Updates in Screening Recommendations for Female Cancers
For the IAPA Women’s Health issue, I decided to sort through the muck of current screening guidelines and some of the new testing technologies for female cancers. The guidelines are backed by evidence (although with variable interpretations) with the overall goals of preventing cancer morbidity and mortality while improving patient access, convenience, and cost.
Breast cancer is the leading cause of new cancers diagnosed in 2016 with 1 in 8 women developing breast cancer in the United States within their lifetime, including 10,000 in Illinois alone.1,2 In 2016, over 40,000 women in the United States will die of the disease.
After performing a systematic review of the literature, the American Cancer Society (ACS) stirred up the status quo in 2015 with their release of updates on the breast cancer screening recommendations for asymptomatic, average risk patients. This includes patients with no personal or significant family history of breast cancer, or chest radiation exposure. ACS’ new evidence-based recommendations looked to address the risks of false positives, biopsies, and “overdiagnosed” breast cancers (diagnosis of noninvasive and invasive breast cancers that would have otherwise not have become a threat).2 ACS advised against clinical breast examination and recommended starting annual screenings at 45 years old.2 These transformed recommendations were quite a change, since clinical breast exams were well-established as standard practice and the start of mammograms had previously been advised at 40 years old, or as early as 35 years old in the 1980’s. The US Preventive Services Task Force (USPSTF) agreed with starting imaging later, since data suggests that starting screenings at age 40 will prevent only 1:1000 deaths from breast cancer.3 Therefore, screening in patients 40-44 years old was advised on an individual patient basis.
The American College of Obstetricians and Gynecologists (ACOG) quickly responded by organizing a multidisciplinary review board with the vision of developing a uniform set of guidelines.4 In the meantime, ACOG continues to recommend annual screening mammograms for women beginning at age 40, clinical breast exams, and breast awareness.4, 5 Breast awareness is a concept defined as a woman being familiar with her breasts and promptly reporting any changes to their health care provider.5 That’s right, no more shower-hanging cards! In contrast, the USPSTF released their own updated guidelines in January 2016 with recommendation for biennial mammogram screenings from ages 50-74 years old.3 They also favored breast awareness over breast self-examination (BSE).
Overall, the recommendations of ACS, NCCN, USPSTF and ACOG differ due to varying interpretations of the literature and have caused commotion in the media and confusion among providers and patients (see Table 1). In general, the various organizations agree that breast screening with mammography 1) improves rates of early detection, 2) decreases the risk of death from breast cancer, 3) has improved accuracy between the ages of 40-69 years old, and 4) has limited benefit over the age of 75, especially if life expectancy is less than 10 years. In addition, they agree that Breast Self-Examinations (BSE) lead to unnecessary imaging procedures and biopsies.
In patients with an increased risk of developing breast cancer, serious consideration should be given to referral to a Cancer Genetics Counselor for risk-reduction counseling. These specialists can help quantify a patient’s risk using models such as the NCI Breast Cancer Risk Assessment Tool and determine an appropriate screening strategy. Women in this population should be counseled on increased surveillance with more frequent clinical encounters and imaging, with possible inclusion of Breast MRIs, risk-reduction agents (i.e. Tamoxifen, Raloxifene, or Aromatase inhibitor) and in some cases, as with BRCA mutation carriers, prophylactic bilateral mastectomy.6,7
Providers need to also be aware that women with breast implants should continue to have mammography imaging using an implant protocol (i.e. implant displacement views). The indication for imaging of implants placed as part of breast reconstruction should be decided on an individual basis.
Lastly, providers will be hearing more about advanced screening with 3D Mammogram. Also known as tomosynthsis, “tomo,” or digital breast tomosynthesis (DBT), this new imaging technique captures high-resolution breast images from multiple angles. A breast radiologist once described it to me as being able to see in-between slices of a loaf of bread, instead of just squishing the loaf and trying to sort through the bulk. The argument in favor of this modality is the benefit of less call backs for additional imaging or biopsies, fewer false-positives, and a small increase in detectable cancers.8 The downside is slightly more radiation exposure since, although it uses low-dose x-rays, it is performed in combination with standard mammograms.8 The USPSTF concludes that there is insufficient evidence to assess the benefits and harms for use of tomosynthesis as a primary screening tool for breast cancer.3 As a result, testing is not currently FDA approved and most likely not covered by insurance plans for now. The self-pay cost varies, but is typically around $100.
In the end, shared conversations between the patient and provider should determine the patient’s breast cancer risk, in order to come to a mutual decision regarding the individual’s screening strategy and frequency of mammograms.
