From the Guidelines
The most appropriate strategy for ovarian cancer screening in this patient is no screening. Despite her concerns about ovarian cancer due to her cousin's death and friend's diagnosis, this patient does not meet criteria for routine ovarian cancer screening. She has only one affected relative (cousin) with ovarian cancer, which does not constitute a strong family history. Current evidence, as supported by the U.S. Preventive Services Task Force recommendation statement in 2012 1, does not support screening for ovarian cancer in average-risk women as it has not been shown to reduce mortality and leads to unnecessary procedures with potential complications. Available screening methods like transvaginal ultrasound and CA-125 testing have poor specificity and sensitivity, resulting in false positives that lead to anxiety and invasive procedures. The PLCO Cancer Screening Trial, a randomized, controlled trial, found no difference in ovarian cancer death rates between the screening group and the control group 1.
Some key points to consider in this patient's case include:
- Her age and menopausal status do not increase her risk significantly enough to warrant screening.
- Her history of taking combined oral contraceptives and hormone replacement therapy does not significantly impact the decision for screening.
- The patient's smoking habit is a significant risk factor for many health conditions, and smoking cessation counseling would be beneficial.
- Counseling the patient about recognizing symptoms of ovarian cancer, such as persistent abdominal bloating, pelvic pain, difficulty eating, and urinary symptoms, is a more appropriate approach than screening.
Given the potential harms and lack of benefit, no screening is the most appropriate strategy for this patient. The U.S. Preventive Services Task Force recommends against routine screening for ovarian cancer in asymptomatic women without known genetic mutations that increase risk, as stated in their 2012 recommendation statement 1.
From the Research
Ovarian Cancer Screening
- The patient is concerned about ovarian cancer due to a family history of the disease, but there is no other history of cancer in the family 2.
- The strongest risk factors for ovarian cancer are advancing age and family history of ovarian and breast cancer 2.
- Guidelines recommend against routine screening for ovarian cancer in average-risk women because screening is ineffective and associated with harm 2, 3, 4.
Screening Methods
- Transvaginal ultrasonography and measurement of biomarkers such as cancer antigen 125 are used to diagnose ovarian cancer, but these methods are not recommended for routine screening in average-risk women 2, 3.
- A combination of serum proteins may improve sensitivity, specificity, and positive predictive value, but such studies have yet to be validated 3.
- Annual screening using an algorithm based on serial cancer antigen 125 measurements followed by transvaginal ultrasonography may be beneficial for women at increased risk 2.
Risk Reduction
- Long-term hormonal contraceptive use reduces the risk of ovarian cancer by about 50% 2, 5.
- Risk-reducing salpingo-oophorectomy (RRSO) decreases ovarian cancer incidence and mortality and is recommended for women at over a 4-5% lifetime risk of ovarian cancer 6.
- Opportunistic salpingectomy may be offered at routine gynaecological surgery to all women who have completed their family 6.
Patient-Specific Recommendations
- The patient has a history of combined oral contraceptive use, which may have reduced her risk of ovarian cancer 5.
- The patient's family history of ovarian cancer is limited to a cousin and a friend, which may not significantly increase her risk 2.
- The patient's age and well-controlled hypertension do not significantly impact her risk of ovarian cancer 2.