On February 13th, in the Journal of the American Medical Association, the US Preventive Services Task Force (USPSTF) published an updated recommendation statement on ovarian cancer screening. Based on a review of the literature, the task force recommended against screening for ovarian cancer in women who do not have any signs or symptoms of the disease, stating that the evidence shows current screening methods do not actually prevent women from dying of ovarian cancer and can sometimes lead to unnecessary surgery in women with no evidence of cancer. This recommendation is consistent with the task force’s 2012 recommendations. Stephanie Blank, MD, a professor of gynecologic oncology at the Icahn School of Medicine at Mount Sinai in New York City, discussed the updated USPSTF recommendations.
-Interviewed by Anna Azvolinsky
Cancer Network: Before we get to the updated guideline, please give us an overview of symptoms of ovarian cancer that women can experience, if any, and tell us whether there are currently ways to screen for ovarian cancer in patients who are suspected to have the disease.
Dr. Blank: Sure, thank you. I would like to make a couple of points, starting with possible symptoms. Just to be clear about these recommendations, screening is really for women without any signs or symptoms of the disease. However, it’s very important to be aware of possible signs and symptoms of ovarian cancer, while recognizing that ovarian cancer is not characterized by a single hallmark sign or symptom. The symptoms that women experience are actually nonspecific and can affect all people at various times; that makes it hard, if you have one of these symptoms, to know whether or not it is related to ovarian cancer. Frankly, most of the time it’s unrelated. One of the hard things about giving people information about signs and symptoms of ovarian cancer is that this can cause women to panic. Nonetheless, signs and symptoms of ovarian cancer include bloating; some degree of abdominal or pelvic pain and urinary frequency; and experiencing changes in bowel movements and the ability to eat. Those are among the main signs of ovarian cancer and, of course, people have these symptoms all the time; however, if one of these symptoms lasts for 2 weeks or longer and does not seem to be improving or is worsening, it is important to see a doctor.
In terms of planning a work-up for women who might have some of these symptoms, of course one should carefully obtain a patient history, conduct a physical, and perform a pelvic exam and transvaginal ultrasound, to evaluate what is going on with the ovaries. There is also a blood test called CA125, which is a blood marker that we follow when a woman is known to have ovarian cancer; however, it is not actually a good screening test. There is also the possibility of performing a CT scan to evaluate a patient for possible ovarian cancer, but that is usually a secondary test.
Now, if someone has no signs or symptoms of disease and is not at increased genetic risk, there is really nothing that we would recommend as far as screening. And when you talk about screening and what these recommendations [from the USPSTF] are about, those are for people who have no signs or symptoms, women who are feeling well and just undergo testing, similar to a screening mammogram or colonoscopy.
Cancer Network: So, the Task Force just recently again recommended against screening for ovarian cancer in women who have no signs or symptoms. Is there anything new in the details of the early 2018 recommendation compared with the Task Force’s 2012 recommendation? What are your general thoughts about this updated USPSTF recommendation?
Dr. Blank: There is really not too much that is new in this recommendation. However, it is still just as valid as it was before. Current screening for ovarian cancer, employing the CA125 blood test and transvaginal ultrasound, is not good enough to warrant use in women with a normal—not elevated—risk of ovarian cancer, and is really one of the reasons that it is especially important to identify women at increased, inherited risk of ovarian cancer through genetic testing. The reason these tests are not suitable as screening tests is that they are not specific enough. There are many reasons that a woman could have elevated CA125 levels, and most of the findings obtained by looking at the ovaries will not be clinically significant. However, if you do have a finding that you cannot otherwise explain, then the next step is oftentimes a surgery. This is a very invasive next step following from a relatively noninvasive test.
Cancer Network: For women who have a family member diagnosed with ovarian cancer, suggesting that they may be at an increased genetic risk of this disease, what screening steps should be taken?
Dr. Blank: It’s important that women at increased genetic risk for ovarian cancer be identified. These women really should undergo risk-reducing surgery, which is removal of the fallopian tubes and ovaries at the age when their risk becomes high enough to warrant it, which varies based on the gene variant they carry. So [genetic testing] is actually much more effective than screening. High-risk women who are not ready for risk-reducing surgery may benefit from ultrasound and CA125 blood testing; we do not have evidence yet that these tests actually save lives, but this is the best screening method that we have at this point. As I mentioned, most women with a normal genetic risk of ovarian cancer will not benefit from screening. However, if you do not know your level of risk, getting a genetic test is more effective and helpful than the [approach to screening for] ovarian cancer that we have right now.
Cancer Network: Is there anything else that patients and clinicians should understand about these new guidelines and ovarian cancer screening in general?
Dr. Blank: Instead of focusing on screening, which is not effective, as I mentioned, finding out your genetic risk for ovarian cancer can basically allow you to potentially avoid a deadly illness. Knowing your complete family history of the disease—and if someone has or had cancer in the family, when and where did it start and at what age was the family member diagnosed—is very helpful, and this information should be shared with your doctor and possibly a genetic counselor. However, I think the other important thing to acknowledge is that [genetic testing] is not going to identify everyone who is at an increased risk for cancer. That said, it is important to maintain one’s knowledge regarding cancer in the family and to maintain good communication with one’s doctor.