The standard recommended risk reducing procedure for BRCA 1 or 2 mutation carriers remains prophylactic salpingooophorectomy, tailored to the type of BRCA mutation and the patient’s age. Nonetheless, it should… Click to show full abstract
The standard recommended risk reducing procedure for BRCA 1 or 2 mutation carriers remains prophylactic salpingooophorectomy, tailored to the type of BRCA mutation and the patient’s age. Nonetheless, it should also be underlined that, despite the robust evidence about the safety and feasibility of risk reducing salpingooophorectomy, approximately 30% of BRCA mutation carriers are unwilling to undergo this prophylactic approach, concerned by the premature onset of menopause. For this reason, and based on the hypothesis that a precursor of ovarian cancer lesions often arises from the fallopian tube, salpingectomy with delayed oophorectomy has been proposed as an alternative. Data suggest that this procedure is feasible and seems to mitigate menopausal symptoms, compared with bilateral salpingooophorectomy at ages 35–45. However, the data are still immature. The accurate level of risk reduction of ovarian cancer and the long term impact of ovarian function remain undefined and prospective trials are ongoing but require further enrollment and longer followup. For this reason, in the current guidelines it is clearly stated that salpingectomy alone cannot yet be recommended, outside the setting of a clinical trial. With regard to hysterectomy, we believe that some considerations are necessary when counseling BRCA carriers undergoing risk reducing surgery. First, it has been reported that BRCA1 women undergoing risk reducing salpingooophorectomy without concurrent hysterectomy might have an increased risk of developing aggressive histological endometrial cancer, such as serous/serouslike endometrial cancer. Second, several BRCA carriers who undergo risk reducing salpingooophorectomy are still at an increased risk of a diagnosis of endometrial cancer because they receive tamoxifen in order to reduce the risk of breast cancer. Finally, for young oophorectomized healthy BRCA carriers, hormone replacement therapy might be an option; therefore, it should be remembered that estrogen monotherapy is associated with a lower risk of developing breast cancer compared with the combination of estrogen/progesterone while the effect of progesterone containing hormone replacement therapy among BRCA1 mutation carriers is unclear. Therefore, in accordance with current guidelines, we believe that the hysterectomy procedure deserves to be carefully discussed with the patient during the decision making process, particularly in BRCA1 carriers.
               
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