1. Nalley, Catlin

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With a growing understanding of gynecologic cancers, screening practices for these diseases continue to evolve as advancements continue. "As gynecologic oncologists, we manage several different cancers and the screening protocols for each disease are different," noted Mehdi M. Kebria, MD, a gynecologic oncologist at City of Hope. "A clear understanding of these various approaches and recommendations is important."

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Current Screening Practices

Screening practices vary across disease types, with some having more robust options compared with others. For instance, there has been significant progress and success for the screening of cervical cancer with the introduction of Pap and HPV testing, Kebria noted.


The American Cancer Society (ACS) updated their cervical cancer screening guidelines in 2020, recommending primary HPV testing every 5 years for individuals ages 25-65 years. If primary HPV testing is not available, HPV/Pap co-testing every 5 years or Pap testing every 3 years is acceptable.


Individuals 65 years or older can discontinue cervical cancer screening if they have no history of cervical cancer intraepithelial neoplasia Grade 2 or more severe disease within the past 25 years, and documented negative screening tests in the prior 10 years (CA Cancer J Clin 2020; doi: 10.3322/caac.21628).


These updates differ from the 2012 ACS recommendation in several key ways, including an emphasis on HPV testing alone. While all three testing modalities can detect cervical cancer precursors, studies have demonstrated that HPV tests are more accurate and reliable when compared with Pap tests. Given their accuracy, HPV tests also don't have to be administered as frequently, according to the National Cancer Institute.


Additionally, the ACS adjusted the recommended age for initial screening from 21 to 25 years old. Based on the most recent research, they determined that the benefits of cervical screening do not outweigh the harm from individuals ages 21-24.


Other gynecologic malignancies, such as ovarian cancer, do not currently have effective screening options available. While doctors will perform a pelvic exam, which includes checking the ovaries, this often does not detect smaller cysts. Educating patients on the common symptoms associated with ovarian cancer, including persistent bloating, abdominal pain, and an increase in the frequency of urination, is important.


"For ovarian cancer, unfortunately, we still do not have an effective way to screen the general population," Kebria told Oncology Times. "However, genetic testing is evolving rapidly and in the last few years we have seen an increase in testing that can potentially detect the genetic conditions that could cause ovarian cancer.


"Among patients with a genetic abnormality, we can conduct additional screening to hopefully detect cancer earlier or uncover lesions that could progress to cancer," he added. "We have a clinical trial at City of Hope that includes comprehensive genetic testing. And so, for instance, if a patient has a BRCA mutation, we would conduct an ultrasound or tumor marker checks every 6 months, and the hope is that this will detect their cancer earlier and give them a better chance of survival."


Currently, there is also no screening method available for uterine-or endometrial-cancer; however, some women are at an increased risk for the disease, according to Kebria. Those with Lynch syndrome or a family history of the condition are recommended to undergo transvaginal ultrasound and endometrial biopsy on a yearly basis.


In terms of vaginal and vulvar cancer, there are no screening tests available and the best option for detection is an awareness of the signs and symptoms as well as annual pelvic exams to look for changes or abnormalities in the vagina or skin of the vulva.


Patient Education & the Oncologist's Role

Patient compliance and access to care remain an issue when it comes to preventive care, including gynecologic cancer screening, and this issue has only been exacerbated by the COVID-19 pandemic.


A cross-sectional study that analyzed National Health Interview Survey data from 2019 found that a substantial proportion of women who were not vaccinated for HPV never received cervical cancer screening or were not up to date on screening per recommendations (JAMA Netw Open 2021; doi: 10.1001/jamanetworkopen.2021.31129).


"These findings are particularly important in the context of declining cervical cancer screening uptake, recent stabilization in cervical cancer incidence, and the COVID-19 pandemic, which has further exacerbated HPV vaccination and cervical cancer screening rates," the study authors wrote. "For instance, a more than 75 percent decrease in screening rates occurred among women ages 21-29 years during the stay-at-home order in Southern California.


"Findings of the present study also suggest that non-Hispanic Asian women, those with educational attainment up to a high school diploma, and those who are uninsured are less likely to undergo or adhere to screening recommendations, implying a need for targeted prevention in these groups," they concluded. "Poor cervical cancer screening uptake among U.S. women who are not vaccinated for HPV is a major public health concern. Vigorous efforts are needed to reduce existing screening disparities."


While annual exams and general checkups are handled by gynecologists and primary care providers, gynecologic oncologists can still play a role and support patient education efforts.


"When we see patients, for instance, who have presented with genetic abnormalities, we can educate them on risk factors as well as provide information on tools for prevention and early detection," Kebria said. "Ensuring access and compliance to screening recommendations is a key component of diagnosing these cancers earlier, which will hopefully allow for better patient outcomes."


Catlin Nalley is a contributing writer.