Choice of Ovarian Cancer Surgery Influenced by Risk Perception

An investigation of 24 women from the United Kingdom’s PROTECTOR trial has revealed that their concerns toward cancer risk and menopause affect their choice of surgery as treatment for ovarian cancer, according to findings published online today in Journal of Medical Genetics.

Some of the women, all at high risk of the cancer due to presence of the BRCA gene, would rather manage this risk via a 2-step surgical course of treatment, step 1 being salpingectomy (fallopian tube removal) and step 2 being oophorectomy (ovary removal), instead of 1 more extensive surgery. For this study, the former was classified as early-salpingectomy with delayed oophorectomy (RRESDO) and the latter, risk-reducing salpingo-oophorectomy (RRSO).

Concerns over induced menopause and its adverse effects influenced their preventive choice, the authors noted in a statement announcing their findings. Those more concerned about their cancer risk would opt for the more extensive procedure, they added.

“Standard surgery, removing both the tubes and ovaries, induces menopause in women who have not yet reached this stage of life,” the authors from Queen Mary University in London, stated. “The proposed alternative two step protocol delays the induced menopause caused by the removal of the ovaries, and therefore avoids menopause side effects.”

The lifetime risk of ovarian cancer ranges from 17% to 44% among women with BRCA1 or BRCA2. Of the women in the present study, who ranged in age from 34 to 46 years, 91.7% were Caucasian, 16.7% had never given birth, 16.7% had a breast cancer history, 37.5% had undergone a risk-reducing mastectomy (RRM), 58.3% had BRCA1, and 41.7% had BRCA2.

The investigators conducted 1:1 interviews with all of the women, eliciting responses via open-ended questions, and 7 interconnected themes emerged about decision-making when all answers had been recorded:

1. Fertility
2. Menopause
3. Cancer risk reduction/surgical choices
4. Surgical complications
5. Sequence of ovarian and breast prophylactic surgeries
6. Support with decision-making
7. Satisfaction with treatment choices

The authors uncovered that taking fertility out of the picture helped to facilitate the women’s choice. Of the 18 women in the study who ultimately chose surgery, 16 had children and 2 did not want children.

Their analyses also discovered the following:

• Women with a history of breast cancer who were BRCA carriers chose RRESDO despite awareness of the benefits of premenopausal oophorectomy
• Maintaining quality of life was of equal concern among BRCA carriers, breast cancer history notwithstanding
• Approaching natural menopause and potential poor health concerns emerged as potential barriers to RRESDO
• Not wanting hormone replacement therapy (HRT), worries about adequately dealing with menopause symptoms, positive experiences with prior surgery, reducing anxiety, and flexibility of delayed oophorectomy influenced the decision to undergo RRESDO
• Women receiving care in high-risk familial cancer, or specialized clinics, reported greater care satisfaction vs women receiving care in nonspecialist clinics

The authors attribute this last finding to the increasing amounts of multidisciplinary support that high-risk women require and which those in nonspecialist clinics claim there is a dearth of due to “poorly developed care pathways,” such as those for HRT counseling. This encompasses care from geneticists, gynecologists, and menopause and fertility specialists, among others, including communicating genetic test results to family members.

“Multiple contextual factors (medical, physical, psychological, social) influence timing of risk reducing surgeries. RRESDO offers women delaying/declining premenopausal oophorectomy, particularly those concerned about menopausal effects, a degree of ovarian cancer risk reduction while avoiding early menopause,” the authors concluded. “Care of high-risk women should be centralised to centres with specialist familial gynaecological cancer risk management services to provide a better-quality, streamlined, holistic multidisciplinary approach.”

They express confidence in their findings, due to their study’s structured in-depth interview approach, independent data analysis, and inclusion of patients from a variety of settings. However, they also caution on their generalizability because only 2 of their study patients were non-Caucasian and some had already undergone an RRM, which could have introduced recall bias.

Reference

Gaba F, Goyal S, Marks D, et al. Surgical decision making in premenopausal BRCA carriers considering risk-reducing early salpingectomy or salpingo-oophorectomy: a qualitative study. J Med Genet. Published online February 10, 2021. doi:10.1136/jmedgenet-2020-107501