COMMENTARY

Well-Woman Care: The Evidence That Less Is More

Kenneth W. Lin, MD, MPH

Disclosures

April 17, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hello, everyone. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.

The content and performance of well-woman exams has changed significantly since I began my family medicine residency nearly two decades ago. At that time, it was not unusual for me to screen for cervical cancer in a sexually active teenager, and to advise most women to return for a Pap smear and clinical breast exam every year. I remember our clinic's medical director admonishing the residents not to skip routine breast and pelvic exams in women without symptoms.

Times have changed. Cervical cancer screening is no longer recommended for any woman younger than age 21, and a woman with a normal Pap smear and/or negative high-risk HPV test can now wait 3-5 years to repeat screening.[1] The American College of Physicians (ACP) and the American Academy of Family Physicians have concluded that in women without symptoms who are up-to-date on cervical cancer screening, the screening pelvic examination is unnecessary.[2]

And in a guidance statement published in April 2019 on screening for breast cancer, the ACP recommended not performing clinical breast exams in average-risk women[3] without breast symptoms due to a lack of benefit and potential harm, echoing the position of the American Cancer Society.[4] In women who are receiving regular screening mammography, the clinical breast exam does not detect additional cancers but produces more false positives and can lead to unnecessary biopsies.

Although some colleagues of my and previous generations may not be completely comfortable with these guideline changes, I feel that "less is more," as the time saved by no longer providing inappropriate services in the well-woman exam can be utilized for other tasks that are more likely to benefit patients.

Deintensifying recommendations in clinical practice guidelines is relatively uncommon. For example, an analysis of recommendations in 22 guidelines for outpatient care of patients with diabetes and cardiovascular disease[5] found that 71% preferentially recommended intensifying care, while only 29% recommended discontinuing medical services or delivering them less frequently or at a lower intensity.

Recent federal regulations and recommendations now threaten to replace discontinued components of the well-woman exam with other well-intentioned services that unfortunately have little basis in evidence. On March 27, 2019, the FDA announced that it would amend mammography quality standards to require specific language about breast density in lay patient summaries and medical reports that would encourage women with dense breasts to undergo additional imaging. A study of state laws on dense breast notification after screening mammography[6] found that such laws are associated with more supplemental breast ultrasound screening and more cancers detected. The problem with making dense breast notification mandatory nationwide is, as I discussed in a previous Medscape commentary, that while we do know that additional testing in women with dense breasts increases false-positive rates,[7] we don't know if it improves breast cancer outcomes[8] or only leads to more anxiety, more biopsies, and more overdiagnosis.

Similarly, last year the Women's Preventive Services Initiative (WPSI), a federally funded collaboration of medical specialty organizations that develops recommendations for women's preventive healthcare services, recommended screening all women for urinary incontinence every year,[9] even though the group's own review found insufficient evidence[10] that systematic annual screening improves health outcomes.

The WPSI is now seeking public comment on a draft recommendation to screen for anxiety in all adolescent and adult women, which has a similar dearth of supporting evidence on benefits and harms.

Although expanding the scope of the well-woman exam to include more screening for breast cancer, urinary incontinence, and anxiety may seem innocuous enough, I would argue, as have others,[11] that clinical practice guidelines should only increase burdens on clinicians and patients when there is strong supporting evidence that doing so helps patients live longer or better. Time is a limited resource in primary care, and past experience with recommendations based on weak evidence demonstrates that the road to poorer health is paved with good intentions.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.

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