No more breast exams and annual exams?

Report
No more breast exams and annual
exams? Update on
recommendations from ACOG’s Gyn
Practice committee
Peggy A. Norton, M.D.
Chief of Female Pelvic Medicine and
Reconstructive Pelvic Surgery
University of Utah School of Medicine
Learning Objectives
• Describe the source of committee opinions
and practice bulletins in ACOG
• Describe the history of changes in basic gyn
services in the U.S. over the past five years
• Know if there are to be no more breast exams!
Or no more annual exams!
..dedicated to the advancement of women’s health
care through continuing medical education, practice,
and research
Structure of ACOG
ACOG executive
Board
Gynecologic
Practice
Committee
Subcommittees
on REI, FPMRS,
Gyn Oncology
Clinical
Document
Review Panel
Gyn Practice
Bulletins
Committee
Obstetric
Practice
Committee
Subcommittee
on MFM
Obstetric
Practice
Bulletins
Types of ACOG practice documents
• Practice Bulletin: high quality data exists from
which to recommend practice.
• Committee Opinion: important issue to
gynecologists and their patients, but
insufficient data exists to generate a Bulletin.
• Technology Assessment: technologic
assessment, usually for new technology, for
which members need guidance on use in the
absence of extensive data.
Types of ACOG practice documents
• Practice Bulletin: high quality data exists from
which to recommend practice. Committees of
Gyn Practice and Practice Bulletins consider
initial data. An expert is selected who writes
the bulletin under the direction of the Practice
Bulletins Committee
Types of ACOG practice documents
• Committee Opinion: important issue to
gynecologists and their patients, but
insufficient data exists to generate a Bulletin.
Decision is made between PB and GP
committees. COs demand absence of bias in
committee members, who write and edit the
documents
The way it was…
•
•
•
•
Annual exam by Ob/Gyn
Breast exam, pap and pelvic
Annual prior to any treatment including OCPs
Aggressive screening for cervical and breast
CA
• Primary care issues for women beginning in
the 1980s
Shift in thinking about
cervical cancer
screening 2009-2011
• ASCCP issues new guidelines in cervical cancer
screening
– Prevent morbidity and mortality from cervical
cancer
– Prevent overzealous mgmt of precurser lesions
that most likely will regress or disappear and for
which and for which the risks of management
outweigh the benefits.
ACS, ASCCP, ASCP
• No screening prior to age 21 years
• 21-29 years, cytology every three years. HPV testing
should not be used as a screening test
• 30-65 years, cytology plus HPV co-testing every five
years, or cytology every three years
• Stop screening after hysterectomy unless there is a
history of CIN2 or greater
• Screening should not resume after 65 years, even if
there is a new partner
• If h/o CIN 2, 3, or AIS, continue screening for 20 years
thereafter.
Management of Abnormal Cervical Cancer Screening
Test Results and Cervical Cancer Precursors PB 140 2013
The following recommendations are based on good and
consistent scientific evidence (Level A):
• For women with ASC-US cytology test results, reflex HPV
testing is preferred.
• For women with HPV-positive ASC-US, whether from reflex
HPV testing or co-testing, colposcopy is recommended.
• For women with LSIL cytology test results and no HPV test
or a positive HPV test result, colposcopy is recommended.
• For women with a histologic diagnosis of CIN 2, CIN 3, or
CIN 2,3 and adequate colposcopic examination, both
excision and ablation are acceptable treatment modalities,
except in pregnant women and young women.
The Well Woman Visit
CO 534, August 2012 reaffirmed 2014
• The annual health assessment should include screening, evaluation
and counseling, and immunizations based on age and risk factors.
The interval for specific individual services and the scope of services
provided may vary in different ambulatory care settings.
• The performance of a physical examination is a key part of an
annual visit, and the components of that examination may vary
depending on the patient’s age, risk factors, and physician
preference.
• In general, the physical examination will include obtaining standard
vital signs, determining body mass index, palpating the abdomen
and inguinal lymph nodes, and making an assessment of the
patient’s overall health.
• Many, but not all, women will have a pelvic examination and a
clinical breast examination as a part of the physical examination.
