Screening for Gynecologic and Colorectal Cancer: Is It Adequate? Mary C. Ciotti, MD,
FACOG
Assistant Professor, Department of Obstetrics and Gynecology Michigan State University East Lansing, Michigan
here are several issues inherent in the question of the adequacy of gynecologic and colorectal screening: 1) are the available screening tests effective; 2) are they appropriate to use in w o m e n over 65; and if so, 3) are they being used in this group of w o m e n ? The incidence of gynecologic and colorectal cancers increases with age. Additionally, gynecologic cancers are diagnosed at more a d v a n c e d stages in older w o m e n . Older w o m e n are at greatest risk for these cancers but are often less likely to be screened than y o u n g e r w o m e n . The following is a review of the incidences of individual cancers, their effects on w o m e n aged 65 and older, available screening methods, and their use in older w o m e n .
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CERVICAL CANCER The incidence of cervical cancer increases with a g e ) It is estimated that in 1991 there will have b e e n 13,000 newly diagnosed cervical cancers, and 4500 w o m e n will die from this disease. 2 T w e n t y - s e v e n percent of these cases and 41% of the deaths will occur in w o m e n over the age of 65. The relative 5-year survival rate decreases with age: 62% for w o m e n u n d e r the age of 65 and 50% for those age 65 and older. 3 The incidence of cervical cancer is greater in black w o m e n , and the relative 5-year survival rate in blacks is dramatically lower at 37%.~ W h e n the data from several cancer registries are reviewed, there is a definite relationship b e t w e e n the stage at which cervical cancer is diagnosed and a patient's age, with older w o m e n being diagnosed at more advanced stages of cervical cancer. 4~ The Pap smear is the most c o m m o n l y used m e t h o d of screening for cervical cancer. It allows the clinician to detect and treat preinvasive cervical neoplasia. A l t h o u g h the efficacy of the Pap smear has never been tested in a prospective study, 7 there have been several epidemiologic studies that show a decrease in invasive cervical cancer w h e n the Pap smear has been introduced as a screening test. 8-H Concomitantly, the incidence of cervical cancer has increased in u n s c r e e n e d populations, n If the Pap smear is an effective screening test, w h y do w o m e n still die of invasive cervical cancer? Using the Pap smear as a screening tool involves WHI Vol. 2, No. 2 Summer 1992
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multiple steps and multiple individuals; consequently, there is a potential for noncompliance and error. Proper sampling of the cervix is critical and can influence the accuracy and reliability of the test. The smear should contain cells from the ectocervix and endocervix. In older w o m e n , it is also beneficial to sample cells from the vaginal pool 7 to increase the potential for finding abnormal cells from the endometrium. The slide must then be fixed immediately. It has been reported that as m a n y as 60% of false-negative Pap smear results are due to poor sampling technique. 12 Once in the laboratory w h e r e the slide is stained, care should be taken to filter the stain to p r e v e n t "floating cells" from attaching to slides. 7 Although the Pap smear can be screened by a trained cytotechnologist, all abnormal smears should be reviewed by a pathologist. 7 Approximately 40% of false-negatives have been attributed to laboratory error. 12 N e w regulations of the Health Care Financing Administration of the U.S. D e p a r t m e n t of Health and H u m a n Services regarding quality assurance in the performance of cervical cytology became available February 28, 1992, t h r o u g h the Federal Register. Also included are exact regulations as well as enforcement strategies (personal communication with Dr. G. Thomas, Michigan Department of Public Health, June 1992). Appropriate follow-up of abnormal Pap smears is imperative. In as m a n y as 50% of cases of invasive cervical cancer, there is a history of a previously abnormal smear that did not have adequate follow-up. 11,13 Solely repeating the Pap smear is not advised, because as m a n y as 40% of repeat Pap smears will be falsely negative. ~4 Follow-up with colposcopy is generally recomm e n d e d for abnormal Pap smears, is In order for the Pap smear to be an effective screening m e t h o d , it needs to be utilized in w o m e n at risk for cervical cancer. As has been noted, the risk of cervical cancer increases with age, yet older w o m e n are the least likely to have had a Pap smear.16 The Pap smear ceases to be a leading reason for a physician visit after the age of 44.17 Fifteen percent of w o m e n over the age of 65 report never having had a Pap smear, and in a n o t h e r 25% it had been more than 5 years since their last Pap smear. TMOne study of older poor w o m e n w h o received care from a hospital clinic f o u n d that 25% had never had a Pap smear and 75% had irregular screening. ~9.2° It does not a p p e a r that this is due to less frequent physician contact. Older w o m e n were more likely to have been to one or more physicians within the previous year but were less likely to have had a Pap smear in the r e c o m m e n d e d time frame. 21 Socioeconomic status and ethnicity also influence screening. Poor w o m e n of all ages and races are less likely to have preventive screening than the nonpoor. 16 Prior to 1973, it was f o u n d that poor black w o m e n were the least likely to have a Pap smear; however, b e t w e e n 1973 and 1985 there was a remarkable increase in the n u m b e r of Pap smears p e r f o r m e d in black w o m e n . N o w those least likely to have Pap smears are poor white w o m e n . ~6 Having an obstetrician-gynecologist as the "usual source" of medical care is associated with a great probability of having regular Pap smears, and obstetrician-gynecologists are more likely to remind w o m e n to have a Pap smear. 17'~-24 Obstetrician-gynecologists, however, are less likely to serve as primary care physicians for elderly w o m e n . 23,24 The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists, the American Medical Association, the American Medical W o m e n ' s Association, and the National Cancer Institute r e c o m m e n d that annual Pap smears be p e r f o r m e d on all w o m e n w h o are sexually active or are age 18 or older. At the discretion of the physician, Pap smears m a y be done less frequently once three or more annual smears have been negative. 25 Suggestions that screening end at age 60 or 6525 assumes a history of prior
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negative screens, which, w h e n considering the previous information, m a y not be applicable to all w o m e n . In s u m m a r y , the incidence of cervical cancer increases with age. Although the Pap smear has been s h o w n to decrease the incidence of cervical cancer, it has not been utilized effectively in older w o m e n . W o m e n need to be aware that obtaining Pap smears can be as i m p o r t a n t at age 65 as it is at age 25 and that the Pap smear allows the detection of precancerous and treatable conditions. Physicians need to include cervical screening in the general care of older w o m e n .
ENDOMETRIAL
CANCER
Endometrial cancer is the most c o m m o n gynecologic cancer. It is estimated that there will be 33,000 new cases diagnosed in 1991, and endometrial cancer will cause 5500 deaths. 2 Forty-five percent of endometrial cancer deaths are in w o m e n w h o are age 65 or older. 3 The incidence of endometrial cancer rises sharply after the age of 45 and peaks b e t w e e n the ages of 55 and 69. 26 Only about 5% of cases occur in w o m e n y o u n g e r than 40 years of age. 27 Fortunately, endometrial cancer is often diagnosed at an early stage, which carries a very favorable prognosis. Older w o m e n , however, are more often diagnosed at a d v a n c e d stages. 4-6 W o m e n over 64 years have a worse 5-year survival rate than w o m e n 45-64 years (75 versus 91%, respectively), and black w o m e n have a p o o r e r prognosis than do white w o m e n (55 versus 84%). 2 It seems that black w o m e n are more likely to have a more aggressive endometrial cancer. 28 Classically, the w o m a n w h o is t h o u g h t to be at risk for endometrial cancer is postmenopausal, obese, and hypertensive. Many of the risk factors seem to be related to increased estrogens, either e n d o g e n o u s l y or exogenously derived, which are the result of obesity, late m e n o p a u s e , estrogen therapy, nulliparity, or infertility related to anovulation. H o w e v e r , these factors are not present in all patients with endometrial cancer. 27"28 Two types of endometrial cancer have been described28"29: type I is estrogen-related and is preceded by hyperplasia. It occurs more frequently in white w o m e n , and the grade tends to be low with minimal invasion and a less aggressive behavior. 28 It accounts for 60% of endometrial cancers. 27 Type II is not estrogen-related and it occurs in older w o m e n . It is more likely to occur without hyperplasia in black w o m e n and is a more aggressive cancer. 28 Vaginal bleeding is usually the first and only s y m p t o m of endometrial cancer. Approximately 75% of w o m e n will initially present with bleeding, 3° although one source reported 90-95% with this finding. 31 Unfortunately, w o m e n w h o are on estrogen replacement therapy may find it difficult to ascertain if bleeding is a normal side effect of their therapeutic regimen.27 Postmenopausal bleeding is a s y m p t o m that is to be considered a s y m p t o m of endometrial cancer until p r o v e n otherwise and d e m a n d s a t h o r o u g h investigation. Approximately 20% of w o m e n with p o s t m e n o p a u s a l bleeding will have a malignancy, and the remaining will have n o n m a l i g n a n t conditions such as hyperplasia, atrophic vaginitis, or u n d e t e r m i n e d causes. 3° There are no tests that are r e c o m m e n d e d for general screening for endometrial cancer, although the ACS r e c o m m e n d s endometrial tissue sampling on w o m e n during m e n o p a u s e w h o are at risk (those w h o are obese, infertile, anovulatory, or on estrogen t h e r a p y or those with abnormal uterine bleeding). The following is a review of tests that have been p r o p o s e d as useful in the detection of endometrial cancer. 1. The Pap s m e a r - - A l t h o u g h not considered a screening test for endometrial cancer, it has been reported that as m a n y as 50% of endometrial cancers
