Month: January 2023

Should a woman consider having her fallopian tubes removed to lower her risk for developing ovarian cancer? Recent recommendations from the Ovarian Cancer Research Alliance (OCRA), endorsed by the Society for Gynecologic Oncology, encourage this strategy, if women are finished having children and would be undergoing gynecologic surgery anyway for other reasons.

Why is this new guidance being offered?

Ovarian cancer claims about 13,000 lives each year, according to the American Cancer Society. The new guidance builds on established advice for women with high-risk genetic mutations or a strong family history of ovarian cancer.

This idea isn’t new for women at average risk for ovarian cancer, either: in 2019, the American College of Obstetricians and Gynecologists (ACOG) floated this strategy in a committee opinion.

A Harvard expert agrees the approach is sound, considering established evidence that many cases of aggressive ovarian cancers arise from cells in the fallopian tubes.

“We’ve known for a long time that many hereditary cases of ovarian cancer likely originate in lesions in the fallopian tubes,” says Dr. Katharine Esselen, a gynecologic oncologist at Beth Israel Deaconess Medical Center. “Although we group all of these cancers together and call them ovarian cancer, a lot actually start in the fallopian tubes.”

Can ovarian cancer be detected early through symptoms or screening?

No — which helps fuel these recommendations.

Ovarian cancer is notoriously difficult to detect. Symptoms tend to be vague and could be related to many other health problems. Signs include bloating, pelvic pain or discomfort, changes in bowel or bladder habits, feeling full earlier when eating, fatigue, unusual discharge or bleeding, and pain during sex.

Disappointing results from a large 2021 study in the United Kingdom reported in The Lancet show that lowering the risks of a late-stage diagnosis isn’t easy. The trial tracked more than 200,000 women for an average of 16 years. It found that screening average-risk women with ultrasound and a CA-125 blood test doesn’t reduce deaths from the disease. By itself, the CA-125 blood test isn’t considered reliable for screening because it’s not accurate or sensitive enough to detect ovarian cancer.

Only 10% to 20% of patients are diagnosed at early stages of ovarian cancer, before a tumor spreads, Dr. Esselen notes. “There’s never been a combination of screenings that has reliably identified the majority of these cancers early, when they’re more treatable,” she says.

What does it mean to be at higher risk for ovarian cancer?

Family history is the top risk factor for the disease, which is diagnosed in nearly 20,000 American women annually. A woman is considered at higher risk of ovarian cancer if her mother, sister, grandmother, aunt, or daughter has had the disease.

Additionally, inherited mutations in the BRCA1 or BRCA2 gene raise risk considerably, according to the National Cancer Institute. (These mutations are more common among certain groups, including people of Ashkenazi Jewish heritage.) While about 1.2% of women overall will develop ovarian cancer in their lifetime, up to 17% of those with a BRCA2 mutation and up to 44% with a BRCA1 mutation will do so by ages 70 to 80.

How much can surgery lower the odds of ovarian cancer?

It’s not clear that all women — even those not scheduled for surgery — should undergo removal of their fallopian tubes to reduce this risk once they finish having children, Dr. Esselen says. This surgery can’t totally eliminate the possibility of ovarian cancer — and surgery carries its own risks. She recommends discussing options with your doctor depending on your level of risk for this disease:

For those at average risk for ovarian cancer: Available data seem to support the idea of removing the fallopian tubes. Studies of women who underwent tubal ligation (“tying the tubes”) or removal to avoid future pregnancies indicate their future risks of ovarian cancer dropped by 25% to 65% compared to their peers. And if a woman is already undergoing gynecologic surgery, such as a hysterectomy, the potential benefits likely outweigh the risks.

Before menopause, removing the fallopian tubes while leaving the ovaries in place is preferable to removing both. That’s because estrogen produced by the ovaries can help protect against health problems such as cardiovascular disease and osteoporosis. Leaving the ovaries also prevents suddenly experiencing symptoms of menopause.

“The fallopian tubes don’t produce any hormones and aren’t really needed for anything other than transporting the egg,” she says. “So there’s little downside to removing them at the time of another gynecologic procedure if a woman is no longer interested in fertility.”

For those at high risk for ovarian cancer: “In a world where we don’t have good screening tools for ovarian cancer, it makes sense to do something as dramatic as surgery to remove both ovaries and fallopian tubes when a woman is known to be at higher risk because of a strong family history or a BRCA gene mutations,” Dr. Esselen says.

Currently, preliminary evidence suggests it may be safe to proactively remove the fallopian tubes while delaying removal of the ovaries to closer to the time of menopause to avoid an early menopause. However, it’s unclear how much this procedure lowers the odds of developing ovarian cancer.

