Post on 17-Aug-2020
transcript
Top Women’s Health Articles of 2016-17
Rebecca Jackson, MDObstetrics, Gynecology and Reproductive SciencesUCSF
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Articles that might change practice or topics in the newsRoutine pelvic examUterine fibroid embolizationHSV screeningOCP’s and cancerOverdiagnosis of breast cancerThreats to reproductive health
No more Pelvic Exams?
Pelvic Exam Potential Benefits
Can detect numerous conditions (Ca, vaginitis, warts, STI, fibroids, ov cysts, polyps, prolapse)
What is the accuracy of detecting these before symptoms occur? UNKNOWN
What is the benefit of detecting these before symptoms occur (rather than waiting for sx)? UNKNOWN
Pelvic Exam Potential Harms
False positives: For ovarian cancer: 1.2-8.6%; False negative (ie false reassurance): 0-100%May lead to unnecessary and sometimes
invasive work-ups5-36% went on to have surgery
Psychological harms, pain, discomfort: 11-80%, median 35%, all of which may be a barrier to receiving healthcareWomen who experienced pain or discomfort less
likely to have a return visit
Pelvic Exam Conclusion
“In the absence of clear evidence on the balance of benefits and harms of using pelvic examination to screen for asymptomatic gynecologic conditions, clinicians are encouraged to consider the patient's risk factors for various gynecologic conditions and the patient's values and preferences, and engage in shared decision making with the patient to determine whether to perform a pelvic examination.”
What do patients think?
Mixed cross-sectional study and RCT of 452 women undergoing cervical cancer screening
Preference for pelvic exam when given info about ACOG guidelines vs ACP guidelines
Phase 1 (baseline): 262 women asked about desire to have an exam, without being given information
Phase 2: RCT: 190 got randomized to review ACOG vs ACP guidelines and rationale
ACOG: recommends annual pelvic exams in women >21 yo:
ACP: strongly recommends against routine pelvic exam
What do patients think?
Results: In phase 1 (baseline): 79% wanted routine examACOG group: 82% ACP group: 39%94% believed potential benefits and harms
should be discussed prior to the exam
ACOG: recommends annual pelvic exams in women >21 yo:
ACP: strongly recommends against routine pelvic exam
Sushi? Monstera
At the Shops at Muana Lani (1 resort down the road). Sit at sushi bar if you can. Go early (6pm ish)
OCP and Cancer…. Again OCP Safety…. Again
Prospective cohort study of 46K women in 1968 for up to 44 years. Ever vs Never use of OCP. Adjustment for age, parity, SES, smoking. Outcome: Cancer incidence (15 types)
Of 15 cancer sites, none had increased risk assocwith ever use of OCP including breast and melanoma
Decreased risk seen for:1. CRC 0.81 (0.66-0.99) Attrib risk: -11%2. EmCa 0.66 (0.48-0.89) Attrib risk: -10%3. Ov 0.67 (0.5-0.89) Attrib risk: -11%4. Blood Ca 0.74 (0.58-0.94) Attrib Risk: -11%
There is increased incidence in current and recent use (<5yrs) for:
Breast 1.48 (1.1-2.0)Cervical 2.3 (1.2-4.3)
These disappear by 5 to 15 years after stopping
3 questions: 1. How long do EmCa, OvCa and CRC benefits
persist2. Does OCP use in repro years produce new
cancer risks later in life3. What is the overall balance of cancer among
past users as they enter later stages of life
3 questions: 1. How long do EmCa, OvCa and CRC benefits
persist- >35 years2. Does OCP use in repro years produce new cancer
risks later in life NO3. What is the overall balance of cancer among past
users as they enter later stages of life lower risk of Ovarian, endometrial, CRC and blood cancers
How do these studies compare with past evidence?
