Specific and unspecific gynecological alarm symptoms - prevalence estimates in different age groups: a population-based study

Black-White differences in uterine cancer symptomatology and stage at diagnosis

OBJECTIVE

To examine whether uterine cancer symptoms differ between Black and White patients and how this may influence their stage at diagnosis.

METHODS

Using the Surveillance, Epidemiology and End Results-Medicare database, we identified 2328 Black and 21,774 White patients with uterine cancer in 2008-2017. Their symptoms in the 18 months before diagnosis were categorized as postmenopausal bleeding (PMB) alone, PMB together with other symptoms (e.g., abdominal/pelvic pain, bloating), non-PMB symptoms alone, or no symptoms. Stage at diagnosis was dichotomized as advanced (i.e., regional/distant) versus localized. The association between race and stage was analyzed using regression models incrementally adjusting for symptoms and other patient characteristics.

RESULTS

A larger proportion of Black than White patients experienced PMB together with other symptoms (63.1% versus 58.0%) or experienced non-PMB symptoms alone (13.1% versus 9.4%) (p < 0.001). Black patients had a higher risk of advanced-stage diagnosis than White patients (45.0% versus 30.3%, unadjusted RR = 1.52, 95% CI: 1.44-1.59). Adjusting for Black-White differences in symptoms attenuated the RR to 1.46 (95% CI: 1.39-1.53). Compared to PMB symptoms alone, having additional non-PMB symptoms (RR = 1.21, 95% CI: 1.15-1.26) and having non-PMB symptoms alone (RR = 1.99, 95% CI: 1.88-2.10) were associated with increased risk of advanced-stage diagnosis. Further adjusting for histology and other patient characteristics reduced Black-White disparity in advanced-stage diagnosis to 1.08 (95% CI: 1.03-1.14) but symptoms remained significantly associated with stage at diagnosis.

CONCLUSIONS

Having non-PMB symptoms was associated with more advanced stage at diagnosis. Non-PMB symptoms were more common among Black than White patients, which might hinder symptom recognition/evaluation.

Is concern for gynaecological alarm symptoms associated with healthcare-seeking? A Danish population-based cross-sectional study

Background

Diagnosing cancer at an early stage increases survival, and for most gynaecological cancers the diagnostic pathway is initiated, when women seek medical attention with symptoms. As many factors influence healthcare-seeking, knowledge about these factors is important. Concern can act as a barrier or a trigger for women experiencing gynaecological alarm symptoms. This study aimed to examine whether concern for the symptom or the current health was associated with healthcare-seeking among women with gynaecological alarm symptoms.

Methods

Some 100,000 randomly selected Danish citizens were invited to a national web-based survey. The questionnaire included items regarding symptom experiences, healthcare-seeking and concern for the experienced symptoms and current health. This study included 5019 women with self-reported gynaecological alarm symptoms (pelvic pain, pain during intercourse, bleeding during intercourse and postmenopausal bleeding). Concern was reported on a 5-point Likert scale from ‘not at all’ to ‘extremely’. Data were analysed using multivariate logistic regression models.

Results

Women who were ‘extremely’ concerned about a gynaecological alarm symptom had two to six times higher odds of reporting healthcare-seeking compared to women who were ‘not at all’ concerned. Symptom concern was associated with higher odds of healthcare-seeking for all four gynaecological alarm symptoms and the odds increased with increasing levels of concern. Additionally, concern for current health was associated with higher odds of healthcare-seeking. Concern for current health as expressed by others was positively associated with healthcare-seeking but had only minor influence on the association between concern for current health and healthcare-seeking.

Conclusions

Concern for a gynaecological alarm symptom and for current health was positively associated with healthcare-seeking. The results can be used for future informational health campaigns targeting individuals at risk of postponing warranted healthcare-seeking.

Direct access from general practice to transvaginal ultrasound for early detection of ovarian cancer: a feasibility study

OBJECTIVE

To investigate the feasibility of providing general practitioners (GPs) direct and fast referral access to transvaginal ultrasound (TVUS).

DESIGN

A prospective cohort study.

SETTING

A total of 232 Danish general practices in parts of the Central Denmark Region.

SUBJECTS

Women aged ≥40 years who consulted their GP for vague and non-specific symptoms (n = 479).

