Ovarian Cancer Screening

You may notice that I haven't posted in awhile. I have certainly not stopped my blog, I have just been very busy. Even so, there are thousands of people who read this blog from all over the world. And it is still growing. Google is linking in from Ob/Gyn kinds of searches. Many of these blog posts have information that will not change much over time, so the search engines keep linking in here.

I have been a bit busy to blog much. I had to do my yearly boards exam. That is about 35 hours of open book testing, done in "free time". So it always takes me a long time. I score very well on these tests, but I am very careful to read the questions and the reading material. Also, we had summer vacations to deal with. My covering doctor, Fred Rezvani, took some time off, and that leaves me with covering his patients as well. I like doing it, but it does take up a lot of time.

Today's blog post is about Ovarian Cancer Screening. This is a contentious subject. It is certainly not a hopeless subject, but we can certainly do a lot better than random screenings.

Occasionally I will get a request from a patient to do some kind of medically unnecessary testing. This might include some unnecessary testing for ovarian cancer. Similarly, sometimes a patient or her family will want to have an obstetrical sonogram that is not on the list of traditionally accepted indications. I have seen instances where the patient's family is in from overseas and they have not seen the baby yet.  They would like to see the baby before they leave to go back home.  And in a situation like that I will sometimes do a so-called unofficial sonogram and show the baby to the family. Also, there are situations where the patient does not feel the baby moving.  It may be too early in the pregnancy to expect such fetal movements.  But even so, the stress level can get so high, a quick peek at the baby with the sonogram is valuable to convince the woman that she and her baby are fine.  The stress reduction is so gigantic, that it is a very worth while sonogram to do.  Sometimes, if the sonogram is not available, just checking the fetal heartbeat with the Doppler is rewarding.

Ovarian cancer screening, however, is very murky.  The scientific evidence at this time seems to be that the usual screening methods do more harm than good. There is a recurrent ovarian cancer e-mail that goes around on the Internet.  It is extremely common.  This email advises woman to take control of the own destiny and demand a sonogram and a CA 125 test. If the patient asks me about this situation, this is what I usually try to do:

I will not utterly deny her the testing.  If she is completely convinced she needs the test, and I don't do it, I will have likely lost this patient for good.  This means that I will be unable to give her good medical care in the future, and she may not get any good medical care at all. I think this scenario is even riskier then doing the scientifically unproven ovarian cancer screening.

But, I will explain to the patient that the scientific evidence is at best murky, and that at worse shows actual harm to the patient.

A smart person might legitimately ask "how can a simple blood test and a simple sonogram harm a person?".  The answer lies in the fact that no lives are saved by this set of testing.  Sure, we find many ovarian cysts, many ovarian tumors, and even a few cancers.  But the comparison group between screened and the non screened   individuals shows no difference or worse for the screened group. This was originally proven by the Gilda Radner study. Gilda was a famous and wonderful comedian who died when she was young. She died of ovarian cancer.  Her husband, the famous Gene Wilder (the first Willy Wonka), sponsored a medical study to try to help save women from ovarian cancer.  This study, and several since, showed harm to the screening group, or at least no benefit.  I am told that the Gene Wilder study cost $7 million dollars.  And it was a good study.

Why is the screened group harmed?  Because, among other things, they are exposed to a lot of unnecessary surgery.  This surgery has a lot of risks.  Surgery, if unnecessary, still leads to the risks of infections, bleeding, scarring, and damage to adjacent organs.  These risks are high enough to lead to more harm to the screened group then to the non-screened group.  But the situation is worse than that. The women who get the screening tests done become very reluctant to really come in when it actually becomes necessary.

What I mean is, that a patient who has an ovarian sonogram, will have a feeling that she is so healthy that she will refuse to come for medical care even when it is necessary, when her ovaries are painful or bloated. When a woman has painful or bloated ovaries,she must come in for an evaluation.  But, not for a screening evaluation, it is now a medically necessary diagnostic intervention. The scientific analysis that these tests are valuable is indisputable. The problem with the screened group of women, is that they will not come back for these tests.  I have had women say, "but I just had a sonogram and it was normal!"  I will tell them, that I don't care if the sonogram was done last month, she needs another one. People can certainly get a clinically evident ovarian tumor in the space of the single day.  It is a mathematical and  medical certainty for any given person who has a tumor, that it was undetectable prior to becoming detectable, and since we have no control over when that transition to detectability occurs, we must start a new evaluation every time there are new symptoms of problems. The woman who have been screened for ovarian cancer will sometimes not come back for years despite the new onset of problems. they seem to forget that every cancer is undetectable before it is detectable. When a woman says to me "but I just had it done...", I will look in the chart and sometimes see that it was years ago. That doesn't surprise me at all, because I certainly cannot remember the last time I had an EKG, or anything else. I feel like my colonoscopy was 2 days ago, but it was years ago, and I certainly cannot remember which year. Who wants to remember those things? That's what medical records are for.

