Manuel de Prise en Charge du Cancer du Col de l’Utérus

Objectives

Provide a national, pragmatic reference for harmonising and improving cervical-cancer care in Algeria, supporting effective and efficient prevention, diagnosis, staging, treatment and follow-up while leaving patient-specific decisions to clinicians’ professional judgement.[1]Cervical cancer is treated as a major women’s health priority, reported as Algeria’s second most common gynaecological cancer, with an incidence of 8.7 per 100,000 women and 12.5% of female cancers.[2]

• Reduce incidence and mortality through organised cervical screening, detection and treatment of pre-invasive lesions, and prophylactic human papillomavirus vaccination.[2]
• Prevent human papillomavirus-related cervical malignancy, particularly infection associated with types 16 and 18, which are reported in approximately 70% of cervical cancers.[2]
• Standardise the pathway from cervical cytology and histopathology through International Federation of Gynecology and Obstetrics staging, pre-treatment assessment, surgery, radiotherapy, systemic treatment, surveillance and recurrence management.[3][4]
• Identify and treat dysplasia, carcinoma in situ and invasive cancer using cervical smears, colposcopy-directed biopsy, conisation and pathology reporting.[2][5][6]
• Apply stage-adapted treatment according to tumour size, local and distant extension, histology, lymph-node status, general condition and, where relevant, fertility intentions.[7][8][9]
• Preserve fertility for selected patients through conservative treatment, including trachelectomy for eligible early-stage tumours, subject to multidisciplinary assessment.[10][9][11]
• Deliver locoregional control through surgery, external-beam radiotherapy and brachytherapy, with concomitant radiochemotherapy identified as the reference treatment for stages IB2 to IVA.[7][12][9]
• Support long-term follow-up to detect recurrence, metastatic disease, treatment complications and effects on sexual, urinary and bowel function.[13]

Implementation

The guide was initiated by the Ministry of Health, Population and Hospital Reform and developed by a multidisciplinary group of experienced health professionals, including pathology, surgery, medical oncology, gynaecology, radiology and radiotherapy experts from Algerian university hospitals and cancer centres.[1][14]It is intended for all practitioners involved in cancer care, is not exhaustive, and should be updated when national or international recommendations or major diagnostic and therapeutic advances warrant revision.[1][3]

• Organise screening through public or private centres linked to anatomical pathology services, with cervical sampling undertaken by midwives, general practitioners or gynaecologists and processed by Papanicolaou staining and light microscopy.[5]
• Use the Bethesda 2001 system to classify cervical cytology and guide management, including colposcopy for high-risk abnormalities, surveillance for selected low-grade lesions, and treatment of cervical intraepithelial neoplasia grade 2 or 3.[6][15]
• Require clinical information and patient identifiers with cervical specimens, including sampling date, menstrual or menopausal status, examination indication, relevant history and contraception details.[6]
• Provide pathology services capable of examining biopsies, conisation and hysterectomy specimens, documenting lesion type, invasion, margins, vascular emboli and nodal findings needed for staging.[5][16][17]
• Use joint surgeon and radiotherapist examination, colposcopy where lesions are not visible, and magnetic resonance imaging as the principal technique for locoregional assessment; complement this with thoraco-abdominal computed tomography and other tests according to availability, symptoms and disease extent.[18][19]
• Apply magnetic resonance imaging, computed tomography, positron emission tomography-computed tomography and tumour markers to assess local, nodal and distant extension, using FIGO 2009 and Union for International Cancer Control TNM classifications.[20][21]
• Deliver radical surgery through appropriately trained teams, using colpohysterectomy with pelvic lymph-node dissection as the reference operation for relevant early-stage disease and reserving pelvic exenteration for selected locally extensive or recurrent cases.[7][10][12]
• Plan radiotherapy through multidisciplinary review of clinical, imaging, biopsy, surgical pathology, staging and laboratory information; define gross tumour, clinical and planning target volumes, nodal coverage and organs at risk.[22][23]
• Use three-dimensional conformal radiotherapy, treatment-plan validation by the radiation oncologist and medical physicist, patient and positioning checks, and imaging-based verification of treatment geometry.[24][25]
• Integrate brachytherapy as a core modality, adapting dose and technique to tumour extension, and administer platinum-based chemotherapy concurrently with radiotherapy when indicated and tolerated.[25][8][9]
• Base complex treatment decisions, including postoperative irradiation, fertility-preserving procedures and management during pregnancy, on multidisciplinary consultation.[8][11]
• Conduct post-treatment follow-up every three months for two years, every six months for the following three years and annually thereafter, adapting review to clinical circumstances and investigating symptoms or findings with examination, cytology, tumour markers and imaging as appropriate.[13]

The supplied material specifies clinical reporting, staging, treatment-planning and delivery checks, but does not define programme-level governance arrangements, implementation timetables, budgets, financing mechanisms, population-level indicators, audit procedures or formal accountability systems.[16][22][25][14]

