YOLANDA LAWSON M.D. , F.A .C.O.GMADEWELL OBGYN

ASSOCIATE ATTENDING BAYLOR UNIVERSITY MEDICAL CENTER

Women's Health Screening Guidelines

Women's Health Screening Guidelines

No disclosures, commercial bias or interests

Women's Health Screening Guidelines

Overview of current screening and compare the current recommendations

Breast Bone HealthCervicalOvarian

Women's Health Screening Guidelines

Whose evidence is substantiated How to apply the evidencePatient populations/demographics of your

practiceResources availableHow to explain and educate your patients

Women's Health Screening Guidelines

Breast CancerUS Preventive Task Forcebiennial screening mammography for women

aged 50 to 74 yearscurrent evidence is insufficient to assess the

additional benefits and harms of screening mammography in women 75 years or older

recommends against teaching breast self-examination (BSE).

Women's Health Screening Guidelines

Insufficient evidence on benefit of digital mammography or MRI

No recommendation on 3D FDA approved reduces call-backs and 40% less false-positives

ACOG recommends annual mammograms starting at age 40

Clinical breast exams annually for 40 and older and 1-3 years for ages 20-39

Women's Health Screening Guidelines

Patients over 75 to discuss and physician and patient decide

American Cancer Society is consistent with ACOG and states as long as the woman is in good health to continue mammograms

Women's Health Screening Guidelines

Hereditary Cancer Screening ToolsBRAC Analysis-hereditary breast and ovarian

cancerColaris- hereditary colon and endometrial

cancerColaris AP- polyposis syndromesMelaris-hereditary melanoma

Women's Health Screening Guidelines

Any male with a personal history of breast cancer or close male relative at any age (BRCA2)

Personal history of female breast cancer ≤ 50

Personal history of epithelial ovarian cancer at any age

Any person of Ashkenazi Jewish descent

A first-degree relative (mother, daughter, sister) diagnosed with simultaneous bilateral breast cancer

Two first-degree relatives diagnosed with breast cancer, one of whom was diagnosed ≤ 50

Three or more first-degree or second-degree (grandmother, aunt) relatives diagnosed with breast and/or epithelial ovarian cancer regardless of their age at diagnosis

A first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis

Two or more close relatives with diagnosis of pancreatic cancer at any age

Personal history of pancreatic cancer at any age with more than two close relatives with breast and/or ovarian and/or pancreatic cancer at any age

Women's Health Screening Guidelines

BRCA=Breast Cancer Susceptibility GeneOne inherits 1 mutated BRCA allele from a

carrier parent but still has one allele to suppress tumor growth. If one allele is damaged by the inevitable genetic errors from age the normal copy fails and the mutated BRCA will be of no help to prevent uncontrolled cell growth

Women's Health Screening Guidelines

1/400-1/800(<1%) of the general population is estimated to carry either the BRCA1 or 2 mutation

Ashkenazi Jews 1/4012% of women in the general population will

develop breast cancer vs. 60% with hereditary BRCA

The Genetic Information Nondiscrimination Act (GINA) is federal law signed in 2008 by President Obama. GINA prohibits Americans from being treating unfairly by health insurers or employers on the basis of DNA information, including information about an individual’s genetic tests and the genetic tests of an individual’s family members.

However, the law does not apply to life, long-term care, or disability insurance! (National Human Genome Research Institute, 2012).

Women's Health Screening Guidelines

17 billion dollars spent on osteoporosis related fractures in the U.S.

Osteoporosis is five times more prevalent in women than men

Women have twice the rate of fracture than men and 80% of hip fractures occur in elderly women

Bone health should be addressed in all of your female patients

Women's Health Screening Guidelines

Bone Density screeningUSPSTF recommends bone density screening

at age 65 and if there are risk factors 60ACOG recommends age 65 unless they have

significant risk factors (smoking, long-term steroid use, rheumatoid arthritis, premature menopause)

8% risk in African-American women over the age of 50

Mexican-Americans have same risk as Caucasians

Women's Health Screening Guidelines

Cervical Cancer screeningNew Guidelines recommend against

screening younger than 21 years revised from previous of age 21 or 3 years after intercourse

Women's Health Screening Guidelines

The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.

recommends against screening for cervical cancer in women younger than age 21 years.

recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.

recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years

Cervical Cancer Screening Guidelines for Average-Risk Women 1

American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP),

and American Society for Clinical Pathology (ASCP) 2

American College of Obstetricians and U.S. Preventive Services Task Force (USPSTF) 3 Gynecologists (ACOG) 4

2012 2012 2012

When to start screening 5

Age 21. Women aged <21 years should not be screened regardless of the age of sexual initiation or other risk fac tors .

(Strong recom m enda tion ) Age 21. (A recom m enda tion) Recom m end against screening women

aged <21 years. (D recom m endation) Age 21 regardless of the age of onset of sexual activity. W om en

aged <21 years should not be screened regardless of age at sexual initiation and other behavior-re lated risk factors. (Level A

evidence)

Statement about annual screening

Women of any age should not be screened annually by any screening method. (Strong recom m enda tion)

Individuals and clinicians can use the annual Pap test screening v is it

as an opportunity to discuss other health problems and preven tive measures. Individuals, clinicians, and health systems should seek effective ways to facilitate the receipt of recom m ended preven tive services at intervals that are beneficial to the patient. Efforts also

should be made to ensure that individuals are able to seek care for additional health concerns as they present.

