Risk‐reducing surgery for women at high risk of epithelial ovarian cancer

Abstract

Key content The lifetime risk of ovarian cancer in the general population is 1.4% but women with hereditary ovarian cancer syndromes have a lifetime probability as high as 25–60% for developing epithelial ovarian cancer. Screening has not been found to be associated with a statistically significant reduction in mortality from ovarian cancer and cannot be routinely recommended even for women at high risk. Serum CA125 levels are only elevated in 50–60% of stage I ovarian cancers and interval cancers may develop between screening visits. Studies show a 4–20% risk of finding an occult malignancy at the time of risk‐reducing bilateral salpingo‐oophorectomy. Studies support the efficacy of risk‐reducing bilateral salpingo‐oophorectomy in significantly reducing the risk of gynaecological and breast cancer in women who carry BRCA1 or BRCA2 mutations. Women undergoing risk‐reduction bilateral salpingo‐oophorectomy should be counselled about the effects of early menopause and the available management options including hormone replacement therapy. Learning objectives To be able to identify those women at increased risk of ovarian cancer. To be able to appropriately counsel those at high risk of ovarian cancer regarding modifiable risk factors, screening and the role of risk‐reducing surgery, including prophylactic bilateral salpingo‐oophorectomy and its alternatives such as tubal ligation and salpingectomy. To understand the limitations of current screening modalities for the reduction of ovarian cancer risk. Ethical issues Ethical concerns exist pertaining to the performance of screening modalities, which have not been found to significantly reduce mortality from ovarian cancer and can cause harm in terms of psychological and surgical morbidity from false‐positive results. For those with a positive family history of ovarian cancer but no genetic cancer syndrome, the discussion to perform risk‐reducing surgery should be balanced against the risk of surgical morbidity and early menopause. Individual patient risk factors must be considered in the decision‐making process.