Susan M. Lemagie, MD
ACOG has been spotlighted in many public debates over the last year. As I write this, the New York Times has another front-page article featuring the ACOG recommendation that birth control pills should be available over the counter.
In April, a federal judge ruled that Plan B One-Step emergency contraception should be available over the counter without age restrictions, consistent with scientific evidence. Earlier this month, the Justice Department filed a notice to appeal this ruling. Days prior to this filing, the US Food and Drug Administration approved the availability of Plan B One-Step without a prescription to adolescent girls ages 15 and older.
Clearly, the politics of women’s reproductive control remains solidly in the public eye. If you have not seen it yet, I recommend you watch the Public Broadcasting Service special about the history of the women’s movement to better understand today’s debate. “MAKERS: Women Who Make America” is a three-part documentary covering the women’s movement from the 1950s to today.
Robotic surgery debate
ACOG Immediate Past President James T. Breeden, MD, past District VIII chair, did a super job as president this last year. He mobilized ACOG’s rapid response to hot topics in the media, from politicians’ scientific blunders to robotic surgery. As evidence is published, ACOG is sorting out the marketing hype and salesmanship from the benefits and risks of robotic surgery. Vaginal hysterectomy is still the procedure of choice.
At the 2013 Interim District VIII Advisory Council Meeting, the topic of robotic surgery engendered a spirited discussion between Fellows and Junior Fellows. Residents are concerned about losing the art of vaginal surgery, in addition to competing with attending surgeons for the robot console. Hysterectomies, in general, are decreasing as more endometrial ablations and levonorgestrel intrauterine devices are being used to manage menorrhagia. The complication rate expert surgeons report may not accurately reflect the issues faced by general practice gynecologists, who do an average of 15 to 20 hysterectomies per year.
Hereditary breast and ovarian cancer
The recent New York Times article from Angelina Jolie describing her decision for bilateral prophylactic mastectomy, nipple conservation, and breast reconstruction in light of her mother’s early death from breast cancer and her discovery of her own BRCA1 carrier status will likely catch your patients’ attention. Even in Alaska, my phone rings off the hook with this type of news item. You will want to refresh your memory about which patients warrant referral to a genetic counselor for additional evaluation.
ACOG Practice Bulletin #103 “Hereditary Breast and Ovarian Cancer Syndrome” addresses the role ob-gyns should play in identifying, managing, and counseling patients with inherited cancer risks. It recommends further genetic risk assessment for women who have more than a 20% to 25% chance of having an inherited predisposition to breast or ovarian cancer. These women include:
- Women with a personal history of both breast cancer and ovarian cancer
- Women with ovarian cancer and a close relative—defined as mother, sister, daughter, grandmother, granddaughter, aunt—with ovarian cancer, premenopausal breast cancer, or both
- Women of Ashkenazi Jewish decent with breast cancer who were diagnosed at age 40 or younger or who have ovarian cancer
- Women with breast cancer at 50 or younger and who have a close relative with ovarian cancer or male breast cancer at any age
- Women with a close relative with a known BRCA mutation
Genetic risk assessment may also be appropriate for women with a 5% to 10% chance of having hereditary risk. Refer to the Practice Bulletin for a complete discussion of risk factors in these women.
Screening for breast cancer in women with BRCA mutations should start at age 25 or sooner based on earliest age onset in the family. Screening should include semiannual clinical breast exams, as well as annual mammograms and breast magnetic resonance imaging. Screening for ovarian cancer in women with BRCA mutations should start between the ages of 30 and 35 or five to 10 years sooner than the earliest age onset in the family. Screening should include periodic screening with CA 125 and transvaginal ultrasonography.
It is important to remember that the gene mutations can come from either the mother’s or father’s side, so both sides of a woman’s family should be carefully examined. Hereditary breast and ovarian cancers are also associated with other rare hereditary cancer syndromes, such as Li-Fraumeni and Cowden syndromes and hereditary diffuse gastric cancer. Thus, the guidance of a professional genetics counselor is warranted.
Ob-gyns play a crucial role in identifying women at risk for hereditary cancer, providing them with important counseling and peer support, and educating them about strategies to manage risk, including surveillance, chemoprevention, and surgery. Prophylactic surgery receives much media attention, but it is not the only option. We need to step forward as compassionate experts who are truly women’s health care physicians.
New ACOG app available
Have you tried out the new ACOG app for iPhone and iPad yet? It features ACOG news, Committee Opinions, contact information for ob-gyns, as well as information for our patients. It will soon be released for Android as well.
Tests and procedures to question
In February, ACOG released a list of the top five tests and procedures to question in ob-gyn as part of the Choosing Wisely campaign, led by the American Board of Internal Medicine Foundation. The five tests and procedures are:
- Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age
- Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable
- Don’t perform routine annual Pap tests in women 30 to 65 years of age
- Don’t treat patients who have mild dysplasia of less than two years in duration
- Don’t screen for ovarian cancer in asymptomatic women at average risk
The ACOG Congressional Leadership Conference, The President’s Conference (CLC), in Washington, DC, March 3–5, was dynamite! Many members consider this the best ACOG event of the year. The conference teaches attendees how to lobby and allows them to interact with members of Congress on behalf of their patients.
At the CLC, we celebrated the million-dollar milestone of ACOG’s federal political action committee, Ob-GynPAC, with $1 million raised from ACOG members. Currently, 7% of District VIII members support Ob-GynPAC. We need everyone’s support so we can continue to promote women’s health and support those who align with our agenda in Congress. (You will not be favored or disadvantaged by reason of the amount of your contribution or a decision not to contribute. Contributions from foreign nationals are not permitted.)
Because of the enthusiasm and support of our Junior Fellows, we have added a Junior Fellow legislative chair position to the District Advisory Council. The council has also recommended that each section add a Junior Fellow legislative chair position to its officers. If you have legislative concerns in your state that need to be addressed, ACOG can help. Each District VIII section has a legislative chair who can assist with coordinating efforts. More information and helpful resources are available on the State Legislative Activities website.
Congratulations to the Hawaii Section for its honorable mention for the ACOG Improvement in State Legislative Advocacy Award and to the Montana Section for its honorable mention for the ACOG Accomplishment in State Legislative Advocacy Award. The Hawaii Section worked hard to pass legislation that would require emergency contraception provision for rape victims in Hawaii. The Montana Section worked hard to pass legislation for maternal mortality review in Montana.
Register now for the 2013 Annual District Meeting at the Grand Wailea Resort, in Maui, HI, September 26–28. The joint meeting will be held with Districts V, VI, and IX. View an ADM teaser from Tod C. Aeby, MD, District VIII program chair.
The Second Annual Dancing with the Docs competition will happen on Saturday night, September 28, in the Tsunami Room, with all proceeds benefitting the Ob-GynPAC. Two groups from each district will compete for the mirror ball trophy. Join the fun! See you in Hawaii!