OB/GYNs play a significant role across the spectrum of cancer awareness, from cervical and endometrial cancers to breast cancer. Patients may know that they should get regular mammograms and report any breast lumps, but they may not be aware of the complex factors involved in their personal breast cancer risk.
By assessing a patient's risks, educating patients about breast health and suggesting the appropriate slate of screenings, clinicians serve as front-line defenders of long-term wellness.
Assessing Risk
The annual gynecology visit is regarded as an ideal time to discuss breast health, perform a breast exam and walk your patient through screening recommendations based on their risk factors.
Younger patients may be surprised to learn their youth is not a guarantee of breast health. Although advancing age may heighten the risk of breast cancer, other factors play a role. These include a family history of breast, ovarian or associated cancers; certain genetic mutations; previous breast anomalies; nulliparity; early first menstruation and late onset of menopause.
Patients and providers may also need a reminder that breast cancer does not only affect cisgender women. Transgender men and nonbinary OB/GYN patients who retain breast tissue can also get breast cancer, and should also be screened regularly. A recent nationwide cohort study from the Netherlands also found that the risk of breast cancer rapidly increases for transgender women who undergo hormone therapy.
Gaining a complete understanding of a patient's potential risk can inform clinical decision-making about breast health, such as the age to start screening, the appropriate combination of screening methods — mammography or ultrasound, for example — and whether annual or biennial breast cancer screenings are the best course. A thorough risk assessment can also inform counseling on risk reduction, breast cancer surveillance and genetic testing.
Mammography or Ultrasound
Regular screening via mammography reduces breast cancer deaths in women with an average risk of contracting the disease. However, screening too often may expose patients to false-positive test results and overtreatment, reports a 2015 systematic review in JAMA. At the same time, more targeted imaging exams are advised in individuals with a higher risk of breast cancer.
As you discuss screening with patients, the American College of Obstetricians and Gynecologists (ACOG) encourages a process of shared decision-making that includes a thorough review of the potential benefits and harms of different imaging methods.
For average-risk patients, the most recent committee opinion from ACOG suggests beginning mammograms at age 40. Effective imaging modalities include digital mammography, 2D mammography and 3D mammography, which typically require fewer followup visits for additional screening.
Ultrasound can also play a role in breast health and breast cancer screening, particularly among those with dense breast tissue, where mammography alone cannot always reveal breast cancer. People with dense breast tissue, as ACOG notes, carry a modestly higher risk of breast cancer.
One newer ultrasound approach, Automated Breast Ultrasound, may catch significantly more cancers in dense breast tissue. The painless, 15-minute exam also proves effective in detecting additional cancer in highly dense breast tissue where mammography alone may prove insufficient.
In the case of suspected cancers, an efficient referral system can quickly connect the patient to the appropriate specialist. This referral network may include those with expertise in cancer genetics counseling, testing for breast cancer-related germline mutations and cascade testing to identify family members who also may face increased risk.
Wellness for Cancer Survivors
With more than 3.8 million survivors of breast cancer in the United States alone, according to the Breast Cancer Research Foundation, monitoring cancer survivors for long-term health is another important task. The role of the OB/GYN often includes closely monitoring survivors for a second wave of cancer arising from a family history of cancer or cancer treatment.
For example, the breast cancer drug tamoxifen is linked to a two- to threefold increase in the risk of uterine cancer among women age 50 and older, according to ACOG. The most recent ACOG committee opinion on uterine cancer screening recommends close monitoring for signs of endometrial hyperplasia or cancer in postmenopausal women taking tamoxifen. Educate your patients and encourage them to promptly report any abnormal vaginal symptoms, including spotting, staining and whitish or bloody discharge. ACOG further notes that premenopausal patients on tamoxifen do not appear to carry a higher risk for uterine cancer and thus require no additional monitoring beyond standard gynecologic care.
Patients rely on strong information and clinically appropriate screening. As clinicians working on the front lines of preventive care, OB/GYNs are instrumental in preserving breast health and protecting patients for the long term.
