New surgical approach for women at risk of ovarian cancer
A study led by researchers from Barts Health and Queen Mary’s Wolfson Institute has found that premenopausal women who are considering surgery to prevent ovarian cancer believe a new two-stage approach for cancer prevention is highly acceptable.
For women at high risk of ovarian cancer, the standard preventive practice is to offer removal of both the fallopian tubes and ovaries, but the surgery induces menopause prematurely.
Early menopause is associated with side effects like increased risk of heart-disease, osteoporosis, vasomotor-symptoms, neurocognitive decline, and sexual-dysfunction, especially in women who do not use hormone replacement therapy.
The PROTECTOR trial assesses an alternative procedure where the fallopian tubes are removed (salpingectomy) as an initial step to offer some risk reduction, but ovary removal (oophorectomy) is delayed until women have reached menopause.
This two-step procedure, ‘Risk Reducing Early Salpingectomy with Delayed Oophorectomy’ (RRESDO), will provide some ovarian cancer risk reduction while avoiding detrimental consequences of premature surgically induced menopause.
In this multicentre UK study, researchers examined the acceptability of the proposed alternative two-step surgical protocol and effect of surgical prevention. The 638 study participants were all at increased risk of ovarian cancer; 346 had undergone standard risk reducing surgery, and 337 had not.
Of premenopausal women who had not undergone standard surgery, 69% found it acceptable to participate in a research study offering the proposed new surgical option. Among those who had undergone standard preventive surgery, 9.4% of premenopausal and 1.2% of postmenopausal women regretted their decision.
The study showed that the new two-step surgical protocol was particularly acceptable to women concerned about the sexual dysfunction side effects of ovary removal.
Professor Ranjit Manchanda, lead researcher and consultant gynaecological oncologist at Barts Health, said: “Undergoing an operation to prevent ovarian cancer can be a complex decision-making process.
“Although removal of tubes and ovaries prevents ovarian cancer, it can lead to early surgical menopause which has significant detrimental consequences on long-term health. A number of women opt to delay or decline preventive surgery as a result.
“The new two-step operation offers additional options for women (who may have not undergone surgical prevention) to reduce their ovarian cancer risk while avoiding the negative impact of early menopause.
“Our study shows a large proportion of eligible women wish to consider this and women in the UK who wish to do so now have the option of joining the PROTECTOR (Preventing Ovarian Cancer through early Excision of Tubes and late Ovarian Removal) study.”
Dr Faiza Gaba from Queen Mary University of London said: “While HRT-use has been shown to mitigate some symptoms, it does not appear to alleviate sexual-dysfunction or increase satisfaction levels following standard preventive surgery involving removal of ovaries.
“However HRT-use in breast cancer unaffected women undergoing premenopausal removal of their ovaries is essential to reduce the risk of heart disease, osteoporosis and neurocognitive decline. The new two-step surgery, RRESDO, offers further options to women considering surgical prevention.”
The study was funded by the Rosetrees Trust and Barts Charity.
Lisa Anderson, 38, was tested positive for a BRCA1 gene mutation at St Bartholomew’s Hospital, which put her at high risk of breast and ovarian cancer.
Cancer is not usually inherited, but some types – mainly breast, ovarian, colorectal and prostate cancer – can be strongly influenced by genes and can run in families.
BRCA1 and BRCA2 are two examples of genes that increase your risk of cancer if they become altered. Having a variant BRCA gene greatly increases a woman's chance of developing breast cancer and ovarian cancer.
Lisa opted into taking part in the PROTECTOR trial and had her fallopian tube surgically removed as part of the two-step surgery at The Royal London Hospital in Whitechapel. As a premenstrual woman, she was eligible to take part in the trial.
Six weeks after surgery Lisa was back at work.
“It was an easy recovery and I’ve had no problems since the surgery. It was a very positive experience – it went smoothly and there were no complications. The doctor was lovely and so was his team. I can’t fault them.”
One of the advantages of this two-step surgery was that she was able to keep her ovaries and is still able to produce hormones at this stage of her life.
“I don’t regret my decision at all – I didn’t want to go into forced menopause. It’s not nice to have any kind of cancer but it’s important to raise awareness about this. If you can take a bit of control back into your own hands then it’s a worthy cause.”
Photo caption: Patient Lisa Anderson