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can be detected with the Pap smear. 7"32Detection is more likely if one obtains a vaginal pool sample. 2. Endometrial cytology p e r f o r m e d by aspiration, brushing, or w a s h i n g - The success rate is fairly high in obtaining cells; however, interpretation is difficult. 33,34 Endometrial hyperplasia is more difficult to detect than endometrial cancer, and a sensitivity of approximately 50% is reported. 3s 3. U l t r a s o u n d - - A s a screening test for endometrial cancer, u l t r a s o u n d appears to have a low sensitivity. In a s t u d y by Osmers et al, 36 an endometrial thickness greater than 4 m m was defined as abnormal. Follow-up indicated that 22% of patients meeting that criteria had endometrial cancer, 4% had hyperplasia, and 64% had n o n m a l i g n a n t changes. 36 4. Endometrial biopsy---The appropriateness of using the endometrial biopsy for the detection and diagnosis of endometrial cancer is often argued. 37 The sensitivity ranges from 87-100%.34 A recent study by Stoval and coworkers 3s reported a 97% accuracy with pipelles. Biopsy as a screening test in asymptomatic w o m e n was recently evaluated by Archer et a139 w h o f o u n d that of 801 asymptomatic postmenopausal women, one had endometrial cancer. They concluded that the yield was too low to r e c o m m e n d mass screening in asymptomatic w o m e n . 5. H y s t e r o s c o p y - - E s p e c i a l l y w h e n used with biopsy, h y s t e r o s c o p y has been s h o w n to be effective in diagnosing endometrial cancer as a cause of abnormal uterine bleeding. Some studies s h o w it is more effective than dilation and curettage. *° It is more reliable in the detection of endometrial cancers than hyperplasia--92 versus 70%. 34 H o w e v e r , h y s t e r o s c o p y is not widely available, is expensive, and may be more difficult to p e r f o r m in postmenopausal w o m e n . There have been no controlled trials to evaluate the effectiveness of screening for endometrial cancer. 41 Considering cost, patient acceptability, and ease of performance, an i m p r o v e d cytologic detection system would be extremely beneficial. At the present time, practitioners n e e d to consider t h o r o u g h evaluation of w o m e n with p o s t m e n o p a u s a l bleeding. W o m e n should be asked about this s y m p t o m , be informed that this is not a normal finding, and be told that it is often an early warning sign of a treatable form of endometrial cancer. Practitioners should also be mindful of p o s t m e n o p a u s a l w o m e n on estrogen replacement therapy, especially if they are on low doses of progestins; w o m e n w h o have breast cancer and/or are on tamoxifen; w o m e n w h o have colon cancer; and w o m e n w h o have a strong family history of endometrial or colon cancer. Such w o m e n should be followed closely and probably offered periodic endometrial biopsies.
OVARIAN
CANCER
There will be an estimated 20,700 new cases of ovarian cancer and 12,500 associated deaths in 1991. 2 Although its incidence is lower than other gynecologic cancers, it causes over 50% of all deaths from gynecologic cancer. It is a virulent neoplasm and carries a poor prognosis. The 5-year survival rate of 38% has not changed markedly since 1973. The incidence of ovarian cancer is 46% higher in whites than nonwhites, 2 and both the incidence and d e a t h rate continue to increase with age. 26 Forty-three percent of all ovarian cancers occur in w o m e n over the age of 64. 3 The relative 5-year survival rate, which accounts for other causes of mortality, is only 24% for w o m e n over age 65 versus 48% for those u n d e r the age of 65. 3 This seems to be related to the fact that ovarian cancer is f o u n d at more advanced stages in older women, 4-~'42 and, stage for stage, older w o m e n have a worse prognosis. 86
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The latter finding m a y be due to less aggressive treatment; 76% of the cases in which no treatment was given occurred in w o m e n over 64 years. 42 The natural history of ovarian cancer is not well k n o w n and the early diagnosis of ovarian cancer is likely to be a fortuitous finding at the time of surgery for other indications. Currently there are no r e c o m m e n d a t i o n s for routine screening for ovarian cancer. 43 Risk factors for ovarian cancer have been investigated. A significant family history has been f o u n d to be one of the most identifiable risk factors and includes w o m e n w h o s e m o t h e r or sister had ovarian cancer and w o m e n w h o have a strong familial incidence of ovarian and/or breast cancer and of colon cancer. ~5 Additionally, there is an increased risk of ovarian carcinoma in w o m e n diagnosed with endometrial, breast, or colon cancer. 44 "Incessant ovulation" as seen in nulliparas and in w o m e n with early m e n a r c h e and/or late m e n o p a u s e also is a risk factor. 4s A diet high in fat, a history of m u m p s in adolescence, and perineal talcum p o w d e r usage also have been implicated. 46,47 W o m e n w h o are at lower risk include those w h o have m a n y children, w h o started their families at an early age, or w h o used birth control pills. 48"49 S y m p t o m s of ovarian cancer are often v e r y vague. A history of several m o n t h s of abdominal discomfort such as bloating and digestive disturbances may be suggestive of ovarian cancer. Unfortunately, all of these can be attributed to more c o m m o n causes. H o w e v e r , if a w o m a n over age 40 complains of persistent gastrointestinal s y m p t o m s , one should consider ovarian cancer in the differential diagnosis. 15 Available screening tests are the pelvic exam, CA 125 antigen, ultrasound, and the combined use of CA 125 and ultrasound. CA 125 is a serum t u m o r associated antigen. Initially it was t h o u g h t that CA 125 would be an excellent marker for ovarian tumors and could be used as a screening test. Early reports indicated that 85% of w o m e n with epithelial tumors had an elevated CA 125, 50 d e m o n s t r a t i n g that it is more likely to be elevated in w o m e n w h o have stage I disease w h e r e surgical treatment could be curative. 5~ Unfortunately, CA 125 lacks specificity, although it is more specific in p 0 s t m e n o p a u s a l w o m e n . 52 As a screening tool for ovarian cancer, ultrasound has a high sensitivity, but there are a large n u m b e r of false-positives. In Campbell et al's 53 s t u d y of 5479 w o m e n over a 3-year period, 338 w o m e n had abnormal scans. Of these, 326 had surgery but only five were diagnosed with ovarian cancer. These cancers were f o u n d t h r o u g h o u t the 3-year s t u d y period so that optimal screening intervals are not k n o w n , s3 In p o s t m e n o p a u s a l w o m e n , the false-positive rate m a y be decreased. Van Nagell and coworkers 54 studied 1300 postmenopausal w o m e n , 27 of w h o m had abnormal scans and two had cancer. The use of CA 125 w h e n there is an abnormal u l t r a s o u n d finding improves the specificity of the ultrasound. 52 To date, there are no long-term studies of the effect on morbidity or mortality. Also, these tests are more likely to be positive w h e n a w o m a n has metastatic disease. In s u m m a r y , ovarian cancer is a highly malignant disease w h o s e natural course is not well k n o w n . The risk of ovarian cancer increases with age, it is found at more a d v a n c e d stages in older w o m e n , and treatment tends to be less aggressive in older w o m e n . Research should address the etiology of this disease as well as identification of risk factors and premalignant conditions. Screening and treatment m u s t then be applied to older w o m e n . Currently it does not seem that there is an effective and appropriate screening m e t h o d that is applicable to the general population. Clinicians need to be vigilant and have a high degree of suspicion regarding older w o m e n w h o present with abdominal complaints and w o m e n w h o have a history that places them at high risk for ovarian cancer. At present, it m a y be beneficial to follow such w o m e n with CA 125 and ultrasound.
