It is well-known that women who carry a mutation in BRCA1 or BRCA2 are at high risk to develop breast cancer (50-85% lifetime risk) and ovarian cancer (15-60% lifetime risk). Because the screening options for ovarian cancer (transvaginal ultrasound, the blood test CA-125, and physical exam) are not effective at finding ovarian cancers at earlier more treatable stages, and because the survival rates of ovarian cancer are low, the recommendation has long been for female BRCA carriers to have their fallopian tubes and ovaries removed in a procedure called bilateral salpingo-oophorectomy (BSO). Most recommendations call for BRCA carriers to have a prophylactic (preventative) BSO after childbearing or by age 40, although some protocols recommend age 35 or even younger, based on the family history of cancer.
This preventative surgery has radical pros and cons, with high stakes. The pros are that, if the tissue removed during surgery comes back clean, the chance for that woman to develop ovarian cancer has been reduced by over >95%. Removal of ovaries also reduces her future risk of developing breast cancer by >50% when performed before menopause, even if she takes hormone replacement therapy to offset the impact of premature menopause.
Which takes us right to the cons … This surgery causes immediate menopause in young women who opt for BSO. Premature menopause is no laughing matter. Every woman experiences this phenomenon differently, and it’s impossible to predict the impact for any one person. The possible side effects include hot flashes, vaginal dryness, lowered libido, mood swings, and depression. The procedure likely increases the risk of bone loss and possibly of cardiovascular disease and dementia. Of course, BSO also prematurely closes the woman’s reproductive window and has been shown to negatively alter body image in many BRCA carriers.
We need a better option.
In recent years, we have learned that many ovarian cancers actually begin in the fallopian tubes. Researchers have questioned whether removing only the fallopian tubes (salpingectomy) in young BRCA carriers would reduce the majority of their risk. This hypothesis is exciting and the early data on salpingectomy and ovarian cancer reduction in the general population are promising, but we still lack the data to make the big leap of advising women at high-risk for ovarian cancer to have only salpingectomy.
Issues to consider:
- While we are hopeful that salpingectomy will be effective in reducing ovarian cancer risk in BRCA carriers, we do not know that it will be as effective as BSO in this population. Having salpingectomy instead of oophorectomy in high-risk women is taking a potentially deadly gamble. Until we have conclusive data, BRCA carriers should still plan to have their ovaries removed by age 40, even after salpingectomy.
- However, this approach would mean two surgeries and two sets of surgical- and anesthesia-related risks. There is also a chance that scar tissue from the first surgery would reduce the chance of a laparoscopic approach during the second surgery.
- We do not know if insurance companies will cover a second surgery (oophorectomy) after salpingectomy in BRCA carriers. There is at least one national case example in which the second surgery was denied. This could leave those who opt to later proceed with oophorectomy with tens of thousands of dollars of unpaid medical bills.
- We do not know the most effective age for BRCA carriers to have salpingectomy or the impact on fertility or menopausal development.
- Importantly, salpingectomy will not likely reduce the risk of breast cancer in BRCA carriers because the ovaries remain intact producing hormones. The risk of breast cancer in BRCA carriers is much higher than the risk of ovarian cancer, and BSO reduces this risk by >50% in premenopausal women.
More research is needed before we can safely and definitively recommend salpingectomy for BRCA carriers. We may reach the day when female BRCA carriers who have not completed their families are offered egg retrieval (with egg and/or embryo freezing) and salpingectomy at age 25 or 30, followed by oophorectomy by age 40 or 45, both prolonging fertility and postponing menopause. Salpingectomy may also be an option for BRCA carriers who have refused BSO. But for the majority of BRCA carriers, we are not yet ready to roll the dice on this critical issue without the necessary data.