How I approach ovarian cancer screening with patients

How I approach ovarian cancer screening with patients Ovarian cancer screening clearly touches a nerve.

No one doubts that ovarian cancer is a devastating diagnosis, often found when the disease is at an advanced stage. Tests to look for the disease, such as the transvaginal ultrasound or the CA-125 blood test, are not specific enough. That leads to false positive tests that necessitate more studies that may not be beneficial to patients.

A recent anecdote on this blog talked about how the CA-125 blood test turned into a $50,000 ordeal.

But if you also read the ensuing comments, plenty of people are not persuaded and would ask for ovarian cancer screening anyways.

And many doctors think along the same lines, despite the fact that no professional medical organization, including the USPSTF and the American Congress of Obstetricians and Gynecologists, recommends screening for ovarian cancer.

According to a study from the Annals of Internal Medicine, primary care doctors responded to several ovarian cancer screening vignettes:

Some 28.5% of the 1,088 primary-care docs — OB/GYNs, family physicians and general internists — surveyed said they “sometimes” or “almost always” offered or ordered ovarian-cancer screening tests for low-risk women. When the vignette involved a woman at medium risk of the disease, that proportion jumped to 65.4% of physicians.

What’s more interesting is when the doctor is faced with a patient who specifically asked to be screened:

The study also found that physicians were more likely to say they’d order screening for patients who requested it — even if the doctor herself didn’t believe screening was effective.

Why? According to the authors, “physicians may be trying to maintain a relationship with the patient, or they ‘may lack confidence in explaining why the test is more harmful than beneficial.’”

Perhaps.

Another reason would be the fear of malpractice. If a doctor didn’t screen for ovarian cancer and missed the disease, that’s almost a certain malpractice lawsuit. Ask Daniel Merenstein, who was sued in such a scenario involving prostate cancer screening.

Immunizing doctors who adhere to evidence-based practice guidelines from lawsuits makes sense in these cases. Nobody recommends ovarian cancer screening, and doctors who miss such cancers shouldn’t be penalized for following established practice guidelines.

Another approach is to discuss the pros and cons of ovarian cancer screening with patients. Make them understand what the current guidelines are, explain the limits of testing, and anticipate the potential need for future, more invasive, studies. If patients still want to go down that path, then order the test, documenting that it was a shared decision between doctor and patient.

With malpractice reform unlikely to happen anytime soon, it’s the latter approach I recommend when it comes to ovarian cancer screening.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Christine Molloy

    As is usually the case, what has not been mentioned here is the importance of regular pelvic exams. I am aware that ovarian cancer is difficult to detect in its later stages. I am also aware that I have a mother who went for an overdue annual pelvic exam, with no symptoms, and thought to have fibroids, which they were not. She had a diligent doctor who pursued this and those fibroids were actually Stage 2 ovarian cancer. There may not be approved screening for this cancer but rest assured, I get regular CA 125′s done as well as transvaginal ultrasounds (yearly basis). They might not pick up an ovarian cancer, but they could. And it could save my life.My doctor does not do this to avoid malpractice or to appease me; she does it because she values my life.

  • http://twitter.com/DoctorPullen Edward Pullen

    A very emotional issue.  Still Kevin, this discussion is not a brief one, say a minimum of 2-3 minutes, or nearly 10% of a 30 minute PE appointment.  Does anyone believe that a discussion of CA-125 testing deserves 10% of the preventative and management time of a woman’s annual PE.  I hope not.  This post is politically correct, the “best practice” only if time was not an element of decision making.  Time spent discussing weight loss, exercise, diet, immunizations, colon cancer screening, smoking cessation, and the list goes on is far more valuable.  

    • http://www.kevinmd.com kevinmd

      I don’t voluntarily bring up ovarian cancer screening routinely, as it is not recommended by any clinical guideline. This approach only applies to patients who specifically ask for the test.

      Kevin

      • http://twitter.com/zindoc Keith Marton

        We live in an uncertain, imperfect world. The best we can do is to choose in which direction our potential errors will lead us. Kevin’s approach of honestly stating the pro’s and con’s of a spontaneous patient request to undergo CA-125 testing and then honoring the patient’s subsequent decision minimizes the chances of overlooking a patient concern. To me, that sounds like the right direction.

    • Anonymous

      What is there to discuss about weight loss?  ALL overweight people know they are overweight and they all know that eating less and exercising more is what is called for.  They all know this. If they don’t loose the weight they are accepting those risks.  All smokers know that smoking can make them sick.  Everyone knows that exercise is good for you.  Everyone knows to eat his or her vegetables and lay off the candy and chips.  What we do not know and what we need to have explained to us are the limitations of certain preventative tests.  

      Ironically we accept the above-mentioned risks that are most certainly associated with a whole slew of disease but we will demand a test that has not been proven to reduce the mortality rate of the disease it is supposed to prevent.

  • Sarah Wells

    Physicians cannpot and should not be immunized from patient -specific appropriate care.  Evidence based guidelines are not going to be an appropriate measure of individual needs, priorities or outcome.   You are not managing a herd,  but a single patient.  That’s who counts,  and no one and nothing else.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Well, as the posts have shown, this is a “hot potato.”  I believe that Dr. Pho’s approach is the correct one.   Further comments by Dr. Pullen are very useful.  The list of items needed to be discussed are necessary as evidence has shown that brief comments by doctors concerning these topics have a positive impact.  Physician discussion of weight loss, for instance, can be a very motivating factor for a patient. 

    Thanks again, Dr. Pho, for taking the risks of the discussions that you lead.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    This is a volatile subject especially in women who have been traumatized by losing a loved one or friend to the disease. Kevin’s approach makes sense and is very professional. I wonder how many patients would choose to go ahead with the testing after they have been explained the pros and cons and that they are low risk if they were paying for the testing out of their pocket instead of using their insurance?

    • Anonymous

      Not that I condone willy nilly blood tests, but as a point of information, there are labs all over the place that will do blood testing without a doctor’s prescription.  The cost of a CA 125 is under $50.

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