Surgical options for reducing risk in BRCA mutation carriers
In 2015, more than 21,000 women will be diagnosed with ovarian cancer in the United States, and 14,180 will die from their disease.1 Inherited, or germline, mutations are believed to be responsible for up to 24% of ovarian cancers2 and more women—such as those with BRCA1 and BRCA2 mutations—are being identified as being at high risk. The lifetime risk of ovarian cancer is 20%–46% for BRCA1 mutation carriers and 10%–27% for BRCA2 mutation carriers.3-5
Among BRCA mutation carriers, risk-reducing bilateral salpingo-oophorectomy (RRSO) results in an 80% reduction in risk of ovarian cancer and a 50% reduction in risk of breast cancer if the surgery is performed before the onset of menopause.6-8 Research suggests that the optimal age for RRSO is between 35 and 40; however, cancer risks are affected by BRCA mutation type as well as personal and family history of cancer, and decisions require individualized discussions with each patient. Age at onset of ovarian and tubal cancer is observed to be later in BRCA2 mutation carriers, therefore, some experts contend that it may be acceptable to delay risk-reducing surgery in this population until age 45–50.7,9
This article provides perspective on surgical techniques for RRSO, the role of hysterectomy, postsurgical surveillance, and issues related to interval salpingectomy.
Ovarian cancer can begin in the Fallopian tube
Recently, detailed histologic analysis of the adnexa from BRCA mutation carriers removed at prophylactic surgery has led to one of the most important discoveries about the origin of ovarian cancers. Surprisingly, the majority of occult carcinomas occur in the Fallopian tube rather than the ovary.10-15 Serous tubal intraepithelial carcinoma (STIC), which originates in the fimbriae, is the definitive precursor of the most common and lethal ovarian cancer, high-grade papillary serous cancer.16 The fimbrial location of STIC provides a plausible mechanism for early shedding of cancer cells into the adjacent ovaries and the peritoneum.17,18