ovarian cancer screening :
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OVARIAN CANCER SCREENING :. Edward J. Pavlik University of Kentucky Ovarian Cancer Screening Research Program July 26, 2011. CANCER SCREENING: Definitions. - PowerPoint PPT PresentationTRANSCRIPT
OVARIAN CANCER SCREENING:
Edward J. Pavlik University of Kentucky
Ovarian Cancer Screening Research
ProgramJuly 26, 2011
CANCER SCREENING:Definitions Cancer Screening: The act of testing for a
condition in a population that is presumed to be asymptomatic when detection will result in the possibility of cure or extending life.Predicting disease is present before it is evident.
Cancer Diagnostic Workup: The act(s) of testing when clinical evidence or symptoms indicate that a condition is present and cancer must be ruled out as an explanation for this condition.
Perspectives --- Ovarian Screening
1. What are current perceptions about screening?
2. Why screen for ovarian cancer?
3. How good is transvaginal ultrasound screening?
4. What do women want?
5. What about costs?
Perceptions --- Screening
What are current perceptions about screening?
What do we mean by “perceptions?”
Perspectives --- Ovarian Screening What are current perceptions about ovarian
screening?
My doctor does it
The PAP test does it
I don’t need it
I don’t want to talk about it
It doesn’t work
My insurance doesn’t pay for it
My doctor didn’t tell me about it
The Holy Grail: distinguishing benign from malignant ovarian tumors with precision high enough and cost low enough to please everyone: the Kentucky ovarian cancer screening experience with 37,200+ women and 230,000+ screens.
Perspectives --- Ovarian Screening
Why screen for ovarian cancer?
UK Ovarian Screening Program
Ovarian Screening Video
Perspectives --- Ovarian Screening
How good is transvaginal ultrasound screening?
#3. TVS vs Pelvic Exam
Ueland, DePriest, DeSimone, Pavlik, Lele, Kryscio, van Nagell JR Jr. The accuracy of examination under anesthesia and transvaginal sonography in evaluating ovarian size. Gynecol Oncol. 2005 Nov;99(2):400-3.
TVS is significantly more accurate (p< 0.001)
Detection TVS PE N =
Overall 85% 44% 289
> 55 yrs 74% 30% 88
> 200 lbs 73% 9% 66
> 200 gram ut 80% 16% 74
#4. Performance: TVS vs Mammography
van Nagell JR Jr, DePriest PD, Ueland FR, DeSimone CP, Cooper AL, McDonald, JM, Pavlik EJ, Kryscio RK. Ovarian Cancer Screening With Annual Transvaginal Sonography. Cancer 2007; 109: 1887-1196
TVS Mammography Mammography US
MRI
Sensitivity 86.4% 27.6 - 89% 27.6, 35.3, 36.1, 54.1 %
71 - 91%
Specificity 98.8% 90.2 - 99.4% 94, 96.2, 99.4 86 - 91%
PPV 14.5-24.2%
13% NA 21 - 33%
NPV 99.97% NA NA 99 - 100%
N = 37293 1,234,962 1,029,894 969
Humphrey LL, Hefland M, Chan BKS, Woolf, SH. Breast Cancer Screening: A Summary of the Evidencefor the U.S. Preventive Services Task Force. Annals of Internal Med. 137: E347, 2002 (Multi-study report)
Lehman CD, Gatsonis C, Kuhl CK, Hendrick RE, Pisano ED, Hanna L, Peacock S, Smazal SF, Maki DD, Julian TB, DePeri ER, Bluemke DA, Schnall MD. MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer. N. Engl. J. Med. 2007; 356:1295
Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA 293: 1245, 2005
TVS performs similarly to mammography & MRI
TVS screening results in improved survival
#4. Performance: TVS vs Mammography
Perspectives --- Ovarian Screening
What do women want?
