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Ovarian Cancer Screening

The United States Preventive Services Task Force issued a recommendation AGAINST ovarian cancer screening.

  1. Why did they do this?
  2. Who do they think they are?
  3. Isn’t all screening for cancer (that might catch cancer early enough to be successfully treated) a good thing?

Google ‘ovarian cancer’ and poor Gilda pops up.

Reverse order:

  1. No.
  2. Experts, unbiased by commercial ties.
  3. Because screening the general population, i.e. “average risk” women, makes no sense, medically or economically. [I would add to that, because of the first two, ethically also. That is, until there’s a perfect test to screen for ovarian cancer, we’re better off not doing it.]

The USPSTF has a lot of enemies. Among them are cancer advocacy groups, cancer survivors, and companies (both testing companies and medical enterprises) that make a lot of money from disease-mongering. Though it’s unpopular to say it, and hits patients and families directly in the solar plexus when they’ve been through the medical ringer and simply don’t want what happened to them happening to other people, non-evidence-based screening is wrong.

We only hear about the “successes.” The message about screening is powerful. Anecdotes always are.

But there are many more people harmed by the cost,  hassle, and anxiety caused by “abnormal” screening tests than benefit from it.

Lest you think I’m picking on women, I feel the same way about the PSA test for men. (Just ask my Dad.)

Lest you think I’m a total crackpot, I heartily support screening tests for cervical cancer (PAP smears) and colon cancer (colonscopies, and other sundry tests). The medical evidence supports them. I ESPECIALLY support VACCINATION. There. I said it. It’s a medical no-brainer.

Ovarian cancer sucks. By the time it’s diagnosed, it’s usually in advanced stages which confers a very low five year survival rate (<26% if the cancer has spread to sites beyond the pelvis at the time of diagnosis).

I wish we had a screening test. But checking CA-125 in well women is a recipe for medical churn. It’s great business for gynecologists. And for those few cases of ovarian cancer that are discovered (like looking for needles in haystacks), it’s great for their GYN-oncologist brothers and sisters.

There are select populations in whom CA-125 and a pelvic ultrasound make sense: People whose mothers or sisters have/had ovarian cancer. People that have had the disease and are monitoring treatment. People testing positive or in families positive for BRCA-1 and 2 mutations.

I’d love to hear your thoughts about this. Chime in with a comment.

11 Comments

  1. I’m a primary care doctor, and my mom died of ovarian ca at age 57. I’m also Jewish, so I seem to be at higher risk of the disease, though I am BRCA1 and 2 negative. I am currently a patient in the National Ovarian Cancer Early Detection Program, a long-term study looking for an ovarian ca tumor marker.

    While I agree with what the USPTF says about ovarian ca screening, I wish NIH, etc. would put more money into trying to find a good screening test. Treatment is so overrated, especially when it hardly ever works.

    • glasshospital

      September 11, 2012 at 5:43 pm

      Thanks for the comment. Based on your family history, I’m glad (and it sounds fortunate) that you’re part of the long-term study to find a better tumor marker. If one is found, it could become a screening test perhaps…?

      The USPSTF recommendation against general population screening certainly wouldn’t apply to you.

  2. wow- thank you for this post!

  3. Isabelle Headrick

    September 11, 2012 at 10:21 pm

    Hi John,
    Not being a doctor or expert, my reaction is the same as when the Dept of Health and Human Services said that women shouldn’t be screened for breast cancer starting at age 40 (and maybe your argument doesn’t encompass that). At the time we were told that too many women were getting false positives which caused them undue stress and anxiety. But the damage caused by a false positive cannot on ANY level be equated with the damage caused by a false negative, or lack of diagnosis altogether.

    Anecdotally (!) speaking, I have a friend who is in amazing health, no family history, who was diagnosed with BC at age 40 with her first mammogram. I, on the other hand, who at 43 is the same age my mom was when she was diagnosed with BC, have had a couple of false positives which resulted in a few hours of “oh shit” followed by “whew!”. So yes, I get myself tested early and often, for which I pay lots of money and put my breast doctor’s and radiologists’ kids through college, etc. And I may be an obvious candidate for this type of uber-testing. But since most BCs—whether this is the case for OC or not I don’t know—are not a result of genetic mutations but of the overarching risk factor of living in the US, it makes sense to me intuitively that screenings should not be limited to those with family histories.

    Like I said, what you are talking about may have nothing to do with breast cancer, so I apologize if I’m completely missing your point. I just wanted to raise the problem of equating the hassle of false positives with the dangers of no negatives.

    best to you all and hope to see you at thanksgiving!
    Isabelle

  4. Thanks for the comment and being willing to share your stories.

    Yes, this was about ovarian cancer screeing only.

