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 This is an original JGO publication from 2016. Please visit the JGO website  to access the full article. 


Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline

 

 Authors

Linus T. Chuang, Sarah Temin, Rolando Camacho, Alfonso Dueñas-Gonzalez, Sarah Feldman, Murat Gultekin, Vandana Gupta, Susan Horton, Graciela Jacob, Elizabeth A. Kidd, Kennedy Lishimpi, Carolyn Nakisige, Joo-Hyun Nam, Hextan Yuen Sheung Ngan, William Small, Gillian Thomas, Jonathan S. Berek

THE BOTTOM LINE

Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline

Guideline Question

In basic-, limited-, enhanced-, and maximal-resource settings, what are the appropriate care options for women diagnosed with invasive cervical cancer?

Target Population

Women at all levels of resource settings diagnosed with invasive cervical cancer.

Target Audience

This clinical practice guideline globally targets health care providers (including gynecologic oncologists, medical oncologists, radiation oncologists, obstetricians and gynecologists, surgeons, nurses, and palliative care clinicians), policymakers, patients, and caregivers.

Methods

A multinational, multidisciplinary Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature and/or an expert consensus process.

Author ’s note. It is the view of the American Society of Clinical Oncology (ASCO) that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guidelines are intended to complement but not replace local guidelines.

Key Points*

  • If follow-up is available, the Expert Panel recommends cone biopsy for women with stage IA2 disease in basic settings and cone biopsy plus pelvic lymphadenectomy in limited settings. In enhanced and maximal settings, radical trachelectomy is recommended for patients with stage IB1 cervical cancer with tumor size up to 2 cm who desire fertility-sparing surgery.
  • In basic settings where patients cannot be treated with radiation therapy, extrafascial hysterectomy either alone or after chemotherapy may be an option for women with stage IA1 to IVA cervical cancer.
  • In basic settings, for women with larger tumors or advanced-stage cervical cancer, neoadjuvant chemotherapy is recommended, whenever chemotherapy is available, for the purpose of shrinking the tumor before performing hysterectomy.
  • Concurrent radiotherapy and chemotherapy is standard in enhanced and maximal settings for women with stage IB to IVA disease.
  • The panel stresses the addition of low-dose chemotherapy during radiotherapy but not at the cost of delaying radiation therapy if chemotherapy is not available.
  • In limited-resource settings where there is no brachytherapy, the ASCO Expert Panel recommends extrafascial hysterectomy or its modification for women who have residual tumor 2 to 3 months after concurrent chemoradiotherapy and additional boost.
  • For patients with stage IV or recurrent cervical cancer, single-agent chemotherapy (carboplatin or cisplatin) is recommended in basic settings.
  • If the resources are available and the patient cannot receive treatment with curative intent, palliative radiotherapy should be used to relieve symptoms of pain and bleeding.
  • Where resources are constrained, single- or short-course radiotherapy schemes can be used with retreatments if feasible for persistent or recurrent symptoms.

Qualifying Statements

ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.

Palliative care and pain management are part of the treatment of cancers, including cervical cancer, to avoid unnecessary suffering during the final stages of disease. Pain control is a vital component of palliative care, a basic human right often neglected in cancer control programs.

Additional Resources

More information, including a Data Supplement with additional evidence tables, a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/rs-cervical-cancer-treatment-guideline . Patient information is available at www.cancer.net. *Not all recommendations for all settings are listed. Please see Tables 3 - 7 . 

SUMMARY OF RECOMMENDATIONS

Type of DiseaseSetting
BasicLimitedEnhancedMaximal
IA1, LVSI negative, FS

1A1 (negative margins): cone biopsy1 (with scalpel)

Repeat cone biopsy or extrafascial hysterectomy for positive margins

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

1A1 (negative margins): cone biopsy

Repeat cone biopsy or extrafascial hysterectomy for positive margins

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

1A1 (negative margins): cone biopsy

Repeat cone biopsy, or extrafascial hysterectomy for positive margins.