MAIN OUTCOME MEASURES

The feasibility assessment included the GPs' referral rate, indications for referral, management of test results, and findings from TVUS.

RESULTS

A total of 479 women were referred to TVUS. The examinations revealed abnormalities in 104 (21.7%) women. Additional investigations were needed in 68 (14.2%) women of whom seven (1.5%) underwent major surgery. No case of ovarian cancer was diagnosed during the study period or the 6-month follow-up. However, three (0.6%) women with an abnormal transvaginal ultrasound were diagnosed with urogynecological cancer; this yielded a PPV of 4.4% (95% confidence interval: 1.5-12.2) and an NPV of 100.0% (95% confidence interval: 96.7-100.0) for urogynecological cancer.

CONCLUSION

Providing GPs with direct access to transvaginal ultrasound was feasible; 80% of the investigated women were referred back to the GP, 14% were further investigated, 0.6% were diagnosed with urogynecological cancer, and 1.5% had major procedures performed without complications.

IMPLICATIONS

Direct access to TVUS could be an important pathway to ensure fast evaluation of women presenting with vague non-specific symptoms of potential ovarian cancer. Future studies should explore the patient experience, cancer outcomes, and health economics issues.KEY POINTS   Current awareness  • GPs have no fast referral option for women presenting with vague non-specific symptoms that could indicate underlying ovarian cancer.   Key findings  • We offered GPs direct and fast referral access to TVUS; 51.7% of practices used the opportunity.  • The GPs referred 479 women to TVUS; 104 had an abnormal TVUS and 68 needed additional investigations.  • Seven women underwent major surgery, leading to three cases of urogynecological cancer. No woman had a false negative TVUS result.

Gastrointestinal symptoms and diagnosis preceding ovarian cancer diagnosis: Effects on treatment allocation and potential diagnostic delay

OBJECTIVE

To determine whether gastrointestinal (GI) disorder insurance claims in the year preceding a diagnosis of ovarian cancer (OC) lead to differing treatment allocations. The hypothesis is that GI disorders may be indicative of advanced OC.

METHODS

This retrospective study identified patients with newly diagnosed OC from January 2015 to January 2019 in the IBM® MarketScan® US commercial insurance and Medicare databases. Analysis was limited to patients with primary or interval debulking surgery or chemotherapy, with or without GI claims in the year prior to diagnosis, with commercial or Medicare coverage for ≥12 months prior and ≥1 month after the index date. Patients were compared in terms of the odds of treatment with neoadjuvant chemotherapy (NCT) or primary debulking surgery (PDS) (logistic regression analysis). Median treatment-free interval in the subset of patients with antineoplastic treatment was compared (Kaplan-Meier analysis).

RESULTS

Of the 6286 patients, 22% had a diagnosis of ≥1 GI disorder before their OC diagnosis. Of these patients, 39% were diagnosed with a GI disorder between 6 and 12 months before OC diagnosis and 61% were diagnosed <6 months prior. Women with a GI diagnosis were more likely to undergo NCT than PDS (odds ratio [OR], 1.37; P < 0.0001); this remained significant even when controlling for age, region, insurance plan type, and index year (OR, 1.24; P = 0.001).

CONCLUSIONS

In this database, ≈25% of women with OC had a GI claim within the past year and were more likely treated with NCT, an indicator of more advanced disease with a worse prognosis. This suggests that OC should be considered in the differential diagnosis among women with GI complaints, which could alter treatment allocation.

Hysterectomy Versus Hysteropexy at the Time of Native Tissue Pelvic Organ Prolapse Repair: A Cost-Effectiveness Analysis

OBJECTIVE

The aim of the study was to determine whether a hysterectomy at the time of native tissue pelvic organ prolapse repair is cost-effective for the prevention of endometrial cancer.

METHODS

We created a decision analysis model using TreeAge Pro. We modeled prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension (TVH-USLS) versus sacrospinous ligament fixation hysteropexy (SSLF-HPXY). We modeled incidence and diagnostic evaluation of postmenopausal bleeding, including risk of endometrial pathology and diagnosis or death from endometrial cancer. Modeled costs included those associated with the index procedure, subsequent prolapse repair, endometrial biopsy, pelvic ultrasound, hysteroscopy, dilation and curettage, and treatment of endometrial cancer.

