Bottom line: Routine screening still not justified
Nothing in the findings reported here suggests that we need to revise the current (from 1996) ovarian cancer screening guidelines of the US Preventive Services Task Force,1 which state that “routine screening for ovarian cancer by US, the measurement of serum tumor markers, or pelvic examination is not recommended.”
We will need to wait until the PLCO trial results come in to see the effect of repeated annual ovarian cancer screens on detection rates and mortality.
Consider ovarian conservation in hysterectomy for benign disease
Parker W, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol. 2005;106:219–226.
As discussed earlier, we have no good screening tool for the early detection of ovarian cancer. Although rare, ovarian cancer is a lethal, scary disease, and most ObGyns prophylactically remove the ovaries at the time of hysterectomy in most postmenopausal and many perimenopausal women.
The downside to this strategy seems low among postmenopausal women, and the upside, in terms of not having to worry about ovarian cancer, seems high. The study by Parker and colleagues, while having definite limitations, asks us to question this routine practice pattern. The authors found that prophylactic oophorectomy may be associated with decreased overall survival.
Model used SEER data, Nurses’ Health Study to predict survival
Parker and colleagues used a Markov decision-analysis model (a hypothetical mathematical model that uses published data to create cohorts of patients to estimate risk of morbidity or mortality, or both, over time) to evaluate the risks and benefits of ovarian conservation at the time of hysterectomy for benign disease. Age-specific mortality estimates for ovarian cancer were based on Surveillance, Epidemiology and End Results (SEER) statistics.
For women at average risk of ovarian cancer, the probability of surviving to 80 years of age after hysterectomy between 50 and 54 years varied, and was 62.8% and 62.5% for ovarian conservation with and without estrogen therapy, respectively, compared with 62.2% and 53.9% for oophorectomy with and without estrogen therapy. The main reason that the model found decreased overall survival with prophylactic oophorectomy was an increase in coronary artery disease after oophorectomy—a finding that was based on data from the Nurses’ Health Study.
At the very least, think hard about the decision to remove the ovaries
This report estimated that about 300,000 prophylactic oophorectomies are carried out annually in the United States. Although this study has limitations, we believe it encourages debate and reexamination of the benefit of prophylactic oophorectomy for benign indications in young, low-risk patients.
The most important finding from the study is that oophorectomy conferred no survival advantage. Given the rarity of ovarian cancer among the general population, this effect is not that surprising.
For now, careful risk assessment remains a fundamental component of management, so that women who are at increased risk of ovarian cancer can undergo prophylactic salpingo-oophorectomy.
For low-risk women, who constitute the majority of patients, the data to support removing ovaries at the time of hysterectomy are less clear.
Make sure the patient understands the low risk of cancer and possible cardiac benefits of preservation
- Conduct a thorough discussion with the patient about the pros and cons of oophorectomy for benign disease.
- The risk of ovarian cancer in the general population is low; patients should understand that they may derive cardiac protection from postmenopausal ovarian function.
Do consider oophorectomy among carriers of a BRCA mutation
Domchek SM, Friebel TM, Neuhausen SL, et al. Mortality after bilateral salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers: a prospective cohort study. Lancet Oncol. 2006;7:223–229.
Women known to have BRCA1 or BRCA2 mutations are now managed by means of surveillance or with prophylactic bilateral salpingo-oophorectomy. Although bilateral salpingo-oophorectomy has been shown to reduce the risk of ovarian cancer by 90% and the risk of breast cancer by 50%, until this study few data shed light on the effect of the procedure on overall mortality among women with BRCA mutations.
This prospective cohort study identified 155 patients with BRCA1 or BRCA2 mutations who elected to undergo bilateral salpingo-oophorectomy and matched them by age with a control group of 271. All women were followed until death by any cause or by breast, ovarian, or primary peritoneal cancer. The women were followed for a mean of 3.1 years in the bilateral salpingo-oophorectomy group and 2.1 years in the control group.
Overall and cancer-specific survival improved with oophorectomy
Among BRCA mutation carriers, women who chose prophylactic bilateral salpingo-oophorectomy had improved overall and cancer-specific survival, compared with women who did not undergo the surgery.