Question

When should pBSO be considered?

Recommendation

The guideline development group recommends telling women with an elevated risk of ovarian cancer due to BRCA1/2 gene mutations about the pros and cons of screening and preventive bilateral salpingo-oophorectomy (pBSO), and asking them to consider a pBSO starting at age 35 or 40.

 

The group recommends considering pBSO starting at age 35 for BRCA1 and starting at 40 for BRCA2.

Conclusions

Screening for ovarian cancer in women with a BRCA1/2 mutation or family history of breast and/or ovarian cancer is not cost-effective.

Level 2: B Oei 2006, Vasen 2005, Meeuwissen 2005, Stirling 2005, Hermsen 2007

Literature summary

Studies have investigated whether ovarian cancer is cost-effective screening in women who have a family history of breast/ovarian (or tubal) cancer. The most recent Dutch study included a group of 888 BRCA1/2 carriers who had annual screening by ultrasound and CA 125 measurement. Five of the 10 ovarian cancers found in this group were interval cancers, diagnosed between 3 and 10 months after a normal screening, and eight of them were stage III/IV [Hermsen 2007]. Up to the present there has been no evidence that routine screening for ovarian cancer results in diagnosing early stage ovarian cancer or in reducing mortality. Other authors have also come to the conclusion that screening for ovarian cancer in women with a mutation or hereditary risk of breast and/or ovarian cancer is not cost-effective [Stirling, 2005; Oei, 2006; Vasen, 2005; Meeuwissen, 2005].

Considerations

Ovarian cancer has no detectable preliminary stage that is detectable with current diagnostic tests, and therefore does not meet the criteria for screening. An alternative to screening for ovarian cancer at present is a preventive bilateral salpingo-oophorectomy (pBSO). A meta-analysis of 10 studies on the effects of a pBSO found an 80% reduction in ovarian cancer and 50% reduction in breast cancer in BRCA1/2 mutation carriers, with consistent results in the different studies [Rebbeck 2009]. Bilateral pBSO before the age of 45 is associated with higher mortality, especially if no hormone replacement therapy is given [Rivera, 2009]. Other drawbacks are menopausal symptoms and poorer sexual function [Madalinska, 2005; Madalinska, 2006].

The reported effects of early menopause include a higher risk of cardiovascular disease, neurological disease, osteoporosis and mood disorders, which can be partially mitigated by hormone replacement therapy [Sushter, 2010]. It is unknown whether and to what degree this is also true for women with a BRCA1/2 mutation who undergo a pBSO premenopausally. It is important to monitor these women in order to learn about the delayed effects of premenopausal pBSO. In a study conducted by Rebbeck (2005) in BRCA1/2 mutation carriers, the reduced risk of breast cancer did not change substantially with short-term hormone replacement therapy after pBSO.

From the age of 35, women with BRCA1/2 mutations are referred to the gynaecologist, becoming eligible for a pBSO starting at age 35-40 if they have BRCA1 and starting at age 40-45 if they have BRCA2. There is no consensus on the policy before pBSO. There are gynaecologists who do annual screening until the patient has a pBSO. The disadvantage of such an approach is the risk of false-positive results and the associated unnecessary additional diagnostic testing, which adds to the woman's distress. Other gynaecologists support BRCA mutation carriers to decide for themselves what the best time is for a pBSO and do not offer any screening. We therefore recommend informing women about the pros and cons of screening and pBSO.

Authorization date and validity

Last review : 13-02-2012

Last authorization : 13-02-2012

Initiative and authorization

Initiative : Nationaal Borstkanker Overleg Nederland

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Nederlandse Vereniging voor Radiotherapie en Oncologie