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Crosbie EJ, Flaum N, Harkness EF, Clayton RD, Holland C, Martin-Hirsch P, Wood N, Keating P, Woodward ER, Lalloo F, Donnai P, Edmondson RJ, Evans DG. Specialist oncological surgery for removal of the ovaries and fallopian tubes in BRCA1 and BRCA2 pathogenic variant carriers may reduce primary peritoneal cancer risk to very low levels. Int J Cancer 2020; 148:1155-1163. [PMID: 33152107 PMCID: PMC7839461 DOI: 10.1002/ijc.33378] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/27/2020] [Accepted: 10/16/2020] [Indexed: 01/04/2023]
Abstract
Risk‐reducing bilateral salpingo‐oophorectomy (RRBSO) is highly effective for the prevention of high‐grade serous ovarian cancer (HGSOC) in BRCA1/2 pathogenic variant carriers (PVCs), but does not completely eliminate future risk of primary peritoneal cancer (PPC). The requirement to completely remove fallopian tubes at RRBSO and carefully exclude occult cancer/serous tubal intraepithelial carcinoma (STIC) lesions may not have been appreciated historically. We calculated rates of HGSOC and PPC in confirmed BRCA1/2 PVCs registered on the regional database in those who did (cases) and did not (controls) undergo RRBSO after genetic testing. Expected annual rates of ovarian/peritoneal cancer were 1% for BRCA1 ≥ 35 years and 0.5% for BRCA2 ≥ 45 years. Follow‐up before 35/45 years was “risk free” and lead time excluded RRBSO <35 years and <45 years for BRCA1 and BRCA2, respectively. Women were followed from personal mutation report (controls) or RRBSO (cases) to death, ovarian/peritoneal cancer or last follow‐up, whichever was sooner. In total, 891 cases (BRCA1 = 468, BRCA2 = 423) and 1302 controls had follow‐up ≥35 years (BRCA1 = 736) and ≥45 years (BRCA2 = 566), respectively, over a total of 7261.1 risk eligible years (mean = 8.15 years). Twenty‐one occult ovarian cancers were found at RRBSO (2.4%), 16 at stage 1. Post RRBSO, 56.97 ovarian/peritoneal cancers were expected but only 3 were observed (HR = 0.053; 95% CI = 0.013‐0.14), with combined Kaplan‐Meier analysis HR = 0.029 (95% CI = 0.009‐0.100, P < .001). Risk reduction was greater in specialist (HR = 0.03; 95% CI = 0.001‐0.13) compared to non‐specialist centres (HR = 0.11; 95% CI = 0.02‐0.37) (P = .07). In controls, 23.35 ovarian/peritoneal cancers were expected with 32 observed (HR = 1.37; 95% CI = 0.95‐1.91). RRBSO <35/<45 years reduces the risk of ovarian/peritoneal cancer by 95% in BRCA1/2 PVCs and may be greater in specialist centres. What's new? Women who carry genetic variants in BRCA1/2 that are linked to high‐grade serous ovarian cancer are advised to undergo risk‐reducing prophylactic bilateral salpingo‐oophorectomy (RRBSO). RRBSO, however, is associated with a significant residual risk of primary peritoneal cancer (PPC). Here, the rate of PPC following prophylactic surgery for high‐grade serous ovarian cancer was investigated among 2,193 BRCA1/2 mutation carriers who had undergone RRBSO. Estimates indicate that prophylactic surgery reduced the overall risk of PPC by 95 percent, a far greater reduction than previously described. Residual risk was lowest when RRBSO was carried out at specialist centers compared to non‐specialist centers.