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

1A1 (negative margins): cone biopsy

Repeat cone biopsy or extrafascial hysterectomy for positive margins

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong
IA1, LVSI positive, FS

Cone biopsy in selected cases, if follow-up possible

  • Type of recommendation: consensus-based
  • Evidence: intermediate
  • Recommendation: weak

Cone biopsy

  • Type of recommendation: consensus-based
  • Evidence: intermediate
  • Recommendation: weak

Cone biopsy plus PLND (see Discussion regarding current evidence on FS sparing for women desiring fertility preservation)

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: strong

OR radical trachelectomy plus pelvic LND

  • Type of recommendation: evidence and consensus-based
  • Evidence: intermediate
  • Recommendation: moderate

Cone biopsy plus PLND

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: strong

OR radical trachelectomy plus PLND (may offer ± SLN)

  • Type of recommendation: evidence and consensus-based
  • Evidence: intermediate
  • Recommendation: moderate
IA1, non-FS (no LVSI)

Cone biopsy (if follow-up possible) OR extrafascial hysterectomy,2 then observe after initial cone biopsy, repeat cone, or extrafascial hysterectomy if margins are positive

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: strong

Cone biopsy (if follow-up possible); observe (after cone biopsy)3 OR extrafascial hysterectomy2 (extrafascial hysterectomy OR modified radical hysterectomy plus PLND OR if positive margins repeat conization4)

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: strong

Cone biopsy3 OR extrafascial hysterectomy2 (extrafascial hysterectomy OR modified radical hysterectomy plus pelvic LND OR if positive margins repeat conization4)

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Cone biopsy3 OR extrafascial hysterectomy2 (extrafascial hysterectomy OR modified radical hysterectomy plus pelvic LN sampling if positive margins [may offer ± SLN] OR repeat conization4 )

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong
IA1, non-FS (with LVSI)

As above

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak

Stage IA1 (with LVSI) and stage IA2: modified radical hysterectomy

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak

Stage IA1 (with LVSI) and stage IA2: modified radical hysterectomy (when positive margins on repeat cone) plus PLND ± PANB (pelvic irradiation plus brachytherapy [with LVSI] if patient is not eligible for surgery)

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

Stage IA1 (with LVSI) and stage IA2: modified radical hysterectomy plus pelvic LND ± para-aortic (may offer ± SLN OR pelvic irradiation plus brachytherapy [if patient is not eligible for surgery])

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate
IA2 FS

Cone biopsy (if follow-up possible)

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak

Cone biopsy (if follow-up possible)

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak

Cone biopsy plus PLND ± paraaortic LN sampling3

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Cone biopsy plus pelvic LND ± paraaortic LN sampling3

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Radical trachelectomy plus PLND

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

Radical trachelectomy plus PLND

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate
IA2, non-FS

Cone biopsy (if follow-up possible) or extrafascial hysterectomy (non-FS)

  • Type of recommendation: evidence and consensus-based
  • Evidence: low
  • Recommendation: weak

Cone biopsy plus PLND ± paraaortic LN sampling3

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Cone biopsy plus PLND ± paraaortic LN sampling3

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak
See above

Extrafascial hysterectomy

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Modified radical hysterectomy plus PLND ± para-aortic LN sampling4

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

Modified radical hysterectomy plus PLND ± para-aortic LN sampling4

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

Modified radical hysterectomy plus PLND ± para-aortic LN sampling4

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

OR pelvic RT and brachytherapy

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

OR pelvic RT and brachytherapy

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate
IB1, FSNo recommendationNo recommendation

Radical trachelectomy plus PLND (if adding trachelectomy > 2 cm) Adjuvant therapy may be needed for patients with tumors > 2 cm with risk factors

  • Type of recommendation: evidence and consensus-based
  • Evidence: intermediate
  • Recommendation: moderate

