ACOG Cervical Cancer Guidelines

The Committee on Practice Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has issued guidelines on diagnosis and treatment of cervical carcinoma. ACOG practice bulletin no. 35 appears in the May 2002 issue of Obstetrics and Gynecology.

Invasive cervical carcinoma is the third most common reproductive-tract cancer in the United States, comprising 16 percent of an estimated 80,300 cases per year. Human papillomavirus is considered the most important risk factor for development of cervical cancer.

The signs and symptoms of early cervical carcinoma include watery vaginal discharge, intermittent spotting, and postcoital bleeding. The symptoms often go unrecognized by the patient. Accurate diagnosis often can be made with cytologic screening, colposcopically directed biopsy, or biopsy of a gross or palpable lesion. When microinvasion or early-stage cervical carcinoma is suspected, cone biopsy of the cervix is indicated. Cold knife cone biopsy provides the most accurate evaluation of the margins.

Early-stage carcinomas usually can be managed with surgery or radiation therapy. The more advanced carcinomas require primary treatment with radiation therapy. New evidence has shown that survival rates improve when radiotherapy is combined with cisplatin (Platinol)-based chemotherapy.

Staging of invasive cervical cancer with the system developed by the International Federation of Gynecology and Obstetrics (FIGO) requires clinical evaluation. Examinations should be performed by experienced clinicians, and general anesthesia can be used.

Examinations should include inspection, palpation, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous pyelography, and radiographic examination of the lungs and skeleton. Conization of the cervix is considered a clinical examination, and bladder or rectal involvement should be confirmed histologically. If there is a question about the most appropriate stage, the earlier stage should be assigned. Once established, the clinical stage must not be revised because of subsequent findings, even if the cancer recurs.

Based on the FIGO staging system, ACOG has developed the following recommendations.

• For stage Ib and selected stage IIa carcinomas, physicians should consider radical hysterectomy and lymph node dissection or radiation therapy with cisplatin-based chemotherapy. Adjuvant radiation therapy may be required in patients treated surgically, based on pathologic risk factors, especially in those with stage Ib2 carcinoma.

• For stage IIb and greater, consider external-beam and brachytherapy radiation with concurrent cisplatin-based therapy.

• For stage Ia1 microinvasive squamous carcinoma, consider treatment with conization of the cervix or simple extrafascial hysterectomy.

• Stage Ia2 invasive squamous carcinoma of the cervix should be treated with radical hysterectomy with lymph node dissection or radiation therapy, depending on clinical circumstances.

• Stage Ib1 should be distinguished from stage Ib2 because the distinction predicts nodal involvement and overall survival. Therefore, it could affect treatment and outcome.

• Patients with squamous cell cancers and patients with adenocarcinomas should be managed similarly, except for those with microinvasive disease. Criteria for microinvasive adenocarcinomas have not been established.

• Patients should be monitored regularly after treatment for cervical carcinoma (i.e., thrice-yearly follow-up examinations for the first two years and twice-yearly visits subsequently to year 5, with Papanicolaou smears performed annually and chest radiographs done annually for up to five years).

• Treatment for pregnant patients with invasive carcinoma should be individualized on the basis of evaluation of maternal and child risks.

CDC Update on AIDS

Since the implementation of highly active antiretroviral therapy (HAART) in the United States, the number of persons diagnosed with acquired immunodeficiency syndrome (AIDS) and the number of deaths among persons with AIDS have declined substantially. As a result, the number of persons living with AIDS has increased. The Centers for Disease Control and Prevention (CDC) has issued a report describing changes in AIDS incidence and prevalence, and deaths among persons with AIDS. The report, “Update: AIDS—United States, 2000” is available atwww.cdc.gov/mmwr/preview/mmwrhtml/mm5127a2.htm.

Data indicate that the decline in new AIDS diagnoses is slowing and that the number of deaths among people with AIDS continues to decline. These findings indicate that AIDS is still a burden on the U.S. health care system and that access to medical and preventive services must be improved.

From 1996 to 2000, the incidence of AIDS declined in the West; declined and then leveled in the South, Midwest, and U.S. territories; and declined and then increased in the Northeast. During the same period, AIDS incidence declined sharply and then slowed among whites and declined more slowly and then leveled among blacks, Hispanics, Asians, and Pacific Islanders. From 1998 to 2000, incidence increased among American Indians and Alaska natives.

AIDS incidence declined sharply and then slowed among homosexual men and intravenous-drug users. Among people exposed through heterosexual contact, incidence declined slowly from 1996 to 1998, then increased.

In 1996 and 1997, the estimated number of deaths among people with AIDS declined 42 percent; from 1998 to 2000, declines were smaller (5 percent during 1998 and 1999 and 10 percent during 1999 and 2000). From 1996 to 2000, the number of deaths declined in the Northeast, West, and Midwest; from 1996 to 1999, deaths declined in the South and in U.S. territories, then leveled during 1999 and 2000. The number of deaths declined in all racial and ethnic groups and among homosexual men and intravenous-drug users.

USPSTF Osteoporosis Screening Recommendations

The U.S. Preventive Services Task Force (USPSTF) has issued new recommendations on osteoporosis screening in women. The recommendations appear in the September 17, 2002 issue of Annals of Internal Medicine and are available atwww.ahrq.gov.

Women aged 65 years and older should be routinely screened for osteoporosis to reduce the risk of fracture and spinal abnormalities often associated with the disease. The USP-STF also recommends routine screening beginning at age 60 for those women identified as high risk because of their weight or estrogen use.

For women who live to be 85, approximately 50 percent will have an osteoporosis-related fracture during their lives. Twenty-five percent of these women will develop an abnormality of the spine, and 15 percent will experience a hip fracture.

Age is the greatest risk factor for osteoporosis. The USPSTF found that 12 to 28 percent of women 65 years and older have osteoporosis and that the proportion increases with age. Screening and treating women in this age group would prevent the greatest number of fractures. Although risk of osteoporosis and fracture is lower in women aged 60 to 64 years, the USP-STF concluded that it was sufficiently high in a subgroup of these women (those under 154 lb and not using estrogen) to justify selective screening in this age group. Screening women without risk factors and those younger than 60 years may detect additional cases of osteoporosis; however, the number of fractures that might be prevented was too small to make a general recommendation for screening those women. The USPSTF advises physicians to use their judgment in deciding which women to screen.

The USPSTF found that dual-energy x-ray absorptiometry (DEXA), a noninvasive test, is the most accurate method for measuring bone density. DEXA of the hip (which can cost between $125 and $200, depending on whether it is performed in a physician's office or hospital) is the best predictor of hip fracture, but bone density of the hand, wrist, forearm, and heel (which can cost between $38 and $75) also can be measured to detect risk. Medicare Part B covers DEXA screening for women 65 years and older once every two years if their physicians determine that they are at risk for bone loss.