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COLORECTAL CANCER Colorectal cancer is the second most common cancer in w om en and the third leading cause of cancer death behind lung and breast cancer. 2 It is estimated that there will be 75,000 new cases detected in w om en and approximately 30,500 attributable deaths in 1991. 2 Approximately 73% of colon cancer and 67% of rectal cancers occur in w om e n over the age of 64. Survival has improved for both whites and blacks, with the relative 5-year survival rate being 57% for whites and 48% for blacks in 1986. 2 There does not appear to be a difference in survival between age groups.~ However, there is improved survival noted in blacks diagnosed under the age of 65 (52 versus 43%). 1 Although in general there is a correlation between advancing age and the stage at which gynecologic cancers are diagnosed, this relationship has not been noted in colorectal cancer. 1,s Factors that place one in the highest risk group include history of familial polyposis, cancer family syndrome, or ulcerative colitis for greater than 8-10 years. Moderate risk factors are history of previous colon cancer or adenoma and a first-degree relative with colon cancer or history of pelvic radiation therapy. Women with a history of endometrial, breast, or ovarian cancer also are at increased risk. 31,s5,s6 However, the majority of patients who develop colorectal cancer do not have any apparent risk factors. 55 The symptoms of colorectal cancer vary with location. 31 Tumors of the ascending colon tend to become very large before resulting in symptoms. They often bleed, and this may be a cause of anemia. Frequently there is no change in the stools. Tumors in the transverse colon may cause cramping and, thus, lead to earlier diagnosis. In the rectosigmoid, tumors cause pain with defecation, narrowing of stools, and bloody stools. 31 There is evidence to suggest that most colorectal cancers arise from preexisting adenomas or neoplastic changes, ss Therefore, it would seem that a screening test aimed at finding these premalignant or early cancers would be effective. The ACS recommends annual rectal exams after the age of 40, fecal occult blood testing annually after the age of 50, and sigmoidoscopy every 3-5 years after the age of 50. The U.S. Preventive Services Task Force did not find sufficient evidence to recommend for or against screening for colorectal cancer.2S The rectal exam will diagnose 10% of colorectal cancers, but there is no evidence indicating that detection by rectal exam reduces mortality, s7 Fecal occult blood testing has a sensitivity of about 50-70% and a specificity of 98%.s8 Rehydration of the slide will improve sensitivity but decrease specificity. 58"59 Data from five ongoing screening trials have detected more cases of colorectal cancers and at earlier stages. The heine-positive slides range from 1-2.4% of those tested, and 22-59% of those are adenomas or colorectal cancers. They have found more Dukes A and B stages. 59 Presently the effect on mortality is not known. Fecal occult blood testing should be done by taking two slides from three consecutive stools; testing of stool from a gloved finger at the time of rectal exam is not a substitute. 6° If any slide is positive, colonoscopy or air-contrast barium enema should be performed. 6° Sigmoidoscopy would seem to be an effective screening method because the clinician should be able to diagnose cancers at an earlier stage and remove polyps and adenomas, which might decrease the incidence of invasive cancer. 5s Studies that review sigmoidoscopy are limited, and there does not appear to be evidence that screening is effective in altering morbidity and mortality. There is indirect evidence based on patient history that finding disease at an earlier stage reduces mortality, s5 Sigmoidoscopy is effective in detecting cancers in the areas that it visualizes; however, it does not examine the entire colon, and there does appear to be a shift to the right (more cancers
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found in the proximal portion of the colon) in older w o m e n . It is important to use a longer sigmoidoscope in this population, s° Although sigmoidoscopy is r e c o m m e n d e d by the ACS, it appears that their guidelines are less likely to be followed by practitioners than the guidelines for cervical and breast cancer screening. T w e n t y - t h r e e percent of family practitioners, 33% of internists, and only 6% of obstetrician-gynecologists report following these guidelines, although the majority of them feel it is important to do so in asymptomatic patients over the age of 50. 61 If sigmoidoscopy is p e r f o r m e d , it is more likely to be d o n e in m e n than in w o m e n . 62 Lack of patient compliance is also a contributing factor to not having this test performed. In a controlled s t u d y that a t t e m p t e d to evaluate the effectiveness of sigmoidoscopy, only 31% of the patients in the s t u d y group had a sigm o i d o s c o p y although they were u r g e d to do so during this 10-year study. 63 In s u m m a r y , colorectal cancer is the third most c o m m o n cause of death in w o m e n . It carries a poor prognosis; however, if f o u n d at an earlier stage there is an i m p r o v e d prognosis. It progresses from p o l y p s o r a d e n o m a s to malignancy, so screening should be effective. Although evidence does not exist showing a decrease in mortality w h e n using these screening methods, there are several such studies u n d e r w a y . It is important to educate patients regarding signs and s y m p t o m s of colorectal cancer, the factors that increase risk, and the tests that are available and r e c o m m e n d e d for screening. CONCLUSION Screening for gynecologic and colorectal cancers in elderly w o m e n is not adequate. Effective and appropriate screening tests have not been identified for all gynecologic and colorectal cancers, and efforts need to be directed toward the d e v e l o p m e n t of such screening modalities. H o w e v e r , even w h e n certain tests are available, they are often not used in older w o m e n despite the fact that this population is at greater risk for these cancers. The reasons for inadequate screening need to be investigated further and intervention strategies developed. Older w o m e n need to be better educated about the signs and s y m p t o m s of gynecologic and colorectal cancers and be knowledgeable about early detection m e t h o d s so that they may become more responsible for their health. It is i n c u m b e n t u p o n the entire health care system to recognize the importance of cancer prevention in older w o m e n and to advocate the use of effective and appropriate screening m e t h o d s aimed at decreasing this population's incidence of gynecologic and colorectal cancer. REFERENCES
1. National Cancer Institute. Cancer statistics review: 1973-1986 including a report on the status of cancer control. Bethesda, Maryland: U.S. Department of Health and Human Services Publication, 1980. 2. Boring CC, Squire TS, Tong T. Cancer statistics, 1991. CA 1991;41:19-36. 3. Baranovsky A, Myers MH. Cancer incidence and survival in patients 65 years of age and older. CA 1986;36:27-41. 4. Goodwin JA, Samet JM, Key CR, Humble C, Kutvirt D, Hunt C. Stage at diagnosis of cancer varies with the age of the patient. J Am Geriatric Soc 1986;34:20-6. 5. Grover SA, Cook EF, Adam J, Coupal L, Goldman L. Delayed diagnosis of gynecologic tumors in elderly women: Relation to national medical practice patterns. Am J Med 1989;86:151-7. 6. Holmes FF, Hearne E. Cancer stage-to-age relationship: Implications for cancer screening in the elderly. J Am Geriatric Soc 1981;29:55-7. 7. Koss LG. The Papanicolaou test for cervical cancer detection: A triumph and a tragedy. JAMA 1989;261:737-43. WHI Vol. 2, No. 2 Summer1992
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8. Breslow L. Early case-finding, treatment and mortality from cervix and breast cancer. Prey Med 1971;1:141-52. 9. Cramer DW. The role of cervical cytology in the declining morbidity and mortality of cervical cancer. Cancer 1974;34:2018-27. 10. Miller AB, Lindsay J, Hill GB. Mortality from cancer of the uterus in Canada and its relationship to screening of the cervix. Int J Cancer 1976;17:602-12. 11. Stenkvist B, Bergstrom R, Eklund G, Fox CH. Papanicolaou smear screening and cervical cancer: What can you expect? JAMA 1984;252:1423-6. 12. Wilkinson EJ. Pap smear and screening for cervical neoplasia. Clin Obstet Gynecol 1990;33:817-25. 13. Martin PL. How preventable is invasive cervical cancer? Am J Obstet Gynecol 1972;113:541-6. 14. Nyirjesy I. Atypical or suspicious cervical smears: An aggressive diagnostic approach. JAMA 1972;222:691-3. 15. DiSaia PJ, Creasman WT. Clinical gynecologic oncology. 3rd ed St. Louis: C.V. Mosby, 1989. 16. Makuc DM, Freid VM, Kleinman JC. National trends in the U.S. of preventive health care by women. Am J Public Health 1989;79:21-6. 17. National Center for Health Statistics. Office visits by women. National Ambulatory Medical Care Survey (DHEW # 80-1796), Hyattsville, Maryland: NCHS, March 1980. 18. National Center for Health Statistics. The National Health Interview Survey design 1973-1984 and procedures 1975-1983. (Series 1, Number 18. DHHS # 85-1320). Hyattsville, Maryland: U.S. Department of Health and Human Services, 1985. 19. Mandelblatt JS, Faks MC. The cost effectiveness of cervical cancer screening for low-income elderly women. JAMA 1988;259:2409-13. 20. Mandelblatt J, Gopaul I, Wistreich M. Gynecological care of elderly women: Another look at Papanicolaou smear testing. JAMA 1986;256-367-71. 21. Hayward RA, Shapiro MF, Freeman HE, et al. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 1988;148:117781. 22. Celentano DD. Early detection of cervical cancer in elderly women. In: Yancik R, Yates JW, eds. Cancer in the elderly: Approaches to early detection and treatment. New York: Springer, 1989. 23. Celentano DD, Shapiro S, Weisman CS. Cancer prevention screening behavior among elderly women. Prev Med 1982;11:454-63. 24. National Center for Health Statistics. Patterns of ambulatory care in obstetrics and gynecology (DHHS # 84-1737). Hyattsville, Maryland: NCHS, February 1984. 25. U.S. Preventive Services Task Force. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: Williams & Wilkins, 1989. 26. Droegemueller W, Herbst AI, Mishell DR, Stenchever MA. Comprehensive gynecology. St. Louis: C.V. Mosby, 1987. 27. Gusberg SB, Shingleton HM, Deppe G. Female genital cancer. New York: Churchill Livingstone, 1988. 28. Kurman RJ, ed. Blaustein's pathology of the female genital tract. 3rd ed. New York: Springer-Verlag, 1987. 29. Bokkman JV. Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 1983;15:10-7. 30. Rubin S. Postmenopausal bleeding: Etiology, evaluation and management. Med Clin North Am 1987;71:59-6. 31. Rubenstein E. Scientific American medicine. New York: Scientific American, 19781991. 32. Koss LG, Schreiber K, Oberlander SG, et al. Detection of endometrial carcinoma and hyperplasia in asymptomatic women. Obstet Gynecol 1984;64:1-11. 33. Campion MJ, Reid R. Screening for gynecologic cancer. Obstet Gynecol Clin North Am 1990;17(4):695-726. 34. Mencaglia L, Valle RF, Perino A, Gilardi G. Endometrial carcinoma and its precursors: Early detection and treatment. Int J Gynecol Obstet 1990;31:107-16. 35. LaPolla JP, Nicosia S, McCurdy C, et al. Experience with the Endopap device for
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36. 37. 38. 39. 40.
