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## Complete Summary

#### GUIDELINE TITLE

Cervical cancer.

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Cervical cancer. Singapore: Singapore
Ministry of Health; 2003 Feb. 45 p. \[112 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Cervical cancer

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Oncology\
Radiation Oncology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the screening, diagnosis, classification,
staging, management, and treatment of patients with cervical cancer

#### TARGET POPULATION

-   Women in the general population in Singapore (*Prevention;
    Screening*)

-   Women with cervical cancer in Singapore (*Diagnosis; Evaluation;
    Risk Assessment/Prognosis; Management; Treatment*)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening/Evaluation/Diagnosis**

1.  Population screening

2.  Diagnosis based on histopathology (e.g. Pap smear, cone biopsy)

3.  Classification and staging of cervical cancer using Gynecology
    Oncology Committee of the International Federation of Gynecology and
    Obstetrics (FIGO) or other staging procedures

**Management/Treatment**

1.  Cone biopsy

2.  Total hysterectomy

3.  Fertility-sparing surgery

4.  Pelvic radiotherapy

5.  Post-operative treatment using a combination of platinum-based
    chemotherapy and radiotherapy

6.  Palliative medical care

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of and mortality related to cervical cancer

-   Overall and progression-free survival rates

-   Cure rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level Ia**: Evidence obtained from meta-analysis of randomised
controlled trials.

**Level Ib**: Evidence obtained from at least one randomised controlled
trial.

**Level IIa**: Evidence obtained from at least one well-designed
controlled study without randomisation.

**Level IIb**: Evidence obtained from at least one other type of
well-designed quasi-experimental study.

**Level III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies,
and case studies.

**Level IV**: Evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected authorities.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendations**

**Grade A** (evidence levels Ia, Ib): Requires at least one randomised
controlled trial as part of the body of literature of overall good
quality and consistency addressing the specific recommendation.

**Grade B** (evidence levels IIa, IIb, III): Requires availability of
well conducted clinical studies but no randomised clinical trials on the
topic of recommendation.

**Grade C** (evidence level IV): Requires evidence obtained from expert
committee reports or opinions and/or clinical experiences of respected
authorities. Indicates absence of directly applicable clinical studies
of good quality.

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The recommendations that follow are those from the guideline\'s
executive summary; detailed recommendations can be found in the original
guideline document. Each recommendation is rated based on the level of
the evidence and the grades of recommendation. Definitions of the grades
of the recommendations (A, B, C, Good Practice Points) and level of the
evidence (Level I-Level IV) are presented at the end of the Major
Recommendations field.

**Screening**

**B** - To reduce the incidence and mortality rate of cervix cancer,
effective screening and preventive strategy must be actively pursued, in
addition to early detection of disease and effective therapy (Anderson
et al., 1995; Laara, Day, & Hakama, 1987). (**Grade B, Level IIa**)

**Stage IA**

**B** - Total hysterectomy is the treatment of choice for microinvasive
cervical cancer in patients who have completed their family. In selected
patients, fertility-sparing surgery may be considered. (**Grade B, Level
III**)

**Stage IB -- IIA**

**A** - Current evidence indicates that both radical surgery and pelvic
radiotherapy result in equivalent cure rates for early localized
cervical cancer (Landoni et al., 1997). (**Grade A, Level Ib**)

**A** - The addition of post-operative treatment using a combination of
chemotherapy and radiotherapy has been shown to improve survival outcome
for patients with tumour involvement of pelvic lymph nodes, resection
margins, and/or parametrial tissue (Sedlis et al., 1999; Peters et al.,
2000). (**Grade A, Level Ib**)

The optimal treatment for bulky (\>4cm) cervical cancer remains
controversial.

**Stage IIB -- IVA**

**A** - The treatment of choice for locally advanced cervical cancer is
concurrent chemoradiation. (**Grade A, Level Ia**)

**Metastatic Cancer**

**B** - The main aim of treatment for patients with metastatic cancer is
palliation of symptoms. (**Grade B, Level IIa**)

**Recurrent Cancer**

**B** - The treatment employed for patients with recurrent cervical
cancer is dependent on their previous treatment modality and the exact
anatomical site of relapse. (**Grade B, Level IIa**)

**Ovarian Conservation**

**B** - Ovarian conservation should be considered for young patients
(Sutton et al., 1992). (**Grade B, Level IIa**)

**Hormone Replacement Therapy**

**B** - There is no clinical evidence that Hormone Replacement Therapy
should be withheld from patients with a history of cervical cancer
(Gadducci et al., 1997; Burger et al., 1999; Ploch, 1987; Sadan et al.,
1989; Wren, 1994). (**Grade B, Level IIa**)

**[Definitions]{.underline}**:

**Grades of Recommendations**

**Grade A** (evidence levels Ia, Ib): Requires at least one randomised
controlled trial as part of the body of literature of overall good
quality and consistency addressing the specific recommendation.

**Grade B** (evidence levels IIa, IIb, III): Requires availability of
well conducted clinical studies but no randomised clinical trials on the
topic of recommendation.

**Grade C** (evidence level IV): Requires evidence obtained from expert
committee reports or opinions and/or clinical experiences of respected
authorities. Indicates absence of directly applicable clinical studies
of good quality.

**Good Practice Points**: Recommended best practice based on the
clinical experience of the guideline development group.

**Levels of Evidence**

**Level Ia**: Evidence obtained from meta-analysis of randomised
controlled trials.

**Level Ib**: Evidence obtained from at least one randomised controlled
trial.

**Level IIa**: Evidence obtained from at least one well-designed
controlled study without randomisation.

**Level IIb**: Evidence obtained from at least one other type of
well-designed quasi-experimental study.

**Level III**: Evidence obtained from well-designed non-experimental
descriptive studies, such as comparative studies, correlation studies
and case studies.

