1. YOLANDA LAWSON M.D., F.A.C.O.G MADEWELL OBGYN ASSOCIATE ATTENDING BAYLOR UNIVERSITY MEDICAL CENTER Women's Health Screening Guidelines

2. No disclosures, commercial bias or interests

3. Women's Health Screening Guidelines Overview of current screening and compare the current recommendations Breast Bone Health Cervical Ovarian

4. Women's Health Screening Guidelines Whose evidence is substantiated How to apply the evidence Patient populations/demographics of your practice Resources available How to explain and educate your patients

5. Women's Health Screening Guidelines Breast Cancer US Preventive Task Force biennial screening mammography for women aged 50 to 74 years current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older recommends against teaching breast self- examination (BSE).

6. Women's Health Screening Guidelines Insufficient evidence on benefit of digital mammography or MRI No recommendation on 3D FDA approved reduces call-backs and 40% less false-positives ACOG recommends annual mammograms starting at age 40 Clinical breast exams annually for 40 and older and 1-3 years for ages 20-39

7. Women's Health Screening Guidelines Patients over 75 to discuss and physician and patient decide American Cancer Society is consistent with ACOG and states as long as the woman is in good health to continue mammograms

8. Women's Health Screening Guidelines Hereditary Cancer Screening Tools BRAC Analysis-hereditary breast and ovarian cancer Colaris- hereditary colon and endometrial cancer Colaris AP- polyposis syndromes Melaris-hereditary melanoma

9. Women's Health Screening Guidelines  Any male with a personal history of breast cancer or close male relative at any age (BRCA2)  Personal history of female breast cancer ≤ 50  Personal history of epithelial ovarian cancer at any age  Any person of Ashkenazi Jewish descent  A first-degree relative (mother, daughter, sister) diagnosed with simultaneous bilateral breast cancer  Two first-degree relatives diagnosed with breast cancer, one of whom was diagnosed ≤ 50  Three or more first-degree or second-degree (grandmother, aunt) relatives diagnosed with breast and/or epithelial ovarian cancer regardless of their age at diagnosis  A first- or second-degree relative diagnosed with both breast and ovarian cancer regardless of age at diagnosis  Two or more close relatives with diagnosis of pancreatic cancer at any age  Personal history of pancreatic cancer at any age with more than two close relatives with breast and/or ovarian and/or pancreatic cancer at any age

10. Women's Health Screening Guidelines BRCA=Breast Cancer Susceptibility Gene One inherits 1 mutated BRCA allele from a carrier parent but still has one allele to suppress tumor growth. If one allele is damaged by the inevitable genetic errors from age the normal copy fails and the mutated BRCA will be of no help to prevent uncontrolled cell growth

11. Women's Health Screening Guidelines 1/400-1/800(<1%) of the general population is estimated to carry either the BRCA1 or 2 mutation Ashkenazi Jews 1/40 12% of women in the general population will develop breast cancer vs. 60% with hereditary BRCA

12. The Genetic Information Nondiscrimination Act (GINA) is federal law signed in 2008 by President Obama. GINA prohibits Americans from being treating unfairly by health insurers or employers on the basis of DNA information, including information about an individual’s genetic tests and the genetic tests of an individual’s family members. However, the law does not apply to life, long-term care, or disability insurance! (National Human Genome Research Institute, 2012).

13. Women's Health Screening Guidelines 17 billion dollars spent on osteoporosis related fractures in the U.S. Osteoporosis is five times more prevalent in women than men Women have twice the rate of fracture than men and 80% of hip fractures occur in elderly women Bone health should be addressed in all of your female patients

14. Women's Health Screening Guidelines Bone Density screening USPSTF recommends bone density screening at age 65 and if there are risk factors 60 ACOG recommends age 65 unless they have significant risk factors (smoking, long-term steroid use, rheumatoid arthritis, premature menopause) 8% risk in African-American women over the age of 50 Mexican-Americans have same risk as Caucasians

15. Women's Health Screening Guidelines Cervical Cancer screening New Guidelines recommend against screening younger than 21 years revised from previous of age 21 or 3 years after intercourse

16. Women's Health Screening Guidelines The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. recommends against screening for cervical cancer in women younger than age 21 years. recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer. recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years

18. Women's Health Screening Guidelines Guidelines developed to address screening in the general population DO NOT apply to special, high risk populations who may need more intensive or alternative screening For those older than 65 recommendation = GradeD Must have had adequate negative prior screening

19. Women's Health Screening Guidelines The USPSTF recommends against screening for Ovarian Cancer CA-125 and transvaginal ultrasounds not accurate enough If patient is BRCA positive and opts to preserve her ovaries then those patients are screened with CA-125 and transvaginal sono

20. Women's Health Screening Guidelines Over 22,280 women will be diagnosed with ovarian cancer About 15,000 women will die of Ovarian Cancer 10-15% of women with ovarian cancer have BRCA1 or BRACA2 gene mutations BRCA 1 associated with a 40% lifetime risk of developing ovarian cancer BRCA 2 associated with a 15% lifetime risk of developing ovarian cancer

21. Women's Health Screening Guidelines Ovarian Cancer accounts for about 3% of all cancers in women Ranks 5th in cancer deaths among women Approximately 5% to 10% with a family history of ovarian cancer Risk of 1 in 71 women will develop ovarian cancer 1st in cancer deaths involving the female reproductive system

22. Women's Health Screening Guidelines In summary Annual Exam remains pertinent Preventive care guidelines – Keep up to date Core measures insurers, ACO’s, medical home Utilize the annual exam to focus on mental health, reproductive counseling, diet, exercise,STI counsel and risky behaviors