Risk Reducing Salpingo–oopherectomy
Risk reducing salpingo-opherectomy is an effective option for the primary prevention of breast and ovarian cancers. However, the decision making for your patient can be complex and emotionally charged.
This section is written to provide you with some useful information to assist you during the consult.
Our team at NZFCS offer a multidisciplinary approach to help your patient make an informed choice when considering RRSO.
- removal of both ovaries and fallopian tubes to prevent cancer
- Implies ovaries and fallopian tubes are normal at the time of removal
- Women with BRCA1 and BRCA 2 mutations
- Women with a strong family history of breast and or ovarian cancer without a genetic mutation
- Women who have a strong family history of breast and or ovarian cancer who choose not to have genetic testing
Should these Women see a Gynaecological Oncologist?
Internationally, this has been recommended for the following reasons:
- Gynaecological oncologists are trained in cancer care and prevention. They are able to provide more robust information about risk management and the role of RRSO
How Surgery is Performed
- Even though technically it can be done by a gynaecologist, it is important to identify the R and L adnexae separately as there is possibility of identifying occult cancers. The procedure is also done according to the guidelines of International gynaecological cancer bodies
- Pathology has to be examined according to the SEE-FIM protocol. This involves extensive sectioning of the fallopian tube
- Follow up and management of any occult cancers ,there is a 4-5% risk of picking this up
What Should be Discussed at the Consult?
Lifetime risks of ovarian cancer
- The lifetime risk of ovarian cancer in a BRCA1 mutation carrier is 40%
- The lifetime risk of ovarian cancer in a BRCA 2 mutation carrier is 12%
How much benefit is the surgery to cancer risk?
- There is an 80-90% reduction in the risk of ovarian cancer
- There is a 50% reduction in risk of breast cancer when the operation is performed in women before the menopause
- In the Prevention of Surgical Endpoints (PROSE) multicenter prospective cohort study showed that the surgical group had a lower all-cause mortality, breast cancer specific mortality and ovarian cancer specific mortality
- The discovery that many pelvis serous cancers arise in the fimbria of the fallopian tube raising the question whether bilateral salpingectomy with delayed oophorectomy could be an option. Data regarding the efficacy of this investigational approach is lacking.
What is the risk of surgery?
- Most of the RR-SO can be done with a minimal invasive approach and a UK study specifically looking at this cohort noted the surgical risk of 2-3%
- Risks include the usual risk associated with laparoscopic procedures including bleeding, infection and organ damage
Menopause and HRT after RR-SO
- Women who are premenopausal will be rendered menopausal by the surgery and can experience cardiovascular disease, osteoporosis and cognitive decline in later life
- Use of HRT does not negate the benefits of RR-SO in BRCA 1 and 2 carriers. There is also data to suggest that short-term use of HRT until the age of menopause is safe from a cancer perspective
Is there a role for hysterectomy?
- From a cancer perspective in BRCA 1/ 2 carriers there is no indication to do a hysterectomy. However, some women have other gynaecological conditions that also need managing at the time. This can include fibroids, heavy periods and endometriosis
- In women who are at an increased risk of endometrial cancer because of tamoxifen usage, hysterectomy seems a reasonable decision
- There should be good indication to do a hysterectomy as it does increase the surgical risk
Timing of Surgery
This can be contentious but most of the major professional bodies recommend;
- Delay surgery until 40y in BRCA1 unless there have been family members who developed cancer in 30’s
- Delay surgery until late 40’s in BRCA2 unless surgery is to decrease breast cancer risk or ovarian cancer that occurred at younger age in family member
(RRSO performed before 40 yr in BRCA1 carriers confers a 64% reduction in breast cancer risk compared to 50% reduction if carried out 40-50yr)
Surgical Guidelines for RRSO
- Inspect the upper abdomen, all peritoneal surfaces, omentum and diaphragm
- Obtain pelvic/abdominal washings for cytology
- Remove ovaries and fallopian tubes as completely as possible
- use a specimen retrieval bag to avoid port site contamination in case of occult cancers
- Label R and L side
- Alert pathologist to completely embed and step section each adnexa to look for occult malignancies (SEE-FIM protocol)
Why do Women Choose Risk Reducing Surgery?
- Proven in research to be effective in reducing risk of ovarian and breast cancer. There is no screening for ovarian cancer
- Way of taking control of anxiety producing situation
- Done by minimally invasive approach so decreases recovery time and complications
Why do Women Choose Not to Have Surgery?
- Concerns regarding the side effects of menopause
- Not the right time for them
- Alternative options e.g. coc, clinical trials
- Perception of risk
- Does not eliminate the risk to zero