Tag Archives: ovarian cancer

Talcum Powder and Ovarian Cancer

Ovarian Cancer, ,
Diana Zuckerman, PhD, and Danielle Shapiro, MD, MPH Cancer Prevention & Treatment Fund

A growing body of evidence suggests that using talcum powder (also called talc) in the genital area can increase a woman’s chances of developing ovarian cancer. The more years she uses talc, the more likely she is to develop ovarian cancer.[1] Talc is an ingredient in many baby powders. If you have ever used talcum powder or baby powder, or if you are still using it on yourself or your baby, here’s what you need to know.

About 1.3% of women in the United States will be diagnosed with ovarian cancer in her lifetime.[2] Although this is much lower than the lifetime risk for developing breast cancer,[3] there is no recommended test to screen for ovarian cancer, so unlike breast cancer, ovarian cancer is rarely diagnosed early. When ovarian cancer is found early, a woman has nearly a 93% chance of surviving at least 5 years after she is diagnosed. Those chances drop off significantly to about 30% if the cancer is found after it has spread to other parts of her body.[4] According to the American Cancer Society, over 21,000 women are estimated to receive a new diagnosis of ovarian cancer in 2021, and almost 14,000 women are estimated to die from it.[5] 

Based on many research studies involving thousands of women, those who have used talcum powder are about 30% more likely to be diagnosed with ovarian cancer than women who have not.[6,7] This means that over her lifetime, a woman who uses talcum powder increases her chances of developing ovarian cancer from 1.3% to 1.7%. That is still a low risk for any individual woman, but if 1 million women use talcum powder, approximately 4,000 more of those women will develop ovarian cancer, compared to the number that would have developed ovarian cancer if they hadn’t used talcum powder.

How Good Is the Evidence?

Most of the evidence comes from a type of study known as a case-control study.  For these studies, researchers recruit two groups of women – women with ovarian cancer (called “cases”) and women without ovarian cancer (called “controls”). All of the women are asked to recall whether they used talcum powder in the past, and if so, how often and how it was used. These studies cannot tell us for sure that using talcum powder causes ovarian cancer, but they can tell us if women who report using the powder in the genital area are more likely to develop ovarian cancer.

It is possible that there is a bias in women’s responses. Women with ovarian cancer might inaccurately recall having used more talc in the genital area than they actually did, leading to a false association between genital use of talc and ovarian cancer. However, it does not seem likely that these results are due to biased answers or faulty memory. While there is never a guarantee that memories are 100% accurate, many women are very sure about whether or not they regularly used talcum powder in the genital area. The International Agency for Research on Cancer (IARC), a well-respected agency within the World Health Organization (WHO), concluded that there was an “unusually consistent” increased chance of developing ovarian cancer among women who reported using talcum powder in the genital area.[8] In addition, the results are consistent for one particular type of epithelial ovarian cancer, called serous carcinoma. If the association between genital talc use and developing ovarian cancer were due to faulty memory or biased responses, we would see an association between it and all forms of ovarian cancer. The fact that it is consistently associated with one type of ovarian cancer means it is more likely that these findings are accurate.[9]

Important Studies

Some of the most convincing evidence comes from two case-control studies published in 2016: the African American Cancer Epidemiology Study (AACES) and the New England study.[10,1]

The AACES study compared 584 African American women who had been diagnosed with ovarian cancer to 745 African American women who did not have ovarian cancer. The women in the study came from 11 different geographic regions of the United States, and women with ovarian cancer were compared to women of the same ages and from the same geographic regions.[10] In this study, talc use was common – about 63% of women with ovarian cancer and 53% of the healthy women said they had used talc.  

The study found that the women who had only used talc in the genital area, as well as women who used talc only in non-genital areas, or who used it in both, were significantly more likely to have been diagnosed with epithelial ovarian cancer than women who did not use talc. Those who used talc in the genital area had a more than 40% increased risk of cancer, whereas those who used talc only in non-genital areas had an increased risk of over 30%. Instead of having a 1.3% lifetime risk, the women who used talc in the genital area would have over a 1.8% risk. Johnson & Johnson has been shown to target African American women in their marketing of talc, and African American women are more likely to use the product than other women,[11] so it is important to understand the risks for this population. 

