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Female BRCA1/BRCA2 mutation carriers are known to have an elevated risk for developing ovarian, fallopian tube, peritoneal, and breast carcinoma. Ablative surgery with bilateral salpingo-oophorectomy (BSO) has been shown to significantly reduce this risk to a greater degree than surveillance or chemoprevention alone. However, the impact of surgically induced menopause on cancer risk must be balanced against overall health implications and quality of life.
To gain greater insight into the holistic effect of BSO, international investigators extended a prior study (Gynecol Oncol 2011; 121:163) to follow 5783 BRCA1 or BRCA2 mutation carriers for an average of 5.6 years; 47% had a history of breast cancer. The researchers used time-dependent survival analysis to determine hazard ratios for oophorectomy-associated cancer incidence and all-cause mortality.
A total of 186 women developed ovarian (132), peritoneal (32), or fallopian cancer (22). Of these, 108 with intact ovaries were diagnosed through symptoms or screening, 46 had an occult cancer at the time of oophorectomy, and 32 had peritoneal cancer after oophorectomy. A total of 68 patients died. In women with intact ovaries, the annual rate of cancer diagnosis was 0.91% for BRCA1 mutation carriers and 0.30% for BRCA2 mutation carriers. For ovarian, fallopian, or peritoneal cancer associated with BSO, the hazard ratio was 0.20 (P<0.001). For all-cause mortality to age 70 associated with BSO in women with no history of cancer at baseline, the hazard ratio was 0.23 (P<0.001).
Finch AP et al. Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation. J Clin Oncol 2014 Feb 24; [e-pub ahead of print]. (http://dx.doi.org/10.1200/JCO.2013.53.2820)
Comment
These results confirm that bilateral salpingo-oophorectomy has a very significant impact on all-cause mortality in BRCA1 and BRCA2 mutation carriers, including those with a history of breast cancer. This finding suggests that the protective effect extends to beyond those at risk for ovarian cancers. The practical implication is that the age distribution of ovarian cancer should not be the primary determinant of the age to perform a BSO. Additionally, efforts to provide genetic testing in low-resource countries must be considered worthwhile as surgical intervention may be available, whereas more advanced screening modalities may be out of reach.