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.'”
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.
Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today. He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.