日前,预防服务工作组(USPSTF)在其网站和《内科学年鉴》(Annals of Internal Medicine)上撰文建议临床医生不需对健康女性和已知无BRCA1或BRCA2基因突变(此类突变可增加发生卵巢癌风险)的女性进行卵巢癌筛查。

    USPSTF对2008年至2011年发表的随机对照试验数据进行回顾后发现,每年通过经阴道超声检查和血清CA-125检测进行的筛查并未显著降低美国女性卵巢癌死亡病例数量。此外,这些数据还显示,无症状女性的假阳性率较高,并可能因假阳性结果而进行不必要的手术和发生其他伤害。USPSTF将该建议定为D级,即“中度或高度肯定此类筛查无净益处,或者弊大于利。”USPSTF表示,美国癌症学会和美国妇产科医师学会均不建议对无症状的卵巢癌中危女性进行筛查。

    纳入78,216例美国女性的前列腺、肺、结直肠和卵巢癌筛查随机对照试验显示,每年筛查组在13年内诊断卵巢癌的病例数量与常规治疗组无显著差异(212 vs. 176)。两组的癌症死亡例数也无显著差异。在具有假阳性结果的女性中,约1/3进行卵巢切除术,基于假阳性结果每进行100例手术,就有约21例主要并发症。

    静冈卵巢癌筛查队列研究显示,在因常规筛查发现卵巢癌而进行手术的患者中,约33例手术才确诊1例卵巢癌病例。

    该建议不适用于具有BRCA1和BRCA2基因突变、Lynch综合征(遗传性非息肉性结肠癌)或卵巢癌家族史的的高危女性。家族史通常指有≥2名一级或二级亲属具有卵巢癌或乳腺癌合并卵巢癌史;对于具有德系犹太人血统的女性,家族史指有1名患有乳腺癌或卵巢癌的一级亲属(或2名属于同一边家庭的患病二级亲属)。

    随刊述评:留意有症状的患者

    俄亥俄州立大学哥伦布分校妇产科妇肿瘤分科的Georgia A. McCann博士和Ritu Salani博士表示,鉴于卵巢癌是导致女性癌症死亡的5大原因之一,继续评估卵巢癌的筛查方法和早期发现卵巢癌具有重要意义。由于大部分女性直到出现疾病转移才出现症状,而此时已进入晚期(IIIC)疾病阶段,因此应重点筛查无症状的女性,力求在疾病早期予以诊断,并进而改善生存几率。鉴于USPSTF明确发现对无症状女性进行经阴道超声检查和血清CA-125检测等筛查并无多大益处,这就需要从其他方面着手,比如询问完整病史了解可能的遗传易感性,并核查腹胀、腹部/盆腔疼痛、早饱和在肠道/膀胱功能改变等卵巢癌症状。如发现患者具有高度风险或有症状,则需进行适当检查和处置。此外,还应告知患者有关卵巢癌症状的相关信息,增加其对卵巢癌的认知。

 

By: HEIDI SPLETE, Internal Medicine News Digital Network

Clinicians need not screen women for ovarian cancer if they are otherwise healthy and have no known genetic mutations, such as BRCA1 or BRCA2 that could increase their ovarian cancer risk, according to a recommendation from the U.S. Preventive Services Task Force published online in the Annals of Internal Medicine and on the USPSTF website on Sept. 11.

After reviewing data from randomized, controlled trials between 2008 and 2011, a USPSTF Task Force determined that the number of deaths from ovarian cancer in U.S. women was not significantly reduced by annual screening with transvaginal ultrasound and serum CA-125 testing.

In addition, the data revealed a high rate of false-positive results in asymptomatic women, who then may undergo unnecessary surgery and other harm, the USPSTF said in its statement.

In the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized, controlled trial of 78,216 women in the United States, there was no significant difference in the number of ovarian cancer cases diagnosed in women randomized to annual screening vs. usual care (212 vs. 176) over 13 years. No significant differences were seen in the number of cancer deaths between the two groups. One-third of the women with false-positive results underwent oophorectomies, with nearly 21 major complications per 100 surgeries performed on the basis of false-positive results.

Data from another recent trial, the Shizuoka Cohort Study of Ovarian Cancer Screening, suggested that approximately 33 surgeries would be needed to diagnose 1 case of ovarian cancer detected by routine screening. More data are pending from an ongoing trial, the U.K. Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

Based on the available data, "There is adequate evidence that there is no mortality benefit to routine screening for ovarian cancer with transvaginal ultrasonography or single-threshold serum CA-125 testing, and that the harms of such screening are at least moderate," according to the USPSTF.

