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ACOG's CME-eligible podcast episodes, designed for ob-gyns and primary and ob-gyn care professionals, explore early onset breast cancer, hereditary cancer, and gynecologic cancers. Tune in to hear expert-led discussions about diagnosis, treatment conversations, genetics, and patient-centered care.
If you are a health care practitioner, you can apply for free CME credits after listening to these informative podcast episodes.
For more information, visit https://www.acog.org/womenscancerpod.
Dr. Shirley Mei: [00:00:00] Welcome to this episode of our new podcast from ACOG, where we bring you timely conversations to help improve the care you provide to your patients.
Dr. Arjeme Cavens: We're your co-host. I'm Arjeme Cavens. I'm a practicing general of obstetrician and gynecologist at Northwestern Chicago for the last six years,
Dr. Shirley Mei: and I'm Dr. Shirley Mei. I'm also an OB GYN in New York City at a public city hospital that takes care of the underserved population in the heart of Brooklyn. In this episode, we're talking about gynecologic cancers with a focus on prevention, early diagnosis, and how you can better support your patients. Starting from that very first visit.
Dr. Arjeme Cavens: We'll walk through what providers should be looking for, how to counsel patients effectively in some areas where innovations are helping move the field forward.
So let's get started.
Dr. Shirley Mei: All right, so I'll start with the first question. What is the role of the well person visit in the prevention and [00:01:00] early diagnosis of gynecologic cancer?
Dr. Arjeme Cavens: So I really think the first step is advising patients about what these visits entail, really what to expect, why they're important because of, we really haven't done an, and they aren't attending these visits.
We really miss this opportunity, to be evaluating patients and really preventing cancers. And it's an opportunity really to obtain an updated clinical history from patients, assess their risk factors, identify any symptoms that may be concerning for cancer or pre-cancerous condition, and also updating their family history in ways that may guide changes to the testing or screening that we should be undertaking for each of those patients.
It's important that we take the opportunity to talk about their general, as well as their individualized cancer risk and what practices there are that might minimize these risks and make sure we're implementing the correct screening processes for patients and educating and counseling them for health maintenance and cancer prevention also.
Shirley, what are the parts of the history that you asked to really help with prevention and early diagnosis of gynecologic cancers?
Dr. Shirley Mei: So obtaining a thorough [00:02:00] history is very important. So you can ascertain information that may make you suspicious or may want to do further workup to rule out different gynecological cancers, for example, for uterine cancer, we want to talk to our patients about their menstrual cycles, look for any abnormalities or deviations from their normal, talk about if they have any intermenstrual bleeding.
And then for someone who's postmenopausal, we also wanna ask if they're experiencing any postmenopausal bleeding. For cervical cancer, we typically want to ask when their last cervical cancer screening exam was, if it's ever been abnormal, and if yes, if it required any further workup or treatment such as a Colposcopy or leap.
And then post-coital bleeding can be an important initial symptom of cervical cancer So it's also important for us to ascertain that information. When it comes to ovarian cancer, these symptoms tend to be a little bit more subtle and often can mimic [00:03:00] many other diagnoses. So we're looking for symptoms such as pelvic or abdominal pain, increased abdominal size or bloating, difficulty eating, feeling full quickly, urinary symptoms such as urgency or frequency.
So what are some other key pieces of other gynecological cancers?
Dr. Arjeme Cavens: So I think breast, for example, that's something we'd evaluated at a, you know, well, person exam. So for breast, has the patient identified any new concerning breast changes? Have they noticed any lumps or bumps in their breasts or even the skin changes with their breast tissue?
Have they noticed any nipple bleeding or nipple discharge? Those are certainly things we'd want to illicit.. And while much less common, it's also important to keep in mind vulva cancers, vaginal cancers, anal cancers. Especially noting that the incidence of vulva and anal cancers is actually increased in recent years according to C-ER data that is at least through 2022.
So things you would look for or ask about for vulva cancer would include new pain in the vulva area, itching, and certainly [00:04:00] any visible or palpable lesions that the patients have noticed for vaginal cancer that might present. Usually asymptomatically, but painless bleeding would be a concerning sign or some symptom, , discharge or pain. And for anal cancer that might present with rectal bleeding, pain, itching, tenuousness, or also feeling or noticing a lp. So these are things to be asking patients about.
Dr. Shirley Mei: Yeah, and I often find that patients may be reluctant to bring up some of these symptoms 'cause they're either embarrassed or maybe even uninformed that these might be a abnormal, they may even feel like the symptoms are mild and don't warrant medical attention.
So it's important to bring up these symptoms during our review of Symptoms with patients. And also important to educate our patients to let them know that when these symptoms do arise, they shouldn't wait for their next annual and to come in earlier for an evaluation. I also think it's important to discuss new medical problems that may have developed, or new [00:05:00] prescriptions that may increase a patient's risk for one or more gynecological cancers.
So things like obesity, diabetes, hypertension, polycystic ovarian syndrome. These are all risk factors for endometrial cancer. So, important to get an updated medical history and medications like tamoxifen can also increase risk of endometrial cancer. So important for us to know. Lastly, I like to do a overview of family cancer history as several cancer genetic syndromes can increase risk of gynecological cancers.
Dr. Cavens what are some of the specifics that you focus on when taking a family cancer history and identifying women who may have hereditary cancer syndromes related to their gynecologic cancers?
Dr. Arjeme Cavens: So in taking a family history, I think it's important that there's. An open-ended part of questioning, but also really being more specific and directed about the cancers that we may hone in a little bit more on from a gynecologic risk [00:06:00] perspective, cancers that make us a little more suspicious that there's a genetic mutation or hereditary component to a cancer syndrome.