**Level IV**: Evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected authorities.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=3747)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Overall Benefits**

-   Guideline implementation may help reduce the incidence and mortality
    of cervical cancer and improve cure rates and survival rates.

-   Cervical cancer screening will allow doctors to detect pre-invasive
    disease and early-stage cervical cancer, both of which carry a good
    prognosis.

-   Well-run population-based cervical cancer screening programmes with
    good coverage can reduce the incidence and mortality of cervical
    cancer.

**Specific Benefits**

-   The addition of concurrent weekly intravenous platinum-based
    chemotherapy, up to a total of 6 cycles, has been found to improve
    survival outcome in three randomised studies, in particular for
    patients without extra-pelvic nodal involvement.

-   Current evidence indicates that both radical surgery and pelvic
    radiotherapy result in equivalent cure rates for early localized
    cervical cancer.

-   The addition of post-operative treatment using a combination of
    chemotherapy and radiotherapy has been shown to improve survival
    outcome for patients with tumour involvement of pelvic lymph nodes,
    resection margins, and/ or parametrial tissue.

#### POTENTIAL HARMS

-   Side effects/complications of treatment

-   False-negative Pap-smear results, even in women who have regular
    screening

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Contraindications for Chemotherapy**

-   Poor patient performance status

-   Advanced age

-   Inadequate bone marrow and renal function

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines are not intended to serve as a standard of medical
    care. Standards of medical care are determined on the basis of all
    clinical data available for an individual case and are subject to
    change as scientific knowledge advances and patterns of care evolve.

-   The contents of the guideline document are guidelines to clinical
    practice, based on the best available evidence at the time of
    development. Adherence to these guidelines may not ensure a
    successful outcome in every case, nor should they be construed as
    including all proper methods of care or excluding other acceptable
    methods of care. Each physician is ultimately responsible for the
    management of his/her unique patient in the light of the clinical
    data presented by the patient and the diagnostic and treatment
    options available.

-   This set of management guidelines covers the majority, and common
    aspects, of cervical cancer but is not meant to be exhaustive. Where
    situation necessitates, the treatment of a patient must be tailored
    to the individual.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Clinical Audit**

-   All patients treated for cervical cancer must have histopathological
    confirmation before commencement of treatment.

-   The diagnosis of microinvasive disease of the cervix requires a
    single large cone biopsy with clear margins.

-   All patients must be assigned a clinical stage based on recognized
    criteria and investigative procedures set out in the main
    guidelines.

-   The reasons for deviation from these practice guidelines must be
    documented.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Singapore Ministry of Health. Cervical cancer. Singapore: Singapore
Ministry of Health; 2003 Feb. 45 p. \[112 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Feb

#### GUIDELINE DEVELOPER(S)

Singapore Ministry of Health - National Government Agency \[Non-U.S.\]

#### SOURCE(S) OF FUNDING

Singapore Ministry of Health

#### GUIDELINE COMMITTEE

Workgroup on Cervical Cancer

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Workgroup Members*: Assoc Prof Ho Tew Hong, Chief of Gynaecology, Head
and Senior Consultant, Gynaecological Oncology Unit, KK Women\'s &
Children\'s Hospital (Chairman); Assoc Prof Tay Sun Kuie, Senior
Consultant, Department of Obstetrics and Gynaecology, Singapore General
Hospital; Assoc Prof Lim Fang Kan, Senior Consultant, Department of
Obstetrics and Gynaecology, National University Hospital; Assoc Prof A
Ilancheran, Senior Consultant, Department of Obstetrics and Gynaecology,
National University Hospital; Assoc Prof G C Raju, Senior Consultant,
Department of Pathology, National University Hospital; Dr Soh Lay Tin,
Senior Consultant, Department of Medical Oncology, National Cancer
Centre; Dr Christopher Wynne, Chief/Senior Consultant, Department of
Radiation Oncology, National University Hospital; Dr Tay Eng Hseon,
Consultant, Gynaecological Oncology Unit, KK Women\'s & Children\'s
Hospital; Dr Jeffrey Low, Consultant, Gynaecological Oncology Unit, KK
Women\'s & Children\'s Hospital; Dr Chew Sung Hock, Consultant,
Histopathology, KK Women\'s & Children\'s Hospital; Dr Khoo Tan Hoon
Seng, Consultant, Department of Therapeutic Radiology, National Cancer
Centre; Dr Lee Khai Mun, Consultant, Department of Therapeutic
Radiology, National Cancer Centre; Dr Lim Siew Eng, Consultant,
Department of Haematology-Oncology, National University Hospital; Dr
Pornchai Jonglertham, Senior Registrar (Oncology), Johns Hopkins - NUH
International Medical Centre; Dr Pritam Singh, Consultant Gynaecologist,
Gynaecology Associates, Mt Elizabeth Hospital; Dr Ching Kwok Choy, K C
Ching Clinic and Surgery, Mt Elizabeth Hospital, Visiting Specialist, KK
Women\'s & Children\'s Hospital

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Singapore Ministry of Health Web
site](http://www.hpp.moh.gov.sg/HPP/1130910778681.html).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

The following is available:

-   Patient education brochure on cancer of the cervix. Singapore:
    Singapore Ministry of Health; 2003. 41 p.

Electronic copies: Available in Portable Document Format (PDF) from the
[Singapore Ministry of Health Web
site](http://www.hpp.moh.gov.sg/HPP/MungoBlobs/328/216/2003 peb_cervical cancer.pdf).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on November 28, 2003.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Ministry of Health, Singapore by e-mail at <MOH_INFO@MOH.GOV.SG>.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008