage women to take advantage of early detection.

This excellent document should go a long way to help improve the care of women with cervical cancer in Scotland and the rest of the UK. However, prevention remains the holy grail in the management of this condition. We need to reverse the current decline in coverage in the NHS cervical screening programme and encourage widespread uptake in the national HPV vaccination programmes.

- Mr Tito Lopes is consultant gynaecologist, Treliske Hospital, Royal Cornwall Hospitals NHS Trust

1. Scottish Intercollegiate Guidelines Network. Guideline 99: Management of Cervical Cancer . SIGN, Edinburgh, January 2008.

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