In that study of African American women, the women who had a respiratory condition (such as asthma) were slightly more likely to develop ovarian cancer if they used talc, compared to women who did not have a respiratory condition.[10] The researchers believe that talcum powder causes the body to develop inflammation, which is known to potentially cause the growth of cancer cells. Women who are more likely to develop inflammation, such as those who have an underlying respiratory condition, may be at a slightly higher risk of developing ovarian cancer from talc.

The New England ovarian cancer study also suggests that the body develops cancer as a result of inflammation caused by talcum powder.[1] The researchers compared approximately 2,041 women living in Massachusetts and New Hampshire who had been diagnosed with ovarian cancer with 1,578 women of the same age and geographic location who did not have cancer. They reported that the women who used talc in the genital area, whether or not they used it elsewhere in their bodies, were significantly more likely to be diagnosed with epithelial ovarian cancer. Most reported using Johnson & Johnson Baby Powder or Shower to Shower brand powder. Many body powders are now made with cornstarch instead of talc, but women who used powders made with cornstarch were not considered talc users in the study.

Overall, the women using talc were about 33% more likely to develop ovarian cancer. Instead of having a 1.3% lifetime risk, a woman who used talc increased their lifetime risk to about 1.7%. However, some women were more at risk than others. Women who used talc and were sterilized prior to menopause (underwent a tubal ligation or hysterectomy) or who took hormone therapy for menopausal symptoms were even more likely to develop ovarian cancer compared to other talc users. The researchers believe that the hormone estrogen may make women less vulnerable to the risk of talc.[1] 

One study published in 2020 reports that there are no consistent findings of a relationship between talc exposure and developing ovarian cancer.[12] However, it is important to note that the study was funded by the Cosmetics Alliance Canada and Industrial Minerals Association-North America. Since the researchers were funded by companies that profit off of talc use, that could have biased their results. Another study published in 2020 also found no statistically significant association between genital application of talc and ovarian cancer across 4 studies.[13] However, the researchers warn that their study may have been underpowered and could have missed a small increase in risk due to talc use. This is especially likely because there are some shortcomings in the research, such as inconsistency with how talc use was measured and no information about the amount of talc in the powders women reported using.

How Could Talc Cause Ovarian Cancer? 

Talc is often found in the same places in the earth as asbestos, so asbestos may be contaminating talc when it is mined.[14]  Asbestos is known to cause cancer in humans. In 2019, the U.S. Food and Drug Administration (FDA) found that a bottle of Johnson & Johnson baby powder tested positive for asbestos.[15] The FDA gathered a team of experts from 8 different federal agencies, and these experts developed recommendations for standardizing testing talc products for asbestos.[15,16]

However, this team of experts said that it is “irrelevant” whether the products contain asbestos because both asbestos and similar minerals (such as talc) are suspected of causing “similar pathological outcomes.”[16] In fact, microscopic photos of talc show that it can look very similar to asbestos, regardless of whether it is contaminated with asbestos. The team of experts asserted that talc, even without any asbestos present, is suspected to cause health problems. One reason that researchers believe genital application of talc can cause ovarian cancer is that talc can enter the ovaries and cause inflammation, and inflammation can cause cancer.[17,18] 

Lawsuits Over Talc and Cancer 

Since 2014, Johnson & Johnson has defended its talcum powder in lawsuits brought by families of women who had used their talcum powder products and died from ovarian cancer. In February 2016, the courts ruled in favor of the family of a woman who died of ovarian cancer at 62 years old. Particles of talc were found in her ovaries, which were removed after her cancer diagnosis. The courts overturned the ruling just a few months later based on jurisdictional issues that were not related to the science.[19] In another matter, a California woman with ovarian cancer won a $70 million dollar against Johnson & Johnson. She continues to fight for fair warning labels on the products it sells. A powder sold by the brand Assured already carries such a warning: “Frequent application of talcum powder in the female genital area may increase the risk of ovarian cancer.”[20]

