Treatment and Palliative Care of Invasive Cancers

Care for Women with Cervical Cancer

Timely diagnosis, treatment, pain management and palliative care are essential components to achieve elimination and important for dignity, comfort, and wellbeing of women living with cervical cancer.

Prompt initiation and completion of the full treatment plan with access to high-quality multidisciplinary teams gives women the best chance of cure or optimal management of their cancer.

Early and late stage disease treatment options may include surgery, radiotherapy and chemotherapy.

Many women, especially in low and low-middle income countries, are diagnosed with advanced stage cervical cancer, where the cancer has spread to other parts of the body where treatment may be more costly and outcomes less positive.

Health facilities in low- and middle-income countries are currently faced with limited equipment and trained professionals to treat cervical cancer and provide palliative care services.

Civil society groups, including cervical cancer patients and survivors play an important role in supporting patient navigation, identifying weaknesses in the health system, advocating for change, and providing information to the women living with cervical cancer.

Treatment Overview

Screening services aim to detect abnormal cells and treat (ablate) them, before they become cervical cancer. However, in some cases screening may reveal suspicion of cervical cancer, in which case, women should be promptly referred to a facility for diagnosis and treatment.

No woman should be lost to the health system between screening and diagnosis and treatment. Effective patient-centered referral mechanisms that minimize inconvenience to patients must be established for suspicious cases to be further managed and tracked – many e-health solutions are emerging that can play a significant role in improving referral rates. Civil society organisations can also play an important role in supporting women and helping them through this stressful time, including in some cases, providing financial support for transport and treatment.

Early stage (stage I or II) cervical cancer is highly treatable by surgery and/or radiotherapy that can result in long-term survival and/or cure. The five-year survival rate for early stage cancer is more than 80% in countries where timely diagnosis and high-quality treatment are available. Surgery and radiotherapy, with or without chemotherapy, are among the cost-effective interventions WHO recommends for early-stage cervical cancer. Even some locally advanced cervical cancers (stage III) are curable with high-quality radiotherapy and chemotherapy.

Specific attention needs to be applied to support women in rural communities or women in marginalized populations to access treatment and care, which is often highly centralized. Poor outcomes are often associated with lack of standardized treatment and palliative care, weak infrastructure, lack of trained professionals, lack of (or unreliable) availability of treatment and financial challenges. These elements also contribute to too many women still presenting with advanced (stage II and IV) cervical cancers, necessitating costlier treatment, often with poor outcomes.

Social and/or cultural barriers shape community misconceptions and often impact on women’s ability to seek care early and complete treatment and follow-up care, underscoring inequities in access and outcomes both within and between countries. More research is required to understand and overcome these barriers with communities, especially those with high risk of cervical cancer such as women living with and at risk of HIV.

Demonstrating good care and positive outcomes for women diagnosed with cervical cancer is a key step in reducing fear and stigma of this debilitating cancer and helping shape the readiness of women to engage in prevention and early detection. Part of demonstrating good care for women with diagnosed cervical cancer involves addressing the great suffering that the disease can cause. Pain management and palliative care are essential components to achieve elimination and important for dignity, comfort, and wellbeing of women living with cervical cancer, investment here is imperative and provides strengthened services for all cancers and other health issues in an integrated approach to care.

Palliative Care Overview

It is important to provide support and services to improve the comfort and wellbeing of women from the outset of the disease. Treatment plans should thus integrate palliative care throughout the course of the disease. Palliative care should not only include support and services for managing pain and other distressing symptoms, but also psychosocial and spiritual care for women and their families. Where possible, home-based models of palliative care should be integrated into primary health care. Treatment plans should not only be about end-of-life care and pain relief for patients but also about support and services to improve the comfort and wellbeing of women from the outset of the disease.

Currently, palliative programs in low- and middle-income countries are under-developed both in terms of comprehensiveness and national reach. Countries are encouraged to expand the availability of palliative services, which could readily be extended to other forms of advanced cancers and chronic illnesses.  Provisions for palliative care need to be included in cancer planning and budgets. Civil society organizations can also play a significant supporting role in this setting both in patient support but also in services provision.

Action for Elimination

In addition to preventing 70 million cases of cervical cancer by the end of the century, modelling in 78 low- and middle-income countries has shown that achieving the elimination goal has the potential to avert 62 million deaths due to cervical cancer.

On average the current mortality rate of cervical cancer is 3 times higher for low and medium HDI (human development index) countries as compared to high HDI countries. But real progress is possible. Several high burden countries are demonstrating that improvements in access and outcomes are possible through investments in strengthening health systems; ensuring adequate human capital; strengthening referral pathways; strengthening pathology services; building multidisciplinary teams to manage gynaecologic surgery and radiotherapy; and establishment of standardised protocols.

Action for Elimination

The adoption of the global strategy presents an ideal opportunity to review national cancer control plans and update cervical cancer strategies in line with the 90% target for follow-up of women with cervical disease. Implementation plans must be addressed by governments through evidenced-based polices, and strategies costed through national budgets, as part of a national cancer control plan. Equally, this is good timing to assess opportunities for integration of cancer prevention and control into universal health care plans and address financial protection for those that risk being pushed further into poverty by a cancer diagnosis. This will provide high returns for cervical cancer outcomes, as well as building capacity to address other cancers.

An integrated approach to treatment and palliative care services will increase the capacity to provide community-near services. This will particularly improve comfort and wellbeing for women diagnosed in late stages who need support and palliative care at home. Timely treatment, pain management and palliative care are essential components for ending cervical cancer and for ensuring the dignity, comfort, and wellbeing of women living with cervical cancer.

