In the JournalsPerspective

USPSTF recommends against ovarian cancer screening in asymptomatic women

The U.S. Preventive Services Task Force does not recommend ovarian cancer screening for asymptomatic women who are not known to have a high-risk hereditary cancer syndrome.

The recommendation is based on four trials including 293,587 participants that evaluated ovarian cancer mortality or psychological outcomes associated with three screening interventions: CA-125 testing alone, CA-125 testing plus transvaginal ultrasound and transvaginal ultrasound alone produced mixed results.

“Evidence shows that current screening methods do not prevent women from dying of ovarian cancer and that screening can lead to unnecessary surgery in women without cancer,” Michael J. Barry, MD, task force member and director of the Informed Medical Decisions Program at Massachusetts General Hospital, said in a press release.

“Given the lack of mortality benefit of screening, and the moderate to substantial harms that could result from false-positive screening test results and subsequent surgery, the USPSTF concludes with moderate certainty that the harms of screening for ovarian cancer outweigh the benefit, and the net balance of the benefit and harms of screening is negative,” the task force wrote in its recommendation, published in JAMA.

Primary care physicians can still help improve their female patients’ health, according to another task force member.

Chien Wen-Tseng
Chien-Wen Tseng

 

“There are many ways that primary care physicians can help improve women’s health, including screening the appropriate women for breast, cervical, and colorectal cancer, prescribing a statin for those at higher risk for cardiovascular disease, and referring people with obesity to programs that can help them reach a healthy weight. Unless a woman is at high risk for ovarian cancer or raises specific concerns, clinicians’ limited time should be spent ensuring that women get the preventive services that have been proven to help them live longer, healthier lives,” Chien-Wen Tseng, MD , MPH, MSEE, of the department of family medicine and community health at the University of Hawaii and a USPSTF member, told Healio Family Medicine.

Further research is needed on new screening strategies that “minimize false-positive results and be highly specific,” the task force wrote. In addition, more specific and sensitive serologic tests and better imaging techniques are also in demand, as are additional studies on preventing ovarian cancer and studies that look at the benefits and harms of screening strategies.

The recommendation mirrors the group’s 2012 recommendation, according to a press release. The task force also noted that no major U.S. public health or medical society recommends ovarian cancer screening.

In a related editorial, Karen H. Lu, MD, of the department of gynecologic oncology at the University of Texas MD Anderson Cancer Center wrote that the “important lessons” learned over the past 20 years — a two-stage strategy that has an affordable test followed by an imaging test; samples used for finding new biomarkers need to be “prediagnostic”; biomarker validation; and a prevention strategy— should be utilized to create a method of detecting ovarian cancer early.

She wrote that her suggestions are based on the changing mindset of where ovarian cancer originates.

“It appears that many high-grade serous ovarian cancers ... may not originate from the ovarian surface epithelium, as was previously believed, but rather from the fimbrial epithelium of the fallopian tube. Early and microscopic cancers in prophylactic specimens from women with BRCA1 or BRCA2 genetic mutations are fallopian tube cancers, and surgical removal of the fallopian tubes and ovaries are the foundation of prevention in these high-risk women,” Lu wrote. “Broadening the strategy to include accurate risk models and genetic testing, novel prevention options, and effective early detection may help reduce the incidence and high mortality associated with ovarian cancer.”– by Janel Miller

References:

Henderson JT, et al. JAMA. 2018:doi:10.1001/jama.2017.21421.

Lu, KH. JAMA. Feb. 13, 2018. Vol. 9, No. 6, pages 557-558.

U.S. Preventive Task Force. JAMA. Feb. 13, 2018. Vol. 9, No. 6, pages 588-594.

Disclosures: Please see the studies for the authors’ relevant financial disclosures.

The U.S. Preventive Services Task Force does not recommend ovarian cancer screening for asymptomatic women who are not known to have a high-risk hereditary cancer syndrome.

The recommendation is based on four trials including 293,587 participants that evaluated ovarian cancer mortality or psychological outcomes associated with three screening interventions: CA-125 testing alone, CA-125 testing plus transvaginal ultrasound and transvaginal ultrasound alone produced mixed results.

“Evidence shows that current screening methods do not prevent women from dying of ovarian cancer and that screening can lead to unnecessary surgery in women without cancer,” Michael J. Barry, MD, task force member and director of the Informed Medical Decisions Program at Massachusetts General Hospital, said in a press release.

“Given the lack of mortality benefit of screening, and the moderate to substantial harms that could result from false-positive screening test results and subsequent surgery, the USPSTF concludes with moderate certainty that the harms of screening for ovarian cancer outweigh the benefit, and the net balance of the benefit and harms of screening is negative,” the task force wrote in its recommendation, published in JAMA.