RESULTS

TVH-USLS costs US $587.61 more than SSLF-HPXY per case of prolapse. TVH-USLS prevents 1.1% of women from experiencing postmenopausal bleeding and its diagnostic workup. It prevents 0.95% of women from undergoing subsequent major surgery for the treatment of either prolapse recurrence or suspected endometrial cancer. Using our model, it costs US $2,698,677 to prevent one cancer death by performing TVH-USLS. As this is lower than the value of a statistical life, it is cost-effective to perform TVH-USLS for cancer prevention. Multiple 1-way sensitivity analyses showed that changes to input variables would not significantly change outcomes.

CONCLUSIONS

TVH-USLS increased costs but reduced postmenopausal bleeding and subsequent major surgery compared with SSLF-HPXY. Accounting for these differences, TVH-USLS was a cost-effective approach for the prevention of endometrial cancer. Uterine preservation/removal at the time of prolapse repair should be based on the woman's history and treatment priorities, but cancer prevention should be one aspect of this decision.

Signs and symptoms associated with uterine cancer in pre- and postmenopausal women

Uterine cancer is the most and second most common gynecological malignancy in developed and developing countries, respectively. The majority of endometrial cancers are diagnosed early due to the presence of abnormal uterine bleeding. The existing literature however contains only little data regarding the prevalence of such symptoms compared to patients with no or benign pathology. Therefore, a systematic review was conducted in order to determine the significance of various clinical signs and symptoms predicting uterine cancer. Embase, Web of Science and Medline databases were searched from inception until 18 June 2019. Studies eligible for selection inclusion assessed the diagnostic accuracy of clinical signs and symptoms in pre- and postmenopausal women aged 18-99 years old with uterine malignancy. Case reports, case series and studies of which full text was not available, were excluded. The risk of bias was assessed using the QUADAS-2 tool by two independent reviewers. Results were visualized by forest plots using RevMan(5.3). Forty-one studies were eventually included in this systematic review. Abnormal uterine bleeding occurring in pre-, post- and perimenopausal women was proven to be the most widely investigated symptom in relation to cancer of the uterus. Thirty-two articles examined patients with postmenopausal bleeding of which sensitivity and specificity varied between 0.28 to 0.86 and 0.63 to 0.84, respectively. Abnormal bleeding in pre- and perimenopausal women on the other hand showed a sensitivity ranging from 0.63 to 0.81. Its specificity could not be calculated due to missing data. Other symptoms appeared not sufficiently examined to assess their diagnostic accuracy range. This review highlights the current lack of knowledge regarding the diagnostic accuracy of several signs and symptoms for uterine cancer. After a thorough in-depth review of the literature, meta-analysis could not be performed due to the absence of control populations in the majority of articles. Further research is needed to establish the rule-in or rule-out value of specific clinical signs to identify patients at risk for uterine malignancy prompting further clinical assessment.

Associations between lifestyle, erectile dysfunction and healthcare seeking: a population-based study

Objective: To investigate associations between age, lifestyle and erectile dysfunction (ED) in the general population and to explore associations between age, lifestyle and contact with a general practitioner (GP) regarding ED.Design: Cross-sectional web-based questionnaire study.Setting: The general Danish population.Subjects: A randomly selected sample of 48,910 men aged 20 years and older.Main outcome measures: Prevalence of ED and probability of contacting a GP regarding ED. In logistic regression models we analysed associations between age, smoking status, alcohol consumption, body mass index (BMI), and self-rated physical fitness on both ED and GP contact.Results: A total of 22,198 men (47.6%) completed the question regarding ED. The overall prevalence of ED was 19.3%, varying from 2.3% among men aged 20-29 years to 55.3% among men aged 80 years and above. 31.8% of men reporting ED had contacted a GP regarding ED. Increasing age, current or former smoking, complete alcohol abstinence or alcohol consumption above seven units per week, high BMI, and poor self-rated physical fitness were significantly associated with reporting ED. The proportion of GP contacts was significantly associated with age. Overall, no significant associations between lifestyle and healthcare seeking were observed, although lower odds of GP contact were found when physical fitness was rated as poor.Conclusion: Reporting ED and GP contact were significantly associated with age. Furthermore, lifestyle was significantly associated with reporting ED, but largely not associated with healthcare seeking. These findings are important for future interventions aiming to improve diagnosis and treatment of ED.Key pointsExperiencing erectile dysfunction is frequent in the general population, especially among older men.  • In this large-scale national survey, age and lifestyle were significantly associated with reporting erectile dysfunction.  • Healthcare seeking with erectile dysfunction was significantly associated with age, but not with lifestyle.  • Diagnosis and treatment of erectile dysfunction might be challenged when erectile dysfunction does not lead to healthcare seeking.