There is some evidence that men may also be harmed by talc. For example, the courts ruled in favor of a New Jersey man because the powder had caused an asbestos-related lung cancer known as mesothelioma. In this case, the talcum powder was likely contaminated with asbestos. Despite the jury’s decision, Johnson & Johnson continues to deny claims that their product contains asbestos or that it causes cancer. However, the court held that exposure to asbestos from another source was not a likely cause of his cancer.[21] 

A 2018 investigation by Reuters examined Johnson & Johnson’s internal reports, company memos, and confidential documents from 1971 to the early 2000s.[22] According to the documents, as early as 1971, researchers from Mount Sinai Medical Center had told Johnson & Johnson that they had found traces of asbestos in the company’s baby powder made with talc. The documents suggest that Johnson & Johnson claimed that the tiny amount of asbestos found in some samples of its powders was too small to cause health problems, and the company lobbied the Food and Drug Administration to agree with that assessment. 

Currently, Johnson & Johnson is facing over 15,000 lawsuits from people who believe that their cancers were caused by talc products sold by the company.[16] In one lawsuit, a group of 22 women who developed ovarian cancer sued the company and were awarded $2 billion. The company tried to appeal the case before the Supreme Court, but in June 2021, the Supreme Court rejected the appeal, which means that the $2 billion award still stands.[23]

In May 2020, Johnson & Johnson announced that they would stop selling talc-based baby powders in the U.S. and Canada.[24] Nevertheless, the company denies any claims that their product is associated with cancer. Instead, they claim that they are no longer selling the talc-based powder due to low demand and “misinformation around the safety of the product and a constant barrage of litigation advertising.” The company will still sell baby powders that are cornstarch-based, rather than talc-based. 

The Bottom Line

While the scientific evidence has shown a consistent link between talcum powder and ovarian cancer and possibly other health risks, many questions remain. The bottom line question is: why take the risk?