So for example, things you really wanna ask patients are about first and second degree relatives, making sure you're getting that information from both the maternal and paternal sides. What are the ages of diagnoses for cancers in in their family members? If there's any Ashkenazi ancestry taking note of patterns such as multiple cancers in the same person, or the same cancer types in multiple people and multiple generations, those are all things that might make us a little bit more suspicious.
I think particular cancers that we may consider with regard to genetic syndromes would be uterine cancer, colon gastric cancers, breast cancer, ovary, cancer, pancreas, prostate, melanoma included. And there are some guidances that can help us understand when we should be testing someone for a particular genetic cancer syndrome, or at least referring them to a genetic counselor.
And so for example, for patients with Lynch [00:07:00] syndrome, you could use the Bethesda criteria, the Amsterdam or Amsterdam II criteria. Some components of that would be patients with a personal history of a colorectal or endometrial cancer who are diagnosed at an age under 50, or who have another Lynch related cancer.
Who have a family member with a Lynch related cancer at an age younger than 50, or who have two or more relatives with a Lynch related cancer at any age. Those are patients that should be evaluated for Lynch syndrome. And there's also a recommendation that any patient that's diagnosed with endometrial cancer or colon cancer should have universal testing for Lynch syndrome as well are microsatellite instability.
Regarding BRCA mutations and consideration of other hereditary breast and ovarian cancer genes, there are guidelines from the American College of Medical Genetics and Genomics from the National Society of Genetic Counselors from the NCCN and Society of GY Oncology that gives some guidance about which patient should be referred for genetic testing.
Dr. Shirley Mei: Very, very well said, and very thorough. And just to highlight the [00:08:00] CDC has highlighted hereditary breast and ovarian cancer syndrome and Lynch syndrome as high priority syndromes for cascade testing. So it's our jobs as physicians to make sure our patients are getting the appropriate referrals to genetic counseling, as well as following through and getting that genetic testing done.
So what's the role of the physical exam and what are some concerning signs for gynecologic cancers that we should be on the lookout for?
Dr. Arjeme Cavens: So I think your physical exam really is dictated by the conversation you have with the patient, the history you obtain, the symptoms that they may note or mention.
So certainly if they mention something that makes you worried about a particular symptom, you will examine that portion of the body. I think an interesting conversation is what is the routine portion of a physical exam. That certainly has changed over time and over recent years, particularly related to things like a breast exam or pelvic exam.
Dr. Arjeme Cavens: So I think the physical exam is always an important piece of any patient evaluation and with regard to a wellness [00:09:00] exam or, , an annual physical exam and evaluation, , you for sure want to be evaluating things based on the history you've obtained from a patient based on the symptoms that they have mentioned or the review of systems elements that were positive for you. So if you pick up that a patient is having a breast symptom, that's gonna dictate what you're doing from a breast exam or abdominal symptoms or pain, it's gonna dictate what you're doing. I think it's also important to differentiate what you may be doing as an evaluation of a symptom or a problem that you've identified.
First is what you may be doing as a screening exam, especially because recently there have been a lot of changes in whether or not there are recommendations for different elements of screening exams.
Dr. Arjeme Cavens: So one thing we'll talk about a little bit later is the role of breast exams, but just to focus for a moment on the screening pelvic exams, there are different recommendations from different societies, and this is certainly something that has changed over time.
I would say. Back in the day, it used to be you came to the gynecologist, you automatically got a screening, [00:10:00] pelvic exam, meaning a speculum exam, probably a bimanual exam. , whether or not you needed any testing, whether or not you had any, pap smear or cervical cancer screening that was due, that was an automatic part of your examination, that's really not the case anymore. So to just talk through a few organizations and what their recommendations are. The American Academy for Family Physicians actually recommends against screening examinations, as is the American College of Physicians, the ACP and specifically the a ACP makes a strong recommendation that screening pelvic exams should not be performed in asymptomatic non-pregnant women.
Given evidence that the harms might outweigh the benefits of screening in this population, they note that low quality evidence has indicated that pelvic exam screening can lead to harms, possibly even preventing some women from getting medical care and that false positives that result from pelvic examination.
Can lead to women having unnecessary laparoscopies or laparotomies. So really where this weighs in is that there [00:11:00] is not evidence that screening pelvic exams or doing a pelvic exam in the absence of any symptoms or necessary testing, is likely to find any abnormalities that would lower a cancer risk or find something that significantly changes a person's health.
But on the flip side of that, you may find an abnormality that you then work up or do further testing that leads to interventions that can cause harms, but again, without actually doing anything beneficial to lower someone's cancer risks increase the likelihood of finding cancer or changes their overall survival or health outcome.
Some of the other organizations of note, the USPSTF has concluded there is insufficient evidence to make a recommendation regarding screening pelvic examinations for asymptomatic and non-pregnant women. ACOG states that when an asymptomatic non-pregnant patient presents for a well woman visit, the provider should explain the lack of data and the potential benefits and harms of a routine pelvic exam and should discuss whether or not that examination should be [00:12:00] performed.
So more of a shared decision making approach. I think, interestingly, I'd like to note the SGO opinion, which in their position statement from 2016, they note that a pelvic exam should be offered to every patient that presents for a well woman examination, but within the context of a balanced discussion of the risk and benefits.
Shirley, what kind of anticipatory guidance do you think we should be giving as providers to our patients?
Dr. Shirley Mei: So at the end of a well person visit, I always like to summarize what we found during this visit and what to expect during the next visit. This guidance varies based on the patient's age, their symptoms, and risk factors.
For example, I like to start talking about cervical cancer screening with my patients who will be turning 21 in the next year to help them prepare for their next visit. This also gives me an opportunity to talk about the purpose and the frequency of testing and what they should expect. So cervical cancer predominantly occurs in patients who are inadequately screened, and the [00:13:00] purpose of the cervical cancer screening test is to detect high grade precancerous lesions and remove them prior to them becoming cancerous.