Radical trachelectomy plus pelvic LN sampling; may offer SLN

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate
IB1, Non-FS

Extrafascial hysterectomy

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

Radical hysterectomy plus PLND or radical hysterectomy (see Note) with adjuvant RT or RT with concurrent low-dose chemotherapy (concurrent chemoRT), if needed

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: moderate to strong

Radical hysterectomy plus pelvic LND

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Radical hysterectomy plus PLND; may offer SLN

  • Type of recommendation: evidence-based
  • Evidence: high (SLN option, low)
  • Recommendation: strong (weak)

NACT if available, then extrafascial hysterectomy

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

ChemoRT or RT followed by extrafascial or radical hysterectomy (see Note) ± PLND ± PANB5

If no RT is available but chemotherapy is available, NACT may be used to shrink the tumor to make it removable by surgery (extrafascial or modified radical hysterectomy [see Note] ± PLND ± PANB5)

If the patient’s tumor does not shrink and is not resectable with negative margins, palliative measures, including best supportive care, ± chemotherapy should be offered

  • Type of recommendation: evidence and consensus-based
  • Evidence: low
  • Recommendation: weak

Pelvic RT plus brachytherapy plus concurrent low-dose platinum-based chemotherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Pelvic RT plus brachytherapy plus concurrent low-dose platinum-based chemotherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong
Note 

Wherever radical hysterectomy with concurrent chemoRT listed as a surgical option above, extrafascial hysterectomy is recommended if there is residual disease after RT or chemoRT with a boost of 68 Gy or initial tumor > 6 cm.

Radical hysterectomy may be used following RT or chemoRT to a dose of 50 Gy

  
IB2 and IIA2


If chemotherapy is available, use NACT followed by extrafascial hysterectomy; if chemotherapy is not available, extrafascial hysterectomy (modification as deemed necessary) may be performed if the surgical capacity is present

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak



If chemotherapy is available, NACT followed by radical hysterectomy (see Note) plus PLND ± para-aortic LN sampling may be an option4,6

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

Pelvic RT plus concurrent lowdose platinum-based chemotherapy plus brachytherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Pelvic RT plus concurrent low-dose platinum-based chemotherapy plus brachytherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

If EBRT is available, but not brachytherapy, then chemoRT followed by extrafascial hysterectomy or RT (if chemotherapy not available) followed by extrafascial hysterectomy (see Note)

  • Type of recommendation: consensus-based
  • Evidence: low
  • Recommendation: weak

OR if no EBRT is available, then brachytherapy and concurrent low-dose platinum-based chemotherapy followed by radical hysterectomy (see Note)6

When brachytherapy is not available, extrafascial or radical hysterectomy is recommended only when there is persistent central pelvic disease and selective lymphadenectomy or LN biopsy for suspicious lesions

  • Type of recommendation: evidence and consensus-based
  • Evidence: low/intermediate
  • Recommendation: weak/moderate

Pelvic RT plus concurrent low-dose platinum-based chemotherapy plus brachytherapy plus adjuvant hysterectomy; adjuvant hysterectomy is not recommended except if evidence of presence of residual disease

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: weak

Pelvic RT plus concurrent low-dose platinum-based chemotherapy plus brachytherapy plus adjuvant hysterectomy; adjuvant hysterectomy is not recommended except if evidence of presence of residual disease

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: weak

Radical hysterectomy plus PLND ± para-aortic LN sampling

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Radical hysterectomy plus pelvic LND ± para-aortic LND sampling3 and adjuvant RT or chemoRT if needed

  • Type of recommendation: evidence-based
  • Evidence: low
  • Recommendation: weak

Radical hysterectomy plus pelvic LND ± para-aortic LN sampling and adjuvant RT or chemoRT if needed (plus RT ± concurrent low-dose platinum-based chemotherapy after hysterectomy if risk factors)3

