Preventive ovary removal for BRCA carriers reduces mortality
the ONA take:
Preventive ovary removal for BRCA carriers reduces mortality and cancer risks
Rebecca McLamara, RN, OCN, provides additional commentary on this topic. To read it, click here.
Women who carry a BRCA gene mutation and opt for a preventive oophorectomy had an 80% reduction in the risk of ovarian, fallopian tube, or peritoneal cancer. Also, they had a 77% reduction in all-cause mortality.
The best age for women to have the surgery and its impact on mortality has not been well studied. This study, published in the Journal of Clinical Oncology (2104; doi:10.1200/JCO.2013.53.2820), is the first to observe these effects over a nearly 6-year follow-up period.
The study identified 5,783 women from an international registry who had a BRCA1 or BRCA2 mutation. The women completed a baseline questionnaire and one or more follow-up questionnaires. Their average age at cohort entry was 46.0 years. The women were followed for an average of 5.6 years, until either a diagnosis of ovarian, fallopian tube, or peritoneal cancer; death; or date of most recent follow-up.
Among the 5,787 women, 2,274 did not have oophorectomy, 2,123 had already had the surgery when they began the study, and 1,390 underwent oophorectomy during the study follow-up period. After an average follow-up period of 5.6 years (with some women followed for as long as 16 years), 186 women developed either ovarian, fallopian tube, or peritoneal cancer.
Of the 511 women who died during this study, 333 died of breast cancer; 68 from ovarian, fallopian tube, or peritoneal cancer; and the remainder from other causes. Prophylactic oophorectomy reduced the risk of death by any cause by 77% (largely by lowering the risks of ovarian, fallopian tube, peritoneal, and breast cancers). Corresponding author Steven Narod, MD, a senior scientist at Women's College Research Institute in Toronto, Ontario, Canada, noted that the 77% risk decrease is even greater than the benefit of chemotherapy, and was equally strong for both BRCA1 and BRCA2 mutation carriers.
The authors explained that, although the 77% reduction in mortality risk after oophorectomy largely came from the reduced incidence of ovarian, tubal, and peritoneal cancers, an important component also came from reducing incidence and mortality from breast cancer. A total of 46 invasive cancers were identified in 1,390 women at the time of prophylactic oophorectomy. These cancers had a prevalence of 4.2% in BRCA1 mutation carriers and 0.6% in BRCA2 mutation carriers.
"Our study supports the notion that women who carry a BRCA gene mutation will have a much lower risk of developing or dying from cancer if they have an oophorectomy at age 35 [years]," said Narod. "If a woman with a BRCA1 mutation opts to delay the surgery until age 40 or 50 [years], her chance of developing ovarian, fallopian tube, or peritoneal cancers jumps to 4% or 14.2%, respectively."
The results differed between mutations in BRCA1 and in BRCA2. Narod explained, “To me, waiting to have oophorectomy until after 35 [years] is too much of a chance to take. These data are so striking that we believe prophylactic oophorectomy by age 35 should become a universal standard for women with BRCA1 mutations. Women with BRCA2 mutations, on the other hand, can safely delay surgery until their 40s, since their ovarian cancer risk is not as strong."
Although oophorectomy is a safe procedure, it can carry some complications, including premature menopause. The study also stated that previous studies had found that women who had an early oophorectomy reported an increase in symptoms of menopause such as hot flashes and palpitations, loss of libido, and a modest decrease in quality of life.
"After an oophorectomy, the long-term effects on a woman's cardiovascular health and her bone health are less well known, and further research is needed," said first author Amy P.M. Finch, MD, also of the Women's College.
Preventive strategies for reducing cancer risks are exciting, and since the Journal of Clinical Oncology published the results of a study by Finch and colleagues, women are provided more data about the benefit of prophylactic oophorectomy for BRCA mutation carriers.1 The data not only show an 80% reduction in the risk of ovarian, fallopian, or peritoneal cancer in BRCA mutation carriers after preventive oophorectomy, but a 77% reduction in all-cause mortality as well.1
With a discussion on the exciting news about the benefits of risk-reducing surgery, comes the importance of discussing the quality-of-life concerns that may be faced after surgical menopause. As many women will certainly choose risk-reducing measures such as oophorectomy, it is still important for the woman to understand life after oophorectomy; not only to understand the effects of menopause but also to begin the discussion about how to live with these effects. Support for women facing this decision and living with its effects should be as important as the surgery itself. Quality of life should not be taken for granted during discussions with women about preventive surgery.
Rebecca McLamara, RN, OCN, is the survivorship and genetics coordinator at Global Robotics Institute at Florida Hospital Celebration Health in Celebration, Florida. She is also the author of “Addressing the psychological impact of BRCA testing” (Oncol Nurse Adv. 2014;5:29-31).
1. Finch AP, Lubinski J, Møller P, et al. Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation [published online ahead of print February 24, 2014]. J Clin Oncol. 2014.