Is healthcare-seeking with gynaecological alarm symptoms influenced by personal and professional relations? A Danish population-based, cross-sectional study

OBJECTIVES

To identify the personal and professional relations of women experiencing gynaecological alarm symptoms, to analyse if involving a personal relation is related to healthcare-seeking with gynaecological alarm symptoms, and to analyse if having an available social network is associated with involvement of this relation.

DESIGN

Web-based, population-based, cross-sectional questionnaire survey.

SETTING

The general population in Denmark.

PARTICIPANTS

The study invited 100 000 individuals randomly drawn from the Danish Civil Registration System. Pregnant women and women who did not answer relevant questions about social network were excluded. A total of 5053 women who experienced at least one gynaecological alarm symptom were included in the study. PRIMARY AND SECONDARY OUTCOMES: (1) Personal and professional relations that women experiencing gynaecological alarm symptoms involve; (2) the association between involving a personal relation and healthcare-seeking; and (3) the association between having an available social network and involvement of this relation.

RESULTS

The general practitioner (GP) was the most involved professional relation, while the spouse/partner was the most involved personal relation. When experiencing gynaecological alarm symptoms, more than 50% of women did not involve a professional relation and 20% did not involve a personal relation. For all four gynaecological alarm symptoms, the odds of involving the GP were higher in the oldest age group. Women were two to seven times more likely to involve their GP if they had personal relation involvement. No statistically significant association was found between having an available social network and involving the GP.

CONCLUSION

Involving a personal relation in healthcare-seeking was associated with increased involvement of the GP, who consequently was the most involved professional relation when experiencing gynaecological alarm symptoms. Spouse/partner was the most involved personal relation. The oldest age group had the highest odds of involving the GP. No association was found between having an available social network and involving the GP.

Predictive values of lung cancer alarm symptoms in the general population: a nationwide cohort study

We aimed to firstly determine the 1-year predictive values of lung cancer alarm symptoms in the general population and to analyse the proportion of alarm symptoms reported prior to diagnosis, and secondly analyse how smoking status and reported contact with general practitioners (GPs) regarding lung cancer alarm symptoms influence the predictive values. The study was a nationwide prospective cohort study of 69,060 individuals aged ≥40 years, randomly selected from the Danish population. Using information gathered in a survey regarding symptoms, lifestyle and healthcare-seeking together with registry information on lung cancer diagnoses in the subsequent year, we calculated the predictive values and likelihood ratios of symptoms that might be indicative of lung cancer. Furthermore, we analysed how smoking status and reported contact with GPs regarding the alarm symptoms affected the predictive values. We found that less than half of the patients had reported an alarm symptom six months prior to lung cancer diagnosis. The positive predictive values of the symptoms were generally very low, even for patients reporting GP contact regarding an alarm symptom. The highest predictive values were found for dyspnoea, hoarseness, loss of appetite and for current heavy smokers. The negative predictive values were high, all close to 100%. Given the low positive predictive values, our findings emphasise that diagnostic strategies should not focus on single, specific alarm symptoms, but should perhaps focus on different clusters of symptoms. For patients not experiencing alarm symptoms, the risk of overlooking lung cancer is very low.

Serum HE4 and diagnosis of ovarian cancer in postmenopausal women with adnexal masses

BACKGROUND

Transvaginal ultrasound and serum CA125 are routinely used for differential diagnosis of pelvic adnexal mass. Use of human epididymis 4 was approved in the United States in 2011. However, there is scarcity of studies evaluating the additional value of human epididymis 4.

OBJECTIVE

The objective of the study was to evaluate the performance characteristics of transvaginal ultrasound, CA125, and human epididymis 4 for differential diagnosis of ovarian cancer in postmenopausal women with adnexal masses.