Ovarian cancer meta-analysis 2013: OR 0.73 (0.66-0.81)
Meta-analysis of 4 major cancersBreast: 1.08 (1.00-1.17) p<0.05
(higher risk in more recent users)CRC: 0.86 (0.79-0.95)Cervix: Higher risk in women with
HPV, but significant heterogeneity so no meta-analysis done
Endometrial 0.57 (0.43-0.77)
Havrilesky, ObGyn 2013
Gierisch, Ca EpidBiomarkers Prev, 2013
What about breast cancer mortality?Meta-analysis of OCP
and all-cause and specific-cause death
9 prospective cohort studies
No difference in all cause mortality or breast cancer mortality
Reduction in ovarian cancer mortality: OR 0.58 (0.34-0.94)
Zhong, Int J Gyn Ob, 2015
Breast Cancer Mortality, n=199K
OR 1.0 (0.95-1.06
Quantifying overdiagnosis in mammography screening
Quantifying ^ overdiagnosis in mammography screening
over-treatment
Overdiagnosis/Overtreatment—we know is exists—how do we quanitify it? Effective screening program should lead to an
increase in smaller tumors at time of diagnosis and, over time, a concordant decrease in larger tumors. Should also see a decrease in mortality (although that
could also be due to better treatments)
In Walsh paper, approximates overdiagnosis as the extent to which diagnosis of smaller tumors exceeds the decrease in larger tumors If no over-diagnosis: small tumor increase=large tumor
decreaseOver-diagnosis = small tumor increase - large tumor
decrease
Shift in size distribution over time. Note in early period, large tumors predominated and over time, small tumors predominate. Screening works?
Modest decrease in larger tumors (30/100K)
Very large increase in smaller tumors (162/100K)
Conclusion: 30/100K were destined to become large tumors but detected earlier by screening. 132/100K=over-diagnosis
162-30=132
Women in some areas offered screening, and in other areas, not.
Allows adjustment for change in incidence over time in unscreened vs in screened population
With screening: found substantial increase in small tumors and no difference in large tumors
Estimated overdiagnosis as 15-39% if exclude DCIS and 24-48% if include it
What to do about over-diagnosis?
Its not the over-diagnosis that’s the problem…. Its over treatment
Better biomarkers and prognostic prediction methods
Encourage ourselves and patients that less aggressive treatment is acceptable
Change terminology: For DCIS, move away from “carcinoma” to IDLE: indolent lesions of epithelial origin
Hike: White Road—Upper HamakuaDitch Trail
Kapu??Very muddy/wet2 miles to cliff (45 min)Extremely lush, lots of
birds singingEnd of White Road—on
left as you leave last Waimea subdivision—mile 54
HSV Screening and Serotyping Genital Herpes
Very Common: 1 in 6 adults. Morbid though not mortal Increases risk of HIV transmissionNeonatal HSV, though rare, has substantial
morbidity and mortality
WHY NOT SCREEN FOR IT?
For screening:HSV infection may not have a long symptomatic
period during which screening, early identification, and treatment may alter its course.
Benefits: No cure so “small” benefit at bestHarms: False Positives and associated labelling!
50% false positives, no confirmatory test availableRecommend against screening of
asymptomatic people, even pregnant women
With population prevalence of 15%, screening 10,000 would result in 1485 true positive, 1445 false positive.
What about serotyping? NO role!HSV2 tests have low specificity and high false
positive rateHSV1, which is an increasingly common cause of
genital herpes, cannot differentiate oral from genital infections
What about pregnant women?No screening recommended. If h/o HSV: observe carefully for outbreaks.
Alternatives to hysterectomy Uterine Fibroid Embolization
Alternative to hysterectomy or myomectomy for select women with fibroids and heavy bleeding and dysmenorrhea in women who don’t desire future fertility
Mixed findings related to improvement in bulk symptoms
5 year results in meta-analysis of 7 studies showed similar satisfaction and long-term major complications but higher rate of minor complications, readmissions and reoperation in the UAE arm
EMMY Trial at 10 years
RCT of UAE vs Hysterectomy in 156 women, at 10yrs, 84% follow-up
At 10yrs: 90% improved/acceptable bldingRate of reoperation: 2 yrs- 24%, 5 years-28%;
10years-35%Both groups had significantly improved QOL
compared to baseline and high overall satisfaction (78% UAE, 87% hyst)
UAE is contraindicated in women desiring fertility due to unknown effect on fertility and on pregnancy outcomes
Meta-analysis of 227 pregnancies (observational studies) showed increased SAB (35% vs 17%) and C/S (66% vs 49%). Underpowered to examine PTB, IUGR, placental issues
Fertility: 1 rct of UAE vs myomectomy: lower pregnancy rate (50% vs 78%) and delivery (19% vs 48%), higher SAB (64% vs 23%)
“Partial” UFE= only small arterial vessels feeding fibroids are embolized, leaving large vessels patent
Retrospective cohort: 359 women with fibroids or adenomyosis desiring pregnancy and 1 yr infertile
Age: avg 36yo, 22-52(!) (20% over 40yo) From 2005-9, full UAE -199 pts 2009-14: partial UAE-160 ptsMedian f/u: 69 months; 7.5% lost to f/u
Spontaneous Pregnancy at 2 yrs:Partial UFE; 45%Conventional UFE: 36%
Live Birth: Partial: 38%Conventional: 31%
SAB:Partial-10%Conventional-7.5%
Surprisingly high rate of pregnancy and live birth in women>40yo
Very low SAB rates: 13% in <40yo8% in >40yo!!!