So primary care physicians, MPs, and PPAs, should appropriately refer patients with abnormal pap smears to a provider who is able to perform a Colposcopy or further workup if it's required. Also on the other end of the spectrum, for my patients who will be turning 65 who've had adequate prior screening, I also like to talk about the end of cervical cancer screening testing.
The USPSTF and the American Cancer Society recommends discontinuing screening at the age of 65, as long as adequate screening in the prior 10 years have been negative. So it's almost like a kind of a celebratory time for the patients to know that they no longer need the screening test anymore.
And I do similar things for breast and colorectal cancer as well. [00:14:00]
Dr. Arjeme Cavens: So Shirley, then I'll ask, what do you then tell a patient that here's, oh, I'm turning 65, I've completed my cervical cancer screening and I don't need any more of that. So then do I need to come back at all?
Dr. Shirley Mei: Yeah, I definitely have encountered many patients who say, oh, I thought I didn't need to come back anymore 'cause you said I was done. I do think it's still important to see a gynecologist or someone who is addressing your gynecological issues, such as your primary care physician, even beyond 65 and beyond cervical cancer screening.
Dr. Arjeme Cavens: Are there certain signs or symptoms that you specifically tell patients to look out for as it relates to being mindful of any signs or signals for cancer?
Dr. Shirley Mei: Yeah. So besides the anticipatory guidelines for screening tests, it's also important to review symptoms that patients should, , be aware of that may prompt them to come in for an earlier visit. Things like change in menstrual [00:15:00] patterns, including abnormal uterine, inter menstrual post-coital, and post-menopausal bleeding should be brought up to their physicians as soon as possible.
These symptoms can be early warning signs for uterine or endometrial cancer, and this workup can even be started at the primary care physicians or APPs office with a pelvic ultrasound, but important to refer to a gynecologist who may consider doing an endometrial biopsy.
Unlike endometrial cancer, ovarian cancer symptoms tend to be a little bit duller as we, previously explained, and thus, early warning signs may be dismissed by both the patient and practitioners.
Therefore, attentiveness to these symptoms, especially when there are multiple of them and they're prolonged or persistent. Should also warrant patients to come in earlier for an evaluation. Now in terms of breast self examinations, which some of my older patients have [00:16:00] grown up doing, ACOG, the USPSTF, and American Cancer Society actually no longer recommends this due to lack of evidence showing that it improves any outcomes.
In fact, there is risk of harm from false positive tests. Uh, however, ACOG does recommend breast self-awareness, so not breast self-examination, but awareness which just involves patient becoming familiar with the normal feel and appearance of their breasts and reporting any changes to their healthcare providers.
So, although there are no studies that have directly examined the effectiveness of breast self-awareness in the United States, approximately 50% of cases of breast cancer in women in 50 years and older, and 71% of cases of breast cancer in women younger than 50 are actually detected by themselves. So I think that's a, a important tidbit to know.
So in your experience, what prompts a workup and what does that workup typically [00:17:00] include?
Dr. Arjeme Cavens: So again, this always goes back to the patient history, the interview, the information you've gotten from them. What are the symptoms? How is your review of systems to really identify things that may represent a malignant process or pre-malignant process and warrants further evaluation.
And again, using your physical exam to inform what those next steps in evaluation might be. So for example, if I elicit a history from a patient or on an exam that I'm performing, I. Pick up something that makes me concerned about a breast cancer. My next step would be breast imaging. Usually that is gonna be a diagnostic mammogram, especially in someone over the age of 30.
I think an important tidbit is when you are ordering a mammogram, if that's a, you know, a electronic order or however you're communicating with the radiologist, that you also communicate what it is that you were concerned about. What was that symptom? What did you feel on the exam? Where was that? That really helps, , the radiologist know how to target the diagnostic mammogram.
If you have a patient under 30 and you are looking to do some diagnostic imaging, that is usually gonna start with a [00:18:00] diagnostic ultrasound. But again, really important to, include a note of what it is that you are evaluating for. On the other side, if this is symptoms that you've, , elicited that make you more concerned about uterine cancer, ovarian cancer, or pelvic mass, pelvic pain, pelvic ultrasound would usually be the first line imaging.
For example, if I elicit a symptom from a patient or notice something on my examination that makes me concerned about a breast abnormality or breast mass or breast cancer, my next step would be to perform or order some diagnostic imaging. Typically, for a patient that's over the age of 30, that will be starting with a breast mammogram, a diagnostic mammogram.
I think something that's really important to remember is to give the imagers, give the radiologist information about why you're ordering the study. What was the symptom the patient had? Where did you feel a mass in relation to their breast tissue? How far from the areola? That's all important information to include.
If it's a patient that's under the age of 30, the first line imaging often will be [00:19:00] a diagnostic breast ultrasound instead.
Now, if instead I'm worried about uterine mass, uterine cancer, ovarian cancer, or a pelvic process, the first line imaging would usually be a pelvic ultrasound. There are some instances where an MRI or CT might be better employed based on that patient's particular characteristics and preventing symptoms.
And these risk factors might include a history of imposed estrogen exposure, such as in PCOS or obesity. These might be patients that have failed medical management and have persistent A UB. So all these patients should be sampled according to ACOG guidance. I think it's also important to think about lower anal genital tract evaluations.
And while there's no specific testing that has been studied, it is important to biopsy any visible lesion that has an atypical appearance. And atypical may mean new or change in pigmentation and durations. If it feels more affixed to the underlying tissue, if it's a lesion that is bleeding or ulcerated, [00:20:00] if there are other reasons to be concerned for a malignancy or if it's an immunocompromised patient.
And really if you have an uncertain diagnosis that is not responsive to other therapies that you're trying, and also postmenopausal patients with new lesions or new genital wards, those are also things that should have some histologic evaluation. And then thinking about laboratory testing. It's more directed by what exactly you're looking for.
