Hormone Replacement and Ovarian Cancer: Competing Risks in Decisions about Bilateral Salpingo-oophorectomy


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Recently reported findings that bilateral salpingo-oophorectomy and hysterectomy decreased the risk of ovarian cancer compared to ovarian conservation and hysterectomy, without increasing cardiovascular, fracture, and other cancer risks, should “challenge” current thinking about bilateral salpingo-oophorectomy and broaden its use among women concerned about ovarian cancer risk, according to Robert A. Burger, MD. He is Director of the Women’s Cancer Center at Fox Chase Cancer Center in Philadelphia, and Professor in the Department of Surgical Oncology, Section of Gynecologic Oncology. Based on data from the Women’s Health Initiative (WHI) observational study, bilateral salpingo-oophorectomy need not be limited to women at high risk of ovarian cancer, Dr. Burger said, “because there is a risk reduction in ovarian cancer even for low-risk women.”

Robert A. Burger, MDReported in the Archives of Internal Medicine,1 the prospective study followed 25,448 postmenopausal women aged 50 to 79 years, with no family history of breast cancer, but with a history of hysterectomy with bilateral salpingo-oophorectomy (56% of the total) or with ovarian conservation (44%). Most women (78.6%) were current or past users of estrogen and/or progestin. As expected, the women who underwent the bilateral surgical procedure had a decreased rate of ovarian cancer, 0.02% vs 0.33% in the ovarian conservation group, at a mean follow-up of 7.6 years. Although previous studies have shown increased rates of adverse effects, including coronary heart disease and fractures following bilateral salpingo-oophorectomy, in the current analyses the procedure was not associated with an increased risk of cardiovascular disease, hip fractures, or breast, colorectal, or lung cancer.

Already Low Risk

“It is important to point out,” Dr. Burger said, that “in women without a family history of ovarian cancer, even though there is a significant decrease in the risk of developing ovarian cancer with bilateral oophorectomy vs not, the absolute risk level is extremely low.” The overall lifetime risk of developing ovarian cancer is presently estimated to be 1.4%, but that includes women at elevated risk based on family history, while the study included only those with no family history. Despite the low risk, Dr. Burger said, “I think it is worth maximizing your level of prevention for ovarian cancer because the consequences of the disease are so grave.”

With a mean follow-up of 7.6 years, the study results cannot indicate how bilateral salpingo-oophorectomy affected lifetime risk of ovarian cancer for the study participants. “We can learn from the hereditary breast ovarian cancer syndrome studies because we have a fairly accurate assessment of the risk of developing ovarian cancer with or without bilateral salpingo-oophorectomy,” Dr. Burger said. “We know that the protective effect is greater than 90% for women in those populations who have their ovaries and tubes removed. It is not 100%. Because of the way ovarian cancer develops, we think that probably there are women who have preexisting cancers or high-grade precancerous lesions that develop into primary peritoneal cancers even after the ovaries and tubes are removed. Some of these cases can be explained by evidence of disease in the ovaries or fallopian tubes not recognized at the time of preventive surgery.”

Educated Decisions

The study authors noted that historically, estrogen and progesterone were commonly prescribed to treat menopausal symptoms that may result from an abrupt decline in ovarian hormone levels caused by bilateral salpingo-oophorectomy. “However, since the Women’s Health Initiative randomized trials demonstrated more harm than benefit associated with postmenopausal therapy, there has been a dramatic decline in the use of [hormonal therapy],” the authors stated. Data from those earlier WHI trials were first reported in 2002.

Those trials “reported adverse outcomes related to the use of estrogen with progestin, and there was a reluctance for women to use hormone replacement even if they were symptomatic,” Dr. Burger said. “But now it is becoming clearer that if ovarian hormone replacement is used in the setting of menopausal symptoms as a consequence of these surgeries and these women are monitored, there is a reasonable safety profile. That, together with this study, should make women a little more comfortable with the idea of having prophylactic bilateral salpingo-oophorectomy at the time of the hysterectomy,” he said.

A woman who is familiar with ovarian cancer risk and the potential of bilateral salpingo-oophorectomy to reduce that risk “can make an educated decision” about whether to have the procedure, Dr. Burger said. She can consider whether she would be “comfortable with the idea of hormone replacement” should she develop menopausal symptoms following the surgery.

“When a woman is faced with a decision as to whether her ovaries and tubes should be removed and she appears to be at low risk based on family history, the main issue is the competing risk of hormone replacement for maybe up to 5 years vs the risk of ovarian cancer,” Dr. Burger said. “Those are the two balancing factors.”

Combined Surgery

Women who are having abdominal surgery and the surgeons performing the procedures should consider including bilateral salpingo-oophorectomy, Dr. Burger advised. The surgeons “need to be aware of the potential of bilateral salpingo-oophorectomy for risk reduction of ovarian cancer and integrate that into their counseling,” Dr. Burger said.

Those surgeons could also refer a patient to her gynecologist for advice about whether to have a bilateral salpingo-oophorectomy at the same time as the abdominal surgery. “I would hope that they would have the gynecologist come in and do that part of the surgery,” Dr. Burger added. “There are general surgeons who are certainly trained to be able to do that, but generally speaking, it would probably be a better decision to have a gynecologist who does those surgeries all the time to maximize the expertise in the room.” ■

Financial Disclosure: Dr. Burger reported no potential conflicts of interest.

Reference

1. Jacoby VL, Grady G, Wactawski-Wende J, et al: Oophorectomy vs ovarian conservation with hysterectomy. Arch Intern Med 171:760-768, 2011.


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