Cut the Clutter in Gynaecological Cancer Diagnosis

Medscape

3 days ago

More than 60% of patients with cervical cancer and 30% of those with endometrial cancer are diagnosed at an advanced stage, when survival rates are lowest. Although intensifying screening may seem logical, unnecessary procedures can be harmful.
Routine procedures such as ultrasound, though often considered harmless, can lead to poorly indicated hysteroscopies and unnecessary biopsies, causing physical and psychological discomfort, warned Louise De Brot, MD, PhD, in the Department of Pathology, São Paulo, Brazil.
Therefore, prevention does not require as many clinical tests.
'The real challenge is applying screening to the population that will actually benefit from it,' explained Eduardo Batista Cândido, MD, PhD, president of the National Specialized Commission on Gynecologic Oncology of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO).
This is the principle behind quaternary prevention, which avoids unnecessary medical interventions that may cause more harm than good. However, this can be challenging for healthcare professionals who lack confidence. Studies have shown that less experienced doctors, particularly those with less than 10 years of practice, are more likely to prescribe unnecessary tests, leading to higher costs for patients.
Cervical Screening
International and Brazilian guidelines, such as those from the Ministry of Health and the National Cancer Institute, recommend cervical cancer screening using oncotic cytology in women aged 25-64 years who are sexually active. After two consecutive normal results, screening may be repeated every 3 years.
In women aged under 25 years, human papillomavirus infections are often cleared without progressing to malignant disease. Cândido stated that 'If I identify a cellular alteration, I will have to perform a colposcopy, a targeted biopsy, and sometimes a mutilating procedure, such as high-frequency surgery, and this will have deleterious effects on the patient's health, without any benefit.'
In the Unified Health System, oncotic cytology has been replaced by the human papillomavirus DNA test, a genomic test designed to identify viral subtypes 16 and 18, which are responsible for 70% of cervical cancer precursor lesions.
In addition to its high specificity, the test can be performed every 5 years.
Andréia Gadelha, MD, a clinical oncologist and president of the Brazilian Group of Gynaecological Tumours, explained that patients who test positive should be closely monitored.
It is important to perform diagnostic tests and assess their clinical relevance. Therefore, continuing the screening of older patients is often not beneficial for the patients. According to Louise, these patients may no longer be candidates for curative treatments.
Other Cancers
Although screening strategies for cervical cancer are well established, other types of gynaecologic cancers require a different approach. Ovarian and endometrial cancers should not be routinely screened in asymptomatic women without a family history of the disease. 'There is no evidence that imaging tests reduce mortality from a population perspective,' said Cândido.
In these cases, imaging tests are not screening tools but serve as diagnostic aids when symptoms are present. 'If the patient has postmenopausal bleeding and endometrial thickening detected by ultrasound, the next step is to obtain a sample of the endometrium by biopsy,' explained Cândido.
'There's no need for an immediate biopsy if the lesion has completely benign characteristics and remains stable over time, if the complementary tests are reassuring, and if the patient is asymptomatic and at low epidemiological risk,' added Gadelha.
According to the gynaecologic oncologist, further investigation is warranted in cases involving a complex mass or abnormal vascularisation, persistent bleeding with endometrial thickening, high-grade cytology or glandular atypia, growth of an adnexal mass, or elevated biomarkers with suspicious findings.
'Early detection is beneficial when it improves the prognosis without causing unnecessary harm. This means selecting patients with relevant risk factors and avoiding screening in low-risk populations,' explained Gadelha, reinforcing that clinical practice must be based on updated evidence and recommendations.