See Chapter 2.

Breast cancer is the most common cancer in women, with a lifetime incidence of 12%. For those at average risk, the American College of Obstetricians and Gynecologists (ACOG), the American Cancer Society (ACS), and the National Comprehensive Cancer Network (NCCN) recommend routine mammography annually beginning at age 40 years. The U.S. Preventive Services Task Force (USPSTF), in contrast, recommends biennial screening between ages 50 and 74 years. In addition, ACOG recommends regular clinical breast examinations in all women as well as breast self-examination in high-risk women.

ACOG and the Society of Gynecologic Oncology recommend referral for genetic counseling and BRCA testing in patients with 20% or greater chance of having an inherited predisposition to developing breast or ovarian cancer. This includes women with the following family history:

Additionally, further genetic risk assessment may be helpful in the following women (estimated to have between 5% and 10% risk of having an inherited predisposition toward developing breast or ovarian cancer):

Women at high risk for breast cancer, such as those with BRCA1 or BRCA2 mutations, may undergo prophylactic mastectomies to reduce their risk of breast cancer.

Lung cancer, the second most common cancer in women, is the leading cause of cancer-related death. In 2009, in the United States, 95,784 women were diagnosed and 70,387 died from lung cancer.

Risk factors include cigarette smoking (associated with 90% of lung cancers), radiation therapy, environmental toxins such as asbestos, and pulmonary fibrosis.

The majority of studies examining screening modalities for lung cancer (via chest x-ray, sputum cytology, or computed tomography [CT] scan) have failed to show a mortality benefit from early detection of lung cancer. In 2011, the National Lung Screening Trial was the first to show approximately a 20% mortality benefit in asymptomatic heavy smokers (>30 pack-year history) screened with low-dose CT scans. The 2013 ACS recommendation (in abstract form) is that providers discuss lung cancer screening with a low-dose helical CT of the chest for patients between
ages 55 and 74 years with at least a 30 pack-year smoking history. At this time, the recommendation is that providers and patients have an informed discussion about the current data regarding lung cancer screening and use shared decision making to decide whether to initiate lung cancer screening.

Smoking may confer a greater relative risk for women than men; however, many of the early studies on lung cancer screening did not include women. It is theorized that screening in women may have different outcomes due to higher rates of peripherally located adenocarcinoma.

Smoking cessation, as well as continued abstinence in nonsmokers, is the single most important modifiable risk factor for lung cancer.

Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer in women, with an annual incidence of 38.9 per 100,000. Most colorectal cancers have a long latency period and are curable or easily treatable if detected at an early stage.

Risk factors include a family history of colorectal cancer, a personal history of colon polyps or cancer, a personal history of inflammatory bowel disease, and the genetic syndromes familial adenomatous polyposis and hereditary nonpolyposis colon cancer (HNPCC). High-risk individuals should be screened with colonoscopy beginning at earlier ages depending on risk.

Women with a diagnosis of HNPCC should initiate screening at age 20 to 25 years or 10 years before the youngest age of colon cancer diagnosis in the family.

The USPSTF recommends screening for colorectal cancer for all persons aged 50 years and older. The American College of Gastroenterology recommends beginning screening at age 45 years in African Americans due to higher incidence and earlier age of onset.

Many screening protocols exist, including flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, double-contrast barium enema every 5 years, CT colonography every 5 years, guaiac-based fecal occult blood test annually (two samples from each of three consecutive stools), fecal immunochemical test annually, and stool DNA test. The 2008 U.S. Multi-Society Task Force on Colorectal Cancer guidelines support any of the aforementioned regimens; ACOG encourages colonoscopy but ultimately recommends shared decision making to determine which screening modality the patient is most likely to comply with.

See Chapter 47.

No routine screening is recommended for asymptomatic women. Certain highrisk groups (those with known or prior endometrial hyperplasia or patients with HNPCC) may undergo screening, such as endometrial biopsy, pelvic ultrasound, dilation and curettage, or a combination of these. All episodes of postmenopausal bleeding should be investigated. Additionally, in premenopausal obese women with a significant change in bleeding pattern, endometrial sampling should be considered.

Melanoma is the seventh leading cancer in women; risk factors include light skin tone and ultraviolet ray exposure, particularly childhood sunburns. People with between 50 and 100 typical nevi or large congenital nevi are also at increased risk (relative risk of 5 to 17 and >100, respectively).

Although there are no consensus guidelines for total skin examination, ACOG recommends evaluation in those patients at high risk. All patients should be educated regarding sunscreen use and ultraviolet ray avoidance. In particular, all atypical vulvar lesions should be thoroughly investigated (see Chapter 44.)

Guidelines regarding suspicious lesions are as follows:

See Chapter 48.

No North American expert group recommends routine screening for ovarian cancer. Instead, a careful family history and an annual pelvic exam are recommended for all women.

Women at high risk for ovarian cancer, such as those with BRCA1 or BRCA2 mutations, may undergo prophylactic bilateral salpingo-oophorectomy to reduce their risk of ovarian cancer.

See Chapter 46.

Routine screening for cervical cancer with either liquid-based or conventional Papanicolaou (Pap) testing is recommended starting at age 21 years, regardless of age of first sexual activity. The ACS and ACOG have suggested that women between the ages of 21 and 30 years should be screened with cytology alone every 3 years, provided the patient does not have a history of cervical intraepithelial neoplasia grade 2 (CIN 2) or worse, is not HIV positive or immunocompromised, and has no history of diethylstilbestrol exposure. Routine human papillomavirus (HPV) testing is not recommended in this age group given the high incidence of transient asymptomatic infection. Women ages 30 to 65 years should be screened every 5 years with cotesting (cytology and HPV testing). Alternatively, Pap screening with cytology alone (without HPV testing) every 3 years may be performed, but cotesting is preferable. After age 65 years, no further screening is recommended if the patient has had adequate negative screening for the past 10 years. Women with prior loop electrosurgical excision procedure/cryotherapy should continue agebased screening for at least 20 years from procedure.

ACOG and the USPSTF both agree that cervical cancer screening may be discontinued for women who have had a total hysterectomy for benign indications and no history of CIN 2 or worse.

Women with abnormal Pap smears should be managed per the American Society for Colposcopy and Cervical Pathology guidelines.

There are currently two U.S. Food and Drug Administration-approved vaccines for the primary prevention of cervical cancer. Cervarix protects against high-risk HPV strains 16 and 18 known to cause cervical cancer, and Gardasil protects against HPV 6, 11, 16 and 18 conferring additional benefit against HPV strains known to cause genital warts. ACOG recommends universal vaccination of women against these HPV strains before initiation of sexual activity (as early as age 9 years) as well as in sexually active women up to age 26 years. Women who have received HPV vaccination should be screened for cervical cancer using the same schedule as unvaccinated women.