Primary care physicians can still help improve their female patients’ health, according to another task force member.

Chien Wen-Tseng
Chien-Wen Tseng

 

“There are many ways that primary care physicians can help improve women’s health, including screening the appropriate women for breast, cervical, and colorectal cancer, prescribing a statin for those at higher risk for cardiovascular disease, and referring people with obesity to programs that can help them reach a healthy weight. Unless a woman is at high risk for ovarian cancer or raises specific concerns, clinicians’ limited time should be spent ensuring that women get the preventive services that have been proven to help them live longer, healthier lives,” Chien-Wen Tseng, MD , MPH, MSEE, of the department of family medicine and community health at the University of Hawaii and a USPSTF member, told Healio Family Medicine.

Further research is needed on new screening strategies that “minimize false-positive results and be highly specific,” the task force wrote. In addition, more specific and sensitive serologic tests and better imaging techniques are also in demand, as are additional studies on preventing ovarian cancer and studies that look at the benefits and harms of screening strategies.

The recommendation mirrors the group’s 2012 recommendation, according to a press release. The task force also noted that no major U.S. public health or medical society recommends ovarian cancer screening.

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In a related editorial, Karen H. Lu, MD, of the department of gynecologic oncology at the University of Texas MD Anderson Cancer Center wrote that the “important lessons” learned over the past 20 years — a two-stage strategy that has an affordable test followed by an imaging test; samples used for finding new biomarkers need to be “prediagnostic”; biomarker validation; and a prevention strategy— should be utilized to create a method of detecting ovarian cancer early.

She wrote that her suggestions are based on the changing mindset of where ovarian cancer originates.

“It appears that many high-grade serous ovarian cancers ... may not originate from the ovarian surface epithelium, as was previously believed, but rather from the fimbrial epithelium of the fallopian tube. Early and microscopic cancers in prophylactic specimens from women with BRCA1 or BRCA2 genetic mutations are fallopian tube cancers, and surgical removal of the fallopian tubes and ovaries are the foundation of prevention in these high-risk women,” Lu wrote. “Broadening the strategy to include accurate risk models and genetic testing, novel prevention options, and effective early detection may help reduce the incidence and high mortality associated with ovarian cancer.”– by Janel Miller

References:

Henderson JT, et al. JAMA. 2018:doi:10.1001/jama.2017.21421.

Lu, KH. JAMA. Feb. 13, 2018. Vol. 9, No. 6, pages 557-558.

U.S. Preventive Task Force. JAMA. Feb. 13, 2018. Vol. 9, No. 6, pages 588-594.

Disclosures: Please see the studies for the authors’ relevant financial disclosures.

    Perspective
    Maurie Markman

    Maurie Markman

    Considerable efforts have been undertaken by multiple investigators to develop and subsequently validate the clinical utility of an ovarian cancer screening strategy. The justification for these endeavors is not difficult to understand considering the observation the large majority of women found to have this malignancy are diagnosed with advanced disease (stage III or IV). The basic approach employed by multiple research groups has been to argue that through obtaining serial biomarkers (likely serum), routine pelvic ultrasounds, or a combination of biomarker and imaging, it would be possible to discover the disease at the earliest possible time (stage I), where existing data suggest a far superior cure rate. A more recent approach has explored changes in biomarker levels from baseline in the individual rather than considering the population-based normal range.

    These strategies have assumed that by simply finding the disease at an earlier point in time, it will be possible to substantially change the natural history of the malignancy, meaning that the underlying molecular biology of stage I cancers discovered through screening will be the same as (or similar to) that of the uncommon situation where ovarian cancer is currently found to be stage I. There are other theoretical and practical concerns with the development of an effective epithelial ovarian cancer screening strategy, including the fact that most malignancies are high grade; normal ovaries are relatively small, and their location will be difficult to image within the pelvis; and the normal peristaltic motion of the bowel will assist in the early dissemination of escaped tumor cells throughout the abdominal cavity.

    Therefore, while very disappointing, it should not be surprising that existing data fail to support the clinical utility of any of the currently proposed ovarian cancer screening strategies. The recently published update from the USPSTF has confirmed their previous conclusions that “in randomized trials conducted among average-risk asymptomatic women, ovarian cancer mortality did not significantly differ between screened women and those with no screening or in usual care.” Further, these data again emphasize the potential harms associated with screening including the morbidity associated with unnecessary surgical intervention in women who are not found to have cancer. In the opinion of this commentator, the conclusion of the USPSTF that “recommends against screening for ovarian cancer in asymptomatic women” is justified based on existing data from well-designed and conducted large population based randomized clinical trials.

    • Maurie Markman, MD
    • president, medicine and science, Cancer Treatment Centers of America
      editorial board member, HemOnc Today

    Disclosures: Markman reports no relevant financial disclosures.