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USPSTF releases draft recommendation on ovarian cancer screening
The U.S. Preventive Services Task Force has issued a draft recommendation against screening for ovarian cancer in women without signs or symptoms of the disease, except in instances of women who are known carriers of the genetic mutations that increase the risk for ovarian cancer, such as the BRCA1 or BRCA2.
The task force gave the recommendation a D grade, which is consistent with its 2012 final recommendation, after reviewing four randomized clinical trials containing 293,587 patients.
“After reviewing the evidence, [we] found that current screening tests for ovarian cancer do not adequately identify whether a woman does or does not have ovarian cancer,” Maureen G. Phipps, MD, MPH, task force member and chief of obstetrics and gynecology at Women & Infants Hospital of Rhode Island, told Healio Family Medicine in an interview. “Due to the unreliability of these screening tests, some women may receive a positive screening test result when no cancer is present, which is often called a false-positive result. These women may undergo surgery to remove one or both ovaries and the fallopian tubes when they do not need to do so; this is considered a significant potential harm of screening.”
She acknowledged that detecting cancer in the beginning stages is critical to initiating sometimes successful treatment options, and suggested some dialogue between medical professionals and patients who are concerned about their risk of ovarian cancer.
“Until a more reliable screening test is available to detect ovarian cancer, [we] encourage women who are concerned about their risk of ovarian cancer to have a conversation with their clinician about the potential benefits and harms of screening,” she said.
Phipps also said the draft findings suggest room for improvement across certain components of the disease’s spectrum.
“Given that most cases of ovarian cancer are diagnosed at later stages, when associated mortality is high, further research is needed to identify new screening strategies that could accurately detect ovarian cancer earlier, at a point when outcomes could be improved. Given the potential for serious harms from diagnostic workup of positive screening results, including surgical removal of the ovary, new screening strategies should minimize false-positive results and be highly specific,” she said in the interview.
“Additionally, studies evaluating the benefits and harms of using these screening strategies in women not at increased risk and without signs or symptoms for ovarian cancer are needed. Study outcomes should include ovarian cancer mortality, surgery rates, surgical complication rates, and psychological harms.”
Data from the CDC indicate that ovarian cancer is the fifth most common cause of cancer death among U.S. women. In addition, the National Cancer Institute states that the age-adjusted incidence of ovarian cancer from 2010 to 2014 was 11.4 cases per 100,000 women per year.
The task force’s draft recommendation is consistent with guidelines from AAFP, American Congress of Obstetricians and Gynecologists and the American Cancer Society, all of which recommend against screening for ovarian cancer in asymptomatic, average-risk women.
The new draft statement and evidence review has been posted for public comment on the USPSTF website, at www.uspreventiveservicestaskforce.org. Input will be accepted through Aug. 14 at www.uspreventiveservicestaskforce.org/tfcomment.htm . – by Janel Miller
Disclosure: Phipps reports no relevant financial disclosures.
References:
CDC Web Page on Ovarian Cancer
National Cancer Institute's Web Page on Ovarian Cancer
Perspective
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Ovarian cancer is one of the deadliest cancers in the United States, with 22,440 cases and 14,080 deaths expected in 2017, and the search for an effective ovarian cancer screening method to improve survival through early detection has long been thwarted. The new USPSTF evaluation and recommendations confirm, once again, that ovarian cancer screening of normal-risk women DOES NOT improve outcomes and, in fact, imparts potentially significant harm due to false positive screening tests that result in surgery without improving ovarian cancer mortality. The latest USPSTF recommendation reaffirms the consensus of multiple other national organizations (eg, the FDA, the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology, to name a few) that recommend against any screening of normal-risk populations while potentially leaving the door open for screening of women at high risk for ovarian cancer based on inherited genetic predispositions.
What about ovarian cancer has stymied development of an effective screening paradigm despite overwhelming resources worldwide devoted to the effort? Ovarian cancer misses multiple criteria necessary for diseases that are amenable to successful screening. The first issue is a very low incidence and prevalence of ovarian cancer, which ultimately affects only 1% to 2% of the female population; thus, even a highly sensitive/specific screening test will have relatively poor positive and negative predictive values. Further, it remains unclear if a preclinical, treatable phase of ovarian cancer truly exists or can be detected and if such detection positively impacts mortality. Emerging data have confirmed that ovarian cancer is a much more heterogeneous disease than previously recognized, with multiple likely etiologies. For example, about 65% of high-grade serous “ovarian” cancers likely originate in the fallopian tube. In this scenario, any early detection modalities that rely on radiographic testing (or even serologic testing) may be doomed to failure as dissemination of microscopic cancerous cells occurs prior to the establishment of macroscopic tumor deposits that are radiologically or potentially serologically detectable with current screening regimens. Only time will tell if emerging diagnostics focusing on detection of minute amounts of tumor-related products (eg, cell-free DNA or circulating tumor cells or other changes associated with early carcinogenesis) could ever tip the balance in favor of universal ovarian cancer screening.
For now, our best strategy to decrease ovarian cancer lethality is to focus continued research efforts on: 1) identifying high-risk women who carry an inherited cancer predisposition in order to implement known successful risk-reduction measures that indisputably improve survival, like risk-reducing salpingo-oophorectomy; 2) elucidating the myriad pathways leading to ovarian cancer to identify potential novel screening modalities; and 3) educating providers about already proven effective ovarian cancer risk-reduction measures that are available for all women like birth control pills for chemoprevention and opportunistic salpingectomies. If at all possible, we must focus efforts on ultimately achieving universal ovarian cancer prevention rather than universal ovarian cancer screening.
References:
Falconer H, et al. J Natl Cancer Inst. 2015;107(2).
Jacobs IJ, et al. Lancet. 2016;387:945-956.
Modesitt SC. Cancer Screening in Women. In: Alvarez-Secord A and Gehrig P, eds. Gynecologic Oncology, 1st ed. Landes Bioscience; 2009.
Perets R, Drapkin R. Cancer Res. 2015;76:10-17.
Ring KL, et al. Am J Obstet Gynecol. 2017. [Epub ahead of print]
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