Recently, the American College of Physicians (ACP) released a statement on its website with the headline “American College of Physicians recommends against screening pelvic examination in adult, asymptomatic, average risk, non-pregnant women.” After a systematic review of previously published research from 1946 to January 2014 apparently showed that when it comes to the manual pelvic exam, the risks outweigh the benefits, the ACP published new clinical practice guidelines in the Annals of Internal Medicine. Coauthor Linda Humphrey, MD, FACP, stated “Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost.” The ACP further indicated that “the pelvic exam is appropriate for women with symptoms such as vaginal discharge, abnormal bleeding, pain, urinary problems, or sexual dysfunction.”1 The ACP statement was reported on the internet under the headline “Pelvic exam not needed for all women: US doctors’ group,”2 creating a buzz in the ovarian cancer patient community. I and many others are aware of a number of survivors whose ovarian cancer either was discovered or became an issue for further testing with CT scan or transvaginal ultrasound based on the results of a pelvic/rectal examination even without any subtle suggestive symptoms. Without a screening test for the early detection of ovarian cancer, the pelvic/rectal exam is the only procedure we presently have to assist in diagnosing this most lethal gynecologic cancer at an early stage. Currently, the overall 5-year survival rate for ovarian cancer is dismal—only 44%—as most women are diagnosed at stage III or IV after the cancer has metastasized, and most will face recurrences, eventually succumbing to this disease; however, the overall 5-year survival rate increases to over 90% if the cancer is detected early at stage I disease!3 Some women are aware, but, unfortunately, at the present time most are not aware that they are at a higher risk due to family medical history or other factors. My concern is that this ACP statement will encourage women to make the decision to pass on this important component of the annual gynecologic checkup. It seems the term “average risk” can often be misinterpreted. The ovarian cancer patient community would prefer to see a clarification as to what the term “average risk” means for the general public. We would also welcome assistance to increase awareness by listing the accepted common symptoms and risk factors for ovarian cancer to ensure that forgoing the pelvic exam does not become the sweeping norm for all women. Symptoms listed in the ACP statement that can be related to ovarian cancer in particular include pain, urinary problems, abnormal bleeding (most often for uterine cancer but can be a symptom for some subtypes of ovarian cancer), and sexual dysfunction1; other generally accepted symptoms include bloating, difficulty eating, or feeling full quickly.4 With all the increased emphasis on genetic mutations and family medical history, it is known that a woman with a family medical history of ovarian, uterine, or colon cancer or personal history of breast cancer is at an increased lifetime risk for ovarian cancer. The BRCA1 and BRCA2 genetic mutations are being publicized and addressed more often, and researchers are working diligently to identify other genetic mutations in the fight against this deadly disease. On June 30, 2014, the American College of Obstetricians and Gyne-cologists (ACOG) issued an opinion5 in regard to the ACP’s statement: The American College of Obstetricians and Gynecologists (The College) has reviewed the recommendations from the American College of Physicians about annual pelvic examinations and continues to stand by its guidelines, which complement those released recently by the ACP. The College’s guidelines, which were detailed in this year’s Committee Opinion on the Well-Woman 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....While not evidence-based, 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. In addition, the ACOG Committee Opinion #477, March 2011, The Role of the Obstetrician-Gynecologist in the Early Detection of Epithelial Ovarian Cancer,6 states: Women with persistent and progressive symptoms, such as an increase in bloating, pelvic or abdominal pain, or difficulty eating or feeling full quickly, should be evaluated, with ovarian cancer being included in the differential diagnosis. Evaluation of the symptomatic patient includes physical examination and may include transvaginal ultrasonography and measurement of levels of the serum tumor marker CA 125. Patients suspected of having ovarian cancer should be managed by a gynecologic surgeon, such as a gynecologic oncologist, who is trained to perform comprehensive surgical staging and cytoreductive (debulking) surgery. Currently, it appears that the best way to detect ovarian cancer is for both the patient and her clinician to have a high index of suspicion of the diagnosis in symptomatic women. This requires education of both as to the symptoms commonly associated with ovarian cancer [author underlined]. Persistent and progressive symptoms such as an increase in bloating, pelvic or abdominal pain, or difficulty eating or feeling full quickly, should be evaluated, with ovarian cancer being included in the differential diagnosis. In evaluating these symptoms, physicians should perform a physical examination, including a pelvic examination. A rectovaginal examination may provide additional information. Imaging studies, especially transvaginal ultrasonography, may be helpful in recognizing increased ovarian size or morphologic changes associated with ovarian cancer. For this article, I also contacted a highly respected gynecologic oncologist, Robert A. Burger, MD, Director of Clinical Research and Fellowship Program in Gynecologic Oncology and Professor of Obstetrics and Gynecology at the Hospital of the University of Pennsylvania for a comment. He stated, “In my opinion, the diagnosis of ovarian cancer can be greatly facilitated by proper physical assessment, including combined rectal-vaginal-abdominal examination.” The outreach programs of my organization, Ovarian Cancer Alliance of San Diego (www.ocaofsd.org), are designed with the goal of increasing awareness among both the medical community and general public as to the symptoms and risk factors of ovarian cancer in order to promote the early detection of this disease. We strongly support ACOG’s Committee Opinion and recommendation that the performance of a pelvic examination be discussed and a shared decision reached between healthcare provider and patient, based on the patient’s individual needs, requests, and preferences. We are committed to our efforts, as well as to those of other organizations across the country, to empower women to be informed and involved in their healthcare. We also encourage all healthcare providers to think of ovarian cancer first, not last, in their differential diagnosis to save more women’s lives. Because I am a firm believer in evidence-based medicine, I would also advocate for a clinical trial to be designed and/or a systematic review to be conducted that would focus on patients with ovarian cancer to ascertain the benefit of pelvic and/or rectal examinations in the diagnosis of ovarian cancer, with an emphasis on possible early detection.
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