Cost vs. Care? New Gynecologic Cancer Screening Guidelines

Okay, I give. I had promised that I wasn’t going to be just one more voice in the breast cancer screening debate. But when the US Preventive Screening Task Force (USPSTF) of the Department of Health and Human Services came out with revised Breast Cancer Screening and Pap Smear recommendations in one week, I could no longer sit idly by and say nothing.

Last week the USPSTF blew us all out of the water when they recommended that women no longer perform breast self examinations (BSE’s) and that annual screening mammography not begin until age 50. This is a huge departure from the previous guidelines promoted by the task force, The American Cancer Society and the American College of Obstetricians and Gynecologists which state that “women should perform breast self examinations monthly and that they should have clinical breast examinations by their physicians annually. Screening mammography should begin at age 40, be performed every 1-2 years and then be performed annually after age 50.”

Courtesy of BreastCancer.org

The Task Force concluded that BSE is not effective in reducing the incidences of breast cancer and that rather than doing BSE, women should just be “aware” of their breasts.” WTF??? How are you going to be aware of your breasts if you don’t know how they feel? Are women to rely solely on visible discoloration, dimpling or nipple retraction? What about non visible tumors, such as those that are close to the axilla (arm pits) that are typically only found on palpation? Many breast cancers in young women under 40 are found via BSE. Just before my 33rd birthday I found a cyst during a BSE. It actually bursted when I had a mammogram, but I found it initially myself. What if I hadn’t been doing BSE and it hadn’t been a benign cyst?

As far as the mammography recommendations go, the USPSTF states that for every 1900 women screened between the ages of 40 and 49, only one breast cancer is diagnosed. According to them, this small yield does not make the test worthwhile. However, the one breast cancer that will be detected out of 1339 women screened between the ages of 50 and 59, makes the test worthwhile. So what makes the life in the 50′s more valuable than the life in the 40?  Their argument is that you have to screen more women in the 40′s to find a cancer and the rates of false positives, “unnecessary” biopsies and  surgeries make the screening in this age population “not cost effective.” And with that statement, I think we have found the rationale.

Thankfully the American Cancer Society and The American College of Obstetricians and Gynecologists have flat out rejected these recommendations. Research studies have repeatedly demonstrated that breast self examination and annual screening mammograpy after age 40 saves lives. While the USPSTF may not be impressed at” just one life saved”, the families of those mothers, sisters, daughters, aunts, cousins, etc…are most grateful that their loved ones with breast cancer were diagnosed early and that many of them are alive and well today.

Later in the week news broke that Pap smear guidelines were also revised. The USPSTF now recommends that Pap Smears, the test used to detect cervical cancer, no longer be performed annually, but every 2 years and that the screening not be initiated until age 21. Previously the recommendation was that Pap Smears be initiated at age 18 or at age of first intercourse and then be performed annually but at least once every 3 years. Since cervical cancer is rare in women under age 25, the Task Force feels comfortable recommending that onset of screening not take place before age 21. Again their rationale stems from the fact that many women will have abnormal pap smears and be subject to potentially invasive screening and treatment and yet have no actual abnormality. In simple terms, It’s just not cost effective.

This makes me wonder, if  Pap smears are of little benefit for women under age 25 because they are at little risk for developing cervical cancer, why the big push to vaccinate 11 year old girls with Gardasil, The “Cervical Cancer” vaccine ? If the task force is not concerned about screening for Cervical Cancer before age 21 (since it is rare in women under age 25), why not wait until a girl is actually at risk for “developing” cervical cancer and give her the vaccine at say, 18? Gardasil is designed to prevent young women from contracting 4 strains of the Human Papilloma Virus, two of which are known to lead to cervical cancer and two which cause more than 90% of all cases of genital warts. If we are so concerned about each of our young women becoming “One less” woman stricken with cervical cancer, doesn’t it stand to reason that we should do all that we can to be sure that they are healthy, including routine Pap Smears? The USPSTF does not differentiate between those young women who are sexually active and those that are not, they  just issue the blanket statement that all women begin screening at age 21. Likewise, the recommendation for Gardasil is for all girls at age 11. But again, if cervical cancer is slow growing and highly treatable, is the vaccine really necessary? Why not just treat once disease is more likely detectable-that is what they are advocating for breast cancer, isn’t it? Seems to me that a “scare” tactic was utilized. Cancer scares people and fear sells.

