For families with a history of breast or ovarian cancer, there is a strong likelihood that the BRCA gene mutations causing these cancers are carried from generation to generation.1
The age of onset may indicate risk of inheritance; for example, if there is a history of breast cancer prior to the age of menopause, this may indicate that members of the family have a genetic predisposition to the disease, since this form of cancer, like many others, typically does not emerge until later in life.
Genetic testing and subsequent counseling can help to determine the next best steps for individuals who are concerned about their family history of breast and/or ovarian cancer.
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In the case of breast cancer, thankfully, not all women who test positive for these gene mutations develop cancer, but there are many who do; however, preventative strategies are often considered and implemented as a means of reducing the risk of developing cancer associated with BRCA1 and BRCA2 gene mutations (Related: Recent News Brings Focus on BRCA Testing and Management).
While prophylactic mastectomy has been identified as a prevention strategy for women with these mutations, it is not the only means of risk reduction; another key consideration is oophorectomy.1,2
The Gift of Time
Ovarian cancer can be very difficult to diagnose at an early stage, so researchers in Canada looked at histologic subtypes, stage of disease, and screening performance to determine which biomarkers might successfully identify early stage ovarian cancer. The study concluded, however, that stage 1 ovarian cancer consists primarily of non-serous histologies, which are not reliably detected using CA-125, a protein that is found at elevated levels in most ovarian cancer cells, and ultrasound markers.3,4
Because of the difficulties in early detection of ovarian cancer, the oncology team may counsel patients who carry these mutations about the removal of ovaries as a risk reduction strategy, in addition to mastectomy.
The risk reduction is noteworthy. For premenopausal women who undergo mastectomy, the risk of breast cancer is decreased by 50%. For women (not specifically premenopausal) who have their ovaries removed, the risk of ovarian cancer is reduced by 80% to 90%, according to the Mayo Clinic.1 Although it is not a guarantee, these procedures may provide more cancer-free years to patients than a watchful waiting approach. Other considerations include the quality-of-life issues that occur as a result of these procedures.
Sexual Dysfunction: A Serious Concern for Patients
While oophorectomy can significantly reduce a BRCA gene mutation carrier’s chance of developing ovarian cancer, there may still be resistance to undergoing this procedure. In some cases, child-bearing years are still ahead of a woman, and she may also have concerns about the potential side effects—hot flashes, vaginal dryness, sexual problems, sleep disturbance, and cognitive changes—which are symptoms of early menopause brought on by removal of the ovaries. Sexual dysfunction, in particular, was addressed at the 2013 Annual Meeting of the American Society of Clinical Oncology (ASCO) during a session about patient and survivor care.
Results of a pilot study of 36 patients who underwent prophylactic bilateral salpingo-oophorectomy (PBSO), which includes removal of the fallopian tubes, were presented. The intervention study included information about sexual health education, relaxation training, and cognitive behavioral therapy skills to manage symptoms.
Patients completed assessments such as the Female Sexual Function Index (FSFI) and a measure of sexual knowledge after PBSO at baseline and 2 months post-intervention. FSFI scores improved from baseline to post-intervention for desire (P = 0.003), arousal (P = 0.001), and satisfaction (P = 0.031). These promising results may lead to additional study of this issue in future randomized clinical trials.5
Side effects associated with an oophorectomy may also include increased risk of heart disease and osteoporosis.1 A study conducted by the Mayo Clinic evaluated cardiovascular health of patients younger than 45 years who underwent oophorectomy prior to the onset of menopause compared with women of the same age who did not undergo ovary removal. The study concluded that increased cardiovascular mortality was observed in patients who underwent bilateral oophorectomy, but also suggested that use of estrogen may offset the risk. 6
Although early menopause from preventive surgery may lead to osteoporosis, an animal study that compared eggshell-casein phosphopeptide (ES-CPP) with use of calcium supplementation as a way to help mitigate the bone loss, concluded that ES-CPP was superior to calcium alone. 7
Despite the potential side effects of oophorectomy, which can, for the most part, be managed, patients with BRCA1 and/or BRCA2 gene mutations and their oncology team should weigh the benefits versus the risks to help reduce their chances of developing breast and ovarian cancer.
References
1. Oophorectomy (ovary removal surgery). Mayo Clinic Web site. http://www.mayoclinic.com/health/breast-cancer/WO00095. Accessed July 29, 2013
2. BRCA1 and BRCA2: Cancer Risk and Genetic Testing. National Cancer Institute Fact Sheet. http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA. Accessed July 29, 2013
3. Eiriksson L, Reade C, Lennox G, et al. Ovarian cancer distribution of histology, stage, and screening performance. J Clin Oncol. 31, 2013 (suppl; abstr 5543)
4. Ovarian Cancer. Johns Hopkins Pathology. http://ovariancancer.jhmi.edu/ca125qa.cfm. Accessed July 29, 2013
5. Bober S, Garber J, Recklitis C, et al. A pilot intervention addressing sexual dysfunction after risk-reducing oophorectomy. J Clin Oncol. 31, 2013 (suppl; abstr 9644).
6. Rivera CM, Grossardt BR, Rhodes DJ, et al. Increased cardiovascular mortality after early bilateral oophorectomy. Menopause. 2009 Jan-Feb;16(1):15-23.
7. Kim JH, Kim MS, Oh HG, et al. Treatment of eggshell with casein phosphopeptide reduces the severity of ovariectomy-induced bone loss. Lab Anim Res. 2013 Jun;29(2):70-6.