"Final results from UKCTOCS should provide more information about the relative benefits and harms of an algorithm-based approach to screening for ovarian cancer," the Task Force stated.

Neither the American Cancer Society nor the American College of Obstetricians and Gynecologists recommend screening asymptomatic, average-risk women for ovarian cancer, according to a USPSTF press release about the new recommendation.

The recommendation is a grade D, which the USPSTF defines as "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits," and providers therefore are discouraged from using the service.

This recommendation does not apply to women who are considered at high risk for ovarian cancer. Populations at increased risk of developing ovarian cancer include women with BRCA1 and BRCA2 genetic mutations, Lynch syndrome (hereditary nonpolyposis colon cancer), or a family history of ovarian cancer. A family history "generally means having two or more first- or second-degree relatives with a history of ovarian cancer or a combination of breast and ovarian cancer; for women of Ashkenazi Jewish heritage, it means having a first-degree relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer," according to the USPSTF statement.

As one of the top five leading causes of cancer death among women, it is important that methods of screening and early detection of ovarian cancer be continually evaluated, according to Dr. Georgia A. McCann and Dr. Ritu Salani. Because of the lack of symptoms until metastatic disease is present, the majority of women are diagnosed with advanced-stage (stage IIIC) disease. For this reason, it is important that screening focus on asymptomatic women in an attempt to diagnose at an earlier stage and thus provide an opportunity for improved survival.

Based on the evidence reviewed, the USPSTF recommendation against screening asymptomatic women with CA-125 and pelvic ultrasound is valid and should be considered definitive, said Dr. McCann and Dr. Salani of the division of gynecologic oncology, department of obstetrics and gynecology at the Ohio State University, Columbus, commenting on the USPSTF findings.. Furthermore, these recommendations reiterate the results of previous studies and, once again, report that screening does not provide an improvement in the detection of early-stage disease or translate to a survival advantage. Thus, screening asymptomatic women with current technologies does little more than provide false reassurance for women with normal findings and result in potentially unnecessary surgery (with a high complication rate) in women with abnormal findings.

However, the lack of screening tests amplifies the importance of asking patients about possible genetic predisposition by obtaining a thorough family history, as well as reviewing ovarian cancer symptoms such as abdominal bloating, abdominal/pelvic pain, early satiety, and changes in bowel/bladder function. If patients are found to be high risk or symptomatic, it is imperative that we, as health care providers, engage in the appropriate evaluation and management, they said.

Given the morbidity and mortality of this disease, it is vital that research continues on the early detection of ovarian cancer. New biomarkers, improvements in imaging, and an enhanced understanding of genetics may allow for better screening methods to be evaluated soon. In the interim, providers should be aware of the pitfalls of ovarian cancer screening and continue to educate patients on the symptoms of ovarian cancer.

Dr. McCann and Dr. Salani said they had no relevant financial disclosures.

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As one of the top five leading causes of cancer death among women, it is important that methods of screening and early detection of ovarian cancer be continually evaluated. Because of the lack of symptoms until metastatic disease is present, the majority of women are diagnosed with advanced-stage (stage IIIC) disease. For this reason, it is important that screening focus on asymptomatic women in an attempt to diagnose at an earlier stage and thus provide an opportunity for improved survival, according to Dr. Georgia A. McCann and Dr. Ritu Salani.

Based on the evidence reviewed, the USPSTF recommendation against screening asymptomatic women with CA-125 and pelvic ultrasound is valid and should be considered definitive. Furthermore, these recommendations reiterate the results of previous studies and, once again, report that screening does not provide an improvement in the detection of early-stage disease or translate to a survival advantage. Thus, screening asymptomatic women with current technologies does little more than provide false reassurance for women with normal findings and result in potentially unnecessary surgery (with a high complication rate) in women with abnormal findings.

However, the lack of screening tests amplifies the importance of asking patients about possible genetic predisposition by obtaining a thorough family history, as well as reviewing ovarian cancer symptoms such as abdominal bloating, abdominal/pelvic pain, early satiety, and changes in bowel/bladder function. If patients are found to be high risk or symptomatic, it is imperative that we, as health care providers, engage in the appropriate evaluation and management.

Given the morbidity and mortality of this disease, it is vital that research continues on the early detection of ovarian cancer. New biomarkers, improvements in imaging, and an enhanced understanding of genetics may allow for better screening methods to be evaluated soon. In the interim, providers should be aware of the pitfalls of ovarian cancer screening and continue to educate patients on the symptoms of ovarian cancer.

DR MCCANN and DR. SALANI of the division of gynecologic oncology, department of obstetrics and gynecology at the Ohio State University, Columbus, commented on the USPSTF findings. They said they had no relevant financial disclosures.