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GlobalGuidanceFor

CervicalCancerPreventionandControl

October2009

2

TableofContents

1. Overview:FIGOComprehensiveGuidance

2. CervicalCancerControl:RightsandEthics

JoannaCain,MD,WomenandInfantsHospital,BrownUniversity

CarlaChibwesha,MDMSc.UniversityofAlabamaatBirmingham,Center

forInfectiousDiseaseResearchofZambia(CIDRZ)

3. AComprehensiveApproachtoCervicalCancer:ImprovingImpactToday

SarahGoltzShelbaya,MPH,MIA

DebbieSaslow,PhD,AmericanCancerSociety

4. Overview:PrimaryPrevention

5. HPVVaccines:Characteristics,TargetPopulationandSafety

MarthaJacob,MBBS,FRCOG,MPH,PATH

6. Vaccine:PresentDeliveryStrategiesandResults

ScottWittet,MA,PATH

SuzanneGarland,MD,UniversityofMelbourne

7. Overview:EarlyScreeningandTreatment

8. TheSingleVisitApproach

NeerjaBhatla,MBBS,MD,FICOG,AllIndiaInstituteofMedicalSciences

9. VisualInspectionwithAceticAcid(VIA)

NeerjaBhatla,MBBS,MD,FICOG,AllIndiaInstituteofMedicalSciences

EnriquitoLu,MD,Jhpiego

10. EarlyDiagnosisofCervicalNeoplasia:PapTest(Cytology)

NahidaChakhtoura,MD,UniversityofMiamiMillerSchoolofMedicine

11. HPVTesting:anAdjuvanttoCytologybasedScreeningandasaPrimary

ScreeningTest

JoseJeronimo,MD,PATH

12. Colposcopy

HextanY.S.Ngan,MBBS,MD,FRCOG,UniversityofHongKong

13. Cryotherapy

JohnSellors,MD,McMasterUniversity,Canada

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14. LEEP/CervicalCone

KatinaRobison,MD,WomenandInfantsHospital,BrownUniversity

15. Overview:CervicalCancerTreatment

16. FIGOCancerCommitteeGuidelinesforEarlyInvasiveCervicalCancer

Management

HextanY.S.Ngan,MBBS,MD,FRCOG,UniversityofHongKong

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Overview:FIGOComprehensiveGuidance

TheInternationalFederationofGynecologyandObstetrics(FIGO)offersthisguidanceasafocusedupdateoncervicalcancerprevention,screeningandtreatmentstrategies.ItisintendedtobecomplimentarytotheWorldHealthOrganization2006ComprehensiveCervicalCancerControl:AGuidetoEssentialPractice1andbridgethegapwithemergingdatanowavailableuntilthenextedition,expectedoutin2011.ItalsotakesdirectionfromtheAmericanCollegeofObstetricsandGynecology(ACOG)andSocietyofObstetriciansandGynecologistsofCanada(SOGC)intheseareas.

Theinformationprovidedisrelevanttoallsettings,withanemphasisonlowresourcesettingswherethediseasecontinuestobethelargestcauseofcancerdeathamongwomen.Itisintendedtoprovideguidancetocliniciansandpolicymakersandinformcurrentandfutureplanningtopreventandcontrolcervicalcancer.

Theauthorsofthisguidanceforcervicalcancercontrolseektobringtogetherthemostuptodateknowledgeaboutoptionsthatwillprovideapproachesfordiversesettings,thatwillalsoencourageculturalsensitivity,resultinginnotonlycontrolofcervicalcancerbutimprovementinassuringtherightsandhealthofwomenglobally.

Oursincerethankstothemanycontributors,writers,editors,reviewersandmostofalltheresearchers,cliniciansandwomenshealthadvocateswhoaremakingthecontrolofthisdiseasepossible.

1 World Health Organization. Comprehensive cervical cancer control: A guide to essential practice. 2006. Available at: http://www.rho.org/files/WHO_CC_control_2006.pdf

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Authors

NeerjaBhatla,MBBS,MD,FICOG

JoannaCain,MD

NahidaChakhtoura,MD

CarlaChibwesha,MD,MSc.

