What is the most appropriate screening approach for a 40-year-old asymptomatic woman with a family history of ovarian cancer?

Appropriate Screening Approach for Ovarian Cancer in Women with Family History

The correct answer is B - counseling about ovarian cancer symptoms. The USPSTF gives a Grade D recommendation (recommends against) screening for ovarian cancer in all asymptomatic women, including those with a family history, because screening does not reduce mortality and causes significant harms through false-positive results and unnecessary surgeries 1, 2.

Why Screening Tests Are Not Recommended

Neither CA-125 nor transvaginal ultrasound should be used for routine screening, even in women with family history. The evidence is clear and consistent:

• The PLCO trial of 78,216 women (17% with family history) demonstrated no reduction in ovarian cancer deaths with annual CA-125 and transvaginal ultrasound screening, with actually more deaths in the screened group (118 vs 100 deaths, relative risk 1.18) 2, 3
• Screening produces a high false-positive rate: approximately 300 women (using CA-125) or 350 women (using ultrasound) per 10,000 screened will be recalled for further testing despite not having cancer 1, 2
• The positive predictive value is only 1-2%, meaning 98-99% of positive screening tests are false positives 1, 3
• Approximately 20 women (CA-125) or 65 women (ultrasound) per 10,000 screened will undergo unnecessary surgery each year 1, 2
• Nearly 21 major complications occur per 100 surgical procedures performed for false-positive results 3

The Correct Approach: Symptom Counseling and Risk Assessment

Counseling about ovarian cancer symptoms is the appropriate intervention because:

• The American College of Obstetricians and Gynecologists recommends remaining vigilant for early signs and symptoms rather than routine screening 1, 2
• The American College of Family Physicians specifically recommends focusing on symptom awareness and educating patients about ovarian cancer symptoms 3
• Key symptoms to discuss include: abdominal or pelvic pain, unexplained weight loss, bloating or increased abdominal size, and early satiety 2, 3

Critical Next Step: Genetic Counseling Referral

This patient requires evaluation for genetic counseling referral based on her family history details 2, 3:

• Referral criteria include: two or more first- or second-degree relatives with ovarian cancer, or a combination of breast and ovarian cancer in the family 1, 2
• For Ashkenazi Jewish women: one first-degree relative or two second-degree relatives on the same side with breast or ovarian cancer 1, 3
• If genetic testing reveals a BRCA mutation, management changes entirely, potentially including risk-reducing bilateral salpingo-oophorectomy between ages 35-40 (BRCA1) or 40-45 (BRCA2) 4
• Women with confirmed BRCA mutations who decline surgery may be offered 6-monthly transvaginal ultrasound plus CA-125 starting at age 30-35, though this has limited effectiveness 2, 4

Risk-Reducing Factors to Discuss

Counsel about proven risk-reduction methods 1, 2, 3:

• Oral contraceptive use reduces ovarian cancer risk by approximately 50% 3
• Other protective factors include pregnancy, breastfeeding, and bilateral tubal ligation 1, 2

Why Other Options Are Incorrect

Option A (CA-125): Not recommended for screening due to lack of mortality benefit and high false-positive rate, particularly in premenopausal women where CA-125 is frequently elevated for benign reasons 1

Option C (Transvaginal ultrasound): Not recommended for screening as it does not reduce mortality and leads to unnecessary surgeries 1, 2

Option D (CEA): Carcinoembryonic antigen is not a marker for ovarian cancer and has no role in ovarian cancer screening 1

Common Pitfall to Avoid

Do not order screening tests simply because a patient has a family history. The evidence shows no mortality benefit even in this higher-risk population, and the harms from false-positives remain substantial 1, 2. Instead, focus on genetic risk assessment and symptom education 2, 3.