    Mammographic screening for breast cancer inovolves different controversies that I will not wade into here. You’ll have to wait for the book. (Don’t interpret that as a total non-endorsement of mammography).

    -JS

  5. we need to better understand ovarian cancer .The currently thought of disease may not even originate in the ovaries ie it’s a peritoneal disease . Maybe ” ovarian cancer” doesn’t have an early stage perhaps it becomes a widespread killer from a yet undetermined pre disease.All challenging and slightly depressing thoughts.
    But until we understand it better we may not have a good screening test
    First do no harm I agree it is a dreadful disease but don’t give women false hope and potentially do them harm in the process

  6. Hey John,

    Thanks for the post. It’s a difficult conversation to have with patients in 7 minutes flat! Unrelated, but I’m curious to hear how you feel about new evidence showing lung cancer mortality benefit with low dose CT of the chest for heavy smokers? Some of the pulmonologists in my hospital are starting to push it, but I think it’s too new for USPSTF to have evaluated it.

    Cheers,
    Dan

  7. glasshospital

    September 16, 2012 at 1:10 pm

    USPSTF’s last update on lung cancer screening was 2004. According to American Lung Assn. (who unsurprisingly recommends low dose CT screening of smokers based on the NLST) USPSTF will soon look at the new available evidence and make a recommendation.

    The NLST and the change in recommendation to screen smokers is controversial, like a lot of this stuff. I’ve seen pulmonologists push screening, too. When you’re a hammer, we go after nails. I’ve had two patients request it of me, and after long conversations agreed to order it.

    Don’t need to tell you, but quitting smoking is the FAR safer and more cost-effective way to prevent lung cancer and avoid unnecessary screening.

    In my seven minutes, I try to push tobacco cessation. Smoking rates are high in Oklahoma (top 5 in the country, around 25%). I don’t want to add a lot of radiation to the masses–low dose or otherwise.

    This post is pretty good on the controversies–especially the 2nd half of it, which echoes things I’ve read about (both of the books are great and well worth it) and written about:
    http://pulmccm.org/main/2012/review-articles/american-lung-association-recommends-ct-screening-for-lung-cancer/

  8. Just curious…on the average, how much is a Ca-125 and what is the rate of false positives and false negatives for those who have been screened with it?

  9. glasshospital

    October 1, 2012 at 12:06 pm

    A quick web search turned up a price range for the assay of $79-200.

    from the esteemed medical source, Wikipedia, on CA-125 (any test that can turn ‘positive’ from routine menstruation seems iffy to me):

    Specificity and sensitivity

    CA-125 has limited specificity for ovarian cancer because elevated CA-125 levels can be found in individuals without ovarian cancer. For example, while CA-125 is best known as a marker for ovarian cancer,[24] it may also be elevated in other cancers, including endometrial cancer, fallopian tube cancer, lung cancer, breast cancer and gastrointestinal cancer.[4] CA-125 may also be elevated in a number of relatively benign conditions, such as endometriosis,[25] several diseases of the ovary, menstruation[22] and pregnancy.[26] It also tends to be elevated in the presence of any inflammatory condition in the abdominal area, both cancerous and benign.[27] Thus, CA-125 testing is not perfectly specific for ovarian cancer and often results in false positives.[22] The specificity of CA-125 is particularly low in premenopausal women because many benign conditions that cause fluctuations in CA-125 levels, such as menstruation, pregnancy, and pelvic inflammatory disease, are seen in this population.[21]

    CA-125 testing is also not perfectly sensitive for detecting ovarian cancer because not every patient with cancer will have elevated levels of CA-125 in their blood.[28] For example, 79% of all ovarian cancers are positive for CA-125, whereas the remainder do not express this antigen at all.[29] Also, only about 50% of patients with early stage ovarian cancer have elevated CA-125 levels.[30] Since many patients with early stage ovarian cancer do not have elevated levels of CA-125, this biomarker has poor sensitivity for ovarian cancer, especially before the onset of symptoms.[22]

    –JS

  10. Interesting. That’s a lot of information to give a patient asking for that test! It won’t deter those that have heard about it and are generally test lovers. Even if educated they feel wronged, so I just give in. Fortunately, most don’t ask. I’m not sure insurance companies cover it for the purpose of screening which is how I code it ( ICD-9)

    Here’s my sweet story of the day:
    Today, on Piedmont Ave., I passed a frail elderly woman with a plastic bag I first took for a bag lady who was going to ask me for money. Then I stopped and took a better look and the poor thing was dressed nicely, carrying a heavy small bag of groceries and holding onto a post. Looked like she had rheumatoid arthritis. She just wanted help across the street to get to her car. So she gave me her bag, and held my arm and millimeter by millimeter we crossed the street. She had gone out without her cane, I suppose. I guess it teaches you to really re-evaluate the automatic judgments that come to mind.

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