SuzanneGarland,MD

SarahGoltzShelbaya,MPH,MIA

MarthaJacob,MBBS,FRCOG,MPH

JoseJeronimo,MD

EnriquitoLu,MD

HextanY.S.Ngan,MBBS,MD,FRCOG

KatinaRobison,MD

DebbieSaslow,PhD

JohnSellors,MD

ScottWittet,MA

Editors

JoannaCain,MD

SarahGoltzShelbaya,MPH,MIA

Reviewers

PaulBlumenthal,MD

LynetteDenny,MD

HextanY.S.Ngan,MBBS,MD,FRCOG

EnriquitoLu,MD

SuzanneGarland,MD

CarlaChibwesha,MD,MSc.

AishaJumaan,PhD,MPH

DebbieSaslow,PhD

FIGOExecutiveBoardMembers

FIGOCervicalCancerWorkingGroup

FIGOCervicalCancerWorkingGroup

JoannaCain,MD

LynetteDenny,MD

SuzanneGarland,MD

SarahGoltzShelbaya,MPH,MIA

MarthaJacob,MBBS,FRCOG,MPH

HenryKitchener,MD

HextanY.S.Ngan,MBBS,MD,FRCOG

ConnieTrimble,MD

ThomasWright,MD

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Sponsorship

ThisguidancewasfundedbyFIGO.FIGOreceivesunrestrictededucationalgrantsfromPATH,QIAGEN,GlaxoSmithKlineBiologicalsandMerckandCo.Inc.tosupportthisandothercervicalcancereducationactivities.

ConflictofInterestStatementbyAuthors

NeerjaBhatla,MBBS,MD,FICOGNoconflictofinterest

JoannaCain,MDNoconflictofinterest

NahidaChakhtoura,MDNoconflictofinterest

CarlaChibwesha,MD,MSc.Noconflictofinterest

MarthaJacob,MBBS,FRCOG,MPHNoconflictofinterest

JoseJeronimo,MDNoconflictofinterest

EnriquitoLu,MDNoconflictofinterest

KatinaRobison,MDNoconflictofinterest

DebbieSaslow,PhDNoconflictofinterest

JohnSellors,MDNoconflictofinterest

ScottWittet,MANoconflictofinterest

SuzanneGarland,MDReceivedadvisoryboardfeesandgrantsupportfrom

CommonwealthSerumLaboratoriesandGlaxoSmithKline,lecturefeesfromMerckand

GlaxoSmithKline.Institutionalresearchsupporthasbeenprovidedbybothvaccine

manufacturers.

SarahGoltzShelbaya,MPH,MIAConsultantforGlaxoSmithKlineBiologicalsin2006

andQIAGENin20072008.Notpresentlyconsultingwithanycompanies.

HextanY.S.Ngan,MBBS,MD,FRCOGNodirectconflictwithsectionswritten.

AdvisortoMerckandGlaxoSmithKlineforvaccines.Spokeatconferenceorganisedby

GSK.

7

CervicalCancerControl:RightsandEthics

JoannaCain,MD,andCarlaChibwesha,MD

Inthisdecade,theexpandingknowledgeofhumanpapillomavirus(HPV)anditsrelationshiptocervicalcancerhasledtonewtoolsforprimarypreventionwithHPVvaccinesandnewscreeningstrategiesthatgivecliniciansoptionsforeveryresourcesetting.Theabilitytosubstantiallyreducethemorethanonehalfmillionwomenperyearthatarediagnosedwithcervicalcancer,andmoreimportantlytheabilitytoreducethequarterofamillionwomenperyearthatdieofthediseaseparticularlyinunderresourcedareasofdevelopinganddevelopedcountriesisnowinthehandsofwomenshealthprofessionalsandgovernments.ThereisnolongeranyjustificationforNOTaddressingthehumanrightsdeniedtowomenwithcervicalcancerdiagnosestherighttothehighestattainablestandardofhealthcareandtherighttoqualityoflife.Controllingcancernotonlypreventsdeathanddisabilitybutalsowillcreateimprovementinthehealthandwellbeingoffamiliesbypreservingtheeconomicandparentalsupportofwomen,children,families,andcommunities.