41. 42.
43. 44. 45. 46. 47. 48. 49. 50.
51.
52. 53. 54.
55. 56. 57. 58. 59. 60. 61. 62.
the cytologic detection of uterine cancer and its precursors: A comparison of the Endopap with fractional curettage and hysterectomy. Am J Obstet Gynecol 1990;163:1055-60. Osmers R, Volksen M, Schauer A. Vaginosonography for early detection of endometrial carcinoma? Lancet 1990;1569-71. Grimes DA. Diagnostic dilation and curettage: A reappraisal. Am J Obstet Gynecol 1982;142:1-6. Stovall TG, Photopulos GJ, Poston WM, et al. Pipelle endometrial sampling in patients with known endometrial carcinoma. Obstet Gynecol 1991;77:954-6. Archer DF, McIntyre-Seltman K, Wielborn WW, et al. Endometrial morphology in asymptomatic postmenopausal women. Am J Obstet Gynecol 1991;165:317-22. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilation and curettage. Am J Obstet Gynecol 1988;158:1489-92. Pritchard KI. Screening for endometrial cancer: Is it effective? Ann Intern Med 1989:110:177-9. Yancik R, Ries, LG, Yates JW. Ovarian cancer in the elderly: An analysis of surveillance, epidemiology and end results program data. Am J Obstet Gynecol 1986;154:639-47. American College of Obstetricians and Gynecologists. Cancer of the ovary (ACOG technical bulletin 141) Washington, DC: ACOG, May 1990. Reimer RR, Hoover R, Fraumeni JF, et al. Second primary neoplasms following ovarian cancer. J Natl Cancer Inst 1978;61:1195. Fathalla MF. Incessant ovulation: A factor in ovarian neoplasia? Lancet 1971;263. Cramer DW, Welch WR, Cassalls S, et al. Mumps, menarche, menopause, ovarian cancer. Am J Obstet Gynecol 1983; 147:1. West RO. Epidemiologic study of malignancies of the ovaries. Cancer 1966;19:1001. Cramer DW, Hutchinson GB, Welsh WR, et al. Factors affecting the association of oral contraceptives and ovarian cancer. N Engl J Med 1982;307:1047-51. Dicker RC, Webster LA, Laydle PM, et al. Oral contraceptive use and the risk of ovarian cancer. J Natl Cancer Inst 1983;71:681. Bast RC Jr, Klug TL, St. John E, et al. A radio-immunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer. N Engl J Med 1983;309:883-7. Mann WJ, Pastner B, Cohen H, Loub M. Preoperative serum CA 125 antigen levels in patients with surgical stage I ovarian adenocarcinoma. J Natl Cancer Inst 1988;80:208-9. Jacobs I, Stabile IS, Bridges J, et al. Multimodal approach to screening for ovarian cancer. Lancet 1988;263-71. Campbell S, Bhan V, Royston P, et al. Transabdominal ultrasound screening for early ovarian cancer. Br Med J 1989;299:1363-70. Van Nagell JR, DePriest PD, Pues LE, et al. Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer 1991;68:45862. Fleischer DE, Goldberg SB, Browning TH, et al. Detection and surveillance of colorectal cancer. JAMA 1989;261:580-5. Winawer SJ, Sherlock P, Schottenfeld D, Miller DG. Screening for colorectal cancer. Gastroenterology 1976;70:783-9. Eddy DM. Screening for colorectal cancer. Ann Intern Med 1990;113:373-84. Simon J. Occult blood screening for colorectal carcinoma: A critical review. Gastroenterology 1985;88:820-37. Winawer SJ, Schottenfeld D, Flehinger BJ. Colorectal cancer screening. J Natl Cancer Inst 1991;83:243-53. Bayless TM. Current therapy in gastroenterology and liver disease--3. Toronto: B.C. Decker, 1990. American Cancer Society. Survey of physicians' attitudes and practices in early cancer detection. CA 1985;35:197-213. Bernstein AB, Thompson GB, Harlan LC. Differences in rates of cancer screening by usual source of medical care: Data from the 1987 National Health Interview Study. Med Care 1991;29:196-209.
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63. Selby J, Freidman GD. Sigmoidoscopy in the periodic health examination of asymptomatic adults. JAMA 1989;261:595-601.
DISCUSSION Participants agreed in unison that a major obstacle to appropriate screening for gynecologic and gastrointestinal cancers would be removed if physicians treating women in this age group were to view their role as being primary care providers and accept responsibility for providing preventive services in addition to treating episodic illness and rendering acute care. Several persons made the observation that interspecialty cooperation and coordination are crucial, as are the provision of additional training opportunities and continuing medical education and the development of screening guidelines and protocols. Currently, the major determinant of whether a woman receives screening for colorectal cancer or for gynecologic cancers appears to be her choice of specialist (eg, internist or obstetrician-gynecologist), Dr. Ruth Merkatz observed; both those specialty groups as well as family practitioners need to resolve on a unilateral basis to provide all appropriate testing to the population of aging women under their care. Dr. Dunn reported that ACOG has appointed a primary care task force to explore these issues (which he chairs); among other things, it has discovered that in many instances obstetriciangynecologists don't realize they have assumed the role of primary care provider nor are they aware of what obligations for screening come with that role. Lack of experiences and education in obstetrics and gynecology residency training reinforce this point, according to Dr. Ciotti. Dr. Dunn observed that within the obstetrics and gynecology specialty, repeated contact for contraception and particularly the yearly Pap smear associated with oral contraception traditionally have provided the venue for establishing long-term, preventive care relationships. Women who have had tubal ligations or who are no longer fertile fall outside this system, he noted. Dr. Judith LaRosa commented that particularly for minority women, whose disproportionately high rates of cancer may reflect lack of access to the health care system, it is important that obstetrician-gynecologists extend their influence beyond the childbearing years. An increasing percentage of women rely upon their obstetrician-gynecologists for essentially all of their health care, or at least their entry into the health care system; past surveys from ACOG show that at least half of all patients see no other physicians on a regular basis, and that about the same number rely upon that contact for primary care. Dr. Speroff suggested that it might be possible to construct a widespread preventive screening approach based on successful models for providing contraceptive services, such as family planning and Planned Parenthood clinics. In private practice settings, the practitioner can assess his or her role (ie, primary care or specialist) and provide the level of care required, Dr. Dunn advised, although both Drs. Speroff and McQuarrie warned that there may be resistance from practitioners who argue that they are too busy to perform routine cancer screening when patients present for other indications. Alternative options that appear to be successful include systems for computergenerated reminders or flagging charts, both aimed at bringing the patient back on a repeat visit for screening purposes. Because patients do expect obstetrician-gynecologists to be their primary care physicians, the knowledge and skills to provide preventive screening (or refer patients) need to be incorporated in residency training, Dr. Ciotti emphasized. Although time is of
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essence, issuing reminders and developing a checklist for screening is part of providing good care to this population. Patient attributes, in particular lack of knowledge about the need for preventive screening, are another major obstacle. Most older women enter the health care system for specific interventions (ie, problems with joint pain, hearing loss, etc); few express concerns about or seek out preventive screening tests, according to Dr. McQuarrie. Compounding this, it has become apparent that some women receiving radiation therapy or follow-up care after treatments for gynecologic malignancies have relied upon that treatment environment as their sole contact with the health care system, and thus have not received regular Pap smears, mammograms, and other preventive testing; this at least has been Dr. Dunn's experience at his own institution. Similarly, Dr. Schwarz shared his own center's experience in treating vulvar lesions, which showed that women will delay seeking care for an extended period simply due to embarrassment over their presenting condition. All this reinforces the fact that the importance of taking responsibility for one's own health must be emphasized for this age group, Dr. Speroff concluded. In addition, more research on older women's behaviors in this area are needed. Data are scarce, due in part to women's traditional exclusion from research trials and also to the impossibility of establishing proper controls. Dr. Yancik reported that the National Institute on Aging and the National Cancer Institute are embarking on a prospective study of illness behaviors in older women to determine, among other things, comorbidity upon their entrance to the health care system. The women will also be surveyed about their knowledge of appropriate cancer screening tests. Finally, money is an issue that cannot be overlooked, and state laws vary widely with regard to whether or not they require insurers to provide reimbursement for preventive screening services. Often women are forced to pay out-of-pocket to have these tests, Dr. Ravnikar observed. ACOG's primary care task force has found physicians to be excluded (by insurers) from most discussions about managed care for preventive services of this nature, according to Dr. Dunn. This is another area in which physicians and other professionals involved in the care of older women could be influential.