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References

  1.     Cramer DW, Vitonis AF, Terry KL, et al. The association between talc use and ovarian cancer: A retrospective case–control study in two US states. Epidemiology. 2016;27(3): 334-346.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820665/
  2.     Torre LA, Trabert B, DeSantis CE, Miller KD, Samimi G, Runowicz CD, Gaudet MM, Jemal A, Siegel RL. Ovarian cancer statistics, 2018. CA: A Cancer Journal for Clinicians. 2018 Jul;68(4):284-96.
  3.     National Cancer Institute. Cancer Stat Facts: Female Breast Cancer. Seer.cancer.gov. https://seer.cancer.gov/statfacts/html/breast.html. 2020. 
  4.     U.S. Preventive Services Task Force. Final Recommendation Statement: Ovarian Cancer: Screening. Rockville, MD:U.S. Preventive Services Task Force. 2018. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/ovarian-cancer-screening1\
  5.     American Cancer Society. Key Statistics for Ovarian Cancer. Cancer.org. https://www.cancer.org/cancer/ovarian-cancer/about/key-statistics.html. Updated 2021. 
  6.     Berge W, Mundt K, Luu H, Boffetta P. Genital use of talc and risk of ovarian cancer: a meta-analysis. European Journal of Cancer Prevention. 2018; 27(3):248-57.
  7.     Terry KL, Karageorgi S, Shvetsov YB, Merritt MA, Lurie G, Thompson PJ, Carney ME, Weber RP, Akushevich L, Lo-Ciganic WH, Cushing-Haugen K. Genital powder use and risk of ovarian cancer: a pooled analysis of 8,525 cases and 9,859 controls. Cancer Prevention Research. 2013; 6(8):811-21.
  8.     International Agency for Research on Cancer. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Volume 93 Carbon Black, Titanium Dioxide, and Talc; 2010. http://monographs.iarc.fr/ENG/Monographs/vol93/mono93-8F.pdf
  9.     Berge W, Mundt K, Luu H, Boffetta P. Genital use of talc and risk of ovarian cancer: a meta-analysis. European Journal of Cancer Prevention. 2018; 27(3):248-57.
  10. Schildkraut JM, Abbott SE, Alberg AJ, et al. Association between body powder use and ovarian cancer: The African American Cancer Epidemiology Study (AACES). Cancer Epidemiology, Biomarkers & Prevention. 2016;25(10):1411-1417. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050086/
  11. Cohen R.  Talc linked to ovarian cancer risk in African-American women. Reuters Health News. June 6, 2016. https://www.reuters.com/article/us-health-talc-ovarian-cancer/talc-linked-to-ovarian-cancer-risk-in-african-american-women-idUSKCN0YO2T7
  12. Goodman JE, Kerper LE, Prueitt RL, Marsh CM. A critical review of talc and ovarian cancer. Journal of Toxicology and Environmental Health, Part B. 2020; 15:1-31.
  13. O’Brien KM, Tworoger SS, Harris HR, Anderson GL, Weinberg CR, Trabert B, Kaunitz AM, D’Aloisio AA, Sandler DP, Wentzensen N. Association of powder use in the genital area with risk of ovarian cancer. JAMA. 2020; 323(1):49-59.
  14. U.S. Food and Drug Administration. Talc. Fda.gov. https://www.fda.gov/cosmetics/cosmetic-ingredients/talc. Updated March 2020. 
  15. The Mesothelioma Center. FDA Panel Recommends Standardized Talc Testing for Asbestos. Asbestos.com. https://www.asbestos.com/news/2020/01/21/standardized-talc-testing-asbestos/. January 2020. 
  16. Reuters. Government experts urge new talc testing standards amid asbestos worries. Reuters.com. https://www.reuters.com/article/us-usa-fda-talc-testing/government-experts-urge-new-talc-testing-standards-amid-asbestos-worries-idUSKBN1Z92I4. January 2020. 
  17. Trabert B. Body powder and ovarian cancer risk–what is the role of recall bias?. Cancer epidemiology, biomarkers & prevention: a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2016; 25(10):1369.
  18. Penninkilampi R, Eslick GD. Perineal Talc Use and Ovarian Cancer: A Systematic Review and Meta-Analysis. Epidemiology. 2018; 29(1):41‐49. doi:10.1097/EDE.0000000000000745
  19. Taylor J. Missourinet. Johnson & Johnson case from St. Louis gets heard in Missouri Supreme Court. Missourinet. March 5, 2018. https://www.missourinet.com/2018/03/05/johnson-johnson-case-from-st-louis-gets-heard-in-missouri-supreme-court/
  20. DailyMed. LABEL: ASSURED MEDICATED BODY POWDER- menthol powder. Dailymed.nlm.nih.gov. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8dad6e4-748f-41c1-98d6-1afa836967ce. Updated November 2017. 
  21. Bellon T.  J&J, Imerys unit must pay $117 million in N.J. asbestos cancer case. Reuters. April 11, 2018. https://www.reuters.com/article/us-johnson-johnson-cancer-lawsuit/jj-imerys-unit-must-pay-117-million-in-n-j-asbestos-cancer-case-idUSKBN1HI2ZD
  22. Girion L, Wood M. Johnson & Johnson knew for decades that asbestos lurked in its Baby Powder. Reuters. December 14th 2018, https://www.reuters.com/investigates/special-report/johnsonandjohnson-cancer/#johnson-research-sidebar
  23. National Public Radio. Supreme Court Says A $2 Billion Verdict In A Baby Powder Cancer Case Should Remain. Npr.org. https://www.npr.org/2021/06/01/1002149828/supreme-court-johnson-johnson-talc-verdict-ovarian-cancer. June 2021.
  24. National Public Radio. Johnson & Johnson Stops Selling Talc-Based Baby Powder In U.S. And Canada. Npr.org. https://www.npr.org/2020/05/19/859182015/johnson-johnson-stops-selling-talc-based-baby-powder-in-u-s-and-canada. May 2020.

Ovarian Cancer CA-125 Blood Test: Does It Work?

Ovarian Cancer, Prevention, ,
Stephanie Portes-Antoine, Brandel France de Bravo, MPH, and Laura Gottschalk, PhD, Cancer Prevention and Treatment Fund

Ovarian cancer is a deadly disease because it is rarely diagnosed early. There is not yet an effective, life-saving screening tool for the early diagnosis of ovarian cancer.