Stateofthescience:rightsandethics

FifteenyearsagokeystakeholdersinthehumanrightsanddevelopmentmovementsconvergedinCairoforthelandmarkInternationalConferenceonPopulationandDevelopment(ICPD).Sexualandreproductivehealthwasembracedasabasichumanright,aswellasbeingcriticaltoeconomicandsocialdevelopmentforallcountries.1,2Assuch,educators,politicians,andhumanrightsandlegaladvocacygroupsplayaroleaspivotalastheroleofhealthprofessionalsinthepreventionandtreatmentofcervicalcancer.Protectinghealthandensuringaccesstohealthcareistheresponsibilityofallsocieties.Ifwomenaredeniedaccesstohealtheducation,qualityevidencebasedhealthcare,andautonomousdecisionmakingaboutthewayinwhichtheyaccessthatcare,theirrightsareviolated.

Contemporarymedicalethicsprovidesadditionalguidanceforhealthpractitioners.Theprinciplesofbeneficence,nonmaleficence,autonomy,andjusticeformthecornerstoneofthisethicalframework.Beneficencerelatestoaprovidersobligationtoprotectpatientsinterestsaboveallelse.Theprincipalofnonmaleficenceremindsustoavoidpracticesthatmaybeharmful.Furthermore,providersareobligatedtorespectthoseforwhomtheycareasautonomousindividuals.This,inturn,impliesthatpatientsbefullyeducatedabouthealthanddisease,andwhenill,thattheirtreatmentoptionsrepresentcurrentevidencebasedstandards.Finally,theprincipalofjusticedictatesthatwomenaretreatedfairly;inparticularthattheybenefitequallyfromscientificadvancesregardlessoftheirsocioeconomicstandingortheirracial,ethnic,cultural,orreligiousbackground.3Table1highlightsexamplesoftheseprincipalsastheyrelatetocervicalcancerpreventionandtreatment.

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Barrierstoapplicationandgapsinknowledge

Althoughdiscoursesurroundingwomenshealthhasbeenreframedtoreflectacontemporaryhumanrightsparadigm,actionslagfarbehind.4Tragically,thecaseofcervicalcancerisnotunlikeotherpreventableillnessesforwhichthegreatestdiseaseburdenfallsonthepoorandthosewithlimitedaccesstohealthcare.

Thebarrierstopreventionandtreatmentincludeabroadlackofawarenessofcervicalcancerandtheconsequentburdensofbleeding,bowelandbladderdysfunction,fistulas,andpainandsufferingthatresultfromadvanceddisease.ThislackofawarenessisfurthercomplicatedbyculturalsensitivitiesthatpreventdiscussionofuniquelywomenscancersandthesexualtransmissionofHPV.Theabsenceofcancerregistriesanddatainmanydevelopingcountriesperpetuatesthisgapandinhibitsthepositiveinfluencethatdemonstratingimprovementsinpublichealthcanhavetoenhancethesupportofanddemandforhealthservices.5

Otherbarrierscomefromlimitedresources.Sometimesthebarrierisresistancetolowerlevelprovidersprovidingservicesandalackofacceptanceofpracticaltechnologiesforscreeningwheretechnologysuchascytologyisnotfeasible.Treatmentoptionsmustbetailoredtotheavailabilityofhealthcarefunding,trainedpersonnel,healthinfrastructureandportabilityoftechnology,aswellastotheaccessibilityofpopulationsinneed.Barrierstoprimarypreventionthroughvaccination,andsecondarypreventionthroughscreeningandtreatmentofprecancerouslesions,arenotdissimilar.Competinghealthcareneedsmayalsocontributetounderprioritizationofcervicalcancercontrol.Moreover,thefactthatwomenwithpreinvasivediseasearetypicallysymptomfreemayresultindelayedpresentationtocare,particularlyin

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