#2 What Women Wanthttp://ovarianscreening.info
I realize that the risk of ovarian cancer is a lot lower than breast cancer and I:A. Feel that ovarian cancer is still a concern or threat to me 647 = 97% B. Feel that my chances of getting ovarian cancer are too low to be concerned with. 22 = 3% When I am near or at age 50, I feel strongly that I would:1. Probably be undecided about ovarian cancer screening 10 = 2% 2. NOT want to participate in ovarian cancer screening 5 = 1% 3. Might consider ovarian cancer screening 91 = 18% 4. Would definitely want to participate in ovarian cancer screening 413 = 80%
#2 What Women Wanthttp://ovarianscreening.info
For what I am paying for medical insurance, my insurance should:1. Pay for ovarian screening no matter what the cost
488 = 70% 2. Pay up to $500 for ovarian screening 50 = 7% 3. Pay up to $250 for ovarian screening 44 = 6% 4. Pay up to $150 for ovarian screening 48 = 7% 5. Pay up to $100 for ovarian screening 25 = 4% 6. Pay up to $50 for ovarian screening 13 = 2% 7. Not pay for ovarian screening 27 = 4%
#2 What Women Wanthttp://ovarianscreening.info
If my medical insurance would NOT pay for ovarian cancer screening, I consider the risk of ovarian cancer to be sufficient to pay for screening out of my own pocket so that I might:
1. Pay for ovarian screening no matter what the cost 162 = 23%2. Pay up to $500 for ovarian screening 56 = 8% 3. Pay up to $250 for ovarian screening 100 =
14% 4. Pay up to $150 for ovarian screening 131 = 19% 5. Pay up to $100 for ovarian screening 122 = 18% 6. Pay up to $50 for ovarian screening 110 =
16% 7. I do not consider the risk of ovarian cancer to be worth paying for
screening myself or would never pay for anything that my medical
insurance would not pay for. 12 = 2%
Perspectives --- Ovarian Screening
What about costs?
#5. Cost & Number of Recovered Screens
* Current Women’s Health Reviews 5, 44-50 (2009)**Pavlik EJ, van Nagell JR Jr, DePriest PD, Wheeler L, Tatman JM, Boone M, Sollars S, Rayens MK, Kryscio RK. Participation in transvaginal ovarian cancer screening: compliance, correlation factors, and costs.Gynecol Oncol. 1995 Jun;57(3):395-400
SR: “Screens Recovered” at $25**/screen
Stage IIIC
$-Collections(All)
SR/IIIC case
$- Collections(Chemotherapy)
SR
N = 25* 25
Mean + SEM
$92100 + 10280 3684 $14675 + 1903 587
Median $80200 3208 $13102 524
Highest $239600 9584 $40838 1634
Over 2000 screens can be paid for by preventing a single IIIc cancer and over 500 screens by chemotherapy alone!
#5. Costs & Screens
ASSUMPTION: IIIC expense is if all 68 detected malignancies progressed to IIIC.
Stage IIIC $-Collections [A]
Per case
IIIC Expense
[B] = 68 x [A]
Screen Equivalents
[C] = [B]/$25
N = 25 $25/screen
Mean + SEM
$92100 + 10280 $6,262,800 250,512 screens
Median $80200 $5,453,600 218,144 screens
Highest $239600 $16,292,800 651,712 screens
Cases that can be stopped from progressing to a IIIC expense can pay for a large number of TVS screens.