  • Type of recommendation: evidence and consensus-based
  • Evidence: low
  • Recommendation: weak
Note

With risk factors on pathology specimen: adjuvant chemotherapy after hysterectomy

  • Type of recommendation: evidence and consensus-based
  • Evidence: insufficient
  • Recommendation: weak

With risk factors on pathology specimen: adjuvant RT ± chemotherapy after hysterectomy

Adjuvant RT (intermediate risk) or with concurrent low-dose platinum-based chemotherapy (high risk) in a referral center

Wherever radical hysterectomy with concurrent chemoRT listed as a surgical option above, extrafascial hysterectomy is recommended if there is residual disease after RT or chemoRT with a boost of 68 Gy or initial tumor > 6 cm.

Radical hysterectomy may be used following RT or chemoRT to a dose of 50 Gy

  • Type of recommendation: evidence and consensus-based
  • Evidence: low
  • Recommendation: weak

With risk factors on pathology specimen: adjuvant RT ± concurrent low-dose platinum-based chemotherapy after hysterectomy

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

With risk factors on pathology specimen: adjuvant RT ± concurrent low-dose platinum-based chemotherapy after hysterectomy

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate
IIA1See IB1See IB1See IB1See IB1
IIA2See IB2See IB2See IB2See IB2
IIB and IIIA

NACT followed by extrafascial hysterectomy (modification as deemed necessary)

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

ChemoRT or RT6 followed by extrafascial or modified hysterectomy ± PLND7 ± PANB NACT followed by extrafascial or modified hysterectomy ± PLND7 ± PANB6

  • Type of recommendation: consensus-based
  • Evidence: low/intermediate
  • Recommendation: weak/moderate

Pelvic RT plus concurrent lowdose platinum-based chemotherapy plus brachytherapy

Adjuvant hysterectomy is an option only if residual disease after chemoRT

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Pelvic RT plus concurrent low-dose platinum-based chemotherapy plus brachytherapy

Adjuvant hysterectomy is an option only if residual disease after chemoRT

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Extrafascial hysterectomy when chemotherapy is not consistently available

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

Extrafascial or modified hysterectomy plus pelvic LND ± para-aortic LN sampling4 plus adjuvant therapy

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

Palliative care

  • Type of recommendation: consensus-based
  • Evidence: intermediate
  • Recommendation: strong
IIIB to IVA

Palliative care

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: strong

ChemoRT or RT6 followed by extrafascial or radical hysterectomy (see Note) ± PLND7 ± PANB

NACT (followed by radical hysterectomy plus PLND7 ± PANB may be an option] and/or palliative care

  • Type of recommendation: consensus-based
  • Evidence: low/intermediate
  • Recommendation: weak/moderate

Pelvic RT plus brachytherapy plus concurrent low-dose platinum-based chemotherapy (in some cases extended-field RT)

AND/OR palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Pelvic RT plus brachytherapy plus concurrent low-dose platinumbased chemotherapy (in some cases extended-field RT) AND/OR palliative care (Options before palliative care alone include: RT boost, salvage surgery, or chemotherapy)

  • Type of recommendation: evidence and consensus-based
  • Evidence: high
  • Recommendation: strong
 

NACT followed by extrafascial hysterectomy

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

RT ± concurrent low-dose platinum-based chemotherapy (may offer systemic adjuvant chemotherapy)

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: moderate

RT + brachytherapy ± concurrent low-dose platinum-based chemotherapy (may offer systemic adjuvant chemotherapy)

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: weak

RT + brachytherapy ± concurrent low-dose platinum-based chemotherapy (may offer systemic adjuvant chemotherapy)

  • Type of recommendation: evidence-based
  • Evidence: intermediate
  • Recommendation: weak
Note 

Wherever radical hysterectomy with concurrent chemoRT listed as a surgical option above, extrafascial hysterectomy is preferred if there is residual disease or initial tumor > 6 cm

