Selecting the most appropriate risk-reducing strategy is not a straightforward task. The impact of risk-reducing strategies on cancer risk, survival, and overall quality of life are the key criteria considered for making a good decision. There is no sole risk-reducing strategy which is able to fully meet all expectations and requirements in an individual woman. On the one hand, non-surgical procedures provide a good body image and quality of life, but may be associated with increased risk of advanced-stage cancer and mortality; on the other hand, surgery ensures a very high protection from cancer but is associated with a number of disadvantages of invasiveness, non-reversibility and surgical morbidity.
Based on the available literature, it is deemed appropriate to acknowledge that the clinical management of cancer risk in BRCA1 and BRCA2 mutation carriers is a rather complex and stressful task, which should consider individual patients' expectations and preferences. Such preferences can be informed by accurate knowledge of the risks and benefits of the interventions considered. Available studies confirm the essential role of PBSO in reducing the risk of both breast and ovarian cancer. Furthermore, other options for risk reduction should be considered, such as chemoprevention and risk-reducing mastectomy. Although coordinated, PBM and PBSO are feasible procedures with acceptable morbidity in selected high-risk patients; the timing of prophylactic surgery is still a matter of paramount importance to both patients and clinicians to consider during the counselling process.
It is recommended that prophylactic surgery should be performed as soon as possible, simply because of the early development of cancer in BRCA mutation carriers. Although ovarian cancer rarely occurs in premenopausal women, it is advised that BRCA mutation carriers should undergo PBSO immediately after childbearing is complete in order to reduce the risk of early breast cancer development.
Prospective randomised controlled trials examining the various interventions in relation to the woman's age and type of mutation are needed. However, the randomisation of BRCA carriers to different arms of trials is an extremely difficult and rather impossible process given the current available evidence.
DCIS: Ductal carcinoma in-situ; MRI: Magnetic resonance imaging; SERMs: Selective oestrogen receptor modulators; AIs: Aromatase inhibitors; PO: Prophylactic oophorectomy; OCPs: Oral contraceptive pills; PBSO: Prophylactic bilateral salpingo-oophorectomy; PBM: Prophylactic bilateral mastectomy; PCM: Prophylactic contralateral mastectomy; SSM: Skin sparing mastectomy; IBR: Immediate breast reconstruction
We are grateful to Breast Cancer Hope Charity (Reg: 1110926) for funding and supporting the production of this article.
MS performed literature search/review and manuscript writing. SB: helped in manuscript writing, KM involved in the concept, manuscript revision and writing. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
BMC Womens Health. 2010;10(1) © 2010 BioMed Central, Ltd.
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Cite this: Risk-reducing Strategies for Women Carrying brca1/2 Mutations with a Focus on Prophylactic Surgery - Medscape - Oct 26, 2010.