Cost of Chemotherapy & ScreeningChemotherapy Total Cost
Per caseScreen Equivalents @ $25
(x 51 cancers detected)
1 Carboplatin AUC 6 or 515 mg ($4511.40) + Paclitaxel 135 mg/m2 ($5148.00)
$9659 386 (19704)
2 Taxotere 75 mg/m2] $11644 466 (23754)3 Doxil 40 mg/m2 $8730 349 (17809)4 Cytoxan 50 mg po qd $699 28 (1426)5 Cytoxan 50 mg po qd ($699.10) +
Avastin 15 mg/kg ($140646.00)$141345 5654 (288344)
6 Gemzar 800 mg/m2 $8345 334 (1702)7 Gemzar 800 mg/m2 ($8344.80) +
Taxotere 75 mg/m2 ($11643.75)$19989 800 (40778)
8 Cisplatin 50 mg/m2 $1868 75 (3811)9 Cisplatin 50 mg/m2 ($1867.50)
+ Paclitaxel 135 mg/m2 ($4290.00) $6158 246 (12562)
10 Intraperitoneal:Paclitaxel 135 mg/m2 ($5148.00) + Cisplatin 100 mg/m2 ($4482.00) + Paclitaxel 60 mg/m2 ($2376.00)
$12006 480 (24492)
11 Topotecan 1.0 mg.m2 $9788 392 (19968)
#5. Costs & Relativity
$25/screen is within the Co-Pay
#5. Costs & Relativity
$25/screen is less than Styling
Summary of Perspectives 1. Women want ovarian screening
2. TVS outperforms manual PE
3. TVS performs as well as mammography
4. TVS ovarian screening has reasonable cost
Ovarian Cancer
2011: 21,990 new cases/yr; 2011: 15,460 deaths
Fifth leading cause of cancer death among women
Leading cause of death among gynecologic malignancies
5 yr survival: Stage I - ~ 90% Stage III/IV - 20%
Prevalence- 50/100,00 in women > 50 yrs. 75% cases diagnosed with advanced disease
Delay in Diagnosis Retrospective review of 277 pts. On average patients sought medical attention 9
months after onset of symptoms On average patients received pelvic exam 9 months
after seeking medical attention Gilda Radner, Ella Grasso, Madeline Kahn, Liz
Tilberis, Cassandra Hanis-Brosnan, Coretta Scott King, Patsy Ramsey, Loretta Young, Dinah Shore, Jessica Tandy, Lauro Nyro, Joan Hackett, Dixie Lee, Rosalind Franklin (discoverer of DNA), Sandy Dennis; Bess Myerson & Carol Channing are survivors
Sackett, et. al., Clinical Epid., Boston: Little, Brown & Co., 1985http://en.wikipedia.org/wiki/Ovarian_cancer#Notable_victims_of_ovarian_cancerhttp://www.wect.com/Global/story.asp?S=5466000
Transvaginal Sonography (TVS)
Transvaginal Sonography (TVS)
Faces With A Future
Symptoms & Tests
Out of 100 women with symptoms, only 1 will have OvCa.Symptoms occur in women without OvCa 60-1500 times more than the incidence of OvCa.
OVA1 is an FDA-cleared blood test that uses results of 5 biomarkers, with an algorithm to indicate the probability of malignancy of an ovarian mass. It is not a screening or stand alone test.
Transvaginal Sonography (TVS)
Echos not degraded in air-space @ ovary
Easy to perform Well-accepted Relatively cost-effective (~$25/screen) Acceptable sensitivity
Unresolved Issues
Who should be screened? (Who decides?)
What is the optimal screening interval? What is the optimal screening
algorithm? How should the screening be done?
Disease Prevention Is Related To Education
“The one social factor that researchers agree is consistently linked to longer lives in every country where it has been studied is education. It is more is more important than race; it obliterates any effects of income.”
And, health economists say, those factors that are popularly believed to be crucial — money and health insurance, for example, pale in comparison.http://www.nytimes.com/ref/health/newage_index.html
Finding More InformationGoogled 07/21/2011
http://ovarianscreening.info
Women's Health Care - Ovarian Cancer Screening - UK HealthCareukhealthcare.uky.edu/WomensHealth/ovariancancer.aspFeb 4, 2010 – Early detection is vital to surviving ovarian cancer. The UK Markey Cancer Center Ovarian
Screening Program was started in 1987 and provides ...►
Ovarian Screening Programovarianscreening.info/Apr 4, 2011 – Free ovarian cancer screening for women is performed using transvaginal ultrasound as a
protocol to reduce mortality due to ovariancancer.
Ovarian Screening Programovarianscreening.info/Faceswithafuture.htmApr 4, 2011 – Ovarian Cancer. Screening Program. Ovarian Cancer ...
Ovarian Screening Memorials - Ovarian Screening Programovarianscreening.info/Memorials.htmlApr 4, 2011 – The Monroe County Extension Homemakers have initiated ...
Show more results from ovarianscreening.infoOvarian cancer screening : Cancer Research UK : CancerHelp UKcancerhelp.cancerresearchuk.org/.../ovarian.../ovari... - United KingdomNov 1, 2010 – Over the next 5 years the researchers in the study will look at whether an ovarian screening
programme using these tests could help to...