STUDY DESIGN

This was a cohort study nested within the screen arms of the multicenter randomized controlled trial, United Kingdom Collaborative Trial of Ovarian Cancer Screening, based in England, Wales, and Northern Ireland. In United Kingdom Collaborative Trial of Ovarian Cancer Screening, 48,230 women randomized to transvaginal ultrasound screening and 50,078 to multimodal screening (serum CA125 interpreted by Risk of Ovarian Cancer Algorithm with second line transvaginal ultrasound) underwent the first (prevalence) screen. Women with adnexal lesions and/or persistently elevated risk were clinically assessed and underwent surgery or follow-up for a median of 10.9 years. Banked samples taken within 6 months of transvaginal ultrasound from all clinically assessed women were assayed for human epididymis 4 and CA125. Area under the curve and sensitivity for diagnosing ovarian cancer of multiple penalized logistic regression models incorporating logCA125, log human epididymis 4, age, and simple ultrasound features of the adnexal mass were compared.

RESULTS

Of 1590 (158 multimodal, 1432 ultrasound) women with adnexal masses, 78 were diagnosed with ovarian cancer (48 invasive epithelial ovarian, 14 type I, 34 type II; 24 borderline epithelial; 6 nonepithelial) within 1 year of scan. The area under the curve (0.893 vs 0.896; P = .453) and sensitivity (74.4% vs 75.6% ;P = .564) at fixed specificity of 90% of the model incorporating age, ultrasound, and CA125 were similar to that also including human epididymis 4. Both models had high sensitivity for invasive epithelial ovarian (89.6%) and type II (>91%) cancers.

CONCLUSION

Our population cohort study suggests that human epididymis 4 adds little value to concurrent use of CA125 and transvaginal ultrasound in the differential diagnosis of adnexal masses in postmenopausal women.

Lifestyle, socioeconomic status and healthcare seeking among women with gynaecological cancer alarm symptoms: a combined questionnaire-based and register-based population study

OBJECTIVES

To determine the proportion of contacts to general practitioner (GP) with recent onset gynaecological cancer alarm symptoms (pelvic pain, postmenopausal bleeding, bleeding during intercourse or pain during intercourse) and to analyse the associations between lifestyle factors, socioeconomic status and GP contact for these symptoms.

DESIGN

Cross-sectional survey combined with data from national registers.

SETTING

The general Danish population.

PARTICIPANTS

A total of 25 866 non-pregnant women ≥20 years completed the survey. Women reporting at least one of four gynaecological alarm symptoms within the preceding 6 months form the study base (n=2957).

RESULTS

The proportion of women reporting GP contact ranged from 21.1% (pain during intercourse) to 32.6% (postmenopausal bleeding). Women aged 60+ years had higher odds of reporting GP contact for at least one of the four gynaecological cancer alarm symptoms compared with those aged 20-39 years (OR 2.56, 95% CI 1.69 to 3.89), and immigrants had higher odds of reporting GP contact for at least one of the symptoms (OR 1.56, 95% CI 1.13 to 2.15) compared with ethnic Danish individuals. Among those reporting postmenopausal bleeding and/or bleeding during intercourse, women in the age group 60+ years had higher odds of reporting GP contact compared with those aged 20-39 years (OR 2.79, 95% CI 1.33 to 5.87). A high educational level (>12 years) was positively associated with reporting GP contact for postmenopausal bleeding and/or bleeding during intercourse compared with a low educational level (<10 years) (OR 2.23, 95% CI 1.19 to 4.19). No associations were found with lifestyle factors.

CONCLUSIONS

Few women contacted their GP with recent onset gynaecological cancer alarm symptoms. Higher age, being immigrant and higher educational level increased the odds of GP contact. Future studies should explore the reasons for these findings as this may aid in prompting early diagnosis and thereby improve the prognosis of gynaecological cancer.

Detection of recurrence in early stage endometrial cancer - the role of symptoms and routine follow-up

BACKGROUND

Considerable controversy remains as to the optimal organization of endometrial cancer follow-up.

AIM

To evaluate the relationship between the way recurrence was detected and survival after treatment for endometrial cancer. Further, to identify characteristics associated with a pre-scheduled examination in women with symptomatic recurrence.