When ovarian cancer is diagnosed in the early stage—before the cancer has spread beyond the ovaries—chances of a woman’s survival are very good, with about 93% of women surviving at least 5 years.  Unfortunately, only 15% of cases are caught this early, because the symptoms of ovarian cancer are not obvious. For women diagnosed with advanced ovarian cancer, the chances of 5-year survival drop to less than 30%.[1] Given the dramatic differences in survival outcomes between advanced and early onset diagnosis, it is vitally important to detect ovarian cancer early.

Most women whose ovarian cancer is detected in the late stages will have a relapse (usually many times) following their initial treatment, requiring additional treatment.[2] The most widely used test to screen for the recurrence of ovarian cancer is the CA-125. This blood test measures a protein that tends to be higher in women with ovarian cancer. The test was approved for use on women who have already been diagnosed with ovarian cancer once. In 2008, Dr. Vladimir Nosov from UCLA Medical Center and his co-authors reported that elevated levels of the CA-125 biomarker are found in approximately 83% of women with advanced stage ovarian cancer and 50% of patients with stage I disease.[3]

Is testing for this “biomarker” an effective way to tell early on if a woman’s ovarian cancer has returned? And what about women who have never been diagnosed with ovarian cancer? Why can’t the CA-125 test be used to screen them?

Women with No Symptoms or Who Have Never Been Diagnosed with Ovarian Cancer

Other studies have confirmed that CA-125 by itself is not sensitive enough to diagnose ovarian cancer in the very early stage of the disease, before there are symptoms. Dr. Saundra S. Buys is co-director of the Family Cancer Assessment Clinic at the Huntsman Cancer Institute in Salt Lake City, Utah. According to Dr. Buys, CA125 testing “may be appropriate to screen for ovarian cancer in women who have abdominal symptoms, but for women who have no medical symptoms, doing screening for ovarian cancer results in a lot of false-positives.”[4] False positives are test results that inaccurately show the person might have cancer. Dr. Buys based her conclusions on data for women ages 55 to 75 who were participating in a large study called the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial.[5]

In 2011, Dr. Buys and her colleagues published more results from that trial which involved more than 78,000 women. They concluded that using the CA-125 blood test to screen for ovarian cancer doesn’t prevent women from dying from the disease, it actually is harmful.[6] False positives resulted in many women having unnecessary surgery: 3,285 women received false positives and 1080 of these women underwent biopsy surgery. In 15% of cases, the unnecessary surgery caused serious complications. At the same time, there was no benefit in terms of survival for the women who took the test as compared with those who did not.

Women Who Have Previously Had Ovarian Cancer

CA-125 by itself is clearly not reliable at detecting early ovarian cancer in women of low or average risk—women who have never before been diagnosed with ovarian cancer, and women who have no symptoms. Is it at least effective at detecting a recurrence of ovarian cancer?  In 2010, Dr. Gordon Rustin of the Mount Vernon Cancer Centre in England published the results of a study done with women who had already been diagnosed with and treated for ovarian cancer. He found  that women who started chemotherapy early, based on a CA125 test result indicating relapse of ovarian cancer, did not live any longer than women who did not begin treatment until symptoms of relapse appeared.[7]

The Future of Ovarian Cancer Screening

Research is underway to evaluate whether the CA-125 test can be used more reliably, either by administering it only to women with other biomarkers that indicate increased risk (such as elevated levels of the protein HE4) or combined with other screening tests such as vaginal ultrasound.

Dr. Karen Lu from the MD Anderson Center at the University of Texas has had success correctly identifying postmenopausal women at high risk for ovarian cancer by measuring CA-125 at regular intervals and relying on a mathematical model. Only women whose CA-125 levels went up over time were given a vaginal ultrasound, and only those with suspicious findings on the ultrasound had surgery. This two-staged approach seemed potentially effective .[8] However, when this approach was studied on more than 200,00 women, it did not significantly prevent death from ovarian cancer.[9]

The Bottom Line:

The CA-125 test by itself is not a good screening tool for ovarian cancer. When used alone on women with no symptoms or previous history of ovarian cancer, it leads to many false positives. Among women who have already been treated for ovarian cancer once, it doesn’t seem to matter whether they get treatment for their ovarian cancer recurrence based on CA-125 results or based on their symptoms. Either way, women who relapsed and got treatment lived about the same amount of time.

