Screening Guidelines And Ageism

Most of the controversy surrounding mammography involves when to start screening - 35? 40? 50? However, the US Preventative Services Task Force has also suggested that the evidence for continued screening after age 75 is lacking. Now there may be some evidence for older women.

Malmgren et al from the Swedish Cancer Institute in Seattle reported on findings to suggest the benefit of continued breast cancer screening in older women.

The researchers recently looked at the impact of mammography detection on older women by studying data from an institutional registry that includes more than 14,000 breast cancer cases with 1,600 patients aged older than 75 years.

The majority of mammography-detected cases were early stage, while physician- and patient-detected cancers were more likely to be advanced stage disease. Patients with mammography-detected invasive breast cancer were more often treated with lumpectomy and radiation and had fewer mastectomies and less chemotherapy than patient- or physician-detected cases.

Mammography detection was associated with a 97% five-year disease-specific invasive cancer survival rate, compared with 87% for patient- or physician-detected invasive cancers.

“Mammography enables detection when breast cancer is at an early stage and is easier to treat with more tolerable options,” said Dr. Malmgren. “In this study, older women with mammography-detected invasive cancer had a 10% reduction in breast cancer disease-specific mortality after 5 years.”

This all has little to do with ultrasound but everything to do with the doctor patient relationship. Ultimately, the decision to screen or not to screen should properly rest with the patient and her doctor, based on medical evidence, not cost. Older folks are people too.

If you've any questions or need to schedule an ultrasound, please call (718) 925-6277.

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Cervical Cancer Rates Rising in Seniors

Recent changes in pap smear frequency suggest that pap smears may no longer be necessary for women 65 years of age or older. There are a few big IF's:

Those with three consecutive negative Pap tests in the last 10 years, or two consecutive negative Pap tests combined with negative HPV tests in the last 10 years, with the most recent test performed within the past 5 years.

Now comes this news.

Previous studies determined that the rate of cervical cancer was approximately 12 cases per 100,000 women in the U.S. The incidence of the disease peaks in women between 40 to 44 years, then tapers off. However, such estimates did not take into account women who had hysterectomies, and are therefore no longer at risk for developing cervical cancer. Once these women were factored out, the incidence of this type of cancer increased to 18.6 cases per 100,000 women. The rate steadily increased as women age, particularly in women between 65 and 69 years of age.

African-American women had a higher incidence of cervical cancer at nearly all ages compared to caucasian women, with the discrepancy becoming more pronounced at older ages.

The study’s lead author Anne F. Rositch, Ph.D., M.S.P.H., an assistant professor of epidemiology and public health at the University of Maryland School of Medicine and a researcher at the University of Maryland Marlene and Stewart Greenebaum Cancer Center, believes these findings are important when reevaluating the screening guidelines for cervical cancer in older women in the U.S. Appropriate interventions need to be initiated to lower the burden of cervical cancer in these women.

Will the abandonment of the annual pap snatch defeat from the jaws of victory in the fight against the cancer that killed Evita Peron? While we do not want to spend precious healthcare dollars on needless testing, we do not want to put women's lives at risk in the process. I would urge any woman to have these conversations with her doctor before choosing either to continue or to forgo pap smears. Choose wisely indeed.

For more information or to schedule an appointment for an ultrasound exam, call: (718)-925-6277.

Five Prenatal Tests Women Over 35 Should Consider

The other day, this piece on prenatal diagnosis appeared in my inbox.

While the CDC reports almost 15 percent of all U.S. babies -- or 1 in 7 -- were born in 2010 to women 35 and over, much tongue-clucking persists about women waiting to have a baby at "advanced maternal age." The reason may stem from data that shows certain risks (such as having a baby with Down syndrome) can increase with age. However, many women are happily embracing motherhood later on.

That said, certain tests and procedures are often recommended for women over 35. Here, 5 prenatal protocols these expectant moms may want to consider and what "older" moms who've been through them say about their experience.