“Generally, the findings so far have focused on the safety of the surgery itself and women’s quality of life,” Dr. Esselen says. “Long-term data in high-risk women takes a great number of years to accumulate. We need this data to know whether removing the fallopian tubes alone is equally effective in preventing ovarian cancer as removing the tubes and ovaries.”

Discussing your options is key

Ultimately, Dr. Esselen says that she advocates OCRA’s new recommendations. “For anyone who’s completed childbearing, if I’m doing surgery that wouldn’t necessarily include routinely removing their fallopian tubes, I’m offering it,” she says. “A woman and her doctor should always discuss this at the time she’s having gynecologic surgery.”

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

Screening tests, such as Pap smears or blood pressure checks, could save your life. They can detect a disease you have no reason to suspect is there. Early detection may allow treatment while a health condition is curable and before irreversible complications arise.

Some screening tests help prevent the disease they are designed to detect. For example, colonoscopies and Pap smears can identify precancerous abnormalities that can be addressed so they cannot continue to grow and become cancerous. And missed screening tests contribute to thousands of avoidable deaths each year in the US. Yet there’s a point of diminishing returns, as a new study on Pap smears illustrates. And many of us could benefit from a better understanding of the limits of screening, and how experts decide when people should stop routine screening tests.

Know the limits of screening tests

Even the best screening test has limitations. It can miss the disease it’s intended to detect (false-negative results). Or it can return abnormal results when no disease is present (false-positive results).

Equally important, as people grow older life expectancy declines and screening benefits tend to wane. Many conditions detected by routine screenings, such as prostate cancer or cervical cancer, typically take a while to cause trouble. A person in their 80s is more likely to die from another fatal condition before cervical cancer or prostate cancer would affect their health. Additionally, certain diseases, such as cervical cancer, become less common with advancing age.

As a result, many screening tests are not recommended forever: at some point in your life, your doctor may tell you that you no longer need to repeat a screening test, even one you finally got used to having.

Know when screening tests usually end

Expert guidelines for many common screening tests include an “end age” when people can reasonably stop having the test. For example:

• Pap smear: age 65
• mammogram: age 75
• colonoscopy: age 75
• chest CT scan (recommended for people with a significant smoking history): age 80.

There are exceptions, of course. For example, if a colonoscopy found abnormalities in an otherwise healthy 72-year-old, repeat testing after age 75 may be recommended.

Many women have Pap smears after guidelines suggest stopping

Pap smears screen for cervical cancer. In 1996, new guidelines recommended that women who received Pap smears at appropriate intervals before age 65 could safely stop.

Yet many women continue to have this screening after turning 65, according to a recent study published in JAMA Internal Medicine that looked at data from 15 to 16 million women per year between 1999 and 2019. Their average age was 76, most (82%) were white, and all were enrolled in Medicare.

The study found:

• In 1999, nearly three million women over age 65 (almost 19% of the study population) had Pap smears. By 2019, the number had fallen to 1.3 million (8.5%), a reduction of more than half.
• Among women older than age 80, about 3% had Pap smears.
• In 2019, the estimated cost related to Pap smears in these older women was $83.5 million.

Possibly, some women in this study had good reasons to continue having Pap smears. Perhaps they weren’t adequately screened when they were younger. Perhaps they had previous Pap smear abnormalities. Maybe their doctors recommended they continue having Pap smears despite their advanced age. We don’t know, because this study didn’t collect that information. Still, it’s quite likely that many (or even most) of these Pap smears represent overscreening: routine testing with little chance of benefit.

Why does overscreening matter?

Overscreening may cause

• discomfort that may be tolerable when there’s an expectation of benefit, but less acceptable when the test is unnecessary
• anxiety while awaiting the results of the test
• false-positive results that lead to additional testing and unnecessary treatment
• complications of testing, such as infection or bleeding after a Pap smear, or perforation or bleeding after a colonoscopy. (Fortunately, complications are rare.)
• unnecessary costs, including medical appointments and lab fees, time wasted, and taking health providers away from more valuable care.

The bottom line

Screening tests are typically performed for people without symptoms, signs, or a high suspicion of disease. In many cases, they’re looking for a condition that is probably not there. For most screening tests, we have guidelines developed by experts and backed by data suggesting when to start — and when to stop — screening.

But guidelines are only general recommendations, and individual preferences matter. If foregoing a screening test will cause you excessive anxiety, or if having a test will provide significant peace of mind, it may be reasonable to have a test even after the recommended end age. Be sure you understand potential downsides, such as additional tests and complications.

So, never hesitate to ask your doctor when your next screening tests are due — but don’t forget to also ask if they are no longer worth having.

