Screening Recommendation for 56-Year-Old Woman with Maternal History of Ovarian Cancer
Routine screening with CA-125 or transvaginal ultrasound is not recommended for this patient, as the harms of screening outweigh the benefits even in women with a single first-degree relative with ovarian cancer. 1
Key Recommendation
The U.S. Preventive Services Task Force (USPSTF) gives a Grade D recommendation (recommends against) screening for ovarian cancer in asymptomatic women, including those with a family history of ovarian cancer. 1 This is the most recent and authoritative guideline position, reaffirmed in 2012-2013.
Why Screening Is Not Recommended
Evidence Against Screening Effectiveness
- No mortality benefit: Annual screening with transvaginal ultrasound and CA-125 does not reduce ovarian cancer deaths, even in women with family history. 1
- In the only randomized trial reporting mortality outcomes, women with a family history of ovarian or breast cancer comprised 17% of participants, and the overall trial showed no mortality benefit for any subgroup. 1
Substantial Harms of Screening
- High false-positive rate: For every 10,000 women screened annually, 300 (using CA-125) or 350 (using ultrasound) without cancer would be recalled for further testing, causing anxiety. 1
- Unnecessary surgery: Of those recalled, 20 (CA-125) or 65 (ultrasound) women without cancer would undergo surgery each year. 1
- Poor positive predictive value: At best, only 2% of positive screening tests represent actual cancer in average-risk women. 1
What Defines "High-Risk" Family History
Your patient does not meet criteria for high-risk family history, which requires: 1
- Two or more first- or second-degree relatives with ovarian cancer, OR
- A combination of breast and ovarian cancer in the family, OR
- For Ashkenazi Jewish women: one first-degree relative (or two second-degree relatives on the same side) with breast or ovarian cancer
Having only a mother with ovarian cancer (one first-degree relative) does not constitute "high-risk" by guideline definitions. 1
What You Should Do Instead
Genetic Counseling Referral
- Consider referral for genetic counseling to assess for BRCA1/BRCA2 mutations or Lynch syndrome, particularly if: 1
- Mother was diagnosed at young age (<50 years)
- There is additional family history of breast cancer
- Patient is of Ashkenazi Jewish descent
- There are other cancers in the family suggesting Lynch syndrome
Clinical Vigilance
- The American College of Obstetricians and Gynecologists (ACOG) recommends remaining vigilant for early signs and symptoms of ovarian cancer rather than routine screening. 1
- Symptoms to evaluate promptly include: 1
- Abdominal or pelvic pain
- Unexplained weight loss
- Bloating or increased abdominal size
- Early satiety
Risk Reduction Strategies
Discuss proven risk-reduction methods: 1
- Oral contraceptive use (most significant modifiable factor)
- Pregnancy and breastfeeding history
- Bilateral tubal ligation reduces risk
- Risk-reducing salpingo-oophorectomy (only for confirmed genetic mutation carriers)
Common Pitfalls to Avoid
- Do not order "just one" CA-125 or ultrasound thinking it will provide reassurance—this leads to the cascade of false positives and unnecessary interventions described above. 1
- Do not assume family history alone justifies screening—even expert opinion from older guidelines suggesting screening for high-risk women has not been validated by subsequent trials. 1
- Recognize that no medical organization recommends routine ovarian cancer screening, including the American Cancer Society, ACOG, and Canadian Task Force. 1
If Patient Insists on Screening
If the patient strongly desires screening despite counseling about lack of benefit and potential harms: 1
- Document thorough discussion of evidence showing no mortality benefit
- Explain specific risks: false positives, unnecessary surgery, anxiety
- Note that even in high-risk screening studies, sensitivity ranges from 75-89% with specificity of 98-99%, meaning cancers can still be missed and false positives are common. 2, 3