So for example, if you have concern that a patient has a symptom of a pelvic mask or you identify a pelvic mask on your physical examination, you may want to employ blood testing like serum markers of, of serum, , tumor markers such as a CA125 level.
So when you are evaluating a patient that you may, that you have some concern, may have endometrial cancer or hyperplasia or bleeding abnormality that warrants further evaluation, one distinction you wanna make is whether or not they're premenopausal or postmenopausal.
So in postmenopausal patients, there's. Pretty strict guidance. It's specifically ACOG would recommend that a patient that is [00:21:00] postmenopausal, that has postmenopausal bleeding and has an ultrasound with an endometrial stripe of greater than four millimeters, should have some endometrial tissue sampling.
That could be by an office endometrial biopsy, or with diagnostic hysteroscopy, which affords more directed sampling now in premenopausal patients. There still is a role for histologic evaluation in endometrial tissue sampling. So ACOG recommends that in a premenopausal patient that's over the age of 45, that endometrial sampling should be performed as a first line test.
However, in premenopausal patients that are under the age of 45 sampling should be directed toward patients that have other risk factors. Now, additional risk factors in this setting might include a history of unopposed estrogen, such as obesity or PCOS might include that they've already failed medical management and have persistent AUB.
So those patients still should undergo some endometrial sampling. Let's transition to discussion a little bit to more average risk populations.
Dr. Shirley Mei: [00:22:00] Yeah. So let's talk about screening and other imaging that guidelines recommend for our average risk populations. When we talk about average risk patients, we are talking about individuals assigned female sex at birth, including cisgender women, transgender men, and non-binary individuals. Individuals with a personal history of breast cancer, genetic mutations associated with high risk of breast cancer, a history of high dose radiation therapy to their chest at a young age, or a history of high risk lesion on a breast biopsy are not included.
So, Dr. Cavens, how do you counsel a patient on the current guidance of mammograms?
Dr. Arjeme Cavens: So I probably have a longer conversation with patients than they're looking for, but really trying to explain and explore with them that there are some differences in what different professional organizations may recommend or may advocate for, but that neither of these recommendations are better or worse than the others.
So again, this is an element of shared decision making and coming up with a [00:23:00] plan that they are most comfortable with that still accomplishes the same goal of preventing or detecting early any breast cancer and breast cancer risk. So again, for average risk patients, the American Cancer Society would recommend that clinical breast exam, so exams that we would do in the office at a preventative visit, as a provider, they do not recommend that these are done for average risk women.
Now that being said, women should be familiar with how their breasts normally look and feel, and should be educated to report any of those changes to their provider, but not that we should be automatically doing a clinical breast exam at every visit. American Cancer Society also says that women between the ages of 40 and 45 have the option to start mammogram yearly at 45.
They should start mammogram screening mammograms yearly and at the age of 55. They can continue to do this yearly or transition to doing it every two years and continue mammogram screening while their life expectancy is at least 10 years. The USPSTF advocates or recommends to start mammograms at the age of [00:24:00] 40 and to perform them every other year.
They don't make any separate recommendation for or against additional screening modalities for patients with dense breast, noting that there's not enough evidence to assess the balance of benefits nor to assess the balance and benefits of screening beyond the age of 75. ACOG recommends beginning screening mammograms at the age of 40 and performing them every one to two years until at least the age of 75.
Dr. Shirley Mei: Yeah. So I think the cadence and the age of initiation of screening should be determined using a shared decision making model. And patients should really understand the rationale behind those decisions. For example, when deciding when to start mammogram screening, , patients should know that although the highest incidence of breast cancer occurs in women age 65 to 74, the incidences of breast cancer in younger women between 40 to 49 years are actually increasing.
Furthermore, black patients are less likely to be diagnosed [00:25:00] with breast cancer compared to their white counterparts. But are more likely to die from breast cancer. In fact, black women younger than age 50 had a death rate that was twice as high as their white counterparts of the same age group. So this information is especially important for my patients who are predominantly African American and Afro-Caribbean and descent.
So, I use these to kind of talk to them about how often and, when they should initiate screening tests and let them decide based on the risk and benefits.
Now, I also have some patients who come in with a preconceived notion of how often and when they should get a mammogram from things they've heard on social media or from friends and families.
What are some common misconceptions that you have heard from your patients regarding things that they've heard on the internet and how do you handle that?
Dr. Arjeme Cavens: So I really think it goes kind of in both directions and kind of both ends of the spectrum I certainly have patients that [00:26:00] know someone that got diagnosed with, knows with breast cancer or saw something on social media that makes them want to start screening much earlier and really feel like nothing is being done, or why would I wait until I get cancer?
I should be starting at the age of 30 or 35. And it's really important, again, to explain to them why the recommendations are what they are, the risk of false positives and unnecessary interventions. And I think having those in-depth conversations can really help persuave a patient's concerns and educating them on what would prompt earlier workup or evaluation.
Not just that we won't ever look at, you know, your breast for example, or ever do an exam unless you meet one of these time markers. I think that's important to notify patients about. And I think the opposite end of the Spectrum, where there are patients that maybe have a stronger family history or know a lot of people with breast cancer and that makes them more hesitant to pursue a mammogram or other screening tests, either because they think the cause of the breast cancer was related to the test that they had, or just that they're more fearful [00:27:00] about it.
And again, I think just education is our biggest tool in trying to combat some of those.
Dr. Shirley Mei: Absolutely.
Dr. Arjeme Cavens: So what are some of the recommendations you talk about with patients regarding cervical cancer screening?
Dr. Shirley Mei: So the USPSTF which is endorsed by ASCCP, recommends cervical cancer screening every three years with cytology alone, starting at the age of 21 to 29, then for women aged 30 to 65. You can either continue the cytology alone every three years or every five years with high risk HPV testing alone, or co testing. The American Cancer Society actually has some different guidelines. They recommend cervical cancer screening starting at the age of 25, to 65 with the preferred test being primary testing with high risk HPV alone.