Information on these core elements of the physical examination is
provided in the following sections.
Age-based ACOG recommendations
• Patients under 21 do not need internal pelvic
exams unless there are symptoms that
warrant such exam.
• Patients over 21: The decision whether or not
to perform a complete pelvic examination at
the time of the periodic health examination
for the asymptomatic patient should be a
shared decision after a discussion between
the patient and her health care provider.
Well woman visit: pelvic exam
• The pelvic examination includes three elements:
– inspection of the external genitalia, urethral meatus, vaginal
introitus, and perianal region (external examination);
– speculum examination of the vagina and cervix; and
– bimanual examination of the uterus, cervix, and adnexa (the
latter two elements constitute the internal examination).
When indicated, a rectovaginal examination also should be
performed.
– Additionally, cultures for STIs can be obtained from the
cervix during an internal pelvic examination. However,
current evidence shows that screening for STIs also can be
performed without an internal pelvic examination using
nucleic acid amplification testing from urine samples or
vaginal swab specimens.
Shared Communication and Decision Making
• The decision to perform an internal pelvic examination,
breast examination, or both should be made by the
physician and the patient after shared communication and
decision making.
• Concerns, such as individual risk factors, patient
expectations, or medical–legal concerns may influence the
decision to perform an internal pelvic examination or
clinical breast examination.
• In these situations, the medical record should reflect the
pertinent details of the patient’s medical and family history
and overall condition, documentation of the physical
examination, and the issues discussed between the patient
and physician.
January 2013 American Academy of Family
Practice: “Time not well spent”
• Breast CA: In contrast to ACOG's recommendations,
the USPSTF has found insufficient evidence to assess
the benefits and harms of clinical breast examination,
and recommends against teaching breast selfexamination
• Ovarian CA: Routine screening for ovarian cancer with
bimanual examination, transvaginal ultrasonography,
or cancer antigen 125 testing is not recommended. It
does not reduce ovarian cancer mortality, and leads to
complications from diagnostic evaluation of falsepositive results.
“Preventative time not well spent”
editorial Nguyen et al 2014
• Primary care physicians need to make the best use of their limited
time to deal effectively with patients' medical concerns, address
preventive care, and nurture the doctor-patient relationship. It has
been suggested that to address every preventive service
recommended by the U.S. Preventive Services Task Force (USPSTF),
a typical physician with a standard patient panel would need to
spend 7.4 hours per working day providing these services.
• Consequently, when considering the health maintenance
examination, we must think carefully about which tasks are
supported by evidence and which are being performed merely out
of habit. Given the lack of evidence to support annual pelvic
examinations, it would be better for patients if we spend that time
addressing screening, counseling, and other preventive services for
which strong evidence exists.
Response to AAFP
• The College continues to firmly believe in the clinical value of pelvic
examinations, through which gynecologists can recognize issues
such as incontinence and sexual dysfunction. While not evidencebased, the use of pelvic exams is supported by the clinical
experiences of gynecologists treating their patients. Pelvic
examinations also allow gynecologists to explain a patient’s
anatomy, reassure her of normalcy, and answer her specific
questions, thus establishing open communication between patient
and physician.
• Of course, pelvic examinations represent just one part of the annual
well-woman visit, which can help to identify health risks for women
and which can also feature clinical breast examinations,
immunizations, contraceptive care discussions, and health care
counseling. Importantly, annual well-woman visits help to
strengthen the patient-physician relationship.
Over-the-Counter Access to Oral Contraceptives
CO 544: December 2012
• Unintended pregnancy remains a major public health problem
in the United States. Access and cost issues are common
reasons why women either do not use contraception or have
gaps in use.
• A potential way to improve contraceptive access and use,
and possibly decrease unintended pregnancy rates, is to
allow over-the-counter access to oral contraceptives (OCs).
• Screening for cervical cancer or sexually transmitted infections
is not medically required to provide hormonal contraception.
• Weighing the risks versus the benefits based on currently
available data, OCs should be available over-the-counter.
Women should self-screen for most contraindications to OCs
using checklists.
