Angelina Jolie Pitt Discusses Ovarian Cancer

Once again, Angelina Jolie Pitt is shining a bright spotlight on women’s health.

On March 24, Ms. Jolie Pitt wrote an op-ed piece for the New York Times in which she announced her decision to have a risk-reducing laparoscopic bilateral salpingo-oophorectomy (removal of her ovaries and fallopian tubes.) This is following her decision to undergo a preventive double mastectomy in 2013, after learning through genetic testing she carried a BRCA1 gene mutation.

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A Lesson In Breasts, Starring Angelina Jolie

Sometimes, public interest in the lives of celebrities helps us in medicine. For years, I have wished that a celebrity would champion the importance of contraception, planned pregnancies, and reproductive choices. Someone to share that planning for a pregnancy, optimizing health, taking preconception folic acid, and making healthy choices was fashionable. Alas, I’m still waiting for this to happen.

But this week, Angelina Jolie did a great service by bringing attention to the very difficult choices women face in the complex world of breast cancer, screening, prevention, and genetics. It was almost 40 years ago when First Lady Betty Ford openly discussed her breast cancer, mastectomy (surgical removal of the breast), and the importance of a screening mammogram. There was a surge in screening mammography after her revelations, and she personally helped Nancy Brinker get the Susan G. Komen Foundation started. It’s a great example of a well-known individual making a big impact on women’s health.

Hopefully, Ms. Jolie’s announcement will have a similar effect. She has taken the key message of preventive health, and used a very important term, “empowerment.” Clearly, her decision to have a double mastectomy in order to lower her cancer risk was not made lightly—it was made with a collaborative team that factored in her family history, risk factors, and the individual options available to her. In describing her experience, Ms. Jolie addressed the concerns many women have about their family support, family impact, and perception of self. She discussed how rare BRCA gene mutations increase a woman’s risk of developing cancer and the health disparities that stand in the way of more screening and treatment for women with these inherited risk factors. These are the issues our ACOG Fellows face daily—determining which patients need a comprehensive screening approach, providing the appropriate care, and having a team well-versed in genetics and risks to tailor the care to the individual.

Quite frankly, we as ob-gyns can’t know it all, but we sure can get a team that collectively does! We need to be knowledgeable in the appropriate screening protocol (ACOG recommends routine screening for hereditary breast and ovarian cancer). We also need to be prepared to counsel patients with elevated risk, and to call on the expertise of geneticists, surgeons, oncologists, and radiologists to collaboratively manage a patient’s care. It is up to us to be aware of risks for our patients and develop the best available system to help them make personal decisions.

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Gynecologic Oncologist = Women’s Cancer Specialist

For many women, ob-gyns are their primary health care provider. It’s not uncommon for women to see their ob-gyn at least annually, and for good reason. Ob-gyns receive a comprehensive education in caring for women from adolescence through childbearing and into menopause. Our training includes care of both pregnant and non-pregnant women, surgery, pharmacology, and more.

Because we see our patients regularly, especially during their reproductive years, ob-gyns have the opportunity to build and maintain a strong patient-doctor relationship. We can observe patients when they’re healthy, establish a baseline of what’s normal, and potentially spot suspicious changes or health problems when they are most treatable.

When a patient reports out-of-the-ordinary changes and symptoms, an ob-gyn can perform diagnostic exams and tests to confirm the problem. He or she can treat changes that may lead to cancer and prevent cancer from ever developing. When invasive cancers of the female reproductive organs—cervix, ovary, uterus, vagina, or vulva—are diagnosed, ob-gyns will often consult with other ob-gyns with advanced training and experience, such as gynecologic oncologists. This can be especially helpful for cases that are thought to be more advanced.

Gynecologic oncologists are ob-gyns who have completed several additional years of training in surgery, treatment, and research on women’s cancers and received board certification in gynecologic oncology. They see patients with these cancers every day. Following diagnosis, gynecologic oncologists can perform the sometimes complicated surgical procedures (staging) necessary to improve a woman’s chances of controlling and beating cancer. They are experts in the timing and order of treatment and can also serve as the “traffic controllers” overseeing the coordination of nurses, primary care physicians, radiologists, and other health care professionals who will be involved in all aspects of the patient’s care.

Today, there are more than 1,000 board-certified gynecologic oncologists in the US. To learn more about these cancer specialists, visit the Society for Gynecologic Oncology website.

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With Routine Medical Tests and Procedures, Choose Wisely

Hal C. Lawrence III, MD, ACOG Vice President, speaking during the press briefing.

Hal C. Lawrence III, MD, ACOG Executive Vice President, speaking during the press briefing.

Open lines of communication are the basis of successful doctor-patient interactions. However, when it comes to medical tests and procedures, doctors and patients alike can easily slide into cruise control without taking the time to discuss what’s truly needed, appropriate, supported by evidence-based research, and in the best interest of the patient’s care.

With this in mind, ACOG has teamed up with the Choosing Wisely campaign—an initiative that aims to spark a conversation about commonly performed tests and exams in different areas of medicine. By taking a critical eye to routine health care practices, we can make better decisions on how to provide thorough and comprehensive care while avoiding unnecessary, redundant, or even risk-increasing procedures.

Today, at a joint press conference with 16 other partnering organizations, ACOG made the following recommendations:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average–risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems and to have appropriate screening with consideration of a pelvic examination.

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average–risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

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