STEP 3: Diagnosis, staging and treatment planning
Step 3 outlines the process for confirming the diagnosis and stage of cancer, and planning subsequent treatment. The guiding principle is that interaction between appropriate multidisciplinary team members should determine the treatment plan.
All cervical cancer must be histologically confirmed. In the vast majority of cases this will occur as an outcome of the screening and subsequent investigation process. For women presenting with signs and symptoms suggesting the presence of cervical cancer, expedited colposcopy and histological evaluation is required.
After a thorough medical history and examination, the sequence of investigations depicted may be considered.
Investigations include:
- gynaecological examination
- colposcopic assessment prior to treatment by a practitioner certified in this field
- cervical biopsy for confirmation of diagnosis
- cone biopsy (conisation)/type 3 excision is recommended if the cervical biopsy is inadequate to define invasiveness or if accurate assessment of microinvasive disease is required) (NCCN 2017)
- complete blood count (including platelets), and liver and renal function tests (NCCN 2017)
- pelvic ultrasound (in cases where no lower genital tract abnormality is detected at colposcopy after referral with abnormal glandular cytology)
- endocervical sampling for suspected glandular abnormalities and HPV 16/18 positivity
- endometrial sampling to exclude an endometrial origin for atypical glandular cells (if required) (Cancer Council Australia 2016).
Timeframes for completing investigations should be informed by evidence-based guidelines (where they exist) while recognising that shorter timelines for appropriate consultations and treatment can reduce the woman’s distress.
The following recommended timeframes are based on expert advice from the Cervical Cancer Working Group:
- For obvious abnormalities, a colposcopy within two weeks of referral.
- Diagnostic investigations should be completed within two weeks of specialist review.
Staging is the cornerstone of treatment planning and prognosis. Staging for cervical cancer is clinical but aided by the following investigations as appropriate:
- chest x-ray
- CT/MRI/PET.
Structured reporting by a pathologist is encouraged (Royal College of Pathologists 2013; 2017).
All newly diagnosed women should be discussed in a multidisciplinary team meeting so that a treatment plan can be recommended. The level of discussion may vary depending on both clinical and psychosocial factors.
The results of all relevant tests and imaging should be available for the multidisciplinary team discussion. Information about the woman’s concerns, preferences and social circumstances should also be available.
These are to:
- nominate a team member to be the lead clinician (the lead clinician may change over time depending on the stage of the care pathway and where care is being provided)
- nominate a team member to coordinate patient care
- develop and document an agreed treatment plan at the multidisciplinary team meeting
- circulate the agreed treatment plan to relevant team members, including the general practitioner.
The general or primary medical practitioner who made the referral is responsible for the patient until care is passed to another practitioner.
The general or primary medical practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, coordination and continuity of care as well as providing information and support to the woman and her family.
The care coordinator is responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase. The care coordinator may change over the course of the pathway.
The lead clinician is a clinician responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.
The multidisciplinary team should comprise the core disciplines that are integral to providing good care. Team membership will vary according to cancer type but should reflect both the clinical and psychosocial aspects of care. Additional expertise or specialist services may be required for some women (Department of Health 2007b).
Team members may include a:
- care coordinator (as determined by multidisciplinary team members)*
- gynaecological oncologist*
- medical oncologist*
- nurse (with appropriate expertise)*
- pathologist with expertise in gynaecological pathology*
- radiation oncologist*
- radiologist*
- expert in providing culturally appropriate care to Aboriginal and Torres Strait Islander people with cancer (this may be an Aboriginal and/or Torres Strait Islander health worker, health practitioner or hospital liaison officer)
- clinical trials coordinator
- dietitian
- fertility expert
- psychosexual counsellor
- women’s health physiotherapist
- general practitioner
- geriatrician
- gynaecologist
- occupational therapist
- palliative care specialist
- pharmacist
- physiotherapist
- psychologist
- psychiatrist
- social worker.
* Core members of the multidisciplinary team are expected to attend most multidisciplinary team meetings either in person or remotely.
Participation in research and/or clinical trials should be encouraged where available and appropriate. Cross-referral between clinical trials centres should be encouraged to facilitate participation.