Table 1. Current screening mammography recommendations for women with average risk of developing breast cancer [Adapted from the ACOG Practice Bulletin. Number 122, August 2011.10]
Clinical Breast Examination
American College of Obstetricians and Gynecologists4,9
≥40 years old: annually. Consider biennial screening for select patients
19 years old: annually
American Cancer Society2
40-44 years old: option to start screening
Not recommended at any age
45-54 years old: annually
≥55 years old: consider transition to biennial screening
Continue screening as long as overall health is good and life expectancy is 10 years or longer
National Comprehensive Cancer Network6
40-74 years old: annually
25-40 years old: every 1-3 years
≥74 years old: on individual basis, no screening if limited life expectancy where no intervention would occur based on the findings
≥40 years old: annually
U.S. Preventative Services Task Force3
40-49 years old: option to begin biennial screening on individual basis
Not recommended at any age
50-74 years old: Biennial screening mammogram
≥75 years old: Insufficient current evidence to assess balance of benefits and harms of screening mammography in these women
Ovarian Cancer Screening
Ovarian cancer is the 5th most common cause of cancer-related death with an estimated 14,000 deaths predicted for 2016.1 Unfortunately, due to the limited ability of Transvaginal Ultrasound (TVUS) and CA125 to detect ovarian cancers at an early or curable stage, regular ovarian cancer screenings are not recommended for the general population. In September 2016, ACOG released a practice advisory supporting a statement by the FDA that any currently available ovarian cancer screening tests, “are neither accurate nor reliable to screen asymptomatic women for early ovarian cancer.”11 This included both the average and high risk populations of asymptomatic women. Studies are ongoing to find new technologies that may increase the efficacy of ovarian cancer screening programs. For instance, at Northwestern University, the Division of Gynecologic Oncology is currently performing a large validation study of a novel nanotechnology that can distinguish women with ovarian cancer and risk-stratify women with increased risk (BRCA1/2 mutation or positive family history) of ovarian cancer using cervical cells collected during a routine Pap test. Until new, reliable tools are identified, providers should continue education of patients encouraging reporting of any new suspicious symptoms that persist greater than 2 weeks, including abdominal bloating, early satiety, and changes in bowel or bladder habits.
On the other hand, women at increased risk of developing ovarian cancer should be referred to a Genetic Counselor or Gynecologic Oncologist to discuss risk-reducing options.11 High risk patients include those with a genetic mutation like BRCA or Lynch Syndrome, with a family history of ovarian cancer (2 or more first or second degree relatives with ovarian cancer or a combination of ovarian and breast cancer), or from Ashkenazi Jewish descent. Women with BRCA1 and BRCA2 mutations have a 39-46% and 12-20% risk of developing ovarian cancer, respectively; and those with Lynch Syndrome have up to a 24% risk.7,12 The evidence to support screening in high risk populations is stronger for BRCA mutations than for Lynch Syndrome. Close surveillance in these groups can be performed with TVUS and CA125 beginning at the age of 30 or 5-10 years earlier than the first ovarian cancer diagnosis in their family.7 However, mutation carriers should be offered risk-reducing salpingo-oophorectomy by age 40 or when childbearing is completed. Prophylactic BSO can decrease the risk of ovarian cancer by 85-90% in BRCA carriers.7 Of note, the risk of ovarian cancer in women with BRCA1 mutations is greatest in their 40’s, while the risk for pre-menopausal ovarian cancer is less for BRCA2 mutation carriers.7 Therefore, timing of surgery can be customized based on the known mutation.
Cervical Cancer Screening
ACS predicts nearly 13,000 new cases and 4,120 deaths from cervical cancer in the US during 2016.1 Since the initiation of cytology testing with Papanicolaou (Pap) testing in the 20th century, the incidence and mortality of the more common squamous cell cervical cancer has decreased from once being the primary cause of cancer deaths in women to currently a rank of 14th.13 However, even with high-quality screening tests, the main challenge is patient access to screening. About half of the cervical cancers diagnosed in the US are in women who were never screened and 10% of the cancers are among women not screened within the past 5 years.13 While cytology allows for increased detection of treatable pre-invasive lesions and invasive cancers, the addition of human papilloma virus (HPV) testing (co-testing with Pap + HPV) allows for longer term safety after a negative test than cytology alone.13 This is a significant benefit to patients who are unable to have regular screenings. In women with no history of abnormal pap smears, the ACS-American society for Colposcopy and Cervical Pathology (ASCCP)-American Society for Clinical Pathology (ASCP) guidelines recommend cytology alone (aka pap smear) every 3 years for women aged 21-29. Women aged 30-65 should have co-testing (HPV + cytology) every 5 years or cytology alone every 3 years. Women over 65 years old should discontinue cervical cancer screening if their prior testing has been unremarkable. In addition, cervical cancer screening is not recommended after total hysterectomy (includes removal of the cervix).13 Management of any abnormal cervical cancer screening tests should be managed according to the ASCCP guidelines.14References
Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2016. CA: A Cancer Journal for Clinicians. 2016; 66(1):7-30.
