Pedoman Nasional Pelayanan Kedokteran
Tata Laksana Kanker Serviks

1. Introduction

Cervical cancer remains one of the leading causes of cancerrelated mortality among Indonesian women. The Pedoman Nasional Pelayanan Kedokteran Tata Laksana Kanker Serviks (National Guideline for Cervical Cancer Management) was developed by the Ministry of Health together with the Indonesian Association of Gynecologic Oncology (Perhimpunan Onkologi Ginekologi Indonesia) to provide a standardized, evidencebased approach for prevention, early detection, treatment, and followup.

The guideline aligns with the World Health Organizations (WHO) cervical cancer elimination strategy and incorporates local epidemiology, resources, and healthsystem structure.

2. Scope and Target Audience

The document is intended for:

• Obstetriciansgynecologists and oncology specialists
• Primary care physicians and midwives
• Nurses, pathology technicians and radiologists
• Healthpolicy makers and program managers
• Medical students and residents

While the primary focus is on clinical management, the guideline also addresses publichealth initiatives such as vaccination and screening programmes.

3. Prevention Strategies

3.1 Primary Prevention HPV Vaccination

The guideline recommends a twodose schedule of a nonavalent (2valent or 4valent) HPV vaccine for girls aged 914 years, with a threedose schedule for those older than 15. Key points include:

• Integration of vaccination into the national immunisation programme.
• Schoolbased delivery as the preferred method.
• Catchup vaccination for women up to 26 years if they have not been previously immunised.
• Public awareness campaigns to counter vaccine hesitancy.

3.2 Secondary Prevention Screening

Screening is recommended for all women aged 3050 years, with the following options:

• HPV DNA testing every five years (preferred method).
• Visual Inspection with Acetic acid (VIA) every three years in lowresource settings.
• Cytology (Pap smear) every three years where laboratory capacity exists.

Women who test positive for highrisk HPV should receive a triage colposcopic examination. The guideline stresses the importance of screenandtreat algorithms to reduce loss to followup.

4. Diagnostic Workup

Once a suspicious lesion is identified, the following steps are required:

1. Colposcopic assessment with directed biopsy.
2. Histopathology for definitive diagnosis and grading.
3. Imaging pelvic MRI is the imaging modality of choice for local staging; CT or PETCT is reserved for evaluating distant metastasis.
4. Laboratory tests complete blood count, renal and liver functions, and tumor markers (SCCAg) as baseline.

The guideline adopts the FIGO 2018 staging system, which incorporates imaging and pathology findings for more accurate categorisation.

5. Treatment Modalities

5.1 EarlyStage Disease (FIGO IAIB1)

For tumours confined to the cervix:

• Surgical options radical hysterectomy (type II or III) with pelvic lymphadenectomy is the standard for women who desire fertility preservation (conization or trachelectomy) when tumour size 2cm.
• Adjuvant radiotherapy is indicated when pathological risk factors (positive margins, deep stromal invasion, lymphvascular space invasion) are present.

5.2 Locally Advanced Disease (FIGO IB2IVA)

The preferred treatment is concurrent chemoradiotherapy (CCRT):

• External beam radiotherapy (EBRT) 4550Gy in 25 fractions to the pelvis.
• Weekly cisplatin 40mg/m as radiosensitiser.
• Intracavitary brachytherapy (highdoserate) delivering a total equivalent dose in 2Gy fractions (EQD2) of at least 80Gy to point A.

Patients with bulky tumours (>4cm) may benefit from neoadjuvant chemotherapy (34 cycles of paclitaxelcarboplatin) before CCRT, though evidence is still emerging.

5.3 Metastatic or Recurrent Disease (FIGO IVB or recurrence)

Management is palliative and systemic:

• Firstline: platinumbased doublet chemotherapy (cisplatin/paclitaxel) bevacizumab.
• Secondline options include pembrolizumab for PDL1positive tumours, or enrolment in clinical trials.
• Palliative radiotherapy for symptomatic lesions.

5.4 Special Considerations

Fertilitypreserving surgery, management during pregnancy, and care for HIVpositive patients are addressed with specific algorithms. For example, pregnant women with stage IA2IB1 disease may undergo conization in the second trimester, while more advanced cases require multidisciplinary planning.

6. Followup and Survivorship

After completion of primary treatment, a structured followup schedule is recommended:

• Every 3months for the first 2years.
• Every 6months for years 35.
• Annually thereafter.

Each visit should include: symptom review, physical examination, and, when indicated, a Pap smear or HPV test. Imaging is reserved for clinical suspicion of recurrence.

Survivorship care should also address:

• Psychosocial support and counselling.
• Management of treatmentrelated sequelae (e.g., lymphedema, sexual dysfunction).
• Vaccination against HPV for survivors.

7. Implementation Challenges and Solutions

Key barriers identified in Indonesia include limited access to HPV testing, shortage of trained colposcopists, and uneven distribution of radiotherapy facilities. The guideline proposes:

• Taskshifting: training midwives and nurses in VIA screening.
• Telecolposcopy networks for remote image review.
• Publicprivate partnerships to expand radiotherapy capacity.
• Integration of cervical cancer indicators into the national health information system for monitoring.

8. Monitoring & Evaluation

Performance metrics include:

• Vaccination coverage among target age groups.
• Screening uptake rates (HPV test or VIA).
• Proportion of cases diagnosed at early stage (IAIB).
• 5year overall survival for each stage.
• Patientreported outcome measures (quality of life).

Annual reports are to be submitted to the Ministry of Health, with feedback loops to adjust programme components.

9. Conclusion

The Pedoman Nasional Pelayanan Kedokteran Tata Laksana Kanker Serviks provides a comprehensive, evidencebased roadmap for tackling cervical cancer in Indonesia. By harmonising prevention, early detection, curative treatment, and survivorship care, the guideline aims to reduce mortality, improve quality of life, and move the nation closer to the WHOs goal of eliminating cervical cancer as a public health problem.

Successful implementation will require coordinated action across government, healthcare providers, community organisations, and patients themselves. Continuous training, resource investment, and robust data collection are essential to translate the guidelines recommendations into realworld impact.