CANCER SCREENING:Science
First:Global Thoughts on Cancer Screening in general
Edward J. Pavlik, Director
University of Kentucky
Ovarian Cancer Screening Research Program
July 26, 2011
CANCER SCREENING:Definitions Cancer Screening: The act of testing for a
condition in a population that is presumed to be asymptomatic when detection will result in the possibility of cure or extending life.Predicting disease is present before it is evident.
Cancer Diagnostic Workup: The act(s) of testing when clinical evidence or symptoms indicate that a condition is present and cancer must be ruled out as an explanation for this condition.
Perception vs Preconception: What Is Reality?
Do you stop?
Do you slow down?
Do you speed up to get through before it turns red?
Perception vs Preconception: What Is Reality?
Colorado LawSTEADY YELLOW LIGHT: A red light is about to appear.Stop unless you are already within the intersection. Kentucky Law
STEADY YELLOW LIGHT means stop if you can do so safely. A vehicle mayclear an intersection on a red light, if the vehicle entered the intersection while the signal was yellow; but it is against the law to enter an intersection after the light turns red.
Ohio LawOhio LawSTEADY YELLOW LIGHT: clearance of vehicle within intersection.
Indiana LawIndiana LawSTEADY YELLOW LIGHT: means that the right-of-way is ending.
Perspective What Is Reality?
Is the glass half empty?
Is the glass half full?
What other quantitative relationship applies?
Perspective What Is Reality?
Are too few medical services provided in the USA?
Could more medical services be provided?
Are the number of medical services that could be provided too great for payer resources in the USA?
Screening = a medical service
Perspective What Is Reality?
What quantitative relationship applies?Is this a full cup?Is this a full half cup?
Is this a way of adjusting services (contents) to perception? (i.e. a consumer can get all the services a medical plan provides by restricting the plan)
Perspective What Is Reality?
Types of Service Plan Restrictions:1. Age eligibility2. Pre-existing conditions3. PSA & consequences4. Breast screening (40-50)
Ways of adjusting services
Perspective What Is Reality?
It ALL has to work!
Sometimes half isn’t good enough!
CANCER SCREENING:Definitions Cancer Screening: The act of testing for a
condition in a population that is presumed to be asymptomatic when detection will result in the possibility of cure or extending life.Predicting disease is present before it is evident.
Cancer Diagnostic Workup: The act(s) of testing when clinical evidence or symptoms indicate that a condition is present and cancer must be ruled out as an explanation for this condition.
CANCER SCREENING:Applications & Controversy
Ways of thinking about screening
Ask the assay
Find the cancer
CANCER SCREENING:Application
DO YOU KNOW WHO THIS IS?
CANCER SCREENING:Application
DO YOU KNOW WHO THIS IS?
CANCER SCREENING:Visual Bias / Context
CANCER SCREENING:Science
Visual Bias / Selective Attention ---1
Task Orientation & Awareness:
The Elephant In The Room
CANCER SCREENING:Visual Bias / Selective Attention ---1
Did you see Carmen Sandiego?
CANCER SCREENING:Science
Visual Bias / Selective Attention ---2
Task Orientation & Awareness:
Multiple Events
CANCER SCREENING:Science
Visual Bias / Selective Attention ---3
Task Orientation & Awareness:
Tracking Multiples
CANCER SCREENING:Science
Four Questions That Must Be Answered 1. How good is the test when disease is there?Ability to identify true disease = SensitivitySensitivity = TP/(TP+FN)
2. How good is the test when disease is not there?
Ability to identify the absence of disease= Specificity = TN/(TN+FP)
CANCER SCREENING:Science
Four Questions That Must Be Answered 3. How many of those that are positive really have the disease?% of positive subjects who have disease =
Positive Predictive Value = TP/(TP+FP) 4. How many of those that are negative really do not have the
disease?% of negative subjects who do not have the disease =
Negative Predictive Value = TN/(TN+FN)
CANCER SCREENING:Screened Population Features
1. Disease has a high enough Prevalence to justify screening
2. Medical care available if screening test is positive
3. Patient is willing & able to undergo further evaluation
CANCER SCREENING:
Role of Education What do you have to be able to do?
CANCER SCREENING:
Role of Education
What do you have to be able to do?