Oeffinger KC, Fontham ETH, Etzioni R, et al. Breast Cancer Screening for Women at Average Risk : 2015 Guideline Update From the American Cancer Society. JAMA. 2015;314(15):1599-1614.
Saslow D, Solomon D, Lawson H, et al. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer. American Journalof Clinical Pathology. 2012;137:516-542
Alissa Newman, MMS, PA-Cis a Physician Assistant in Gynecologic Oncology at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago, Illinois. She previously practiced Breast Medical Oncology at the Memorial Breast Cancer Center in Hollywood, Florida and the University of Miami Sylvester Cancer Center in Miami, Florida. She received her PA degree from the Nova Southeastern University and undergraduate degree from the University of Michigan, Ann Arbor.
Is Your Patient At Risk for Preterm Birth?
Mother Gina Schroeder, who delivered at 31 weeks, did not know she was at risk for having a premature baby. “It happens so fast”, said Schroeder.
Premature, or preterm, birth, is any birth that occurs before 37 weeks of pregnancy1. According to the March of Dimes, there are approximately 380,000 preterm births each year, which is approximately 1 in 10 babies born in the U.S.
While there are factors that can increase a woman’s risk of preterm birth, such as advanced maternal age, high blood pressure, short duration between pregnancies, certain ethnicities, or previous history of preterm birth, research shows that:
40% of preterm births occur in first time moms, and
50% of preterm births occur when there are no known risk factors
“Each week of gestation up to 39 weeks is important for a fetus to fully develop before delivery and have a healthy start,” said Jeffrey L. Ecker, M.D., chair of the American College of Obstetrics and Gynecology’s Committee on Obstetric Practice. Premature babies lack a complete gestation process and face long-term health issues as a result. Many suffer from neurological disabilities, breathing problems, developmental delays, impaired cognitive skills, vision problems, hearing impairment, and trouble feeding2.
Given all of this, how do you know which patients in your practice are at increased risk for preterm birth? Now there is a new proteomic test, PreTRM®, that can assess each woman’s individual risk for premature birth. The PreTRM test is the first and only prenatal blood test that provides early and accurate risk assessment for preterm birth. A simple blood draw at 19-20 weeks, before symptoms occur, the PreTRM test measures proteins secreted from the placenta into the mother’s blood that are highly predictive of preterm birth. If a patient is at increased risk, the good news is you found out early in her pregnancy. There are established interventions designed to help prolong gestation with the goal of helping the baby develop more fully.
According to Dr. Lee Shulman, Chief of Clinical Genetics in the Department of Obstetrics and Gynecology, Northwestern “the ability to identify, from the large pool of low risk women, those women who may in fact go on to have preterm labor and delivery is of incredible value, and allows us to not only monitor these patients better, but allows us to counsel patients better, and develop those interventions that will eventually reduce, hopefully eliminate preterm birth.”
“As a mom, you will do everything, anything you can to help your child. When you know you are at risk for having a premature baby, you’ll do anything to keep them out of the hospital. I didn’t get that chance. I hope other women will get that chance”, said Schroeder.
For more information on the PreTRM test, please visit www.PreTRM.com, or call 855-5-PRETRM
It’s that time of year again! Time when the leaves start to change, the kids are back in school, and low and behold….it’s National PA Week! It’s a good time to be a PA isn’t it? In the last two years alone, we have the fastest growing profession, the top master’s degree, and been in the top 5 on the Forbes list for the best jobs. I’ll say it again….it’s a great time to be a PA! And that’s especially true for PAs in Illinois.
Illinois PAs have good reason to celebrate. We have had many accomplishments this year, many which could have not been accomplished without your support. From the PA “Rules and Regs Clean-up” Bill being signed by the governor, to a much anticipated upcoming CME event, Illinois is a great place for PAs. As we celebrate PA Week 2016, let’s take some time to reflect on who we are now and where we have been. I happened to be looking for something in the IAPA archives the other day and found an old newsletter. It just happened to be the newsletter where we celebrated the first “PA Day” on October 6, 1987. How timely! This is an excerpt from that newsletter published in September of 1987.
