Development of an evidence-based algorithm for the management of cervical cancer

Objective: To develop a description of the management of cervical cancer to support locally developed, regional guidelines and to identify the level of primary research evidence to support it. Design: Development of a flow-charted algorithm, using regional guidelines and clinician consensus. A Medline literature search for primary research was done to validate the algorithm and selection of papers, to verify if they were valid according to pre-defined criteria and to compare algorithm management with an alternative. Main Outcome Measure: The highest level of evidence for algorithm management was based on the design of the supporting research. Results: Twenty percent of the algorithm is supported by level I evidence (randomised controlled trials), 70% by level II evidence (cohort studies) and 10% by level IV evidence (expert opinion or case series). Level II evidence supports the management of Stage la, squamous cell carcinoma by cone biopsy or a simple hysterectomy. This level of evidence also applies to research on the management of Stages Ib-IIa, by radical hysterectomy and pelvic lymphadenectomy followed by radiotherapy, if the lymph nodes are positive. Radiotherapy to treat Stages IIb-IV cervical cancer is supported by level I evidence. The management of Stage I adenocarcinoma is supported by level II evidence. Conclusions: Evaluations of the effect of informing clinicians of the strengths of the proposed management are now required, as constructing evidence-based algorithms is worthwhile, only if they are likely to affect clinical practice.