MATERIAL AND METHODS

All women with early stage endometrial cancer during 2005-2009 were included in a population-based historical cohort derived from the Danish Gynecological Cancer Database. Women diagnosed with recurrence within three years after primary surgery and the mode of recurrence detection were identified from hospital charts: asymptomatic recurrence detected at regular follow-up, symptomatic recurrence detected at regular follow-up or symptomatic recurrence detected in between follow-up. Survival of women with symptomatic and asymptomatic disease was compared. Furthermore, characteristics associated with self-referral as compared to presenting symptoms at regular follow-ups were identified using univariate analyses.

RESULTS

In total, 183 cases of recurrence (7%) were identified in the cohort of 2612 women. Of these, 65.5% were symptomatic with vaginal bleeding as the most prevalent symptom. Asymptomatic women had a significantly better three-year survival rate compared to symptomatic women (80.3% vs. 54.3%, p < 0.01). A total of 2.3% of the entire population had an asymptomatic recurrence. Women diagnosed at a pre-scheduled visit due to symptoms had a higher educational level (p = 0.03) and more often high-risk disease (p = 0.02) than symptomatic women diagnosed at regular follow-up.

CONCLUSION

Early stage endometrial cancer carries a low risk of recurrence. Survival appears to be superior in asymptomatic patients, but length-time bias, i.e. the effect of aggressive tumor biology in symptomatic recurrences, may bias results in non-randomized controlled trials. Well educated patients with symptoms of recurrence more often sought medical attendance compared to less educated counterparts. This should be considered if patient-initiated follow-up is the standard care.

Estimating the Prevalence of Ovarian Cancer Symptoms in Women Aged 50 Years or Older: Problems and Possibilities

Diagnostic testing is recommended in women with "ovarian cancer symptoms." However, these symptoms are nonspecific. The ongoing Diagnosing Ovarian Cancer Early (DOVE) Study in Montreal, Quebec, Canada, provides diagnostic testing to women aged 50 years or older with symptoms lasting for more than 2 weeks and less than 1 year. The prevalence of ovarian cancer in DOVE is 10 times that of large screening trials, prompting us to estimate the prevalence of these symptoms in this population. We sent a questionnaire to 3,000 randomly sampled women in 2014-2015. Overall, 833 women responded; 81.5% reported at least 1 symptom, and 59.7% reported at least 1 symptom within the duration window specified in DOVE. We explored whether such high prevalence resulted from low survey response by applying inverse probability weighting to correct the estimates. Older women and those from deprived areas were less likely to respond, but only age was associated with symptom reporting. Prevalence was similar in early and late responders. Inverse probability weighting had a minimal impact on estimates, suggesting little evidence of nonresponse bias. This is the first study investigating symptoms that have proven to identify a subset of women with a high prevalence of ovarian cancer. However, the high frequency of symptoms warrants further refinements before symptom-triggered diagnostic testing can be implemented.

Endometrial Cancer Associated Symptoms: A Case-Control Study

BACKGROUND

The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined.

METHODS

A case-control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence.

RESULTS

The cases (n = 75) were significantly older than the AV (n = 203) and PV (n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m², p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge.

CONCLUSIONS

Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation.

Preclinical and Undiagnosed Crohn's Disease: The Submerged Iceberg

Little is known on the natural history of Crohn's disease (CD) before diagnosis. By the time the patient is diagnosed, the disease has often produced considerable damage to the intestinal mucosa and sometimes other organs. Such period before diagnosis might involve both a silent and a symptomatic phase. The silent phase, or preclinical CD, might last several years after the biological disease onset. Evidence is accumulating that the symptomatic phase might also go undiagnosed for months or years. In fact, for each established case of CD, there are probably several undiagnosed cases, a classic iceberg phenomenon of disease. Such status quo--lagging behind diagnostic standards for many other diseases--effectively hampers efforts to block disease evolution and the development of complications. This is no longer tenable because CD is a debilitating, severe, and costly affection, whose incidence is rapidly rising worldwide. Here, we will review what is currently known on preclinical and undiagnosed CD and what could be done to improve accuracy and timeliness of diagnosis.

Screening Pelvic Examinations in Adult Women: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center

Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.