• Cervical Cancer
• Radiation
• Surgery

Although the incidence of cervical cancer in Europe is declining it remains a major public health problem, particularly in limited-resourced countries, with wide variations in regional and national management. Cervical cancer is still the leading cause of cancer-related death in women in eastern, western, middle, and southern Africa.1 In East Europe it is the most frequent cause of cancer death in women aged less than 44 years.2 The WHO recently launched a cervical cancer elimination initiative, aiming to reduce its global incidence, from currently 13/100 000/year to less than 4/100 000 by the end of the century.1 3 4

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) aims to notably establish multidisciplinary standards for training and care, to develop a set of quality indicators for the management of gynecological cancers, and to act as the European authority in the field of gynecological oncology. The ESGO quality indicators facilitate the documentation of quality of care, the comparison of performance structures, and the establishment of organizational priorities as a basis for accreditation in European countries.

ESGO has previously launched a hospital accreditation program based on ESGO quality indicators to assess adherence to European standards of care as established by ESGO through its evidence-based clinical practice guidelines. This accreditation program aims to evaluate the quality of surgery and to play an essential political role in the centralization of care for women with gynecological cancers. ESGO accreditation is awarded to institutions that offer patients the specific skills, experience, organization, and dedication required to achieve optimal levels of surgical care. The intention is incentive, not punitive. Certified centers can make the award known to doctors, patients, patient advocacy groups, and lay persons.

ESGO hospital accreditation programs in advanced ovarian and endometrial cancer surgery have already been launched and centers interested in being accredited can start the accreditation process online using the following link: https://esgo.org/explore/esgo-accreditation/. Centers receiving ESGO accreditation are entitled to:

• Use the subtitle ‘ESGO accredited center in Endometrial and/or Ovarian cancer surgery’ (depending on the accreditation process followed/completed)

• Use the ESGO Accredited Center logo in its endometrial and/or ovarian cancer-related communication

• Be listed on the ESGO website as an ESGO accredited center.

As a continuation of this effort to improve overall quality of care for gynecological cancer patients, an ESGO accreditation program has been initiated in cervical cancer.

ESGO has defined and established a list of quality indicators for optimizing and ensuring the quality of surgical care essential to improving the management and outcomes of patients with cervical cancer.5 With regard to the major role of radiotherapy in the management of this disease, ESGO and the European Society for Radiotherapy and Oncology (ESTRO) collaborated to extend the quality indicators to include aspects of radiation therapy management. This was done to give practitioners and administrators a quantitative basis to improve care and organizational processes notably for recognition of the increased complexity of modern external radiotherapy and brachytherapy techniques. The extended quality indicators aim to homogenize treatment across Europe and beyond, to minimize treatment related morbidity and complications, and to develop an accreditation program for cervical cancer management.6 7

A list of 29 quality indicators has been defined, including 11 general indicators (Table 1), 11 indicators for radiation therapy (Table 2), and seven indicators dedicated to surgical management (Table 3). Quality indicators 1 to 11 are related to center case load, training, experience of the surgeon, time to treatment, and the overall management including active participation in clinical trials, the decision-making process within a structured multidisciplinary team, adequate pre-operative investigations, and patient outcomes. Quality indicators 12 to 22 address the indications of radiation therapy including brachytherapy boost, intensity modulated radiotherapy techniques, individualized image-guided radiotherapy protocol with daily imaging based on on-board three-dimensional imaging, image-guided adaptive brachytherapy, combined intracavitary/interstitial brachytherapy and curative intent radiotherapy, and concurrent chemotherapy. The recommended radiation therapy doses, overall treatment time, indications for lymph node boost in patients with macroscopic lymph node spread, and adhering to minimum required criteria for brachytherapy treatment planning are also highlighted. Quality indicators dedicated to the surgical management (23–29) address the quality of surgical procedures, the compliance of management with the ESGO-ESTRO-ESP (European Society of Pathology) guidelines, and the need for a systematic assessment of surgical morbidity and oncologic outcomes as well as standardized and comprehensive documentation of surgical and pathological elements.8–10

Tumor stages are indicated following the 2018 Fédération Internationale de Gynécologie Obstétrique (FIGO) classification and the new (version 9) American Joint Committee on Cancer Tumor, Node, Mestatasis Staging for Cervical Cancer, both updated in 2021.11 12 Using a structured format, each quality indicator has a description specifying what the indicator is measuring.13 Measurability specifications are then detailed to define how the quality indicators will be measured in practice. The time frame for assessment of criteria is the last calendar year (unless otherwise indicated). Further to measurement of the indicator, a target is indicated. This specifies the level which each center should be aiming to achieve. When appropriate, two targets were defined: an optimal target, expressing the best possible option for patients, and a minimal target, expressing the minimal requirement when practical feasibility factors are taken into account.

Each quality indicator was associated with a score, and a self-assessment form was built (Table 4). Centers interested in being accredited are required to fill in the self-assessment form. The sum of the individual scores being 109, it was decided that an institution that meets at least 80% of the score (score ≥88) provides satisfactory surgical and radiotherapeutical management of patients with cervical cancer. However, this sum is not the only criterion to take into account. Centers interested in becoming accredited must accept that ESGO may perform random audits of applicants by asking for operative reports and pathology reports from select cases in their database.

A database including all referred cases of cervical cancer, including surgical and non-surgical cases during the last 3 consecutive years, must be provided in order to allow the ESGO accreditation committee to validate the center’s self-assessment form. The following additional documents should be provided:

• Documentation of clinical trials (NCT number and recruitment numbers overall per year, and if available publication list with PMID)

• Description of how complications are documented and quality management is performed.

ESGO has also developed criteria distinguishing centers with accreditation for the management of cervical cancer into two categories, either ‘Standard Accreditation’ or ‘Center of Excellence’. These criteria are outlined in Box 1. Centers accredited as a Center of Excellence may then build a network for education, training, and research. The system will be refined in the future with the feedback provided by the scoring of candidate centers, and by prospective research on the multivariate correlation between survival outcomes, patient characteristics, and quality indicators. The ESGO hospital accreditation program for cervical cancer management has been launched and centers interested in being accredited can start the accreditation process online using the following link: https://esgo.org/explore/esgo-accreditation/.