1 Primary and Preventive Care

Hannah Anastasio

Silka Patel

Obstetrician-gynecologists are in a unique position to interact with women across the reproductive and age spectrum and are seen by many patients as the sole provider of primary and preventive health care.

SCREENING AND TREATMENT

• The majority of deaths among women younger than the age of 65 years are preventable or have modifiable risk factors (Table 1-1).

• Primary prevention is identification and control of risk factors before disease occurs

• Secondary prevention is early diagnosis of disease to reduce morbidity/mortality

• A condition which is a good target for screening should have the following:

• A significant effect on the quality and quantity of life

• An acceptable and available treatment

• An asymptomatic period during which detection and treatment significantly reduce the risk for morbidity and mortality

• An incidence sufficient to justify the cost of the screening

• An asymptomatic phase during which treatment yields therapeutic results superior to those obtained by delaying treatment until symptoms develop

• The screening test should be:

• Acceptable to patients and available at a reasonable cost

• Reasonably accurate with acceptable sensitivity and specificity

ξ Test sensitivity: percentage of patients with the disease who test positive

ξ Test specificity: percentage of patients without disease who test negative

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TABLE 1-1 Leading Causes of Death among Females of All Races in the United States (2010)

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CANCER

Screening for Breast Cancer

• See Chapter 2.

• Breast cancer is the most common cancer in women, with a lifetime incidence of 12%. For those at average risk, the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the National Comprehensive Cancer Network (NCCN) recommend routine mammography annually beginning at age 40 years. The U.S. Preventive Services Task Force (USPSTF), in contrast, recommends biennial screening between ages 50 and 74 years. In addition, ACOG recommends regular clinical breast examinations in all women as well as breast self-examination in high-risk women.

• ACOG and the Society of Gynecologic Oncology recommend referral for genetic counseling and BRCA testing in patients with 20% or greater chance of having an inherited predisposition to developing breast or ovarian cancer. This includes women with the following family history:

• Women with a personal history of both breast and ovarian cancer

• Women with ovarian cancer and a close relative with ovarian cancer or premenopausal breast cancer

• Women with breast cancer at age 50 years or younger as well as either a close relative with ovarian cancer or breast cancer in a man at any age

• Women of Ashkenazi Jewish ancestry with a diagnosis of breast cancer at age 40 years or younger or with ovarian cancer at any age

• Women with close relative with known BRCA1 or BRCA2 mutation

• Additionally, further genetic risk assessment may be helpful in the following women (estimated to have between 5% and 10% risk of having an inherited predisposition toward developing breast or ovarian cancer):

• Breast cancer at age 40 years or younger

• Primary peritoneal, ovarian, or fallopian tube cancer at any age

• Breast cancer at age 50 years or younger and a close relative with breast cancer at age 50 years or younger

• Ashkenazi Jewish ancestry with breast cancer at or before age 50 years

• Breast cancer at any age in addition to two close relatives with breast cancer (any age)

• Unaffected women with a close relative that meets any of the previous criteria

• Women at high risk for breast cancer, such as those with BRCA1 or BRCA2 mutations, may undergo prophylactic mastectomies to reduce their risk of breast cancer.

Screening for Lung Cancer

• Lung cancer, the second most common cancer in women, is the leading cause of cancer-related death. In 2009, in the United States, 95,784 women were diagnosed and 70,387 died from lung cancer.

• Risk factors include cigarette smoking (associated with 90% of lung cancers), radiation therapy, environmental toxins such as asbestos, and pulmonary fibrosis.

• The majority of studies examining screening modalities for lung cancer (via chest x-ray, sputum cytology, or computed tomography [CT] scan) have failed to show a mortality benefit from early detection of lung cancer. In 2011, the National Lung Screening T rial was the first to show approximately a 20% mortality benefit in asymptomatic heavy smokers (>30 pack-year history) screened with low-dose CT scans. The 2013 ACS recommendation (in abstract form) is that providers discuss lung cancer screening with a low-dose helical CT of the chest for patients between

P.4 ages 55 and 74 years with at least a 30 pack-year smoking history. At this time, the recommendation is that providers and patients have an informed discussion about the current data regarding lung cancer screening and use shared decision making to decide whether to initiate lung cancer screening.

• Smoking may confer a greater relative risk for women than men; however, many of the early studies on lung cancer screening did not include women. It is theorized that screening in women may have different outcomes due to higher rates of peripherally located adenocarcinoma.

• Smoking cessation, as well as continued abstinence in nonsmokers, is the single most important modifiable risk factor for lung cancer.

Screening for Colorectal Cancer

• Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer in women, with an annual incidence of 38.9 per 100,000. Most colorectal cancers have a long latency period and are curable or easily treatable if detected at an early stage.

• Risk factors include a family history of colorectal cancer, a personal history of colon polyps or cancer, a personal history of inflammatory bowel disease, and the genetic syndromes familial adenomatous polyposis and hereditary nonpolyposis colon cancer (HNPCC).

• Women with a diagnosis of HNPCC should initiate screening at age 20 to 25 years or 10 years before the youngest age of colon cancer diagnosis in the family.

• The USPSTF recommends screening for colorectal cancer for all persons aged 50 years and older. The American College of Gastroenterology recommends beginning screening at age 45 years in African Americans due to higher incidence and earlier age of onset.

• Many screening protocols exist, including flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, double-contrast barium enema every 5 years, CT colonography every 5 years, guaiac-based fecal occult blood test annually (two samples from each of three consecutive stools), fecal immunochemical test annually, and stool DNA test. The 2008 U.S. Multi-Society Task Force on Colorectal Cancer guidelines support any of the aforementioned regimens; ACOG encourages colonoscopy but ultimately recommends shared decision making to determine which screening modality the patient is most likely to comply with.

