WHO Referral Guidelines for Women

Dr Magrath attended a two-day meeting at the World Health Organization (WHO) in Geneva on November 23rd and 24th. He worked with Drs Cecelia Sepulveda of WHO and Sankaranarayanan of the International Agency for Research on Cancer (IARC) to draft guidelines for the referral of women with suspected breast or cervical cancer at the primary health care (PHC) level in low resource settings to higher level hospitals for further investigations. The draft referral guidelines were based upon a review of evidence that had been prepared by a committee charged with assisting the WHO Guidelines Development Group to ensure that recommendations are based on the available evidence. Immediate referral of cases with clinical characteristics consistent with the possibility of cancer to higher level of care facilities is fundamental to a strategy for early detection and diagnosis and should translate into better treatment outcomes for patients at lower cost. Evidence-based guidelines for referral of patients with suspected cancer at the PHC level have so far not been developed by WHO or by any LMIC.

Discussions were held about the methodology used by WHO to develop referral guidelines. One issue that arose was that the evidence provided upon which to base the guidelines was almost exclusively risk factors for the development of the disease. However, it is the clinical features that determine referral - the symptoms noted by the patient or signs noted by the doctors. It was agreed that risk factors have little or no influence on referral, although they may alter the likelihood that a given sign is caused by cancer.

On the second day, Drs Sankaranarayanan, Sepulveda and Magrath continued with the development of the guidelines and held a teleconference with the advisory committee to discuss the guidelines. A relatively small number of revisions to the draft were required and there was considerable agreement among the committee members about signs and symptoms that could lead to a diagnosis of breast or cervical cancer. The modified guidelines are presently undergoing final editing and should be ready for publication early next year.

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