More effective marketing would have been to market Gardasil as a prevention against genital warts. Each year women under the age of 25 account for the majority of new genital warts cases. Approximately 6.2 million new HPV infections occur every year in the United States and approximately 20 million individuals are currently infected. Some women are diagnosed via Pap smear and subsequent colposcopy or cone biopsy while other young women will actually present with lesions that can be excised and biopsied. Treatments for warts include cryotherapy, Tricloracetic Acid therapy, laser therapy and more invasive procedures such as Loop Electrosurgical Excision Procedures (L EEP). But with such readily available and effective treatments for genital warts available is there the same urgency to prevent genital warts as there is to prevent cervical cancer? Would consumers be willing to take the vaccine if marketed to prevent genital warts as opposed to cervical cancer? (Surveys show that less than 1/3 of young women in the appropriate age range for vaccination have actually received Gardasil to date.)  To push consumers towards vaccination, something stronger was needed and cervical cancer became the “buzz” used to promote (push) Gardasil.

But I digress. Has anyone else noted that these two new recommendations, both calling for reduction in screening for gynecologic cancers, came just before the US senate was about to debate the Democratic Health Care Reform Bill which includes a public (government sponsored) option? Look, if the public option is accepted and the Democratic Health Care Reform bill becomes law, women who are currently uninsured and very likely not receiving any sort of cancer screening, as well as women who choose the government sponsored health insurance plan instead of a private (more expensive) insurance plan (such as Cigna, Blue Cross & Blue Shield, Aetna, etc…) will cause an increase in utilization of health care screening services. A government subsidized plan with see an increase in claims and subsequent payout while private insurance companies may very well see a decrease in revenues. More utilization of services with less profit. Hmmm…

I won’t profess to know the collective mind of the USPSTF and since I was not present during the review of the recommendations nor privy to the discussions, I won’t state that these recommendations are a means of cost containment in the event that Congress does pass a health care reform bill that includes a public option. But the timing is suspect. It behooves all of us to watch vigilantly as the health care reform bills are debated. The recommendations by the USPSTF may be the very means by which the government and private insurances deny women access to preventive screening tests. I am worried that women won’t receive screening mammograms and Pap Smears more frequently than the USPSTF recommends-even if their health situations dictate more frequent screening. I worry that young girls will be forced to receive a vaccine for which we have no long term data (side effect profile) and no proven long term efficacy. I am worried that young girls may later be denied treatment for HPV related diseases if they didn’t take the vaccine, increasing their morbidity and mortality. I worry that we’ll see an increase in the incidence of more deadly cases of breast cancer. No one can predict the future, but I am concerned that if these guidelines are enforced “One Less” may very soon become “a whole lot more”.

Add a comment November 23, 2009

Implosion Within: A Ruptured Ovarian Cyst

I woke up early yesterday morning to go to the bathroom. It was oddly annoying to be awakened from a sound sleep to move my bowels, but when nature calls….Shuffling back to bed I began to feel pain in my lower right side. “Perhaps I’m not done,” I thought and shuffled back into the bathroom. The pain increased. This was not coming from my bowels. Lying down was completely out of the question, so I meandered around my house for a bit, trying to find comfort. The more I wandered, the stronger the pain got until I finally climbed back into bed in a fetal position. When the pain became so intense that it was difficult to breathe, I woke up my husband.

“Something’s wrong,” I said. “I’m in pain.”

