Preventing BRCA-related cancers: The case for oophorectomy
The team that conducted the recent prospective trial of risk-reducing surgery versus surveillance reviews the evidence, plus surgical technique, psychosocial factors, use of estrogen after surgery, and insurance issues.
Is anxiety a factor?
We have limited information about the psychosocial impact of RRSO. Several studies have found that a patient’s level of anxiety is a more important factor than objective cancer risk in the decision to undergo RRSO.30,31 Unfortunately, we do not yet know whether the surgery successfully reduces these patients’ subjective concerns.
A recent study showed that risk-reducing surgery did not impair women’s overall health or psychological well-being.32 However, 20.7% of the women reported substantial cancer-related anxiety despite the risk-reducing surgery. This issue requires further investigation.
Is estrogen the best option for surgical menopause?
The role of hormone replacement after RRSO is unclear. The issue is important because many women considering salpingo-oophorectomy are in their late 30s or early 40s, when premature surgical menopause is a predictable result. Consequences can include considerable vasomotor and pelvic symptoms.
Preliminary data suggest that a woman’s satisfaction with RRSO depends in large part on its impact on sexual functioning.32 Urogenital symptoms that adversely affected sexual function, such as vaginal dryness and dyspareunia, were the most significant predictors of dissatisfaction with surgery.
Premature surgical menopause also has a substantial impact on osteoporosis risk, while its effect on heart disease remains uncertain.
While nonhormonal therapies can address each of these issues, we need more data on their long-term use. We counsel women considering RRSO that hormone replacement may be an option. We believe it is unlikely to reduce the efficacy of RRSO in preventing ovarian cancer, but it may reduce the protective effect of RRSO against subsequent breast cancer. Until further studies are available, we recommend that decisions regarding hormone replacement be individualized to the patient’s specific symptoms and personal history.
Not all insurers cover RRSO
One study explored insurance carriers’ policies about reimbursing risk-reducing surgical procedures and found that 10% to 11% of private insurers and 48% to 50% of governmental carriers had policies specifically denying coverage for such operations.
An additional 40% to 64% of insurers had no identifiable policy regarding these procedures in women with BRCA mutations.33 The authors speculated that, without identifiable policies, this critical health-care decision may be subject to arbitrary criteria that result in substantial variation.
When we recently investigated the reimbursement experience of women with BRCA mutations undergoing RRSO at our institution, we found that 97% of the procedures were reimbursed in full, less any applicable coinsurance and deductibles.34 Two important limitations of our study: It was conducted at a tertiary cancer center and was retrospective. It is not known if the findings reflect the experience of women with BRCA mutation who have risk-reducing surgery in other settings.
Unresolved issues
RRSO clearly has a role in preventing breast and ovarian cancer in women at inherited risk. However, several questions remain unanswered:
- Who is the best candidate?
- What is optimal timing of the procedure?
- What, if any, concomitant procedures should be performed?
- What is the role of hormone replacement after the surgery?
These issues will be best addressed through multicenter prospective trials, such as the one now being conducted by the Gynecologic Oncology Group.
Hope also remains that further research will improve serum and radiological detection of early ovarian cancer, and that basic research on the molecular etiology and progression of these cancers will ultimately render it unnecessary to remove organs at risk.
The authors report no financial relationships relevant to this article.