In women aged 30–65 years, annual cervical cancer screening should not be performed. (Level A evidence) Patients should be counseled that annual well-woman visits are recom mended even if

cervical cancer screening is not performed at each visit.

Screening method and intervals 6

Cytology 21-29 years of age

(conventional or liquid based) 30-65 years of age

HPV co-test 21-29 years of age

(cytology + HP V test adm inis tere d together) 30-65 years of age

Primary HPV testing 9

7 Every 3 years. (Strong recom m enda tion )

Every 3 years. 7 (Strong recom m endation)

HPV co-testing should not be used for women aged <30 years .

Every 5 years (Strong recom m endation ) ; this is the preferre d method (Weak recom m enda tion) .

For women aged 30-65 years, screening by HPV testing alone is

not recom m ended in most clinical settings. (W eak recom m enda tion) 10

Every 3 years. (A recom m endation)

Every 3 years. (A recom m endation)

R ecom mend against HPV co-testing women aged <30 years. (D

recom m endation)

For women who want to extend their screening interval, HPV co-

testing every 5 years is an option. (A recomm endation )

Re com m end against screening for cervical cancer with HPV tes ting (alone or in combination with cytology) in women aged <30 years. (D

recom m endation)

Every 3 years. (Level A evidence)

Every 3 years. (Level A evidence)

HPV co-testing 8 should not be performed in women aged < 30

years. (Level A evidence )

Every 5 years; this is the preferred method. (Level A ev iden ce )

Not addressed.

When to stop screening

Aged >65 years with adequate screening history. 11,12

Aged >65 years with adequate screening history. (D recom m endation) 11

Aged >65 years with adequate screening history 11, 13 (Level A

eviden ce )

Screening post-hysterectom y Women who have had a total hys terec tom y (removal of the uterus

14 and cervix) should stop screening. Women who have had a

supra-cerv ica l hys tere c tom y (cervix intact) should con tinue screening according to guidelines. (Strong recom m endation)

Re com m end against screening in women who have had a

hys terec tom y (removal of the cervix). 13 (D recom m endation)

Women who have had a hys tere c tomy (removal of the cerv ix) should stop screening and not restart for any reason. 13 (Level A

evidence) 15

The need for a bimanual pelvic exam

Not addressed in 2012 guidelines but was addressed in 2002 A CS

guidelines. 16

Addressed in USPSTF ovarian cancer screening recom m endations (draft). 17

Addressed in 2012 well-woman visit recomm endations.18 A ged <21 years, no evidence supports the routine internal examination of

the healthy, asymptom atic patient. An “ex ternal-on ly” genital examination is acceptable. Aged ≥21 years, no evidence supports or refutes the annual pelvic examination or speculum and bim anual

exam ina tion. The decision whether or not to perform a com plete pelvic examination should be a shared decision after a discuss ion

between the patient and her health care provider. Annual

examination of the external genitalia should continue .19 Screening among those immunized against

HPV 16/18

Women at any age with a history of HPV vaccination should be screened according to the age specific recom m endation s for

the general popula tion . The possibility that vaccination might reduce the need for screen ing

with cytology alone or in combination with HPV testing is not established. Given these uncertainties, women who have been

vaccinated should continue to be screened.

Women who have received the HPV vaccine shou ld

be screened according to the same guidelines as women who have not been vaccinated. (Level C ev idence)

Women's Health Screening Guidelines

Guidelines developed to address screening in the general population

DO NOT apply to special, high risk populations who may need more intensive or alternative screening

For those older than 65 recommendation = GradeD Must have had adequate negative prior screening

Women's Health Screening Guidelines

The USPSTF recommends against screening for Ovarian Cancer

CA-125 and transvaginal ultrasounds not accurate enough

If patient is BRCA positive and opts to preserve her ovaries then those patients are screened with CA-125 and transvaginal sono

Women's Health Screening Guidelines

Over 22,280 women will be diagnosed with ovarian cancer

About 15,000 women will die of Ovarian Cancer

10-15% of women with ovarian cancer have BRCA1 or BRACA2 gene mutations

BRCA 1 associated with a 40% lifetime risk of developing ovarian cancer

BRCA 2 associated with a 15% lifetime risk of developing ovarian cancer

Women's Health Screening Guidelines

Ovarian Cancer accounts for about 3% of all cancers in women

Ranks 5th in cancer deaths among women

Approximately 5% to 10% with a family history of ovarian cancer

Risk of 1 in 71 women will develop ovarian cancer1st in cancer deaths involving the female reproductive system

Women's Health Screening Guidelines

In summary Annual Exam remains pertinentPreventive care guidelines – Keep up to dateCore measures insurers, ACO’s, medical

homeUtilize the annual exam to focus on mental

health, reproductive counseling, diet, exercise ,STI counsel and risky behaviors