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February 17, 2003
News this month Every year, about 23,000 U.S. women are diagnosed with ovarian cancer and 14,000 women die from the disease. Data has been limited on whether ovary removal prior to cancer diagnosis actually prevents ovarian cancer.
Women who carry the genes BRCA1 or BRCA2 are at increased risk for developing ovarian cancers, in addition to their increased risk for developing breast cancer. In about 5 percent (1,000 cases) of the ovarian cancer cases, the disease is due to a mutation in one of the BRCA genes. Such mutations are more common in Jewish women with eastern or central European ancestry than in the general population. Some women who carry the BRCA genes undergo removal of both ovaries before cancer is ever detected in a procedure called prophylactic oophorectomy. But until recently, the data on whether this procedure actually does prevent ovarian cancer had been very limited. Two studies show benefit Overall, 551 women who carried the BRCA gene were identified from hospital cancer registries. Among these, 259 women underwent bilateral prophylactic oophorectomy. Another 292 women chose not to have the procedure and were therefore used as controls. The women were followed for an average of eight years. Researchers looked for any incidence of ovarian cancer. At the beginning of the study, when doctors operated to remove ovaries, they found that six women (2.3 percent) already had stage 1 ovarian cancer. The average age was about 41 for both groups. Removing the ovaries appeared to have significantly reduced the incidence of ovarian cancer….
Reducing risk of ovarian cancer In contrast, among the control group that did not have the procedure, 58 women (19.9 percent) were diagnosed with ovarian cancer over the following eight to nine years. This led the researchers to conclude that performing the procedure in women with a BRCA gene significantly reduced the risk of ovarian-type cancers. Protection against breast cancer In that same issue of the NEJM, a second study carried out by Noah D. Kauff from Memorial Sloan-Kettering Cancer Center described a prospective investigation of 170 carriers of these two mutations. They looked at whether performing salpingo-oophorectomy (removing the ovaries and the fallopian tubes) had any effect on the incidence of subsequent breast cancer and BRCA-related gynecologic cancers in these women. During two years of follow-up, among the women who had the procedure:
In contrast, among the 72 women who chose surveillance, there were:
It also took longer for the cancers to develop in the women who had
the procedure, prompting the team to conclude that the procedure had
a beneficial effect in women who carried a BRCA gene. In an editorial,
the NEJM noted that the studies underscored the benefits
of cancer genetic testing in high-risk women. 
Physician Referral Online A free and confidential service Physician Referral Online Request an appointment 203-688-2000
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 Understanding preventive oophorectomy Testing for the BRCA1 and 2 genes has been available for about seven years. Entering into testing is not an easy decision for anyone. Genetic testing "Until these studies were published, there was little conclusive evidence that having an oophorectomy had any real benefit."
Women at risk for breast cancer sometimes choose to have both breasts removed, which is a procedure called prophylactic mastectomy. This is a major surgical procedure that greatly reduces but does not eliminate the risk of breast cancer. Another option, which this study looked at, is to have both ovaries and the fallopian tubes removed. But until these studies were published, there was little conclusive evidence that having an oophorectomy had any real benefit. There was a great deal of excitement when these new studies were published. For the first time we had hard evidence that there was a benefit. Those of us in the cancer genetics field had long suspected there would be a benefit in removing the ovaries, but we needed the data to show it. "The surgery helps reduce not only the risk for
ovarian cancer, but the risk of breast cancer as well."
The surgery helps reduce not only the risk for ovarian cancer, but the risk of breast cancer as well. The numbers would have been even more impressive, but the way the study was set up, we had to include in the first group the six cases of ovarian cancer detected when the oophorectomy was performed. If ovarian cancer is detected early, the chance of a full recovery is high. However, we lack good tests for detecting such cancers early. The current screening tools—Doppler ultrasound and the CA-125 tumor marker blood test—-are not terribly accurate. New technologies are on the horizon that are very promising, but they are not available yet to the general public. So that is why there is such great interest in a procedure that might actually prevent a cancer that is hard to screen for or detect early. Why it works The decreased risk of breast cancer associated with prophylactic oophorectomy was more surprising. It appears that by removing the ovaries, the amount of estrogen circulating in a woman's blood is greatly reduced. Total estrogen exposure over a woman's lifetime has been linked to breast cancer risk. The theory suggests that the higher the exposure, the higher the risk. Who should be tested?
"These procedures do not completely eliminate the risk of cancer, but rather reduce the risk."
Each person considering genetic screening or a preventive procedure must weigh all the factors first, including lifestyle, body image and the risks versus the benefits. Remember that these procedures do not completely eliminate the risk of cancer, but rather reduce the risk. If a person has concerns, seek out a qualified cancer genetic counselor at a major medical center for a consultation. Ellen Matloff, MS, is the director of cancer genetic counseling at the Yale Cancer Center. 
For the 12th year in a row, Yale-New Haven has been highly ranked by U.S. News & World Report for its programs in gynecology. |