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FACOG
Assistant Professor, Department of Obstetrics and Gynecology Michigan State University East Lansing, Michigan
here are several issues inherent in the question of the adequacy of gynecologic and colorectal screening: 1) are the available screening tests effective; 2) are they appropriate to use in w o m e n over 65; and if so, 3) are they being used in this group of w o m e n ? The incidence of gynecologic and colorectal cancers increases with age. Additionally, gynecologic cancers are diagnosed at more a d v a n c e d stages in older w o m e n . Older w o m e n are at greatest risk for these cancers but are often less likely to be screened than y o u n g e r w o m e n . The following is a review of the incidences of individual cancers, their effects on w o m e n aged 65 and older, available screening methods, and their use in older w o m e n .
T
CERVICAL CANCER The incidence of cervical cancer increases with a g e ) It is estimated that in 1991 there will have b e e n 13,000 newly diagnosed cervical cancers, and 4500 w o m e n will die from this disease. 2 T w e n t y - s e v e n percent of these cases and 41% of the deaths will occur in w o m e n over the age of 65. The relative 5-year survival rate decreases with age: 62% for w o m e n u n d e r the age of 65 and 50% for those age 65 and older. 3 The incidence of cervical cancer is greater in black w o m e n , and the relative 5-year survival rate in blacks is dramatically lower at 37%.~ W h e n the data from several cancer registries are reviewed, there is a definite relationship b e t w e e n the stage at which cervical cancer is diagnosed and a patient's age, with older w o m e n being diagnosed at more advanced stages of cervical cancer. 4~ The Pap smear is the most c o m m o n l y used m e t h o d of screening for cervical cancer. It allows the clinician to detect and treat preinvasive cervical neoplasia. A l t h o u g h the efficacy of the Pap smear has never been tested in a prospective study, 7 there have been several epidemiologic studies that show a decrease in invasive cervical cancer w h e n the Pap smear has been introduced as a screening test. 8-H Concomitantly, the incidence of cervical cancer has increased in u n s c r e e n e d populations, n If the Pap smear is an effective screening test, w h y do w o m e n still die of invasive cervical cancer? Using the Pap smear as a screening tool involves WHI Vol. 2, No. 2 Summer 1992
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multiple steps and multiple individuals; consequently, there is a potential for noncompliance and error. Proper sampling of the cervix is critical and can influence the accuracy and reliability of the test. The smear should contain cells from the ectocervix and endocervix. In older w o m e n , it is also beneficial to sample cells from the vaginal pool 7 to increase the potential for finding abnormal cells from the endometrium. The slide must then be fixed immediately. It has been reported that as m a n y as 60% of false-negative Pap smear results are due to poor sampling technique. 12 Once in the laboratory w h e r e the slide is stained, care should be taken to filter the stain to p r e v e n t "floating cells" from attaching to slides. 7 Although the Pap smear can be screened by a trained cytotechnologist, all abnormal smears should be reviewed by a pathologist. 7 Approximately 40% of false-negatives have been attributed to laboratory error. 12 N e w regulations of the Health Care Financing Administration of the U.S. D e p a r t m e n t of Health and H u m a n Services regarding quality assurance in the performance of cervical cytology became available February 28, 1992, t h r o u g h the Federal Register. Also included are exact regulations as well as enforcement strategies (personal communication with Dr. G. Thomas, Michigan Department of Public Health, June 1992). Appropriate follow-up of abnormal Pap smears is imperative. In as m a n y as 50% of cases of invasive cervical cancer, there is a history of a previously abnormal smear that did not have adequate follow-up. 11,13 Solely repeating the Pap smear is not advised, because as m a n y as 40% of repeat Pap smears will be falsely negative. ~4 Follow-up with colposcopy is generally recomm e n d e d for abnormal Pap smears, is In order for the Pap smear to be an effective screening m e t h o d , it needs to be utilized in w o m e n at risk for cervical cancer. As has been noted, the risk of cervical cancer increases with age, yet older w o m e n are the least likely to have had a Pap smear.16 The Pap smear ceases to be a leading reason for a physician visit after the age of 44.17 Fifteen percent of w o m e n over the age of 65 report never having had a Pap smear, and in a n o t h e r 25% it had been more than 5 years since their last Pap smear. TMOne study of older poor w o m e n w h o received care from a hospital clinic f o u n d that 25% had never had a Pap smear and 75% had irregular screening. ~9.2° It does not a p p e a r that this is due to less frequent physician contact. Older w o m e n were more likely to have been to one or more physicians within the previous year but were less likely to have had a Pap smear in the r e c o m m e n d e d time frame. 21 Socioeconomic status and ethnicity also influence screening. Poor w o m e n of all ages and races are less likely to have preventive screening than the nonpoor. 16 Prior to 1973, it was f o u n d that poor black w o m e n were the least likely to have a Pap smear; however, b e t w e e n 1973 and 1985 there was a remarkable increase in the n u m b e r of Pap smears p e r f o r m e d in black w o m e n . N o w those least likely to have Pap smears are poor white w o m e n . ~6 Having an obstetrician-gynecologist as the "usual source" of medical care is associated with a great probability of having regular Pap smears, and obstetrician-gynecologists are more likely to remind w o m e n to have a Pap smear. 17'~-24 Obstetrician-gynecologists, however, are less likely to serve as primary care physicians for elderly w o m e n . 23,24 The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists, the American Medical Association, the American Medical W o m e n ' s Association, and the National Cancer Institute r e c o m m e n d that annual Pap smears be p e r f o r m e d on all w o m e n w h o are sexually active or are age 18 or older. At the discretion of the physician, Pap smears m a y be done less frequently once three or more annual smears have been negative. 25 Suggestions that screening end at age 60 or 6525 assumes a history of prior
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negative screens, which, w h e n considering the previous information, m a y not be applicable to all w o m e n . In s u m m a r y , the incidence of cervical cancer increases with age. Although the Pap smear has been s h o w n to decrease the incidence of cervical cancer, it has not been utilized effectively in older w o m e n . W o m e n need to be aware that obtaining Pap smears can be as i m p o r t a n t at age 65 as it is at age 25 and that the Pap smear allows the detection of precancerous and treatable conditions. Physicians need to include cervical screening in the general care of older w o m e n .
ENDOMETRIAL
CANCER
Endometrial cancer is the most c o m m o n gynecologic cancer. It is estimated that there will be 33,000 new cases diagnosed in 1991, and endometrial cancer will cause 5500 deaths. 2 Forty-five percent of endometrial cancer deaths are in w o m e n w h o are age 65 or older. 3 The incidence of endometrial cancer rises sharply after the age of 45 and peaks b e t w e e n the ages of 55 and 69. 26 Only about 5% of cases occur in w o m e n y o u n g e r than 40 years of age. 27 Fortunately, endometrial cancer is often diagnosed at an early stage, which carries a very favorable prognosis. Older w o m e n , however, are more often diagnosed at a d v a n c e d stages. 4-6 W o m e n over 64 years have a worse 5-year survival rate than w o m e n 45-64 years (75 versus 91%, respectively), and black w o m e n have a p o o r e r prognosis than do white w o m e n (55 versus 84%). 2 It seems that black w o m e n are more likely to have a more aggressive endometrial cancer. 28 Classically, the w o m a n w h o is t h o u g h t to be at risk for endometrial cancer is postmenopausal, obese, and hypertensive. Many of the risk factors seem to be related to increased estrogens, either e n d o g e n o u s l y or exogenously derived, which are the result of obesity, late m e n o p a u s e , estrogen therapy, nulliparity, or infertility related to anovulation. H o w e v e r , these factors are not present in all patients with endometrial cancer. 27"28 Two types of endometrial cancer have been described28"29: type I is estrogen-related and is preceded by hyperplasia. It occurs more frequently in white w o m e n , and the grade tends to be low with minimal invasion and a less aggressive behavior. 28 It accounts for 60% of endometrial cancers. 27 Type II is not estrogen-related and it occurs in older w o m e n . It is more likely to occur without hyperplasia in black w o m e n and is a more aggressive cancer. 28 Vaginal bleeding is usually the first and only s y m p t o m of endometrial cancer. Approximately 75% of w o m e n will initially present with bleeding, 3° although one source reported 90-95% with this finding. 31 Unfortunately, w o m e n w h o are on estrogen replacement therapy may find it difficult to ascertain if bleeding is a normal side effect of their therapeutic regimen.27 Postmenopausal bleeding is a s y m p t o m that is to be considered a s y m p t o m of endometrial cancer until p r o v e n otherwise and d e m a n d s a t h o r o u g h investigation. Approximately 20% of w o m e n with p o s t m e n o p a u s a l bleeding will have a malignancy, and the remaining will have n o n m a l i g n a n t conditions such as hyperplasia, atrophic vaginitis, or u n d e t e r m i n e d causes. 3° There are no tests that are r e c o m m e n d e d for general screening for endometrial cancer, although the ACS r e c o m m e n d s endometrial tissue sampling on w o m e n during m e n o p a u s e w h o are at risk (those w h o are obese, infertile, anovulatory, or on estrogen t h e r a p y or those with abnormal uterine bleeding). The following is a review of tests that have been p r o p o s e d as useful in the detection of endometrial cancer. 1. The Pap s m e a r - - A l t h o u g h not considered a screening test for endometrial cancer, it has been reported that as m a n y as 50% of endometrial cancers
