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Don't Screen Healthy Women for Ovarian Cancer

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Watch for Symptomatic Patients

As one of the top five leading causes of cancer death among women, it is important that methods of screening and early detection of ovarian cancer be continually evaluated. Because of the lack of symptoms until metastatic disease is present, the majority of women are diagnosed with advanced-stage (stage IIIC) disease. For this reason, it is important that screening focus on asymptomatic women in an attempt to diagnose at an earlier stage and thus provide an opportunity for improved survival, according to Dr. Georgia A. McCann and Dr. Ritu Salani.

Based on the evidence reviewed, the USPSTF recommendation against screening asymptomatic women with CA-125 and pelvic ultrasound is valid and should be considered definitive. Furthermore, these recommendations reiterate the results of previous studies and, once again, report that screening does not provide an improvement in the detection of early-stage disease or translate to a survival advantage. Thus, screening asymptomatic women with current technologies does little more than provide false reassurance for women with normal findings and result in potentially unnecessary surgery (with a high complication rate) in women with abnormal findings.

However, the lack of screening tests amplifies the importance of asking patients about possible genetic predisposition by obtaining a thorough family history, as well as reviewing ovarian cancer symptoms such as abdominal bloating, abdominal/pelvic pain, early satiety, and changes in bowel/bladder function. If patients are found to be high risk or symptomatic, it is imperative that we, as health care providers, engage in the appropriate evaluation and management.

Given the morbidity and mortality of this disease, it is vital that research continues on the early detection of ovarian cancer. New biomarkers, improvements in imaging, and an enhanced understanding of genetics may allow for better screening methods to be evaluated soon. In the interim, providers should be aware of the pitfalls of ovarian cancer screening and continue to educate patients on the symptoms of ovarian cancer.

Dr McCann and Dr. Salani of the division of gynecologic oncology, department of obstetrics and gynecology at the Ohio State University, Columbus, commented on the USPSTF findings. They said they had no relevant financial disclosures.


 

FROM ANNALS OF INTERNAL MEDICINE

Clinicians need not screen women for ovarian cancer if they are otherwise healthy and have no known genetic mutations, such as BRCA1 or BRCA2 that could increase their ovarian cancer risk, according to a recommendation from the U.S. Preventive Services Task Force published online in the Annals of Internal Medicine and on the USPSTF website on Sept. 11.

After reviewing data from randomized, controlled trials between 2008 and 2011, a USPSTF Task Force determined that the number of deaths from ovarian cancer in U.S. women was not significantly reduced by annual screening with transvaginal ultrasound and serum CA-125 testing.

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New data show that young women do not need to be screened for ovarian cancer, if they are otherwise healthy and have no known genetic mutations that could increase their risk for ovarian cancer.

In addition, the data revealed a high rate of false-positive results in asymptomatic women, who then may undergo unnecessary surgery and other harm, the USPSTF said in its statement.

In the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized, controlled trial of 78,216 women in the United States, there was no significant difference in the number of ovarian cancer cases diagnosed in women randomized to annual screening vs. usual care (212 vs. 176) over 13 years. No significant differences were seen in the number of cancer deaths between the two groups. One-third of the women with false-positive results underwent oophorectomies, with nearly 21 major complications per 100 surgeries performed on the basis of false-positive results.

Data from another recent trial, the Shizuoka Cohort Study of Ovarian Cancer Screening, suggested that approximately 33 surgeries would be needed to diagnose 1 case of ovarian cancer detected by routine screening. More data are pending from an ongoing trial, the U.K. Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

Based on the available data, "There is adequate evidence that there is no mortality benefit to routine screening for ovarian cancer with transvaginal ultrasonography or single-threshold serum CA-125 testing, and that the harms of such screening are at least moderate," according to the USPSTF.

"Final results from UKCTOCS should provide more information about the relative benefits and harms of an algorithm-based approach to screening for ovarian cancer," the Task Force stated.

Neither the American Cancer Society nor the American College of Obstetricians and Gynecologists recommend screening asymptomatic, average-risk women for ovarian cancer, according to a USPSTF press release about the new recommendation.

The recommendation is a grade D, which the USPSTF defines as "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits," and providers therefore are discouraged from using the service.

This recommendation does not apply to women who are considered at high risk for ovarian cancer. Populations at increased risk of developing ovarian cancer include women with BRCA1 and BRCA2 genetic mutations, Lynch syndrome (hereditary nonpolyposis colon cancer), or a family history of ovarian cancer. A family history "generally means having two or more first- or second-degree relatives with a history of ovarian cancer or a combination of breast and ovarian cancer; for women of Ashkenazi Jewish heritage, it means having a first-degree relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer," according to the USPSTF statement.

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