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Re: Primary Peritoneal CancerFrom: Anthony Evans (ahcevans@execpc.com)Fri Dec 4 08:55:48 1998
First, the lifetime risk is about 1 in 70 (of ovarian and PPC) , not 1 in 55. Second, I think everyone on this list is aware that there is no rational basis for annual or other periodic CA125 testing of asymptomatic women with no other risk factors for ovarian cancer and a normal pelvic exam. The risk factors for PPC are much more murky than they are for ov ca so it would even be more of a stretch to consider screening the adult female population for this rare malignancy. There is no question that it (CA125) is an integral component of the workup of women with symptoms, signs, radiologic findings, or genetic histories that place them at elevated risk for harboring ovarian or peritoneal malignancies. There are obviously many stories like the one presented in the original post. I find it hard to fault family practitioners and others who don't diagnose the disease right off the bat. These people may see only one or two cases of ovarian cancer their whole career. It is a relative zebra in the differential diagnosis of many of these patients. What I do find fault with, however, is the lack of performing an adequate exam (including a pelvic) on women with a baffling array of symptoms. Just as GI tract conditions are in the DDx of many gynecologic problems, practitioners need to realize better that GI symptoms may also be related to gynecologic conditions. Additionally, if the symptoms don't abate with treatment, these physicians need to seriously reconsider the diagnosis and continue to pursue it. Patients often ask me how long their cancer has been there and could it have been cured if it was found X number of weeks/months earlier. That is always hard to know. Certainly, there is a point at which an earlier diagnosis could have led to a better chance of cure/remission. Once women have symptoms of stage IIIC ovarian or prim. peritoneal cancer, it is hard to say whether a few weeks or months would make a significant difference. We will never know because we treat it when we diagnose it and the number of women who delay treatment for their own personal reasons is too small to get any meaningful data. Anyway, the short answer to the question posed by the original post is that CA125 is not the standard of care for asymptomatic women with normal exams and in a low risk population. Is it contraindicated? No, but the test is FDA approved only for women with known ovarian cancer for monitoring the status of their disease. That might be one strategy for dealing with the question from patients. You can also point to the NIH Consensus Development Conference statement on ovarian cancer screening, treatment and follow-up (quoting): "With current knowledge and technology, the benefits of screening a woman who has one or no first-degree relatives with ovarian cancer are unproven. The benefits may outweigh the risks, particularly in women with no family history or other high risk factors. There is currently no evidence to support screening these women." Also refer to the ACOG Educational Bulletin from August 1998 (disclaimer-I helped write it): "Until a prospective randomized study has established the effectiveness of screening in a large population, routine screening by abdominal or pelvic ultrasound or measurement of CA125 levels in serum cannot be recommended for women with no known risk factors." For more on use of CA125 and other markers for screening: Evans, AC and Berchuck, A. Tumor Markers. Chapter 7 in Principles and Practice of Gynecologic Oncology edited by Hoskins et al. (1997) Craig Evans, M.D., Ph.D. Vince Lombardi Cancer Clinic Milwaukee, WI
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