Who is the best to do a prophylactic, risk-reducing surgery for BRCA – General gynaecologist or gynaecological oncologist?
I received an email from one of my patients last week. She knows about her BRCA mutation for a year and saw me 8 months ago to discuss her options. Now she made up her mind and wants to proceed with risk-reducing bilateral salpingo-oophorectomy to minimise the risk of ovarian cancer. Prior to her first visit she saw a colleague general gynaecologist who harvested eggs for fertility reasons. She saw the gynaecologist recently asking to discard the eggs because our patient has no further need for them any longer.
In her email she said that the gynaecologist offered to perform her surgery himself. She is now unsure as to who would be the better surgeon to remove her reproductive organs.
“Who is the better surgeon to perform a prophylactic salpingo-oophorectomy on patients with familial cancer” is also popular and commonly asked at AGES conferences. “Who is doing a better job – do patients need to be referred to a gynaecological oncologist?”
A mutation in the BRCA1/2 gene predisposes women to an extremely high risk of breast and ovarian cancer. Prophylactic, risk-reducing salpingo-oophorectomy (SO) is the most effective way to virtually eliminate the risk of ovarian cancer and reduces the risk of breast cancer also by 50%. Alternative methods, such as regular screening with ultrasound and tumour marker tests unfortunately fail completely. The risk of occult cancer (most of them develop within the fallopian tubes) is between 2% and 4%. Therefore, pathology providers will section the entire adnexae every 1 to 2 mm if they know that the procedure has been performed for prophylactic reasons.
A recent Australian study¹ examined the quality of prophylactic surgery, as well as the quality of the pathology work-up in 201 women who had prophylactic surgery for known or suspected BRCA during a 10-year period. Only 20% of all women had adequate surgery plus histopathology workup. In some women the fallopian tubes were left behind, the labelling of the specimen was confusing, and in others the pathology workup in the lab was inadequate.
In 26% of the cases, a primary laparotomy was performed to do the operation and in another 5% of the cases a laparoscopic operation was converted to an open operation. Ovarian cancer was found in 2.5% of patients and in some of those only peritoneal cytology detected it.
I am not sure if it really matters who is doing the operation. Isn’t it more relevant that the operation is done properly, the histopathology workup is adequate and the women who trust us receive full information on the relevant aspects of this surgery?
Here are some indicators I consider good surgical quality:
- All operations need to be done laparoscopically. It is totally inappropriate and out of date to aim for a laparotomy for risk reducing BSO.
- Patients with a history of breast cancer should be given the option of a hysterectomy at the same time. The risk of uterine cancer in breast cancer patients is 150% higher compared to the general population².
- Surgery needs to be performed through a retroperitoneal approach that ensures that all fallopian tube and ovarian tissue is removed completely.
- Peritoneal washings need to be taken.
- Patients are informed not only about the nature of the genetic condition (BRCA1/2, Lynch), their associated cancer risks, the best timing of surgery and its risks but also about the alternatives to surgery even if they are not our/the patient’s first choice.
- Patients need to be informed about the risk of failure (peritoneal cancer) and why some women still develop (what types of) cancer following risk-reducing surgery.
- The specimen needs to be labelled adequately so that pathology assessment is complete for a high-risk patient. If an abnormal test results comes back we need to see where the abnormal cells come from.
Is it important who does the operation?
¹ Kiely et al.: Familial Cancer 2011; 10: 505-14.
² Youlden DR, Baade PD: The relative risk of second primary cancers in Queensland, Australia: a retrospective cohort study. BMC Cancer. 2011;11: 83.