Gynecologic Cancer Screening

Erin Snyder= , MD

7/2/07

1. An 18 year old, healthy female presen= ts for a routine visit. How should y= ou counsel her regarding her need for cancer screening and prevention?

Cervical Canc= er

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HPV Vaccine

Gardasil is currently FDA approved for women ages 9-26
Effective at prevention of HPV types 6,11,16,18. HPV subtypes 16 and 18 are re= sponsible for 50% and 20% of cervical cancers.&= nbsp; Subtypes 6 and 11 cause 80% of genital warts.
Immunization is NOT effective in clearing HPV if the patient already has been expos= ed.
Vaccine doses are given at 0, 2, and 6 months. It is not known if booster immunization is required to maintain immunity.

Breast Cancer=

Most guideline writers have n= ot made recommendations for or against self exams
ACOG recommends yearly clinic= al breast exams, ACP recommends every three years from 20-39 and then yea= rly.

Answer: Needs= pap smear only if she has been sexually active >3 years. Offer Gardasil, especially i= f she is not yet sexually active (ie, no exposure to HPV). Would counsel on safe sexual pract= ice, avoiding HIV/STDs and pregnancy. No need for clinical breast exam, can coun= sel on self exams if you wish.

2. A 40 y= o female comes to see you to establish care. On family history you discover her moth= er was diagnosed with ovarian cancer at age 45, one sister was diagnosed with breast cancer at age 40, and the other sister was diagnosed with breast can= cer at age 38. What is your approach to screening?

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BRCA muta= tion testing: USPSTF recommends that cert= ain families should be offered genetic counseling for BRCA mutations.

1st degree relatives

Two with breast cancer, one diagnosed before age 50
One with bilateral breast cancer

1st or 2nd degree relatives

Three with breast cancer at any age
Two with ovarian cancer at any age
Breast and ovarian cancer in any combination

Any male relative with breast cancer

This patient has three fir= st degree relatives with breast or ovarian cancer, all before age 50. She should get BRCA mutation testi= ng.

Breast Cancer

§ = ACOG/USPSTF recommends that all women 40 and= older be screened with mammography every 1-2 years. ACP has recommended that each doct= or have a discussion regarding risks and benefits of screening for patients 40= -49, prior to recommending mammography.

§ = ACS recommends M= RI screening in addition to mammogram for women who are at especially high ris= k by family history or by common models of risk.

§ = Patients with >1.66% risk of breast cancer by Gail Model can be offered chemopreventio= n of breast cancer with Tamoxifen or Raloxifene. Currently Tamoxifen is the only FDA approved agent for primary chemoprevention of breast cancer

o Potential harms = of tamoxifen are: thromboembolic disease (stroke, DVT, PE) and endometrial cancer<= /span>

o Tamoxifen 20mg d= aily x 5 years, Raloxifene 60mg qd x 5 yrs

Ovarian C= ancer

§ = Currently there = are no guideline writers that recommend ovarian cancer screening in women at avera= ge risk.

§ = Possible screeni= ng choices for higher risk women include:

o CA 125: specific= ity is poor- also positive in a wide range of cancers, as well as lupus, PID, DM, cirrhosis, and at variable times in the normal menstrual cycle. =

o Pelvic ultrasoun= d: sensitivity 80-100%, specificity 94-99%. Better at detecting disease in lower risk wome= n.

o In those women w= ho are at high risk, and request screening, most would recommend yearly CA 125 and pelvic ultrasound if CA 125 >30

Answer: This patient has three first degree relatives diagnosed at young ages with breast or ovarian cancer. She clearly fits the risk profile = for BRCA mutation screening and should be sent for genetic counseling. If she elects not to get the test,= you should consider MRI screening for breast cancer, SERM for chemoprevention, = and CA 125 screening for ovarian cancer.

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3. 68 yea= r old female returns for her routine appointment. She remarks that it has been 4 yea= rs since her last pap smear. She= had a hysterectomy 10 years prior for abnormal bleeding.

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Cervical = Cancer

If a patient= had a complete hysterectomy (ie, no cervix) for a benign reason, then they= no longer need pap smears. = If the hysterectomy was for invasive cervical cancer, there is a risk of dysplastic transformation of vaginal cells. ACOG recommends continuing ye= arly screening indefinitely for these women, although the risk clearly decl= ines over time.

Breast Ca= ncer

There are no clear guidelines on when to stop screening for breast cancer. Most studies were done with w= omen between 40-70 years old. General guidelines for all screening tests would recommend stop= ping when the patients life expectancy is limited to the point where treatm= ent for the disease would not be indicated.

Answer: T= his patient does not need further Pap smears as she has no cervix, and minimal risk of transformation of vaginal cells. There is no ad= equate screening test for ovarian cancer for women at average risk. She should likely continue yearly mammograms +/- clinical breast exams as long as she would be a candidate for treatment if a cancer was found.

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Reference= s

1. USPSTF. The Guide to Clinical Preventive Servi= ces. 2006

2. Smith RA, et al. American Cancer Society Guidelines for the Early Detection of Cancer. CA Ca= ncer J Clin 2003;53:27-43

3. Saslow D et al. = ACS Guidelines for breast cancer screening with MRI as an adjunct to mammograph= y. CA Cancer J Clin 2007; 57:75-89

4. ACOG Practice Bu= lletin Cervical Cytology Screening. Int J Gynecology and Obstetrics 2003; 83:237-4= 7

5. Up To Date 15.1.= Screening for Ovarian Cancer. 2007