Ask the Doctor: July 2008

Question: I am 23 years old and my pap smear came back positive for HPV and had some abnormal cells. I am very worried about this. Can I still get the vaccine for HPV?

Answer: The vaccine for HPV (human papilloma virus) is marketed under the name Gardasil. When they studied the effectiveness of Gardasil before it was approved by the FDA, they studied women who were already infected with one strain of HPV. Gardasil contains the 4 strains of HPV most likely to cause cervical cancer and genital warts. The women who had previously been diagnosed with one strain of HPV were still protected from the other three strains, and the FDA has approved Gardasil for women who have already been infected with one strain. Make sure you talk to your gynecologist about getting the vaccine series. Also, make sure you are getting treated for the abnormal cells on your pap and you follow through with your repeat pap smears, as they will have to be more frequent than once a year of a while.

Question: Last month when you talked about screening for breast and ovarian cancer, you mentioned the CA-125 test. I have read about this in my women’s magazines, which say I should have it done, but my gynecologist has never ordered that test for me. Do I need this test done?

Answer: This is a great question and my patients ask about this test all the time. Ovarian cancer is a rare cancer, with most women only carrying a 1.7% lifetime risk (compared to 13.2% lifetime risk for breast cancer). Unfortunately, due to the location of the ovaries deep within the pelvis, it is difficult to screen for ovarian cancer, thus ovarian cancer is not usually found until it is at a later stage and is harder to cure. Many studies have been done, and no effective screening test has been found for ovarian cancer. The CA-125 blood test is supposed to be used after a woman is diagnosed with ovarian cancer, to follow to see if the cancer has come back. Not all women with ovarian cancer have a positive CA-125 before surgery, so this does not help all patients. In addition, not all patients with a high CA-125 have ovarian cancer, so the false positive rate is quite high; too high for a screening test. As an example, a patient of mine had severe pelvic pain, an ultrasound was done showing an ovarian mass and the CA-125 was very high, around 1700 (normal is less than 25). However, when she went into surgery the results showed that she did NOT have ovarian cancer, and she had endometriosis instead. She is a very lucky woman, but this just illustrates why we don’t use the CA-125 as a screening test for all women. All of that being said, for the women who are at very high risk for ovarian cancer, we have to screen somehow. For my patients with a first degree relative (mother, sister, or daughter) with ovarian cancer, I recommend a pelvic ultrasound every year to look at the ovaries and the CA-125 blood test. This however is not standard of care and generally not covered by insurance for screening purposes. With women that are such high risk, usually the expense is worth the possibly of early diagnosis and a chance at a cure. I would discuss your personal risk with your gynecologist and determine if the CA-125 is right for you.

Dr. Karen Lockwood is a graduate of University of Oklahoma College of Medicine.  She completed her residency in Internal Medicine at Henry Ford Hospital in Detroit.  She is board-certified in Internal Medicine and is currently in private practice in Troy, MI.

If you would like to submit a medical question to Dr. Lockwood, Please email your question to askthedoc@healthandleisureonline.com.

*Advice found within this article is for informational purposes only and should not replace the advice or recommendations of your physician.

Ask the Doctor: May 2008

Question: I am 45 and I see my gynecologist and get my mammogram every year. I have been hearing recently about other ways to screen for breast cancer, like ultrasound and MRI? Should I be getting these tests as well as my mammogram?

Answer: The gold standard for breast cancer screening is still a yearly mammogram after age 40, so I am glad that you are getting yours each year. The ultrasound and MRI are used to improve the sensitivity of the mammogram for women with higher risks and lumps that we can feel on exam. If you, or your doctor, find a lump on the breast exam, you should have an ultrasound to determine if the lump is a cyst or a solid mass.

Rarely, a breast cancer is not seen on mammogram, but can be picked up on ultrasound, especially if your breasts are dense. Breast MRI is currently recommended for a specific group of high risk women. The evidence has not yet proven that it gives any advantage over mammogram in a normal risk woman.

The American Cancer Society guidelines for breast MRI are for women who test positive for the genes BRCA1 and BRCA2. They also recommend breast MRI for women who have a first degree relative (mother, sister, or daughter) who tested positive for BRCA1 or BRCA2, even if the patient has not been tested themselves. Women who carry a lifetime risk of breast cancer of 20-25% based on family history and other factors are candidates for breast MRI. Women who had radiation to the chest between ages 10 and 30 are at higher risk of breast cancer and should also be screened with breast MRI. These women should also continue to have routine mammograms.

Question: My mom and her sister both had breast cancer in their 50s. I am 36. Should I be tested for the breast cancer gene?

Answer: This is a difficult question to answer, because everyone’s risk is different, and only 10% of patients with breast cancer also have a family history of breast cancer, and not all patients with a family history carry the breast cancer gene.

There are two known genes that increase the risk of breast and ovarian cancer, BRCA1 and BRCA2. Testing involves a blood test that can be very expensive and not all insurance companies will cover the cost of testing.

The other issue with the breast cancer genes is that they only increase the risk of getting breast or ovarian cancer; they do not guarantee that a patient who tests positive will get those diseases. Testing positive for either gene will increase the risk of developing breast cancer to a 36-85% lifetime risk, and the risk of developing ovarian cancer to a 16-60% lifetime risk. The large range of risk is due to the information we get from the different studies of women with positive genetic tests, and accounts for the other factors in developing breast cancer including environmental factors.

It is generally recommended that the family member with breast cancer be tested for the genes first, in your case it would be your mom. If she tests positive, you can decide if you want to be tested. If she is negative, then you do not need to be tested.

I recommend genetic counseling by a gene specialist or oncologist before deciding whether or not to be tested. I also recommend careful consideration of your early detection and prevention options if you are positive. Early detection is the most important for the survival rates of breast cancer. As I discussed in the previous reader’s question, you should get a breast MRI and possibly more frequent mammograms and clinical breast exams. You must also consider the increased risk for ovarian cancer and you may chose to screen more aggressively with a yearly pelvic ultrasound and the CA-125 blood test.

The other option is to surgically remove as much of the breast or ovarian tissue as possible with a mastectomy and/or oophorectomy to prevent the cancers. This would be done before you ever show signs of cancer. This is the most effective way of preventing breast or ovarian cancer if you are very high risk. However, it is not a guarantee you won’t develop cancer and it is a very difficult, life changing decision and should not be made without the appropriate counseling.

You may also choose to take tamoxifen to prevent developing breast cancer. Tamoxifen is a drug previously only used for patients who have survived breast cancer to help prevent recurrence, but is now used to prevent breast cancer in high risk women. Tamoxifen is not without side effects and needs to be discussed as one of your options in your pre-testing counseling.

For more information about genetic testing and breast MRI you can visit the American Cancer Society’s website at www.cancer.org or call the National Cancer Institute’s information line 1-800-4- CANCER (1-800-422-6237).

Dr. Karen Lockwood is a graduate of University of Oklahoma College of Medicine.  She completed her residency in Internal Medicine at Henry Ford Hospital in Detroit.  She is board-certified in Internal Medicine and is currently in private practice in Troy, MI.

If you would like to submit a medical question to Dr. Lockwood, Please email your question to askthedoc@healthandleisureonline.com.

*Advice found within this article is for informational purposes only and should not replace the advice or recommendations of your physician.