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can be detected with the Pap smear. 7"32Detection is more likely if one obtains a vaginal pool sample. 2. Endometrial cytology p e r f o r m e d by aspiration, brushing, or w a s h i n g - The success rate is fairly high in obtaining cells; however, interpretation is difficult. 33,34 Endometrial hyperplasia is more difficult to detect than endometrial cancer, and a sensitivity of approximately 50% is reported. 3s 3. U l t r a s o u n d - - A s a screening test for endometrial cancer, u l t r a s o u n d appears to have a low sensitivity. In a s t u d y by Osmers et al, 36 an endometrial thickness greater than 4 m m was defined as abnormal. Follow-up indicated that 22% of patients meeting that criteria had endometrial cancer, 4% had hyperplasia, and 64% had n o n m a l i g n a n t changes. 36 4. Endometrial biopsy---The appropriateness of using the endometrial biopsy for the detection and diagnosis of endometrial cancer is often argued. 37 The sensitivity ranges from 87-100%.34 A recent study by Stoval and coworkers 3s reported a 97% accuracy with pipelles. Biopsy as a screening test in asymptomatic w o m e n was recently evaluated by Archer et a139 w h o f o u n d that of 801 asymptomatic postmenopausal women, one had endometrial cancer. They concluded that the yield was too low to r e c o m m e n d mass screening in asymptomatic w o m e n . 5. H y s t e r o s c o p y - - E s p e c i a l l y w h e n used with biopsy, h y s t e r o s c o p y has been s h o w n to be effective in diagnosing endometrial cancer as a cause of abnormal uterine bleeding. Some studies s h o w it is more effective than dilation and curettage. *° It is more reliable in the detection of endometrial cancers than hyperplasia--92 versus 70%. 34 H o w e v e r , h y s t e r o s c o p y is not widely available, is expensive, and may be more difficult to p e r f o r m in postmenopausal w o m e n . There have been no controlled trials to evaluate the effectiveness of screening for endometrial cancer. 41 Considering cost, patient acceptability, and ease of performance, an i m p r o v e d cytologic detection system would be extremely beneficial. At the present time, practitioners n e e d to consider t h o r o u g h evaluation of w o m e n with p o s t m e n o p a u s a l bleeding. W o m e n should be asked about this s y m p t o m , be informed that this is not a normal finding, and be told that it is often an early warning sign of a treatable form of endometrial cancer. Practitioners should also be mindful of p o s t m e n o p a u s a l w o m e n on estrogen replacement therapy, especially if they are on low doses of progestins; w o m e n w h o have breast cancer and/or are on tamoxifen; w o m e n w h o have colon cancer; and w o m e n w h o have a strong family history of endometrial or colon cancer. Such w o m e n should be followed closely and probably offered periodic endometrial biopsies.
OVARIAN
CANCER
There will be an estimated 20,700 new cases of ovarian cancer and 12,500 associated deaths in 1991. 2 Although its incidence is lower than other gynecologic cancers, it causes over 50% of all deaths from gynecologic cancer. It is a virulent neoplasm and carries a poor prognosis. The 5-year survival rate of 38% has not changed markedly since 1973. The incidence of ovarian cancer is 46% higher in whites than nonwhites, 2 and both the incidence and d e a t h rate continue to increase with age. 26 Forty-three percent of all ovarian cancers occur in w o m e n over the age of 64. 3 The relative 5-year survival rate, which accounts for other causes of mortality, is only 24% for w o m e n over age 65 versus 48% for those u n d e r the age of 65. 3 This seems to be related to the fact that ovarian cancer is f o u n d at more advanced stages in older women, 4-~'42 and, stage for stage, older w o m e n have a worse prognosis. 86
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The latter finding m a y be due to less aggressive treatment; 76% of the cases in which no treatment was given occurred in w o m e n over 64 years. 42 The natural history of ovarian cancer is not well k n o w n and the early diagnosis of ovarian cancer is likely to be a fortuitous finding at the time of surgery for other indications. Currently there are no r e c o m m e n d a t i o n s for routine screening for ovarian cancer. 43 Risk factors for ovarian cancer have been investigated. A significant family history has been f o u n d to be one of the most identifiable risk factors and includes w o m e n w h o s e m o t h e r or sister had ovarian cancer and w o m e n w h o have a strong familial incidence of ovarian and/or breast cancer and of colon cancer. ~5 Additionally, there is an increased risk of ovarian carcinoma in w o m e n diagnosed with endometrial, breast, or colon cancer. 44 "Incessant ovulation" as seen in nulliparas and in w o m e n with early m e n a r c h e and/or late m e n o p a u s e also is a risk factor. 4s A diet high in fat, a history of m u m p s in adolescence, and perineal talcum p o w d e r usage also have been implicated. 46,47 W o m e n w h o are at lower risk include those w h o have m a n y children, w h o started their families at an early age, or w h o used birth control pills. 48"49 S y m p t o m s of ovarian cancer are often v e r y vague. A history of several m o n t h s of abdominal discomfort such as bloating and digestive disturbances may be suggestive of ovarian cancer. Unfortunately, all of these can be attributed to more c o m m o n causes. H o w e v e r , if a w o m a n over age 40 complains of persistent gastrointestinal s y m p t o m s , one should consider ovarian cancer in the differential diagnosis. 15 Available screening tests are the pelvic exam, CA 125 antigen, ultrasound, and the combined use of CA 125 and ultrasound. CA 125 is a serum t u m o r associated antigen. Initially it was t h o u g h t that CA 125 would be an excellent marker for ovarian tumors and could be used as a screening test. Early reports indicated that 85% of w o m e n with epithelial tumors had an elevated CA 125, 50 d e m o n s t r a t i n g that it is more likely to be elevated in w o m e n w h o have stage I disease w h e r e surgical treatment could be curative. 5~ Unfortunately, CA 125 lacks specificity, although it is more specific in p 0 s t m e n o p a u s a l w o m e n . 52 As a screening tool for ovarian cancer, ultrasound has a high sensitivity, but there are a large n u m b e r of false-positives. In Campbell et al's 53 s t u d y of 5479 w o m e n over a 3-year period, 338 w o m e n had abnormal scans. Of these, 326 had surgery but only five were diagnosed with ovarian cancer. These cancers were f o u n d t h r o u g h o u t the 3-year s t u d y period so that optimal screening intervals are not k n o w n , s3 In p o s t m e n o p a u s a l w o m e n , the false-positive rate m a y be decreased. Van Nagell and coworkers 54 studied 1300 postmenopausal w o m e n , 27 of w h o m had abnormal scans and two had cancer. The use of CA 125 w h e n there is an abnormal u l t r a s o u n d finding improves the specificity of the ultrasound. 52 To date, there are no long-term studies of the effect on morbidity or mortality. Also, these tests are more likely to be positive w h e n a w o m a n has metastatic disease. In s u m m a r y , ovarian cancer is a highly malignant disease w h o s e natural course is not well k n o w n . The risk of ovarian cancer increases with age, it is found at more a d v a n c e d stages in older w o m e n , and treatment tends to be less aggressive in older w o m e n . Research should address the etiology of this disease as well as identification of risk factors and premalignant conditions. Screening and treatment m u s t then be applied to older w o m e n . Currently it does not seem that there is an effective and appropriate screening m e t h o d that is applicable to the general population. Clinicians need to be vigilant and have a high degree of suspicion regarding older w o m e n w h o present with abdominal complaints and w o m e n w h o have a history that places them at high risk for ovarian cancer. At present, it m a y be beneficial to follow such w o m e n with CA 125 and ultrasound.