Of course there are grey areas in between non detectable and detectable tumors, and there is a fuzzy kind of logic in between the two situations, but that doesn't change the fact that all tumors are not detected before they are in fact detected. And we don't know when that transition happens.

So, we have a situation where we have screening tests done, but in general do more harm than good. But Diagnostic Testing does more good than harm. All women should strive for diagnostic testing instead of screening testing.

But, women should think about this: How often does a women get a screening test? Since there is no science that screening helps women, we have no idea how often to do it. This is like the mathematical equivalent of dividing by zero, the result is not defined. So, we can guess that maybe yearly screens are a good idea. Or, if a woman has a lot of time and money, she could get screened twice a year. There is no good answer.

But, Diagnostic testing is different. Diagnostic testing for ovarian pain and bloating can be done more often than once a year, if it is necessary.   Diagnostic testing has been indisputably proven to help women better than screening.  And, it can be done more frequently, if and when it is necessary.

What happens when we follow this diagnostic protocol? It seems to me that something magical happens. Women themselves become an integral part of the chain of events that are necessary to save their lives from cancer. Think of how empowering that is for women. Think of one woman, who says, "I demand a sonogram and CA125 blood test, even though I feel good". The science shows that that woman is harming herself, under the misguiding thought that these tests might help save her. And, she may wind up paying for these harmful procedures, since they are not medically necessary. That is quite expensive. But, another women, a bit smarter maybe, will get yearly checkups of course, but will reserve her ovarian cancer testing for the one unfortunate day when she is bloated, or in pain. Her diagnosis may be dramatically sooner in the disease process than a previously screened women. So, the second women is empowered to become part of the system. She is, herself, by force of will alone, becoming a link in the ever important chain of human events that create an early detection system for ovarian cancer. This is so much better than a dumb and blind stab in the dark at a random screening for ovarian cancer.

Despite these proven the advantages of diagnostic testing done when indicated, some women still want to be screened.  If I explain the harm proven in the above studies, and the patient still wants screening, I will do it for them.  But I will emphasize for them, that they still need to come back if they ever get ovarian pain and bloating.

There are physicians who dispute the above science.  They will screen either every woman who comes through the door, or every woman who asks. These physicians will of course be doing a lot of surgery on healthy women.  These surgeries can become the most lucrative part of their practice. They may make a very good living by doing this style of practice.  And they are making a lot of women very happy by telling them they don't have cancer in the postoperative recovery room. They will say it with a big dramatic sigh of relief.

Don't get me wrong, I don't think that ovarian cancer screening is impossible.  I just don't think it is ready for prime time. There is lots of cancer screening that has been proven beneficial.  The Pap smear is great. The Pap smear is so great that we are probably overusing it. Colonoscopies most definitely save lives. I have had mine done. One day, we will get a protocol that works. It might involve proteomics, or it might involve MRI's.

Like I said before, when woman understands the above, and she still wants her ovarian cancer screening, I will do it. You would all be surprised, however, how many women believe the above scientific analysis.  Most women agree to follow the scientific protocols.  Most women agree to hurry back to the office if her ovaries become sore or bloated.  Then I can do the indicated testing, and maybe help save her life.  This is more successful than any screening protocol yet devised. And maybe I will get to see her more often than once a year.  This is fine by me.  I know that, without a doubt, I am providing better care by doing this.

Thank you sincerely.

I hope I have explained the above two groups of women adequately. Those two groups being the unscreened women and the screened women. And you may notice that this post is nonscientific. It is just my thoughts. There are no peer reviewed references. If I did that, this blog would be very different.

Please feel free to forward this note on to other people. Maybe we can get it to go viral. Just be sure to include the following lines:

John Marcus MD Obstetrician and Gynecologist.
Ridgewood, NJ, USA
Phone number 201-447-0077
Member of The Lifeline Group at www.lma-llc.com
Blog at doctorjohnmarcus.blogspot.com