Older age should not deter healthy women with a genetic predisposition to ovarian cancer from considering risk-reducing bilateral salpingo-oophorectomy (BSO), according to a study involving BRCA carriers.
A 30-year-old BRCA1 carrier who postpones BSO until the age of 50 still faces a 23.9% lifetime risk of developing ovarian cancer. At age 75, this residual risk drops to 8.4% for BRCA1 carriers and 3.7% for BRCA2 carriers. Actuarial risk computations up to age 80 indicate that BRCA1 carriers have a 56.8% lifetime risk of ovarian cancer, while BRCA2 carriers exhibit a 25.4% risk.
These risk estimates surpass those presented in earlier studies, as reported by Vasily Giannakeas, PhD, of Sinai Health System in Toronto, and team in JAMA Surgery.
“These findings advocate for personalized counseling on BSO timing, which includes residual lifetime ovarian cancer risk alongside critical factors such as breast cancer history, menopausal consequences, fertility aspirations, and patient preferences,” stated the authors. “Although these actuarial tables quantify leftover ovarian cancer risk, they do not assess the overall net advantage of BSO, as elements like cardiovascular health, bone health, cognition, vasomotor symptoms, mental wellness, and quality of life following early menopause were not taken into account.”
“For older women, discussions regarding BSO should reflect whether the anticipated decrease in ovarian cancer risk justifies the surgery, taking into consideration the patient’s comorbidities, life expectancy, and potential surgical and anesthetic complications,” they wrote.
The residual risk for older, healthy women is notably high enough to warrant consideration of preventive surgery, potentially reaching a “substantial risk” for BRCA1 carriers who delay BSO until they are 50 years old.
According to the authors of an accompanying commentary, many high-risk patients postpone risk-reducing surgery due to a perceived trade-off between risk reduction and quality of life. The effect of BSO on fertility could potentially be minimized through improved access and funding for fertility specialists and egg freezing. Concerns over quality of life following premature surgical menopause may be alleviated through adequate patient counseling and education regarding menopausal hormone therapy.
“Interval salpingectomy with delayed oophorectomy is an encouraging strategy that could reduce tubo-ovarian cancer risk without the extra burden of surgical menopause and while preserving fertility possibilities,” remarked Kara C. Long, MD, from Memorial Sloan Kettering Cancer Center in New York City, along with colleagues. “Data indicates up to an 80% reduction in tubo-ovarian cancer risk in the general population following salpingectomy.”
This strategy is currently being evaluated in two large ongoing clinical trials, they noted.
According to Karen Lu, MD, of Moffitt Cancer Center in Tampa, Florida, the study by Giannakeas and colleagues can aid discussions about the optimal timing for risk-reducing BSO. Both the National Comprehensive Cancer Network and the Society of Gynecologic Oncology have suggested age ranges for BSO: 35-40 for BRCA1 carriers and 40-45 for BRCA2 carriers.
“As we encounter more ‘previvors’—young women at increased cancer risk without a personal cancer history—we must continue to gather more information for appropriate counseling regarding risk-reducing salpingo-oophorectomy, a procedure that significantly reduces ovarian cancer risk but comes with certain quality of life implications,” Lu stated.
Monica Avila, MD, also from Moffitt Cancer Center, added that the study conveys vital messages for clinicians caring for patients with genetic risks for ovarian cancer.
“The highest risk identified for BRCA1 is at ages 30-35 and for BRCA2 at 30-40, in accordance with previous literature rates and age recommendations for optimal risk-reducing surgery,” explained Avila. “The likelihood of developing ovarian cancer in BRCA patients diminishes over time, especially post-menopause, but this risk is not eliminated, and risk-reducing surgery remains the standard of care, even for patients presenting later in life. The sooner we identify the risk, the better the chance to intervene and prevent ovarian cancer fatalities.”
Giannakeas and colleagues undertook a prospective cohort study to explore an unanswered question concerning risk-reducing BSO: the absence of guidelines about upper age limits at which BSO is no longer advisable.
Participants in the study were recruited between 1995 and 2024 across 24 international centers, with an average follow-up period of 4.4 years. The investigators implemented life table analysis utilizing age-specific ovarian cancer incidence and competing mortality metrics to estimate the lifetime ovarian cancer risk among women with a BRCA1 or BRCA2 pathogenic variant.
The analysis comprised 4,286 BRCA1 carriers and 1,427 BRCA2 carriers aged 30 to 74 (mean age 42.0) having intact ovaries and no history of ovarian cancer. The analysis considered data indicating that 34% of 30-year-old women would succumb to competing causes before age 80. Consequently, 249 participants developed ovarian cancer, translating to an annualized incidence of 1.18% per person-year for BRCA1 carriers and 0.40% for BRCA2 carriers.
The anticipated benefit of BSO gradually diminished from ages 30 to 75. For BRCA1 carriers, the residual risk was 54.8% at age 35, 42.7% at age 50, and 8.4% at age 75. Corresponding residual risks for BRCA2 carriers were 24.2%, 22.2%, and 3.7%.
Disclaimer: Consult a healthcare professional for personalized medical advice and before making any decisions regarding treatments or surgeries.
Fuente: https://www.medpagetoday.com/hematologyoncology/ovariancancer/123123
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