And interestingly, my hospital actually just transitioned over to primary high [00:28:00] risk HPV testing. , we previously didn't have it available, so I've been having some in-depth discussions with my patients about why we changed our method of testing, since primary high risk HPV has shown to be as effective as co-testing with fewer false positives, which then lead to less unnecessary follow ups and procedures also gives me the opportunity to discuss how we're better at understanding the natural progression and history of, cervical cancer and, and kind of. Give my tidbit about why we no longer need yearly cervical cancer screening and that, you know, we're also much more informed of how the infection with high risk HPV types, plays such a large causal role in cervical cancer. So we still offer co testing for our patients if after counseling, they still prefer cytology to be done alongside high risk HPV [00:29:00] testing.
However, I do find most of my patients are okay with this new testing 'cause not much has changed for them in terms of the way we perform the actual test.
Dr. Arjeme Cavens: I think there's, there's so much that has changed recently and will be changing, , in the near future about what cervical cancer screening recommendations look like.
What we even call the test, what we call it as providers versus what patients just think of as I'm here for my pap smear. And I think really taking the opportunity to educate patients so that they maintain trust when they see a different provider that does a different test or get a result that looks different than their last one, that they really have some kind of background information, and understanding and maintain trust kind of across the healthcare spectrum is really important.
Dr. Shirley Mei: Yeah, absolutely. And I think also, especially with now, home testing becoming available, I think we're gonna start to see some changes ahead with cervical cancer screening. I often find that my patients who come to me for cervical cancer screening are [00:30:00] not properly vaccinated for HPV, and I've even heard from patients that they thought it was too late. How do you counsel your patients regarding HPV vaccination?
Dr. Arjeme Cavens: Yeah, it's definitely something I encounter a lot too. I tell patients and my patient population is more late teenage, early adult into late adulthood, much less commonly like early teenage patients. , but I do counsel patients that the HPV vaccine is recommended for routine vaccinations starting as early as nine years old, with the target age being around 11 to 12. And ideally just to be administered before the onset of any sexual intercourse and sexual activity. And the recommendation is that everyone is vaccinated through the age of 26 and that the Gardasil vaccination, for example, that's widely available is approved for adults up to the age of 45. So patients that previously thought they were not eligible for the vaccine because they were past the age of 26, it's an opportunity to let them know, Nope, you're still eligible up to the age of 45.
And I [00:31:00] explained what the vaccine course would be. And so in an adult population, it is a three vaccine course, but for patients that have started the series. But under the age of 15 for their first dose, it's just a two dose series. And it's important to explain to patients the purpose of the vaccination and the benefits in terms of their cervical cancer risk reduction, but also that it doesn't treat any existing infections or exposures that they may have had.
Dr. Shirley Mei: Yeah, and a great time to talk about this HPV vaccine is when you're talking about cervical cancer screening, they go hand in hand. So what are recommendations for screening and other gynecological cancers in average risk women that we have not talked about yet?
Dr. Arjeme Cavens: I think it's a also a great opportunity when you're seeing patients talking about their own HPV vaccination status or their cervical cancer screening, that if they have children that are at an age eligible for HPV vaccination, that we recommend that for them as well.
Dr. Shirley Mei: So what are the recommendations for screening in other gynecological cancers in average risk of women [00:32:00] that we haven't talked about yet?
Dr. Arjeme Cavens: So really there, is more so a lack of recommendation for screening in other cancers, for example, uterine and ovarian cancers, there is not evidence that any particular screening modality or test has utility in the prevention or earlier detection of those cancers.
As we kind of mentioned before, uterine cancer often will present with signs of abnormal bleeding. So things that have been studied are even like pap smears and cytology or ultrasounds as a screening for an average risk person. And that has not been shown to have any benefit from a uterine cancer perspective.
For ovarian cancer, the most studied modalities would be an over transvaginal or pelvic ultrasound or CA125 level. And again, those have not shown benefit as screening tests for ovarian cancer, for average risk populations. , similarly when thinking about lower anal genital tract cancer, there aren't any screening modalities.
These are things that it's really important to educate patients and to ask thorough review of systems in order to detect. Any changes that [00:33:00] that warrant further evaluation, but we don't have specific screening modalities.
Dr. Shirley Mei: All right. Let's switch gears a little bit and talk about genetic testing and family history.
So why is knowing family history so critical in our practice
Dr. Arjeme Cavens: It's really important to understand a patient's family history because it really dictates what are screening modalities or timing or changes to standard intervals that we may use for them. And also whether or not we should be referring them to a genetic counselor or for genetic testing.
And I think also there are definitely populations that may be more likely to have those genetic counseling and referrals. Do you feel like you have in your patient population patients are screened or referred appropriately?
Dr. Shirley Mei: Yeah. Well, research has definitely shown that minorities such as black, Hispanic, and Asian women are much less likely to be referred to genetic counseling and undergo genetic testing.
Same for patients who are low socioeconomic status and those who don't speak English, , are less likely to be recommended. [00:34:00] To genetic counseling. So I think as providers we have to keep this in mind and make sure that we're providing equitable care to all our patients and letting them know in their preferred language, why it's important to get these testing done, when it's necessary.
So I work with predominantly, low SES and, , non proficient English speakers, , as well as, African Americans. So we strive to make sure that all our patients are getting genetic counseling appropriately. We actually introduced a genetic counselor in our team, part of the OB-GYN team to specifically do genetic testing for our patients who need it.
Dr. Arjeme Cavens: I think something else, Shirley, that comes up a lot is there's sometimes a generational difference in the level of detail of what patients know about their family history. Things people share amongst their family members. What is the level of detail whether or not someone really explicitly knows.