The article goes on to list the 5 tests -

1. amniocentesis
2. nuchal translucency screening
3. Noninvasive Prenatal Testing (NIPT)
4. chorionic villus sampling (CVS)
5. midtrimester ultrasound

While this is a useful article as it provides background prep for moms to be for conversatons with their OB's and midwives, it lumps screening tests together with diagnostic tests, losing some perspective.

So let's look at this issue in another way. Put simply, a screening test is one which is relatively noninvasive, provides odds and stratifies risk, but does not tell you yes or no. A diagnostic test is often more invasive with real risks and answers specific questions. For example, a screening test for Down's Syndrome would yield a risk in the form of odds. A diagnostic test for Down's would yield a definitive result.

Amniocentesis and CVS are diagnostic tests. While they usually provide definitive results (with a few, thankfully rare exceptions,) nuchal translucency, NIPT and midtrimester ultrasound are more screening tests.

Also, some of these are performed in the first trimester, others in the second. NIPT, nuchal scan, and CVS are first trimester tests. The advantage here is that the earlier this hurdle is jumped, the less stressful the longer remainder of the pregnancy is.

Finally, a few words about ultrasound. IMHO, both first and second trimester ultrasound will remain standard in prenatal care, similar to early newborn physicals and the more comprehensive baby visit a month or so after birth. Many abnormalities and syndromes do not have a basis in chromosome complement, thus a test designed to screen for a chromosome issue such as Down's would not find cases of spina bifida, for example.

Prenatal ultrasound is also more than just looking at structure. It keeps pregnancy real in a tangible way for not only mom but also for dad.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Can Ovarian Cancer Be Found Early?

Ovarian cancer is the deadliest of all pelvic cancers for a woman. Overall, about one in seventy-two women will develop this disease. Of these, over half will have died within five years of diagnosis. If ever a disease cried out for a screening test, this would be it. Unlike the breasts, for example, the ovaries lie deep within the body and are therefore less accessible to physical exam. The bimanual pelvic exam is also uncomfortable and the discomfort causes women to tighten the abdominal muscles, making detection that much more difficult. If you add factors such as obesity and scars from Cesareans, you find the examiner's ability to feel the ovaries decreases exponentially.

Ultrasound has been suggested as a screening technique since the 1980's. In the US, the leading proponent of transvaginal ultrasound for ovarian cancer screening has been Dr. Van Nagell's group at the University of Kentucky.

Some have tried utilizing blood markers such as CA-125. Most recently, the group at MD Anderson found that evaluating changes in the level of CA-125 over time and combining that with transvaginal ultrasound yielded promising results in finding more early ovarian cancers.

Others, however, have not met with similar success. The US Preventive Services Task Force, in fact, recommends not screening for ovarian cancer.

Later this year, The UKCTOCS,the largest randomized trial of screening will publish its results, hopefully shedding more light on this issue.

In the meantime, there are some women at significantly higher risk for ovarian cancer, those whose strong family history or genetic tests place in a high risk group. For this group of women, screening, with all its foibles, should be considered. For more information or to schedule an ultrasound, please call: (718) 925-6277.

Hepatitis C: To Screen Or Not To Screen, That Is The Question

Recently, NY State passed a law requiring screening for Hepatitis C be offered to all patients born between 1945 - 1965. Hepatitis C is a potentially fatal disease which can attack the liver silently over time. It is thought that as many as 1 in 30 "Baby Boomers" could be infected with the virus. For these reasons, screening this group makes sense. But of course, as always, there is a catch. It seems the cost of treatment for those infected is prohibitive for all but those on research protocols, better than platinum insurance plans, or those with incomes in the Warren Buffett range. Sovaldi, a new drug for Hep C treatment, costs about $84,0000 for a 12 week treatment.

What can be done about the cost? Right now, not much save to check with your insurer about treatment coverage and copay, etc. Still think screening asymptomatic folks is a good idea? For each individual, the answer may be different. Before asking a question, it's always best to know what you'll do with the answer.