Patti Power

Colposcopic management of abnormal cervical cytology and histology.

OBJECTIVE To provide a guideline for managing abnormal cytology results after screening for cervical cancer, to clarify the appropriate algorithms for follow-up after treatment, and to promote the best possible care for women while ensuring efficient use of available resources. OUTCOMES Women with abnormal cytology are at risk of developing cervical cancer; appropriate triage and treatment will reduce this risk. This guideline will facilitate implementation of common standards across Canada, moving away from the current trend of individual guidelines in each province and territory. EVIDENCE Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in October 2008 using appropriate controlled vocabulary (e.g., colposcopy, cervical dysplasia) and key words (e.g., colposcopy management, CIN, AGC, cervical dysplasia, LEEP, LLETZ, HPV testing, cervical dysplasia triage). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Expert opinion from published peer-reviewed literature and evidence from clinical trials is summarized. Consensus opinion is outlined when evidence is insufficient. VALUES The quality of the evidence is rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table 1). VALIDATION This guideline has been reviewed for accuracy from content experts in cytology, pathology, and cervical screening programs. Guideline content was also compared with similar documents from other organizations including the American Society for Colposcopy and Cervical Pathology, the British Society for Colposcopy and Cervical Pathology, and the European Cancer Network.

Efficacy of pegylated liposomal doxorubicin (PLD) plus carboplatin in ovarian cancer patients who recur within six to twelve months: A phase II study

OBJECTIVES Pegylated liposomal doxorubicin is one of the preferred alternatives for ovarian cancer patients with early relapse (<6 months) and taxane/carboplatin for late relapse (>12 months), but the optimal therapy for the partially platinum-sensitive (6-12 months) population has not been defined. This single-arm phase II trial was designed to assess the efficacy of pegylated liposomal doxorubicin (PLD)/carboplatin in ovarian cancer patients who relapse between 6 and 12 months after initial treatment with platinum-based chemotherapy. METHODS Ovarian cancer patients who previously completed a course of therapy with paclitaxel/carboplatin were administered PLD 30 mg/m(2) followed by carboplatin AUC 5 mg/mL/minute every 4 weeks. RESULTS Fifty-eight patients were enrolled in the study and 54 were eligible for the efficacy analysis, of whom most (75%) received at least 6 cycles of PLD/carboplatin. The objective response rate was 46% (4% CR and 42% PR), with an additional 33% experiencing disease stabilization >6 months. For those patients with measurable CA-125, the response rate was 66% (28% CR and 38% PR), with an additional 18% experiencing disease stabilization >6 months. Median time-to-progression was 10 months (1.5-25). Median overall survival was 19.1 months (2.2-38.9). The most frequent adverse effects were neutropenia, thrombocytopenia, and constipation. CONCLUSIONS The combination of PLD/carboplatin is efficacious and well tolerated in women with partially platinum-sensitive ovarian cancer and represents a valuable alternative for patients who relapse within 6-12 months of completing paclitaxel/carboplatin chemotherapy.

Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses

OBJECTIVES To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management. OPTIONS Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer. OUTCOMES To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. RECOMMENDATIONS 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Epidemiology and investigations for suspected endometrial cancer.

OBJECTIVE To review the evidence relating to the epidemiology of endometrial cancer and its diagnostic workups. OPTIONS Women with possible endometrial cancer can undergo an endometrial evaluation by office biopsy, hysteroscopy, or dilatation and curettage. To assist in treatment planning, pelvic ultrasound, CT scan, or MRI may be considered. OUTCOMES The identification of optimal diagnostic tests to evaluate patients with possible endometrial cancer. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. 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, national and international medical specialty societies, and recent conference abstracts. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS This document is intended to guide the development of a standardized cost-effective investigation of patients with suspected endometrial cancer. VALIDATION The guideline was reviewed for accuracy by experts in pathology, radiation oncology, and medical oncology. Guideline content was also compared with relevant documents from the American Congress of Obstetricians and Gynecologists.

The role of surgery in endometrial cancer.

OBJECTIVE To review current practice and make recommendations for the management and treatment of endometrial cancer. OUTCOMES This guideline makes recommendations with respect to extended surgical staging, which provides important prognostic information and aids in determining the need for adjuvant treatments. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. 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, national and international medical specialty societies, and recent conference abstracts BENEFITS, HARMS, AND COSTS This guideline reviews the benefit of extended surgical staging compared with the potential harm of a limited surgery in grade 2 and 3 disease. VALUES The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

The Role of Adjuvant Therapy in Endometrial Cancer

OBJECTIVE To review the evidence relating to the use of adjuvant therapy after surgical treatment for endometrial cancer. OPTIONS Women with endometrial cancer can be given the option of receiving adjuvant radiotherapy and/or chemotherapy according to pathologic findings at time of surgery. OUTCOMES The outcomes measured are postoperative progression-free and overall survival in endometrial cancer patients. EVIDENCE Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. 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, national and international medical specialty societies, and recent conference abstracts. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS This guideline is intended to help standardize postoperative treatment of endometrial cancer and minimize undertreatment and overtreatment. VALIDATION The guideline was reviewed for accuracy by content experts in pathology, radiation oncology, and medical oncology. Guideline content was also compared with relevant documents from the American Congress of Obstetricians and Gynecologists.