My grandmother on my mom's [00:35:00] side had uterine cancer versus they had some female pelvic cancer. So I think it's important as providers that we really try to elicit that detail, , and encourage them to get that information from their families and also that educates them on what they should be passing down or informing their other family members about.
Dr. Shirley Mei: Yeah, absolutely. What should providers be doing to make sure patients get the right referrals for genetic counseling and testing?
Dr. Arjeme Cavens: So, kind of as we discussed, making sure that you have a history on the patient to know who you should be referring to and having a network, as you've mentioned, a network of genetic counselors or access to genetic counselors that you can refer to.
I also think following up with patients, making sure you don't just recommend this, but that you circle back and make sure they got that testing asked, what those results were for, so that you're employing any changes that need to be made based on those results. I think it's also important to keep in mind that genetic testing availability and the kind of expansiveness of the genes that we can test for has changed, especially since [00:36:00] 2013, 2014, ovarian cancer.
Hereditary breast and ovarian cancer is an example of this, where panel testing is much more expansive than it used to be. Even in patients that have been tested previously. It's important to know when that testing was, what did that testing entail, because especially in the setting of previous negative testing, there may be an opportunity for newer testing, more expansive testing that really is informative for their care.
So when patients have a known genetic mutation or they're asking, why should I get tested in the first place, what are you gonna do different? How do you inform that conversation with patients?
Dr. Shirley Mei: Yeah. So depending on what type of genetic mutation, that they may have, and depending on what type of cancer we're looking to screen, there might be some additional testing that we can perform.
For example, for women with BRCA mutations, both ACOG and NCCN recommend self-breast awareness starting at the age of 18, clinical breast exam by a provider every six to 12 months, starting at the age of 25. [00:37:00] Screening breast MRI at ages 25 to 29, and mammograms with MRI every year, starting at the age of 30.
Dr. Arjeme Cavens: So thinking more about the pelvic portion of these cancer risks there, it can be challenging because there isn't any evidence-based screening strategies that have been shown to be effective. For example, for the BRCA mutation, there is not a recommendation to perform any ultrasounds or CA125 or any other tor marker testing.
The only proven recommendation is to perform a risk reducing surgery. So for the BRCA1 mutation, the recommendation would be for risk reducing salpingectomy between the ages of 35 and 40, or when childbearing is complete.
Dr. Shirley Mei: For ovarian cancer, it's often diagnosed at an advanced stage, and therefore screening tests such as a transvaginal ultrasound with or without CA125 measurements have been proposed in the past.
However, meta-analysis have shown that although screening may [00:38:00] increase the likelihood of a diagnosis at an early stage and lengthened survival screening actually didn't improve ovarian cancer related mortality overall. So for those with high risk factors like the BRCA gene risk reducing salpingectomy is generally preferred over any screening tests.
However, those who defer or decline such treatment screening tests with CA 125 monitoring and transvaginal ultrasound can be considered, based on NCCN guidelines. So for endometrial cancer screening in patients with Lynch syndrome, total hysterectomy with risk reducing BSO can be considered starting at the age of 40.
Endometrial cancer screening has not been shown to be beneficial in patients with Lynch syndrome as well. However, screening with an endometrial biopsy can be considered every one to two years, starting at the age of 30 to 35, , according to NCCN and a transvaginal ultrasound can also be [00:39:00] considered in postmenopausal women with Lynch syndrome, who have foregone the hysterectomy procedure.
But this is not recommended for patients who are premenopausal due to the wide range of endometrial stripe thickness throughout a normal menstrual cycle. So, Dr. Cavens what's our current understanding of hormonal medications that can help reduce the risk of gynecological cancers for our patients? And what are some of those strategies that we can talk to them about?
Dr. Arjeme Cavens: So as it relates to uterine and ovarian cancer, there is good evidence that combined hormonal contraceptives can offer risk reduction for both uterine and ovarian cancer. I think it stands for sure that for uterine cancer, those combined, so estrogen and progesterone containing contraceptives lower the risk of uterine cancer.
Also, that progestins can lower the risk of ovarian cancer, including a progestin or hormonal IUD for ovarian cancer Combined estrogen, progesterone contraceptives, particularly oral contraceptives also have evidence of risk reduction. , [00:40:00] and there are some newer evidence that a leave in IUD may also offer a lower risk of ovarian cancer and a general population for ovarian cancer.
So, not yet known in patients that have an elevated risk or mutation, for example. Are there any like surgical management strategies that you recommend or discuss with patients for risk reduction?
Dr. Shirley Mei: I always make sure to counsel my patients about an opportunistic salpingectomy whenever performing pelvic surgery for benign disease.
Especially for a procedure such as a hysterectomy where the fallopian tubes will no longer serve any function anymore. Now informing patients that removal of the fallopian tubes can potentially decrease their risk of ovarian cancer while not interfering with ovarian function and does not increase intraoperative complications such as infection rates or blood loss, or the need for blood transfusions.
I think it's important to counsel and make a shared decision about whether you would be doing a salpingectomy at that time of [00:41:00] another pelvic surgery. Now this is important for our residents to make sure they understand the difference between an opportunistic salpingectomy, which is what we just talked about, and a risk reducing salpingectomy So, Dr. Cavens do you wanna talk more about what a risk reducing salpingectomy
Dr. Arjeme Cavens: So the risk reducing cell ectomy is in someone that we've already determined and identified has an elevated risk. And so we are recommending that they have those components of a surgery. And so kinda like we've mentioned for a BRCA1 or 2 mutation.
And there are also some other hereditary ovarian and breast cancer mutations for which a risk reducing bilateral salpingectomy is recommended. So this would be your RAD51C mutation, your RAD501D mutation BIRP1 mutation in a PALB2 mutation along with BRCA1 and 2.