Monitoring & Evaluation

Monitoring is principally embedded in clinical diagnosis, staging, treatment planning, pathology reporting and post-treatment follow-up rather than in a formal programme-wide evaluation framework. The guide is intended to be updated regularly in response to national and international recommendations and significant diagnostic or therapeutic advances.[1][3]

• Organise screening and diagnostic follow-up through cervico-vaginal cytology, examination of conisation specimens and assessment of women with relevant symptoms.[2][26][5]
• Use standardised pathology reports to record lesion type, tumour location and extent, invasion depth, margin status, vascular emboli, lymph-node findings and other information required for International Federation of Gynecology and Obstetrics staging.[16][17]
• Measure suspected microinvasion in millimetres, including lateral extension and depth from the relevant epithelial or glandular reference point, and systematically search for vascular emboli and residual tumour.[17]
• Assess pre-treatment tumour extension through joint clinical examination, magnetic resonance imaging and, where indicated, thoraco-abdominal computed tomography, ultrasound, chest radiography, rectoscopy, cystoscopy or positron emission tomography.[18][19]
• Interpret magnetic resonance imaging performance cautiously: it is the reference technique for locoregional assessment, but reported sensitivity for lymph-node extension is approximately 60% and normal-sized nodes may contain metastases.[18]
• Use dynamic magnetic resonance imaging sequences to improve tumour detection, for which reported sensitivity is 78%, compared with 61% for T2-weighted imaging and 39% for delayed T1-weighted imaging.[27]
• Assess nodal and metastatic disease using progressive evaluation of pelvic, common iliac and para-aortic chains, contrast-enhanced thoraco-abdomino-pelvic computed tomography, and positron emission tomography-computed tomography where appropriate.[20][21]
• Use positron emission tomography-computed tomography performance information, reported as 84% sensitivity and 95% to 100% specificity for pelvic or para-aortic nodes, alongside anatomical imaging for assessment of metastatic spread.[21]
• Measure Squamous Cell Carcinoma Antigen in squamous cervical carcinoma, including after treatment, and use CA-125 particularly for adenocarcinoma; pretreatment Squamous Cell Carcinoma Antigen elevation is associated with disease stage.[21]
• Validate radiotherapy plans jointly through the radiation oncologist and medical physicist, calculate dose distributions and monitor units, use dose-volume histograms where available, and verify patient identity, parameters, positioning and treatment geometry during delivery.[24][25]
• Apply documented dose constraints for organs at risk, including bladder, small bowel and femoral structures, as part of treatment-quality control.[24]
• Schedule clinical post-treatment follow-up every three months for two years, every six months for the following three years and annually thereafter, with adjustment to individual circumstances.[13]
• Assess follow-up visits for locoregional recurrence, nodal or visceral metastasis, treatment complications, and sexual, bladder and bowel effects; select imaging and tumour-marker testing according to symptoms, stage and initial marker elevation.[13]
• Intensify surveillance in the early post-treatment period, as more than 90% of recurrences are reported to occur within two years, with more than half occurring in the pelvis.[13]
• Conduct annual surveillance after treatment for cervical intraepithelial neoplasia grade 2 or 3, and use repeat smear testing or clinical surveillance for selected low-grade lesions.[6][28]

Formal population-level indicators, routine reporting schedules, audit processes, data systems, named accountability bodies and a comprehensive monitoring and evaluation framework are not specified in the supplied material beyond the clinical reporting, treatment-verification and surveillance measures described.[1][18][22][9][29][14]

Costing & Financing

No explicit costing, budget allocation, financing source, funding gap, resource-mobilisation mechanism or economic assumption is provided. The material identifies substantial service and technology requirements, but does not attach financial values to them.[1][2][5][18][7][22][24][9][6][29][30][14]

• Require pathology and cytology capacity, including public screening centres, anatomical pathology services, colposcopy-guided biopsy processing and, at higher service levels, immunocytochemistry, immunohistochemistry and polymerase chain reaction-related investigations.[5][16][17]
• Require diagnostic imaging capacity, including magnetic resonance imaging, computed tomography, ultrasound, chest radiography and positron emission tomography for selected staging and surveillance indications.[18][20][21]
• Require specialised multidisciplinary clinical capacity for radical and fertility-preserving surgery, pelvic exenteration, external-beam radiotherapy, brachytherapy, chemotherapy and treatment planning.[7][12][25][8][9]
• Require quality-assurance resources for radiotherapy planning and delivery, including computed tomography simulation, contouring, treatment-plan approval, medical physics input, verification systems and imaging-based positioning checks.[24][25]

The source identifies these diagnostic, treatment and workforce inputs as components of care, but does not specify their quantities, unit costs, capital costs, recurrent costs, affordability, funding arrangements or prioritisation criteria.[5][18][7][24][8]