The Role of Risk Reducing Salpingo-opherectomy in Hereditary Breast and Ovarian Cancer

This information section is to help explain what is involved with a risk reducing (prophylactic) salpingo-oophorectomy (RRSO). You may be considering this because you have an increased risk of developing ovarian cancer due to your family history, or because you have been found to carry a genetic fault. (BRCA1 or BRCA2).This surgery has been shown by multiple studies to be effective in preventing ovarian cancers.

This decision can be dif ficult to make but there will be healthcare  professionals in our team that you can discuss issues with and who will be able to support you in your decision-making.

Definition of Risk Reducing Salpingo-opherectomy
This is an operation where both your fallopian tubes and ovaries are removed whilst there is no evidence of cancer, to help reduce your risk of developing ovarian/breast cancer.

What is a salpingo-oopherectomy?
In this surgery the surgeon will remove both your fallopian tubes and ovaries. Latest research shows that 70% of ovarian cancer starts from the fimbrial end of the fallopian tube (tube between your womb to near the ovary). The rest of your abdomen will also be inspected and saline solution will be instilled into the abdomen then aspirated to be sent for tests.

Your ovaries contain eggs and secrete hormones that control your reproductive cycle so removing them if you are in child bearing age will significantly reduce hormones in the body. This can make you menopausal though there are ways that this can be managed.

This procedure can be mostly be carried out by keyhole surgery which involves minimum down time and recovery.

Who should consider prophylactic salpingo-opherectomy?
This procedure is usually recommended to women with a significant risk of breast and ovarian cancer due to an inherited mutation in the BRCA1 and BRCA2 genes (genes linked to breast, ovarian and other cancers)

It may also be recommended to you if you have a strong family history of breast and ovarian cancer but no known genetic alteration that is detected. Sometimes it might be recommended if you have a strong family history but choose not to proceed with genetic testing.

How much does RR-SO reduce the risk of cancer?
In women with BRCA mutation, RR-SO will reduce your Ovarian cancer risk by 80 to 90%.

In BRCA 1 where a woman has a 40% chance of being diagnosed with ovarian cancer at some time in her life, the procedure will reduce her risk to 6%

In BRCA 2 where a woman has a 12% chance of being diagnosed with ovarian cancer at some time in her life the procedure will reduce her risk to 0.4%

If a woman has a 60% chance of being diagnosed with breast cancer at some point in her lifetime, RR-SO could reduce her risk to 30%

Individual risk of breast cancer also varies depending on other factors like family history, lifestyle choices and other strategies you are using to reduce your risk of cancer.

When should it be done?
Current guidelines recommend that women with BRCA1 mutation should have their surgery by the age of 40 after completing their child bearing.

As the onset of cancers with BRCA2 is later, current guidelines recommend the procedure to be done in the mid 40’s.

The health professionals could modify the timing of surgery if the onset of cancer in that particular family is much younger.

What are the risks of RR-SO?
From a surgical perspective, as it is done mainly by a keyhole approach, the risk of complication is around 2%. This includes the risk of bleeding, infection and organ damage.

More concerning is the impact of losing your hormones supplied by your ovaries in women who are yet to undergo menopause.

Menopause and HRT
Each woman has a different experience of her menopause. Some women do not have any symptoms whilst others may have a number of symptoms that affect their daily life.

You will be going through early menopause because of surgery, so it is important that you discuss the options for menopause management before your operation. Sometimes we refer you to discuss the issue with an endocrinologist who is a specialist with expertise in managing menopause.

Use of hormones will help relieve any menopausal symptoms such as hot flushes, night sweats and vaginal dryness. Women are usually prescribed HRT (hormone replacement therapy) and there are a number of ways in which this can be taken, including tablets, patches and gels.

Some women are concerned about breast cancer risk and HRT use.

It is important to remember that the HRT is only replacing the hormones your ovaries would normally be producing and is not additional HRT following a natural menopause.

It is also important to remember that the increase in breast cancer risk is associated with long-term use of HRT following the natural menopause, not with replacing hormones following removal of the ovaries at an earlier age.

Data has shown that HRT does not negate the benefits of RR-SO in BRCA 1,2 carriers.

If you have any questions please write them down here before you see the doctor as a reminder.

Are there any other alternatives to RR-SO?
Other ways of preventing ovarian cancer haven’t been proved to reduce risk as much as RR-SO has. For this reason, for most women with BRCA mutations, doctors recommend surgery.

Options include:

• Increased screening for ovarian cancer – There is no evidence that any screening tests available saves lives
• Birth control pills – Studies suggest that taking birth control pills reduces the risk of ovarian cancer in average-risk women. There is good evidence that birth control pills can reduce the risk of ovarian cancer and can also be beneficial in reducing risk in high-risk women, such as those with BRCA mutations. There is some concern that birth control pills may increase the risk of breast cancer in this high-risk group of women. However, the benefits of reducing ovarian cancer risk seem to outweigh the small risk of breast cancer.

Who should I see for this surgery?
It is generally recommended that you see a gynaecological oncologist. This is a specialist who has trained to be a gynaecologist and carried out an additional 3 years training in women’s cancer prevention and treatment.

The specialist will have the expertise to counsel you appropriately, do the surgery according to the recommended international guidelines and request the specialist examining your specimen (pathologist) to follow the right protocol. In about 4-5% cases there is an occult cancer (cancers only detected on the tissue removed) in which case a gynaecological oncologist can continue treating you.

What questions should you ask your doctor?
The decision to have RR-SO is a challenging and difficult one with no clearly a right or wrong answer. It comes down to a personal choice you alone can make, but advice from a genetic counselor, a breast health specialist or a gynecologic oncologist can help you make a more informed decision.

Questions to ask your doctor or other health care provider include:

• What is my risk of ovarian cancer?
• What are my options to lower my risk of ovarian cancer?
• What are the benefits and risks of each option?
• What are some good sources of information about reducing my cancer risk?
• How much time can I take to research my options and make a decision?
• If I decide that prophylactic oophorectomy isn’t right for me right now, can I change my mind later?
• What advice would you give your friend or family member if she were in my situation?

Determining whether RR-SO is right for you, and when it might be right for you depends on your individual risk of cancer and how aggressive you want to be in your cancer-prevention efforts.

We will assist you on that journey with our genetic counselors, breast specialists, gynaecological oncologists and psychologists.