References:

  1. The National Cancer Institute. Surveillance Epidemiology and End Results. SEER Stat Fact Sheets. Cancer: Ovary. http://seer.cancer.gov/statfacts/html/ovary.html
  2. NCI Cancer Bulletin. Early Chemo to Prevent Ovarian Cancer Recurrence Fails to Increase Survival. June 2, 2009. Volume 6/Number 11. http://www.cancer.gov/ncicancerbulletin/060209/page2
  3. Nosov V., et al. The early detection of ovarian cancer: from traditional methods to proteomics. Can we really do better than serum CA-125? American Journal of Obstetrics and Gynecology. September 2008: 199(3): 215-223.
  4. Reinberg, S. Ovarian screening Methods Inaccurate. National Women’s Health Resource Center. November 7, 2005. http://www.healthywomen.org/resources/womenshealthinthenews/dbhealthnews/ovariancancerscreeningmethodsinaccurate
  5. Buys S.S., et al. Ovarian cancer screening in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial: Findings from the initial screening of a randomized trial. American Journal of Obstetrics and Gynecology. November 2005: 193(5): 1630-1639.
  6. Buys S.S., et al. Effects of Screening on Ovarian Cancer Mortality: The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. The Journal of the American Medical Association. July 2011; 2011 (616):1.
  7. Rustin, G.J. and van der Burg. Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomized trial. Lancet. October 2010
  8. Lu, Karen et al. A 2-Stage Ovarian Cancer Screening Strategy Using the Risk of Ovarian Cancer Algorithm (ROCA) Identifies Early-Stage Incident Cancers and Demonstrates High Positive Predictive Value. Cancer. September 2013; 2013 (119):17.
  9. Jacobs  IJ, Menon  U, Ryan  A,  et al.  Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial . Lancet. doi:10.1016/S0140-6736(15)01224-6.

Choosing wisely: tests and treatments cancer patients usually DON’T need

Medical Treatments with Cancer Risks, , , ,
By Jennifer Yttri, PhD
2013

The thought of cancer is so frightening that many patients depend on their physicians to make all the decisions about screening, prevention, and treatment.  Or they may ask for whatever “new cure” they have heard about.  That can result in too many tests or treatments that do more harm than good.  Not every test, procedure, or medication is appropriate for every patient, and many are over-used. What is beneficial for one person isn’t worth the risks for another.

The best health decisions can be made when physicians take the time to talk with their patients and patients ask questions rather than just assuming the doctor always knows best.

The ABIM Foundation and Consumer Reports collaborated with specialty medical societies to create lists of “5 Things Physicians and Patients Should Question” as part of a national effort called Choosing Wisely (www.choosingwisely.org). These medical groups represent more than 500,000 physicians. The lists contain evidence-based recommendations made by experts. Here is the list of their recommendations on cancer.

Breast cancer screening

Breast cancer screening is done through mammograms, which are like x-rays.  A breast cancer diagnosis involves giving the cancer a stage (0 through 4, with 4 being the most advanced) based on the size of the tumor, how advanced it is, and how likely it is to spread. Other imaging tests, like PET, CT, and bone scans are not recommended for screening early stage breast cancer (stages 0-3), patients newly diagnosed with Ductal Carcinoma In Situ (DCIS), or people without symptoms. This testing does not benefit patients, and false-positives (test results that indicate cancer when no cancer is present) can lead to unnecessary procedures and misdiagnosis. For anyone who has been treated for early-stage breast cancer and is symptom free, mammograms and regular clinical exams are the best ways to check that the cancer has not come back.  Advanced imaging tests and tumor marker tests should only be used for patients with later-stage breast cancer.

Cancer therapy

The first round of cancer therapy works best at reducing or eliminating a tumor. Multiple treatments, including chemotherapy, will not always help get rid of cancer, especially more advanced cancers or tumors that return. After three different treatments, another round is unlikely to improve quality or length of life. It is better to stop therapy and not suffer through the side effects of treatment.  (In fact, there is some evidence that patients live longer, with better quality of life, if they stop aggressive treatments earlier.)