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Affiliation(s)
- Emma J Crosbie
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicola Flaum
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Genetic Medicine, Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Elaine F Harkness
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK
| | - Richard D Clayton
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Cathrine Holland
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Pierre Martin-Hirsch
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Obstetrics and Gynaecology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - Nick Wood
- Department of Obstetrics and Gynaecology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - Patrick Keating
- Department of Obstetrics and Gynaecology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Trust, Preston, UK
| | - Emma R Woodward
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Genetic Medicine, Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Fiona Lalloo
- Genetic Medicine, Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Paul Donnai
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard J Edmondson
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - D Gareth Evans
- Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Genetic Medicine, Manchester Centre for Genomic Medicine and NW Laboratory Genetics Hub, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Prevention Breast Cancer Centre and Nightingale Breast Screening Centre, University Hospital of South Manchester, Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK.,Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
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Warren R. Investigation and management of patients at high risk of developing cancer. Br J Radiol 1997; 70 Spec No:S50-9. [PMID: 9534718 DOI: 10.1259/bjr.1997.0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Recent developments in cancer genetics have revealed genes that render individuals susceptible to cancer. These families have a unique set of new problems and benefits that must be thought through for the potential good to be accrued from these discoveries. Individual patients seek early diagnosis and prevention strategies that challenge the limits of current knowledge. Some available methods have not yet been evaluated. There is a need for the evidence to support plans of care, and consistency is required from one centre to the next in the advice given. These familial cancers are often different from the more common sporadic cases, and so traditional treatments need to be tested again in the context of the new genetic knowledge. Three groups of cancers, breast, ovary and colon, have been used to illustrate the issues surrounding these high risk families, their investigation and care. In applying new strategies to these patients, ethical issues arise that are new to the medical world, and must be considered by the lay public. It is up to the medical profession, patients and society to use this knowledge to give benefit to a vulnerable group, and not to give unaffordable hopes and unnecessary anxieties.
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Affiliation(s)
- R Warren
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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Abstract
Advances in medical technology have led to potentially useful techniques for the early detection of epithelial ovarian cancer. Early detection of ovarian cancer is crucial for survival as women found to have Stage I or II disease have a 5-year survival of 90% and 70%, respectively, whereas those with advanced disease (Stage III and IV) have a survival of approximately 20%. The circulating tumour marker CA-125 has been extremely useful in following women known to have epithelial ovarian cancers. It has been employed in differentiating benign tumours from malignancies, and is now being tested in a variety of programmes for its role in the early detection of ovarian cancer. The application of endovaginal ultrasound and colour Doppler flow techniques to early detection of ovarian cancer have resulted in several large series identifying ovarian cancer in 1:1000 to 1:2000 postmenopausal women screened. However, a high false positivity rate persists using CA-125 and ultrasound techniques alone or in sequence. Developments in molecular genetics may be extremely useful in evaluating women with inherited susceptibilities for this disease, but this probably represents only about 3% of the population of the women who develop epithelial ovarian cancer. The cost-benefit analysis of isolated screening for epithelial ovarian cancer using CA-125 and ultrasound techniques, even in women at high risk for the disease, would suggest that such screening is not cost-effective at this time.
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Affiliation(s)
- P E Schwartz
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06520-8063, USA
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Nguyen HN, Averette HE, Janicek M. Ovarian carcinoma. A review of the significance of familial risk factors and the role of prophylactic oophorectomy in cancer prevention. Cancer 1994; 74:545-55. [PMID: 8033032 DOI: 10.1002/1097-0142(19940715)74:2<545::aid-cncr2820740204>3.0.co;2-q] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Women with a family history of ovarian cancer are at increased risk of ovarian cancer. Prophylactic oophorectomy (PO) remains the only effective method of ovarian cancer prevention. This study reviewed current data on the significance of family history and how prophylactic oophorectomy should be used in different risk groups. Approximately 7% of ovarian cancer patients have a positive family history of whom 3-9% may eventually manifest certain hereditary cancer syndromes. Women in direct genetic lineage of family cancer syndromes have up to a 50% lifetime risk of ovarian cancer. Because of the high risk, PO is indicated for women with familial cancer syndromes after childbearing or between the ages of 35-40 at the latest. The majority of women with a positive family history of ovarian cancer do not have one of the recognized syndromes. Women with one or two affected relatives have an increased lifetime risk of ovarian cancer from a baseline of 1.6 to 5-7%. This risk is not high enough to warrant PO for a large number of women. After being properly informed, the patient still chooses surgical prevention, she then receives PO. For women without a family history of ovarian cancer, the role of PO remains controversial. Assuming an annual incidence of 22,000 new cases of ovarian cancer, it is estimated that at least 1000 may be prevented if PO is diligently practiced during hysterectomy. Despite ovarian and breast cancer prevention, PO would lead to shorter life expectancy if estrogen therapy compliance were less than perfect. Thus, the decision on PO as a concurrent procedure should depend on the individual patient and her ability to comply with lifelong estrogen therapy.
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Affiliation(s)
- H N Nguyen
- Division of Gynecologic Oncology, Cleveland Clinic Florida, Ft. Lauderdale 33309
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