แนวทางการตรวจคัดกรอง วินิจฉัย และรักษาโรคมะเร็งปากมดลูก

Objectives

The guideline provides a comprehensive clinical framework for preventing, detecting, diagnosing, staging, treating and following up cervical cancer, spanning human papillomavirus vaccination, screening, management of precancerous lesions, pathological reporting, stage-specific cancer care, recurrence and treatment-related complications.[1][2][3][4][5]It does not set out a broader population-level cancer-control mission, quantified programme targets, budgeted strategic plan or implementation timetable in the supplied material.[1][6][7]

• Promote cervical cancer prevention through human papillomavirus vaccination, screening and identification and management of cervical intraepithelial neoplasia.[2][3]
• Provide screening for women broadly aged 25 to 65 through cervical cytology, human papillomavirus DNA testing, co-testing, primary human papillomavirus testing or visual inspection with acetic acid, with intervals that vary by modality.[8][9][2][10][11]
• Standardise cervical cytology and pathology classification through the 2014 Bethesda System, reporting of specimen adequacy and epithelial abnormalities, and structured histopathological assessment of biopsy, conisation, trachelectomy and hysterectomy specimens.[12][13][14][15][16]
• Manage screening abnormalities, including atypical squamous cells of undetermined significance, low-grade and high-grade squamous intraepithelial lesions, cervical intraepithelial neoplasia and adenocarcinoma in situ, using risk-appropriate surveillance, colposcopy, sampling, ablation, excision or definitive surgery.[17][18][19][20]
• Apply International Federation of Gynecology and Obstetrics staging, alongside tumour, node and metastasis classification, to distinguish microinvasive, early, locally advanced and metastatic cervical carcinoma and support stage-specific treatment selection.[21][22][23]
• Deliver treatment pathways ranging from fertility-preserving conisation or trachelectomy to hysterectomy, lymph-node assessment, radiotherapy, brachytherapy, systemic chemotherapy, palliative care and management of recurrent disease.[24][25][26][27][4]
• Address special clinical circumstances, including neuroendocrine tumours, cervical cancer during pregnancy, cancer identified after inadvertent extrafascial hysterectomy, and complications of surgery, radiotherapy and chemotherapy.[28][29][30][31][5][32]

Implementation

The delivery approach is a linked clinical pathway from specimen collection and screening through diagnostic confirmation, staging, multidisciplinary treatment selection and follow-up.[1][33][34][21][35]Technical quality assurance is incorporated for cytology and laboratory reporting, while clinical decisions are differentiated by test result, lesion grade, pathology, disease stage, prior treatment, performance status and reproductive or pregnancy circumstances.[13][36][17][25][26][37]The extracts identify professional and institutional participation led by Thailand's National Cancer Institute, with representation across gynaecology, radiotherapy, chemotherapy, cytology, pathology and related professional organisations, but do not specify a complete governance structure, accountable delivery institutions, referral network or workforce plan.[38][39][40][41]

• Offer cytology from age 30, with possible initiation from age 25 according to suitability, every two to three years, and cease after age 65 where three consecutive results are normal; use combined cytology and human papillomavirus DNA testing at intervals of three to five years.[9]
• Use primary human papillomavirus testing or co-testing, particularly for women over 30, and stratify positive results through cytology and human papillomavirus 16 and 18 genotyping; refer women positive for human papillomavirus 16 or 18 for further assessment and reassess other positive results at around 12 months where indicated.[10][42][43]
• Provide visual inspection with acetic acid, including a single-visit see-and-treat model where appropriate, particularly in low-resource settings; link eligible positive findings to cryotherapy or other indicated treatment.[3][11][44]
• Maintain specimen and laboratory quality through appropriate sampling of the transformation zone, prompt fixation and staining, defined microscopy procedures, Bethesda reporting, internal quality control and external quality assurance.[45][46][13][36][47]
• Assess abnormal screening findings through human papillomavirus testing, repeat cytology or co-testing, colposcopy, biopsy and endocervical sampling; use diagnostic excision when assessment is inadequate, high-grade disease is suspected or results require confirmation.[17][18][48]
• Stage confirmed cancer through clinical examination, pathology and indicated imaging, including ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography-computed tomography, with cystoscopy or proctoscopy when bladder or rectal involvement is suspected.[49][22][23]
• Match treatment to stage and risk, using surgery and lymph-node dissection for selected early disease, chemoradiation and brachytherapy for locally advanced disease, and systemic therapy, palliative radiotherapy or supportive care for metastatic disease or fistula-related complications.[25][50][26][27]
• Follow patients after treatment through clinical examination, vaginal-vault cytology where applicable, imaging and tumour-marker assessment; one specified pathway uses review every three to four months in years one to two and every six months in years three to five.[35][51]
• Monitor clinical and technical quality through specimen adequacy, cytological and pathological classifications, test-performance measures and documented staging, although the material does not define a programme-wide indicator set, reporting cycle, surveillance system or accountability mechanism.[52][23][36][16]