Cervical cancer screening

Women over 65 should stop being screened for cervical cancer if they have not previously shown risk for disease. Women under 30 should not have HPV tests to screen for cervical cancer. Women with mild dysplasia or cervical intraepithelial neoplasia (CIN1) for less than two years should not be treated for cervical cancer, as CIN1 is usually caused by a short-term HPV infection and goes away within a year.   See below for information about HPV testing. Pap smears should be used to screen for cervical cancer.

Colon cancer screening

For people who are at an average risk for developing colon cancer, tests such as stool tests and sigmoidoscopy can be used instead of colonoscopy to screen for colon cancer. Abnormal results from these tests require follow-up with a colonoscopy. The plasma test named methylated Septin 9 (SEPT9) is an alternative screening test but it is not recommended unless the more conventional tests and colonoscopy are not feasible.

HPV testing

HPV testing is not recommended for low risk infections, such as for HPV associated with genital warts. HPV testing should be used to identify high risk infections in patients with abnormal Pap smears or other clinical symptoms associated with high risk HPV infections.

Ovarian cancer screening

Women at average risk who do not have symptoms should not be screened for ovarian cancer. Screening using ultrasound or blood serum testing might detect early signs of cancer, but ovarian cancer is uncommon in women of average risk without symptoms. An abnormal result that isn’t cancer might require invasive follow-up, and those risks outweigh the benefit of early detection.

Ovarian cysts

Small, simple cysts are common in women and usually won’t affect their health. If one is found, the doctor will schedule an ultrasound to determine if the cyst is benign (not cancer). If the cyst is not cancerous, a follow up ultrasound and surgery is not recommended unless the cyst causes symptoms, like pelvic pain. If the cyst is suspected to be cancerous, a follow up ultrasound is not recommended because the cyst should just be surgically removed.  A second ultrasound is only recommended for larger cysts that the doctor could not be sure about.

Palliative care for bone metastasis

Cancers that spread to bones are often very painful. Local radiation is sometimes used to treat patients with one or a few bone metastases, but some doctors question if the increased risk of cancer warrants radiation as treatment for pain. The American Society for Radiation Oncology recommends using one dose of radiation to relieve pain from any bone metastasis. While another dose might be needed in the future, starting with one dose makes sense, since patients with bone cancer have a short life expectancy.

Prostate cancer screening

Men who do not have symptoms generally should not be screened for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam as it can lead to treatments that may do more harm than good. Gleason and prostate-specific antigen (PSA) tests are used to measure how aggressive prostate cancer is and how likely it is to spread. Imaging tests can then be performed to identify exactly where cancer has spread. These imaging tests, such as bone scans, PET, and CT, are not recommended for detecting disease in men who are newly diagnosed with low-grade prostate cancer. Imaging tests are expensive, can expose men to high levels of radiation, and are unlikely to provide more information about early prostate cancer. Only men with Gleason scores above 7 and PSA levels above 10 nanograms/mL should consider imaging tests.

Prostate specific antigen (PSA)

High PSA levels may be a sign of prostate cancer. However, having a low PSA level does not prevent prostate cancer nor does it mean there is no cancer. It was thought that antibiotics might lower PSA and protect men from prostate cancer. This has not been proven in clinical tests and is not recommended as an alternative preventive therapy.

Stage 1 non-small cell lung cancer (NSCLC)

Lung cancer is the most common type of cancer to spread to the brain. However, the chance of patients with Stage 1 lung cancer developing brain metastasis is very low. Because of the rate of false positives is much higher than the actual rate of brain metastasis, brain imaging by MRI or CT is not recommended for patients with stage 1 NSCLC unless they have neurologic symptoms.

Thyroid scans

Radioactive iodine is absorbed by the thyroid and can be used to give doctors a picture of what the thyroid looks like, how it is functioning, and if there are any nodules in the area. Imaging with radioactive iodine is not recommended for determining whether thyroid nodules are benign or cancerous unless the patient is hyperthyroid. Nodules should be biopsied if the thyroid functions normally.