The recent U.S. Preventive Services Task Force (USPSTF) Reaffirmation Recommendation Statement concluded that in the population of asymptomatic women without known genetic mutations that increase risk for ovarian cancer, clinicians should not screen for ovarian cancer using transvaginal ultrasound and serum CA125 testing.
The USPSTF points out, correctly, that the recommendations only apply to asymptomatic women without known risk factors, including CA1 or BRCA2 deleterious mutations, Lynch syndrome, or family history of ovarian cancer. It is not unreasonable to assume that very few physicians will read the original article in the September 2012 issue of Annals of Internal Medicine.1 Indeed, many physicians will only see, for example, the bold-font headline on the MedPage Today website, “USPSTF Says No Routine Tests for Ovarian Ca”2 or similar headlines in The New York Times or their local newspaper, and conclude only that there are no screening tests for ovarian cancer in general.
Snippets of Headlines
I do not dispute any of the USPSTF recommendations on ovarian cancer screening. What concerns me, though, is how the busy nononcologic physician processes the USPSTF recommendations based on seeing only snippets of headlines. Many physicians may misinterpret the USPSTF’s message and be inclined to ignore the recommendations generally.
A good example of this tendency is the reaction to 2012 USPSTF recommendations on screening for prostate cancer. Also published in Annals of Internal Medicine,3 the authors conclude, “The USPSTF recommends against PSA-based screening for prostate cancer. This recommendation applies to men in the general U.S. population, regardless of age.” It is my understanding that many, if not most, urologists are generally ignoring the USPSTF recommendations.
Among the reasons many urologists ignore those recommendations is a recently published study by Scosyrev and coauthors.4 These investigators calculated that if PSA testing were not done in the modern era, rates of men presenting with metastatic prostate cancer—a highly fatal disease—would triple as compared to the pre-PSA era. If their conclusion is indeed correct, this could be a major tragedy in the making.
Complicating Factors
Primary care physicians and gynecologists face other barriers in implementing the USPSTF recommendations to “not screen for ovarian cancer.” For example, a recent letter that I sent to a generalist obstetrician-gynecologist began as follows:
Thank you for your referral of JL for an elevated CA125. Per your note, she asked you for CA125 because her sister, who had “problems” with her ovaries, told you to order the test. Your patient has no risk factors for ovarian cancer, but you were left in the difficult position of having to order a CA125….
Dr. K. probably had no choice but to order the test. Along similar lines, many doctors and women have received a widely circulated e-mail that claims, “the CA125 test is an effective ovarian cancer screening test.” For years, this e-mail has convinced many women to ask for the test.
Additional statistics add to the difficult decision-making for the nononcologic physician to screen or not for ovarian cancer: In 2012, a projected 226,870 new cases of breast cancer—the number 1 cancer in females—will be diagnosed, compared to only 22,800 cases of ovarian cancer—the ninth most common cancer in women. And yet, many women fear ovarian cancer more than any other cancer because of the lack of defined symptoms, the fact that 70% of ovarian cancer cases present with disease spread to the abdominal cavity, or because they know of someone who died of the disease.
Recommendations
In my opinion, the USPSTF recommendations should not be ignored. Rather, what is needed is a better method of communicating to primary care and nononcologic physicians what is presented in Annals of Internal Medicine, in an easy, concise format. Based on the above, my recommendations to the primary care physician and the general obstetrician-gynecologist are as follows:
1. Unless a patient has known risk factors including first- or second-degree relatives with ovarian cancer, a BRCA mutation, or family history of Lynch syndrome, there is little value in CA125 testing or transvaginal ultrasound, which are not highly sensitive or specific for the diagnosis of ovarian cancer and could lead to harmful major surgery.
2. For patients with a family history of ovarian cancer, BRCA mutation, or history of Lynch syndrome, screening with transvaginal ultrasound and CA125—even given the fact that they have a low sensitivity and specificity—should be done annually.
3. The USPSTF recommendations should not dissuade practicing physicians from using transvaginal ultrasound and CA125 testing in screening symptomatic women who present with a history of abdominal bloating, pelvic pain, or clothes that are too tight. If these tests are accurately evaluated, they can prevent women from having to undergo unnecessary abdominal surgery. ■
Disclosure: Dr. Piver reported no potential conflicts of interest.
References
1. Moyer VA, on behalf of the U.S. Preventive Services Task Force: Screening for ovarian cancer: U.S. Preventive Services Task Force reaffirmation recommendation Statement. September 11, 2012 (early release online).
2. Bankhead C: USPSTF says no to routine tests for ovarian ca. Posted September 10, 2012. Available at http://www.medpagetoday.com/HematologyOncology/OvarianCancer/34675. Accessed October 4, 2012.
3. Moyer VA, on behalf of the U.S. Preventive Services Task Force: Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 157:120-134, 2012.
4. Scosyrev E, Wu G, Mohile S, et al: Prostate-specific antigen screening for prostate cancer and the risk of overt metastatic disease at presentation: Analysis of trends over time. Cancer July 30, 2012 (early release online)