We’ve come a long way since that day and are continuing to have a tremendous impact in healthcare. Let’s look toward our future and continue to modernize the PA profession. I ask all of you to stand up and be loud during National PA Week. Speak to your physicians, your colleagues, your patients, your family and friends, anyone who will listen and tell them how important it is to support PAs and the PA profession. However, the IAPA also needs your continued support. We are a volunteer, non-profit organization who is the voice of the profession in Illinois. If you haven’t already done so, please join! By joining, you will open up a world of opportunities for professional development, advocacy, and the ability to make a difference for not only our patients, but for our profession. Congrats on being part of one of the greatest professions ever created and Happy National PA Week!
Jennifer Orozco, MMS, PA-C, DFAAPA | IAPA President 2016-17, is the Director of Advanced Practice Providers at Rush University, Chicago.
Springfield Scene |
Illinois Practice Act Modernization & State Medicaid Billing Improvments Move Forward
SPRINGFIELD -- In October, IAPA President Jennifer Orozco will be making a presentation to a large group of Illinois State Medical Society physician leaders about modernizing the State of Illinois' Physician Practice Act. Since the Practice Act expires at the end of 2017, IAPA will be pursuing improvements to our practice act to reflect the current roles and responsibility of PAs. IAPA is working with the ISMS and will be working with other health care groups and state regulators to reach a consensus on the modernization.
State Representative Michael Zalewski, D-Riverside, the chairman of the Illinois House Health Care Licenses Committee, has agreed to be the chief sponsor of the PA Act modernization legislation during the 2017 session.
Zalewski and Senator Iris Martinez, D-Chicago, chairman of the Senate Licensed Activities Committee, led the charge during the 2016 spring legislative session in Springfield for a major cleanup of outdated PA regulators on practice roles and responsibilities. Governor Bruce Rauner signed the bipartisan bill and click HERE to view the final language of the new law.
IAPA continues to work to improve the State of Illinois billing for PAs treating Medicaid patients. Since questions and concerns have arose from hospital providers, IAPA is working with the Illinois Department of Healthcare and Family Services to make sure that all PA Medicaid treatments are properly recorded and quickly reimbursed.
We will keep you posted about these issues as new developments arise.
Mindy Sanders, PA-C, CPAAPA | IAPA President Elect 2016-17 [Legislative Chairman] is a Physician Assistant in Family Medicine at Springfield Clinic in Springfield, Illinois. She also practices Acute Care Medicine. She received her PA degree from Southern Illinois University at Carbondale in 2007
The STUDENT Section |
Clinical Year Discomfort: You're NOT Alone!
I remember the first few days of my first rotation as filled with excitement, anxiety, and discomfort. I was excited to put into practice everything I learned during didactic year; anxious to see real patients and have them view me as a provider; uncomfortable to be in a new environment and overwhelmed by how much more I had to learn. My only reprieve was confiding in my classmates about these various emotions. To my surprise, everyone was facing similar struggles. We all feel inadequate and that’s reasonable because we’re still learning. We are not expected to know the answer to every question that a patient or a preceptor asks us. The purpose of “pimping” is to demonstrate the boundaries of our knowledge and what we need to further investigate. This also teaches us how to find information, because no one will ever know ALL the answers.
My advice to other PA students is to look for support in your classmates. Take the time to discuss the frustration you felt in one situation, explore the fascinating case you encountered, or ask a classmate’s opinion about a patient you saw. They are going through incredibly similar experiences and simply reminiscing about rotation experiences is therapeutic. We successfully collaborated during didactic year to study for exams – it is a natural progression to continue supporting each other throughout clinical year. My classmates continue to give me confidence, encouragement, and curiosity to learn all that I can during rotations. As future PAs, we will continue to rely on our team of other medical providers for support and guidance, so we might as well practice that teamwork now!
I am learning to embrace the discomfort of rotations and use it as a learning opportunity. I am a student and have a lot to learn, and it is exciting to be able to ask questions of experienced providers that are eager to teach. I often remind myself of one of my favorite quotes by the author Neale Donald Walsch, “Life begins at the end of your comfort zone.” If we are always comfortable, we will never experience new things or learn about unfamiliar topics. If you feel uncomfortable during clinical rotations, you are not alone; your classmates can empathize and help along the way.
Samantha Thompson, PA-S2 - Northwestern University | IAPA Student Representative
Photo from 2016 IAPA Challenge Bowl (from left to right): Madeline Mazurek, Samantha Thompson (author), Sarah Eitrheim