1. Holt, Chuck

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According to the World Health Organization's (WHO) International Agency for Research on Cancer, in 2012, the latest numbers available, there were an estimated 266,000 deaths from cervical cancer, accounting for 7.5 percent of all cancer deaths in females. Almost nine out of 10 cervical cancer deaths (87%) occur in the less-developed regions of the world. Deaths from all cancers also reveal major global disparities, occurring in three out of every four cases in low- to middle-income countries, as defined by WHO scenarios in 2002, but that number decreases to less than 50 percent in higher-income countries.

Excellence in Oncolo... - Click to enlarge in new windowExcellence in Oncology; cervical cancer. Excellence in Oncology; cervical cancer
Linus T. Chuang, MD.... - Click to enlarge in new windowLinus T. Chuang, MD. GLOBAL HEALTH CARE: Linus T. Chuang, MD, helped establish a guideline to assist clinicians in countries with limited resources so they have the tools to best treat women with cervical cancer based on what is available to them.

Seeking to develop global recommendations guided by the highest stratum of resources available for the management and palliative care of women diagnosed with invasive cervical cancer, ASCO convened the Resource-Stratified Guidelines Advisory Group, a multidisciplinary, multinational panel of cancer control specialized in medical and radiation oncology, health economics, ob/gyn, and palliative care.


In the Journal of Global Oncology, Linus T. Chuang, MD, Chairman of Obstetrics and Gynecology, Western Connecticut Health Network (WCHN), and colleagues, described in detail the ASCO committee's guidelines (2016;2(5):311-340). Recommendations included the following:


* Local clinicians and planners strive to provide access to the most effective, evidence-based, anti-tumor, and palliative care interventions available.


* If a woman cannot access intervention resources within her own or neighboring country or region, she may need to be treated with lower-tier modalities, depending on capacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care.


* For women with early-stage cervical cancer in basic settings, cone biopsy, or extrafascial hysterectomy may be performed.


* Fertility-sparing procedures or modified radical or radical hysterectomy may be additional options in non-basic settings.


* Combinations of surgery, chemotherapy, and radiation therapy (including brachytherapy) should be used for women with stage IB to IVA disease, depending on available resources.


* Pain control is a vital component of palliative care.



Among other accolades, the landmark body of work earned Chuang, et al, an Excellence in Oncology Award from the Oncology Times. Below, Chuang, who is also the Fred and Irmi Bering Endowed Chair in Minimally Invasive Surgery for WCHN, and Professor of Obstetrics and Gynecology at the Icahn School of Medicine at Mount Sinai in New York, N.Y., shared additional insights into the development of the ASCO global guidelines for patient with cervical cancer.


What inspired you to investigate how to better manage care for women with invasive cervical cancer depending on the resources available to them and their access to care?


Over the past 15 years, I've traveled to many countries in Africa, Asia, and Central and South America through my global work in treating women with gynecologic cancers and providing training and education for clinicians. Globally, cervical cancer is the fourth most frequent cancer in women with an estimated 530,000 new cases each year. Approximately 90 percent of the 270,000 deaths globally from cervical cancer each year occur in low- and middle-income countries.


What was striking to me was the lack of established guidelines and essential resources to screen for and treat gynecologic cancers in many of these countries, where cervical cancer is the most or second most common cancer in women. The likelihood of women dying from cervical cancer is higher in these countries than in the U.S. This is due to the absence of effective screening in these countries, resulting in most women with cervical cancer being diagnosed at an advanced stage (stage III or IV). The higher mortality rate in these counties versus the U.S. is also due to lack of radiation machines, surgeons, and chemotherapy to treat the disease.


I saw a need to establish a guideline to assist clinicians in countries with limited resources so they have the tools to best treat women with cervical cancer based on what is available to them. I was fortunate to work with my colleagues in the Society of Gynecologic Oncology on this initiative. We hosted meetings to address this issue, and then, with the assistance of ASCO, we convened an international expert panel to recommend how best to treat cervical cancer based on various resource settings.


What, if anything, surprised you about the former management of care for this population of women?


Prior to having this resource-stratified clinical practice guideline, clinicians were often limited by the available resources in their regions to treat women with cervical cancer. In some areas, substitutes were recommended and some less-than-optimal treatments were given. This frequently resulted in suboptimal outcomes for the women with cervical cancer. In some countries, creative management strategies were already being implemented. Some of these strategies, such as one developed by Mexico's National Cancer Institute, had clinical trials to support its safety and effectiveness. Our resource-stratified practice guideline factored in these types of innovative management strategies that were evidence-based, with the goal for other regions of the world to adopt these strategies.


What are the clinical implications, if any, for the new guidelines?


We advocate when possible to surgically remove early cervical cancer if it can be performed safely with negative cancer margins. Neoadjuvant chemotherapy can also be done to make cancer more treatable. Appropriate usage of resources such as the use of platinum agent in chemoradiation therapy was stressed. Having these treatment options allows flexibility for clinicians to plan on treatments for women with cervical cancer in their respective regions.


What further research needs to be done on this topic?


Confirmation of the recommendations put forth in our resource-stratified clinical practice guideline is vital. What has been unexpected is that the attention that was drawn to this first resource-stratified clinical practice guideline for cervical cancer has inspired additional research. Current ongoing research includes the possibility to use less treatment fractions of radiation to obtain equivalent survival outcomes. If fewer treatment fractions are needed, then it means more women can be treated and more lives can be saved. Research is also being done to determine if surgery can replace brachytherapy as this approach is even less available in low-resource settings comparing to external beam radiation therapy machines.


Is there anything else you want Oncology Times readers to know about management and palliative care of women diagnosed with invasive cervical cancer?


While we are pleased this resource-stratified clinical practice guideline may help clinicians more effectively manage care for women with cervical cancer worldwide, we would like to call for more attention to primary and secondary prevention of cervical cancer through HPV vaccination and screening for cervical cancer. Today we have the means in using HPV vaccination to prevent nearly 90 percent of cervical cancer. If women undergo cervical cancer screening, the cancer can also be detected at its pre-invasive phase, which is highly curable.


Chuck Holt is a contributing writer.