Cervical Cancer Prevention in Saudi Arabia: It is Time to Call for Action

Background: Cervical cancer is the third most common cancer in the world, with 2.3 million prevalent cases and 510,000 incident cases documented each year. Annually, 288,000 women die of cervical cancer, and 80% of these deaths occur in developing countries. The population of Saudi Arabia is young and growing at an increasing rate. The es- timated number of new cases of cervical cancer in 2025 is 309. Lake of comprehensive information on cytological cervi- cal abnormalities and cervical Humen Papiloma virus (HPV) infection in Saudi Arabia. Objectives: One aim of this review is to understand the current status of cervical cancer in Saudi Arabia. Based on this in- formation, another aim is to formulate recommendations for cervical cancer prevention that can be applied in our local setting. Methods: An English literature search was conducted using the Pub Med data base between January 2000 till June 2011 , which aimed to review all the publication which was done regarding cancer cervix and cervical dysplasia in the kingdom of Saudi Arabia. Suggestions and Recommendations: Screening should be started at a later age and should include human papillomavirus (HPV) testing. The age of onset of screening should be determined based on data collected regarding the age of sexual de- but for women.

The Investigations Required Before Referring a Patient to a Gynaecologic Oncologist.

OBJECTIVE To provide guidance for referring physicians regarding what gynaecologic oncologists want and do not require in the referral package for a new patient. METHODS An email survey was circulated to all members of the Society of Gynecologic Oncology of Canada (GOC) asking what they felt was required in a new patient referral package so that they could provide a timely consultation and management plan. RESULTS The survey had a 79% response rate among 121 GOC members. Before referral of patients with endometrial cancer, 50% of respondents did not want additional investigations; only 4% wanted an MRI performed prior to them seeing the patient. For patients with high-grade cancers of the uterus (including serous), 40% wanted to see the patient without further investigations, while 42% wanted a CT scan report to be included in the referral package. For patients with cervical cancer, 56% of respondents wanted to see the patient without any further investigations, while 24% wished to have an MRI report included in the referral package. For patients with vulvar cancer, 50% of respondents did not want any further investigations; for patients with a pelvic mass, the majority of respondents wanted a serum CA 125 level in the referral package, while 0% to 3% only wanted an MRI. The preferred modality for imaging of the chest was a chest X-ray only. CONCLUSION Our survey indicated that gynaecologic oncologists want little information in the referral package beyond the biopsy result. MRI is not required in the workup of most patients with a pelvic mass or uterine cancer.

Prise en charge colposcopique des résultats cytologiques et histologiques anormaux en ce qui concerne le col utérin

Resume Objectif Fournir une directive clinique traitant de la prise en charge des resultats cytologiques anormaux issus du depistage du cancer du col uterin, clarifier les algorithmes appropries aux fins du suivi a la suite du traitement et promouvoir l’offre des meilleurs soins possibles aux femmes tout en assurant une utilisation efficace des ressources disponibles. Issues Les femmes qui obtiennent des resultats cytologiques anormaux sont exposees a un risque de voir apparaitre un cancer du col uterin; la mise en œuvre d’un triage et d’un traitement appropries attenuera ce risque. La presente directive clinique facilitera la mise en œuvre de normes communes a la grandeur du Canada, et ce, en vue de contrer la tendance actuelle qui veut que chaque province et territoire formule ses propres lignes directrices. Resultats La litterature publiee a ete recuperee par l’intermediaire de recherches menees dans PubMed ou Medline, CINAHL et The Cochrane Library en octobre 2008 au moyen d’un vocabulaire controle (p. ex. « colposcopy », « cervical dysplasia ») et de mots cles (p. ex. « colposcopy management », « CIN », « AGC », « cervical dysplasia », « LEEP », « LLETZ », « HPV testing », « cervical dysplasia triage ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n’a ete appliquee en matiere de date ou de langue. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu’en juillet 2012. La litterature grise (non publiee) a ete identifiee par l’intermediaire de recherches menees dans les sites Web d’organismes s’interessant a l’evaluation des technologies dans le domaine de la sante et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et aupres de societes de specialite medicale nationales et internationales. Les opinions de specialistes issues de la litterature publiee soumise a l’examen collegial et les donnees issues d’essais cliniques sont resumees. Une opinion de consensus est presentee lorsque les donnees sont insuffisantes. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits par le Groupe d’etude canadien sur les soins de sante preventifs (Tableau). Validation La precision de la presente directive clinique a ete analysee par des specialistes œuvrant dans les domaines de la cytologie, de la pathologie et du depistage cervical. Le contenu de la presente directive clinique a egalement ete compare a celui de documents similaires issus d’autres organisations, dont l’ American Society for Colposcopy and Cervical Pathology , la British Society for Colposcopy and Cervical Pathology et l’ European Cancer Network .