Over the counter OCPs:
What were they thinking?
They were thinking that the consequences of
unintended pregnancy outweighed the
benefits of being screened for
contraindications to OCPs.
ACOG Practice Advisory on Annual Pelvic
Examination Recommendations: June 30, 2014
• The College’s guidelines, which were detailed in
this year’s Committee Opinion on the WellWoman Visit, acknowledge that no current
scientific evidence supports or refutes an annual
pelvic exam for an asymptomatic, low-risk
patient, instead suggesting that the decision
about whether to perform a pelvic examination
be a shared decision between health care
provider and patient, based on her own
individual needs, requests, and preferences.
CO #615, Access to Contraception
January 2015
• Common medical practices prevent easy initiation
of contraception. There is no medical or safety
benefit to requiring routine pelvic examination or
cervical cytology before initiating hormonal
contraception.
• The prospect of such an examination may deter a
woman, especially an adolescent, from having a
clinical visit that could facilitate her use of a more
effective contraceptive method than those
available over the counter.
• Another common practice is requiring one medical
appointment to discuss initiation of a LARC method and a
second for placement of the device or requiring two visits to
perform and obtain results from sexually transmitted infection
testing.
• Clinicians are encouraged to initiate and place LARC in a single
visit as long as pregnancy may be reasonably excluded.
Sexually transmitted infection testing can occur on the same
day as LARC placement, and women do not require cervical
preparation for insertion.
• Insurer payment policies should support same-day provision
by providing appropriate payment and reimbursement for
multiple services performed during a single visit.
• Similarly, health care providers should encourage patients
initiating combined hormonal contraceptives to start on the
day of the medical visit .
The Initial Reproductive Health Visit
CO #598, May 2014
The initial visit for screening and the provision of reproductive
preventive health care services and guidance should take place
between the ages of 13 years and 15 years. The initial reproductive
health visit provides an excellent opportunity for the OB/GYN to
start a patient–physician relationship, build trust, and counsel
patients and parents regarding healthy behavior while dispelling
myths and fears. …A general exam, a visual breast exam, and
external pelvic examination may be indicated. However, an internal
pelvic examination generally is unnecessary during the initial
reproductive health visit, but may be appropriate if issues or
problems are discovered in the medical history.
Well woman: breast
• Although the value of a screening clinical breast
examination for women with a low prevalence of
breast cancer (eg, women aged 20–39 years) is not
clear, the College, ACS, and the National
Comprehensive Cancer Network continue to
recommend clinical breast examination for these
women every 1–3 years .
• All three organizations also recommend the teaching
of breast self-awareness and inquiry into medical
history and family history of risk factors for breast
disease.
No more breast exams? Probably
continue every 1-3 years unless there
is new evidence of benefit
Self- exam?
Self-awareness
Mammography debates
No more pap smears? Not as many
• Definitely fewer,
probably better
• Start later, stop earlier
• No paps after hyst in
most cases
• Why didn’t we study this
sooner?
No more pelvic exams? Wrong.
• Sound clinical judgment always must be the
guiding factor in determining when a pelvic
examination is indicated.
• The decision to receive an internal
examination can be left to the patient if she is
asymptomatic and has undergone a total
hysterectomy and BSO for
benign indications and has
no history of CIN 2 +
Who are Ob/Gyns and whom does ACOG serve?
ACOG
Is ACOG the advocate
for women’s health
providers?
Or is ACOG the
advocate for
women’s health?
COs and PBs are available at acog.org
• Practice bulletins:
– Management of Abnormal Cervical Cancer Screening Test Results and
Cervical Cancer Precursors PB 140 2013
• Committee opinions:
– The Well Woman Visit.CO 534, August 2012 reaffirmed 2014
– Over-the-Counter Access to Oral Contraceptives
CO 544: December 2012
• Riley et al. Health maintenance in women. Am Fam
Physician. 2013 Jan 1;87(1):30-37.
• Nguyen et al. The Annual Pelvic Examination: Preventive Time
Not Well Spent. Am Fam physician. 2013 Jan 1;87(1):8-9

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