(Maigh/Flickr)

First, let’s review. We’ve been getting a lot of updates to cancer screening tests lately.

Pap Smears, a screening test for cervical cancer, were recommended to be done annually, until a group of experts in prevention concluded that every three years was equally effective. Most medical groups, including the American Cancer Society, agree on this one.

Then there’s mammography. I think everyone knows the debate around that. Every year or every other year? Starting at 40? or 50? The evidence points to every two years after age 50, although many doctors maintain younger and more often is better.

But this latest one — about pelvic exams — caught me by surprise. It turns out there’s really not a whole lot of evidence that doing an annual pelvic exam makes any difference to a healthy woman’s continuing good health. (Again, we’re stressing healthy women. Women having symptoms are definitely candidates for a pelvic exam).

Here’s what the American College of Obstetricians and Gynecologists (ACOG) says about the pelvic exam, after recommending it be done annually:

No evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient. An annual pelvic examination seems logical, but also lacks data to support a specific time frame or frequency of such examinations.

Just take a minute with that. Women get them annually, even though we “lack data” that they do much for us.

Then there’s the “bi-manual exam” part of the pelvic exam. That’s where a doctor palpates a woman’s ovaries, in part to screen for ovarian cancer. But ACOG writes that the test has “low sensitivity” for finding masses in the ovaries.

Still with me? Anyone wondering why women are getting a bi-manual exam every year?

None of this should be news to doctors. But a new survey from UCSF shows that it is. Researchers surveyed 521 OB/GYNS across the country to assess why doctors were doing the exam. Nearly all doctors surveyed said they would perform the bi-manual screen on healthy, asymptomatic women. And here’s the kicker: nearly half said they were performing the bi-manual exam to screen for ovarian cancer.

Professor Jillian Henderson performed the research while at UCSF. (She’s now at the Kaiser Permanente Center for Health Research in Portland.) “We think we’re getting the exam to be told that everything’s OK,” she told me in an interview. “But if it’s not good at detecting one of the main cancers that we think that it’s telling us we’re OK about, we’re falsely reassured.”

There were other caveats too. In the survey researchers asked doctors about varying types of patients, including 18-year-olds. ACOG recommends the bi-manual exam start at age 21, but 87 percent of doctors surveyed said they would perform the exam on the 18-year-old.

Henderson was also troubled that some doctors said they would also require a woman who wanted the birth control pill to have a pelvic exam, again, despite guidelines that say it is not necessary. This creates a barrier to accessing birth control.

Henderson was clear that their survey was not all encompassing, pointing out that there may be reasons for the annual checkup that were not captured in the survey. “Sometimes women want to talk to a specialist about the reproductive organs and body and sexual health,” she said.

In fairness to doctors, about 80 percent of respondents said that patients expected the test. Women probably do, pointing out that we need more information. “We need to understand a little more about what women gain from this exam and whether they really want to have this exam,” Henderson says, “even if it doesn’t have a strong role in preventing cancer.”

On a different note, about half of doctors said it was important to do the test to “ensure adequate compensation.” But this is not necessarily about greed, it’s also a reality of the way health care is reimbursed in this country. “We have a health care system that funds the examinations you conduct,” Henderson said. “I think we do need to shift toward looking at ways to fund women’s contacts with health care providers that they value highly even if it’s just discussions that are taking place.”

While we’re waiting for that to happen, you might want to talk with your doctor if you don’t feel a need to have the bi-manual exam or any other part of the pelvic examination.

Learn More

Questioning the Pelvic Exam (New York Times)

The California HealthCare Foundation issued a new report on cancer in the state. (Flickr: briannaorg)

More than a million Californians are living with cancer, and a new report from the California HealthCare Foundation (CHCF) takes a look at how the disease has affected the population over time.

Stephanie Teleki, senior program officer at CHCF, says some of the most welcome news is about childhood cancers. While the likelihood of a child developing cancer has crept up, the rate of children in the state who die from cancer each year has decreased 21% over the last two decades.

Overall — looking at kids and adults — cancer mortality rates have fallen 22 percent since 1989 and rates of new cancer diagnoses have dropped 9 percent.

On the more sobering side, the report found persistent disparities across race. For instance the mortality rates in California for African Americans were 30 percent to 90 percent higher than in other groups for all cancers. And despite the fact that whites are more likely to be diagnosed with breast cancer, African Americans’ death rate from the disease is 40 percent higher. The inequity holds for prostate cancer, too: black men are two times more likely to die from that disease than whites.

The survey also looked at end of life care and cancer. CHCF took up the general issue of end-of-life care earlier in the year with a survey. The report showed that while 70 percent of Californians want to die at home, only 32 percent actually do so. Most Californians die in a hospital or nursing home.

Teleki says that has disturbing implications for cancer care in the state.

“Obviously the fact that California is 44th in the nation in the use of hospice care for cancer patients is very concerning,” she says. “We’re underutilizing end-of-life care — and especially hospice care — for cancer patients.”

Yet despite all the numbers in the new report, Teleki says it was very hard to find data for the report about cost and quality of cancer care in California.

“The California Cancer Registry is one of the most highly regarded state registries … so it is doing a great job doing what it was designed to do, which is be a public health surveillance tool,” says Teleki. “When it was created we were living in a different era. Now fast forward 20, 30, 40 years, we’re now very focused on quality measurement, transparency those kinds of things and that database wasn’t designed to do that.”

Teleki says an all-payer claims database (APCD) is one tool that the state could implement to start collecting information on cost and treatments. These so-called “rich datasets” would include information from people who have employer-based health insurance, Medicaid, Medicare or are uninsured. On the treatment side, it would include everything from inpatient care to outpatient care; medical and dental treatments.

States that have all-payer claims databases include Utah, Tennessee, Minnesota and Maine. Colorado is launching one this fall.

This post has been changed to reflect an update in the CHCF’s numbers regarding childhood cancer mortality.