[ Editorials | Departments and Series | Index ]

OB/GYN Editorial DECEMBER 2005

Screening for Gynecologic Cancer: Hope and Frustration

Thomas E. Nolan, MD, MBA

This month, The Female Patient is proud to present a concise, well-written article reviewing the status of screening for gynecologic cancers (Brooks SE, Khanna N. Screening for gynecologic malignancies: where are we now? The Female Patient. 2005;30[12]: 9-14). I present a didactic session to third-year students at the Louisiana State University School of Medicine on the principles of screening, testing, and evaluating evidence for diagnosis. When I attended medical school 30 years ago, the link between better screening, early diagnosis, and improved outcomes was just beginning to emerge with the support of epidemiologic data. This impetus came largely from the experience with mass screening for the precursors of cervical cancer with the Papanicolaou smear. We have all witnessed the significant decrease in US cervical cancer morbidity and mortality since the National Breast and Cervical Cancer Early Detection Program was implemented in 1991, with 10,500 new cases and 3,900 deaths in 2004.1 Half of the cases leading to death are due either to lack of access or inappropriate screening. This is in stark contrast to other parts of the world, where cervical cancer remains a major cause of mortality in women.

Uterine cancer should also be readily diagnosed now with the advent of the disposable plastic sampling device and the increased use of pelvic imaging in obese patients. However, the incidence of endometrial cancer has risen slightly—particularly among black women—despite the availability of early diagnosis and effective interventions. It is to be hoped that we can change this picture, especially in view of the excellent prospects for a cure in early-stage disease.

Ovarian cancer is a devastating form of gynecologic cancer. It is a ñsilentî killer and—because the tissue is not readily accessible—no good screening test is currently available. Women everywhere await the development of a better diagnostic model or area of scientific inquiry (ie, proteomics) to produce an effective screening modality for this lethal malignancy. With the introduction of a vaccine for human papillomavirus, perhaps some of the billions of dollars devoted to the battle against cervical cancer can now be shifted to ovarian cancer screening research.

The hallmark of modern medicine is detection of disease in the early stage. Over my clinical career, both the availability of screening tests and the cost of health care have increased logarithmically. Colonoscopy has become routine in screening for colon cancer, but is it truly cost-effective? The key elements of the testing paradigm are sensitivity, specificity, and proper utilization. In reality, though, the cost-benefit ratio for the population served may not be worth the expenditure. Medical costs will continue to rise as more screening tests are developed. The issue remains: Who do we screen, when do we screen, and at what intervals? As the average age of the US population rises, will the funds be there to develop better screening tests and maintain the health over the lifespan?

The New York Times featured a front-page article on the dilemmas facing patients who are trying to navigate today's US health care system.2 One patient had an ovarian tumor that ruptured during laparoscopic removal, and she subsequently experienced a recurrence. The article noted that as patients are given more choices in selecting therapy—especially experimental procedures—there is a concomitant increase in anxiety. More interestingly, it observed that primary care physicians have little time to help patients make these therapeutic decisions; indeed, the physician is also working from a limited database with regard to outcomes and risks. It is gratifying to see that the media recognizes the tremendous stresses confronting physicians and patients in the US health care setting. However, this is only a small step toward solving the complex problems of practice pressures, booming technology, access to care, commercial medical interests, health insurance, and litigation. That we can develop effective screening in such a setting is admirable, but think what we could accomplish if some of these barriers were removed.

The second lesson to be learned from this case is the importance of listening to the patient and carefully reviewing available information. As my mentor taught me, a thorough history and physical examination can reveal the nature of the problem 90% of the time. This simple, fundamental interaction can make all the difference in choosing the right therapy.

In gynecology, the hammer can be anything from the latest slingprocedure for urinary incontinence to the newest electrosurgical instrument for ovariectomy. As we learn from the mistakes of others, we should always remember that when we drive those nails, the hammer can sometimes miss—and in the end, it will be more than our thumb that aches. Ultimately, it is the patient who pays the price.

Thomas E. Nolan, MD, MBA
Editor-in-Chief

back to top

References

1. The National Breast and Cervical Cancer Early Detection Program: saving lives through screening. Fact sheet, 2004/2005. US Centers for Disease Control and Preven-tion Web site. Available at: http://www.cdc.gov/cancer /nbccedp/bccpdfs/about2004.pdf. Accessed October 17, 2005.
2. Hoffman J. Patients turn to advocates, support groups and e-mail, too. New York Times. August 14, 2005;1:19.

back to top