About the Author

Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD

Climate change is an escalating threat to the health of people everywhere. As emergency medicine physicians practicing in Australia and the United States, we — and our colleagues around the world — already see the impacts of climate change on those we treat.

Will we be seeing you one day soon? Hopefully not. Yet an ever-growing number of us will face climate-related emergencies, such as flooding, fires, and extreme weather. And all of us can actively prepare to protect health when the need arises. Here’s what to know and do.

How is climate change affecting health?

As the planet warms, people are seeking emergency medical care for a range of climate-related health problems, such as heat exhaustion and heat stroke, asthma due to air pollution, and infectious diseases related to flooding and shifting biomes that prompt ticks, mosquitoes, and other pests to relocate. News headlines frequently spotlight physical and emotional trauma stemming from hurricanes, wildfires, tornadoes, and floods.

We care for people displaced from their homes and their communities by extreme weather events. Many suddenly lack access to their usual medical team members and pharmacies, sometimes for significant periods of time. The toll of extreme weather often lands hardest on people who are homeless, those with complex medical conditions, children, the elderly, people with disabilities, minoritized groups, and those who live in poorer communities.

On a recent 110º Fahrenheit day, for example, a woman came to an emergency department in Adelaide, Australia complaining of a headache, fatigue, and nausea, all symptoms of heat exhaustion. She told medical staff that she had just walked for two hours in the sun to obtain groceries, as she had no car or access to public transportation. While health advisories in the media that day had advised her to stay inside in air conditioning, walking outside was only the only option she had to feed her family. For this woman and many others, well-intended public health warnings do little to reduce the risk of illness during extreme weather. Achieving safe, equitable health outcomes will require addressing access to shelter, access to transportation, and other societal factors that put people at risk of bad health outcomes.

Extreme weather contributes to large-scale health and safety issues

Increasingly, climate-related extreme weather is leading to interrupted access to medical care, contributing to later illness and death. Extreme weather can damage key infrastructure like the electrical grid, so that those relying on home medical equipment cannot use it. It may shut down health care facilities like a dialysis center or emergency room, or slow care in facilities that stay open.

People fleeing a fire or hurricane can be displaced into settings where they may have difficulty getting medical care or obtaining much-needed medicine, such as insulin, dialysis, high blood pressure treatments, and heart medicines. Such factors can worsen chronic conditions and may even cause death, particularly in people with existing medical conditions like heart failure, lung disease, and kidney disease.

How can you be ready to protect your health?

We all have a part to play in keeping ourselves and our communities well in the face of increasing dangers from climate change. Taking these steps will help.

If you or a loved one has health issues:

• Keep a printed summary handy listing all medical conditions, medications and dosages, and phone numbers for your health providers.
• If you have to leave your home, try to bring all medications with you — even bringing empty pill bottles will help a doctor trying to restart your medications.
• Store medicines in a waterproof bag in a place where you can easily find them. This will help if you need to evacuate quickly.

Think about what to do if you need to leave home quickly. Now is the time to figure out your basic emergency plan:

• Where will you go if you need to evacuate?
• How will you get there?
• How could you communicate with others if there is no electricity or phone service?
• Do you have written contact info for a few family members and friends, in case you lose your phone or the battery dies?

Finally, we all need to look out for others in our community. Check in on elderly neighbors and those around you who may be socially disconnected, and make sure that they are safe where they live and are able to access the medical care they may need when the weather turns hot, cold, smoky, fiery, snowy, wet, or windy.

Climate change is here. It is already having tangible and significant impacts on our communities and the health of people around the world. Moreover, the increased risk of climate-related extreme weather is here to stay for the foreseeable future, and we must prepare for the threats it poses to our health, both now and in decades to come. We all have a part to play — health professionals, communities, and individuals — in keeping ourselves and each other healthy and safe.

About the Authors

Kimberly Humphrey, MD, MPH, Contributor

Dr. Kimberly Humphrey is an emergency physician, a current Fellow in Climate Change and Human Health at Harvard C-CHANGE at Harvard's T.H. Chan School of Public Health, and a visiting scholar at the Harvard FXB Center. Her research focuses on the … See Full Bio View all posts by Kimberly Humphrey, MD, MPH

Caleb Dresser, MD, MPH, Contributor

Dr. Caleb Dresser is an emergency physician and assistant director of the Climate and Human Health Fellowship, cohosted by Beth Israel Deaconess Medical Center, the Harvard FXB Center, and Harvard C-CHANGE. His research focuses on understanding the health implications of climate-related … See Full Bio View all posts by Caleb Dresser, MD, MPH