The WHO cervical cancer elimination strategy target is 90% of women identified with cervical disease are treated by 2030:

  • 90% of women with pre-cancer treated.
  • 90% of women with invasive cancer managed.

What should my country consider?

Among the key areas that need to be strengthened to meet the treatment-related elimination target are: referral systems, palliative care systems, and alignment of national cancer control plans (NCCPs). These should be aligned with a needs-based assessment of  skilled workforce training and disease projections. Including civil society organisations in these efforts, along with perspectives from women affected by the disease is critical.
REFERRAL SYSTEMS

Losing women that screening services have identified as being at risk of developing cervical cancer is a travesty for the women, families, communities and economies.

Improving the referral systems by addressing existing weaknesses and setting up quality control indicators is critical for ensuring diagnosis and treatment in all women in need. This could be done through establishing and reinforcing referral protocols and mobilizing referral physicians into being part of the elimination efforts.

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CANCER CONTROL PLANS

Alignment of national cervical cancer strategies with the 90:70:90 targets is critical for ensuring adequate human, diagnostic, and treatment resources. 

Renewed assessment of available national diagnostic, treatment and palliative care guidelines and alignment with current WHO guidance, along with forecasts of projected resource needs, will permit prioritization of investments and development of a phased scale up plan to achieve the 2030 targets. The WHO has resources available to help inform this type of national strategic health planning.

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PALLIATIVE CARE SYSTEMS

Integrated approaches to care are as important for treatment and palliative care as they are for prevention services.

Because so many women are diagnosed in late stages of cervical cancer, palliative care is an essential element of cervical cancer control. Setting indicators for minimal acceptable palliative care services is essential for improving the quality of life of patients, their families and their caregivers.

Learn More
REFERRAL SYSTEMS
CANCER CONTROL PLANS
PALLIATIVE CARE SYSTEMS

Losing women that screening services have identified as being at risk of developing cervical cancer is a travesty for the women, families, communities and economies.

Improving the referral systems by addressing existing weaknesses and setting up quality control indicators is critical for ensuring diagnosis and treatment in all women in need. This could be done through establishing and reinforcing referral protocols and mobilizing referral physicians into being part of the elimination efforts.

Learn More

Alignment of national cervical cancer strategies with the 90:70:90 targets is critical for ensuring adequate human, diagnostic, and treatment resources. 

Renewed assessment of available national diagnostic, treatment and palliative care guidelines and alignment with current WHO guidance, along with forecasts of projected resource needs, will permit prioritization of investments and development of a phased scale up plan to achieve the 2030 targets. The WHO has resources available to help inform this type of national strategic health planning.

Learn More

Integrated approaches to care are as important for treatment and palliative care as they are for prevention services.

Because so many women are diagnosed in late stages of cervical cancer, palliative care is an essential element of cervical cancer control. Setting indicators for minimal acceptable palliative care services is essential for improving the quality of life of patients, their families and their caregivers.

Learn More

Advocacy and Communication in Action

Paying it forward: Training Physicians

Clinical teams, including nurses as well as physicians often do not have access to specialty training and are therefore poorly equipped to treat the high volume of patients presenting with cancer. This leaves women in high burden countries without access to what is considered standard care. Given the rising rates of cancer in LMICs and the fact that scale up of screening for cervical cancer will, in the early phase of implementation, identify cancers as well as precancers, there is a critical need to train and educate local multidisciplinary teams to address this epidemic. The IGCS Gynecologic Oncology Global Curriculum & Mentorship Program is an education and training program designed for regions around the world that do not currently have formal training in gynecologic oncology.

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A practical approach: Allied Against Cancer

Unfortunately, cancer in many countries of Sub-Saharan Africa is currently characterized by late diagnosis, limited access to treatment, and poor patient outcomes. Most patients seeking treatment are already in the advanced stages of the disease, and it is estimated that fewer than 10% of patients receive adequate treatment. Allied Against Cancer seeks to improve evidence-based oncological practices in Sub-Saharan Africa by bringing together local and regional experts with similar resource environments. For example, over 45 National Comprehensive Cancer Network (NCCN®) Guidelines have been pragmatically adapted to the African setting.

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Giving hope a home: Enabling Treatment

For Kenya’s 45 million people, cancer is already the third leading cause of death and rates are rising annually. With Kenya’s only public comprehensive cancer center based in Nairobi, patients must travel from all corners of the country for treatment, and exhaust their resources doing so. Once there, patients and caregivers find a severe lack of safe and affordable lodging. Many patients in active cancer treatment sleep in the hospital’s corridors or outside. The well-being of these patients – and their hope for survival – is compromised because they are exposed to the elements, without a place to bathe or prepare a proper meal. Lack of accommodation is recognized a key factor in not accessing or continuing treatment. The KNH Hope Hostel will serve more than 2,000 annually, provide free temporary housing and integrated hospital services (such as palliative care and stoma management for patients), and will house a resource center to connect patients and caregivers with cancer information and resources.

 

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Life with dignity: Treating the Pain

More than 3.2 billion people worldwide lack access to adequate pain relief even though morphine, the most effective treatment for severe pain, is safe, effective, plentiful, inexpensive, and easy-to-use. Access to pain treatment is particularly limited in low and middle-income countries where approximately 70% of cancer deaths and 99% of HIV deaths in the world occur, but just 7% of the opioid analgesics are consumed. Treat the Pain is an international program which provides technical support to improve access to pain medicines, focusing on patients in low- and middle-income countries.

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