THE MODERN GYNECOLOGIC EXAMINATION & SCREENING FOR GYNECOLOGIC MALIGNANCIES Denise Uyar, MD Associate Professor OB/GYN Chief Gynecologic Oncology Medical College of Wisconsin April 12, 2019 NO DISCLOSURES 1
The Annual Gynecologic Examination The philosophy: to identify disease in order to institute effective therapy early. The annual gynecologic exam with cervical cytology had been the central component of the well woman exam. The concept of the well woman exam is evolving. The screening pelvic examination has become controversial. The Updated Gynecologic Examination ACOG currently places emphasis on obtaining a thorough comprehensive history to inform providers whether certain aspects of the physical exam are needed. Components of the physical exam may not be required for every well visit. Interval and scope of visits may vary. The periodic well woman exam is an opportunity: counseling on effective preventative care practices /healthy lifestyles counseling on reproductive health and contraception counseling on immunizations based on age/ risk factors counseling on interpersonal violence and substance/ tobacco abuse shared decision making discussions on current screening methods available for diabetes, HIV, HTN, depression, violence and malignancies. 2
Cervical Cancer Screening Evidence based guidelines recommend cytologic screening from ages 21-29 years at 3 year intervals. Ages 30-64 years screening can be cytologic every 3 years or cytology + high risk HPV co-testing every 5 years. In women who have had negative serial screening Pap smears, testing can be discontinued at age 65. Screening can be discontinued sooner if no history of high grade dysplasia and total hysterectomy has been performed. Cervical Cancer Screening: High-Risk Populations Guidelines are lacking HIV: CDC recommends initiation of screening at time of diagnosis; screening twice in first year and then annually Transplant: annual cytology and pelvic examination Autoimmune Disease/ immunosuppressive therapy: annual cytology thought to be reasonable Hx of prior high grade dysplasia: after a period of increased screening may return to routine screening to continue for 20 years 3
Cervical Cancer Screening Clinicians can reduce the burden of cervical cancer by increasing screening among women who have not had regular screening. Women can reduce their initial risk through HPV vaccination. HPV vaccination remains an underutilized cancer prevention strategy. Cervical Cancer Screening: Emerging Data Preliminary data suggests that primary HPV screening is an effective and appropriate screening alternative for women ages 25-65 Roche Cobas HPV test is the only FDA test approved in the US for stand alone cervical cancer screening. In the US, HPV alone testing strategy has yet to be accepted over co-testing. In 2018, the FDA approved the use of Gardasil 9-valent HPV vaccine to include women and men from ages 27-45 The CDC has yet to update its HPV vaccine recommendations 4
Ovarian Cancer Screening Most deadly gynecologic cancer Randomized, controlled trial of average risk patients indicated that annual CA 125 and US did not reduce the rate of ovarian cancer diagnosis or mortality. Evidence recommends against screening the average risk patient with CA 125 and/ or US Estimated 20% of ovarian cancers are linked to genetic predisposition BRCA, BRIP1, RAD51C, RAD51D, MSH2, MLH1, MSH6, PMS2 Despite lack of data, NCCN recommends screening with CA 125 and pelvic US every 6 12 months beginning at age 30-35 for women with Lynch syndrome and for short term surveillance of women with BRCA mutations until risk reducing surgery is performed. Ovarian Cancer Screening Well woman visit should include review of family history and referral to genetics if history includes: Personal history of high grade serous ovary/tubal/peritoneal cancer, breast cancer < 50 yo, triple negative breast cancer, breast cancer and 2 relatives with pancreatic or aggressive prostate cancer, Ashkenazi Jewish ancestry Family history of first degree relative meeting above criteria, known BRCA pathogenic variant in close family member, close family member with male breast cancer 5
Endometrial Cancer Screening Most common gynecologic malignancy and incidence is rising Approximately 5% of endometrial cancers are hereditary Lynch Syndrome (mismatch repair deficiency): 50-70% lifetime risk of endometrial cancer and 9-12% risk of ovarian cancer Endometrial Cancer Screening No standard screening test for endometrial cancer in asymptomatic women In high risk women, endometrial biopsy every 1-2 years and pelvic US starting at age 30 or 5-10 years prior to earliest age of first diagnosis of Lynch associated cancer in the family Risk reducing hysterectomy and BSO at 40 yo or completion of child bearing Prevention: maintain a healthy weight, control HTN and DM, OCPs 6
Endometrial Cancer Screening Genetic risk assessment indicated for: Patients with endometrial cancer < age 50 Patient with endometrial cancer or ovarian cancer with colon or other Lynch associated tumor Patients with endometrial cancer or colorectal cancer and a 1st degree relative with a Lynch associated tumor diagnosed before age 50 Patients with colorectal or endometrial cancer diagnosed at any age with 2 or more 1st degree or 2nd degree relatives with Lynch associated tumors regardless of age Vulvar/ Vaginal Cancer Screening Vulvar cancer incidence: 2.5/100,000 Vaginal cancer incidence: 1/100,000 No evidence to support screening Ask about symptoms. Biopsy. HPV vaccine: 97-100% effective against precancerous vulvar and vaginal lesions in women not previously infected with HPV 7
Conclusions The updated well woman examination is not dependent upon a pelvic exam A comprehensive history (including family history) is needed to inform the components of the exam, determine counseling opportunities and needed screening. Identifying women with inherited risk is crucial in risk reduction HPV vaccination and cervical cytology with HPV co-testing are the most important primary and secondary prevention strategies for cervical cancer. Screening with US and CA 125 is recommended only for high risk populations. Screening with endometrial biopsy only recommended for high risk populations. THANK YOU 8