Clinical Watch: CHAC, THE CLINICAL AND HEALTH AFFAIRS COMMISSION OF THE AAPA: GYNECOLOGY
>WHO SHOULD READ THIS?
Any PA who provides care to women.
>WHY IS THIS IMPORTANT?
The American Cancer Society (ACS) projects that in 2013, ovarian cancer will be diagnosed in an estimated 22,240 women and about 14,300 women will die from the disease.1 Ovarian cancer is the ninth most common cancer among women and fifth in cancer deaths.2 In April 2012, the US Preventive Services Task Force (USPSTF) reaffirmed its stance that no ovarian cancer screening tests should be performed on asymptomatic women with average risk for the disease.3 The USPSTF categorized the results of its evaluation as evidence grade D, meaning that there is no evidence of a reduction in deaths associated with ovarian cancer screening, whereas there may be increased harm related to evaluation and treatment based on false-positive findings from the tests.3–5
>WHAT TESTS ARE USED FOR OVARIAN CANCER SCREENING?
The two methods most commonly used to screen for ovarian cancer are transvaginal ultrasound (TVUS) and the CA-125 blood test. TVUS is used to detect masses but is unable to characterize a mass as benign or cancerous, which may lead to unnecessary surgeries. CA-125 is a protein in the blood that may be elevated in cases of ovarian cancer. However, CA-125 is nonspecific and may not be elevated in the presence of ovarian cancer, or it may be elevated in the presence of other common conditions.2 The National Cancer Institute provides a comprehensive review of the sensitivity and specificity of these screening tests.6
>SHOULD ANYONE HAVE OVARIAN CANCER SCREENING?
According to the USPSTF and supported by the ACS and the American College of Obstetricians and Gynecologists (ACOG),7 screening for ovarian cancer using CA-125 and TVUS leads to unnecessary and invasive procedures that can cause more harm than good. Therefore, clinicians need to take a thorough history in order to determine if their patient is at higher risk for ovarian cancer than the general population. Presence of a BRCA1 or BRCA2 gene mutation, Lynch syndrome (hereditary nonpolyposis colon cancer), or a family history of ovarian cancer places the patient at an increased risk for ovarian cancer.3,5 Increased risk from family history generally means having two or more first- or seconddegree relatives with a history of ovarian cancer or a combination of breast and ovarian cancer.
- Ovarian cancer screening tests should not be performed on asymptomatic women with average risk for ovarian cancer.
- Women with BRCA mutations, Lynch syndrome, or family history of ovarian cancer are at an increased risk for ovarian cancer.
- Genetic counseling is appropriate for individuals at risk and may result in increased ovarian cancer screening.
- Abdominal and urinary symptoms that occur at least once daily and persist over 2 to 3 weeks are suggestive of ovarian cancer and should alert clinicians to place this diagnosis in their differential.
- Although no new screening techniques are available, new therapies are being added to treatment for ovarian cancer.
Women in whom these factors are present should be referred for genetic counseling to further evaluate their risks for certain diseases, including ovarian cancer. Additional testing may be indicated, including TVUS; CA-125 determination; or other additional ovarian cancer screening, such as increased frequency of gynecologic examinations.7
>WHAT SYMPTOMS ARE SUGGESTIVE OF OVARIAN CANCER?
Since no testing methods provide reliable early detection of ovarian cancer, having an increased suspicion for the disease is important. The Women's Cancer Network established guidelines for symptoms that may help to identify patients who are at increased risk. Symptoms suggestive of ovarian cancer include bloating; pelvic or abdominal pain; difficulty eating or feeling full quickly; and urinary symptoms, such as urgency or frequency.8 If these symptoms are new to the patient, tend to occur one or more times daily, and have persisted for 2 to 3 weeks or longer,8 suspicion for ovarian cancer should rise significantly.
>IS THERE ANYTHING NEW?
Unfortunately, nothing is new for the early detection of ovarian cancer. However, the National Comprehensive Cancer Network (NCCN) has recently released new treatment guidelines for women who already have the disease.9 These include first-line use of bevacizumab as a category 3 chemotherapeutic agent. In addition, the use of neoadjuvant chemotherapy (therapy before surgery) was moved to category 1 from category 2A, and the importance of waiting until symptoms occur to start treatment for recurrence was moved from category 2B to category 2A, reflecting data that using CA-125 markers does not improve survival compared to waiting until symptoms begin to restart therapy.10 The NCCN guidelines use categories to reference level of evidence and consensus. Categories are defined as follows: 1, high-level evidence and consensus; 2A, lower-level evidence and uniform consensus; 2B, lowerlevel evidence and consensus that intervention is appropriate; and 3, based on any level of evidence, there is major disagreement that intervention is appropriate.9
1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin.
4. Buys SS, Partridge E, Black A, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Control Trial. JAMA.
5. Clarke-Pearson DL. Screening for ovarian cancer. N Engl J Med.