BRCA1 and Ovarian Cancer: Why Women Choose Preventive Surgery

A personal choice guided by risk factors

For a woman, the decision to have your ovaries and fallopian tubes removed does not come easily. But if you face an alarmingly high genetic risk of ovarian cancer, preventive surgery may be the right choice.

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Angelina Jolie’s surgery in March shined a national spotlight on this issue. She previously brought attention to preventive mastectomy back in 2013. Jolie chose both procedures because her BRCA1 genetic mutation put her at high risk for breast cancer and ovarian cancer.

Jolie may be a high-profile patient, but she’s not alone. About 1 in 400 to 1 in 800 people in the general population have a BRCA1 or BRCA2 mutation.

For women with these mutations, choosing a salpingo-oophorectomy — the surgery that removes the ovaries and fallopian tubes — is a highly personal decision. Several factors play a part.

“If screening won’t find cancer until it’s too late to help, preventive surgery becomes more appealing.”

Charis Eng, MD, PhD

Founding Chairwoman of the Genomic Medicine Institute

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The genetic risk

For genetic risk of ovarian cancer, BRCA1 is the biggest culprit. If you have a BRCA1 mutation, your lifetime risk of developing ovarian cancer rises to 40 percent. That compares to only around 0.5 to 1 percent in the general population.

A BRCA1 mutation does not guarantee you will get ovarian cancer. But a 40 percent lifetime risk is simply too high. Other genes raise the risk level, too, including BRCA2 and several genes associated with Lynch Syndrome, though not as drastically as BRCA1.

If you’re concerned about a possible mutation, start by checking your family health history for red flags. Have multiple family members had breast or ovarian cancer? Did they have breast cancer before age 50? These are major signs of genetic cancer. If you spot them, ask your doctor about genetic counseling.

Screening finds cancer too late

With some genetic mutations, intense screening is enough to prevent disease — or detect it early, when it is curable. 

Sadly, that’s not true for ovarian cancer. Doctors use pelvic exams, blood tests and ultrasounds to screen for ovarian cancer. However, these methods tend to find cancer at late stages of the disease, when treatment is not as effective.

That’s partly why preventive surgery has become an option for women with high genetic risk. If screening won’t find cancer until it’s too late to help, preventive surgery becomes more appealing. For example, if you have a BRCA1 mutation and have your ovaries and fallopian tubes removed, you may reduce your risk of ovarian cancer by up to 90 percent.

Age is a factor

The genetic risk of ovarian cancer rises after your mid-30s. That’s also the age at which many women finish having children. The connection is important, since the desire to have children is another factor in the decision.

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Let’s say you are in your early 30s and have a BRCA1 mutation. But you tell your high-risk cancer specialist you still want to have more children. You may decide you want to wait a few years before making a final decision regarding preventive surgery. This is a common situation.

However, we typically recommend preventive removal of the ovaries and fallopian tubes in women with BRCA1 mutations before age 40. If there is a family history of ovarian cancer — especially early cancer, such as cancer at age 35 — then your doctor may encourage you to act more quickly.

What follows surgery?

The answer to this question depends on your age, too. For women who are premenopause age, having your ovaries removed can cause symptoms of menopause such as hot flashes and vaginal dryness.

Doctors often treat these symptoms with hormone replacement therapy. In women with BRCA1 or BRCA2 mutations, they may consider estrogen-only replacement therapy.

Finding the appropriate therapy and doses takes time. There has been some controversy over whether hormone replacement therapy increases cancer risk in certain populations. Because of that, the goal is to use as little therapy as possible to minimize risk.

Ultimately, the decision to have preventive surgery comes down to you, the patient. But with a team to lean on — from genetics experts to high-risk cancer specialists — it’s not a decision you have to make alone.

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Charis Eng, MD, PhD

Charis Eng, MD, PhD is founding chairwoman of the Genomic Medicine Institute and founding director of its Center for Personalized Genetic Healthcare. Dr. Eng is a global leader in cancer genetics and cancer genomic medicine.
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