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COLORECTAL CANCER Colorectal cancer is the second most common cancer in w om en and the third leading cause of cancer death behind lung and breast cancer. 2 It is estimated that there will be 75,000 new cases detected in w om en and approximately 30,500 attributable deaths in 1991. 2 Approximately 73% of colon cancer and 67% of rectal cancers occur in w om e n over the age of 64. Survival has improved for both whites and blacks, with the relative 5-year survival rate being 57% for whites and 48% for blacks in 1986. 2 There does not appear to be a difference in survival between age groups.~ However, there is improved survival noted in blacks diagnosed under the age of 65 (52 versus 43%). 1 Although in general there is a correlation between advancing age and the stage at which gynecologic cancers are diagnosed, this relationship has not been noted in colorectal cancer. 1,s Factors that place one in the highest risk group include history of familial polyposis, cancer family syndrome, or ulcerative colitis for greater than 8-10 years. Moderate risk factors are history of previous colon cancer or adenoma and a first-degree relative with colon cancer or history of pelvic radiation therapy. Women with a history of endometrial, breast, or ovarian cancer also are at increased risk. 31,s5,s6 However, the majority of patients who develop colorectal cancer do not have any apparent risk factors. 55 The symptoms of colorectal cancer vary with location. 31 Tumors of the ascending colon tend to become very large before resulting in symptoms. They often bleed, and this may be a cause of anemia. Frequently there is no change in the stools. Tumors in the transverse colon may cause cramping and, thus, lead to earlier diagnosis. In the rectosigmoid, tumors cause pain with defecation, narrowing of stools, and bloody stools. 31 There is evidence to suggest that most colorectal cancers arise from preexisting adenomas or neoplastic changes, ss Therefore, it would seem that a screening test aimed at finding these premalignant or early cancers would be effective. The ACS recommends annual rectal exams after the age of 40, fecal occult blood testing annually after the age of 50, and sigmoidoscopy every 3-5 years after the age of 50. The U.S. Preventive Services Task Force did not find sufficient evidence to recommend for or against screening for colorectal cancer.2S The rectal exam will diagnose 10% of colorectal cancers, but there is no evidence indicating that detection by rectal exam reduces mortality, s7 Fecal occult blood testing has a sensitivity of about 50-70% and a specificity of 98%.s8 Rehydration of the slide will improve sensitivity but decrease specificity. 58"59 Data from five ongoing screening trials have detected more cases of colorectal cancers and at earlier stages. The heine-positive slides range from 1-2.4% of those tested, and 22-59% of those are adenomas or colorectal cancers. They have found more Dukes A and B stages. 59 Presently the effect on mortality is not known. Fecal occult blood testing should be done by taking two slides from three consecutive stools; testing of stool from a gloved finger at the time of rectal exam is not a substitute. 6° If any slide is positive, colonoscopy or air-contrast barium enema should be performed. 6° Sigmoidoscopy would seem to be an effective screening method because the clinician should be able to diagnose cancers at an earlier stage and remove polyps and adenomas, which might decrease the incidence of invasive cancer. 5s Studies that review sigmoidoscopy are limited, and there does not appear to be evidence that screening is effective in altering morbidity and mortality. There is indirect evidence based on patient history that finding disease at an earlier stage reduces mortality, s5 Sigmoidoscopy is effective in detecting cancers in the areas that it visualizes; however, it does not examine the entire colon, and there does appear to be a shift to the right (more cancers
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found in the proximal portion of the colon) in older w o m e n . It is important to use a longer sigmoidoscope in this population, s° Although sigmoidoscopy is r e c o m m e n d e d by the ACS, it appears that their guidelines are less likely to be followed by practitioners than the guidelines for cervical and breast cancer screening. T w e n t y - t h r e e percent of family practitioners, 33% of internists, and only 6% of obstetrician-gynecologists report following these guidelines, although the majority of them feel it is important to do so in asymptomatic patients over the age of 50. 61 If sigmoidoscopy is p e r f o r m e d , it is more likely to be d o n e in m e n than in w o m e n . 62 Lack of patient compliance is also a contributing factor to not having this test performed. In a controlled s t u d y that a t t e m p t e d to evaluate the effectiveness of sigmoidoscopy, only 31% of the patients in the s t u d y group had a sigm o i d o s c o p y although they were u r g e d to do so during this 10-year study. 63 In s u m m a r y , colorectal cancer is the third most c o m m o n cause of death in w o m e n . It carries a poor prognosis; however, if f o u n d at an earlier stage there is an i m p r o v e d prognosis. It progresses from p o l y p s o r a d e n o m a s to malignancy, so screening should be effective. Although evidence does not exist showing a decrease in mortality w h e n using these screening methods, there are several such studies u n d e r w a y . It is important to educate patients regarding signs and s y m p t o m s of colorectal cancer, the factors that increase risk, and the tests that are available and r e c o m m e n d e d for screening. CONCLUSION Screening for gynecologic and colorectal cancers in elderly w o m e n is not adequate. Effective and appropriate screening tests have not been identified for all gynecologic and colorectal cancers, and efforts need to be directed toward the d e v e l o p m e n t of such screening modalities. H o w e v e r , even w h e n certain tests are available, they are often not used in older w o m e n despite the fact that this population is at greater risk for these cancers. The reasons for inadequate screening need to be investigated further and intervention strategies developed. Older w o m e n need to be better educated about the signs and s y m p t o m s of gynecologic and colorectal cancers and be knowledgeable about early detection m e t h o d s so that they may become more responsible for their health. It is i n c u m b e n t u p o n the entire health care system to recognize the importance of cancer prevention in older w o m e n and to advocate the use of effective and appropriate screening m e t h o d s aimed at decreasing this population's incidence of gynecologic and colorectal cancer. REFERENCES
1. National Cancer Institute. Cancer statistics review: 1973-1986 including a report on the status of cancer control. Bethesda, Maryland: U.S. Department of Health and Human Services Publication, 1980. 2. Boring CC, Squire TS, Tong T. Cancer statistics, 1991. CA 1991;41:19-36. 3. Baranovsky A, Myers MH. Cancer incidence and survival in patients 65 years of age and older. CA 1986;36:27-41. 4. Goodwin JA, Samet JM, Key CR, Humble C, Kutvirt D, Hunt C. Stage at diagnosis of cancer varies with the age of the patient. J Am Geriatric Soc 1986;34:20-6. 5. Grover SA, Cook EF, Adam J, Coupal L, Goldman L. Delayed diagnosis of gynecologic tumors in elderly women: Relation to national medical practice patterns. Am J Med 1989;86:151-7. 6. Holmes FF, Hearne E. Cancer stage-to-age relationship: Implications for cancer screening in the elderly. J Am Geriatric Soc 1981;29:55-7. 7. Koss LG. The Papanicolaou test for cervical cancer detection: A triumph and a tragedy. JAMA 1989;261:737-43. WHI Vol. 2, No. 2 Summer1992
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8. Breslow L. Early case-finding, treatment and mortality from cervix and breast cancer. Prey Med 1971;1:141-52. 9. Cramer DW. The role of cervical cytology in the declining morbidity and mortality of cervical cancer. Cancer 1974;34:2018-27. 10. Miller AB, Lindsay J, Hill GB. Mortality from cancer of the uterus in Canada and its relationship to screening of the cervix. Int J Cancer 1976;17:602-12. 11. Stenkvist B, Bergstrom R, Eklund G, Fox CH. Papanicolaou smear screening and cervical cancer: What can you expect? JAMA 1984;252:1423-6. 12. Wilkinson EJ. Pap smear and screening for cervical neoplasia. Clin Obstet Gynecol 1990;33:817-25. 13. Martin PL. How preventable is invasive cervical cancer? Am J Obstet Gynecol 1972;113:541-6. 14. Nyirjesy I. Atypical or suspicious cervical smears: An aggressive diagnostic approach. JAMA 1972;222:691-3. 15. DiSaia PJ, Creasman WT. Clinical gynecologic oncology. 3rd ed St. Louis: C.V. Mosby, 1989. 16. Makuc DM, Freid VM, Kleinman JC. National trends in the U.S. of preventive health care by women. Am J Public Health 1989;79:21-6. 17. National Center for Health Statistics. Office visits by women. National Ambulatory Medical Care Survey (DHEW # 80-1796), Hyattsville, Maryland: NCHS, March 1980. 18. National Center for Health Statistics. The National Health Interview Survey design 1973-1984 and procedures 1975-1983. (Series 1, Number 18. DHHS # 85-1320). Hyattsville, Maryland: U.S. Department of Health and Human Services, 1985. 19. Mandelblatt JS, Faks MC. The cost effectiveness of cervical cancer screening for low-income elderly women. JAMA 1988;259:2409-13. 20. Mandelblatt J, Gopaul I, Wistreich M. Gynecological care of elderly women: Another look at Papanicolaou smear testing. JAMA 1986;256-367-71. 21. Hayward RA, Shapiro MF, Freeman HE, et al. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 1988;148:117781. 22. Celentano DD. Early detection of cervical cancer in elderly women. In: Yancik R, Yates JW, eds. Cancer in the elderly: Approaches to early detection and treatment. New York: Springer, 1989. 23. Celentano DD, Shapiro S, Weisman CS. Cancer prevention screening behavior among elderly women. Prev Med 1982;11:454-63. 24. National Center for Health Statistics. Patterns of ambulatory care in obstetrics and gynecology (DHHS # 84-1737). Hyattsville, Maryland: NCHS, February 1984. 25. U.S. Preventive Services Task Force. Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: Williams & Wilkins, 1989. 26. Droegemueller W, Herbst AI, Mishell DR, Stenchever MA. Comprehensive gynecology. St. Louis: C.V. Mosby, 1987. 27. Gusberg SB, Shingleton HM, Deppe G. Female genital cancer. New York: Churchill Livingstone, 1988. 28. Kurman RJ, ed. Blaustein's pathology of the female genital tract. 3rd ed. New York: Springer-Verlag, 1987. 29. Bokkman JV. Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 1983;15:10-7. 30. Rubin S. Postmenopausal bleeding: Etiology, evaluation and management. Med Clin North Am 1987;71:59-6. 31. Rubenstein E. Scientific American medicine. New York: Scientific American, 19781991. 32. Koss LG, Schreiber K, Oberlander SG, et al. Detection of endometrial carcinoma and hyperplasia in asymptomatic women. Obstet Gynecol 1984;64:1-11. 33. Campion MJ, Reid R. Screening for gynecologic cancer. Obstet Gynecol Clin North Am 1990;17(4):695-726. 34. Mencaglia L, Valle RF, Perino A, Gilardi G. Endometrial carcinoma and its precursors: Early detection and treatment. Int J Gynecol Obstet 1990;31:107-16. 35. LaPolla JP, Nicosia S, McCurdy C, et al. Experience with the Endopap device for
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36. 37. 38. 39. 40.