My husband sprang up from his sound sleep and after frantically groping for his glasses, began firing questions at me. “Do you need to throw up?” “Are you having diarrhea?” “Describe the pain; is it sharp, dull, does it move…”

While I realize that he was trying to be helpful, if I could have uncoiled from my fetal position, I would have belted him in the mouth. Instead I did my best to answer his questions.

“I’m taking you to the emergency room,” he declared. It was just after 6am by this point and I really couldn’t see making that arduous trip when my GYN’s office would be open in 2 hours.

“Look,” I said. “Get me one of the Vicodin I have left from my ablation. That will give me time until the doctor’s office opens. In the meantime, you’re going to have to get the kids up and out to school.” There were grumbles at the mention of managing the kids solo, but my husband made me comfortable and proceeded to tend to my children.

Not long after I took the Vicodin the pain began to subside. I slowly began to unfold from my fetal position. After 8am I began calling my GYN’s office to see if I could be seen later in the day. The lines were all busy, but I was finally able to leave a message for my doctor’s nurse. By the time I finally talked to my doctor’s nurse, I was feeling better and the pain had subsided considerably. I probably wouldn’t have even scheduled an office visit except that my husband was hovering over me with the look of panic in his eyes (I think he was more concerned that he would have to care for the children alone indefinitely!), so I took the open 3pm appointment for an ultrasound and examination with one of the nurse practitioners.

My ultrasound showed multiple uterine fibroids (no news there!), a couple of ovarian cysts on my left ovary and a lot of fluid around the right ovary. Watching the scan I realized that I had “fluid in the cul-de-sac” meaning fluid in the area surrounding my ovary. I had seen this when I used to work in infertility when the doctors would retrieve the eggs from women after they had been hyperstimulated. The fluid would often spill into the pelvis after the follicles were punctured and the eggs retrieved or after the follicles had spontaneously ruptured. since I had not been hyperstimulated yet was somewhere near the mid-point in my cycle, an ovarian follicle or cyst had likely ruptured. The nurse practitioner confirmed my suspicions and I returned home with orders to take anti-inflammatories.

Ovarian cysts are quite common and frequently occur in women of childbearing age. Each month several follicles develop to mature eggs for ovulation, but ultimately only one will go on to mature an egg which will be ovulated. The body usually reabsorbs the remaining follicles, but not always.  Follicles that aren’t reabsorbed but persist as fluid filled sacs or (Functional) cysts can cause pain and pressure within the abdomen. When they burst, the fluid they contain irritates the tissue in the abdominal cavity causing intense pain. The pain will gradually subside over a few days, and is relieved with anti-inflammatory drugs. In other cases, the follicles don’t rupture but continue to grow and cause pain as well as put pressure on surrounding structures such as the bowels or bladder, sometimes obstructing them. Cysts that don’t go away and continue to cause problems must be surgically emoved.

In women who repeatedly develop ovarian cysts related to ovulation (functional and luteal cysts), birth control pills can reduce the number of cysts they develop because birth control pills prevent the ovaries from developing follicles. Other types of ovarian cysts such as endometriomas (cysts made up of tissue from endometriosis), cystadenomas (cysts that form on the outer surface of the ovaries), and dermoid cysts (cysts formed from a variety of tissue types) are also easily managed conservatively with careful monitoring is they cause no symptoms, with medications (endometriomas) or via surgery if they cause too many problems.

Overall I would say that I am pretty lucky. While having a ruptured ovarian cyst pretty much knocked out my day, it could have been a lot worse.

If you have any of these symptoms, talk to your doctor, you may have an ovarian cyst.

• Pressure, swelling, or pain in the abdomen
• pelvic pain
• dull ache in the lower back and thighs
• problems passing urine completely
• pain during sex
• weight gain
• pain during your period
• abnormal bleeding
• nausea or vomiting

And get help immediately if you experience any of these symptoms:

• pain with fever and vomiting
• sudden, severe abdominal pain
• faintness, dizziness, or weakness
• rapid breathing

Symptom list is from The National Women’s Health Information Center of the US Department of Health and Human Services. www.womenshealth.gov.

Add a comment November 4, 2009