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Guideline Summary
Guideline Title
Cervical cancer prevention in low-resource settings.
Bibliographic Source(s)
Elit L, Jimenez W, McAlpine J, Ghatage P, Miller D, Plante M. Cervical cancer prevention in low-resource settings. J Obstet Gynaecol Can. 2011 Mar;33(3):272-9. [42 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Cervical cancer

Guideline Category
Management
Prevention
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Oncology
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
  • To help care providers understand the current status of cervical cancer in low-resource countries
  • To review the spectrum of cervical disease from primary prevention to palliation
Target Population
  • Females, age 9 and over, in low-resource settings (screening and prevention)
  • Women with precancerous cervical dysplasia or cervical cancer in low-resource settings
Interventions and Practices Considered

Prevention/Screening

  1. Human papillomavirus (HPV) vaccination
  2. Cytology-based evaluation
  3. Visual inspection with acetic acid (VIA)
  4. Tests for HPV infection
  5. Establishment of cervical cancer screening programs

Treatment/Management

  1. Treatment of precancerous dysplasia with local ablative therapies (e.g., cryotherapy, laser ablation, excisional methods)
  2. Management of cervical cancer in cancer care centres
  3. Ensuring access to palliative care
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests
  • Rates of prevention and early detection of cervical cancer in low-resource countries
  • Safety, efficacy, and cost-effectiveness of tests and treatments
  • Mortality due to cervical cancer

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

PubMed or Medline, CINAHL, and The Cochrane Library were searched for studies published in English between January 2006 and December 2009. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

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

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial.

II-1: Evidence from well-designed controlled trials without randomization.

II-2: Evidence from well–designed cohort (prospective or retrospective) or case–control studies, preferably from more than one centre or research group.

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in The Canadian Task Force on Preventive Health Care.

Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This policy statement has been prepared by The Society of Obstetricians and Gynaecologists of Canada, The Society of Gynecologic Oncology of Canada, and The Society of Canadian Colposcopists, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Recommendations

Major Recommendations

The quality of evidence (I-III) and classification of recommendations (A-L) are defined at the end of the "Major Recommendations" field.

Vaccination

  1. All girls 9 years old or over should have access to the cervical cancer vaccine before they become sexually active. (I-A)

Cervical Screening

  1. Cervical cancer screening by visual inspection with acetic acid is suggested for low-resource settings acceptable. Cervical cytology or human papillomavirus testing may also be used when practical. (II-2B)

Treatment of Dysplasia

  1. Cryotherapy is a safe, effective, and low-cost therapy that should be included in pre-invasive cervical cancer treatment. (III-B)

Screening Program

  1. All countries should have a documented cervical cancer prevention strategy that includes public education built in existing outreach programs. (III-C)

Cancer

  1. Countries should define a centre or centres of excellence for the management of cervical cancer. (III-C) Because these units would serve a larger population, they would be able to identify leaders and develop their skills, and would be able to invest in costly radiation equipment.

Palliative Care

  1. All women with cervical cancer should have access to pain management. (III-C)

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial.

II-1: Evidence from well-designed controlled trials without randomization.

II-2: Evidence from well–designed cohort (prospective or retrospective) or case–control studies, preferably from more than one centre or research group.

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Classification of Recommendations

A. There is good evidence to recommend the clinical preventive action.

B. There is fair evidence to recommend the clinical preventive action.

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.

D. There is fair evidence to recommend against the clinical preventive action.

E. There is good evidence to recommend against the clinical preventive action.

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.

†Adapted from the Classification of Recommendations criteria described in The Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Exposure to human papillomavirus (HPV) can be minimized through vaccination of young women. Vaccination is most effective if given to young women before they become sexually active (primary prevention). Precancerous cellular changes can be identified through screening, assessment of test-positive cases, and treatment (secondary prevention).
  • The goal of secondary screening is to prevent cancer, but it may also identify cervical cancer at an earlier stage, which will increase the likelihood that treatment will be successful.
Potential Harms

Specificity of visual inspection of the cervix after the application of 3% to 5% acetic acid solution (VIA) is lower than that of cytology, and there is a risk of overtreatment.

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

Implementation of the Guideline

Description of Implementation Strategy

Considerable resources and a high level of program coordination are needed to implement a widespread cervical screening program with components expected in industrialized countries: testing, treatment, quality assurance, follow-up, and information dissemination. These programs are impractical and unaffordable in a low-resource setting, but women in these settings deserve access to safe, effective, and affordable services to prevent cervical cancer. If these services are to be provided, it is important to understand the strengths and weaknesses of any existing cervical cancer prevention program and the capacity of the health system in general before planning interventions and providing benchmarks against which to measure change.

Refer to the original guideline document for details on the following issues that must be taken into consideration: competing health needs, limited human and financial resources, lack of understanding and limited commitment, political instability, dedicated staff, geographical challenges, insufficient resources to provide treatment for the additional newly diagnosed, and sociocultural issues.

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)
Elit L, Jimenez W, McAlpine J, Ghatage P, Miller D, Plante M. Cervical cancer prevention in low-resource settings. J Obstet Gynaecol Can. 2011 Mar;33(3):272-9. [42 references] PubMed External Web Site Policy
Adaptation

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

Date Released
2011 Mar
Guideline Developer(s)
Society of Canadian Colposcopists - Professional Association
Society of Gynaecologic Oncologists of Canada - Disease Specific Society
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Principal Authors: Laurie Elit, MD, Hamilton ON; Waldo Jimenez, MD, Toronto ON; Jessica McAlpine, MD, Vancouver BC; Prafull Ghatage, MD, Calgary AB; Dianne Miller, MD, Vancouver BC; Marie Plante, MD, Quebec QC

Financial Disclosures/Conflicts of Interest

Disclosure statements have been received from all authors.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of Canada Web site External Web Site Policy.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 3, 2011. The information was verified by the guideline developer on September 7, 2011.

Copyright Statement

The NCG summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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