Ovarian cancer can be a death sentence for many women. It is difficult to treat and often goes undetected until the late stages when it has spread to other organs in the pelvis and abdomen.
Actress Angelina Jolie has reportedly decided to have her ovaries and fallopian tubes removed, a procedure known as a bilateral salpingo-oophorectomy, to fend off getting the disease. Jolie is a carrier of a BRCA gene mutation, putting her at a 60 percent to 80 percent chance of developing breast cancer and a 25 percent to 40 percent chance of developing ovarian cancer.
Dr. Amanda Nickles Fader, associate professor and director of the Kelly Gynecologic Oncology Service at Johns Hopkins Hospital, says researchers are studying ways to detect ovarian cancer at an early stage. She talks about bilateral salpingo-oophorectomy.
Q: When is a bilateral salpingo-oophorectomy typically performed?
A: A BSO is performed for various indications, including a diagnosis of cancer; benign gynecologic conditions, such as an ovarian cyst or mass; or, in the case of Jolie, as a prophylactic measure to prevent ovarian cancer. In the latter instance, a risk-reducing salpingo-oophorectomy (RRSO) is a procedure for women with a substantially increased risk of ovarian, fallopian tube or breast cancer. Candidates for RRSO include those with a strong family history of premenopausal breast and/or ovarian cancer, women who carry a genetic mutation that puts them at risk for developing a gynecologic malignancy and women with a personal history of premenopausal, estrogen receptor-positive breast cancer. Because of the health risks these women face, an RRSO is considered to be a medically necessary, not elective, surgery.
Q: Who should consider undergoing an RRSO?
A: The most compelling populations in whom a preventive RRSO should be considered are those who carry breast cancer susceptibility genes BRCA 1 and 2 (or other genes), and women with a strong family history of ovarian, fallopian tube or breast cancer, even if they test negative for a BRCA gene. Studies show that women who fall in this high-risk category who undergo an RRSO have significantly lower breast cancer-specific and ovarian cancer-specific mortality rates than similar women who do not undergo the procedure. Given that the risk of ovarian cancer may be as high as 40 percent in this group, an RRSO is an important, life-saving option for them, with benefits far outweighing the risks of the procedure.
For premenopausal women at low risk for ovarian cancer, the risks of the procedure may outweigh the benefits. It was common practice to counsel women in their mid-40s or older who were planning a hysterectomy for benign indications to consider a concurrent BSO. However, new evidence from the Nurses' Health Study suggests that there is an increase in all-cause mortality in premenopausal women who undergo an elective salpingo-oophorectomy. Given that the risk of ovarian cancer for the general U.S. population is less than 2 percent, the risks of a BSO may outweigh the benefits in women with a low risk for developing ovarian cancer. However, postmenopausal women undergoing a hysterectomy procedure (especially those older than 60) should consider concurrent BSO to reduce this risk of cancer, as the likelihood of dying from complications from a BSO is considerably less in this setting.
Q: What are the risks of the procedure?
A: There are risks with any abdominal surgery, including bleeding and infection. However, when BSO is performed by an expert gynecologic surgeon, these risks are quite low and major surgical complications are unlikely. In most cases, a BSO can be performed safely via minimally invasive surgery through small incisions, a procedure associated with faster recovery times, fewer complications and little discomfort compared with surgery done through a larger abdominal incision. When performed in premenopausal women, longer-term health consequences include the potential for sudden, early menopause and infertility.
Q: How is a woman's overall health affected by the procedure?
A: In women with a high risk of ovarian or fallopian tube cancer, an RRSO is life-saving. However, the decision to undergo this procedure must be balanced with the risks of developing other health issues, including hot flashes, osteoporosis and potential effects on sexual health. The good news is that most women who elect to undergo an RRSO can expect to enjoy good health and quality of life, as many of the above issues may be treated successfully with low-dose hormone replacement therapy or non-hormonal therapies and healthy lifestyle modifications.
Q: Are more women with breast cancer getting "preventive" oophorectomies?
A: Yes. The proportion of hysterectomies accompanied by prophylactic oophorectomy in the United States has increased, from 29 percent in 1979 to 45 percent in 2004. As we have learned more about the breast cancer susceptibility genes and/or families with a high prevalence of gynecologic or breast cancers, we have also seen an increase in referrals for genetic testing and prophylactic surgical procedures in women at high risk. These timely referrals can be life-saving.
Q: What can women with a strong family history of ovarian or breast cancer do to decrease their risk of developing cancer?
A: Although it may provoke anxiety to learn that one is at high risk for developing cancer, this knowledge may be extremely empowering for women and families, as it can help them become proactive about their health care decisions and potentially save lives across multiple generations of family members. New guidelines from the Society of Gynecologic Oncology recommend genetic counseling and testing for any women with a personal history of ovarian, peritoneal or fallopian tube cancer, regardless of family history. Women who may be at high risk for ovarian, fallopian tube and/or breast cancer should consider a consultation with both a genetics counselor and a gynecologic or medical oncologist to help them understand their risks and to tailor their decision-making regarding risk-reducing interventions that may help prevent cancer altogether.
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