Pregnancy Outcome (n=150)6.7% PTB5% malpresentation1 cesarean hysterectomy2 placenta previa (1.3%) and 1 accreta1 still birth
UFE as a treatment for infertility?Too good to be true?
… ProbablyNeed controlled studies
Reproductive Health Threatened?
Mexico City Policy aka “Global Gag Rule” Prohibits foreign NGOs that receive US funding from
using ANY of their own $ (regardless of source) to inform or advocate for access to abortion care in their countries
Trump’s executive order re-instated it and expanded scope to include not just USAID but also PEPFAR, NIH
Does it decrease abortion? In Africa, increased abortion likely due to lost funding for
contraception
Does it decrease abortion? No. In Africa, increased abortion was seen in
countries affected by the policy: OR 2.6 (1.8-3.7)Other likely effects
Crippling of long standing integrated programs for global maternal-child health, HIV prevention
Decreased access to condoms, HIV clinics, family planning counseling
Leading to: Increased maternal mortality due to pregnancy-related complications, unsafe abortion, HIV
Since 1976 it has been renewed yearly. One sentence: “None of the [Medicaid] funds
contained in this Act shall be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term.”
Expanded to all federal health programs: Peace Corps, Federal Employees Health Benefits Program,
Federal Prisons, Medicare, ICE, DC, DOD, HIS, VA, ChildrensHealth Insurance Program
More recently, extended to federally subsidized private insurance plans offered through the exchanges
Multiple states have emulated it: 32 now prohibit use of state funds for abortion care
Given these funding restrictions, abortion only available to those who can pay out of pocket for itAs Thurgood Marshall said in 1976: “the class burdened by
the Hyde Amendment consists of indigent women, a substantial proportion of whom are members of minority races” for whom “denial of a Medicaid-funded abortion is equivalent to denial of legal abortion altogether.”
Attempts underway to codify the amendment so that it won’t be necessary to renew it annuallyDemocratic filibuster possible
1. Re-instate and expand Global Gag Rule2. Supreme Court justice selections with intent to
overturn Roe v Wade Unlikely to be overturned…. Has stood for 44 years with
multiple re-affirmations But, real threat to abortion access in US as legislators feel
emboldened to pass restrictive legislation HR7: denial of insurance coverage of abortion Trump would sign a 20-week ban if passed by Congress
3. Limit Access to Contraception Elimination of Medicaid and Title X funding to Planned
Parenthood. In Texas, a similar policy led to substantial decline in use of LARC with
increase in unintended pregnancy in Medi-caid population
Repeal of ACA: ACA gives access to contraception without co-payment/deductible. With ACA, more women using BCM. Decline in national abortion rate may be partly due to this
4. Other losses related to ACA repeal Under ACA, insurance companies may not charge more for
plans that include maternity care ACA guarantees coverage of USPSTF A and B recommendations
without co-pay. These include well-woman visits for cervical cancer and STI screening
5. Decrease in federal funding for Medicaid to states disproportionately affect those with low income
6. Policies that allow discrimination and/or deportation will affect health of immigrants, LGBTQ etc.
“ In the face of this rhetoric, women’s health physicians have a critical role to play: we must be a loud voice in support of evidence-based health care that is unencumbered by political interference.”
Questions?