A 58-year-old woman, gravida 1 para 1, comes to the office for a health maintenance examination. She feels well and has no issues today. However, the patient states she would like screening for ovarian cancer because her cousin died of the disease last year and a close friend was recently diagnosed with advanced-stage ovarian cancer. She has well-controlled hypertension. During her 20s, the patient took combined oral contraceptives until she had a tubal ligation at age 30. Menopause occurred at age 56, and she took hormone replacement therapy for 2 years. The patient smokes half a pack of cigarettes a day and drinks alcohol occasionally. There is no other history of cancer in the family. Which of the following is the most appropriate strategy for ovarian cancer screening in this patient?

Question

A 58-year-old woman, gravida 1 para 1, comes to the office for a health maintenance examination.  She feels well and has no issues today.  However, the patient states she would like screening for ovarian cancer because her cousin died of the disease last year and a close friend was recently diagnosed with advanced-stage ovarian cancer.  She has well-controlled hypertension.  During her 20s, the patient took combined oral contraceptives until she had a tubal ligation at age 30.  Menopause occurred at age 56, and she took hormone replacement therapy for 2 years.  The patient smokes half a pack of cigarettes a day and drinks alcohol occasionally.  There is no other history of cancer in the family.  Which of the following is the most appropriate strategy for ovarian cancer screening in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d9cc_b090_bc81_571c2192fd8b_MD0003_00 Ovarian cancer screening begins with a family history, which differentiates an individual's risk category (eg, high or low) and determines whether additional testing or preventive procedures are indicated. This is because the risk for ovarian cancer in the general population is low (~1.4%). In contrast, the risk for ovarian cancer significantly increases with familial cancer syndromes such as BRCA1 (~40%), BRCA2 (~20%), and Lynch syndrome (~8%). Family histories suggestive of a hereditary cancer syndrome include the following: Multiple members on 1 side of the family with breast or ovarian cancer Male breast cancer Bilateral breast cancer Breast cancer diagnosed age <50 Ashkenazi Jewish ancestry ≥3 relatives with a Lynch syndrome associated cancer This patient has a family history of a remote relative with ovarian cancer that may slightly increase the individual risk to above baseline (ie, average risk). However, the risk is not different enough from that of the general population to warrant additional testing for hereditary cancer syndromes or screening for ovarian cancer. For low- and average-risk women, such as this patient, ovarian cancer screening is not indicated because it is ineffective for early diagnosis or reduction in mortality and only increases false-positive results. (Choice A) The location of the ovaries makes bimanual examinations challenging and nonspecific. When tumors are palpable on a bimanual examination, they are often already at an advanced stage. Given the limited use in detecting early-stage tumors, pelvic examinations are not recommended for screening in asymptomatic women. (Choice B) In women with a family history suggestive of a hereditary cancer syndrome, testing for BRCA1, BRCA2, and Lynch syndrome can be offered, preferably beginning with evaluation of the individual diagnosed with the disease. One distant relative with ovarian cancer does not warrant testing in this patient. (Choices D and E) Due to the high risk of ovarian cancer in women who test positive for BRCA1 or BRCA2, a pelvic ultrasound and a CA-125 level are recommended every 6 months beginning at age 30 until the patient undergoes a risk-reducing bilateral salpingo-oophorectomy. This patient does not meet criteria for BRCA testing or additional screening. Educational objective: Family history stratifies the risk for ovarian cancer. For low- or average-risk patients, ovarian cancer screening is not indicated because it is ineffective for early diagnosis or reduction in mortality. References: Risks and benefits of screening asymptomatic women for ovarian cancer: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23822892)

A 58-Year-Old Woman, Gravida 1 Para 1, Comes to the Office