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Despite a well organised cervical screening programme for preinvasive disease in the United Kingdom, there are still about 2800 new cases of and 1000 deaths from cervical cancer each year.1 Many patients still present to their general practitioner with symptoms associated with cervical cancer. The Joint Committee for Vaccination and Immunisation has announced the introduction of human papillomavirus vaccination for 12-13 year old girls next year, but it is predicted that it may take 40 to 60 years for an effect on the rates of cervical cancer to be seen.
This article summarises the most recent guidance from the Scottish Intercollegiate Guidelines Network (SIGN) on the management of cervical cancer.2 The guideline aims to ensure that equitable standards of care are available to all women who develop cervical cancer and that the social and economic burden it places on women and their carers is minimised.
SIGN recommendations are based on systematic reviews of best available evidence, and the strength of the evidence is indicated as A, B, C, or D (fig 11).). Recommended best practice (“good practice points”) based on the clinical experience of the guideline development group is also indicated (as GPP).
Intermenstrual bleeding, post-coital bleeding, and post-menopausal bleeding are common and non-specific symptoms and may be associated with cervical cancer or with other conditions such as genital Chlamydia trachomatis infection. The probability that a woman aged 45-54 developing post-coital bleeding in the community has cervical cancer is 1 in 2400 (which decreases with younger age to 1 in 44000 for women aged 20-24).
For pathologists, radiologists, and surgeons in particular, it is critical to establish what constitutes an adequate volume of cases for maintaining specialist skills. In the UK it is now accepted that only gynaecologists who have been appropriately trained should undertake radical hysterectomy and pelvic lymph node dissection.
The decline in the incidence of cervical cancer, as a result of well organised screening programmes, will lead to recognised gynaecological oncological surgeons in some regions of the UK having a very small number of cases.10 The acceptability of this situation is questionable, and the need for supraregional surgical centres must be recognised. Such centres will ensure that women get the best outcome from their surgery in terms of cure, lowest risk of side effects, and the possibility of appropriate, newer, less radical procedures, particularly where conservation of fertility is important. Concentrating surgery for cervical cancer in supraregional centres also enables adequately powered clinical trials to be designed and, importantly, completed in reasonable time.
In the UK, PET-CT scanning and contrast enhanced magnetic resonance imaging of the lymph nodes is becoming available for women with cervical cancer. The challenge for those charged with organising cancer services must be to ensure that appropriate imaging and surgery are available to all, not only to those who are treated at the cancer centres with the largest workload.
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
See also Petignat P, Roy M. Diagnosis and management of cervical cancer. BMJ 2007;335:765-8.
Further information about the guidance, a list of members of the guideline development group, and references w1-w8 are in the version on bmj.com.
Contributorship: All authors contributed to reviewing the evidence and writing and correcting the article.
Funding: No funding was received for writing this summary .
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.