Should you have your ovaries removed if you are BRCA positive?
This is a question that every board-certified gynecologist is used to discussing with a patient who has recently undergone BRCA testing. As with any such discussion, I feel it's key to explain all the risks, benefits and alternatives. That is to say: What are the risks of doing surgery and the risks of not doing surgery? What are the benefits to doing surgery and the benefits of not doing surgery? In reality, this is a decision that a woman needs to make with her family and her physician, and it's complicated.
For the average woman, the lifetime risk for ovarian cancer is 1.3 percent (compare to the lifetime risk for female breast cancer of 12 percent in an average woman). It represents the most lethal cancer for women, although it is far from the most common. Part of the reason this cancer is so deadly, and is often referred to as the "silent killer" of women, has to do with anatomy.
The ovaries, which produce sex hormones, are walnut-sized glands that sit free in the pelvic cavity, tethered to the sides of the pelvis. When a cancer develops in the ovary, it can grow to a large size before producing significant signs or symptoms. It can also "seed" the cancer throughout the pelvis and abdominal cavity because the ovaries are not wrapped in any covering that separates them from other organs.
The most concerning symptoms of ovarian cancer are bloating, increased urination and pelvic pain/ pressure that occurs more than 50 percent of the time for a period of more than a few weeks. Other symptoms include early satiety, increasing abdominal girth and a change in weight or bowel habits.
Now the nitty gritty: What are the risks of the surgery to remove your ovaries? Today, this is a surgery that is done laparoscopically (through 1 centimeter incisions in your abdomen) and typically takes less than one hour in skilled hands. For women who are BRCA positive, the fallopian tubes are removed with the ovaries because they can develop the same cancer as the ovaries. The uterus does not need to be removed, so the surgery is not called a hysterectomy but a bilateral salpingoophorectomy (or BSO). Often, patients go home the same day or the day after surgery.
The risks are similar to any surgery and include bleeding, infection, damage to other nearby organs and those associated with general anesthesia. Recent data has shown that women who have their ovaries removed for benign reasons have a slightly increased risk of cardiovascular issues. Also, a woman having her ovaries removed will go through immediate surgical menopause, and the process may cause hot flashes, vaginal dryness and osteoporosis, among other associated low-estrogen-state side effects. The risk of ovarian cancer following surgery does not drop to zero because cancer cells may have escaped before surgery occurred, and women can develop a variant called peritoneal carcinomatosis.
What about the risks of not having surgery? With a BRCA1 mutation, a woman can have as high as a 50 percent increased risk of developing ovarian cancer, and that cancer tends to occur at a younger age than in women who develop the sporadic type of ovarian cancer. Increased surveillance in women who choose watchful waiting include physical pelvic exams, pelvic sonograms and ovarian tumor marker blood tests. But it is important to note that there is no generally accepted screening test for ovarian cancer, the way a mammogram (while not perfect) is an accepted screening test for breast cancer.
Now for the benefits of surgery. Women with a BRCA mutation who remove their ovaries and fallopian tubes have a significantly lower risk of developing ovarian cancer. This risk drops far below that of the average woman.
The benefits of not having surgery is the avoidance of the above-mentioned risks that accompany this procedure.
Options for reducing risk of ovarian cancer include taking oral contraceptives or the birth-control pill, which has been shown to dramatically reduce the risk of cancer by as much as 60 percent in women who have taken the pill for three or more years. There may be a similar protective effect with breast-feeding and full-term pregnancies because of the theory that the ovaries are spared the hormonal stimulation and damage to the ovarian cortex with all of these situations. Diets high in fruits and vegetables have also been associated with a reduced risk of ovarian cancer.
The emotional toll of either option can be significant for a woman and her family. Every woman feels differently about living with risk. Every woman is entitled to her opinion and decision. My hope is for a BRCA-positive woman considering this surgery to discuss these issues with a gynecologic in addition to her general OB-GYN. There is no such thing as minor surgery, even if it is a same-day procedure. All aspects, the physical, psychological, financial and social, should be considered before a plan is made. Understanding the risks, benefits and options/alternatives are at the foundation of any good decision-making process.