687284822Work Code: C620R9089
Incidental Prophylactic Oophorectomy During
Abdominal Surgery
P.E. Schwartz
Department of Obstetrics and Gynecology, Yale University School of Medicine, New
Haven, CT, U.S.A.
Introduction
The purpose of the prophylactic removal of the ovaries during abdominal
surgery is to avoid the subsequent development of ovarian cancer. Ovarian
cancer is the major cancer health hazard for American women. More
women will die from ovarian cancer this year than from all other pelvic
reproductive organ cancers combined.1 Ovarian cancer is a disease that is
not detectable in its early stages on a routine basis because of a lack of
early warning symptoms and a lack of an early detection test for the
disease. Cure rates for ovarian cancer have not varied during the last 30
years.2 Much attention has been focused in recent years in women with an
inherited susceptibility to ovarian cancer based on mutations in the
BRCA1/2 genes or the DNA mismatched repair genes.3 Nevertheless,
these patients represent only 5-10% of all the common epithelial ovarian
cancers. Ninety percent of ovarian cancers are of the sporadic form.
Prophylactic oophorectomy has been recommended in women undergoing
abdominal surgery as a means of avoiding this dreadful disease,
particularly if they fall into a high risk group. However, for the highest
risk group, i.e. women with genetic mutations associated with the
development of ovarian cancer, prophylactic oophorectomy does not
protect these women from developing serous cancers of the peritoneum a
disease that appears to present relatively frequently in women with
BRCA1 gene mutations.4,5
Impact of Concurrent Bilateral Salpingo-Oophorectomy on Cancer
Prevention
In the United States it has been estimated that approximately 854,000
women will undergo hysterectomies in the year 2005. If all of these
women over age 40 undergo prophylactic oophorectomy, 2200 may avoid
ovarian cancer. Thus, one would have to castrate 99.75% of women
undergoing hysterectomies, i.e. remove 1.7 million ovaries, to avoid
ovarian cancer in 0.25%. In Japan, a country with a low incidence of
epithelial ovarian cancer, a recent study failed to demonstrate that
performing prophylactic oophorectomies in all women over age 45
undergoing hysterectomy would have a significant ovarian cancer-sparing
benefit.6 Additionally, 3 case-control studies have suggested that women
undergoing hysterectomy who retain their ovaries are actually at a
decreased for the subsequent development of ovarian cancer7.
Schwartz
Epidemiologic Factors Associated with Ovarian Cancer
Ovarian cancer most commonly occurs in Scandinavian countries,
Western Europe and the United States.6,8 Being Caucasian appears to
significantly increase one’s risk factors for the disease. In addition, the age
of women who develop ovarian cancer rapidly rises as one approaches
menopause and then accelerates. The peak age incidence for ovarian
cancer is in the 75-79 year age group where it is 48.2 per 100,000
population.9 Having a first-degree relative for ovarian cancer increases
one’s risk for developing the disease to 5% and having 2 first-degree
relatives increases one’s risk to 7%.9 Women with a personal history of
breast, colon or endometrial cancer are also at an increased for the
development of ovarian cancer. Having an inherited, genetic susceptibility
to the development of ovarian cancer, such as a BRCA1 or BRCA2 gene
mutation may increase one’s risk from 16-40%.10,11
The greater the number of ovulatory cycles a women experiences in her
lifetime, the great her risk for developing ovarian cancer.12 Nulliparous
women are at an increased for developing ovarian cancer as are women
with primary infertility. Preliminary data regarding ovulation induction
agents does not suggest an association with the development of ovarian
cancer.
Factors Associated with a Decreased Risk of Ovarian Cancer
Factors which reduce the number of ovulatory cycles a women
experiences in her lifetime decrease a woman’s risk for developing
ovarian cancer.10 Prolonged use of oral contraceptives, multiparity and
breast feeding all reduce the number of ovulatory cycles a woman
experiences in her lifetime and have been associated with a reduction in
ovarian cancer7,10 Additionally, tubal ligation has been demonstrated to
reduce the incidence of ovarian cancer in small studies. The Nurse’s
Health Study, which follows 77,544 nurses ages 30-55 originally enrolled
in 1976, has also documented a significant reduction in ovarian cancer in
women who have had a tubal ligation.13 Interestingly, women who have
inherited BRCA1 mutations, the most common of all gene mutations
associated with ovarian cancer can also reduce their risk for ovarian
cancer by prolonged use of oral contraceptives and by undergoing a tubal
ligation.10
Using Risk Factors to Identify those Women who would Benefit from
an Incidental Prophylactic Oophorectomy during Abdominal
Surgery.
Women at an increased for ovarian cancer based on an inherited predisposition or based on risk factors commonly associated with ovarian
cancer such as low parity, lack of use of oral contraceptives, lack of breast
2
Schwartz
feeding or those with a prior history of breast, uterine or colon cancer are
the women who would benefit from an incidental prophylactic
oophorectomy during abdominal surgery. Patients who do not necessarily
benefit from prophylactic oophorectomy would include grand multiparous,
non-Caucasian women and women with no family or personal history of
cancer. Thus, the author would be much more likely to recommend a
prophylactic oophorectomy to a 40 year old nulliparous Caucasian with a
family history of breast and/or ovarian cancer than he would to a 45 year
old grand multiparous non-Caucasian woman undergoing abdominal
surgery who has no family history of cancer.
Conclusions
The major reasons for incidental prophylactic oophorectomy at the time of
abdominal surgery is to avoid the subsequent development of ovarian
cancer. Until we are able to effectively identify which women are likely to
develop ovarian cancer, prophylactic oophorectomy surgery will be
necessary. Hopefully new developments in ovarian cancer detection, such
as the use of proteomics, will allow us in the future to reassess this
aggressive surgical approach by selecting only those women who truly are
at risk for the disease.14
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