Two-stage pelvic surgery approach
Recent research indicates that high-grade serous tumors caused by BRCA mutations often originate in the distal half of the fallopian tube and then progress to the ovary. Serous tumors also may arise from the ovary or peritoneum.10 Building on this finding (that in BRCA previvors serous tumors often begin in the distal fallopian tube), some experts now recommend that a two-stage risk-reducing pelvic surgery option be offered to women with BRCA mutations. No large clinical trials have been reported using the two-stage approach to risk-reducing pelvic surgery, but published case series suggest that it is a plausible approach.
Stage 1: Ovary preservation. In Stage 1 surgery, the fallopian tubes are removed through a laparoscopic approach, but the ovaries are preserved. Some experts also recommend removal of the fallopian tube–peritoneum–ovarian junction.11,12 Stage 1 surgery reduces the risk of developing a cancer that originates in the fallopian tube and preserves ovarian estradiol and progesterone secretion, thereby avoiding premature menopause.
Stage 2: Ovary removal. Years later, as late as age 50, Stage 2 surgery is performed, and the ovaries are removed laparoscopically.
In the Stage 2 operation, consideration should be given to performing a hysterectomy. Since this second surgery will make the woman menopausal, concomitant hysterectomy would permit estrogen-only HT.
It should be noted that, for BRCA previvors, removing the ovaries at an early age is associated with a reduced breast cancer risk. The two-stage surgical approach does not offer this advantage of breast cancer risk reduction.
Appropriate gyn follow-up after risk-reducing BsO
Consider HT or estrogen-progestin contraceptives. For young, premenopausal women who undergo risk-reducing BSO, HT or estrogen-progestin contraceptives will help to reduce the risk of hot flashes, sleep disturbance, and symptoms of vaginal dryness. Although there is a theoretical concern that estrogen and progestin treatment may increase the risk of breast cancer, many experts are comfortable with prescribing estrogen and progestins to young BRCA carriers following risk-reducing BSO.
If your young, premenopausal patient underwent risk-reducing BSO but declines HT, a bone density test should be obtained within 1 or 2 years of surgery; you can offer nonhormonal treatment for her menopausal symptoms.
After undergoing risk-reducing BSO, patients should be prescribed weight-bearing exercise, vitamin D 600 U daily, and calcium supplements. In addition, because of a 5% risk of developing a peritoneal cancer, provide an annual gynecologic exam with CA-125 measurement and pelvic sonography every 6 months.13
Appropriate surveillance for women who forego risk-reducing surgery
This surveillance strategy may be helpful in detecting cancer at an early stage:
1. Beginning at age 25: Perform clinical breast exam once or twice per year
2. Beginning at age 25, or based on individualized assessment influenced by the earliest age of onset of cancer in the family: Alternate breast magnetic resonance imaging and mammography every 6 months
3. Beginning at age 35, or 10 years before the earliest age of onset of ovarian cancer in the family: Perform pelvic examination, CA-125 measurement, and pelvic sonography every 6 months. In women with BRCA mutations, estrogen-progestin contraceptive use may reduce the risk of ovarian cancer without increasing the risk of breast cancer.7
Her genetics can put your patient at risk. You are in a position to help protect her.
Imagine prematurely losing your mother, mother’s sister, and maternal grandmother to breast and ovarian cancers. Each funeral for a young relative resurrects memories of previous painful losses. The children and adults worry, “Who will be the next to die?” The early identification of families with BRCA mutations offers the hope of options to reduce premature death, preserving the quality of life and keeping families intact, so they can gather together for enjoyable holidays, not funerals.
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