BALTIMORE _ 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
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
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
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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
(c)2013 The Baltimore Sun
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