Wednesday, February 21, 2018

USPSTF updates its ovarian cancer screening guidelines

The US Preventive Services Task Force (USPSTF) recommends against screening for ovarian cancer in asymptomatic women who are not at high-risk for ovarian cancer. This update is in consensus with its previous 2012 recommendations. The updated guidelines were published in recent issue of Journal of American Medical Association (JAMA).

USPSTF advise against screening for ovarian cancer in women who are asymptomatic and not at high-risk of hereditary cancer syndrome (D recommendation).

The presenting symptoms for ovarian cancer (bloating, constipation, abdominal pain or pressure, urinary symptoms, back pain, or fatigue) are nonspecific and may be present in both healthy women and women with late-stage ovarian cancer; therefore, these cannot be used to detect cancer at a very early stage.

This decision is based on benefits and harms of the screening test and cost was not considered in formulating the recommendations.

Ovarian cancer is the fifth in the list of cancer-specific mortality and tops the list of deaths due to gynecological malignancies, despite its low incidence of 11.4 cases per 100,000 women per year.

Many women who undergo screening for ovarian cancer receive false positive reports as the screening tests have low specificity.

courtesy: Thinkstock

USPSTF has sufficient evidence to recommend that screening with transvaginal ultrasound, testing for the serum tumor marker cancer antigen 125 (CA-125), or a combination of both does not reduce ovarian cancer mortality.

Routine pelvic examination and bimanual palpation also do not help in early detection of cancer; furthermore, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial discontinued it as a screening test because not a single case was detected based only on bimanual pelvic examination.

The number of false -positive cases may result in unnecessary surgery and further testing for women who are cancer-free.

Women with hereditary cancer syndromes such as women with BRCA1 or BRCA2 genetic mutations should follow the specific recommendations and talk to their healthcare providers for guidance and cancer screening.

The recommendations are in agreement with the 2012 recommendations because the result of large UKCTOCS trial was published which in consensus with the PLCO trial, did not find sufficient evidence that screening for ovarian cancer reduces ovarian cancer mortality in asymptomatic women.

These recommendations are also in consensus with other major organizations like American College of Obstetricians and Gynecologists, American Cancer Society American College of Radiology and the American Academy of Family Physicians. 

Tuesday, February 20, 2018

Novel cross-over sign in cesarean scar pregnancy helps predicts the risk of invasive placentation

power-point slide by ISUOG
First trimester ultrasound scan evaluating the relationship between the gestational sac and the endometrial line in women with cesarean scar pregnancy(CSP) helps predicts the development of abnormally invasive placenta (AIP) and consecutive intra and post-operative surgical morbidities reports the results of a retrospective case series published in Journal of International Society of Ultrasound in Obstetrics and Gynecology.

Recent advances in prenatal imaging and increase rate of cesarean sections have led to increased diagnosis of CSP. Although, most of the patients with CSP present with severe hemorrhage or rupture uterus, that requires emergency surgical management, few advance further, evolving into AIP.

There is no reliable marker that can predict whether a woman with CSP will end up in early abortion or further progress to develop placenta percreta or other less severe forms of AIP.

A novel ultrasound cross-over sign (COS) has recently been thought to predict the evolution of CSP into different forms of AIP so that the intraoperative and postoperative risk can be stratified.

A straight line is drawn from internal cervical os to the fundus of the uterus in sagittal view through the endometrium. The gestational sac is identified, and its superior-inferior diameter measured. The COS is classified according to the relationship of ectopic sac diameter with the endometrial straight line into COS-1 and COS-2.

This case series identified 102 women over a period of 8 years with AIP diagnosis confirmed by histopathological examination (HPE), of whom 68 patients had a first-trimester ultrasound with a diagnosis of CSP. The scans were read by sonographers who did not have any idea about the pregnancy outcome and pathology reports.  

COS sign was assessed as mentioned, and all patients received counseling regarding the prognosis, risk, and post-operative complications. Women with severe AIP were delivered early, as compared to less severe variants.

All women underwent cesarean hysterectomy with temporary occlusion of the internal iliac artery and ureteric stent in place. At HPE, 34 cases were diagnosed with placenta percreta, 13 with placenta increta and 21 with placenta accreta.

Pregnancies with COS-1 had early deliveries, longer operating time, more blood loss and required much more packed red blood cells during surgery mean as compared with those with COS-2+ or COS-2–.

Thus, predicting the likely course CSP diagnosed by COS sign in the first trimester can improve shared decision making between the patient and provider about the surgical difficulties endured, amount of blood loss and need for cesarean hysterectomy.

Large, multi-center studies to determine the role of COS sign in predicting the severity of AIP in CSP is needed in future.

This article has been selected for Journal Club. Click here to view slides and discussion points. 

Monday, February 19, 2018

North American Menopause Society (NAMS) video series about important midlife health topics: Clinical options for treating GSM

The North American Menopause Society (NAMS) is proud of its comprehensive video series for women on important midlife health topics. All the interviews in the series are hosted by NAM Board of Trustees Member and Immediate Past-President Dr. Marla Shapiro, a Canadian physician who led this exciting initiative. Dr. Shapiro is also the medical consultant for CTV News.

In this first video of 2018 series, Dr. Shapiro discusses clinical aspects of the genitourinary syndrome of menopause (GSM) with Dr.Nick Panay, an obstetrician-gynecologist from London and general secretary-elect of the international menopause society(IMS).

This is a very common problem worldwide, but it is severely underreported and undertreated because most of the women are reluctant to come forward and discuss it with the health care providers.

In this video, Dr. Panay discusses treatment options for women with GSM.