  • Type of recommendation: consensus-based
  • Evidence: intermediate
  • Recommendation: weak
  
IVB

Palliative care and chemotherapy (if available)

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Palliative care and/or chemotherapy ± individualized RT (palliative care may include palliative RT)

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Chemotherapy ± individualized RT AND/OR palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Chemotherapy ± bevacizumab ± individualized RT AND/OR palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong
Recurrent

Palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Depending on previous RT and either “no prior RT or failure outside of previously treated field”* (CERV-11) then may offer tumor-directed RT plus platinum-based chemotherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Depending on previous RT and central v noncentral disease:

Central disease: chemoRT or RT ± brachytherapy if no prior RT

If central and prior RT: exenteration

Noncentral: chemotherapy, tumor-directed RT, and palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Depending on previous RT and central v noncentral disease:

Central disease: chemoRT or RT ± brachytherapy if no prior RT

If central and prior RT: exenteration

Noncentral: chemotherapy, tumordirected RT, and palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

AND/OR central disease: chemotherapy

  • Type of recommendation: consensus-based
  • Evidence: insufficient
  • Recommendation: weak

NOTE. this is best managed with exenteration (type of surgery that is not feasible to perform in low-resource setting)


 

Prior RT plus central disease: pelvic exenteration OR radical hysterectomy OR brachytherapy (latter two “in carefully selected patients with small (< 2 cm) lesions”** (CERV-11))

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Prior RT plus central disease: pelvic exenteration ± intraoperative RT OR radical hysterectomy OR brachytherapy (latter two “in carefully selected patients with small (< 2 cm) lesions” **(CERV-11)

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Prior RT plus noncentral disease: chemotherapy or best palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Prior RT plus noncentral disease: tumor-directed RT ± chemotherapy or best palliative care

NOTE. Before palliative care alone, try options such as RT boost, salvage surgery, or chemotherapy

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

Prior RT plus noncentral disease: tumor-directed RT ± chemotherapy OR resection with intraoperative RT for close or positive margins OR clinical trial OR chemotherapy plus bevacizumab AND/OR palliative care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong

If recurrence after any of the above, then clinical trial OR chemotherapy OR best supportive care

  • Type of recommendation: evidence-based
  • Evidence: high
  • Recommendation: strong
NOTE. Bold indicates addition of a recommended action over a previous resource level (eg, in limited setting, a bold action is one that was not recommended in basic). Additional recommendations regarding settings with limited radiotherapy resources are provided in the main article.
Abbreviations: chemoRT, chemotherapy plus radiotherapy; EBRT, external-beam radiation therapy; FS, fertility sparing; LN, lymph node; LND, lymph node dissection; LVSI, lymphovascular space invasion; NACT, neoadjuvant chemotherapy; PANB, para-aortic node biopsy; PLND, pelvic lymph node dissection; RT, radiotherapy.
1This option in basic level only if follow-up is available; 2For negative margins or operable tumor or positive margins for dysplasia or carcinoma; 3For negative margins or inoperable tumor; 4Margins for dysplasia or carcinoma; 5Selective lymphadenectomy or LN biopsy for suspicious lesions 6Recommended in setting where chemotherapy is not consistently available; 7When brachytherapy is not available, extrafascial or radical hysterectomy is recommended only when there is persistent central pelvic disease and selective lymphadenectomy or LN biopsy for suspicious lesions
References
*Koh WJ, Greer BE, Abu-Rustum NR, et al: NCCN Guidelines Version 2.2015: Cervical Cancer Preliminary Resource Stratification—Limited Level. Fort Washington, PA, National Comprehensive Cancer Network, 2015
**Koh WJ, Greer, B.E., Abu-Rustum, NR, et. al.: NCCN guidelines version 2.2015: Cervical cancer preliminary resource stratification: Maximal level, National Comprehensive Cancer Network, Fort Washington, PA, 2015

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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