Monitoring & Evaluation

The material provides extensive clinical and laboratory assessment provisions for cervical cancer prevention, diagnosis, treatment and follow-up, but no unified programme-level monitoring, evaluation, surveillance, reporting or accountability framework.[1][53][54][55]Monitoring is principally embedded in clinical decision-making, pathology reporting, screening quality assurance and post-treatment review.[17][51][13][36]

• Monitor screening-test performance through measures including sensitivity, specificity, positive predictive value and false-positive findings. Co-testing is reported to have sensitivity of approximately 99% and a negative predictive value approaching 100%; visual inspection with acetic acid is reported to have sensitivity of approximately 79–82% and specificity of approximately 91–92%.[52][10][3]
• Record cervical cytology using the 2014 Bethesda System, including specimen type, adequacy, epithelial-cell abnormalities and relevant explanatory information.[12][13][16]
• Assess specimen quality by identifying adequate transformation-zone or endocervical sampling, unsatisfactory or rejected specimens, obscuring factors and air-drying artefacts.[12][45][16]
• Apply internal quality control and external quality assurance for gynaecological cytology, including review of unsatisfactory specimens and epithelial-cell abnormalities.[13][36]
• Classify screening and diagnostic findings, including atypical squamous cells of undetermined significance, low-grade and high-grade squamous intraepithelial lesions, cervical intraepithelial neoplasia, adenocarcinoma in situ and invasive malignancy, to inform surveillance or treatment.[17][18][56][57]
• Use repeat cytology, human papillomavirus DNA testing or co-testing for follow-up of abnormalities, with stated pathways including assessment at 6, 12 and 24 months.[48]
• Undertake colposcopy, biopsy, endocervical sampling and diagnostic excision to reassess persistent or high-grade abnormalities and determine subsequent management.[17][18][48]
• Assess surgical margins and conduct endocervical sampling and co-testing after treatment for high-grade lesions or adenocarcinoma in situ; a six-month co-testing interval is included in the cited pathway.[19][20]
• Document disease extent through International Federation of Gynecology and Obstetrics and tumour, node and metastasis classifications, including primary tumour, regional lymph-node and distant-metastasis categories.[22][23]
• Record pathology variables relevant to prognosis and management, including histological type, grade, tumour dimensions, depth and extent of invasion, lymphovascular space invasion, margins, associated premalignant lesions and lymph-node involvement.[14][58][59][15][60]
• Use pretreatment investigations and pathological risk features, such as positive lymph nodes, parametrial involvement, margin status, tumour size, deep stromal invasion and lymphovascular space invasion, to stratify treatment.[49][25]
• Conduct post-hysterectomy follow-up using vaginal-vault cytology, pelvic examination, assessment of the parametrium and pelvic sidewall, positron emission tomography/computed tomography and squamous cell carcinoma antigen where indicated; stated intervals are every 3–4 months in years 1–2 and every 6 months in years 3–5.[51]
• Observe treatment complications, including bladder dysfunction through residual-urine measurement, and radiotherapy-related effects such as dermatitis, cystitis, urethritis, anaemia and leukopenia.[5][61]
• Report screening activity where data are available: one extract records 9,673,244 women screened using conventional Pap smears, 39,930 high-grade findings and a reported rate of 0.46, although the denominator or unit for that rate is unclear in the source text.[62]

Named professional and institutional participation includes peer review and a working group chaired by Thailand’s National Cancer Institute, with representation from oncology, radiotherapy, gynaecological oncology, cytology, pathology, obstetrics and gynaecology bodies and regional cancer hospitals.[39][40][41]However, the excerpts do not allocate accountability for performance, specify reporting schedules or targets, establish a population surveillance system, or define audit and evaluation arrangements.[54][55][6][7][63]

Costing & Financing

No explicit budget, costed implementation plan, financing source, resource-mobilisation mechanism, funding gap, allocation or quantitative economic assumption is provided in the supplied material.[1][21][53][55]Consequently, no machine-readable cost items can be extracted.[53][54][55]

• Refer to cost-effectiveness when comparing cervical cytology methods, but provide no financial estimate or economic result.[52]
• Refer to cost-effectiveness comparisons of Pap smear, visual inspection with acetic acid and human papillomavirus DNA testing, including single-visit approaches in low-resource settings, without stating costs, budgets or funding sources.[11]
• Refer to cost-effectiveness analysis comparing human papillomavirus testing alone with co-testing, but provide no numerical result.[43]
• Cite studies concerning costs and benefits of screening strategies, including human papillomavirus testing in Thailand, without presenting a budget, allocation, funding mechanism or quantified assumption.[64]
• Identify resource-intensive clinical and technical inputs, including imaging, radiotherapy, brachytherapy, chemotherapy, surgery, laboratory processing, pathology assessment and cytology quality assurance, but do not quantify their costs or resource requirements.[49][25][50][65][14]

The material therefore supports no conclusion on affordability, financial sustainability, unit costs, service-coverage costs, workforce financing, procurement needs or the scale of any funding shortfall.[53][54][55]