Australian Cancer Trials is a national clinical trials database. It provides information on the latest clinical trials in cancer care, including trials that are recruiting new participants. For more information visit Australian Cancer Trials.
Special considerations that need to be addressed at this stage include issues regarding fertility, early menopause and changes to sexual function.
The risk of early-onset menopause continues after chemotherapy/radiotherapy and not only immediately following treatment. Referral for psychological services or a women’s health or sexual and reproductive health practitioner may be appropriate regarding changes to sexual function and loss of fertility, particularly for younger women.
The option of fertility preservation needs to be discussed prior to treatment starting. Referral to a fertility service for counselling and evaluation of options may be appropriate. Fertility-sparing
approaches may be considered in highly selected patients who have been thoroughly counselled regarding disease risk as well as prenatal and perinatal issues (NCCN 2017).
Referral to a social worker, women’s health physiotherapist, psychosexual counsellor, menopause expert, psychologist or psychiatrist may be appropriate.
Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare women for the challenges of cancer treatment such as surgery, chemotherapy, immunotherapy and radiation therapy.
Evidence indicates that for newly diagnosed cancer patients, prehabilitation prior to starting treatment can be beneficial. This may include conducting a physical and psychological assessment to establish a baseline function level, identifying impairments and providing targeted interventions to improve the woman’s health, thereby reducing the incidence and severity of current and future impairments related to cancer and its treatment (Silver & Baima 2013).
Medications should be reviewed at this point to ensure optimisation and to improve adherence to medicines used for comorbid conditions.
Screening with a validated screening tool (such as the National Comprehensive Cancer Network Distress Thermometer and Problem Checklist) and assessment and referral to appropriate health professionals or organisations is required to meet the identified needs of an individual, their carer and family.
In addition to the common issues outlined in the Appendix, specific needs that may arise at this time include:
- treatment for physical symptoms such as fatigue and pain
- malnutrition (as identified using a validated malnutrition screening tool or presenting with unintentional weight loss)
- help with psychological and emotional distress while adjusting to the diagnosis, treatment phobias, existential concerns, stress, difficulties making treatment decisions, anxiety/ depression, psychosexual issues such as potential loss of fertility and premature menopause, and interpersonal problems. Women diagnosed with cervical cancer may experience a unique emotional and psychological burden because it is largely a preventable cancer, as well as being associated with a sexually transmitted virus, raising the spectre of guilt and blame (Hobbs 2008)
- appropriate assistance for women with mental illness, women in residential care facilities, women in custodial care and women who are financially disadvantaged to access care
- guidance for financial and employment issues (such as loss of income, travel and accommodation requirements for rural women and caring arrangements for other family members)
- guidance for smoking cessation
- appropriate information for women from culturally and linguistically diverse backgrounds, including Aboriginal and Torres Strait Islander people.
The lead clinician should:
- establish if the woman has a regular or preferred general practitioner
- discuss a timeframe for diagnosis and treatment with the woman and her carer
- discuss issues regarding fertility and early menopause
- discuss the benefits of multidisciplinary care and make her aware that her health information will be available to the team for discussion at the multidisciplinary team meeting
- offer individualised cervical cancer information that meets the needs of the woman and her carer (this may involve advice from health professionals as well as written and visual resources)
- offer advice on how to access information and support from websites and community and national cancer services and support groups (for example, Cancer Council)
- use a professionally trained interpreter when communicating with women from culturally or linguistically diverse backgrounds (NICE 2004)
- if the woman is a smoker, provide information about smoking cessation.
The lead clinician should:
- ensure regular and timely (within a week) communication with the woman’s general practitioner regarding the treatment plan and recommendations from multidisciplinary team meetings and should notify the general practitioner if the woman does not attend appointments
- gather information from the general practitioner, including their perspective on the woman (psychological issues, social issues and comorbidities) and locally available support services
- contribute to the development of a chronic disease and mental healthcare plan as required
- discuss shared care arrangements, where appropriate
- invite the general practitioner to participate in multidisciplinary team meetings (consider using video or teleconferencing).