Those are all, , situations in which you would be recommending a, an age appropriate salpingectomy and [00:42:00] I agree with you that it's important to educate patients on when it's opportunistic versus when, it is a risk reducing and also that the methodologies are, are different based on that also.
Dr. Shirley Mei: And yeah, so for BRCA1 when NCCN recommends a risk reducing salpingectomy between 35 and 40 BRCA2 and Lynch syndrome anywhere between 40 and 45, it is also recommended for patients to have a CA125 and pelvic ultrasound prior for preoperative planning, , and referral to GYN oncologist if there's any abnormalities noted from either one of those tests.
Dr. Arjeme Cavens: And for the other hereditary breast, breast and ovarian cancer mutations, the age recommendations may be slightly different. And so the recommendations for surgical timing for some of the other hereditary breast ovarian cancer mutations may be slightly different. For example, NCCN recommends to perform a risk reducing bilateral salpingectomy for patients with a [00:43:00] pathogenic RAD51C, RAD501D, or BRIP1 mutation between the ages of 45 and 50.
For a PALB2 mutation, the recommendation is to consider a risk reducing BSO. So for the other mutations it is to perform and for a PALB2 is to consider. And again, those similar ages of 45 to 50 and based on family history included. So in addition to the medication and hormonal options we've discussed and surgical risk reduction, what are some lifestyle modifications that you discuss with your patients that may help decrease their risk for cancer?
Dr. Shirley Mei: Yeah, like with anything else, I think it's important for us to talk to our patients about diet and exercise. Excess estrogen is one of the greatest risk factors for endometrial cancer. So by reducing that risks of obesity, hypertension and diabetes, which are also risk factors, can also be lowered.
Dr. Arjeme Cavens: I think smoking cessation is another one.
There are a million reasons to not smoke. [00:44:00] ACOG recommends that all adults be counseled towards smoking cessation if they are active, , smokers. , But also from a cancer prevention or risk reduction perspective, it's important to talk to patients about. , and particularly we know that smoking's associated with increased, , cervical cancer risks.
So it's another reason to encourage your patients.
Dr. Shirley Mei: Absolutely. And what disparities in gynecologic cancer incidence and treatment should we be aware of as providers?
Dr. Arjeme Cavens: So I think research has shown and continues to show that there are disparities in gynecologic cancers that really warrant more research, more attention to how can we correct what is the reason for these disparities and really warrants a lot more attention.
An example of this is that African American women are much more likely to be diagnosed with uterine cancer. They're more likely to be diagnosed at a later stage. They're more likely to have poor survival outcomes, and there is more research going into why this is happening. What can we do about this?
How can we combat these disparities?
Dr. Shirley Mei: I'm gonna give a clinical vignette. [00:45:00] Mara is a 57-year-old black woman with postmenopausal bleeding. She undergoes transvaginal ultrasound showing an endometrial thickness of 3.8 millimeters. She's reassured, , that her lining looks thin and no biopsy is performed.
Her bleeding continues but she delays follow up assing she was told everything was okay. Months later, a biopsy reveals high grade non endometrioid endometrial cancer.
Dr. Arjeme Cavens: So to talk a little bit about how ultrasound is used to evaluate postmenopausal bleeding in the first place, transvaginal ultrasound is often the first line imaging tool that we would use to evaluate someone postmenopausal bleeding.
This is in accordance with ACOG committee opinion number 734, which states that when the endometrial stripe measures four millimeters or less, the likelihood of endometrial cancer is extremely low, less than 1%. And that's something that's been proven in multiple studies. ACOG notes that this measurement has a greater than 99% [00:46:00] negative predictive value.
So it's the negative predictive value that really dictates why transvaginal ultrasound is the first line and most commonly used tool to assess whether or not endometrial sampling or an endometrial biopsy is needed. But really importantly. ACOG also emphasizes that if bleeding is persistent, if bleeding recurs, if there are other concerning symptoms, you still should perform a histological evaluation regardless of what that initial measurement was.
Shirley, can you talk a little bit about where that, four millimeter endometrial thickness comes from in the first place?
Dr. Shirley Mei: Yeah. So the four millimeter thresholds became a standard, , based on studies showing it reliably ruled out cancer in post-menopausal bleeding. The ACOG Committee opinion actually cites research from Nordic, Italian and Hong Kong cohorts, , as well as Gulls work that confirmed high negative predictive value with a less than or equal four millimeter on transvaginal ultrasound.
So these findings support that transvaginal ultrasound as a safe [00:47:00] first line triage tool. Still, most of these studies involves relatively homogenous populations. , So it's important to consider whether this threshold performs equally well across all different patient groups. And also important to discuss this diagnostic threshold, like the four millimeter rule are designed to balance false positives and false negatives, but no cutoff guarantees, zero missed cases.
Do you think Mara's story happens more often than we think?
Dr. Arjeme Cavens: I absolutely think so. I think this happens probably quite frequently. We appropriately perform an imaging test. That imaging test looks reassuring, as we would say. , And then it can lead to delays in follow up, even if the concerning symptom or presenting symptom is still present.
And that delay might be on the part of the providers, it might be on the part of patient having been explained that things were reassuring and things were normal, so they just go on about having those symptoms. A transvaginal ultrasound really is a helpful tool, but it does have [00:48:00] its limitations and I think it's important that we keep that in mind.
And these are limitations, especially in detecting cancers that might not present with an with a thickened endometrial lining. , If clinical decisions rely too heavily on just that one test or one number we really risk missing the disease or diagnosing it at a later stage. So in our situation here with Mara, this case would show why symptoms should never be dismissed just because one test looked normal.
And also the, the delays in performing further evaluation, , may reflect differences in how symptoms are communicated or interpreted by the patient and the provider. And so equity really requires that we build symptoms that listen with equal urgency and continued urgency across different populations.