Screening for Endometrial Cancer

• See Chapter 47.

• No routine screening is recommended for asymptomatic women. Certain highrisk groups (those with known or prior endometrial hyperplasia or patients with HNPCC) may undergo screening, such as endometrial biopsy, pelvic ultrasound, dilation and curettage, or a combination of these. All episodes of postmenopausal bleeding should be investigated. Additionally, in premenopausal obese women with a significant change in bleeding pattern, endometrial sampling should be considered.

Screening for Skin Cancer

• Melanoma is the seventh leading cancer in women; risk factors include light skin tone and ultraviolet ray exposure, particularly childhood sunburns. People with between 50 and 100 typical nevi or large congenital nevi are also at increased risk (relative risk of 5 to 17 and >100, respectively).

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• Although there are no consensus guidelines for total skin examination, ACOG recommends evaluation in those patients at high risk. All patients should be educated regarding sunscreen use and ultraviolet ray avoidance. In particular, all atypical vulvar lesions should be thoroughly investigated (see Chapter 44.)

• Guidelines regarding suspicious lesions are as follows:

• Asymmetry

• Border irregularities

• Color variegation

• Diameter >6 mm

• EnlargementZEvolution of color change, shape, or symptoms

Screening for Ovarian Cancer

• See Chapter 48.

• No North American expert group recommends routine screening for ovarian cancer. Instead, a careful family history and an annual pelvic exam are recommended for all women.

• Women at high risk for ovarian cancer, such as those with BRCA1 or BRCA2 mutations, may undergo prophylactic bilateral salpingo-oophorectomy to reduce their risk of ovarian cancer.

Screening for Cervical Cancer

• See Chapter 46.

• Routine screening for cervical cancer with either liquid-based or conventional Papanicolaou (Pap) testing is recommended starting at age 21 years, regardless of age of first sexual activity. The ACS and ACOG have suggested that women between the ages of 21 and 30 years should be screened with cytology alone every 3 years, provided the patient does not have a history of cervical intraepithelial neoplasia grade 2 (CIN 2) or worse, is not HIV positive or immunocompromised, and has no history of diethylstilbestrol exposure. Routine human papillomavirus (HPV) testing is not recommended in this age group given the high incidence of transient asymptomatic infection. Women ages 30 to 65 years should be screened every 5 years with cotesting (cytology and HPV testing). Alternatively, Pap screening with cytology alone (without HPV testing) every 3 years may be performed, but cotesting is preferable. After age 65 years, no further screening is recommended if the patient has had adequate negative screening for the past 10 years.

• ACOG and the USPSTF both agree that cervical cancer screening may be discontinued for women who have had a total hysterectomy for benign indications and no history of CIN 2 or worse.

• Women with abnormal Pap smears should be managed per the American Society for Colposcopy and Cervical Pathology guidelines.

• There are currently two U.S. Food and Drug Administration-approved vaccines for the primary prevention of cervical cancer. Cervarix protects against high-risk HPV strains 16 and 18 known to cause cervical cancer, and Gardasil protects against HPV 6, 11, 16 and 18 conferring additional benefit against HPV strains known to cause genital warts. ACOG recommends universal vaccination of women against these HPV strains before initiation of sexual activity (as early as age 9 years) as well as in sexually active women up to age 26 years. Women who have received HPV vaccination should be screened for cervical cancer using the same schedule as unvaccinated women.

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HEART AND VASCULAR CONDITIONS

Screening for Coronary Heart Disease

• Rates of coronary heart disease (CHD) in women increase with age, ranging between 5% and 15%. Risk factors include hypertension, dyslipidemia, diabetes, smoking, and family history of premature CHD (age risk of a CHD event. The Framingham model was updated by the National Cholesterol Education Program (NCEP) Adult T reatment Panel III (ATP III) and adjusts for the following variables: age, gender, low-density lipoprotein cholesterol, high-density lipoprotein (HDL) cholesterol, blood pressure, diabetes, and smoking. The USPSTF recommends against routine screening of asymptomatic low-risk patients (defined as 45 years if they are at increased risk of CHD (level A evidence). Screening of highrisk women aged 20 to 45 years is recommended (level B evidence), and screening of low-risk women is neither recommended nor discouraged (level C evidence). Recommended screening interval is every 5 years, but a shorter interval should be considered in patients at increased risk for dyslipidemia or with previous borderline results.

• Table 1-2 summarizes NCEP/ATP III treatment recommendations. Goal cholesterol level depends on number and severity of risk factors for CHD. CHD equivalents include peripheral arterial disease, abdominal aortic aneurysm, diabetes mellitus, and symptomatic carotid artery disease. Other risk factors (non-CHD equivalents) include smoking, hypertension (>140/90 mm Hg or requiring antihypertensive), low HDL (45 years, women >55 years).

• Lifestyle changes include limiting fat intake (particularly trans and saturated fat), increasing dietary fiber and plant sterol intake, weight loss, and increasing physical activity.

• The most commonly used pharmacologic treatment for dyslipidemia include bile acid-binding resins, statins, nicotinic acid, fibric acid derivatives, and cholesterol absorption inhibitors. Treatment choice depends on the particular lipid profile; however, statins are the drug of choice for cardioprotection.

Screening for Hypertension

• Hypertension (defined as blood pressure >140/90 mm Hg or requiring antihypertensive medication) is a leading risk factor for CHD, congestive heart failure,

P.7 stroke, ruptured aortic aneurysm, renal disease, and retinopathy. Suboptimal blood pressure has been reported as the number one risk factor for death worldwide.

TABLE 1-2 NCEP/ATP III Cholesterol Treatment Guidelines (2002)