41. 42.
43. 44. 45. 46. 47. 48. 49. 50.
51.
52. 53. 54.
55. 56. 57. 58. 59. 60. 61. 62.
the cytologic detection of uterine cancer and its precursors: A comparison of the Endopap with fractional curettage and hysterectomy. Am J Obstet Gynecol 1990;163:1055-60. Osmers R, Volksen M, Schauer A. Vaginosonography for early detection of endometrial carcinoma? Lancet 1990;1569-71. Grimes DA. Diagnostic dilation and curettage: A reappraisal. Am J Obstet Gynecol 1982;142:1-6. Stovall TG, Photopulos GJ, Poston WM, et al. Pipelle endometrial sampling in patients with known endometrial carcinoma. Obstet Gynecol 1991;77:954-6. Archer DF, McIntyre-Seltman K, Wielborn WW, et al. Endometrial morphology in asymptomatic postmenopausal women. Am J Obstet Gynecol 1991;165:317-22. Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilation and curettage. Am J Obstet Gynecol 1988;158:1489-92. Pritchard KI. Screening for endometrial cancer: Is it effective? Ann Intern Med 1989:110:177-9. Yancik R, Ries, LG, Yates JW. Ovarian cancer in the elderly: An analysis of surveillance, epidemiology and end results program data. Am J Obstet Gynecol 1986;154:639-47. American College of Obstetricians and Gynecologists. Cancer of the ovary (ACOG technical bulletin 141) Washington, DC: ACOG, May 1990. Reimer RR, Hoover R, Fraumeni JF, et al. Second primary neoplasms following ovarian cancer. J Natl Cancer Inst 1978;61:1195. Fathalla MF. Incessant ovulation: A factor in ovarian neoplasia? Lancet 1971;263. Cramer DW, Welch WR, Cassalls S, et al. Mumps, menarche, menopause, ovarian cancer. Am J Obstet Gynecol 1983; 147:1. West RO. Epidemiologic study of malignancies of the ovaries. Cancer 1966;19:1001. Cramer DW, Hutchinson GB, Welsh WR, et al. Factors affecting the association of oral contraceptives and ovarian cancer. N Engl J Med 1982;307:1047-51. Dicker RC, Webster LA, Laydle PM, et al. Oral contraceptive use and the risk of ovarian cancer. J Natl Cancer Inst 1983;71:681. Bast RC Jr, Klug TL, St. John E, et al. A radio-immunoassay using a monoclonal antibody to monitor the course of epithelial ovarian cancer. N Engl J Med 1983;309:883-7. Mann WJ, Pastner B, Cohen H, Loub M. Preoperative serum CA 125 antigen levels in patients with surgical stage I ovarian adenocarcinoma. J Natl Cancer Inst 1988;80:208-9. Jacobs I, Stabile IS, Bridges J, et al. Multimodal approach to screening for ovarian cancer. Lancet 1988;263-71. Campbell S, Bhan V, Royston P, et al. Transabdominal ultrasound screening for early ovarian cancer. Br Med J 1989;299:1363-70. Van Nagell JR, DePriest PD, Pues LE, et al. Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography. Cancer 1991;68:45862. Fleischer DE, Goldberg SB, Browning TH, et al. Detection and surveillance of colorectal cancer. JAMA 1989;261:580-5. Winawer SJ, Sherlock P, Schottenfeld D, Miller DG. Screening for colorectal cancer. Gastroenterology 1976;70:783-9. Eddy DM. Screening for colorectal cancer. Ann Intern Med 1990;113:373-84. Simon J. Occult blood screening for colorectal carcinoma: A critical review. Gastroenterology 1985;88:820-37. Winawer SJ, Schottenfeld D, Flehinger BJ. Colorectal cancer screening. J Natl Cancer Inst 1991;83:243-53. Bayless TM. Current therapy in gastroenterology and liver disease--3. Toronto: B.C. Decker, 1990. American Cancer Society. Survey of physicians' attitudes and practices in early cancer detection. CA 1985;35:197-213. Bernstein AB, Thompson GB, Harlan LC. Differences in rates of cancer screening by usual source of medical care: Data from the 1987 National Health Interview Study. Med Care 1991;29:196-209.
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63. Selby J, Freidman GD. Sigmoidoscopy in the periodic health examination of asymptomatic adults. JAMA 1989;261:595-601.
DISCUSSION Participants agreed in unison that a major obstacle to appropriate screening for gynecologic and gastrointestinal cancers would be removed if physicians treating women in this age group were to view their role as being primary care providers and accept responsibility for providing preventive services in addition to treating episodic illness and rendering acute care. Several persons made the observation that interspecialty cooperation and coordination are crucial, as are the provision of additional training opportunities and continuing medical education and the development of screening guidelines and protocols. Currently, the major determinant of whether a woman receives screening for colorectal cancer or for gynecologic cancers appears to be her choice of specialist (eg, internist or obstetrician-gynecologist), Dr. Ruth Merkatz observed; both those specialty groups as well as family practitioners need to resolve on a unilateral basis to provide all appropriate testing to the population of aging women under their care. Dr. Dunn reported that ACOG has appointed a primary care task force to explore these issues (which he chairs); among other things, it has discovered that in many instances obstetriciangynecologists don't realize they have assumed the role of primary care provider nor are they aware of what obligations for screening come with that role. Lack of experiences and education in obstetrics and gynecology residency training reinforce this point, according to Dr. Ciotti. Dr. Dunn observed that within the obstetrics and gynecology specialty, repeated contact for contraception and particularly the yearly Pap smear associated with oral contraception traditionally have provided the venue for establishing long-term, preventive care relationships. Women who have had tubal ligations or who are no longer fertile fall outside this system, he noted. Dr. Judith LaRosa commented that particularly for minority women, whose disproportionately high rates of cancer may reflect lack of access to the health care system, it is important that obstetrician-gynecologists extend their influence beyond the childbearing years. An increasing percentage of women rely upon their obstetrician-gynecologists for essentially all of their health care, or at least their entry into the health care system; past surveys from ACOG show that at least half of all patients see no other physicians on a regular basis, and that about the same number rely upon that contact for primary care. Dr. Speroff suggested that it might be possible to construct a widespread preventive screening approach based on successful models for providing contraceptive services, such as family planning and Planned Parenthood clinics. In private practice settings, the practitioner can assess his or her role (ie, primary care or specialist) and provide the level of care required, Dr. Dunn advised, although both Drs. Speroff and McQuarrie warned that there may be resistance from practitioners who argue that they are too busy to perform routine cancer screening when patients present for other indications. Alternative options that appear to be successful include systems for computergenerated reminders or flagging charts, both aimed at bringing the patient back on a repeat visit for screening purposes. Because patients do expect obstetrician-gynecologists to be their primary care physicians, the knowledge and skills to provide preventive screening (or refer patients) need to be incorporated in residency training, Dr. Ciotti emphasized. Although time is of
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essence, issuing reminders and developing a checklist for screening is part of providing good care to this population. Patient attributes, in particular lack of knowledge about the need for preventive screening, are another major obstacle. Most older women enter the health care system for specific interventions (ie, problems with joint pain, hearing loss, etc); few express concerns about or seek out preventive screening tests, according to Dr. McQuarrie. Compounding this, it has become apparent that some women receiving radiation therapy or follow-up care after treatments for gynecologic malignancies have relied upon that treatment environment as their sole contact with the health care system, and thus have not received regular Pap smears, mammograms, and other preventive testing; this at least has been Dr. Dunn's experience at his own institution. Similarly, Dr. Schwarz shared his own center's experience in treating vulvar lesions, which showed that women will delay seeking care for an extended period simply due to embarrassment over their presenting condition. All this reinforces the fact that the importance of taking responsibility for one's own health must be emphasized for this age group, Dr. Speroff concluded. In addition, more research on older women's behaviors in this area are needed. Data are scarce, due in part to women's traditional exclusion from research trials and also to the impossibility of establishing proper controls. Dr. Yancik reported that the National Institute on Aging and the National Cancer Institute are embarking on a prospective study of illness behaviors in older women to determine, among other things, comorbidity upon their entrance to the health care system. The women will also be surveyed about their knowledge of appropriate cancer screening tests. Finally, money is an issue that cannot be overlooked, and state laws vary widely with regard to whether or not they require insurers to provide reimbursement for preventive screening services. Often women are forced to pay out-of-pocket to have these tests, Dr. Ravnikar observed. ACOG's primary care task force has found physicians to be excluded (by insurers) from most discussions about managed care for preventive services of this nature, according to Dr. Dunn. This is another area in which physicians and other professionals involved in the care of older women could be influential.
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