Risk Reducing Surgery | Chris O'Brien Lifehouse

General Considerations

Chemoprevention

Oral contraceptive pill The use of OCPs is associated with a risk reduction in ovarian cancer of almost 50%, with longer duration of use (>3 years) associated with further reductions in risk, and this risk reduction persists after cessation of the OCP. The cardiovascular risks for women in the general population taking the OCP are well known, however both the breast cancer and cardiovascular risk for women at high risk of ovarian cancer taking the OCP is uncertain. The possible risks need to be balanced against the likely benefits of prescribing the OCP to women to reduce their risk of ovarian cancer.

Issues around surveillance

Ovarian cancer surveillance is not recommended for women at high or potentially high risk. Evidence shows that ultrasound or CA125, singly or in combination, is not effective at detecting early ovarian cancer. The most effective risk-reducing strategy for ovarian cancer is bilateral salpingoophorectomy.

Risk-reducing salpingo-oophorectomy

Risk-reducing salpingo-oophorectomy is a surgical procedure which includes the complete removal of both fallopian tubes and ovaries. RRSO provides a substantial reduction in the risk of developing ovarian and fallopian tube cancers in women with a BRCA1/2 gene mutation.

  • Impact on survival

    RRSO reduces all-cause mortality by 60%, ovarian cancer- specific mortality by 79% and breast cancer-specific mortality by 56%. A survival benefit of RRSO, has been suggested when performed by age 40 (and when combined with prophylactic mastectomy).

    Ovarian cancer

    For BRCA1/2 mutation carriers treated with RRSO resulted in a 79% reduction in gynaecologic cancer.

    Breast cancer

    For BRCA1/2 mutation carriers RRSO results in a 51% reduction in breast cancer The risk reduction may be more for BRCA2 mutation carriers than for BRCA1 mutation carriers. There was evidence for an age effect, with greater reduction in breast cancer risk for BRCA1 carriers who had RRSO before the age of 50, compared to after age 50.

    Peritoneal cancer

    Primary peritoneal carcinoma may occur despite risk-reducing surgery but is uncommon (≤1%)

    Lynch Syndrome

    In women with Lynch Syndrome, there is an increased risk of cancer of the uterus and ovaries, among other cancers. Prophylactic surgery should be considered in these women from around the age of 35 in those who do not wish to preserve their fertility.

    Occult cancers

    Occult cancers have been detected in the fallopian tubes and ovaries at RRSO. Rates of occult ovarian cancer detected at RRSO range from 0 to 17%. They were more often detected in BRCA1 mutation carriers and were often of fallopian tube origin as cancers tend to develop at an earlier age in this population.

  • – Menopausal symptoms

    The main symptoms experienced after RRSO are those associated with surgically-induced menopause. Women more commonly report night sweats, sleep disturbance, hot flushes, and loss of interest in sex and have significantly more severe vasomotor symptoms than women who go through natural menopause. Those who had RRSO before age 50yrs have more palpitations than those with RRSO at ≥ 50yrs. Hormone replacement therapy (HRT) is effective in the management of menopausal symptoms following RRSO. There appears to be no increased risk of breast cancer in BRCA1/2 mutation carriers taking short-term HRT following RRSO performed before age of 50.

    – Long-term health effects

    Studies showed women who had RRSO before age 45 and who had not received oestrogen up until age 45 had significantly higher cardiovascular mortality, compared to women who did have oestrogen following RRSO up until age 45 who showed no increase in mortality. In addition to adverse effects on cardiovascular and bone health, increased risk of Parkinson disease and dementia were also reported.

    – Sexual dysfunction

    Women who undergo RRSO experience more pain/discomfort during sexual activity than those in control groups.

    – Quality of life following RRSO

    There is no consistent evidence of an overall impact on quality of life, either positive or negative, following RRSO. There is reduced anxiety in women following RRSO and also a high level of satisfaction with their decision. There is evidence of reduced cancer worry in women, about both ovarian and breast cancer, following RRSO. Cancer worry is lowest in women who had both RRSO and prophylactic mastectomy. Women who have RRSO report more bodily pain at 12 months post- assessment than before the surgery. Women also report more discomfort (vaginal dryness and dyspareunia), less pleasure and satisfaction during sexual activity and more endocrine symptoms than women who have not undergone RRSO.

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