So to speak a little bit to that, , can you expand a little bit on Dr. Kemi Doll's study?
Dr. Shirley Mei: Yeah, so Dr. Kemi Doll's study explained how well transvaginal ultrasound performs in detecting endometrial cancer in women with postmenopausal bleeding. She found that 11.4% of patients with confirmed [00:49:00] cancer had an endometrial thickness below five millimeter, meaning standard triage could miss these cases.
Her work also highlighted that commonly used thresholds may not perform equally well for all cancer types or patient groups, especially when the disease doesn't present with a thickened stripe. Rather than calling for race-based adjustments, the study emphasizes the need for broader validation of diagnostic tools.
Dr. Arjeme Cavens: And so while recognizing that this is a single study, a single cohort, , I think the point here is that if these findings are confirmed by larger studies, would that prompt a reconsideration of what our endometrial thickness threshold is in the first place? this study doesn't argue for a difference in race-based diagnostics or race-based thresholds, nor does it suggest abandoning transvaginal ultrasound or the thresholds that we have in place.
But the key really is that some of our widely used tools need to be evaluated and validated across more diverse populations than they were originally studied in. , and we really need to [00:50:00] do this to ensure that they apply to more broad populations and to make sure that future research, , keeps this in mind as well.
Okay.
Dr. Shirley Mei: We start this by recognizing that just because you had a normal imaging study, it doesn't always mean no risk. So while tools like a transvaginal ultrasound can reduce unnecessary procedures, persistent symptoms like persistent post-menopausal bleeding should never be ignored and again, warrants endometrial sampling.
Dr. Arjeme Cavens: This is really important because endometrial cancer mortality is rising, it disproportionately affects certain populations like we discussed. , And even with lower incidence, some groups experience later stage diagnoses, worse outcomes. And while again, this study doesn't redefine guidelines, it definitely calls attention to where some of our guidelines and protocols and investigative modalities fall short, , and fall short in terms of being able to equitably diagnose cancers.
And so it's really important that [00:51:00] we continue to advocate for inclusive research that's really essential in closing these gaps.
Dr. Shirley Mei: So how do we interpret tools like transvaginal ultrasound and communicate uncertainty with our patients?
Dr. Arjeme Cavens: I think it's important to know for ourselves and to communicate with patients that transvaginal ultrasounds are helpful, but it is just one piece of their evaluation, one piece of the puzzle.
So a thin endometrial stripe may suggest that it's low risk, but really isn't ruling out cancer. , and especially if concerning bleeding symptoms were to continue. So ACOG very clearly states that ongoing or recurrent bleeding deserves endometrial sampling, and that's regardless of what the ultrasound shows.
So it's vital to explain to patients that imaging does help guide us, but it doesn't override their experience. And even if we have an initial reassuring or normal imaging study, if they're continuing to have symptoms that warrants representation and reevaluation. So if your symptoms don't stop, if your symptoms come back, we want to see you again.
Shirley, can you talk a [00:52:00] little bit more about why it's important to validate diagnostic tools across broader populations?
Dr. Shirley Mei: Because tools like transvaginal ultrasounds were tested on homogenous populations, we risk missing disease in people whose biology or presentation doesn't match that data.
So validation is equity. It's about ensuring safe, accurate care for everyone.
Dr. Arjeme Cavens: And I think along those lines, equity informs care, acknowledges that systems access to systems, a patient's live experience- all of that affects outcomes. Equity informed care really aims to close the gaps, especially through structural awareness and changes and structural pathways.
On the other hand, race-based medicine that relies on what is often flawed biological assptions about race. So what we're advocating for is more equity informed care, which may use race as a lens for context, whereas race-based medicine risk using as a shortcut.
Dr. Shirley Mei: And we have to shift that focus from race as a biology to race as a [00:53:00] proxy for lived experience and systemic exposure.
So instead of adjusting thresholds by race, we have to ask, are our tools validated across all groups? Are we listening to symptoms with equal urgency amongst our patients? And disparity conversations deepen when we move beyond modifiers and move toward meaningful action.
So if there was one thing you wish every provider knew when it comes to gynecologic cancer prevention, what would it be?
Dr. Arjeme Cavens: I think my one thing would just be to use your resources there. Things are changing all the time, which is a good thing. We are learning more, we have more knowledge available, resources available, but it can be hard to keep up.
And really to provide the best care for patients, we need to know where to find the most relevant and up-to-date information. So being updated on ACOG guidance using SGO, NCCN, [00:54:00] USPSTF, what the resources, and recommendations are of the time is really important. That's the one piece of information that I would recommend.
So what's the one thing you wish providers knew? It comes to cancer prevention?
Dr. Shirley Mei: For me, I think I've touched on this a little bit before, but it would really be understanding the subtlety of ovarian cancer. It is often diagnosed at a late stage. My aunt was diagnosed with stage four ovarian cancer, so this kind of hits home for me and understanding that it takes about, on average, eight months for a woman to get diagnosed with ovarian cancer from the time of their first symptom.
So as providers, just making sure that we're cognizant of those mild symptoms and to get a pelvic ultrasound, which is a relatively inexpensive test that can help to detect early ovarian cancer.
Dr. Arjeme Cavens: Thanks for sharing that. And we wanna thank everyone for tuning into this episode of ACOG Podcast. [00:55:00] We hope today's conversation with us gave you some practical takeaways for how you can support your patients in preventing and identifying gynecologic cancers early.
Dr. Shirley Mei: Yeah. And be sure to check out the resources linked in the show notes.
And if you found this helpful, please share it with a colleague or a resident.
Announcer: To find out more information about current evidence-based guidelines on risk factors and screening, please take ACOG CME-accredited free online courses on uterine cancer, ovarian cancer, and lower anogenital tract cancer at acog.org/gyn-cancer